National Ethics Teleconference

**Shared Medical Appointments: Ethical Concerns**

**October 25, 2005**

# INTRODUCTION

**Kenneth Berkowitz:**

Good day everyone. This is Ken Berkowitz. I am Chief of the Ethics
Consultation Service at the VHA National Center for Ethics in Health
Care and a physician at the VA NY Harbor Healthcare System. I am very
pleased to welcome you all to today\'s National Ethics Teleconference.
By sponsoring this series of calls, the Center provides an opportunity
for regular education and open discussion of ethical concerns relevant
to VHA. Each call features an educational presentation on an interesting
ethics topic followed by an open, moderated discussion of that topic.
After the discussion, we reserve the last few minutes of each call for
our \'from the field section\'. This will be your opportunity to speak
up and let us know what is on your mind regarding ethics related topics
other than the focus of today\'s call.

# 

# PRESENTATION

**Dr. Kenneth Berkowitz**:

Today's presentation is entitled *Shared Medical Appointments: Ethical
Concerns.* In our discussion, we will identify ethical concerns relating
to shared medical appointments and explore strategies to protect patient
privacy and confidentiality in shared medical appointments. We will also
discuss ethical concerns regarding informed consent for shared medical
appointments.

Joining me on today's call is:

**Bette Crigger**, PhD, Chief of the Ethics Communications Service,
National Center for Ethics in Health Care

**Michael Ford,** JD, also of the Ethics Communications Service,
National Center for Ethics in Health Care

and

**Mary Beth Foglia**, RN, MN, MA, Ethics Consultant and Evaluation
Specialist, National Center for Ethics in Health Care

Thank you all for being on the call today.

Let's begin our discussion with a brief description of shared medical
appointments. Michael, what are shared medical appointments?

**Mr. Michael Ford:**

Thank you, Ken. According to the American Academy of Family Physicians,
"a shared medical appointment, also known as a group visit, is when
multiple patients are seen as a group for follow-up or routine care."
"SMAs" have evolved as a way to provide care for patients who have
chronic health conditions that supplement the care participants receive
in traditional one-to-one medical appointments. SMAs are designed both
to provide clinical care and to help patients better manage chronic
illness. This model of care delivery has been implemented for a wide
range of conditions, including diabetes, hypertension, COPD, asthma,
hyperlipidemia, fibromyalgia, obesity, congestive heart failure, and
chronic pain. Although the SMA model has its roots in primary care,
shared appointments are also offered in the context of specialty care.
In theory the concept could be used with any group of patients sharing
similar medical conditions.

Typically, a shared medical appointment brings together anywhere from 10
to 20 patients with the same diagnosis, and/or a similar pattern of
(intensive) resource utilization, for sessions of one to two hours.
Under the leadership of a clinical team that includes the patient's
physician, a registered nurse, a medical assistant, and a behavioral
health specialist, sessions combine clinical evaluation, patient
education, and group discussion and problem solving. Patient evaluations
are conducted in the group setting or individually, as appropriate. Time
is set aside either at the beginning or end of the session to see those
patients who need or ask for a private examination. And, of course,
participation in SMAs is voluntary.

Group visits are not new in medicine---they've been used as a modality
of mental health care for many years, of course. But the current model
of SMAs grew out of an emphasis on disease management promoted by health
maintenance organizations like Kaiser Permanente and Group Health
Cooperative of Puget Sound for prevalent conditions other than mental
health. The goal is to provide timely access to care and clinical and
psychosocial support, as well as education, to improve patients' health
status and quality of life.

**Dr. Kenneth Berkowitz**:

Thank you Michael. Could you say a bit more about the role of the
clinical team in shared medical appointments?

**Mr. Michael Ford:**

Certainly. The team is a very important feature of the SMA model for
care delivery. In addition to a physician (primary care provider or
specialist), as I noted most teams consist of a registered nurse, a
medical assistant, and a behavioral health specialist. The nurse and
medical assistant take vital signs, assist the physician during any
physical examination, and help document the visit for each patient.

The behavioral health specialist is a key member of the team, acting not
only as a facilitator for the session, but also providing specific
behavioral interventions. For example, teaching behaviors that will help
patients manage their health status more effectively themselves.

Depending on the condition on which the SMA is focused, the team may
include other health care professionals as well---for example, a
nutritionist or podiatrist---who can counsel patients and/or provide
education on specific topics.

**Dr. Kenneth Berkowitz**:

Thanks, Michael.

Now that we have a general background on shared medical appointments,
let's discuss the rationale for shared medical appointments or SMAs as
we've been referring to them. Mary Beth, can you comment on this?

