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.

Patient-Centered Medical Homes Need To Become More “Patient-Centered”

A recent study in Medical Care about Horizon BCBS’s Medical Home pilot reminded me of the expression a “house does not make a home.”   Or in this case how building a medical house to the spec (as laid out 3rd parties like NCQA and JACHO)  is not the same as building a medical home that is truly patient-centered .   As it turns out, researchers involved in the Horizon study claimed not to have found any significant differences between PCMH practices and non-PCMH practices.

Don’t get me wrong, my hat is off to the thousands upon thousands of primary care practices from New Jersey to Hawaii that have put in long hours going the extra mile to become recognized as Patient Centered Medical Homes.  Due to the efforts of these first generation PCMH pioneers, and their health plan partners, millions of people now have unprecedented access to primary care physicians providing:

• Physician-led team care
• Electronic records (EMR/Registry)
• Embedded care coordinators
• PHRs and web portals

Yes, many of the PCMH pilots, now into their 4^th or 5^th year, are showing promising results with reported reductions in ER visits, hospitalizations and 30-day hospital readmissions.  These pilots are also reporting improvements in HEDIS-related quality indicators.

But while team care, care coordination and EMRs may increase practice efficiency, there is nothing inherently patient-centered about these “things.”

That’s because patient-centered care is a philosophy of care delivery…not simply a punch list of HIT and staffing requirements.  Crossing the Quality Chasm defines patient-centered care as “respectful of and responsive (where practicable) to individual patient preferences, needs, and values”; or as Berwick is quoted as saying, “nothing about me (the patient) without me.” Patient-centered care occurs between people – not things – and manifests itself in the way the clinician and patient talk with and relate to one another, e.g. patient-centered communications.

With all the attention placed on building out the HIT and staffing infrastructure,  this first generation of PCMH pilots, with some notable exceptions, has lost sight of the most what makes a medical house and patient-centered medical home – notably the relationship between the patient and the clinician, beginning with the quality of clinicians’ patient-centered communication skills.

Yes, many accredited PCMH’s have patient advisory boards and conduct patient satisfaction surveys.   But as researchers like Street and Epstein have suggested,  relying just on patients’ impressions and ratings of “patient-centeredness” may provide false reassurance given that many patients have never experienced anything but suboptimal care and physicians that employ a paternalistic, decidedly un-patient-centered style of talking to patients.  (Until recently, I myself had never encountered a real patient-centered physician).

As I discussed in an earlier post, the majority of physicians today employ a paternalistic, physician-directed style of communicating with patients.   As such, there is no evidence to suggest that the patient communication skills of physicians practicing in accredited PCMHs are any more patient-centered that their counter parts in traditional practices.

Based upon the literature, what is absent in this first generation of PCMH pilots is any serious, systematic attention given to assessing and/or improving the quality of the patient-centered communication skills of physicians and their care teams.   This oversight is worth noting since the benefits expected by policy makers and underwriters of PCMHs and ACOs under health care reform have been linked in the research to the strong patient-centered communications and not HIT, team care and care coordinators.

Why Is This Important If PCMH Pilots Are Reporting Positive Outcomes?  

The early saving being reported by many PCMH pilots may well represent the “low hanging fruit.” This is not an unreasonable supposition given that most physician practices have never had EMRs, care coordinators, or team care prior to the PCMH pilots.  As is so often the case, within a short few years, this low hanging fruit will disappear.

But there is another way. Thirty years of research has demonstrated the benefits of patient-centered communications when it comes to increased productivity, greater patient engagement; better outcomes, lower health care use/cost and superior patient experiences.

Going forward, PCMHs, ACOs and their sponsors will need to look past HIT and team care to the quality of their patient-centered communication skills if they are to assume the role envisioned for them under health care reform.

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”:

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Sources:

Epstein RM, Fiscella K, Lesser CS, Stange KC.  Why the nation needs
a policy push on patient-centered health care. Health Affairs. 2010;29(8):1489-1495.

