HIT-Driven Patient Engagement Is A Bust – Effective Patient Engagement Begins With The Doctor-Patient Relationship

I hate saying I told you so.  But to quote myself…”patient engagement is a physician-patient communications challenge and not an HIT (Health Information Technology) challenge.”

Just take a look at the Mayo Clinic’s patient portal experience which was discussed at a HIMMS 2013 and reported on in HIT industry press.

The Headline

Mayo Clinic Struggles To Meet Stage 2 Meaningful Use Thresholds For Engaging Patients.

Always innovating, the Mayo Clinic some three years ago introduced a web-based portal to share information with their patients.  During that time some 240,000 patients have signed up for online accounts.  That’s pretty impressive.  But there’s a problem.  A BIG PROBLEM.

According to Eric Manley, product manager of global solutions at the Mayo Clinic, they are having a hard time “getting more than 5% “of all the patients who registered with the patient portal to actually use it.   You see in order to meet Stage 2 Meaningful Use requirements, and enjoy the benefits that come with meeting this criteria, people actually have to use the portal to access their own health information.  You just can’t build a portal and in Mayo’s case have fewer than 12,000 unique patients actually use it.    Actually you can…hospitals and physicians do it all the time…they just can’t get incentive payments for their efforts.

 So What Went Wrong?

It’s not like the folks at Mayo haven’t tried.  Mayo’s patient portal offer all the requisite techie gizmos – giving patients access to their medical record, lab results, appointment schedule, and lots of health information.  They also recently introduced their first patient-directed mobile health app call “Patient” which makes it easy for people to access their health information online.   Mayo even has a Center for Innovation to figure this kind of stuff out.

Upon reflection Manley admits that “simply making services available doesn’t cut it,” he said. “Unless you are engaging patients, you won’t meet meaningful use requirements. [Messaging and other mechanisms] need to be a part of your practice.”

But Wait – I Thought Patient Portals, EMRS and Health Apps Were Patient Engagement Strategies?? You Mean We Need To Do More?

Manley is quoted as saying that “patient engagement has been a part of what Mayo has done for a long time, meaningful use, especially Stage 2, is a catalyst to kick it up a notch.”

Let’s face it.  Meaningful Use maybe a good way to get providers to adopt badly needed HIT improvements – but it not a great way to force patients to “engage” with you.   Here’s why.

1)    Forcing patients to do anything is wrong and antithetical to the whole idea of patient-centeredness…even if you think it is in the patient’s best interest. Meeting Meaningful Use seems to take precedence over what the patient wants.  Manley is quoted as saying “just having it [information and portals] out there isn’t enough”…”It’s making the patient use them.”

2)    Patients want to engage with other people regarding their health, particularly their physicians. Health after all is an intensely personal and social affair.  Mobile health apps and email just can’t give patients want they want – to be listened to and understood.  Plus 85% of people want face-to-face access to their physician when they want it.  Patients know that HIT threatens to get in between them and their doctors.

3)    The content on most patient portals is not particularly relevant or engaging after the first 10 seconds….at least from the patient’s perspective.   After all, cognitive involvement is a prerequisite of meaningful engagement and it tough to be interested and spend time thinking about information that is not in context (of a medical encounter), you don’t understand, find boring, completely inaccurate or irrelevant.

So What Is The Solution?

There’s no question that if done right patient portals can and do work.  One need look no further than Kaiser Permanente, Group Health and the VA for great examples.  The key to their success…and hopefully every provider’s success…is integration.

Health care for us patients occurs within the context of social relations with our physicians.  To be engaging…the information you want to share with us needs to be relevant to us from our perspective, come from our physician and be integrated into our overall care plan.    Only then will we have the trust and confidence that the information is ours…and is something we need to pay attention to.  We focus on our health while we are in the doctor’s office…if you really want to engage us…do it there.

That’s my opinion…what’s yours?

What Are Your Personal Health Goals? Have You Ever Shared Them With Your Doctor? Has Your Doctor Ever Asked You What Yours Are?

