Thoughts On Patient Engagement, Patient-Centeredness and Communication-Centered Medical Records

Sometimes I come across a post that I absolutely must share… such is the case with this re-print of a post by Rob Lamberts, MD, a primary care physician practicing “somewhere in the southeastern United States.” He blogs regularly at More Musings (of a Distractible Kind), where this post first appeared.

“Patient engagement.”

What is “Patient Engagement?”  It sounds like a season of “The Bachelor” where a doctor dates hot patients.  It wouldn’t surprise me if it was. After all, patient engagement is hot; it’s the new buzz phrase for health wonks.  There was even an entire day at the recent HIMSS conference dedicated to “Patient engagement.”  I think the next season of “The Bachelor” should feature a wonk at HIMSS looking for a wonkettes to love.

Here’s how the Internets define “Patient engagement”:

• The Get Well Network (with a smiley face) calls it: “A national health priority and a core strategy for performance improvement.”
• Leonard Kish refers to it as “The Blockbuster Drug of the Century” (it narrowly beat out Viagra) – HT to Dave Chase.
• Steve Wilkins refers to it as “The Holy Grail of Health Care” (it also narrowly beat out Viagra) – HT to Kevin MD.
• On the HIMSS Patient Engagement Day, the following topics were discussed:
  • How to make Patients Your Partners in Satisfying Meaningful Use Stage 2 Objectives; Case Studies in Patient Engagement, session #64;
  • Review Business Cases for Implementing a Patient-Centered Communication Strategy and Building Patient 2.0, session #84;: and
  • Engaging People in Health Through Consumer-Facing Devices and Tools, session #102.

So then, “patient engagement” is:

• a strategy
• a drug
• a grail (although I already have a grail)
• a “meaningful use” objective
• something that requires a business case
• something that requires “consumer-facing devices and tools” (I already have one of those too).

I hope that clears things up.

So why am I being so snarky about this?  Why make fun of a term used by many people I trust and respect?  I was recently discussing my ideas on a communication-centered medical record with a colleague.  At the end of my pontification, my friend agreed, saying: “you are right; communication is an important part of health care.”  I surprised him by disagreeing.  Communication isn’t important to health care, communication is health care. Care is not a static thing, it is the transaction of ideas. The patient tells me what is going on, I listen, I share my thoughts with the patient (and other providers), and the patient uses the result of this transaction for their own benefit.

But our fine system doesn’t embrace this definition.  We indict ourselves when we talk about “patient engagement” as if it’s a goal, as it reveals the current state of disengagement .  Patients are not the center of care.  Patients are a source of data so doctors can get “meaningful use” checks.  Patients are the proof that our organizations are accountable.  Patients live in our “patient-centered” medical homes.

Replacing patients as the object of our attention (and affection) is our dear friend, the medical record.  We faun over medical records.  Companies earn epic profits from medical records.  We hold huge conferences to celebrate medical records.  We charge patients money to get to see their own medical records.  We even build special booths (portals) where patients are allowed to peer in through a peep hole and see parts of their medical records.

This is why I’ve had such a hard time finding a record system for my new practice.  I want my IT to center on patients, but medical record systems are self-absorbed.  They are an end in themselves.  They are all about making records, not engaging patients.  They are for the storage of ideas, not the transfer of them.  Asking medical records to engage patients is like asking a dictionary to tell a story.

The problem is, documentation has taken over health care.  Just as the practice of a religion can overshadow its purpose: the search for God, documentation chokes out the heart of health care: the communication of ideas .  It did this because we are paid to document, not communicate.  Communication takes time and it is not reimbursed.  Communication prevents unnecessary care, which is a revenue stream.  Communication eliminates waste, and waste is food that feeds the system, the bricks that build the wings to hospitals, the revenue source that pads IT budgets.

So what’s a doctor to do?  I’m not sure.  I am still looking for a solution that will meet the central goals of my practice:

• Communication – health care is a hassle,  with communication relegated to the exam room.  I want care to be easily accessible for my patients,using IT in one of its strongest areas: tools for easy communication.
• Collaboration – the patient should be engaged, but in a two-way relationship.  This means they not only should have access to their records, they should contribute to those records.
• Organization – I want a calendar documenting visits, symptoms, problems, medications, past and future events in each patient’s record.  I also want a task-management system I share with patients to make sure care gets done.
• Education – I want to practice high-quality medicine, care that is informed by good information and the best evidence.  Why not do a yearly stress test?  There’s evidence for that.  Why not use antibiotics for sinus infections?  There’s evidence there.  Why use an ACE inhibitor to control the blood pressure?  I need to be able to support my recommendations with data, not just “because the doctor said so.”

