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Ann Intern Med. 2019 May 7;170(9_Supplement):S70-S78. doi: 10.7326/M18-2227.

Workflow Requirements for Cost-of-Care Conversations in Outpatient Settings Providing Oncology or Primary Care: A Qualitative, Human-Centered Design Study.

Author information

Kaiser Permanente Washington Health Research Institute, Seattle, Washington (N.B.H., L.T., C.L., C.W., A.S.).
Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon (M.P.B., J.L.S., S.M.H.).



Patients prefer to discuss costs in the clinical setting, but physicians and teams may be unprepared to incorporate cost discussions into existing workflows.


To understand and improve clinical workflows related to cost-of-care conversations.


Qualitative human-centered design study.


2 integrated health systems in the U.S. Pacific Northwest: a system-wide oncology service line and a system-wide primary care service line.


Clinicians, clinical team members, operations staff, and patients.


Ethnographic observations were made at the integrated health systems, assessing barriers to and facilitators of discussing costs with patients. Three unique patient experiences of having financial concerns addressed in the clinic were designed. These experiences were refined after in-person interviews with patients (n = 20). Data were synthesized into a set of clinical workflow requirements.


Most patient cost concerns take 1 of 3 pathways: informing clinical care decision making, planning and budgeting concerns, and addressing immediate financial hardship. Workflow requirements include organizational recognition of the need for clinic-based cost-of-care conversations; access to cost and health plan benefit data to support each conversation pathway; clear team member roles and responsibilities for addressing cost-of-care concerns; a patient experience where cost questions are normal and each patient's preferences and privacy are respected; patients know who to go to with cost questions; patients' concerns are documented to minimize repetition to multiple team members; and patients learn their expected out-of-pocket costs before treatment begins.


Results may have limited generalizability to other health care settings, and the study did not test the effectiveness of the workflows developed.


Clinic-based workflows for cost-of-care conversations that optimize patients' care experience require organizational commitment to addressing cost concerns, clear roles and responsibilities, appropriate and complete data access, and a team-based approach.

Primary Funding Source:

Robert Wood Johnson Foundation.


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