Tag Archives: Health Information Technology

Engage Your Patients And Members Where They Are…Not Where You Wish They Were

Not long ago, Lloyd Dean, president and CEO of the San Francisco-based health care-system Dignity Health announced the Dignity Health and Box Patient Education App Challenge. In the course of the announcement, Dean is quoted as saying:

“We recognize the immense potential that (health information) technology has to enhance our patients’ care and overall experience.”

Dean’s use of the term “immense potential” with respect to patient-facing technologies like health apps and patient portals got me thinking. Immense potential compared to what? [pullquote]Dean’s use of the term “immense potential” got me thinking. Immense potential compared to what?[/pullquote]

With all the hype in the health press about the patient engagement potential of patient-facing health information technologies, one could be forgiven for thinking that HIT is the best if not only path to patient engagement. But in fact there is another way. Another more immediate, less costly and proven way. And its potential to engage patients, enhance care and improve patient experiences dwarfs the “immense potential” of patient-facing HIT by comparison.

PC Communications vs HIT
Rediscovering the Power of Physician-Patient Exam Room Conversations

Here’s what I mean. The average office-based physician engages in some 4,224 face-to-face visit-related conversations with patients each year. Depending upon their communication skills, each of these conversations represents an opportunity for physicians to engage patients, enhance care and improve patient experiences.

In the case of Dignity Health’s 11,000 physicians, assuming they see an average of 20 patients/day/physician, this comes out to:
220,000 patient visit per day , 880,000 patient visits per week 45.7 million patient visits per year

Now factor in the 3-4 complaints each patient brings to the visit along with a myriad of beliefs, fears and expectations for service (tests, referrals, new medications, and so on). I hope you are starting to realize that each patient visit is pregnant with opportunities for clinicians – your clinicians – to engage, empower and excite patients…. sometimes by doing nothing more than listening to what the patient wants to say. Remember these are real opportunities that exist in the here and now…not some promise or dream of possibilities to come.
3-4 Complaints + 2-3 Requests + 4-5 Expectations = Lots Of Opportunities To Engage Patients

At this point you might be thinking that your physicians are already leveraging these exam room opportunities to build your organization’s brand, to refer patients to your specialists and ancillary services, and to direct patients to health information on your their/your patient portal. You would probably be wrong. Not because of the limited time available during the office visit…but rather because many physicians have never been trained or provided with the communications tools needed to recognize or facilitate these kinds of opportunities. But that is the topic for a separate post.
The Patient-Facing HIT Opportunity

Now consider the opportunities in Lloyd Dean’s brave new world…a vision shared by HIT professionals health developers, vendors and their respective professional organizations.

Staying with the Dignity Health example, let’s assume that each of Dignity Health’s 11,000 doctors have patient panels of 2,300 adults and that 10% of these people use their respective patient portals or smart health apps 5 times per year (a generous assumption). This comes out to approximately 12.6 million opportunities for Dignity to engage, empower and excite patients/consumers per year.

It’s doubtful that the opportunities for meaningful engagement afforded by a patient portal or health app compare qualitatively to the opportunities possible with a face-to-face physician visit. Being able to check one’s lab tests, schedule an appointment, or refill a prescription while convenient are do not afford the same therapeutic benefits of a listening ear or the touch of a clinician’s hand.
The Take Away

The real “immense opportunity” for engaging patients, enhancing patient care and improving patient experiences lies behind the closed exam room doors of physicians. That is the most frequent point of contact health care consumers have with the health care system. It is also where truly meaningful patient engagement and memorable patient experience take place.

Engaging patients, enhancing care and improving patient experiences is not an either or choice between more health IT or better physician-patient communications. Providers will need both in the long run. HIT will enable clinicians with good patient communication skills to touch more patients and get more done. Physicians in turn will recommend that patients go to their patient portals and smart apps for health information.

Imagine the ROI that organizations like Dignity Health’s could realize from their investments in patient portals and health apps if all 45.7 million annual patient visits were given a tailored information therapy prescription directing them to one or the other or both.

Now that is what I call IMMENSE POTENTIAL!