**Ms. Mary Beth Foglia:**

Sure, Ken. As a model for care delivery, SMAs are seen as offering
benefits at several levels: for patients, practitioners, and the health
care system. For patients, one of the most important benefits of SMAs is
to improve access to timely, appropriate care. This may be especially
significant for patients who are high utilizers of health care services
and patients with chronic illnesses that may benefit from a model of
care that emphasizes ease of access and early detection and treatment of
problems. In addition, SMAs may complement VHA's advance clinic access
model.

Although there are relatively few published studies to date, the
evidence we have indicates that SMAs can improve health outcomes for
patients. For example, Wagner and colleagues found that SMAs for
diabetic patients have been associated with lower serum HbA~1c~ levels.
However, an unpublished short-term (duration of 12 months or less) study
performed by Masley showed a more significant impact on health status
than longer term (duration of 18 to 24 months or longer) studies.

And improvements in health have varied for different patient
groups---for example, frail, high utilization elders appear not to
derive significant clinical benefit from participation in shared
appointments. The data suggests the importance of carefully tailoring
SMAs to specific patient populations and developing robust criteria for
patient selection. For example, in a paper published in 2004, Scott and
colleagues suggest that the SMA model is beneficial for "pre-frail high
usage older adults with limited functional impairments."

Shared medical appointments are also designed to improve patients'
coping skills and self-management relative to their chronic illness.
Group education, individual counseling, and peer support can all enhance
patients' ability to play an informed, active role in managing their
health. SMAs can also help meet patients' other psychosocial needs.
Scott and colleagues have shown that patients who participate in SMAs
are more satisfied with their care and report greater self-efficacy and
better quality of life.

**Dr. Kenneth Berkowitz:**

We can't talk about benefits without also thinking about risks or
burdens for patients. Can you comment on the potential downsides of SMAs
for patients Mary Beth?

**Ms. Mary Beth Foglia:**

Well Ken, one concern is that this model of health care delivery may not
be efficacious or desirous in all patient subgroups for example, in a
study by Wagner et al in 2001, frail older adults in a SMA had poorer
outcomes than those in traditional care. A second study by Coleman and
colleagues in 1999 found no difference in outcomes between fragile
patients enrolled in an SMA and those in traditional care. Hence,
fragile patients with significant functional impairments appear less
likely to benefit and may even be harmed by SMAs.

**Dr. Kenneth Berkowitz:**

You also mentioned benefits for health care providers and the health
care system. Please say more about these.

**Ms. Mary Beth Foglia:**

A key benefit for providers is that SMAs may help them "work smarter,
not harder." Shared appointments can allow providers to work more
efficiently with large panels of patients---they can provide routine
care to many patients in a single session, and reserve one-on-one
appointment times to address more complex needs with individual
patients. Professional expertise is a limited resource, and SMAs are one
way that providers can allocate that resource efficiently and
effectively. Scott et al report that, like patients, providers using the
SMA model report increased satisfaction than alternately with
traditional care delivery.

**Dr. Kenneth Berkowitz:**

It's important to recognize, though, that SMAs create very different
conditions of practice for health care professionals, and not all
providers are comfortable with this model of care delivery. Working with
many patients at once in a group setting can be challenging, and not all
providers will want to participate in SMAs or feel that they have the
skills to deliver care effectively in this way.

Mary Beth, what effects do SMAs have on the health care system?

**Ms. Mary Beth Foglia:**

The system benefits of shared medical appointments may be the ones
people actually think of first \-- reduced costs, increased efficiency,
and improved patient satisfaction.

But the picture is actually quite complex. Scott and colleagues found,
for example, that with older, chronically ill adults, overall health
care costs were about \$42 a month lower for patients who participated
in a group primary care model. Patients in the group visit cohort had
fewer hospitalizations and emergency room visits, but participating in
shared appointments had little or no effect on their use of outpatient,
pharmacy, or home health services or utilization of skilled nursing
facilities. Interestingly, these are the same patients who reported
better quality of life.

**Dr. Kenneth Berkowitz:**

It's also important to note that Scott's findings of the \$42 a month
decrease may or may not translate into similar savings in the VA system.

Let's move our discussion to ethical concerns related to shared medical
appointments. I'd like to focus our attention on four ethics areas \--
the implications of SMAs for patient-provider relationships, privacy,
confidentiality, and, finally, informed consent.

Bette, can you start us off? How do SMAs affect provider-patient
relationships?

