Patient engagement is the holy grail of health care

For health care professionals, patient engagement is the holy grail of health care.  It is the key to patient adherence – a prerequisite to achieving better outcomes, fewer ER visits and hospitalizations and more satisfied patients.  It is easy to recognize an engaged patient – they do what their health care providers recommends …what their health care team knows what is right for them.

But doesn’t engagement depend upon your perspective?

In a earlier life I spent a lot of time looking at health behavior.  Among the many things I learned were the following:

  • We all define health within the context of our own lives and in our own way
  • We all are satisfied with different levels of health

Admittedly there are patterns of health behavior or archetypes which can be used to segment health populations.  One such archetype is characterized as 1) placing a high priority on achieving a high level of personal health, 2) being very proactive in terms of achieving and maintaining their above average health, and 3) having a moderate to high distrust of the medical professionals.

Not surprisingly, people who shared this pattern of health-related thinking demonstrated lower levels of physician visits, fewer hospital and ER visits, lower health care costs.  They were also the healthiest when compared to all other patterns of health thinking and behavior.   Because of their trust issues with their providers, these patients were “mavericks” doing their own thing when it came to staying healthy.  In other words they were not very compliant and would be considered unengaged from the perspective of health care professionals as defined above.

People can be engaged in their own health and never see a doctor, visit a hospital, or take a prescription medication.

If you were to tell these independently healthy folks that they were “not engaged” in their own health they would likely scoff and say “what do you expect … the health care industry doesn’t take the time to understand the patient’s perspective.”  In truth, aren’t people like this doing a better job than the health industry when it comes to “engagement” and staying healthy?

The point is that we as health care professionals need to start looking at things like the definition of health, health goals, compliance, and outcomes from the patient’s perspective.  We need to incorporate the patient’s perspective into outcome and satisfaction measures.   Only then do we have the right to “judge” whether a person (aka patient) is engaged, activated, or empowered.   Once the health industry gets past this paternalistic, “we know better than you do” attitude then we can expect to see real change in health behavior and outcomes.

Steve Wilkins is a former hospital executive and consumer health behavior researcher who blogs at Mind The Gap.

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  • http://www.facebook.com/bfabbio Bob Fabbio

    I would say the holy grail is proving that you can:  lower cost, improve the healthcare experience, and deliver better clinical outcomes.  At WhiteGlove Health, we have!

  • civis isus

    “The point is that we as health care professionals need to start looking at things like the definition of health, health goals, compliance, and outcomes from the patient’s perspective.”No, Steve – no, that’s NOT the point. Not at all.
    Those healthy, unengaged clinical skeptics you’ve so carefully and accurately delineated in your post DO NOT THINK OF THEMSELVES AS PATIENTS. So you canNOT think of them, or most of the people you minister to, AS PATIENTS. Not most of the time. Not much of the time.

    They’re people first. People mostly. Patients, seldom, and temporarily at best.

    • Steve Wilkins

      Civis – Great point about these folks not “being patients”.  Thanks for the clarification. 

  • Anonymous

    Thank you! It is so good to know that not only am I not alone, but  there is an archetype describing my approach to health and medicine. 

  • Anonymous

    Steve; I too am a hospital executive responsible for customer service / service excellence, patient satisfaction and I agree with your perspective of patient engagement and how it is the holy grail of healthcare.

    In today’s healthcare industry we place too much emphasis on diagnoising after the fact instead of preventitative medicine.  I understand that the system (reimbursement) has flaws but…until we begin to focus our efforts on partnering and teaching the young how to live more productive and healthier lives, the world population will continue to be stressed, obese, continue to have heart disease and use those drugs that will only degrade health over the course of a person’s life. I applaude your insight. We as healthcare providers must build trust and solid relationships with our patient population that will assist us with this task. One way to build relationships is to “listen to our patients”.

