Patient Engagement & Health IT – Disillusionment Sets In Poll Shows

This week, the 2015 HIMSS Patient Engagement Summit is taking place in sunny, warm Orlando. According to HIMMS, conference attendees will learn how “leading healthcare organizations” are successfully using health IT and other strategies to engage patients in their care.

Patient What I suspect attendees will not hear much about at the Summit (particularly from speakers and exhibitors – one in the same?) is the growing “disillusionment” with the ability of patient portals, EHRs/PHRs and smart apps to actually engage patients at all. One only need look at the dismal adoption rates of these technologies (in the very low double digits if that) within most provider organizations, Kaiser, Group Health and Geisinger being notable exceptions.

What disillusionment you may ask?

Recently I conducted my own informal poll on LinkedIn’s HIMSS Group by ask the following question:

If a patient chose NOT to use your patient portal, PHR or smart health apps do you consider them to be “unengaged” in their own healthcare?

The question was prompted by all the “over the top claims” by HIMSS (See their Patient Engagement Framework) and EHR and Health IT bloggers that patient portals, EHRs and smart apps are what drive patient engagement.  Come on now.

If that were true, that would mean that prior to the World Wide Web in the early 1990’s it was impossible for people to be engaged in their own healthcare.  That is simply not true!

Who doesn’t recall Healthwise’s big old health handbook.  It must have weighed 5lbs! Or who doesn’t remember “Ask A Nurse” – that ubiquitous 1-800 number you could call at 3:00 AM a health question? And of course there was always the doctor, family member or friend you could discuss your health concern with. To this day, more health conversations among seniors probably occur in McDonalds over morning coffee than on some EMR or health app.

But I digress…

So what were the results of my informal poll?

Take a look for yourself. Below are snippets from some of the 70+ responses (and counting) I received from members of the HIMSS Group which consists of developers, venture capitalists, informatics, vendors and clinicians.

What surprised me the most was how few “good things” people had to say about health IT in general…not just with regards to patient engagement.

• I am in healthcare IT and I still have not used my EPIC portal for scheduling an appt, view results, etc. because it is has been too much trouble to access.

• Are they “unengaged” if they do not use these tools? Absolutely not. [ . . .] I actually consider patients who use the portal, PHR or apps and are NOT having direct contact face-to-face or by telehealth as being “unengaged”. Patient engagement is a very personal and individual decisions made by the patient and can change drastically at any given time.

• It seems we too often try to use technology to replace human interaction. Patient engagement requires human interaction and collaborative work between the provider and patient.

• Until the portal becomes a) easy to use and relevant, b) doesn’t have 20 pages of legalese and c) can converse with you via email, txt, Instant Messages or phone; there will always be a substantial portion of the population that won’t use them.

• Ok, [patient portals]not normally a big deal until you read the terms of service which, paraphrasing the legalese, said “If we are breached, it is your fault. We are not responsible for losses you might incur. If it is determined that the entire system was compromised through your account you will be responsible for our costs to remedy the situation”.

• Match […]the technology to the message. I am aware of HIPAA secure phone mail systems that get 83% of patients using the system to listen to messages left for them by a clinician within 24 hours. We are all used to voice mail and using the phone.

• Engagement should be defined by the level of interaction with a provider, and the resulting outcomes. So, no, I think assessing level of engagement by use of the technology is pretty limited.

• If you want to know why patients and physicians do not use portals, it is because they are designed by EHR companies that design them as poorly as they design EHRs. Combine that with Byzantine security procedures, and you get a somewhat useless system.

• The assumption that a percent of users accessing data on a portal = patient engagement is where we fail! A percentage of people will access a portal for various reasons, and they will also NOT access a portal for various reasons. The real question should be…. what can we do to make the info easier to access and easier to understand.

• Point me to a portal that you believe is patient friendly, put on your flak jacket and give me 30 minutes to make you understand that the portal smells worse than pig effluent.

• Why would I be forced to go through all of the userID creation (I have somewhere around 250 of them in my Google profile) etc. just to give doctors access? Why can’t I tell the people at the radiology site that Drs A, D, V & Z can have access? I am extremely engaged in my health as a nearly 30 yr Type 1 Diabetic. But what you just described sounds like more PITA administration that I have ZERO interest in.