The point of all of this is the moving of medicine from an industry where money is milked from disease to a communications network where diseases are prevented.  ”Patient engagement” that is done to the patient for the sake of the doctor or hospital is a sham.  Engagement is about interaction, listening, and learning in relationship to another person.  Engagement is not a strategy, it is care.

If only I could find the tools to make this happen.

HIT-Driven Patient Engagement Is A Bust – Effective Patient Engagement Begins With The Doctor-Patient Relationship

I hate saying I told you so.  But to quote myself…”patient engagement is a physician-patient communications challenge and not an HIT (Health Information Technology) challenge.”

Just take a look at the Mayo Clinic’s patient portal experience which was discussed at a HIMMS 2013 and reported on in HIT industry press.

The Headline

Mayo Clinic Struggles To Meet Stage 2 Meaningful Use Thresholds For Engaging Patients.

Always innovating, the Mayo Clinic some three years ago introduced a web-based portal to share information with their patients.  During that time some 240,000 patients have signed up for online accounts.  That’s pretty impressive.  But there’s a problem.  A BIG PROBLEM.

According to Eric Manley, product manager of global solutions at the Mayo Clinic, they are having a hard time “getting more than 5% “of all the patients who registered with the patient portal to actually use it.   You see in order to meet Stage 2 Meaningful Use requirements, and enjoy the benefits that come with meeting this criteria, people actually have to use the portal to access their own health information.  You just can’t build a portal and in Mayo’s case have fewer than 12,000 unique patients actually use it.    Actually you can…hospitals and physicians do it all the time…they just can’t get incentive payments for their efforts.

 So What Went Wrong?

It’s not like the folks at Mayo haven’t tried.  Mayo’s patient portal offer all the requisite techie gizmos – giving patients access to their medical record, lab results, appointment schedule, and lots of health information.  They also recently introduced their first patient-directed mobile health app call “Patient” which makes it easy for people to access their health information online.   Mayo even has a Center for Innovation to figure this kind of stuff out.

Upon reflection Manley admits that “simply making services available doesn’t cut it,” he said. “Unless you are engaging patients, you won’t meet meaningful use requirements. [Messaging and other mechanisms] need to be a part of your practice.”

But Wait – I Thought Patient Portals, EMRS and Health Apps Were Patient Engagement Strategies?? You Mean We Need To Do More?

Manley is quoted as saying that “patient engagement has been a part of what Mayo has done for a long time, meaningful use, especially Stage 2, is a catalyst to kick it up a notch.”

Let’s face it.  Meaningful Use maybe a good way to get providers to adopt badly needed HIT improvements – but it not a great way to force patients to “engage” with you.   Here’s why.

1)    Forcing patients to do anything is wrong and antithetical to the whole idea of patient-centeredness…even if you think it is in the patient’s best interest. Meeting Meaningful Use seems to take precedence over what the patient wants.  Manley is quoted as saying “just having it [information and portals] out there isn’t enough”…”It’s making the patient use them.”

2)    Patients want to engage with other people regarding their health, particularly their physicians. Health after all is an intensely personal and social affair.  Mobile health apps and email just can’t give patients want they want – to be listened to and understood.  Plus 85% of people want face-to-face access to their physician when they want it.  Patients know that HIT threatens to get in between them and their doctors.

3)    The content on most patient portals is not particularly relevant or engaging after the first 10 seconds….at least from the patient’s perspective.   After all, cognitive involvement is a prerequisite of meaningful engagement and it tough to be interested and spend time thinking about information that is not in context (of a medical encounter), you don’t understand, find boring, completely inaccurate or irrelevant.

So What Is The Solution?

There’s no question that if done right patient portals can and do work.  One need look no further than Kaiser Permanente, Group Health and the VA for great examples.  The key to their success…and hopefully every provider’s success…is integration.

Health care for us patients occurs within the context of social relations with our physicians.  To be engaging…the information you want to share with us needs to be relevant to us from our perspective, come from our physician and be integrated into our overall care plan.    Only then will we have the trust and confidence that the information is ours…and is something we need to pay attention to.  We focus on our health while we are in the doctor’s office…if you really want to engage us…do it there.