    • Pamela Williams

       From a patients point of view let me explain how most people feel when they go to the doctors. First and foremost they want a doctor who “listens” to the patient. I and most others do not want someone looking down on me, scolding me or telling me everything I did wrong, it really is not relevant at that moment in time when a person is hurting or not feeling well. Second, you slot a person ten minutes and usually have your hand on the door knob ready to go to the next patient, throw some pills at them and usually leave them with 100 unanswered questions when they leave. Only once in my life did I have a doctor who listened, took his time, explained things and allowed you to decide what worked and what didn’t work for you. He was my physician for 20 yrs before he decided to leave his practice and go into administrative work at the local hospital. It was and is a great loss for me and many other patients because now I have no doctor as no one can fill his shoes or knows me better. Doctors need to listen and allow the patient to give their idea that may work for them. Too many times doctors have provided drugs which I stopped taking because the side affects were just as bad if not worse and did nothing for which I was taking them for. Too many times doctors prescribe drugs on the basis of one size fits all and it just does not work. When m doctor was able to work with me on whatever medical problem was at hand and solving or controlling that problem then it was great to listen to him afterwards on ways to which to alleviate the problem in the future. That people is a good doctor. So the key:

      1. Take the time to listen and know your patient
      2. Let them be a part of their health decisions and finding out what works best for them
      3. Do your homework on drugs, not all work for everyone and some people the side affects are worse than the condition being treated
      4, If you work together in this way, then the patient will be more open to listening to how to avoid the problem from happening again in the future
      5. We need compassionate, caring healthcare from physicians

      Signed,
      Just a Patient

  • Ginger

    I think having a moderate level of distrust of the medical profession is essential to maintaining good health. 

    If I believed that medicine could overcome the effects of an unhealthy lifestyle, like those flashy ads on TV would have me believe, there wouldn’t be any reason to battle my bathroom scale and make time in my day for exercise.   

  • Anonymous

    I have seen what happens to people who totally trust the medical profession.  They usually end up in worse heath.  When I see a turnaround in attitudes of medical professionals and a real emphasis on staying healthy than maybe, I  will start trusting them a little more. Until then, I will continue following my own path!

  • Dan Spinato

    Great positive insights from a medical professional! A healthy amount of distrust in healthcare professionals pushes people to be more responsible about their own health, as well as their loved ones’. There has to be a sensible threshold to such distrust, however, especially since self-medication and late detection of some diseases can have critical consequences.

  • http://www.facebook.com/profile.php?id=1311249696 Tanya Woldbeck Gesek

    I think this where behavioral specialists, namely psychologists, are in the best position to assist.  We are lifestyle and behavior change specialists that will ultimately help reduce medical costs.  We are perfectly suited to help folks with goal setting, intervention, and evaluation of progress toward goals, both with individuals and within larger integrated settings like these future ACOs.  Partner with psychologists!!  Engagement in life is our middle name!!  It’s what we do.  ANd guess what the side effects are:  a better life!!

  • Mike Gallamore

    Everything

  • Anonymous

    “It is easy to recognize an engaged patient – they do what their health care providersrecommends …what their health care team knows what is right for them.”

    Not my definition of “an engaged patient.”  The patient you have described is a Passive Patient who is the object of team activity, but not part of the team–like a football is an object of team activity, but not part of the team.  

    “People can be engaged in their own health and never see a doctor, visit a hospital, or take a prescription medication.”  It’s the level of thoughtful decision-making and personal responsibility people employ that determines how “engaged” they are in their own healthcare.
    It is quite possible for one person to be very engaged in their “healthcare” yet passive–or not participating at all–in their “medical care.”

    “Once the health industry gets past this paternalistic, ‘we know better than you do’ attitude then we can expect to see real change in health behavior and outcomes.”  Agreed, with one addition.  We need to have a common vocabulary, all using the same definition for key words like “engagement” and “healthcare” so the conversation can become the path to “real change.”   

