Marilee Donovan, Ph.D., R.N., regional pain management coordinator for Kaiser Permanente Northwest, discusses the tools and techniques that Kaiser Permanente Northwest have implemented to help improve the communication and concepts involved in treating a chronic pain patient.
Tools and techniques can be used to make it easier to do the right thing. We use best practices, and they’re available online in our EMRs. To the extent possible, the medical record is linked to the Best Practice Resource and reflects what the physician is doing with the patient during that particular visit.
We also do everything possible to improve communications and be safe and accurate. We use audio-visuals to explain complex concepts. Over 80 percent of our patients have Internet access, so we put as much information as possible on our public Web site. Much of the health encyclopedia and some of the pain management information is available not only to members, but to anyone who accesses the Web site. About two years ago, we used KP HealthConnect®, Kaiser Permanente’s EHR that is an Epic™-based system. We incorporated two questionnaires that are extremely helpful. One is the Brief Pain Inventory, which is an evaluation of pain and interference with function. The data can be entered into the questionnaire and graphed over time — just as we graph blood pressure and other vital signs.
We identified early on that using a zero-to-10 pain scale resulted in some bizarre answers. Patients reported pain of 10, but they had to hurry back to work. Other patients grimaced in pain but reported a four. We even had patients who reported a 10,000 on a scale of one to 10. None of those answers promotes clear communication between the patient and provider. They also create problems in interpreting the data. Over the years, our medical assistants (MAs) worked with us to find ways to describe pain to the patient so the patient could understand it. The tool that we created is given to every patient we see in the pain clinic. It is posted in many primary care settings, frequently in the examination room. Although we haven’t had the time or resources to conduct statistics validation, patients have reported informally that they love it, and it’s very helpful. When the MAs give patients the pre-visit assessment, they find that patients don’t have as many questions. They’re able to complete the tool and we see a clear test/retest reliability.
There are also tools to make complex concepts easier to understand. We use the electronic image of eight-foot totem poles to illustrate the concept of pacing. We tell patients, “Do something! If you’re getting dinner ready, don’t do all the chopping and cooking and putting it on the table if it results in pain that’s an eight by the end of the preparation. Instead, do it in small increments. In other words, do a portion of the cooking and then sit down and make a phone call. Do another portion and then lay down for a few minutes.” The patient’s response is always, “I’ll never get anything done if I do it that way.” We approach that concern in many different ways, including the totem poles. We often use the totem poles to illustrate this because the totem poles were carved by a patient who was bedridden most of the day. In fact, he could only be out of bed for 15 minutes, five times per day. He carved two totem poles in two years. Through pacing, you can get much done in small increments.
We also use an electronic image of two brains — one with no pain, and a brain with chronic pain — to explain the concept of hyper-sensitization and central sensitization. These are newer concepts in clarifying why chronic pain is so difficult to understand. Both of these patients were in a research lab, and they’re both being subjected to the exact same electrical stimulus. The first patient has a small area of the brain that lights up in reaction to the stimulus. The second patient’s brain lights up in large, multiple areas — 10 to 100 times larger than in the first patient. Interestingly, both sides of the chronic pain patient’s brain lights up regardless of what finger is stimulated. This illustrates the concept of central sensitization. The patient’s brain responds in a magnified way to the pain stimulus they’re exposed to. By viewing electronic pictures of the brains, it is much easier to grasp this concept.
Source: Relieving the Costs and Consequences of Chronic Pain: A Best Practice Multimodal Approach, September 2008
Relieving the Costs and Consequences of Chronic Pain: A Best Practice Multimodal Approach
In this 35-page report, two industry experts describe patient-centric pain management tactics that engage the patient as an active partner and employ creative and alternative therapies and interventions.
Relieving the Costs and Consequences of Chronic Pain: A Best Practice Multimodal Approach is available from the Healthcare Intelligence Network for $107 by visiting our
Online Bookstore or by calling toll-free (888) 446-3530.
