By Jennifer Goldman, DO, MBA, FAAFP
“49-year-old male with Hypertension, Diabetes, and chronic kidney disease. Patient has been non-compliant with health recommendations and prescribed medications.”
Using the word “non-compliant” (“failing to act in accordance with a wish or command”) in a medical context sounds paternalistic and inappropriately simplifies the clinical situation. It seems like the medical community placing patients in labeled boxes rather than looking at the underlying reasons why someone doesn’t follow a treatment plan.
Keep in mind, for some patients, just making and keeping a doctor’s appointment presents a variety of challenges:
- Wait months for the visit
- Get time off from work
- Find childcare
- Find transportation
- Have money for the co-pay and prescription(s)
- Wait hours for the doctor
As a healthcare community, we must understand that visiting a doctor and following all post-visit instructions can be especially daunting for those facing daily life challenges. We have to help providers and care teams identify patients that require assistance, stop labeling them with loaded terms, and connect them with the help they need.
Social Determinants of Health
Electronic Health Record (EHR) systems have helped us build tools to identify those who may have a harder time keeping appointments or following a care plan. Known as the “Social Determinants of Health (SDoH),” it accounts for those who don’t have access to healthy, affordable food, stable housing, caregivers, transportation, and more. These challenges impact communities of color more than others, which has roots in structural and political determinants beyond the scope of this article. Nevertheless, it’s imperative for healthcare systems and providers to seek additional resources for those in need.
As a physician leader, I’ve worked with IT to make the EHR more relevant and easier for providers to navigate. Our collaboration has expanded the health maintenance section and clinical dashboards, ensuring our teams know where gaps exist, making wellness visits and advanced care planning conversations more intuitive and effective. We’ve elevated telehealth and the ambulatory tools we’ve included help our primary care group succeed in value-based care. The approach has been leveraged by others using our version of EPIC.
The Social Determinants of Health (SDoH) wheel in EPIC is where staff can document a patient’s struggles with food insecurity, housing, transportation, etc. This “problem list,” combined with the patient’s active, chronic conditions, helps coordinate care across the healthcare continuum and between systems, enabling any clinician to get a complete picture at a glance.
Taking it a step further, the Best Practice Advisory alerts providers in primary care when a patient screens positive for a Social Determinant of Health, automatically adding it as a diagnosis on the problem list and signaling the care team the individual needs assistance. We’ve also added reminders that trigger staff to re-evaluate these important measures of health outcomes at least annually.
Thinking Differently
Going back to the earlier example, imagine if that patient’s chart had a problem list that included: “Hypertension, Diabetes, kidney disease, food insecurity, housing insecurity, and caregiver fatigue.” Would care teams interact and communicate with that person differently? Would a surgeon view the scheduling of elective surgery and the post-op rehab/care the patient requires from a different perspective? Would it impact the team’s outreach after the visit? As importantly, would we be so quick to label patients as “non-compliant” if they aren’t able to follow all the instructions?
Having devoted my career to community medicine and as an advocate for the marginalized, my hope is that we can change our thinking regarding the often unfairly- labeled “non-compliant” patient and modernize our record-keeping processes. Within Memorial Healthcare System, we’ve already seen how the approach improves outcomes and makes healthcare more equitable.
Dr. Jennifer Goldman is a board-certified family physician and the chief of Memorial Primary Care for the Hollywood-based Memorial Healthcare System (www.mhs.net).
