It goes without saying that people – you and I – need to be actively involved (Ok…I’ll say it…engaged) in our own health. After all it is our health we are talking about. But I have long suspected that there may be motives behind all this talk about patient engagement that go beyond the simple argument that it’s “the right thing for patients to do.” Motives which I believe constitute a fundamental “unspoken truth” about why policy makers, payers, vendors and at least a few providers are so passionate about patient engagement.
Truths that have remained unspoken until now that is.
Sam VanNorman, director of business intelligence, from Park Nicollet, shared this unspoken truth about patient engagement at a recent panel discussion on Pioneer ACOs. In an online Forbes article, Dave Chase quotes VanNorman as saying:
“We have to incorporate the most important member of the care team — the patient. With our finite resources, we must figure out ways to offload what we have thought as tasks that needed to be done by our staff. In most cases, it’s the patient who can do it more effectively. In the process, the patient is more engaged and it’s more efficient for everyone.”
The heretofore unspoken truth to which I refer is that for some, patient engagement is not about getting patients to do what in their own best interest….but rather doing what’s in the self interest of policy makers, payers and perhaps providers.
I am not convinced however that most clinicians think this way.
Call me naïve, but I thought patients were the most important member of the care team because of what they can do for themselves, e.g., share information with the clinician to improve diagnosis and treatment, self-care management and so on. Patient engagement to those thinking this way is about inviting the patient into their care and the care process to advance their activation, quality of care, clinical outcomes and the patient experience. This approach begins with the patient. As such, this approach is patient-centered in that the care delivery process begins by the clinician eliciting the patient’s knowledge and perspectives of their health.
VanNorman seems to believe that patients are the most important member of the care team because of what they can do for the provider and payer, e.g., provide a more efficient, cheaper (free is pretty cheap) labor pool to which clinicians can outsource work they don’t want to do, don’t have time to do or don’t get paid to do. Patient engagement for those that think this way begins with policy makers, payers and administrators looking for ways of offloading tasks (of their choosing) to the patient (e.g., lowest pay grade), irrespective of the patient’s willingness, knowledge or ability to comply. This approach could rightly be called bureaucrat-directed care which is antithetical to patient-centered care and the principle of PCMH and ACO models as well as the Triple Aims.
Don’t Conflate Outsourcing With Patient Engagement – They Are Not The Same
I complete understand VanNorman’s logic and agree with the notion of putting patients to work – they are a vastly underutilized resource in so many ways. What I disagree with is conflating with “outsourcing” with patient-engagement. I feel that the definition of patient engagement I share with most clinicians carries with it a kind of moral authority to do what’s right for the patient. VanNorman’s attempts to cloak “physician workload outsourcing” as patient engagement feels manipulative, self-serving and destined to disengage patients instead.
Furthermore I fundamentally disagree with anyone trying to force patients to do anything without the benefit of first:
- Explaining to patients what you want them to do
- Why you are asking patients to do something
- Asking for their feedback on what you want them to do
- Teaching patients how to do what it is you are asking them to do
- Providing ongoing support to patients regarding what you asked them to do
The Take Away?
Maybe one of the real reasons patient engagement is so hard is that some of us are approaching it from a patient-centered perspective…while others are approaching it from VanNorman’s beauracrat-directed perspective.
This in turn translates into different motives, messages to patients, different measures of patient engagement and so on.
This may also explain why some of my peers in HIMMS and NeHC get so mad at me when I say that patient engagement is a physician-patient communication challenge and not an HIT challenge.
That’s my opinion…what’s yours?
Note: Later this Summer, Mind the Gap will be announcing the Adopt One! Challenge TM. for physicians and their care teams. The goal of the challenge is to encourage physicians and their care teams to adopt one new patient-centered communication skill within 2014.
Sign-up to learn more about this one-of-a-kind “Challenge”:
Mind The Gap 
“We need to get patients engaged in their health….” as if you pocked me up wandering in a fugue state, and carried me to your office. Um… who scheduled the appointment?!? Assuming I’m “not engaged” in my health is a sublte way of saying, “it’s the patient’s fault”. Yet, on the other hand, if a patient *does* show up, fully “engaged” in their health, with charts amd diaries, then the doctor is INTIMIDATED, and you get labled a “problem patient” and malingerer, sick with “Googlitis” (where you only think you’re sick because you read it on The Internet).
The truth is, patient “engagement” is doctor-code for “not my problem.” We know this by doctors refusal to define what “engagement” means, and punishing all attempts to become “engaged” at the same time. Assuming I’m not engaged from the word go means that the doctor also assumes 1) I don’t care about my health (again, who made the appointment? I don’t visit y’all for fun…), 2) I’m not doing enough to take care of myself (because the only reason people get sick is by not taking care of themselves… there’s no such thing as contageous diseases, inherited diseases, and unavoidable accidents), and, probably the worst assumption that this creates, 3) It’s my fault that I’m sick, because I wasn’t “engaged” enough in my health.
