There is no app for engaging patients in their own health care absent a strong doctor-patient relationship.
Physicians, hospitals and other providers are being misled by industry pundits claiming that more health information technology (as in EMRs, PHRs, Smart Phone apps, and web portals) is the key to greater patient engagement. It’s not.
If health information technology were all that was needed to “engage” patients then patient and member adoption rates of provider and payer web portals offering Personal Health Records (PHRs) and Electronic Health Records (EHRs) would not still be hovering around a disappointing 7% (with several notable exceptions Kaiser, Group Health and the VA).*
Part of the misunderstanding concerning the role of HIT comes from how the discussion about patient engagement is being framed. According to the pundits, patient engagement is the physician or hospital’s responsibility… and like everything else these days…we can fix it if we just throw more technology at the problem. Can anyone say Stage 2 Meaningful Use requirements?
Here’s Why HIT Will Not Solve The Patient Engagement Challenge
The role of physicians, hospitals and other providers is not so much one of needing to engage patients in their care. Rather, providers need to “be more engaging” to patients who are already actively engaged in their health.
Here’s What I Mean…
Take the simple act of a trip to the doctor’s office. Before a person shows up at the doctor’s office they have to 1) have a reason or need (symptoms, a concern, chronic condition), 2) they have to believe that the need or reason merits seeing the doctor vs. taking care of it at home themselves – this generally implies cognition and doing research, i.e., talking with friends, going on line, etc., 3) make the appointment (by calling or going online and 4) show up for the appointment, and 5) think about what they want to say to the doctor. The point here is that by definition, people who show up for a doctor’s appointment are already engaged!
Now providers tend to not consider the patient’s perspective when it comes to engagement. For most providers, i.e. physicians and hospitals, engagement means getting patients to do what providers say is in their best interest…what I say is right. But that approach totally dismisses the fact that, as I have shown, that patients are already engaged…just not in the same way that providers expect.
Whether patients remain engaged by the time they leave the doctor’s office, and to what extent, are the questions we should be asking. For example, how “engaged” would readers here find it if they went to their doctor only to have the doctor 1) not ask why they are there (fears and concerns) or worse yet ignore the fears and concerns which they describe to the doctor, 2) disagree with the doctor as to the visit priority and how to diagnose and treat it, including for example being prescribed medication when you don’t want to take pills or 3) found out that you knew more about your problem and how to deal with it than your doctor?
The Point?
The point is that providers need to be engaging to patients in their demeanor, attitudes, and how they talk with and listen to patients. Doctors need to know who the patient is, what their fears, concerns and expectations are and what the patient is able and will to do. Meaningful patient engagement, the kind that leads to long term health behavior change, begins with patient-centered, interpersonal relationships between patients and their doctors. As far as I know, we don’t have an app for that.
That’s what I think. What’s your opinion?
Source:
* John Moore, Chilmark Research
For more information on patient engagement, email me for a copy of my latest white paper on Patient Engagement in Primary Care or fill out the online form on my blog.
Mind The Gap 
Agree with everything that you say here.
The idea that IT can create engagement (of both patients AND physicians) where it was lacking is ridiculous.
Engagement is engendered by two people talking and responding to each other openly and honestly. As an increasingly large portion of the office visit is consumed by data entry and MU chores, engagement will inevitably fall by the wayside.
Brilliant Stephen! Entirely agree? Engagement and adherence depends on mutually setting a goal. Not prescribing. Bidirectional
Totally agree with the article and the bidirectional nature of patient engagement. The lack of easy-to-read documentation readily available for the patient looks to me like one of the major issues: you go to the doctor, you’re being told something and that’s it, you’re left basically alone. IT might help there by providing good content in the hands of patients after a doctor’s visit. But I believe the quality and organization of content would be more important than IT (it could be paper based brochures, which are too rarely available).
Well said, Stephen. If only it were as easy as recommending the latest smartphone app to the patient (as IT marketers tell us it is!)
Let’s look at that example: We know that only 5% of smartphone apps (including health care apps) are still in use within 30 days of initial download. Approximately 26% of apps are used only once, and 74% discontinued by the tenth use.
How “engaged” are these patients? That’s not even the question docs should be asking – but “are they even remotely convinced to embrace health information technology?” is more like it!
cheers,
C.
PS. I just followed up on your thoughtful message here with today’s blog post called “Has industry co-opted patient engagement?” http://ethicalnag.org/2012/10/16/industry-co-opted-patient-engagement/
Carolyn: where can I get these stats ?