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

Helping physicians, hospitals and health plans do a better job of engaging patients, enhancing patient care and improving patient experiences in the exam room is the goal of the Adopt One! Challenge. The Challenge is a great way for physicians to get a comprehensive baseline assessment of their patient communication skills, find out how their communication skills compare to best practices, and get access to online skills development tools.

Be sure to sign up for the Adopt One! Challenge Newsletter for more information. Health plans and hospitals are invited to sponsor the Adopt One! Challenge for physicians in their provider network, including PCMHs and ACOs.

Do You Really Believe That 41% Of People Would Switch Physicians To Gain Online Access To Their EMR?

I love survey data as much as the next person. But some of the survey data finding its way into the health care press these days is pure baloney…which is good if you like baloney.

Such was the case with the finding from an Accenture study which was making the rounds of the Health Information Technology (HIT) Journals, HIT Blogs and Twitter feeds during National Health IT Week. You will no doubt recall the headlines which proclaimed that “41% of U.S. consumers would be willing to switch physicians to gain online access to their own EMRs.”

Upon first glance, the question of “would you be willing to switch physicians” to accomplish a social good (access to your electronic medical records) seems reasonable enough. It’s one of those questions that most of us would be inclined to agree with. It’s kind of like asking people if they would be willing to pay lower taxes or pay less to fill up your car’s gas tank. Of course we will say yes.

In the Accenture study literally everyone did! Remember 36% of respondents said they already had full access to their EMR (whatever full access means), 27% said they had limited EMR access and 37% said they did not yet have any EMR access. So if 41% said they would switch physicians to get EMR access we are left to conclude that all 100% of those without EMR access would switch…plus 4% of those who already had EMR access would also switch doctors presumably because they wanted more EMR access.

At face value, this Accenture data does not hold water…and here are a couple of reasons why.

  • 79% of people (patients) are already very satisfied with their personal physician (patients who rated their physician 9-10 on the 10 point 2012 CHAPS survey released recently by AHRQ. Very satisfied patients are not likely to switch physicians unless they have a darn good reason and access to Health IT is not a good enough reason for most people.
  • People’s criteria for selecting a new physician focus on human interaction skills and clinical competencies – not the physician’s Reasons For Changing Doctorsuse of EMRs and other Health IT (i.e., PHRs, web portals, etc.).
  • Similarly, people’s reasons for switching physicians have to do with changes in insurance, relocation, and the physician’s human interaction skills…not the lack of an EMR, PHR or patient portal.
  • 100% of people can’t agree on anything including EMRs – intuitively we know that seniors (who have the highest health care need/use) have a higher trust in their physicians and are less inclined to care one way or another about Health IT, other people worry about personal data security and so on.
  • A 2012 survey by the Markle Foundation found that “79 percent or more of the public believe using an online PHR would provide major benefits to individuals in managing their health and health care services.” Yet actual consumer adoption of online PHRs has been less than 10% for the last several years (with some notable exceptions like Kaiser, Group Health and the VA). There’s a big difference between what people believe or say they are willing to do…and what they actually do.

The Take Away

What people actually do or intend to do (behavioral intentions) are much stronger and reliable predictors of behavior (switching physicians for example) than attitudinal questions about their beliefs or potential willingness to do something in the future in relation to other behaviors they could engage in. The Accenture study would have been more instructive had it asked respondents to rate the importance of Health IT (EMR) in relation to other physician selection factors like the physician interpersonal skills, their knowledge and experience, etc. It would also be helpful for Accenture to inquire as to the respondent’s knowledge of EMRs and what constituted full versus limited access…and which is addresses the consumer’s level of interest and need.

Is The CEO Of The Cleveland Clinic Serious When He Says “No More Passive Patients”?

If a recent blog post by the CEO of the Cleveland Clinic is representative of how health care executives (and physicians) really think about patients – aka consumers –aka people like you and me…we are all in big trouble.  In it Delos Cosgrove, MD, talks about how under health care reform there will be “No more passive patients.”

