It's time to put the patient in the driver's seat: The keys to creating authentic patient-centered care

The complexity of America's healthcare system makes defining patient engagement difficult. Today, patient engagement means far more than a patient's simple compliance with a physician's orders. According to Practice Fusion, the average middle-aged patient sees as many as 20 physicians in his or her lifetime. This number rises significantly as patients begin to experience more age-related health problems that require the care of specialists.

Modern caregivers lack the long-term relationships with patients to help develop the knowledge and understanding of what drives an individual to actively participate in achieving his or her healthcare goals. By borrowing a few lessons from the retail world and arming themselves with the right tools — knowledge, data, technology and a commitment to change — providers can use patient engagement to transform the patient-caregiver relationship and, in turn, the healthcare industry as a whole. 

The retail perspective
Healthcare would do well to take a cue from retailers in terms of how they engage with customers. Retailers go to great lengths to first understand and then forge a relationship with each customer. Data collection, primarily through Universal Product Codes, has allowed companies to determine details as small as the optimal placement of milk in the grocery store.

With healthcare, it's not as simple as a UPC. The dialogue with the individual patient and the personalization of care necessary to achieve better outcomes is simply missing. While the retail world has been consumer-focused for decades, the healthcare model has focused on volume and business optimization, with little attention given to the non-medical service needs of consumers.

Reform has prompted changes in provider behavior and the adoption of tools to make the provider-patient interaction in the office more effective. It's also motivating the consumer to take a more active role in his or her own healthcare. In a Wolters Kluwer Health Survey, over 80 percent of consumers believe consumerization of healthcare is a positive change for the U.S. healthcare system. These developments make contact with patients between appointments just as important as what happens at the office visit. Just as supermarkets continue engaging with customers as soon as they leave the store, providers need patient engagement solutions to help them interact with patients outside the walls of the clinic.

What patients want
So what does successful patient engagement look like? Start with what patients want. Numerous studies, according to the Journal of General and Internal Medicine, have concluded that provider-patient interaction must be available through a variety of platforms, and that Web-based communication is quickly outdistancing more traditional phone calls in the effort to achieve patient activation.

Beyond a variety of communications platforms, patients want a relationship with their care team. They want to know they are more than a medical record. The best example of this is the interview process that expectant parents will go through to find a pediatrician who fits their ideal for their family's care. When given the time to prepare for these decisions, patients put a great deal of effort into selecting the right provider with the intention of creating a long-term relationship.

Demographic changes are also driving patients to demand an efficient and effective care management system. As the population ages, an increasing number of consumers are tasked with managing the healthcare of their grade school to college-aged children, their aging parents and perhaps their own chronic conditions. This "sandwich generation" interacts with many different general practitioners and specialists. They need communication with their physician to come as easily as communication with everyone else in their lives — in the palm of their hands. Email and text messaging have become essential tools for life management, and consumers appreciate being able to utilize these tools to interact with the healthcare system as well.

Finally, healthcare consumers want a say in their own care, but not without the right information to make the best decisions. When the provider can give patients access to a trusted source of information about their healthcare and boost the patients' health literacy, outcomes can be considerably improved. Patients want to receive actionable information from a trusted resource, delivered at the right time and in the right way. Once patients have this access, they can take the next steps from engagement to true activation.

What the provider needs
Physicians want what patients want — a relationship. It's why they got into medicine in the first place. Yet with the Patient Protection and Affordable Care Act mandates for adoption of EHRs and attestation of meaningful use, as well as the implementation of ICD-10, many providers are feeling the pressure and dissatisfaction of launching multiple systems. These tools will ultimately improve the delivery and continuity of care, but the challenge is to maintain and improve the direct patient relationship during this period of extreme stress and wide-spread technology transformation.  

Further complicating the provider side of the patient engagement equation is the lack of interoperability. For retailers, there is a common denominator in technology: the point of sale (POS) system. Regardless of where an item is sold, it has a single UPC code recognized by all POS systems. This seamless interoperability does not exist in healthcare. There are many barriers to interoperability including lack of electronic data, the burden of security standards, lack of cooperation among vendors with proprietary concerns about technology, and the general complexity of healthcare data, to name a few. Even the Office of the National Coordinator for Health Information Technology admits it is not currently possible to power the continuum of care across a longitudinal healthcare record for a patient with multiple providers across multiple operating systems, according to the ONC Standards and Interoperability Framework.

Despite these challenges, providers need further access to what their patients are doing outside the four walls of his or her practice. To create the dialogue between patient and provider, as opposed to the monologue of provider to patient directives, patient engagement systems need to allow the patient to provide their physician with health status information. It's a dialogue that extends beyond payment for services or scheduling towards a true patient-provider conversation. The provider has greater access to information about what has happened between visits, the interaction becomes more meaningful and the provider has a better chance of achieving successful care plan compliance. The more the patient believes the physician understands about his personal situation and challenges, the stronger the relationship and the greater the chances are that the patient will take action and stay compliant.

Building patient engagement that aligns patient and provider incentives
The patient engagement framework that successfully aligns patient and provider incentives must first be built around the patient, enabling the patient and provider to continue the healthcare dialogue after the appointment. It requires flipping the paradigm from the objective of how to meet the basic requirements of meaningful use, to a discussion of how to change practice communication strategies to create authentic patient-centered care. It must be a win-win for patients AND practices and not something that meets the minimum government requirements.