That’s my opinion…what’s yours?

3 First Principles For Evaluating Patient-Facing HIT Solutions

With the HIMSS13 Conference next week we can expect to hear a lot about how health information technology (HIT) and e-Health is expected to challenge and change the way health care now and in years to come.  To be sure great strides have been made in the adoption of electronic medical records, decision support, and patient web portals… with the promise of more to come.  Health Apps, in spite of their painfully slow uptake by many consumers, press forward with innovative new tools.

Yet in order to realize the full promise of patient-facing like EMRs, PHRs, patient portals and the like, we need to be more mindful of the following “first principles.”

First Principles #1 – Health care delivery and healing occurs in the context of interpersonal relationships.

Today, as in the past, health care is delivered within the context of interpersonal relationships, e.g., the physician-patient relationship.  Sir William Osler, the father of modern medicine, recognized this along with the importance of a clinician’s communication skills when he said “listen to the patient and they will tell you what is wrong.”   Today, as in Osler’s time, encouraging patients to “tell their story” is the hallmark of good communication skills.  Eliciting the patient’s story is also a hallmark of strong healing relationships…since the simple act of “talking” and “feeling heard” have been shown to have clear therapeutic benefits.

The same is true with the intensely interpersonal act of “laying on of hands.”  “Touch” as a method of healing dates back to biblical times and beyond.   Today, physicians like Abraham Verghese, MD continue to speak to about therapeutic value of touch as practiced during patient exams in both the hospital and ambulatory settings.  These same physicians caution us against losing sight of the central role and value of the physician-patient relationship in the false belief that technology will one day be capable of replacing the personal physician.

First Principles #2 – HIT cannot compensate for weak physician-patient relationships or poor physician-patient communication skills.   

We hear today about how primary care physicians are very busy…and getting even busier.  EMR systems, e-visits, decision support tools, patient portals and the like are touted as solutions for saving time, increasing quality, etc.  While all this may be true, a great EMR system or secure e-mail visits cannot turn a physician with sub-optimal patient communication skills into a patient-centered Marcus Welby, MD.  It will probably make things worse.

Absent strong, physician-patient relationships and equally strong patient-centered communication skills, such HIT investments are like building castles upon sand.

Another hallmark of patient-centered communication is a “meeting of the minds” between patients and their physicians regarding issues like the visit agenda, the accuracy and severity of the diagnosis and which treatment options will work best.  Unfortunately since many physicians today continue to employ a physician-directed style of communicating with patients…the patient’s perspective is seldom sought…and a meeting of the minds never has a chance to occur.   Even if EMRs accommodated the patient’s perspective, the clinician first has to ask the patient…and that just isn’t happening.

 First Principles #3 – Beware of unintended consequences

Many HIT professionals will quickly dismiss the above first principles cited above in the name of improving physician productivity.  After all, given today’s shortage of primary care physicians we have no choice but to layer on more HIT like EMRS and self-help patient portals.  But as with anything, one needs to be prepared for the consequences.  And there are always consequences.

In addition to improving productivity, health care professionals cite patient engagement as yet another reason to invest in HIT.  But is that really the case?

We have all seen the research citing how patients would “like” secure e-mail with their doctor, online appointment scheduling, access to their doctor’s notes, etc.   Who in their right mind would not like this?  But liking is not the same as using.  Of perhaps more importance is the finding that the vast majority of patients (85%) want to know that they will still have the ability to see their doctor face-to-face when needed after they have access to the above conveniences .   People aren’t dumb.  We/they know that technology is increasingly getting in between us/them and our/their physician.  Provider organizations that try and channel patients into substituting web portals and PHRs for physician office visits run the risk of pushing patients/members into the waiting arms of their competitors.

A recent study of decision support tools underscores yet another unintended consequence – loss of trust in their physician.  Interestingly, certain patients saw the use of computer decision support tools as a reflection of their physician’s clinical knowledge.   That is, physicians that used decision support tools were perceived as being less knowledgeable than physicians that didn’t employ them.  Since clinical skills are a driver of patient trust, the risk of encouraging physicians to “engage” patients by using decision support tools is that you may well be disengaging them by increasing their distrust.

So What’s The Take Away?

We need to recognize that there are fundamental first principles concerning the delivery of healing and health care.  To that extent that HIT professionals and those that write the checks for HIT understand these principles one has a better chance of meeting their expectations.

