Tag Archives: patient portal

Patient Engagement & Health IT – Disillusionment Sets In Poll Shows

This week, the 2015 HIMSS Patient Engagement Summit is taking place in sunny, warm Orlando. According to HIMMS, conference attendees will learn how “leading healthcare organizations” are successfully using health IT and other strategies to engage patients in their care.

Patient Patient EngagementWhat I suspect attendees will not hear much about at the Summit (particularly from speakers and exhibitors – one in the same?) is the growing “disillusionment” with the ability of patient portals, EHRs/PHRs and smart apps to actually engage patients at all. One only need look at the dismal adoption rates of these technologies (in the very low double digits if that) within most provider organizations, Kaiser, Group Health and Geisinger being notable exceptions.

What disillusionment you may ask?

Recently I conducted my own informal poll on LinkedIn’s HIMSS Group by ask the following question:

Untitled-1

If a patient chose NOT to use your patient portal, PHR or smart health apps do you consider them to be “unengaged” in their own healthcare?

The question was prompted by all the “over the top claims” by HIMSS (See their Patient Engagement Framework) and EHR and Health IT bloggers that patient portals, EHRs and smart apps are what drive patient engagement.  Come on now.

If that were true, that would mean that prior to the World Wide Web in the early 1990’s it was impossible for people to be engaged in their own healthcare.  That is simply not true!Healthwise Handbook

Who doesn’t recall Healthwise’s big old health handbook.  It must have weighed 5lbs! Or who doesn’t remember “Ask A Nurse” – that ubiquitous 1-800 number you could call at 3:00 AM a health question? And of course there was always the doctor, family member or friend you could discuss your health concern with. To this day, more health conversations among seniors probably occur in McDonalds over morning coffee than on some EMR or health app.

But I digress…

So what were the results of my informal poll?

Take a look for yourself. Below are snippets from some of the 70+ responses (and counting) I received from members of the HIMSS Group which consists of developers, venture capitalists, informatics, vendors and clinicians.

What surprised me the most was how few “good things” people had to say about health IT in general…not just with regards to patient engagement.

  • I am in healthcare IT and I still have not used my EPIC portal for scheduling an appt, view results, etc. because it is has been too much trouble to access.
  • Are they “unengaged” if they do not use these tools? Absolutely not. [ . . .] I actually consider patients who use the portal, PHR or apps and are NOT having direct contact face-to-face or by telehealth as being “unengaged”. Patient engagement is a very personal and individual decisions made by the patient and can change drastically at any given time.
  • It seems we too often try to use technology to replace human interaction. Patient engagement requires human interaction and collaborative work between the provider and patient.
  • Until the portal becomes a) easy to use and relevant, b) doesn’t have 20 pages of legalese and c) can converse with you via email, txt, Instant Messages or phone; there will always be a substantial portion of the population that won’t use them.
  • Ok, [patient portals]not normally a big deal until you read the terms of service which, paraphrasing the legalese, said “If we are breached, it is your fault. We are not responsible for losses you might incur. If it is determined that the entire system was compromised through your account you will be responsible for our costs to remedy the situation”.
  • Match […]the technology to the message. I am aware of HIPAA secure phone mail systems that get 83% of patients using the system to listen to messages left for them by a clinician within 24 hours. We are all used to voice mail and using the phone.
  • Engagement should be defined by the level of interaction with a provider, and the resulting outcomes. So, no, I think assessing level of engagement by use of the technology is pretty limited.
  • If you want to know why patients and physicians do not use portals, it is because they are designed by EHR companies that design them as poorly as they design EHRs. Combine that with Byzantine security procedures, and you get a somewhat useless system.
  • The assumption that a percent of users accessing data on a portal = patient engagement is where we fail! A percentage of people will access a portal for various reasons, and they will also NOT access a portal for various reasons. The real question should be…. what can we do to make the info easier to access and easier to understand.
  • Point me to a portal that you believe is patient friendly, put on your flak jacket and give me 30 minutes to make you understand that the portal smells worse than pig effluent.
  • Why would I be forced to go through all of the userID creation (I have somewhere around 250 of them in my Google profile) etc. just to give doctors access? Why can’t I tell the people at the radiology site that Drs A, D, V & Z can have access? I am extremely engaged in my health as a nearly 30 yr Type 1 Diabetic. But what you just described sounds like more PITA administration that I have ZERO interest in.
  • You cannot force adoption, it comes to good products and causes bad ones to fail.
  • I am committed to health (as opposed to healthcare) and I take an active approach to wellness. [ . . . ] Since my hospital-employed PCP implemented EPIC, my relationship with that office and my doctor has significantly degraded. The implementation of EHR and its patient portal caused me to disengage, not engage.
  • Meaningful Use is the worst government policy since the Vietnam Conflict. Over 75% of doctors have stated that MU is a disaster and patients are waking up to this fact.
  • EPIC and others have developed their EHR to generate revenue for the healthcare providers and they are forced to create patient portals due to regulations.
  • Whatever use case you can think of, the patient MUST gain value in issuing a portal (I hate this 15 yr out of date term…) or you’re causing them pain and suffering just to cut administrative costs for the provider.
  • We have to address “what is in it for me?” [when I comes to patient use].  The point is that barely nobody is engaged towards tools
  • Give me a bad patient outcome and an EMR primarily designed to bill, that allows cut and paste, and populates differential diagnoses without requiring the provider to rule each out, and I will show you a lost med mal case.
  • We are looking to technology to fix a human problem… taking their health for granted.
  • Providers, use the portal to tell your patients how they can help you be most efficient. Have your EHR builders “put your heart in your letters” why this is a valuable resource, that you support it also.
  • If the providers don’t trust it, neither will the patients, and then it [patient portal] truly is useless.

