Tag Archives: HIT

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.

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.

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.

Build ItAccording 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 toimagesols.

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.