Here’s my a quote from the post by Delos Cosgrove, MD:

“For too long, healthcare has been something that was done to you. Now it’s going to be something you do for yourself in partnership with your doctor and care giving team. You’ll need to monitor your food input, get exercise, and avoid tobacco. ”

Let’s examine what’s disturbing about comments like this particularly when made by high-profile leaders like Dr. Cosgrove.

First, this statement is factually inaccurate.  Here’s why.  82% of US adults visit their PCP every year at least once a year (often more) for their health.   Think about the trip to the doctor’s office from the patient’s perspective… 1) chances are they have discussed their health problem or concern with family members or friends, 2) they may well have looked up information on their condition to see if it merits a doctor’s visit, 3) they make the appointment, 4) they show up for the appointment and 5) wait in the waiting and exam room thinking about the questions they want to ask their physician.

What about any of this suggests patient passivity?

Second, this statement misrepresents the true nature of the patient passivity of which Dr. Cosgrove speaks.  You see patients (aka people) are socialized by physicians beginning in childhood visits with Mom to the pediatrician to assume a passive sick role.  We are supposed to be passive! Otherwise the doctors gets irritated and ignores or dismisses what we have to say.  While it’s true that patients (even the most empowered among us) ask very few important questions during the typical office exam…the reason isn’t that we are passive.  Rather it’s because we don’t want to be too assertive, confrontational, and argumentative or are simply afraid.

Rather that blaming patients for not being more engaged…why don’t doctors try and become more engaging (e.g., patient-centered) to patients?

Third, patient non-adherence is often not the patients fault…but rather the result of poor communications on the clinician’s part. One recent study found that 20% of medication non-adherence is the direct result of poor physician communication with patients. Poor patient communication skills top the list of complaints people have with their doctor. Poor patient communication is also the leading cause of medical errors, non-adherence and poor patient experiences.

AdoptOneBigButtonFourth, how exactly are patients going to learn all the skills necessary to “do everything” for themselves?  The work of Lorig et al. has shown that simply providing patients with information – the “what” of self care – is not enough to change patient health behavior.  Patients also need and want to develop the skills and self efficacy for self care management – the “how” of self care.   Right now for example clinicians spend on average <50 seconds teaching patients how to take a new medication…and we wonder why patients are non-adherent.

Given the poor patient communication skills of physicians today how exactly are patients supposed to learn how to do it all themselves?

Finally, the Dr. Cosgrove reminds us of the kind of paternalistic, physician-directed thinking and communications which has gotten the health care industry into the mess it’s in.

The following statement says it all:

“If your doctor prescribes a medication, preventive strategy, or course of treatment, you’ll want to follow it.”

What if I don’t want the medication or don’t believe it will help me? Why should I be forced to do something I don’t want to do? Will you drop me as a patient?
What happened to the IHI’s Triple Aims?  What about the need to be more patient-centered as called for in Crossing the Quality Chasm and the ACA reform legislation?

I am sorry if I seem to come down hard on Dr. Cosgrove. But my original point remains…too many health care leaders still think and talk like this.  While they may “talk the talk”…employees, patients and physicians all see how such leaders “walk the talk.“  And as Cosgorove’s comments suggest we have a long, long way to go.

I would like to extend an invitation to Dr. Cosgrove and the physicians at the Cleveland Clinic to see just how “patient-centered” their communication skills really are by participating in the Adopt One! Challenge.   You will not only be able to assess the quality of your team’s patient communication skills but also see how their skills compare to industry best practices.

All physicians are invited to participate in the Adopt One! Challenge.

That’s my opinion…what’s yours?

First Principle of Patient Engagement & Patient Portals– Be “Relevant” From The Patient’s Perspective

One of the biggest challenges facing health care providers today when it comes to engaging patients is RELEVANCE…or more specifically the lack of it.   I say “engaging” because any one presenting in the doctor’s office, visiting a patient portal or using a smart phone health app is already engaged in their health.   By engaged I mean they are already cognitively involved in their health to a certain extent with an end Relevantpoint or goal in mind, i.e., learn something, do something or decide about something.   Face it, who do you know that goes to the doctor’s office just for fun.  There is always a reason…and behind that reason is cognition, e.g., intellectual engagement.