Patient engagement isn’t the problem. Studies show that an overwhelming majority of patients want MORE information from their doctors, and that they research on the Internet because they don’t get enough time with their doctors. Patients are desperate to become engaged, but are often stymied by doctors themselves! This blog has written extensively on how much doctors overestimate what they’ve told their patients. There’s a whole series of books based on, “What Your Doctor Doesn’t Tell You About (fill in the disease here).” There’s a booming health book industry that generates millions every year, and so doctors conclude we’re not “engaged” enough?!? Give me a break. That doesn’t pass the giggle test!!
Patient engagement isn’t hard! And what’s defined in the bullet points isn’t patient engagement…. it’s patient OBEDIANCE. Look at those bullet points again. They’re patronizing. They assume the patient doesn’t understand and is non-compliant due to ignorance. But that’s not why non-compliance happens. And non-compliance and non-engagement are two entirely different things.
When was the last time you left your doctor’s office with anything more than a prescription? Were you offered any print-outs explaining your diagnosis? Were you given book reccomendations? How about a list of support groups? Were you given the URLs to any web sites dedicated to your disease? Were you shown any medical news outlets for the latest and greatest information on your condition? Were you given the names of charities or foundations that could help you with your medical needs outside the doctor’s visits?
No? And yet all these things exist. Many of them are PATIENT-CREATED because otherwise, they wouldn’t exist. And you assume we’re not engaged in our health?!? You have no idea how much work I’ve put in to understanding my disease and helping others understand too. We patients have picked up the slack that the medical industry left. And there’s a LOT of slack, let me tell you. Websites like WEGOHealth and Livestrong wouldn’t be possible if patient’s weren’t engaged in their health. Hell, just look at the Doctor Oz show!
The problem is not a lack of patient engagement. It’s a lack of DOCTOR engagement. Lack of patient engagement is a MYTH and is a smoke-screen for Blame The Patient.
I agree Stephen. Over and over I notice that core concepts such as “patient engagement” are misunderstood or misused, leading to inconsistent – or even detrimental – behaviors and outcomes.
“Patient engagement” in terms of the “new” healthcare standard is engaging your patients in order for them to be willing and interested to reciprocate in like so that ultimately they will be willing to foot more and more of the healthcare bill. The political elite use this euphemism because there is no other way to make the reality of diminished financial resources more savory to an aging population.
Excellent post. As a patient/parent working closely with health care to improve care for all, I’ve abandoned the phrase “patient engagement” and instead use “patient-professional partnership” for exactly this observation. Clearly, what we are striving for is a new way of working together and relating to each other that will result in new, preferred resources and better health, not just cheaper care. While health care continues to see themselves as the ones doing the “activating,” patient communities are finding novel and effective ways to organize themselves, conduct research, and create partnerships outside of the health care establishment. Maybe its already time to start talking about “professional engagement” in these contexts?
The sentence that stands out most strongly to me here is: “With our finite resources, we must figure out ways to offload what we have thought as tasks that needed to be done by our staff.” Offloading tasks??? To someone who is most likely entering the healthcare environment due to illness or injury and already in pain or feeling sub par? Seriously?
I enter each appointment with my family practice doc with a written list of the top 3-4 issues (more than that and I need a second appt) knowing that the very nature of his business constrains him to spending no more than 7 minutes with me. It’s frustrating for both of us, neither leaves feeling as if this was a quality encounter, and yet I would hazard to say that I have one of the best partnerships with my doctor that exists. The business culture of healthcare as it exists today–overwhelming paperwork, no methodology to reimburse physicians for email or Skype consults, and no DRG that allows a doctor to bill for simply getting to know the patient and her concerns (aside from the newly mandated annual visit) sets the stage for assembly line healthcare. Can we not work to repair this broken system, rather than assign “tasks” to those who enter it seeking aid?
I agree that much of what exists in terms of the current knowledge base is there due to “engaged” patients, and thank the Creator that today’s patients do not hold my Mother’s generation’s reluctance to question, nor their extreme veneration for the white coat. (She was known to call me, long distance, to ask what “the little pink pill that the doctor prescribed today does. I didn’t want to ask the doctor, because I didn’t want to bother him!”) I am thankful for this shift in attitude and grassroots knowledge, and take advantage of it almost daily–I am most definitely an “engaged patient”. What I do not want to be is an “indentured” patient. I do not want to assume menial “tasks”, I object to healthcare bureaucrats assuming that their time is more valuable than mine, and that it is therefore appropriate to “offload” items that their overworked staff cannot find time to fit into the day. For the record, I also avoid the self-checkout lanes at the super-market.
Let’s remember that patient engagement is a definable quality metric and NOT a means to use the sick and injured as a free workforce!