Stephen, I couldn’t agree more! THANK YOU for this thoughtful blog… Dr. Calra Rotering and I are about to publish a handbook for physicians called The Language of Caring Guide for Physicians: Communication Essentials for Patient-Centered Care. A critical chapter is about PHYSICIAN communication skills key to patient and family engagement. Also, we are launching a groundbreaking web-based skill-building programs for physicians (The Language of Caring for Physicians) and one of the videos is on patient/family engagement. When this book and program are ready (in about 3 weeks), would you be willing to review them??? I really respect your opinion?
Stephen, I definitely agree with your statements. Just like in the 90’s it was thought IT would improve quality it took some time for people to realize that IT is only an enabler but the real work still needs to be done by the healthcare providers (and I use the word providers very broadly to include all individuals working in healthcare that assist a patient). Improving communication and better understanding each others thought process would be a definite improvement.
Thanks,
Scott
Thank you for your insightful post that we just found. “Meaningful patient engagement, the kind that leads to long term health behavior change, begins with patient-centered, interpersonal relationships between patients and their doctors.” Agree strongly with your comments.
We’re working to enhance relationships and healing in healthcare, and created the International Charter for Human Values in Healthcare, starting with the capacity for compassion. The mission of the International Charter for Human Values in Healthcare is to restore the human dimensions of care – the universal core values that should be present in every healthcare interaction – to healthcare around the world. charterforhealthcarevalues.org
Thank you for having the cojones to say the what few dare to: that the emperor has no clothes (ok maybe just underwear)
Stephen, I appreciate your focus on the patient-physician relationship. I just returned from HIMSS with similar thoughts about how HIT vendors are missing the boat. In a recent blog post, I wrote about the need to reconstitute the interpersonal connection between patients and providers in order to leverage the fundamental value proposition in which trust, accountability, and empathetic fidelity engender health, wellness, and better outcomes. More on my blog at the HealthLens.org website (http://bit.ly/14zs5O7)
Kyle,
I really believe that patient engagement is fundamentally a physician-patient communication issue and not an HIT or technology issue. People (aka patients) know doctors are busy..and they fear that wiz bang technology (like the horrible phone answering trees every doctor uses) will get in between they and their physicians further eroding the physician-patient relationship.
What people don’t realize…and HIT folks do…is that technology can help outsource to patient more responsibility for certain aspects of their health care. All this in the name of freeing up time for busy clinicians. The unintened consequece…there are always unintened consequeces…is the real risk that HIT will disengage and disempower patients “already engaged” in what they though was a personal relationship with their doctor.
I liked you post by the way. Maybe I can talk you into doing a guest post on this subject for Mind the Gap.
Steve Wilkins
I just had a blog published yeterday on strategy and culture. When it comes to HIT there is much energy in the strategy and little in the culture. Love to share this with my providers.
http://www.toddnielsen.com/international-leadership-blogathon/patient-centered-healthcare-conditioning-your-culture-to-go-the-distance/#comment-21053
Susan,
Thanks for you comment…
Excellent article. It is baby steps. The physician-patient communication will be transferable in time, but I see the first step as making it easy dare I say electronic between TEAMS. The key to health is a health team. Physician-patient and physician-physician communication. Real words included.
Great post. At the Iowa Chronic Care Consortium, we’re seeing a dramatic increase in the number of physicians getting trained in clinical health coach techniques as a way to effectively engage and motivate their patients to take a more active role in their own care. And as the healthcare system evolves away from volume and towards value, this approach is going to be increasingly important for physicians and their clinical, patient-facing care teams.
Thanks for the article!
Brendan
Brendan,
Glad you liked the post and thanks for sharing your experiences from the Great American Midwest!
Steve Wilkins
Let’s not fall into the classic conversation on whether an app is the solution for everything as it never is by itself. However, an app can disrupt the way things work today and create new angles that were not there before. Hey, lets just look at this thread. If we didn’t have social networking tools we probably would not be engaged in this conversation and sharing opinions, would we?
I think it would be better to ask to what extent apps can contribute to improving the doctor-patient relationship. And I am sure we will be seeing innovative and disruptive apps coming our way that contribute significantly to improving to the doctor-patient relationship.
Michael.
The reality is that in the US we are rapidly moving to a point, in the hospital as well as the doctor’s office, technology is encroaching into and between the patient and physician. The current thinking from ONC is that we can’t get enough technology fast enough into health care settings. While there is nothing inherently wrong with IT, I myself love it, there are consequences – mostly unintended. And since everyone is focusing on that shiny object in front of their eyes…they don’t see what’s going on in the other hand. The day is fast approaching where like telephone answering “trees,” you won’t be able to access your physician without having go one line to do something first..take a health risk appraisal, view your Doctor’s Notes, etc. You won’t be given a choice…
The question that need to asked is how we can improve the doctor-patient relationship period. If HIT has a meaningful role to play in that challenge then great..if not then forget it. Just because you can build it..doesn’t mean the world needs it.