• You cannot force adoption, it comes to good products and causes bad ones to fail.

• I am committed to health (as opposed to healthcare) and I take an active approach to wellness. [ . . . ] Since my hospital-employed PCP implemented EPIC, my relationship with that office and my doctor has significantly degraded. The implementation of EHR and its patient portal caused me to disengage, not engage.

• Meaningful Use is the worst government policy since the Vietnam Conflict. Over 75% of doctors have stated that MU is a disaster and patients are waking up to this fact.

• EPIC and others have developed their EHR to generate revenue for the healthcare providers and they are forced to create patient portals due to regulations.

• Whatever use case you can think of, the patient MUST gain value in issuing a portal (I hate this 15 yr out of date term…) or you’re causing them pain and suffering just to cut administrative costs for the provider.

• We have to address “what is in it for me?” [when I comes to patient use].  The point is that barely nobody is engaged towards tools

• Give me a bad patient outcome and an EMR primarily designed to bill, that allows cut and paste, and populates differential diagnoses without requiring the provider to rule each out, and I will show you a lost med mal case.

• We are looking to technology to fix a human problem… taking their health for granted.

• Providers, use the portal to tell your patients how they can help you be most efficient. Have your EHR builders “put your heart in your letters” why this is a valuable resource, that you support it also.

• If the providers don’t trust it, neither will the patients, and then it [patient portal] truly is useless.

Take Aways?

No surprises here. When people in the business are honest about it, based upon my limited, informal sample, many just don’t buy into the patient engagement-Health IT hype.

Of the 70+ responses

• No one “believes” that health IT actually “creates or drives” engagement where it did not already exist.

• Many recognize that patient engagement occur between patients and their physicians – HIT is just useful medium for supporting that relationship.

• There are lots of problems with patient portals beginning with:Their purpose

• Who really benefits (clinician-patient-payer)
• Terms and conditions of use, e.g., legalese
• Relevance
• Usability
• Interoperability
• “Byzantine” Sign In and User ID Practices

• Some believe that portals actually caused them to “disengage” rather than engage

• How one “rolls out” their portal to patient and physicians is critical

The bottom line when it comes to portals I would offer the following advice:

1. Be clear about why you are implementing a patient portal
2. Involve patients (and clinicians) in the planning and development
3. Enroll clinicians to introduce portal to their patients
4. Be clear about what constitutes success, including how you will measure it

Satisfaction With Provider Communication In Recent Study Is Lower In Patient Center-Medical Homes (PCMH) Than Non-PCMH

A recent blog headline on the Patient-Centered Primary Care Collaborative (PCPCC) recently caught my attention. It was entitled Patient Satisfaction With Medical Home Quality High. I was intrigued. I asked myself high compared to what? Non-PCMH practices?

The study, which appeared in the November-December 2013 Annals of Family Medicine, asked 4,500 patients (2009 Health Center Patient Survey) of federally-support health centers their perceptions of a number of “patient-centered quality attributes,” including the following measures which the study authors defined as patient-centered communication:

• Clinician staff listened to you?
• Clinician staff takes enough time with you?
• Clinician staff explains what you want to know
• Nurses and MAs answered your questions?
• Nurses and MAs are friendly and helpful to you?
• Other staff is friendly and helpful to you?
• Other staff answered your questions?

Observations About The Study

The first thing that struck me was that compared to patients in the 2012 CHAPS survey (AHRQ) website, patients in the 2009 study actually reported lower levels of 1) patient satisfaction (81% versus 91%) with their clinicians’ patient-centered attributes (including communication) and 2) willingness to recommend their providers (84% versus 89%).

The second thing I was reminded of is that patients themselves are so used to clinicians’ paternalistic, physician-directed communication style that simply allowing them to ask just one question puts the clinician in the top 5% of patient-centered communicators. Stop and ask yourself when the last time was that you encountered a physician that asked you what you thought about your medical condition? Until recently I never have been and I suspect few if any people in the study cited here have either.

[pullquote]Stop and ask yourself when the last time was that you encountered a physician that asked you what you thought about your medical condition? [/pullquote]

The final thing that struck me was that none of the quality measures used in the study captured the “essential and revolutionary meaning of what it means to be patient-centered.” As Street and Epstein point out, patient centered communication is about inviting the patient to get involved in the exam room conversation.