  • Anonymous

    Though I am a physician, as a patient, I am definitely one of these “maverick” types you describe.  I know I am not alone in this seemingly odd juxtaposition of personal health beliefs and professional expertise.  The lovely piece that went viral, “How Doctors Die” also seems to describe a physician with some mistrust of medical interventions, and certainly that struck a chord with a multitude of healthcare providers.  Largely, I do believe that the more I see, the more skeptical I become.  It may be inevitable to realize that standard medical care is by no means magical and has significant limitations.  Still, at the juncture of my personal beliefs and my professional practice, I do sometimes feel like a hypocrite.  I am a strong believer in lifestyle interventions, and I believe that exercise, in particular, receives less attention than it should in traditional medical care of some common conditions.  However, in our world of 10 minute office visits, convincing patients that lifestyle changes may work better than medication or surgery can be very difficult.  I use whatever tools I can offer to empower patients, but barriers abound.  Our healthcare system is loath to provide funding for the best lifestyle interventions, and sharing records and health data directly with patients often meets with some systemic disapproval or other (be it HIPAA concerns, practice policies,etc.)  I wonder at encouraging preventive care strategies for my patients that I myself do not necessarily believe in for myself, even though these practices are the current standard of care (annual mammography is a good example).  I too would love to see a sea change in healthcare that increases patient ownership of health and healthcare and looks at health from a more holistic perspective, rather than this paternalistic obsession with “metrics” alone that currently predominates.  Not only would this improve our overall health as a society, but it would increase my personal satisfaction as a physician. 

    • http://profile.yahoo.com/MR3WWX6OQIJXVPXXGXO67NQQ5I PATHologist

      SaraJMD,
      I suspect that the goal of patient engagement is a form of robotic compliance with whatever medical providers prescribe without exercising their own judgment.

  • Anonymous

     
    Thanks for this good article.  To help facilitate these tough conversations, I suggest that the physician bring in the board certified staff chaplain who has the training and experience to do so. The professional chaplain’s work is not just about “religion” or “faith,” Those elements  can be applied if that’s what the family or patient wants. Most importantly, a central part of the training of a professional chaplain is facilitating communication among family members and between family members and the health care team.

  • Anonymous

    I would love to learn how to engage my patients more, heck, engage my mother into positive health behaviors!  I’m a nurse and am responsible for teaching these preventative practices.  I know that 80% of what I teach at discharge is forgotten.  Plus, I’m required to teach some standard behaviors that I know really don’t work in regards to diet.  I feel like a snake oil salesman telling diabetics to eat up to 6 servings of breads and cereals a day for example.  I always tell people to read up on diet and health behaviors, do their own research although many of these people will not.  We have a segment of our population who are also probably pretty too far gone — advanced congestive heart failure etc. that will be coming back to us every few weeks regardless of how much teaching we do simply because their condition is irreversible.   Introducing palliative care options at that point is where we have to get a doctor buy-in.  Sometimes the palliative care or hospice option is given too late for the patient and their family to benefit from it.

  • MarkC100

    I think Civis hits the nail on the head.  My experiments are showing that it is building and tending to relationships with people over time that is important.  One of my personal favourites is someone who became known as Velcro Man.  You can read about it here http://vanguardinhealth.blogspot.com/2011/10/velcro-man.html.  The answers for him, were elegantly simple but radically different.  By putting our relationship with him at the heart of what we did we were able to solve his problem and give him the life he wanted, not the life the system wanted to give him.  No targets, no pathways, no moves from one specialist service to another.  No plan.  Just understanding. And a willingness to create solutions based on this.  Might be an old fashioned idea to spend time understanding people in the context of how they live their life but no less powerful all the same.

  • http://www.facebook.com/stephy.gardener Steph Gardener

    Voice of the customer is where it’s at.  Nice article.