**Dr. Bette Crigger:**

Well, Ken, shared appointments are clearly a departure from the
traditional dyadic relationship. Of course, as Michael noted, SMAs
aren't intended to replace one-to-one interactions between patients and
providers; they're intended to complement those interactions. But SMAs
do introduce some important differences. Patients who participate in
shared appointments get more time with their providers, in absolute
terms, but in the group setting, the individual relationship is
necessarily somewhat attenuated, if you'll let me put it that way. In an
SMA, the provider has fiduciary obligations to the group as a whole, as
well as to the individual members. So instead of being exclusively
focused on me and my individual needs, the way he or she would be in a
private visit, my provider is focused on the whole group---the needs I
share with all the other "me-s" in the room.

The fact that in an SMA patients interact with providers through a group
process also has implications for trust. Trust has always been one of
the foundations of the patient-clinician relationship, enabling patients
to speak freely without fear that what was said would be shared with
anyone else. But in a shared appointment, not only is the provider not
devoting his or her attention solely to my interests, I'm not sharing
information only with the provider. Everyone else in the group is part
of our interaction. My trust has to extend to my fellow patients (and
their companions, if someone accompanies them to the shared
appointment). By the same token, they also have to trust me.

**Dr. Kenneth Berkowitz:**

That brings us to very important questions of privacy and
confidentiality in shared medical appointments.

Patients willingly divulge personal and private information to
clinicians in a typical medical encounter because that information is
exchanged in an environment that minimizes the possibility that
non-interested third parties will overhear the conversation and it's
also divulged in the patient's best interest. The patient has the intent
to provide personal, private information only to the clinician, and the
clinician intends to maintain that privacy and use the information for
the good of the patient. Both have the expectation that the information
will be revealed, if at all, to only those individuals with a need to
know.

This expectation defines the term "confidentiality," which deals with
how, personally identifiable information is handled once the patient has
shared it with the clinician. Patients expect that their information
will be passed, as needed, to other health care professionals involved
in their diagnosis and treatment. And most patients expect that personal
information will be revealed to family members or significant others
only with their consent. In the typical medical setting private
conversations are not shared in any form with other persons, and
certainly not with other patients.

**Dr. Bette Crigger:**

Right. But there's also the dimension of physical privacy. Providers are
granted unprecedented access to patients' bodies, as well as to intimate
personal information. The traditional patient-provider encounter takes
place---or certainly *should* take place---in a private space, away from
the eyes of others. The SMA model doesn't necessarily offer the same
expectations for physical or bodily privacy.

When physical examinations are part of the shared appointment, they
should always be conducted away from the group, but vital signs, for
example, are often taken in front of the group. Most patients probably
aren't troubled by that kind of touching in a public context, but we
shouldn't assume that they are comfortable. It's important that
providers be alert to the sensibilities of participants---both with
respect to being touched in view of others, and with respect to being
observers when others are touched. And patients should be reminded to be
sensitive to one another's comfort levels too.

**Dr. Kenneth Berkowitz:**

Clearly, it's important that patients understand the differences between
SMAs and traditional appointments. So how should we think about informed
consent for shared appointments? Michael, would you comment on that?

**Mr. Michael Ford:**

I'd be happy to, Ken. There are two important points to remember. You've
just mentioned one of them, actually \-- that patients should give
consent to receive care through shared medical appointments. The other
is that patients have different responsibilities in SMAs than they do in
traditional one-to-one care delivery, and these should be addressed in
the consent conversation.

Although a shared medical appointment is not what we usually think of as
a treatment or a procedure, it is itself an intervention. It is also a
non-traditional model of care. The clinician should promote voluntary
decision making, and ensure that the patient knows that he or she is
free to choose either the traditional clinic visit or the SMA without
prejudice to future access to health care or benefits. Implied
consent---for example, deeming that the patient consented to a group
appointment merely because he or she attended---does not meet consent
criteria.

Prior to their first SMA, patients should be given information that
covers the major elements of informed consent set out in VHA informed
consent policy (Handbook 1004.1, at paragraph 7). Patients should be
given information about what SMAs are and why the clinician thinks this
model of care may be of benefit to the patient given his/her medical
circumstances. Patients should be told what to expect during a shared
appointment---for example, whether vital signs will be taken in public
or private, whether and how a physical examination will be performed, or
that patients can arrange for individual appointments between or
following the group visit to address concerns that arise during the
session that they aren't comfortable bringing up in front of others.
Potential risks, such as increased risk that personal health information
will be disclosed outside the health care relationship or possible
discomfort sharing personal health information in front of the group,
should also be identified.

And patients should explicitly be given the opportunity to return to a
traditional clinic appointment at any time the group model proves to be
unsuitable for them.