Fact – 82% of U.S.  adults see their personal physician at least once a year (avg. is 3 visits/year) and yet experts tell us that most of us are still  unengaged in our health.  What’s with that?

Relevance Is Important In The Doctor’s Office

Now imagine a 55 years old person going into their doctor’s office because of a persistent headache and back pain.  Before deciding to see the doctor they probably talked with their family or friends about their concerns. Maybe they went online to research their concerns before making a doctor’s appointment.  Now imagine that same person in the exam room and all the doctor wants to talk about is the patient’s risk for colon cancer and the need for an overdue colonoscopy.  Bam. Instant patient disengagement.

AdoptOneBigButtonTo be sure, the clinician in this scenario is legitimately trying to “engage” the patient by getting them to comply with a recommended, evidence-based screening.  But there is a disconnect in this scenario between what the person (patient) wants to talk about during their office visit…and what the clinician wants’ to discuss.  The disconnect? A lack of relevance.  What the clinician wants to talk about is not nearly as relevant to the patient as it is to the clinician and that’s a problem.

Here’s another example of a common physician-patient disconnect.  Using the same scenario, imagine that the person/patient concerns regarding their headache and back pain have to do with how these symptoms are affecting their vision (ability to drive), their gait, their ability to sleep at night and their appetite.  For the person/patient, their quality of life is suffering as a consequence of their complaints.

Now consider that physicians – at least those with a physician- or disease- oriented style of communicating with patients (which make up 2/3s of primary care physician) – will focus during the medical exam on the biomedical causes of the patient’s complaints rather than the quality of life issues of concern to the person/patient.  Also realize that most patients are now very good or willing to interrupt or correct their physicians.  Bam. Bam. Instant patient disengagement.

Once again, while what the clinician focuses on may be the cause of the patient’s problems, it’s not relevant to the patient that wants to know how the doctor will fix their loss of vision, gait, sleeping and appetite.

This same scenario is played out every day in physician offices across the country.  Disagreement over the visit agenda isn’t the only reason for communication disconnects or gaps.  Lack of physician-patient agreement is also common when it comes to:

• What’s wrong
• Diagnostic tests needed
• Accuracy of the diagnosis
• Severity of the diagnosis
• Cause of diagnosis
• Appropriateness of the recommended treatment
• Expected efficacy of the recommended treatment
• Need for a specialist referral

Relevance Is Just As Important To Patient Portals

Finally, imagine that the Electronic Medical Records and Open Notes detailing the above scenarios are available to the person/patient via a patient portal.   Imagine also that the HIT folks used the patient’s diagnosis and doctor’s notes to “trigger” personalized, tailored health information for the patient.   That means that the patient is sent messages about this risk of colon cancer, information about diet and colon health and a coupon for a colonoscopy.

Now ask yourself…how in God’s name is the information provided via the patient portal in this scenario relevant or engaging from the person/patient perspective?  Explain to me how the information in the EMR and Open Notes is relevant to the patient if its ignored?  It’s not…and people/patients need only look at their patient portal once to figure that out.

The Take Away?

HIT’s current attempts at patient engagement remind me of the parable of “putting old wine (same old information) in to new wine skins (patient portals). The wine’s going to go bad and few will drink it. The solution is to add relevant, “patient-centered” wine into the new wine skins.

Patient engagement is not an HIT challenge…it is a physician-patient communication challenge. As such, the role of the clinician is to engage patients…but rather to be engaging or at the very least avoid disengaging patients.

That’s my opinion. What’s yours?

Patient Non-Adherence (Like Engagement) Is A Physician-Patient Communication Challenge – Not A Health Information Technology Challenge

Have you noticed all the articles in the health care press lately touting health information technologies’ ability to increase patient medication adherence?  Smart phone-based apps, Smart pill bottles and Patient Portals are all about trying to get patients to do something (take a medication) which some physician somewhere has deemed to be the right thing for the patient to do.   Some would call this process of generating adherence patient engagement.

AdoptOneBigButtonChalk these high-tech patient reminder solutions up to just another well-intentioned but misguided attempt by HIT vendors at patient engagement…one not likely to be met with much long-term success.  Sorry folks.