Ming Tai-Seale, et al.  Recognition as a Patient-Centered Medical Home: Fundamental or Incidental? Annals of Family Medicine. 2013;11:S14-S18.

Street, R., et al.  The Values and Value of Patient-Centered
Care.  Annals of Family Medicine.  2011;9:100-103.

Physicians With High Productivity And Satisfaction Scores Employ Strong Patient-Centered Communication Skills

People are forever telling me that I am wasting my time talking to providers about the need to improve their patient communication skills.  Naysayers typically cite one of the following reasons for why things will never change:

Reason 1 – Every physician thinks they already have good patient communication skills.

Reason 2 – Physicians don’t get paid to talk to patients

Reason 3 – Physicians don’t have time to talk to patients

Reason 1 is relatively easy to debunk. After all, if all physicians were really such good communicators:

• poor communications skills wouldn’t consistently top the list of patient complaints about physicians
• patient non-adherence wouldn’t be so high since physician and patients would always agree on what is wrong and what needs to be done
• patients would not be walking out of their doctor’s office not understanding what they were told
• patients would not experience so many communication-related medical errors

Reason 2 requires a little straightforward logic:

Since physicians are paid to diagnose and treat patients presenting problems…and the accuracy of their diagnosis and treatment depends upon their physicians’ ability to elicit and listen to the patient’s story…then indeed physicians are already being paid to talk to patients.

Reason 3 (physicians don’t have time) has always been hard to address. That is until now.

Most us tend to think about physician time on a zero sum basis.  Take the office visit for example.  Providers will argue that they either spend more time trying to be patient-centered (associated with great patient experiences) or they can use less time to diagnose and treat patients the way they have always done – but no way can they do both at the same time.

A recent published study conducted by HealthPartners in Minneapolis suggests that physician time is not a zero sum game – that providers can in fact be productive while at the same time creating a satisfying patient experience.

Individual productivity and patient experience scores were calculated and plotted for 22 HealthPartners physicians using a scatter diagram like that shown in Figure 1 (for demonstration purposes only). What the study found was that a relatively equal number of physicians fell into each of 4 quadrants – strong productivity/strong satisfaction, strong productivity/weak satisfaction, weak productivity/strong satisfaction and weak productivity/weak satisfaction.

Figure 1

The researchers then looked to explain the difference between physicians in each of the quadrants. They ended up identifying a set of “behaviors and characteristics” to help explain why some physicians had strong productivity/strong satisfaction scores while others did not.

Physicians in the strong productivity/strong satisfaction quadrant exhibited the following behaviors and characteristics:

• Focused on teaching and explanations
• Conveys warmth from the start
• Well-planned flow of visit with focus on patient’s agenda
• Controlled script with clear parts
• Extremely personable—connects with every patient
• Always looking for buy-in from the patient that s/he fully understands
• Recap the history: “I read your chart …”
• Confident but not arrogant
• Finishes dictation and coding each day
• Clinic staff enters orders and prepares after-visit summary

Physicians in the weak productivity/weak satisfaction quadrant exhibited the following behaviors and characteristics:

• Lack of “being there” emotionally
• Lack of smiling
• Abrupt actions
• Behavior changes when not interested in the “case”
• Patients kept waiting and wondering
• No handshake
• Sense of interrogating to get a diagnosis
• No attempt to match the patient’s energy

What struck me about these lists was that were dominated by the presence (strong productivity/strong satisfaction) or absence (weak productivity/weak satisfaction) of communication-related “behaviors and characteristics.”

Perhaps not so surprisingly, the behaviors and characteristics of physicians in the strong productivity/strong satisfaction are consistent with those traits commonly associated with a patient-centered style of communications. This evidence belies the conventional belief among physicians that they will be less productive (rather than more productive) by adopting a patient-centered style of communications with their patients.

Based upon the evidence, HealthPartners has since gone on to provide its physicians with useful guidelines for how to improve their productivity and patient experience scores.