  • http://www.facebook.com/profile.php?id=100000702431537 Ron McLaughlin

    This article on “patient engagement” is absolutely a key way
    for doctors to enhance outreach to a greater set of patients by simply
    understanding their outside perspectives on the health care industry as a
    whole. Providers can also take this one step further and also consider the
    process of billing “from the patient’s perspective.” When doctors do this, they often find that telling patients
    more about WHY medical bills are structured a certain way can actually help
    them collect more money from patients. The negative side of the equation,
    patient disengagement, can really impair a provider’s revenue cycle. Simply,
    patients are unlikely to invest money in their health unless they understand
    what the doctor is trying to accomplish and why it is good for them. Many
    medical offices are putting more of a focus on educating patients about what
    they may owe for procedures at the time of service, making the chain of
    communication clearer, and, often, making it easier for a patient to justify
    paying their bills. Ron McLaughlin, CEO, enhancedmedicalbilling.com.

  • http://twitter.com/GottaBNimble Chris

    Steve, you really hit the nail on the head!  To me engagement is connection.  If you engage in bad health behavior, you are connecting with it.  If you engage with good health behavior, you are connecting there.  How we get someone to connect with what we determine as healthy behavior requires the patient to make the contextual shift and thinking.  When providing them information, engaging them is key but few truly understand what that entails or they do not know how to go beyond their own expectations and therefore limitations to enable this to happen. The opportunities to connect are important to afford the patient opportunities to learn and grow in the appropriate direction. 

  • Stefan Wisbauer

    Could not agree more. And we also need to give people the tools to manage their health. I prefer to do my finances and complain to the bank when I need to call them and don’t remember my phone PIN because something’s not working online. Ok, if I need a mortgage I want to talk to someone… so let’s give people the full picture on their health profile / risks / what guidelines imply for them / their health record & support when they need it… we’re very far from that in standard care delivery… if anyone else is working on it and wants to compare notes, do let me know…

  • Anonymous

    I agree with this. Especially the bit about ‘to incorporate the patient’s perspective into outcome and satisfaction measures’. PROMs can only be defined by the patient and therefore we should understand the patient better on their attributes in their life. Working with the so-called ‘Patient Intelligence’ concept can clarify this. See PIPHealth.

  • http://www.facebook.com/Betafeet Judith Sullivan

    Steve totally agree wit ” incorporate the patient’s perspective into outcome and satisfaction measures” but I need help in achieving this: satisfaction surveys is a good start to improve patient outcomes but what questions are we really needing to ask and how do we measure.

    Judith

  • http://twitter.com/suelizwalters sue walters

    Great article Steve! This is the age old issue – isn’t it down to relationship building and trust?

    • Steve Wilkins

       Sue,

      It is all about the simple things like relationship….which unfortunately are being lost with the reliance on technology (for diagnosis versus the hands-on physical exam and listening to the patient’s story.

      Steve Wilkins 

  • http://www.facebook.com/Betafeet Judith Sullivan

    Thank you for the article on patient engagement it has enabled me to put together protocol have I missed anything:

    Patient
    engagement

    Your appointment:

    ·        
    Inform
    podiatrist if you have any physical needs, hearing, visual impairment, learning
    difficulties, cannot manage stairs, need assistance or translation services.

    ·        
    Bring
    another person to assist if frail, confused or unable to remember
    conversations.

    ·        
    If
    under the age of 16 the child must be accompanied by a legal parent or guardian.
    Evidence of this should be brought along.

    It is helpful to bring along relevant information to your appointment

    ·        
    Prepare
    a list of issues for discussion

    ·        
    Bring
    a list of current medication including vitamins or supplements and discuss
    benefits and side effects

    ·        
    Inform
    your podiatrist any allergies

    ·        
    Report
    accurately on history on current physical and mental status

    ·        
    Bring
    a summary of medical history, current health status and any test results

    ·        
    Ask
    questions and express concerns about recommendations and care

    ·        
    Convey
    relevant information if you are seeing other health professionals

    ·        
    Obtain
    test results and appointment records

    Promote Health and Participate in
    treatment

    ·        
    Keep
    appointments and arrive on time

    ·        
    Evaluate
    treatment options (risks and benefits)