Here are three questions that need to be considered when evaluating any patient-facing HIT solution:

1. Does technology support or detract from the physician-patient relationship in a meaningful way?
2. Does the technology presuppose the presence of strong physician-patient relations and physician-patient communication skills?
   Do you even know what kind of patient communication skills your physicians have?
3. What are the potential unintended consequences of adopting the proposed technology?

That’s what I think…what’s your opinion?

Sources

Agarwa, R. et al.   If We Offer it, Will They Accept? Factors Affecting Patient Use Intentions of Personal Health Records and Secure Messaging.    Journal of Medical Internet Research 2013;15(2):e43.

Want Your ACO To Succeed? …Then You Better Focus On Improving How Your Doctors & Patients Communicate

The basic premise of the Accountable Care Organizations is simple enough.  By incentivizing providers (physicians and hospitals) to assume financial responsibility for coordinating the health care of a defined patient population, it is possible to increase the quality of care while decreasing the cost of care delivery.

For ACOs to succeed, experts tell us that 3 things are required: 1) health information technology is needed to track and manage patient populations, 2) redesigned care delivery processes are needed to support patient care coordination, and 3) the right set of provider financial incentives must be in place.

But The “Experts” Have Overlooked Perhaps The Most Important Requirement

The improvements in quality and cost effectiveness in large part are predicated upon providers being able to engage patients with the goal of changing their health behavior.  

The problem is that most physicians lack the patient-centered communication skills needed to engage patients in their own health care not to mention persuade patients to change their health behavior. 

An Example – Physician and Patient “Meeting of the Minds” 

I think we can all agree that “telling patients what to do” is not an effective patient engagement or behavior management strategy.  After all, if patients don’t agree with or understand the rationale for a recommendation from their doctor, they are not likely to comply with it.

Rather, a meeting of the minds by physicians and patients is needed…and that requires physicians  understanding the patient’s perspective.  The evidence bears this out.  Higher ratings of trust, satisfaction, and intention to adhere occur when patients see themselves as similar to their physicians in personal beliefs, values, and communication.[1]

The problem is that physicians and patients often disagree on even the most fundamental issues…and herein lies the problem:

• Doctors & patients disagree on the principal reasons for office visits 53% of the time.[2]
• There is “substantial discordance” between the problems patients describe to physicians and the symptoms that physicians document in the EMR.[3]
• For diabetic patients who cited pain or depression as their top health concern their physicians rated these conditions “as likely to affect the patient’s health outcomes” in only 9% and 32% of cases respectively. (Remember, 95% of the treatment for diabetes is patient self care). [4]
• 41% of patients disagree with their physician as to whether their presenting symptoms represented a psychological versus a medical problem. [5]
• Physician perceptions of “how pleased, cheerful, relieved, worried, angry, and disappointed” they thought the patients were during office visits differed significantly from patient rating of how they actually felt. [6]
• Physicians tend to underestimate the patient’s desire for health information in 65% of visits.[6]

So What’s The Take Away?

Many physicians today are ill prepared to assume the role or financial responsibility of care coordination (or care management) given their lack of patient-centered communication skills.  Notice I didn’t mention lack of time since effective use of patient-centered communication skills over time can actually save providers time.

Unless and until medical groups, hospitals, health plans, CMS, and ACOs address this critical shortcoming through providing physicians with the  training, tools and resources needed to develop and refine patient-centered communication skills, ACOs will not deliver on their promise of more effective and efficient medical care.

That’s my opinion. What’s yours?

Sources:

[1] Street, R. et al. (2008) Understanding Concordance in Patient-Physician Relationships: Personal and Ethnic Dimensions of Shared Identity. Annals of Family Medicine. 6:198-205.

[2] Greer, J. and H. R. (2006). Predictors of Physician-Patient Agreement on Symptom Etiology in Primary Care. Psychosomatic Medicine, 282, 277-282.

[3] Stein, T. et al. (1999) Inaccuracies in physicians’ perceptions of their patients. Medical Care.  Nov;37(11):1164-8.

[4] Keulers, B. J., Scheltinga, M. R. M., Houterman, S., Van Der Wilt, G. J., & Spauwen, P. H. M. (2008). Surgeons underestimate their patients’ desire for preoperative information. World Journal of Surgery, 32(6), 964-70.

[4] Street, R. et al. (2008) Understanding Concordance in Patient-Physician Relationships: Personal and Ethnic Dimensions of Shared Identity. Annals of  Family Medicine, 6:198-205.