Face it.  We all have personal health goals.  We may not share our personal health goals with family of friends like we do our financial or professional goals, but we all still have them.   I for example aspire to the following personal health goals:

• To defy the conventional wisdom associated with aging (look younger, feel younger, live like I am younger).
• To avoid premature aging – vision problems, flexibility and balance issues, aging and appearance, weight gain, skin tone, etc.
• To not be called old by my grand kids
• To live a more active life than my parents did
• Question authority (yes I am a product of the 60’s and 70’s)

OK so I am vain.  I bet I am not the only one.  I am just the one dumb enough to publicly admit it (LOL).

Have I ever share these goals with my doctor?  Are you kidding me?

He can’t deal with the fact that I experience depression from time to time and insist on telling him about it…eeewww.   Besides…he will just tell me that getting old is part of the natural process.   You are supposed to lose your hearing, lose your balance and flexibility, get fat and wrinkly, become senile, and so on.   Let’s face it. It’s hard to have a conversation with someone – including your physician – when you know from experience that they are simply not interested  in what you have to say…or don’t share your point of view…when it comes to certain subjects.

There’s also another reason I have never shared my person health goals with my physician.   I have never been asked.

In their defense, doctors aren’t trained to care about things beyond the realm of strict biomedical conditions – acute conditions in other words.   That’s why it is so hard for physicians and many other provider types to get their heads around patient-centered care.   To become more patient-centered providers need to deal with touchy feely issues like personal health goals, personal health beliefs and motivations, family issues, depression, anxiety and all the other human emotions.   A physician I know referred to patient-centered care as a kind of “rabbit hole” physicians just don’t want to go down.  Getting to know the “person behind the disease” is time consuming and can take you down paths you not sure where they end up!

Health care executives, providers and payers wonder why patients aren’t more engaged in their health…aka do as they are told.  The problem isn’t that patients (people) aren’t engaged in their health…they are…the problem is that so much of what is passed off as patient engagement these days (EHRs, PHRs, team care, care coordinators, web portals, decision support tools) are not inherently engaging to us patients!   Why?  Go back and read my personal health goals and explain to how today’s technology-enabled vision of patient engagement is at all relevant to my (and I suspect many of your) personal health care goals.   

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

Post Script

As I mentioned in my last post, I am heading up a research team that will be auditing 2,500 physician-patient conversations recorded during primary care office visits from across the US.   Among the many questions we will seek to answer will be the frequency with which physicians and/or patients raise the question of the patient’s personal health goals.

Stay tuned.  For more information on the 2012 Physician-Patient Communication Benchmark Report click here.

The Fastest Way To Disempower, De-Activate, and Disengage Any Patient

I may not know how to tell the difference between an empowered patient, an engaged patient, or an activated patient.  But I do know that fastest way to disempower, disengage, and de-activate any patient is a trip to the doctor’s office or the hospital.  A visit to an average primary care physician (or specialist) is to an empowered/activated/engaged patient what Kryptonite is to Superman.  It will stop all but the strongest willed patients dead in their tracks.

We patients have been socialized that way.   Think about your earliest memories of “going to the doctor.”  For me, I remember my Mom taking me to the Pediatrician.  Early on I learned by watching the interaction between my Mom and the doctor that they each had a role.  The doctor’s role was that of expert – he spoke and my Mom listened.  I was there just to have one or more extremities twisted and prodded.  And oh the medicinal smell…

Things haven’t changed much in the 40 years since I was a kid sitting in Dr. Adam’s office.  Well maybe the smell isn’t as medicinal.  But the roles played by doctors and patients haven’t changed much.   Studies over the last 30 years consistently demonstrate this unfortunate reality.  If you were to believe the admonitions of the NIH, AHRQ, hospitals, pharma and every WebMD-look alike, you would think that patients these days would be more involved in their visit…asking questions, sharing information and making decisions.  But as most physicians will attest…most patients don’t have much to say in the exam room anyway.   And the longer they have to wait before being seen, the less patients are likely to bring up the few questions they wanted to ask.

This is a huge problem.  It belies conventional wisdom that the key to fixing health care begins and ends with changing patient behavior.  If only we could get patients to be more compliant, if only patients would do what I tell them, blah, blah, blah.