    ·        
    Negotiate
    a treatment plan

    ·        
    Set
    priorities for changing behaviour to optimise health and act on them

    ·        
    Monitor
    your own symptoms including danger signs that require urgent attention (diabetes
    monitor blood sugar, blood pressure and check feet)

    ·        
    Manage
    symptoms by following treatment plan such as diet and exercise

    ·        
    Know
    personal health targets and what to do to meet them

    • Steve Wilkins

       Judith,

      Wow..great list.  I suggest that rather than overwhelm your patients at once..you gradually introduce a few of your concepts over repeat visits. 

      The very first thing on your list should be an invitation from you (not your staff) to feel free to ask questions, to say what’s on their mind and to stop me (you) if you don’t understand what I am telling you.

      The point is that people have been socialized for years to play a subservient sick role to the doctor’s expert role.   Simply inviting them to speak up works wonders.

      Good luck and keep in touch with your experiences at http://www.healthecommunications.wordpress.com

      Steve Wilkins

  • http://www.facebook.com/people/Mary-Giles-Darrell/1316742920 Mary Giles Darrell

    I am an RN of 32 years. As a patient in and out of the hospital for the last 6 months I have found that one (just one for now) of the most difficult things was the constant change of nurses. In 3 weeks as an inpatient I probably had at least 40 (forty) different nurses–20 on days; 20 on evenings (12 hour shifts). t was constantly being asked the same questions, constantly telling a different person the particulars of my case, constantly answering “Hello Mrs._______. How are you feeling today?” And that isn’tt counting the number of different aides, also.
        Secondly, I began to wonder about the figures fed to us from the government about unemployment. Hospitals have become like the United Nations. Nurses and aides are employed from every country on the globe–except America. This observation has nothing to do with race. I think probably it has more to do with economics. But it does make one wonder–especially when their English is scratchy.

    • http://profile.yahoo.com/ELMKONIJR5PFR3KXI5MTEROYUY CD

      As a registered nurse of thirty-two years I would assume you would be more understanding of our current global and world-wide options.  I find these comments very self-centered.  We live in a new world that needs to be open to new demands and new perspectives.  One is not to be ignorant of 30 nurses, this and that, I would assume you are not a bedside nurse.  When you need a bedside nurse that has understanding and compassion, a perspective on the changing enviroments and a love for a real care of nursing, do not call me

  • http://twitter.com/PrjHealthDesign Project HealthDesign

    We at Project HealthDesign are in complete agreement with you — we want patients (and all people) engaged in their HEALTH. Engagement with clinicians and the formal health care system is a necessary but not sufficient aspect of patient engagement.

    I´d like to add two points:

    1. Characterizing health from the PERSON´S perspective will require a new vocabulary and a new set of computer and Internet tools. Our current Project HealthDesign teams have some examples of both.  Observations of daily living (ODLs) are both defined and generated by the individual and serve as indicators of their health state and the things around them that influence it. ODLs complement but don´t replace the
    professionally defined signs and symptoms, but they may give important cues to what activates a person towards health.

    2. Full patient engagement is going to force a change in the way patients AND clinicians engage with each other. We need to rethink everything from how clinic exam rooms are set up (better space to encourage conversation, less space for storage), to what makes a good clinical encounter (only use time together for things that both people need to be in the same room for), to who gets to decide what constitutes “good” care.

    Thanks for the great article!

    Patricia Flatley Brennan, Ph.D., R.N.

    • http://profile.yahoo.com/MR3WWX6OQIJXVPXXGXO67NQQ5I PATHologist

      Neubehaviors Corporation is launching a far less
      intrusive, “Big Brother” approach to understanding individual health
      behavior as adaptive response to situational cues. Personally, I would never
      agree to an ODL type of intrusive monitoring of my behavior. Reminds me of a
      lab rat experiment! How is the privacy of such information insured?  Also, patient engagement is a medically-driven
      concept, it is not a public concept, and that is a part of the problem.
      Neubehaviors’ research has identified segments of the society who see the
      concept of patient engagement as a code word to force and coerce behaviors
      which maintain profits for drug companies. I would argue that at the point
      patient engagement is required it is already too late.