Take Aways Physicians and practice managers need to seriously reexamine:

1. their assumptions about the value of and barriers to improving their patient communication skills
2. the evidence in support of the adoption patient-centered communications skills and styles

Physicians and managers should consider assessing the quality and effectiveness of their existing patient communication skills. The last time most physicians focused on their patient communication skills was back in medical school.

Implement interventions and guidelines designed to improve the patient-centered communication skills of physicians and their care teams.

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

Sources:

Boffeli, T., et al. Patient Experience and Physician Productivity: Debunking the Mythical Divide at HealthPartners Clinics. The Permanente Journal/ Fall 2012/ Volume 16 No. 4.

Shared Decision Making – Not Ready For Prime Time – Nor Evidently Is Patient-Centered Care

When it comes to delivering truly patient-centered care…how are providers supposed to know when they have “arrived”?   According to Michael Berry, MD, President of the Informed Medical Decisions Foundation, providers will know they have achieved the “pinnacle of patient-centered care” when they routinely engage their patients in shared decision-making (SDM).

In theory, shared decision-making (aka collaborative decision-making) is what is supposed to happen between patients and their doctors when faced with a difficult choice.  Clinicians engaging in shared decision-making would provide patients with information pertaining to the need for the treatment, the available options, as well as the benefits and risks.  But patient-centered clinicians would also do something else. They would attempt to work with patients to arrive at a decision they could both live with.  A kind of “shared mind” that takes into consideration their clinical perspective as well as the patient’s perspective – their preferences, needs, and values (which ideally have been captured over the course of the patient-provider relationship).

The Problem Is That Most Physicians Don’t Really Engage Patients In Either Shared Decision Making  

 A 2003 study surveyed U.S. physicians (N=1,217) preferences and actual practices regarding shared decision-making.  Table 1 presents a summary of findings from this study.

Table 1

Decision Making Style	What Physicians Preferred	What Physicians Actually Do
Shared decision-making	58%	37%
Physician-dominant decision-making	28%	43%
No patient involvement	9%	13%
Patient dominant decision-making	5%	7%

While most physicians in the study may philosophically believe in and prefer shared decision-making…as this data indicates that is not what most physicians in the study reported actually doing.  In fact, 56% of physicians reported that they actually engaged in decision-making that was physician-dominated (with some patient involvement) or totally physician-dominated decision-making behavior (absent any patient involvement).

The Barriers To Shared Decision Making?

The barriers to SDM include the usual suspects:

•  Lack of time during the visit
• Not having access to the right decision support aids tools and training their use
• Physician attitudes about patient’s willingness to engage in shared decision-making
• Provider reliance upon a physician-directed (versus patient-centered) style of communicating with patients

The Take Away – Why Shared Decision Making Matters

•  SDM is the right thing to do – the benefits associated with SDM include better outcomes, lower utilization and cost, lower malpractice risk and enhanced patient trust and satisfaction

•  SDM is a great way to be engaging to patients – it is a way to get patients involved in their care in a meaningful way they can relate to.

• To be eligible to participate in Medicare’s Shared Savings Program, Accountable Care Organizations must implement processes to promote patient engagement, including shared decision-making.

As readers of Mind the Gap know, I am a proponent of the adoption of patient-centered communication by providers, beginning with primary care.   Shared decision-making has rightly been identified as a leading indicator when it comes to assessing the “patient-centeredness’ of a physician practice.   So before you go around telling everyone how patient-centered your provider teams are first do a reality check.  Because if you aren’t regularly engaging your patients in shared decision making you are not there yet.

That’s my opinion…what’s your?

Sources:

Heisler, M. et al. Physicians’ participatory decision-making and quality of diabetes care processes and outcomes: results from the triad study. Chronic Illness. 2009 Sep;5(3):165-76

Street, R. et al  The importance of communication in collaborative decision making: facilitating shared mind and the management of uncertainty. Journal of Evaluation in Clinical Practice 17 (2011) 579–584.

Frosch, D., et al. An Effort To Spread Decision Aids In Five California Primary Care Practices Yielded Low Distribution, Highlighting Hurdles. Health Affairs. 32, no.2 (2013):311-320.

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?