Tag Archives: patient centered medical home

The Push For Patient Engagement – Who Benefits The Most?

It goes without saying that people – you and I – need to be actively involved (Ok…I’ll say it…engaged) in our own health.  After all it is our health we are talking about.   But I have long suspected that there may be motives behind all this talk about patient engagement that go beyond the simple argument that it’s “the right thing for patients to do.”  Motives which I believe constitute a fundamental “unspoken truth” about why policy makers, payers, vendors and at least a few providers are so passionate about patient engagement.

Truths that have remained unspoken until now that is.

Offloading Work To PatientsSam VanNorman, director of business intelligence, from Park Nicollet, shared this unspoken truth about patient engagement at a recent panel discussion on Pioneer ACOs.  In an online Forbes article, Dave Chase quotes VanNorman as saying:

“We have to incorporate the most important member of the care team — the patient. With our finite resources, we must figure out ways to offload what we have thought as tasks that needed to be done by our staff.  In most cases, it’s the patient who can do it more effectively. In the process, the patient is more engaged and it’s more efficient for everyone.”

The heretofore unspoken truth to which I refer is that for some, patient engagement is not about getting patients to do what in their own best  interest….but rather doing what’s in the self interest of policy makers, payers and perhaps providers.

I am not convinced however that most clinicians think this way.

Call me naïve, but I thought patients were the most important member of the care team because of what they can do for themselves, e.g., share information with the clinician to improve diagnosis and treatment, self-care management and so on.  Patient engagement to those thinking this way is about inviting the patient into their care and the care process to advance their activation, quality of care, clinical outcomes and the patient experience.   This approach begins with the patient.  As such, this approach is patient-centered in that the care delivery process begins by the clinician eliciting the patient’s knowledge and perspectives of their health.

VanNorman seems to believe that patients are the most important member of the care team because of what they can do for the provider and payer,  e.g., provide a more efficient, cheaper (free is pretty cheap) labor pool to which clinicians can outsource work they don’t want to do, don’t have time to do or don’t get paid to do.  Patient engagement for those that think this way begins with policy makers, payers and administrators looking for ways of offloading tasks (of their choosing) to the patient (e.g., lowest pay grade), irrespective of the patient’s willingness, knowledge or ability to comply. This approach could rightly be called bureaucrat-directed care which is antithetical to patient-centered care and the principle of PCMH and ACO models as well as the Triple Aims.

Don’t Conflate Outsourcing With Patient Engagement – They Are Not The Same

I complete understand VanNorman’s logic and agree with the notion of putting patients to work – they are a vastly underutilized resource in so many ways.  What I disagree with is conflating with “outsourcing” with patient-engagement.    I feel that the definition of patient engagement I share with most clinicians carries with it a kind of moral authority to do what’s right for the patient.   VanNorman’s attempts to cloak “physician workload outsourcing” as patient engagement feels manipulative, self-serving and  destined to disengage patients instead.

Furthermore I fundamentally disagree with anyone trying to force patients to do anything without the benefit of first:

  • Explaining to patients what you want them to do
  • Why you are asking patients to do something
  • Asking for their feedback on what you want them to do
  • Teaching patients how to do what it is you are asking them to do
  • Providing ongoing support to patients regarding what you asked them to do

The Take Away?

Maybe one of the real reasons patient engagement is so hard is that some of us are approaching it from a patient-centered perspective…while others are approaching it from VanNorman’s beauracrat-directed perspective.

This in turn translates into different motives, messages to patients, different measures of patient engagement and so on.

This may also explain why some of my peers in HIMMS and NeHC get so mad at me when I say that patient engagement is a physician-patient communication challenge and not an HIT challenge.

That’s my opinion…what’s yours?

AdoptOneBigButton1Note:  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”:

Thoughts On Patient Engagement, Patient-Centeredness and Communication-Centered Medical Records

Sometimes I come across a post that I absolutely must share… such is the case with this re-print of a post by Rob Lamberts, MD, a primary care physician practicing “somewhere in the southeastern United States.” He blogs regularly at More Musings (of a Distractible Kind), where this post first appeared.

“Patient engagement.”

What is “Patient Engagement?”  It sounds like a season of “The Bachelor” where a doctor dates hot patients.  It wouldn’t surprise me if it was. After all, patient engagement is hot; it’s the new buzz phrase for health wonks.  There was even an entire day at the recent HIMSS conference dedicated to “Patient engagement.”  I think the next season of “The Bachelor” should feature a wonk at HIMSS looking for a wonkettes to love.