Physician behavior, specifically, the way they think about, relate to and talk to patients needs to change (no e-mail, text messages and social media will not solve this problem)…before long term, sustainable change in patient behavior is possible.

If you look at most theoretical models underpinning patient empowerment, patient activation, etc., you will see that none of them factor in the impact of the care delivery context, e.g., doctor’s office, hospital room, surgery suite, or pharmacy, on patient behavior.   A patient considered Stage IV (Activated) on the Patient Activation Model (PAM) or the “Action Phase” using Stages of Change would “crash and burn” if their doctor is among the majority who employ a traditional physician-dominated, biomedical communication style or “bedside manner.”

How empowered, activated, or engaged can a patient be if they don’t know when to open their mouth, are ignored , or fear taking up too much of the doctor’s time?

Yes you can and should probably change physicians…but since so many physicians “practice” the same way…even supposedly Patient Centered Medical Homes…what’s the point?

Until health plans and providers take a serious look at incentivizing physicians to become more patient or relationship centered, behavior change efforts directed at patients can only accomplish just so much.

That’s my opinion.  What’s yours?

Sources:

Cegala, D. An Exploration of Factors Promoting Patient Participation in Primary Care Medical Interviews.  Health Communication, March 2011.  1–10, 2011.

Related Posts:

6 Seconds To More Effective Physician-Patient Communications

Lack Of Time And Reimbursement  – Is That Why Physicians Don’t Do a Better Job Communicating With Patients? 

Anticipatory Guidance From Primary Care Physicians Could Prevent Falls Among Seniors

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We hear about stories like this all time. An elderly person falls and breaks something…a hip, a wrist or an arm. Soon, what once was a healthy, independent senior begins an inexorable down hill slide. Such is the case of my 89-year old mother who fell recently and broke her wrist.

Turns out that 30% of people >65 years fall each year. Predictably seniors with the following risk factors are more prone to falls:

• Using Sedatives
• Cognitive Impairment
• Problems Walking
• Urinary Tract Infection
• Eye Problems
• Balance Issues

Similarly, when a person does fall, a cascading series of predictable clinical events occurs. It even has a name “post fall syndrome.” This syndrome is characterized by things like fear of falling again, increased immobility, loss of muscle and control, lack of sleep, nutritional deficits, and so on. Seniors susceptible to falls also have higher rates of hospitalization and institutionalization.

What strikes me about falls among the elderly is that they are seemingly predictable events. And once a fall does occur, the consequences seem pretty predictable as well, e.g., post fall syndrome. So if falls and their consequences are so predictable, why aren’t primary care physicians more proactive it terms of:

1. Preventing falls
2. Treating post fall syndrome patients

In the case of my mother, her primary care physician and orthopedist were both very diligent at treating her episodic needs, i.e., her pain and broken bones.  But little attention if any was given to assessing her her long term needs, i.e., nutrition, inability to do anything with her left hand (she’s left-handed), sensitivity to new medications (she never took drugs because they make her loopy), gait analysis, or depression counseling.

I know, I know, doctors can not be expected to do everything in the confines of a 7-15 minute office visit. Yes I know that doctors aren’t paid what they deserve.  I am also aware that many physicians just don’t like treating geriatric patients.  But hey… this is my mother!

Pediatrics coined a term awhile back called “anticipatory care.” It refers to the act of helping children and parents anticipate and deal with predictable developmental and health issues associated with childhood.

It seems to me that primary care physicians and insurance companies need to get together with respect to providing anticipatory guidance for aging as well. Not only would it improve seniors’ quality of life, it would also prevent unnecessary hospitalizations and institutionalizations.

Besides…wouldn’t you want that for your mother or father?

What If All Chronically Ill Patients Were This Engaged In Their Health

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This video is an excellent testimony of what a truly engaged and knowledgable  patient with chronic diabetes looks and sounds like.  Kudo’s to the Mayo Clinic for sharing this wonderful piece about Shared Decision Making.

Pay particular attention to the fact that the patient in the video was being treated for 8 years for her diabetes by her primary care physician before being referred to a clearly “patient centered” Endochronologist.   Also note her belief that a patient centered approach to chronic care management probably results in shorter, more productive visits in the long run.