[5] Freidin, R., et al. (1980). Patient Physician Concordance in Problem Identification. Annals of Internal Medicine, (93), 490-493.

[6]Stein, T. et al., Inaccuracies in Physicians’ Perceptions of Their Patients.  Medical Care. 1999 Nov;37(11):1164-8.

[7] Pakhomov, S. et al. (2008). Agreement between Patient-reported Symptoms and their Documentation in the Medical Record. American Journal Of Managed Care, 14(8), 530-539.

Here’s Why You Should Ask Your Doctor To Show You Any “Alerts” In Your Electronic Medical Record

Electronic medical records (EMRs) make a lot of sense.  Ideally they capture, store, and report on all the pertinent information that’s floating around out there concerning your health.   One of the supposed advantages of EMRs is their ability to sort through vast quantities of health data to “alert” physicians to important gaps in your care.

Alerts are triggered when something in your EMR is flagged (think red flag) indicating that something that is supposed to happen to you has not yet happened….and vice versa    For example, EMRs can alert physicians when you are overdue for a screening test.  They can also alert physicians to lab and radiology test results that need to be followed up on.

It Is A Great Way To Engage Patients

Since everyone is so concerned about getting patients more engaged in their health care…why not start by turning the computer screen around and showing patients the “alerts” in their EMR.   I am sure that will get most patients’ attention.

Here’s why this is necessary

A study in a recent issue of the Journal of General Internal Medicine found that care gaps persisted among primary care physicians using EMRs and alerts.   Researchers found that:

• Physicians failed to follow-up abnormal lab test results in a timely fashion (<30 days) in 7% to 62% of patients
• Physicians failed to follow-up abnormal radiology test results in a timely fashion in 1% to 36% of patients.

Remember these where practices in which the EMR system was capable of generating electronic alerts telling the treating physicians that action was needed.  These follow-up rates are not all that different from similar studies of physician practices without EMRs.

The lack of timely follow-up by physicians reported in these studies resulted in otherwise preventable hospitalizations and delays in initiating time-sensitive cancer diagnosis and treatment.

In my wife’s case, her Non Small Cell Lung Cancer was identified in a hospital employee health screening when it was Stage 1… yet she was not told of the finding for some 5 years later at which time she was Stage 4.  This despite a “paper copy” of the radiologist report (chest X-ray) being sent to her PCP, OB-GYN and Employee Health Medical Director.

Why The Lack Of Timely Follow-Up?  

Researchers have found that primary care physicians in integrated delivery systems receive an average of 57 alerts per day.  Among the reason given for the lack of timely follow-up, despite the alerts, were the following:

•  Physicians were found to be less likely to acknowledge alerts when they are behind schedule.
• Physicians focused their attention on alerts concerning patients with greater “clinical burdens” (e.g., providers were more likely to acknowledge alerts about elderly or highly co morbid patients).
• Physician lack of knowledge – physician knowledge of EMR alert-management features in one study ranged between 4% and 75%. Almost half (46%) of providers did not use any of these features, and none used more than two.  Put another way, many physicians don’t know how to use all the features of their EMR system.
• Physicians ignored or turned the alert function off

The Take Away?

If you are a patient in a practice that uses an EMR, politely tell your physician that you would like to see any alerts that pertain to you.  If there aren’t any – fine.  If there are, simply ask your doctor what’s the plan for addressing the outstanding issue.  He or she may well have a good reason for ignoring the alert which I am sure they would be happy to explain to you.

If you are a patient in a “pencil and paper” practice, ask your physician what his/her policy is regarding test result notification, including timeliness.  Ask what their policies and procedures are to make sure that no one – particularly you – falls through the cracks.  Never leave your doctor’s office without a copy of all your test results!

If you are a physician with an EMR system…learn how to use the darn thing. Your patients will appreciate you for it and I dare say you prevent what happened to my wife and me.

That’s what I think.  What’s Your Opinion?

Sources:

Hysong, S.  et al.  Provider management strategies of abnormal test result alerts: a cognitive task analysis.  Journal American Medical Informatics  Association. 2010;17:71–77.

Singh, H. et al.  Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting.  Archives of Internal Medicine. 2009;169(17):1578-1586

Sittig, D. et al. Improving Test Result Follow-up through Electronic Health Records Requires More than Just an Alert.  Journal of General Internal Medicine. 2012 Oct;27(10):1235-7.