Shared medical appointments provide ongoing monitoring and follow-up
care. They are delivered as a series of interventions -- similar to,
say, dialysis. Thus it isn't necessary to obtain consent for
participation in an SMA at every single appointment. However, as for any
treatment or procedure, the informed consent discussion should be
repeated and documented in the medical record if (1) there is a
significant deviation from the treatment plan to which the patient
originally consented; or (2) there is a change in the patient's
condition or diagnosis that would reasonably be expected to alter the
original informed consent.

**Dr. Kenneth Berkowitz**:

Is signature consent required for SMAs?

**Mr. Michael Ford:**

Not necessarily. Signature consent is obligatory only if shared medial
appointments meet any of the circumstances detailed in VHA Handbook
1004.1. Clinicians should ask whether participation in SMAs could
reasonably be expected to produce significant discomfort (physical or
psychosocial) or significant risk of complication or morbidity. If the
answer to any one of these questions is yes, then signature consent is
required.

Currently, the only patient management model for which signature consent
may be required is telemedicine when the method used to deliver the
care, i.e., telemedicine and/or telehealth, can be reasonably expected
to produce significant discomfort to the patient or can reasonably be
considered to have a significant risk of complication or morbidity, then
the patient or surrogate must sign an authorized VA consent form. In
addition, signature consent is required for the use of home telehealth.

A few risks normally associated with telemedicine are also relevant to
SMAs---as you mentioned, there is a risk that information relayed to the
clinician can be given to someone else without the knowledge or consent
of the patient. This can occur if third parties, such as family members
or patient companions, who are not actually part of the group, are
present during the shared appointment, or if another patient breaches
the confidentiality of the group. There is also a risk that the
clinician will not receive complete and candid information from the
patient, because the patient does not feel comfortable discussing an
issue in the group or is unable to speak because another patient is
monopolizing the discussion. The clinician should consider these risks,
and take steps to decrease the likelihood they will occur.

If the clinician believes that the risk is significant enough, just like
in telemedicine, signature consent should be obtained for SMAs.

**Dr. Kenneth Berkowitz:**

To sum that up, signature consent would be required just like all other
things in VA if the shared medical appointment could reasonably be
expected to produce significant discomfort or risk of complication or
some other morbidity. Otherwise, I think a consent discussion is
documented and would be fine without the signature consent.

You also mentioned that patients have different responsibilities in
shared medical appointments than they do in traditional
patient-clinician interactions. What are those responsibilities?

**Mr. Michel Ford:**

Well, we've touched on them already. These are the responsibilities
patients have to fellow members of the group: to protect the
confidentiality of one another's personal information, to be sensitive
to other patients' comfort level with self-disclosure and/or bodily
privacy, and to respect the "rules of trust" for the group
process---such as not interrupting one another, being respectful of one
another in speech, etc.

I should add that these are also responsibilities for anyone who
accompanies a patient to a shared medical appointment.

**Dr. Kenneth Berkowitz**:

I'd like to stress a point you and Bette both touched on. In a SMA, the
patient is expected to openly discuss medical problems and concerns in
the presence of third parties---i.e., the other members of the group.
Further, those third parties are given permission to question and
respond to the patient. The patient is asked to trust strangers to keep
secrets. And the practitioner is, in essence, put in the position of
vouching for the trustworthiness of the patients in the group. If the
trust is violated by one of the other patients, the practitioner's
credibility and the groups' credibility can be harmed.

This argues for asking patients to sign a confidentiality agreement
before they participate in shared medical appointments, to underscore
the responsibility they have toward their peers.

But Mary Beth, are there other ethical issues we should consider with
respect to shared medical appointments.

**Ms. Mary Beth Foglia:**

Yes, Ken, there are. It is vital that the clinician carefully identify
the patients who will participate in a SMA. As we've mentioned, SMAs
don't offer benefit for all patients. Criteria for selecting patients
for participation in SMAs should be based not only on a common
diagnosis, ability to benefit, but also on an assessment of the
patient's capacity to maintain confidences and contribute to the success
of a group session.

Further, in some SMA models, family members, significant others, or
those providing in-home assistance are encouraged to attend the shared
appointment with the patient. This is because of the importance of the
social network in helping patients who have chronic illness. That being
said, the literature really doesn't address what responsibilities these
individuals have, if any---for example, to sign a confidentiality
agreement before attending. They aren't bound by the expectations of an
existing patient-provider relationship.