Steve Wilkins
Very powerful statements, and great comments from everyone. At uncleCare, we believe in the patient-physician bond (in this order) and are working to provide apps that improve the efficiency of their communications. Integration with HIT is key, but it is subservient to the goal of improving that bond.
Very interesting post. As you described physicians needing to be more engaging, I kept thinking about the impact of cultural competence – the lack of which is prevalent in medicine.
May technology can help there?
Angela,
Thanks for your comments. Sure technology can help…but it can’t lead… there has to be a decent relationship between the clinician and the person (aka patient). I have witnessed kind empathetic clinicians break trough “cultural barriers” as if they weren’t there…and I have seen the opposite as well. Technology can serve up tailored, culturally sensitive content. But if the patient fundamentally doesn’t like or trust their clinician what good is that in the long run? And no something is not better than nothing…that’s a cop out.
Steve Wilkins
I could not agree more! There is certainly an element of psychology and interpersonal effectiveness involved when a physician interacts with a patient. While interpersonal effectiveness and psychology can be taught, empathy and compassion cannot be taught. It’s either a part of your DNA or it isn’t. And most patients can tell the difference.
Where things begin to fall apart, or, where the rubber meets the road, is when environments aren’t conducive to such interactions mentioned above. Let’s first look at this from a patient’s perspective…oftentimes, while patient engagement begins with recognition of symptoms, the desire for answers/relief, setting up the appointment, driving to the clinic, etc…patient engagement can easily be lost when a patient has been sitting in a waiting room for hours past their appointment time. Then, once they finally get back to a room, they have to play the waiting game again. By this time, their blood pressure is elevated, their blood sugar is dropping because they’ve missed a meal they’ve been waiting so long, they’re aggravated because they’ve missed their favorite TV program, or their grandsons baseball game; by the time the Dr gets into the room to see that patient, their willingness to ‘engage’ done got up and walked out the door an hour ago. I would be willing to bet a lot of money, that if patient satisfaction improved, from the moment he/she walked into the waiting room, to the moment he/she finally got to interact with the Dr, there would be a much more conducive environment for healthy two way engagement. Furthermore, I’d be willing to bet that patient compliance to protocol and adherence to medications would also significantly improve because what the Dr is saying isn’t going in one ear and out of the other, because all the patient really cares about now is getting the heck out of there! In conclusion to the ‘patient’s perspective’, clinics have got to be run more efficiently. The part of the ‘total patient experience’ the office does actually have control over, is what happens the moment a patient walks in to the waiting area, to the moment the patient leaves. Control the variables that can be controlled. Adopt a LEAN culture, implement Six Sigma, do what needs to be done to create an environment in which the patient is encouraged to be engaged.
Please don’t get me wrong. I am not taking sides here. I am a patient, I am a healthcare provider, and I am an observer. What about the healthcare providers perspective? Where do I begin?! Medicare reimbursement cuts, learning and converting to EHR’s, desperately trying to keep up with core measures so they are not penalized, an increased patient load because there aren’t enough Dr’s to see the increased load of patients, reduced staff to cut back on cost, frustration from the staff remaining, charts piling up, PA’s for every single thing they do, order and prescribe, not enough time in the day to stop and eat lunch, etc….I could go on, but you get the picture.
So now let’s combine those two perspectives, the one of the patient and the one of the Dr. It’s very obvious to me why healthy engagement is not even an option any more. I’m exhausted just thinking about it all.
Who’s to blame? No one! Reality is what it is. In life, however, there will always be variables which we do have control over, and those which we do not. We all have to take ownership and be accountable for the variables we can control, and let the rest go. It’s too overwhelming to look at things like this from “the big picture”. Get back down to the basics, fix what can be fixed to improve Dr/pt engagement, whether that be adopting a LEAN organization, implementing Six Sigma or both. Healthcare reform is here, whether we like it or not. Organizations that run efficiently, which requires strong leadership, teamwork, and typically implementation of a program like Six Sigma, will not only survive, but prevail.
You are so awesome! I don’t suppose I’ve truly read anything like that before. So wonderful to discover someone with some original thoughts on this issue. Seriously.. thanks for starting this up. This website is one thing that’s needed on the internet, someone with a bit of originality!
Agreed, the interpersonal connection with the physician and entire care team is absolutely essential. However, there is a role for technology to play for some patients. As an advocate for a spouse who’s managing several chronic conditions, I can tell you that certain healthcare applications have been invaluable in keeping him on track. Let’s talk patient-centered care which for him means a combination of one-to-one communication with members of his care team and technology-enabled tools.
http://www.engagingpatients.org/patient-and-family-engagement-2/chronic-disease-management-rallying-support-journey/