Here’s how the Internets define “Patient engagement”:

  • The Get Well Network (with a smiley face) calls it: “A national health priority and a core strategy for performance improvement.”
  • Leonard Kish refers to it as “The Blockbuster Drug of the Century” (it narrowly beat out Viagra) – HT to Dave Chase.
  • Steve Wilkins refers to it as “The Holy Grail of Health Care” (it also narrowly beat out Viagra) – HT to Kevin MD.
  • On the HIMSS Patient Engagement Day, the following topics were discussed:
    • How to make Patients Your Partners in Satisfying Meaningful Use Stage 2 Objectives; Case Studies in Patient Engagement, session #64;
    • Review Business Cases for Implementing a Patient-Centered Communication Strategy and Building Patient 2.0, session #84;: and
    • Engaging People in Health Through Consumer-Facing Devices and Tools, session #102.

So then, “patient engagement” is:

  • a strategy
  • a drug
  • a grail (although I already have a grail)
  • a “meaningful use” objective
  • something that requires a business case
  • something that requires “consumer-facing devices and tools” (I already have one of those too).

I hope that clears things up.

So why am I being so snarky about this?  Why make fun of a term used by many people I trust and respect?  I was recently discussing my ideas on a communication-centered medical record with a colleague.  At the end of my pontification, my friend agreed, saying: “you are right; communication is an important part of health care.”  I surprised him by disagreeing.  Communication isn’t important to health care, communication is health care. Care is not a static thing, it is the transaction of ideas. The patient tells me what is going on, I listen, I share my thoughts with the patient (and other providers), and the patient uses the result of this transaction for their own benefit.

But our fine system doesn’t embrace this definition.  We indict ourselves when we talk about “patient engagement” as if it’s a goal, as it reveals the current state of disengagement .  Patients are not the center of care.  Patients are a source of data so doctors can get “meaningful use” checks.  Patients are the proof that our organizations are accountable.  Patients live in our “patient-centered” medical homes.

Replacing patients as the object of our attention (and affection) is our dear friend, the medical record.  We faun over medical records.  Companies earn epic profits from medical records.  We hold huge conferences to celebrate medical records.  We charge patients money to get to see their own medical records.  We even build special booths (portals) where patients are allowed to peer in through a peep hole and see parts of their medical records.

This is why I’ve had such a hard time finding a record system for my new practice.  I want my IT to center on patients, but medical record systems are self-absorbed.  They are an end in themselves.  They are all about making records, not engaging patients.  They are for the storage of ideas, not the transfer of them.  Asking medical records to engage patients is like asking a dictionary to tell a story.

The problem is, documentation has taken over health care.  Just as the practice of a religion can overshadow its purpose: the search for God, documentation chokes out the heart of health care: the communication of ideas .  It did this because we are paid to document, not communicate.  Communication takes time and it is not reimbursed.  Communication prevents unnecessary care, which is a revenue stream.  Communication eliminates waste, and waste is food that feeds the system, the bricks that build the wings to hospitals, the revenue source that pads IT budgets.

So what’s a doctor to do?  I’m not sure.  I am still looking for a solution that will meet the central goals of my practice:

  • Communication – health care is a hassle,  with communication relegated to the exam room.  I want care to be easily accessible for my patients,using IT in one of its strongest areas: tools for easy communication.
  • Collaboration – the patient should be engaged, but in a two-way relationship.  This means they not only should have access to their records, they should contribute to those records.
  • Organization – I want a calendar documenting visits, symptoms, problems, medications, past and future events in each patient’s record.  I also want a task-management system I share with patients to make sure care gets done.
  • Education – I want to practice high-quality medicine, care that is informed by good information and the best evidence.  Why not do a yearly stress test?  There’s evidence for that.  Why not use antibiotics for sinus infections?  There’s evidence there.  Why use an ACE inhibitor to control the blood pressure?  I need to be able to support my recommendations with data, not just “because the doctor said so.”

The point of all of this is the moving of medicine from an industry where money is milked from disease to a communications network where diseases are prevented.  ”Patient engagement” that is done to the patient for the sake of the doctor or hospital is a sham.  Engagement is about interaction, listening, and learning in relationship to another person.  Engagement is not a strategy, it is care.

If only I could find the tools to make this happen.

ACO Success Will Depend Upon The Patient-Centered Communication Skills Of Providers

Accountable Care Organizations (ACOs) and “bundled payments” are set to play a central role in the Affordable Care Act.  Under accountable care, physicians and hospitals would be paid out of a “single payment” from CMS or health insurers for all the care needed to treat a clinically defined “episode of care” like a heart attack.   The premise is that bundle payments will incentivize physicians and hospitals to deliver more efficient, high quality care.