That being said however, practitioners should inform significant others
of their obligations in respect to privacy and confidentiality similar
as Michael has already alluded to, to the responsibility that a patient
within a group has to his or her fellow members. If significant others
will be present, other participants should be informed ahead of time
that someone will be present who is neither a patient nor health care
professional. Patients should be provided the opportunity to opt out in
advance.

Practitioners might consider whether non-patients will be included in
group discussions. Ultimately the goal is to provide an atmosphere that
is unencumbered and an open exchange of information with the patient,
and necessary third parties.

# Dr. Kenneth Berkowitz: 

Are there additional considerations that we should mention?

**Ms. Mary Beth Foglia:**

Patients in a group clinic will meet and discuss their diagnosis,
treatment, and follow up. It will quickly become apparent to these
patients that although they share the same diagnosis and may be in the
same age group, medications may vary, as will treatment plans.
Clinicians should make clear to participating patients that each case is
unique, with different variables, such as family history, preexisting
conditions, comorbidities, etc. Medications and treatment plans are
chosen by the clinician based on his or her best medical judgment, given
the specifics of each individual case.

# 

# Dr. Kenneth Berkowitz:

# 

Yes, that is very important.

Summing up the take-home points, shared medical appointments obviously
have tremendous potential and are not without certain concerns. There is
potential for increased efficiency and patient as well as provider
satisfaction, but not without risk of altering our current expectations
regarding privacy, confidentiality and the provider-patient
relationship. At each shared medical appointment, the clinician should
remind participants of the ground rules, confidentiality, obligations
and that participating is voluntary. SMAs should be implemented with
these considerations in mind.

Providers should always be sensitive to cues from their patients
regarding this new delivery model. They should also remain attentive to
reports in the literature regarding shared medical appointments as a
care delivery model and modify their practices as needed in response to
what they learn.

Well, that sums up our presentation on ethical concerns related to
shared medical appointments. Thank you all for the discussion. Now we'll
open the discussion to our listeners and those in the field. Tell us
about your experiences with shared medical appointments, how you have
implemented them and if you've faced any of these ethics concerns that
we've referred to, and if so, how has that played out.

# DISCUSSION

#  San Juan:

We are in the process of implementing SMAs specifically with diabetics
and hypertensive patients. I have a question about determining the
co-payment and travel benefits. Are we supposed to charge for a
co-payment for this type of appointment or are we going to be able to
pay for their travel?

**Dr. Kenneth Berkowitz:**

Would anyone on the call like to try to answer this question? I think
that is beyond the scope of the ethics nature of this call. I would not
be comfortable giving out that kind of that information because I do not
know the answer to that question.

**San Juan:**

Okay.

**Caller, Loma Linda VAMC:**

I can try to answer this question. Here's what our decision was on it.
It depends on what the nature of the group medical visit is. If you are
providing medical care, it is a medical appointment. One of the concepts
is that you are providing medical care one-on-one that just happens to
be in a group setting with onlookers. With that in mind, it is a regular
appointment in a group setting so co-pay and travel pay all goes with
it.

**San Juan:**

Thank you.

**Dr. Kenneth Berkowitz:**

I think that particular discussion isn't totally clear. Again, I don't
think it is really an ethics related question but I do hope that someone
in medical administration or some other group can clarify that for the
field because consistency across the system is something that we would
think is very important to assure.

**Dr. Mary Voss, Hampton VAMC:**

I've run a group medical clinic where I provide the sole primary care
for homeless veterans for the past 18 months. Everything you've said is
right on target. We actually have them sign a release every week that
they come, just to remind them what their responsibilities are and we
give them a verbal counseling about that before we start. I find 90% of
them love it. The 10% who do not like it, it is very important that you
not hold them hostage and that you immediately provide another venue for
them to get the kind of care they need. It has been a very popular and
very efficient way for us to provide care.

**Dr. Kenneth Berkowitz:**

Thank you Dr. Voss. Just one question, you said that that is the sole
way they get their primary care. Does it augment other forms of care?

**Dr. Mary Voss, Hampton VAMC:**

Well this is a homeless population and I am their primary care provider.
I run this clinic twice a week and if they elect to receive their care
this way, that's the way they receive their care. At any point that they
have something personal that needs to be discussed, if we need to do any
type of exam that requires more than a forearm being exposed, that's
done after clinic in a private setting.

**Mary Beth Foglia:**

Dr. Voss could elaborate more about your comment that generally your
patients are very satisfied. What are they satisfied with or what have
they talked to you about? And for those that are not satisfied, what are
some of their concerns?

