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Do You Really Know Your Patient? It's a Key to Advancing Health Equity

Charla Johnson, DNP, RN-BC, ONC

Disclosures

November 15, 2022

If clinical care — both access to care and its quality — account for 20% of an individual's health, why have the Centers for Medicare and Medicaid (CMS) assigned the responsibility to hospitals and clinicians of collecting social determinants of health (SDOH) data? Why is the burden laid on healthcare when the highest attributable cause of an individual's health comes from social and economic factors created by government policies, laws, and regulations? The questions are meant to be rhetorical to inspire further reflection.

CMS recently issued a ruling offering incentives for healthcare organizations to voluntarily report their patients' social drivers of health in 2023. Such reporting is mandated in 2024 for the 2026 CMS payment determination. Whether it's fair, healthcare organizations are charged with improving both patient and community health by addressing SDOH.

The problem with this approach, however, is it can only occur one patient at a time. With screening, the individual patient needs are acknowledged but then only addressed if a connection to a community resource, such as a food bank, occurs. The underlying conditions contributing to the root of the socioeconomic problem within communities still exist.

Physicians, advanced care providers, and nurses need to have authentic conversations with patients to understand the stories that led to their conditions. But, they face obstacles such as limited time with patients and resources, the burden of documentation, and the constraints of clinical workflows.

It takes time to hear a patient's story. Most doctor appointments are scheduled for 15 minutes. The average time primary care physicians spend with patients is 18 minutes per visit in the outpatient clinic setting. The length of a visit depends on whether it's a new patient, whether there are multiple reasons for the visit, and the total number of prescriptions needed.

Much of the time spent with the patient is documenting the encounter in the electronic health record (EHR) and not face to face. Although most items are clinically relevant, the documentation burden stems from external requirements driven by regulatory agencies and CMS. And spending 6 or more hours weekly on after-hours charting is significantly associated with burnout. Organizations can support EHR optimization and improve clinical workflows to reduce burden and burnout, but they cannot make more time.

Because time is the main barrier to screening, finding innovative ways to capture SDOH information prior to a clinician encounter is imperative. It is not the act of screening that will have an impact on health, but the authentic conversation between clinician and patient.

How powerful would it be if a clinician enters the exam room, squishes the hand sanitizer, shakes your hand, sits down, makes eye contact, and ask, "What should I know about you to better take care of you?" If the clinician asked this question prior to opening the EHR, a layer of implicit bias may be removed. Organizations will need to remove obstacles and support initiatives to improve clinical workflows, EHR efficiencies, and in some cases, additional personnel to allow the patients' stories to be heard.

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About Charla Johnson
Charla Johnson, DNP, RN-BC, ONC, is a national leader in the health equity space. The majority of her nursing career has been aimed at the promotion of musculoskeletal care, advocacy, and the integration of evidence-based practice in clinical settings. She is an author and national speaker on topics related to leadership, shared decision-making in osteoarthritis, optimization in arthroplasty, remote workforce, informatics, and health equity. Charla is board certified in orthopedic nursing and nursing informatics. Her mantra: Clinical-Critical Thinking!

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