Much has been written about the health information technology infrastructure needed to support ACOs.  Experts also underscore the need for providers (physicians and hospitals) to get patients with conditions like heart failure more engaged in prevention and self-care.  After all, as much as 90% of the “care” for chronic conditions like heart failure is provided by the patient and their care givers at home.  But effectively engaging patients has been a difficult nut to crack for health care providers.

What Can ACO Providers Do To Increase Patient Engagement?

Here’s the short answer – improve the quality of communications between physicians and patients.  After all, physician-patient communications is how most patients are diagnosed and treated.

The degree to which patients and physicians agree on key aspects of the diagnosis and treatment is said to be an indicator of communication effectiveness.  Disagreements such as the nature or severity of a medical condition or the need for a new medication represent a breakdown in physician-patient communications.  Such breakdowns are common and are closely associated with patient behavioral issues such as non-compliance, excessive health care use, and decreased satisfaction.

High levels of physician-patient agreement are linked with more desirable patient outcomes and behavior.  Physicians that use a patient-centered style of communication tend to report much higher levels of agreement with their patients on critical diagnosis and treatment issues.

The Current State of Physician-Patient Communications

A 2011 study of patients diagnosed with a heart condition, and being seen in a public hospital cardiology clinic, illustrates the scope of the communication problems facing not just ACOs…but all health care providers today.

In the study, 55% of patients diagnosed with heart failure did not recognize (nor agree with their doctor) that they had heart failure.  Even more disconcerting was the finding that “only 15% of those with hypertension agreed with their doctor’s diagnosis.

Physician-Patient Disagreement And A Lack of Patient-Centered Communication Are Greatest Amongst Population Groups That Are The Sickest And Most In Need

African-Americans experience heart failure at a rate this is 20 times higher than their white counterparts.  Physicians that treat blacks are less likely, according to researchers, to use a patient-centered communication style.

Numerous studies have revealed that when treating black patients, as opposed to white patients, physicians tend to “provide less health information, are more physician-directed (versus patient-centered), spend less time building a rapport with patients, and are more verbally dominant.“  In other words, the patients that are in greatest need for patient-centered communications, and the benefits it provides, are presently the least likely to receive it.  The lack of high quality patient-centered communication is not limited to minority groups.  An estimated 60% of practicing physicians use a physician-directed communication style.

 The Take Away?

Needless to say, the quality of physician-patient communications in the U.S. does not bode well for the success of ACOs.  Health plans, physician groups and hospitals looking to realize the financial benefits of bundled payments and accountable care should give serious consideration to investing in benchmarking tools and communications interventions that will measurably improve the quality of physician-patient communication both in the office and hospital.

That’s my opinion…what’s yours?

Sources:

Cené, C. et al. The Effect of Patient Race and Blood Pressure Control on Patient-Physician Communication. Journal of General Internal Medicine. 2009. 24(9):1057–64

Sarkar, U. et al. Patient-physicians’ information exchange in outpatient cardiac care: time for a heart to heart? Patient Education and Counseling. 2011. Nov;85(2):173-9.

Johnson, R. et al. Patient race/ethnicity and quality of patient-physician communication during medical visits. American Journal of Public Health, 2004. 94(12), 2084-90.

Patient-Centered Communications – A Great Differentiation Strategy For Primary Care Physicians

More and more it seems that primary care physicians are becoming commoditized.   You know…where there is nothing to differentiate one group of physicians from another group of physicians down the street.

I really don’t understand why primary care physicians don’t make more of an effort to “stand out” from the competition in some meaningful way.   Being a former hospital marketer, I am even more surprised that hospitals systems, which now employ many primary care physicians, have been so slow to recognize the benefits of differentiating their physician partners from those across town.

That’s why I was surprised with a TV ad which I saw in my local San Jose market run by John Muir Medical Center in Walnut Creek California.   The ad is the first I have seen which uses their physicians’ patient communication skills to differentiate themselves from competitors.    Given that poor communication is the number one complaint most people have about their physician,  this is a great strategy.

In truth I can’t say that John Muir’s physicians are any better at communicating with patients than any other groups of physicians.  I would need to see evidence beyond that captured in patient satisfaction surveys.   You know…the same satisfaction survey everyone uses with the same wonderful results.   What I can say is that if in fact the ad is factually correct, John Muir is on to something.

With Patient Expectations Of Their Doctor’s Communication Skills Being So Low – It Easy For Physicians With Good Communication Skills To Stand Out

Poor communications is an issue for  my doctor and I.   I am reluctant however to change doctors because I doubt that other physicians are any better when it comes to patient communication.   But what if they were!

What if the physicians affiliated with a particular hospital system actually did communicate measurably better than their competitors?  With the advent of the Patient-Centered Medical Home, there’s lots of talk about primary care physicians becoming more patient-centered.    Why don’t hospital executives begin helping their physicians, both independent and employed, become more patient-centered in the way they communicate with patients through training programs?   After all patient-centered communication is the gold standard  for how provider should communicate with patients.  Even more interesting would be those same hospitals teaching patients how to effectively engage their physicians in discussing ways they can get more involved in their own care.