**Dr. Mary Voss, Hampton VAMC:**

Let me start with those that aren't satisfied because that's important.
One, if you're a paranoid schizophrenic, you're not satisfied. It's a
very, very stressful place for you to receive care. Those patients tend
not to be satisfied and I fully understand that. If you require
narcotics, and remember that I'm dealing with a homeless population,
that if a question of narcotics is raised, we do not provide that type
of care. We would immediately get them a primary care provider and an
appointment within a week for them to be seen. If you've never done
this, you just cannot imagine what it's like to sit around a table with
15 people and start talking to people are blood pressure for example,
and how important it is to control their blood pressure and then start
talking to them about preventive medicines and what we do and how proud
we are of the VA, that we care so much about preventive medicine and
that it is important for them to get PSAs, colonoscopies, etc. To spend
a little bit of time talking with each person, going through what their
labs tests are and say to them, you know you have a wonderful LDL, your
LDL is 56. Obviously this has nothing to do with the way they eat and it
has everything to do with their parents and their heritage, but they
like to hear good things about themselves like all the rest of us. I
have been involved in situations in group think where everybody wants
shoe inserts or a multivitamin. But one time I was sitting around a
group and the majority of them were greater than 50 years old and when
we were talking about screening for colonoscopy, everybody wanted to be
screened. They realized this was important. I guess that is what they
are satisfied with.

**Dr. Kenneth Berkowitz:**

Dr. Voss, how do you document the appointments? Is it one note that is
pasted into everyone's chart, one note written for everyone's chart or
is it tailored?

**Dr. Mary Voss, Hampton VAMC:**

I work closely with my HCHV (Healthcare for Homeless Vets) group here.
We just got an excellent rating because of this. We did not stop and
bring in a scribe to do it. After I finish with the 1 ½ to 2 hour group
clinics, I sit down and write notes on everyone and these are individual
notes that talk strictly about what I talked to that individual patient
about. I don't do any cut and paste and it is exactly how I document my
notes for my regular primary care patients.

Now the other thing I will tell you is that my social worker runs an
hour clinic before I get there and she does a lot a group education
about hepatitis C, brings in the HIV nurses or dental care and I think
her notes may easily be a little bit more cut and paste.

**Dr. Kenneth Berkowitz:**

The only reason I raised the question is that I don't know much about
this area. I was wondering if there was a single group note that was
relatively specific to the group process but put in multiple people's
chart with identifiable information about one patient being put in
another chart.

**Dr. Mary Voss, Hampton VAMC:**

No because I practice primary care. I think if you were doing congestive
heart failure or maybe even if diabetes, that might be true, but not
primary care.

**Janet Carroll, Kansas City VAMC:**

I'm the Group Medical Coordinator in Kansas City. We're coming up on
10,000 visits with our group medical appointments. We started about 3
years ago. We widely use personalized templates to do our documentation
and it does pull the objects or specific data into the charts. Most of
our groups are disease specific but we have found that to be very
successful. We do use a scribe although I have heard around the country
that people that are starting to use scribes are using LVNs or med techs
to do this. In all of our groups we are either using a person who is a
clinician in the group, be it a registered nurse, registered dietician,
or that sort of person who knows the patient well and works side by side
with the doctor on a regular basis. This has really speeded up our
process. Clinicians are probably spending less than 30 minutes after
each group finalizing and going in and tweaking the notes to get them
finished.

**Dr. Kenneth Berkowitz:**

Thank you for that helpful information. So personalized templates are
something that you work with your local IRM people to develop?

**Janet Carroll, Kansas City VAMC:\
**

Actually we only have two clinicians that have them actually tied to a
title, where they're an official template in the record. What we
normally do is, in CPRS we use the 'my template' option where clinicians
can go in and develop their own and actually tweak them as they get
better and better at their process in the groups and fix them.
Eventually they may want to move to a shared template that would be
universal throughout the system at each facility. By and large we keep
ours pretty much tied to just the clinician. That way they can be
changed over time if state of the art changes or something else.

**Dr. Kenneth Berkowitz:**

Thank you again for that helpful information from Kansas City.

**Caller, Loma Linda VAMC:**

We actually do a mixture. We have several group visits going on, some
with templates. Our lipid clinic, actually run by a clinical pharmacist,
is templated with personalized information entered but it has a backbone
template. Our diabetic group visit has a backbone template which is
individualized afterwards for patients. Our heart failure clinic and our
primary care group visits tend to be more individualized, free standing
notes. One other thing I wanted to bring up here is enormous group
support. Our heart failure clinic has just been amazing particularly
when the patients are on many medications and their comments have been,
"wow I thought I was the only one taking so many meds" when they hear
the stories and the support when AICDs need to be placed and another
patient has already had one and walks the patient through the process.
It has been very interesting to see how the patient themselves share
their stories and encourage compliance into the medical program with
other patients.