The fact is that these high-tech solutions, like physicians, still talk about non-adherence as if it is all the patient’s fault.  Come on …you have to admit that’s not a very engaging “message.”   You know…patients don’t fill (refill their prescriptions), patient don’t take their meds are directed, patient forget, and so on.  According to people much smarter than I am about such things, this perspective is outdated.

Many researchers now argue that patient non-adherence is more often the result of ineffective patient communication skills and not “disengaged, lazy or forgetful patients.”  One study showed that 19% of patient non-adherence was attributable to poor physician communication with patients.

It is also worth noting that there are two types of patient non-adherence – intention and unintentional…only one of which is addressed by these high-tech solutions.   In this post I want to focus on the intentionally non-adherent patients (the one not addressed by the reminders) .  After all, only bad or stupid people would intentionally go against something that clearly is their best interest…right?

Wrong.  As it turns out there are lots of legitimate reasons (from the patient’s perspective) for non-adherence.

Here are the main reasons cited in the literature:

  • The patient doesn’t agree with the diagnosis necessitating the prescription
  • The patient believes the diagnosis but doesn’t think the diagnosis is serious enough to merit taking a new medication prescription
  • The patient doesn’t believe in taking medications
  • The patient believes the risks associated with the medication outweigh the benefits
  • The patient doesn’t believe the medication will work
  • The patient can’t afford the medication

NonAdherenceThink about your recent physician visits, where your clinician prescribed a new medication.  I’ll bet one or two of the above “reservations” flitted across your mind.  I’ll also bet that your provider never once asked how you felt about taking the prescribed medication.  I’ll even go out on a limb and bet that most of you never mentioned your reservations to your provider either.

Don’t believe me?  Then consider this factoid.  When prescribing a new medication, the average primary care physician spends less than 50 seconds teaching (too strong a word) patient about the medication, e.g. why they need it, how to take it, how much to take, when to take it, indications and contraindications, when to stop and what to do when you stop.  That’s not much time for the physician to say everything that needs to be said (which doesn’t happen).  Nor does it leave time for the patient to say much.

Since most patients are reluctant to interrupt or contradict their clinician, many if not most of the concerns patients have about taking the new medications are never voiced.  Rather, patients just go home and never fill the prescript.

So now help me understand how my patient portal or smart phone app can engage me by implicitly blaming me for not taking my medications.  Or motive me to take my medications  when I don’t believe that they are not necessary or that they may be worse for me than the problem they are intended to solve.

Patient adherence is much more likely to occur when the patient and clinician agree on the basics, e.g., the diagnosis and treatment.  That requires a conversation or two or three.  The goal of effective clinician-patient communication is to resolve such disagreements.  And that is why the solution to patient non-adherence lies in developing the patient-centered communication skills of clinicians…not in trying to cajole patients into using some new app or patient portal that totally ignores their concerns and beliefs.

All together now…patient adherence (and engagement) are a physician-patient communication challenge…not an HIT challenge.

That’s what I think. What’s your opinion?

Note:  Later this Fall, 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”:

Sources:

Koenig, C. J. (2011). Patient Resistance as A in Treatment Decisions. Social Science & Medicine (1982), 72(7), 1105-14.Johnson, J, et al. (2005) Factors Associated with Medication Nonadherence in Patients With COPD. Chest. 128(5).

Wilson, I. et al. (2007). Physician – Patient Communication About Prescription Medication Nonadherence: A 50-State Study of America’s Seniors. Journal of General Internal Medicine. 22(1), 6-12

Johnson, J, et al. (2005) Factors Associated with Medication Nonadherence in Patients With COPD. Chest. 128(5).

Zolnierek, H. et al. (2009) Physician Communication and Patient Adherence to Treatment: A Meta-Analysis. Medical Care. 47(8), 826-834.

Sarkar, U., et al. (2011). Patient-Physicians’ Information Exchange in Outpatient Cardiac Care: Time for a Heart to Heart? Patient Education and Counseling, 85(2), 173-9.