Successful patient engagement frameworks share these characteristics:

1. Secure patient-physician email. Following a study that demonstrated a statistically significant link between secure patient-physician email and improved effectiveness of care for diabetics, physicians noted their satisfaction with the use of this strategy for communication. While many were initially skeptical that patient-physician email would reduce their workload, the reality was that most physicians received few emails during the day and were able to respond quickly. Physicians also noted, according to a look at Kaiser Permanente’s use of email between patients and physicians in Health Affairs, that they liked this form of communication.  Patients were able to print out key instructions and dosages. In the end, secure patient-physician email was "easy, helpful, and better than playing phone tag."

2. Patient self-management must be enabled. Among the barriers to achieving patient engagement is a lack of health literacy on the part of the patients. Technology helps patients develop greater health literacy and boosts their proficiency at self-management. In the context of a trusting relationship with the care provider, the patient can be empowered to ask questions and make decisions. This allows the physicians to move into a coaching position in the management of chronic conditions, and may lead to fewer office visits or readmissions for those patients. App-based push-notifications can also further the development of patient self-management.

3.  Synchronized communication. Extending connections beyond the clinic or hospital builds trust and commitment. When patients receive regular follow-ups from their provider — even if check-ins are automated by text, phone, or email — it shows that the provider cares and is still engaged with the patient. This increases the likelihood that the patient will continue to follow through on the care plan that is in place and provides opportunities for dialogue if the care plan is not working. A 15-minute appointment every six months cannot do this.

4. The always-connected consumer. Patients want a trusted personal relationship, to be assured that their physicians "know" them beyond the medical record number attached to their chart. To this end, patients want their physicians to reach out to them when they are not sick with touch points or health reminders. Once the trusting relationship is well-established, patients want ease of communication through email or other mobile technology, as well as the convenience of self-service options for appointment scheduling and refill requests. Patients do not want to be on hold or play phone tag with physician offices.

5. Make it mobile. According to the Pew Research Internet Project, 90 percent of American adults have a cell phone and 58 percent have a smart phone. Healthcare can't ignore the reality that mobile technology pervades all areas of life. In fact, the technological savvy of a practice is a primary factor in physician selection, second only to cost, according to the Wolters Kluwer Health Survey. Patient engagement solutions need to open the door between hospitals and practices and continue the patient care dialogue to where patients live, work and play.

Research further shows that the average mobile user checks his phone 150 times per day. The healthcare community can and should be tapping into this potential. Mobile apps can now turn a phone into a digital scale, blood glucose meter or blood pressure monitor. These and other medical uses enable remote patient monitoring like we have never seen before. Additionally, app-based push notifications and SMS text reminders allow mobile communication to enhance patient compliance with care plans and inform the provider when there is cause for concern between appointments. The potential for patient activation and improved outcomes is significant.

6. Meaningful use compliance. Some may counter that MU compliance is everything in building a successful patient engagement framework. Certainly, the ultimate goal of MU is to improve patient outcomes. But as mentioned earlier, it needs to be addressed as a tool for measurement of authentically patient-centered care, not an end in itself. Providers and patient engagement vendors need to make sure the tougher MU requirements are being met.

Patient engagement solutions for EHRs aren't turnkey operations — to apply them successfully requires hard work, patience and diligence. With the proper tools, applied effectively, we can transform the patient-caregiver relationship and bring healthcare closer to truly patient-centered care.

Justin Neece is president and chief operations officer for IngagePatient. Starting the patient engagement revolution in the complex world of healthcare has been Justin's mission since 2012. Prior to joining IngagePatient in 2009, he served as chief operating officer for Shared Health, one of the nation's first health information exchanges.

Sources:

Center for Patient and Family-Centered Care. (10 February, 2014).  Patient Engagement Framework. HiMSS. Chicago, IL: Author. http://www.himss.org/ResourceLibrary/genResourceDetailPDF.aspx?ItemNumber=28305. 4 April 2014.

Nelson, T. 2014. 5 Tactics to Enrich Patient Engagement. [online] Available at: http://www.medicalpracticeinsider.com/best-practices/5-tactics-enrich-patient-engagement [Accessed: 3 April 2014]

Wolters Kluwer Health. Consumerization of Healthcare. (12 December 2012). Philadelphia, PA: Author. http://www.wolterskluwerhealth.com/News/Pages/WhitePapers.aspx . 4 April 2014.

Simon, G.E. et al., “Randomized Trial of Depression Follow-Up Care by Online Messaging,” Journal of General Internal Medicine, July 2011: 26 (7) 698-704. doi: 10.1007/s11606-011-1679-8. 4 April 2014.

ONC Standards & Interoperability (S&I) Framework. (2014). Longitudinal Coordination of Care.  http://wiki.siframework.org/Longitudinal+Coordination+of+Care+%28LCC%29 4 April 2014.

Zhou, Yi Yvonne, et al. (2010). Improved Quality at Kaiser Permanente Through E-Mail Between Physicians and Patients. Health Affairs,29(7), 1370-1375. doi: 10.1377/hlthaff.2010.0048

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