Just imaging patients walking out of your physicians’ offices amazed and delighted that their physician:

  • asked their opinion
  • invited their questions
  • was present in the moment and
  • actually listened to what the patient had to say.

Effective patient centered communication is one great way for primary care physicians and their hospitals partners can to avoid being commoditized and to stand out as market leaders.   Are you ready?

That’s my opinion, what’s yours?

Five Myths About Empowered Patients Or E-Patients

[tweetmeme source=”Healthmessaging” only_single=false]Irrational exuberance was a term once used to describe the stock market before the last crash.  It also seems an apt description for much of the talk these days about empowered health consumers.

To be sure, patients today have unprecedented access to health information.  Patient decision-support tool can be found on just about every provider, payer and self-insured employer website.  Consumers can go to any number of websites to find quality data about hospitals, physicians and health plans.  Personal health records (PHRs) promise to make our personal health data portable for meaning that all our treating physicians will be “singing off the same song sheet.”

That’s what the industry experts tell us.  But what’s really going on?  Here I will describe what I see as the top 5 myths about empowered health consumers.

Myth #1 – All Patients Are Empowered or Becoming Empowered

Since pre-internet days (early 1990s), health behavior research has shown that about one third of adults desire above average health, one third are satisfied with average health, and one third don’t care one way or another.   Not surprisingly there is a direct correlation between one’s health aspirations and the degree to which one engages in activities typically associated with “empowerment, i.e., health information- seeking, exercise and good nutrition, and so on.   For example, people who place a low priority on health related activities for example often have an external locus of control.  This means that they don’t believe they can do anything to change their health destiny.

Using health information-seeking as a proxy for empowerment, it does not appear that people are significantly more inclined to seek health information today than they did during pre-internet days.

Myth #2 – Most Patients Choose To Be Empowered

Are patient empowered because they want to be or because they are forced to be out of necessity?  It is noteworthy that much of the research on patient empowerment comes from research pioneered by the National Cancer Institute.   This suggests a causal relationship between one’s condition (cancer) and how one reacts to it (information-seeking).  This trend subsequently spread from cancer care to all health care as physicians started to increasingly delegate health responsibilities to patients…without asking them, telling them or teaching them how to engage in these responsibilities.   Just ask any primary care physician involved in a medical home conversion.  Anecdotal evidence suggests that a good number of patients, when told of their new personal health responsibilities, respond by tell the doctor that “that’s your job.”

To be sure, a fair number of patients have become quite competent at managing their own health.  But it would be a mistake to assume that everyone is equally predisposed or capable of doing so.

Myth #3 – Health Information-Seeking Equal Empowerment  

Almost 80% of adults go online to seek health information according to the Pew Institute.   There is a tacit assumption in health care that information- seeking is synonymous with empowerment.  Yet information alone is not enough to change a person’s health behaviors, i.e., make them empowered, according to leading health care experts like Thomas Bodenheimer, MD, self care management guru Kate Lorig, and others.  Factors such as the person’s skills, self confidence and knowledge of how to navigate the health system are also important pre-requisites of behavior change.

It is worth noting that for some people; too much information can be disempowering resulting in too many choices and decisions.

Myth #4 – An Empowered Patient Trumps The Doctor

Nothing shuts down an empowered patient any faster than a physician who is short on time and communicates with patients using a physician-directed communications style (versus patient-centered).   As it is, the medical exam process does not afford patient much of an opportunity to speak without interruption.  As such most patients, including empowered patients, ask very few important questions.

Anecdotal evidence suggests that the longer one waits in the office to see the doctor, patients are moved to ask fewer questions in the interest of the doctor’s time.

Myth # 5 – Empowered Patient Are At Odds With Their Doctor

Empowered or not, patients and their doctors disagree on a fair number of important issues including reason for the visit, diagnosis, treatment options, amount of information desired, communication preferences and so on.  So disagreements are probably not the cause of the impression that being empowered equates to be obnoxious.   Rather the trick for the most empowered among us is to be able to disagree without being disagreeable.

That’s my opinion…what’s your?

Sources:

Wilkins, S. et al. A New Perspective on Consumer Health Web Use: “Valuegraphic” Profile of Health Information Seekers. Managed Care Quarterly. Vol 9, No. 2, 2001.

Bodenheimer, T. A 63-Year-Old Man With Multiple Cardiovascular Risk Factors and Poor Adherence to Treatment Plans.  JAMA. 2007;298(17):2048-2055.