Doctor–Patient Partnership: Patients of Advanced Age Use Medical Diaries to Improve Coordination of Care

Abstract

Coordination of care suffers when patients are treated by multiple physicians who do not communicate with each other. Medicare patients see about five different physicians a year, and patients with heart failure or diabetes see on average 13 physicians annually. The Institute of Medicine (2006) also notes that Medicare pays providers for the number of patients served rather than patient outcomes or coordination of care. Thus, few health care professionals have the time to volunteer for care coordination. If patients of advanced age are the first to realize their symptoms, then they are in the best position to coordinate their own health care. Some such patients may designate a family member or caretaker to serve this role, but many find taking on this responsibility for themselves both empowering and rewarding. To collect data and to communicate these data to health care providers, we propose that patients keep medical diaries. These are designed to summarize symptoms, test results, diagnoses, treatments, outcomes, and follow-ups. This proposal is based on the hypothesis that patients of advanced age record their test results in a timely way and communicate these data to their health care providers regularly. For patients, we assume that the diaries help them see the cause and effects of unhealthy behaviors. For instance, they may notice decreased blood pressure when they stop shaking salt on their food. Or their body weight may decrease when they omit sweets from their meals. We notice that such observations motivate patients to adopt healthy habits. As for families and caretakers, medical diaries bring them up to date with patients' symptoms, medications, and doctor appointments. In this way, family and caretakers help patients avoid duplicate testing and overmedication. Patients like to customize their medical diaries according to their personal tastes. In addition, we teach them that the following sections in the diary are useful to health care providers (see Appendix A): calendar of doctor appointments; chief concerns; diagnoses; medications and allergies; vaccinations; operations; dietary preferences; tobacco, alcohol, and drug dependence; exercise; healthcare proxy; advanced directives; medical policy statement; blood pressures; body weights; respiratory rates; temperature; teeth; mood; and test results. In this way, we teach patients to focus their efforts on tracking measures proven to save lives and improve health. For instance, we designed medical diaries to focus on evidence-based improvements in medication adherence, hepatitis vaccines, diabetes, substance abuse, inactivity, hypertension, obesity, hypercholesterolemia, HIV infection, depression, and cancer screening with Pap smears and colonoscopy (Farley, 2009). Critical questions about medical diaries are as follows: 1. Are the data recorded by patients true? 2. Is it fair to ask patients of advanced age to maintain diaries and coordinate their own health care? 3. Will medical diaries build goodwill and improve doctor- patient relationships? 4. Will the medical diary benefit all concerned, including the patient's family and home health aides? To address these questions and to illustrate how medical diaries improve patient care, let's consider four patient scenarios. Question 1. Are the data recorded by patients true? Case 1. I am a 95-year-old man with hypertension. On Thursday, 11/5, I didn't take my blood pressure pill because I was out of town. The next day at noon when I returned home, I took my pill. Then, on Saturday 11/7, while running to catch a bus, I felt chest discomfort for 1 minute that stopped as soon as I stepped onto the bus. On Sunday, 11/8, I took my BP pill at 7 a.m., but while walking up the hill to church, I had trouble breathing. However, as soon as I stand still I can breathe again. Such casual observations and concerns are often omitted during the physician's interview because the patient feels that these symptoms are not important and the physician seems too busy. …