**Dr. Kenneth Berkowitz:**

That is a wonderful story. Thank you.

**Kim Schaub, Cleveland VAMC:**

I have a question. We're running group clinics for heart failure
patients and as a psychologist, typically patient communication to me is
confidential. However, during group oftentimes topics come up that need
to be relayed to medical providers who are seeing patients individually.
So patients are participating in group and are being pulled from group
individually for appointments. I'd like to know what the other group
members think about how that information should be shared and in what
contexts.

**Dr. Kenneth Berkowitz:**

Can you give me more specifics?

**Kim Schaub, Cleveland VAMC:**

Sure. For example, I run the education piece in our heart failure group.
Oftentimes, some of the things that may come up are about PTSD or sexual
dysfunction that clearly needs to be shared with a medical provider but
that often patients share in group and later have not been shared during
their individualized medical appointment.

**Dr. Kenneth Berkowitz:**

And do you ask patients when that type of information comes up, do you
point out to them that that might be something that they would want to
share with their provider themselves?

**Kim Schaub, Cleveland VAMC:**

Absolutely. All of our patients fill out a form that documents what
heart failure symptoms they've had in the last few weeks as well as a
section that includes any questions or concerns. I frequently encourage
patients to talk with their medical providers because medications can be
adjusted to address issues like sexual dysfunction. But sometimes I find
that communication doesn't take place.

**Dr. Kenneth Berkowitz:**

Are the patients asked why that didn't take place? Or perhaps ask them
if it would be okay if you did share it. I don't think that there is any
specific reason in the interest of the patient, in the concept of a care
team, that you wouldn't share that information.

**Kim Schaub, Cleveland VAMC:**

Thank you. That is helpful. I just wasn't sure about confidentiality.
Certainly sometimes the application in the group appointment is a bit
different than when a see people individually.

**Dr. Kenneth Berkowitz:**

I mean I certainly would let patients know how important you think it is
and encourage them to talk about it themselves and then maybe offer to
facilitate that for them if that were something they were interested in
further but didn't feel that they were comfortable bring forward.

**Kim Schaub, Cleveland VAMC:**

Thank you. I appreciate the input.

**Dr. Kenneth Berkowitz:**

Does anyone else have any comments on what I just mentioned? That was
just my opinion so I'm not sure if other people would agree with that.

**Janet Carroll, Kansas City VAMC:\
**

We certainly at Kansas City have seen those types of issues come up. I
think those suggestions were right in line with what we have done. Most
of the time if a patient has a concern like that, we always send them
out with something in their hands. During the session they always have a
pen so we encourage them to write these concerns down and show them to
their providers. Many times they'll just forget.

**Dr. Kenneth Berkowitz:**

So it sounds to me that the practice of shared medical appointments is
quite varied. What I just heard described was a range of things from all
the primary care being delivered in this method to it being described as
an education session and then having participants taken out one by one
to have individual appointments concurrently with their providers. Is my
impression correct in that what we're calling shared medical
appointments really is sort of a broad range of activities?

**Dr. Karen Woolfall-Quinn, Providence VAMC:**

I have a question. We were thinking about using the shared medical
appointment for new patients. We were hoping somehow to tie it to the
new patient orientation and then after that do sort of a brief exam and
then book them into an appropriate time interval for a new patient
assessment down the road. We think that maybe it would improve our no
show rates. I didn't know if anybody out there was using the shared
medical appointment in this way?

**Janet Carroll, Kansas City VAMC:\
**

When I first started doing shared medical appointments here in 2003, I
was put in touch with some folks at Bay Pines in Florida. They not only
had been doing this through their social work service getting it started
but they also have a very nice PowerPoint that shows their process. So
you may want to get in contact with someone in Social Work Service in
Bay Pines.

**Keri Justice, Bay Pines**

We have been utilizing a group medical appointment for new patient
orientation. And you're right, it does decrease the no show rate. We
also have a video or DVD that we made. We found that we were saying the
same things over and over to the patients, so we made a presentation for
them as far as how to orient them to the VA. We show it at all the CBOCs
at Bay Pines. I believe a few other places are using it as well.

**Caller:**

Yes, actually in VISN 1 they are developing an entire VISN 1 DVD to
cover all kinds of common areas that they discuss in new patient
orientation. You're ahead of us. We would like to see your DVD actually.