  • http://profile.yahoo.com/2DPD2XM5DIGHBYCB3TGZ75755Y Kim

    Steve, I like your post and too agree that an engaged patient does have better outcomes.  Can you gell me out of the research you did, did you happen to ask also of those providers if they felt an electronic medical record with good patient interactivity such as a patient portal?

  • Anonymous

    Great article Mr. Wilkins! However the Complimentary Alternative
    Medicine (CAM) community, specifically Doctors of Chiropractic (DC), have been
    seeing the healthy ‘disengaged’ population for decades. Chiropractors spend
    more time and provide more scientifically based health related information to
    their patients than their MD/DO colleagues do. Chiropractors often encourage
    their patients to become proactive and Chiropractors work with the patient to
    find and solve the cause of the issue instead of masking the symptoms with one
    drug or another. This is not to say that MD/DO’s do not have a place in the
    health care wheel or that all they do is push prescription drugs on patients
    because I would be remiss to say that; frankly the MD/DO community provides a
    very valuable service to the population however MD/DO’s do need to get over the
    ‘paternalistic’ attitude that is expressed toward the patient and allow the
    patient to become more engaged in the patients treatment. This ‘new’ allopathic
    approach will increase patient satisfaction ergo patient compliance.

    • Steve Wilkins

       Thanks.  I like how you put that!

      Steve Wilkins

  • http://twitter.com/HypTherapeutics David A. Blender

    Thank you for a very good article. It addresses the same issues that I have been addressing with the medical community for some time. As a clinical and medical hypnotherapist, I work with clients / patients and their medical professionals in an effort to complement and enhance patient interaction and patient care. Doctors, presciption and OTC medicine don’t heal people; people do. Without patient interaction and participation and complete mind-body care, the level of comprehensive patient care lacks. Greater awareness, more education, more empowered patients demanding what they want (as opposed to being told what they need), and more open-minded medical professionals will be the catalysts to effect change.  I look forward to more reading more articles from you, Kevin!

  • http://elizacorp.com/ Alexandra Drane

    Love love love LOVE this article…would just add that we need to think of patients as people – that goes hand in hand with recognizing, respecting, and prioritizing their perspective.  We do a lot of work on something we call The Unmentionables – all about how perhaps the real diseases on which we should be focusing as a health industry include (maybe even as an initial focus since they can be overwhelming to the point of total loss of capacity for traditional health factors if not addressed) are caregiver, financial, workplace, relationship stress… Thanks Steve!

  • PRD .Vasan

    Article was too good,  could you please tell me what is “Big Brother Approach”?

  • Anonymous

    Thanks Steve- great post. I agree, consumer empowerment will drive people to take care of themselves. We don’t need the government to provide care for everyone, we need to give people the tools and education to take care of themselves. Awareness + Education leads to action.

  • Anonymous

    I completely agree with both patient and provider engagement including physicians and mid level practitioners and as critical, what preventive services are covered by the insurance carriers. The attitude that the provider speaks and the patient listens and the insurance company or Medicare or Medicaid pays does not truly address the responsibility of any of the three participants. This could serve as a definition of the Big Brother Approach, but the insurance companies are far more controlling than the government. With more and more providers at all levels utilziing EMRs, this aspect will increase the level of understanding between providers and dramatically reduce the time for test results and exchange of data to be placed directly into patients charts, patient education and compliance can be more effectively addressed and the patients can engage fully in maintaining their health status. While there are other factors, this paradigm shift will not be achieved unless there is a commitment to education of the children by the family, in schools at the early grades through high school and as importantly the providers commitment to education of their patient panel.