As articulated in hundreds of studies over the years, patient-centered communication skills include:

• Soliciting the patient’s story
• Visit agenda setting
• Understanding the patient’s health perspective
• Understanding the whole patient (biomedical and psychosocial)
• Shared decision-making
• Empathy

We Need To Raise The Bar For Patient-Centered Medical Homes (PCMH)

Studies like the one cited here set the quality bar (and bragging rights) way too low for PCMH. Patient-centered care has to be different than the paternalistic, physician-directed care we all seem so willing to accept. Such studies trivialize what it means for physicians and their care teams to be patient-centered in the way they relate to and communicate with people (aka patients). Patient-centeredness is a philosophy or care…and does not require team care, extended hours or care coordinators. These are great added features, but to equate such services with patient-centeredness misses the boat…something which professional groups like the PCPCC, NCQA, Joint Commission, and URAC should recognize by now.

The Take Away?

Here’s some thoughts:

1) We need to set the bar higher for PCMHs when it comes to how we define and measure patient-centered communication.

2) We need to find better ways to asses patient-centered communications in actual practice. Patient rating of a clinician’s patiient-centeredness are simply not enough. As part of the 2014 Adopt One! Challenge, we will be using audio recording of actual physician-patient exam room conversations to measure and benchmark clinicians’ patient-centered communication skills.

3) We should stop celebrating being average whether it be in PCMH setting or hospitals when it comes to physician-patient communications.
That what I think. What’s your opinion?

Sources:

Lebrun-Harris et al. Effects of Patient-Centered Medical Home Attributes On Patient’s Perception Of Quality In Federaly-Supported Health Centers. Annals of Family Medicine. 2013; 11:6; 508-516.
Street et al. The Value and Values of Patient-Centered Care. Annals of Family Medicine. 2011; 9; 100-103.

There’s Nothing Engaging About My First Patient Portal…It’s Actually Disengaging

In Fact It’s Downright Disengaging…

Stop the presses!   I now have access to my very own personalized patient portal courtesy of my personal physician.  The big event occurred this last Tuesday.   I have to admit I was a bit excited that my doctor was slowly merging onto the information super highway.  Heck he even sprang recently for an out-of-the box EMR system which he is forever complaining about.

But my excitement was short lived.  Very short lived in fact after reading the e-mail from E-Clinicalworks (the patient portal vendor) which I am sharing with you here.

Now I realize that my doctor works in a solo practice as part of a large IPA…not the Mayo Clinic. But this email…and presumably everything associated with this patient portal is…well…very amateurish and totally disengaging.

A couple of things immediately jumped out at me while reading this e-mail invitation to my patient portal.

The patient portal claims to offer me “the power of the web to track all aspect of my care through my doctor’s office.”That’s pretty powerful!

But I read on to discover that my physician’s concept of what I should have the “power” to do and what he thinks I should be able to do is very different. Why am I surprised…?

First there is no mention of any kind of access to my actual health information…and certainly not my “physician’s notes.”But that doesn’t mean I am willing to leave my doctor for someone who offers this capability.

Second…and perhaps most galling…is that I can’t actually communicate with my doctor via the portal.  I can email his office staff…and maybe they will respond and maybe not. In the non-digital world they would get back to me at their own leisure.

Third, I can’t actually do anything on the portal (as configured by my doctor) other than request that the surly office staff intervene with the doctor to refill my prescriptions. Asking is certainly different than doing in my book. How the heck is this supposed to make me feel engaged?

Finally the email presumes to tell me that up until today my physician apparently does not think that I have been taking an active role in my own health care.   Let me get this right…I am 100% compliant with my medications, exercise, see my doctor regularly and am in good shape…yet I am not actively involved in my own health. Come on now.

In its favor…the email was personalized – it got my first name right. It never did mention my doctor’s name or his office address.

Upon getting this email from my doctor I was immediately reminded of a quote from a recent Dave Chase Forbes article about the value of physician-patient communications in which he said this about patient portals:

“The smart healthcare providers realize simplistic patient portals, however, won’t get the job done. Simple patient portals are like a muddy puddle of water in the Sahara Desert — a big improvement but far from ideal.