**Keri Justice, Bay Pines**

We would be glad to provide you with one. Ours is pharmacy based and
most of the information on the DVD and orientation program is about
pharmacy. We're finding that in the state of Florida that most patients
that are enrolling now into the VA healthcare system are coming for
assistance with their medications so we found that if we clarify the
specifics of the VA policies and procedures up front, it helps with
education and it also clarifies to the patients exactly what benefits
are available to them.

**Dr. Kenneth Berkowitz:\
**

Do you in Bay Pines or do you plan to in VISN 1 include some of the
ethics related concerns that we've just mentioned in your training,
particularly related to consent, voluntariness, privacy, confidentially,
things like that?

**Keri Justice, Bay Pines**

We have a disclaimer that we vocally give before each group session that
we perform. We've found that the patients are not shy at all about
telling you what medications or disease states they have, but we provide
one-on-one counseling after each DIGMA or orientation class so that if a
patient has a specific question about the medication he's taking then he
can approach us one-on-one.

**Dr. Kenneth Berkowitz:\
**

Great and I think you mentioned DIGMA which are drop-in group medical
appointments which I think are a little bit different than shared
medical appointments in one sense that the group may not be as
consistently made up of the same people over time which may raise
different concerns about trust or confidentiality as the group
participants vary. But I would encourage you all to think about the
ethics related things that we've mentioned and try to make sure that
they are specifically discussed with patients. I think sometimes just
expecting that patients understand these things is different than
overtly discussing them.

# FROM THE FIELD

**Dr. Kenneth Berkowitz:**

I do want to take our last few minutes as we always do for our "From the
Field" segment, where we take comments from our listeners on ethics
topics [not]{.underline} related to today's call. Please remember, no
specific consultation requests in this open format, but I invite you now
to make your comments on other ethics-related topics, or to continue our
discussion on shared medical appointments.

**Dr. Maher Roman, Loma Linda VAMC:**

Thank you for putting together this teleconference. It was a great
discussion. Thank you.

I am leaving with an impression. If I am to start a shared medical
appointment, whether DIGMA or otherwise, it seems like a disclaimer that
covers different areas of freedom of choice, voluntary participation and
confidentiality and so on because over the ground the rules, that would
be just fit enough compared to signature consent every time.

**Dr. Kenneth Berkowitz:**

And again that really depends on what you view the specific risks. I
think someone mentioned that they don't discuss narcotic use. I can
assume that that's because there might be some feeling that that would
put that patient especially the homeless population at some risk to know
that they had narcotics. I think you really need to assess your own
group and environment and the things you are going to be talking about
and make sure that rather than just a disclaimer, that this really is a
conversation and that patients understand the voluntary nature of what
they are getting into and what it is and the benefits or perhaps the
burdens they might face from group medical appointments.

**CONCLUSION**

**Kenneth Berkowitz:**

Well, as usual, we did not expect to conclude this discussion in the
time allotted, and unfortunately we are out of time for today\'s
discussion. We will post on our Web site a very detailed summary of each
National Ethics Teleconference. So please visit our Web site to review
today\'s discussion. We will be sending a follow up email for this call
that will include the call summary and the CME credits.

We would like to thank everyone who has worked hard on the development,
planning, and implementation of this call. It is never a trivial task
and I appreciate everyone\'s efforts, especially Bette Crigger, Michael
Ford, Mary Beth Foglia, Nichelle Cherry, and other members of the Ethics
Center and EES staff who support these calls.

-   Let me remind you our next NET call will be on Wednesday, November
    30 from 1:00 -- 2:00 pm EST. Please look to the Web site at
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Thank you and have a great day!

References

American Academy of Family Physicians. Shared Medical Appointments.
<http://www.aafp.org/x14713.xml>

Coleman E et al. Chronic care clinics: A randomized control trial of a
new model of primary care for frail older adults. J Am Geriatr Soc,
1999; 47:775-783.

Masley S, Sokoloff and Hawes, C. Planning group visits for high-risk
patients. <http://www.aafp.org/fpm/FPMprinter/20000600/33plan.html>
Accessed October 11, 2005.

Scott JC et al. Effectiveness of a group outpatient visit model for
chronically ill older health maintenance organization members: A 2-year
randomized trial of the cooperative health clinic. J Am Geriatr Soc,
2004; 52(9):1463-70.

Vantage Point, June 2005, Shared Medical Appointments. Department of
Veterans Affairs Medical Center Chillicothe, Ohio.
<http://www.chillicothe.med.va.gov/StationNewsletter/jun_05/new1.htm>,
Accessed October 11, 2005

Wagner et al. Chronic Care Clinics for Diabetes in Primary Care.
Diabetes Care, 2001; 25(4):695-700.