Take Aways?

No surprises here. When people in the business are honest about it, based upon my limited, informal sample, many just don’t buy into the patient engagement-Health IT hype.

Of the 70+ responses

  • No one “believes” that health IT actually “creates or drives” engagement where it did not already exist.
  • Many recognize that patient engagement occur between patients and their physicians – HIT is just useful medium for supporting that relationship.
  • There are lots of problems with patient portals beginning with:Their purpose
    • Who really benefits (clinician-patient-payer)
    • Terms and conditions of use, e.g., legalese
    • Relevance
    • Usability
    • Interoperability
    • “Byzantine” Sign In and User ID Practices
  • Some believe that portals actually caused them to “disengage” rather than engage
  • How one “rolls out” their portal to patient and physicians is critical

The bottom line when it comes to portals I would offer the following advice:

  1. Be clear about why you are implementing a patient portal
  2. Involve patients (and clinicians) in the planning and development
  3. Enroll clinicians to introduce portal to their patients
  4. Be clear about what constitutes success, including how you will measure it
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There’s Nothing Engaging About My First Patient Portal…It’s Actually Disengaging

In Fact It’s Downright Disengaging…

Stop the presses!   I now have access to my very own personalized patient portal courtesy of my personal physician.  The big event occurred this last Tuesday.   I have to admit I was a bit excited that my doctor was slowly merging onto the information super highway.  Heck he even sprang recently for an out-of-the box EMR system which he is forever complaining about.

But my excitement was short lived.  Very short lived in fact after reading the e-mail from E-Clinicalworks (the patient portal vendor) which I am sharing with you here.

Patient Portal email

Now I realize that my doctor works in a solo practice as part of a large IPA…not the Mayo Clinic. But this email…and presumably everything associated with this patient portal is…well…very amateurish and totally disengaging.

A couple of things immediately jumped out at me while reading this e-mail invitation to my patient portal.

The patient portal claims to offer me “the power of the web to track all aspect of my care through my doctor’s office.”That’s pretty powerful!

But I read on to discover that my physician’s concept of what I should have the “power” to do and what he thinks I should be able to do is very different. Why am I surprised…?

First there is no mention of any kind of access to my actual health information…and certainly not my “physician’s notes.”But that doesn’t mean I am willing to leave my doctor for someone who offers this capability.

Second…and perhaps most galling…is that I can’t actually communicate with my doctor via the portal.  I can email his office staff…and maybe they will respond and maybe not. In the non-digital world they would get back to me at their own leisure.

Third, I can’t actually do anything on the portal (as configured by my doctor) other than request that the surly office staff intervene with the doctor to refill my prescriptions. Asking is certainly different than doing in my book. How the heck is this supposed to make me feel engaged?

Finally the email presumes to tell me that up until today my physician apparently does not think that I have been taking an active role in my own health care.   Let me get this right…I am 100% compliant with my medications, exercise, see my doctor regularly and am in good shape…yet I am not actively involved in my own health. Come on now.

In its favor…the email was personalized – it got my first name right. It never did mention my doctor’s name or his office address.

Upon getting this email from my doctor I was immediately reminded of a quote from a recent Dave Chase Forbes article about the value of physician-patient communications in which he said this about patient portals:

“The smart healthcare providers realize simplistic patient portals, however, won’t get the job done. Simple patient portals are like a muddy puddle of water in the Sahara Desert — a big improvement but far from ideal.

Kudos to physicians everywhere that are trying… But please recognize that your patients are not simpletons and that they are already engaged in their health at least from their perspective. For portals like this to be successful – (meaning that patients actually use them more than once) – they need to offer real value (from the patient’s perspective), they need to be relevant to patients (not you or your staff) and they need to respect my intelligence.

Take Aways

Most patients are already engaged in their own health care. The biggest challenge for providers today is not so much engaging patients but rather to avoid disengaging them.

I realize that my experience offers but one example of a patient portal gone wrong.  If you have samples of patient portal experiences you would like to share e-mail me at stwilkins at gmail.com.

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?

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.