Kudos to physicians everywhere that are trying… But please recognize that your patients are not simpletons and that they are already engaged in their health at least from their perspective. For portals like this to be successful – (meaning that patients actually use them more than once) – they need to offer real value (from the patient’s perspective), they need to be relevant to patients (not you or your staff) and they need to respect my intelligence.

Take Aways

Most patients are already engaged in their own health care. The biggest challenge for providers today is not so much engaging patients but rather to avoid disengaging them.

I realize that my experience offers but one example of a patient portal gone wrong.  If you have samples of patient portal experiences you would like to share e-mail me at stwilkins at gmail.com.

The Lack Of Patient-Centered Communication Skills By Physicians in Your Provider Network Will Limit Your PCMH & ACO Performance

 

The Adopt One! Challenge – The First Step To Better Patient Engagement & Patient Experiences

A journey of a thousand miles begins with a single step.  Or in the case of the Adopt One! Challenge…by encouraging physicians across the U.S. to commit to adopting one new patient-centered communication skill in 2014.

Anyone who has followed my work here on Mind the Gap knows that I am passionate about improving the way physicians and their care teams talk to and interact with patients. My passion stems both from my personal experiences as a health care executive, a patient advocate and patient.  I honestly believe that if we could improve how doctors and patients talk with one another beginning in the exam room we would fix much of what is broken with today’s health care system.

“I have discovered that the biggest problem with physician-patient communications is the illusion that it ever occurred! “

Many physicians readily admit that their patient communication skills need work. But when faced with a burdensome daily practice schedule they make do with the physician-directed patient communication skills they learned in medical school. Besides…most physicians operate under the mistaken impression that patient-centered communications – the alternative to physician-directed communications – takes too much time and requires longer visits.

So How Will The Adopt One Challenge Fix Things?

The Challenge, to be launched later the Fall, is designed to accomplish three objective – behavioral objectives modeled after the Health Belief Model. These three objectives are:

• Help physicians understand that their patient communication skills are not all they could be
• Show physicians how their lack of patient-centered communication skills is a barrier to their ability to effectively engage and activate patients or to provide exceptional patient experiences
• Serve as a “Call to Action” to prompt physicians to take action to improve their patient-centered communication skills

Here’s how the Adopt One! Challenge will accomplish these objectives:

Help physicians understand that their patient communication skills are not all they could be

Using audio recordings provided by participating physicians a team of independent, trained professionals will identify, measure and assess the patient communication skills employed by each physician. This research method – called conversation analysis – is the same method used in medical school. Unlike patient satisfaction surveys like HCAHPS which are not very prescriptive, the Challenge will provide participants with objective, detailed and actionable findings and recommendations.

Show physicians how their lack of patient-centered communication skills is a barrier to their ability to effectively engage and activate patients or to provide exceptional patient experiences

In addition to measuring and assessing their patient communication skills, each physician’s patient communication skills will be benchmarked against patient-centered best practices.

Over 30 years of research has linked the use of specific, patient-centered communication skills to more productive visits, increased patient engagement, better patient health outcomes, lower health care use and superior patient experiences.  By comparing physicians’ skills against these “best practices” we show them how their communication practices may be affecting patients, their practice and the organizations they work for or with.  We also show them which communication skills they may want to focus on improving.

Serve as a “Call to Action” to prompt physicians to take action to improve their patient-centered communication skills

The Challenge serves as a concrete call to action to physicians to take a specific action to learn a new patient-centered communication skill over the course of 12 months.  This call to action will require participants to 1) commit in writing to adopt/develop one new patient-centered communication skill of their choosing and 2) provide them with access to online training and resources needed to help them learn that new communication skill.

Because the Adopt One! Challenge is expected to become an annual event, participating physicians can measure their year-over-year progress as they add new patient-centered communication skills.

In future posts I will share more about the Adopt One! Challenge. In these future posts I will profiling members of the Adopt One! Challenge Advisory Board as well as the Partners that are making the Challenge possible.

The Adopt One! Challenge is Free To Individual Physicians.

If you are interested in offering the Adopt One! Challenge to all the physicians in your provider network?  E-mail us at contact@adoptonechallenge.com.