There is no app for patient engagement

Physicians, hospitals and other providers are being misled by  industry pundits claiming that more health information technology (as in EMRs, PHRs, smartphone apps, and web portals) is the key to greater patient engagement.   It’s not.

If health information technology were all that was needed to “engage” patients then  patient and member adoption rates of provider and payer web portals offering personal health records (PHRs) and electronic health records (EHRs) would not still be hovering around a disappointing 7% (with several notable exceptions Kaiser, Group Health and the VA).

Part of the misunderstanding concerning the role of HIT comes from how the discussion about patient engagement is being framed.  According to the pundits, patient engagement is the physician or hospital’s responsibility.  And like everything else these days, we can fix it if we just throw more technology at the problem. Can anyone say Stage 2 Meaningful Use requirements?

Here’s why HIT will not solve the patient engagement challenge

The role of physicians, hospitals and other providers is not so much one of needing to engage patients in their care.  Rather, providers need to “be more engaging” to patients who are already actively engaged in their health.

Take the simple act of a trip to the doctor’s office.  Before a person shows up at the doctor’s office they have to 1) have a reason or need (symptoms, a concern, chronic condition), 2) believe that the need or reason merits seeing the doctor vs. taking care of it at home themselves – this generally implies cognition and doing research, i.e., talking with friends, going on line, etc., 3) make the appointment (by calling or going online), 4) show up for the appointment, and 5) think about what they want to say to the doctor.  The point here is that by definition, people who show up for a doctor’s appointment are already engaged.

Now providers tend to not consider the patient’s perspective when it comes to engagement.  For most providers engagement means getting patients to do what providers say is in their best interest. But that approach totally dismisses the fact that patients are already engaged, just not in the same way that providers expect.

Whether patients remain engaged by the time they leave the doctor’s office, and to what extent, are the questions we should be asking.   For example, how “engaged” would readers here find it if they went to their doctor only to have the doctor 1) not ask why they are there (fears and concerns), or worse, ignore the fears and concerns which they describe to the doctor, 2) disagree with the doctor as to the visit priority and how to diagnose and treat it, including for example being prescribed medication when you don’t want to take pills, or 3) found out that you knew more about your problem and how to deal with it than your doctor?

The point is that providers need to be engaging to patients in their demeanor, attitudes, and how they talk with and listen to patients.   Doctors need to know who the patient is, what their fears, concerns and expectations are and what the patient is able and will to do.   Meaningful patient engagement, the kind that leads to long term health behavior change, begins with patient-centered, interpersonal relationships  between patients and their doctors.

As far as I know, we don’t have an app for that.

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

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  • Russ Strader

    Agreed. Here’s the problem. I have 10 minutes to see a patient in a 20 minute slot. That is because I have to spend the other 10 minutes “documenting” all the “right” stuff, as defined by the third party payors, in order to get paid for what I do. In the middle of that, I have to make sure that I have properly analyzed the data presented by the patient in order to offer the correct approach to diagnosis or treatment. Given the time constraints, documentation requirements, and medical-legal issues, many docs simply choose to cover the empirical data (what hurts? vitals? reports of tests? ) and order tests or treatment most likely to a) not get them sued, and b) hopefully help the patient.
    You want physicians to be more engaged with their patients? Get the payors — including, and especially the government — off our backs. The medical record is not designed to be a tool by which payors judge whether or not to pay us for our work. It is originally designed to be a tool by which physicians can help remember the medical issues and undertake appropriate diagnostic and therapeutic interventions for their patients. Get the lawyers off our backs. Yes, patients who are harmed by negligent medical acts deserve compensation for their suffering. But I routinely do expert witness work, and can tell you from first hand experience that awareness of the legal use of the medical documentation requires physicians to spend far more time concerned with appropriate charting than with the patient and their issues. And back to the payors, quit cutting our payments for the same work. We have to see 4-6 patients an hour given the ever decreasing rates of reimbursement for what we do. There is no choice; otherwise we go out of business. Given the charting requirements, for both legal and financial reasons, there is no choice but to spend less time with the patient, and more time with their chart, their test results, medication lists, and working on appropriate documentation.
    Mr. Wilkins has a nice idea. Get the doctors back to dealing with people. But in the current health-care climate, that’s not going to happen. You want a doctor to spend time with you, listen to you, and take care with the medical decision making? Let us run health care like we used to. And by the way, if you look at the numbers, health care cost a lot less then too. The key to cutting health care cost and increasing quality is simple: get the bean-counters and lawyers out of the way, and let us, who want to spend time doing quality doctoring, do our jobs without the outside interference and requirements. Then patients will be engaged, costs will come down, and quality will go up. It’s actually not that hard.

  • Ryan Witt

    I think the impediments may be as Russ mentioned, and the truth lies within each specialty and the location of the provider. Some healthcare providers make tons of money seeing 10 patients a day. Others struggle and need to see 60 and upwards patients per day to pay their staff and survive. It’s the hope that EHRs can automate some of the billing work for them, and eventually we may get there. For many other providers of care, I’ve heard phrases like “time is money.” There are many providers who are making a sufficient income to live and enjoy, but still spend 15 minutes per patient (and, more important than the time spent, they don’t spend the time to engage with the patient) so they can see more patients to get more money. That’s the nature of business but we can do better. In the end, market demands will drive this problem forward. Patients will leave as the market becomes more transparent and substitutes are made apparent to the patient. In other words, if you don’t engage with the patient, they won’t come back.

    Imho, market transparency and EHRs will eventually lead to better care and get providers through the day. As far as legalities go, I think patients are too quick to sue. Providers make mistakes and humans make mistakes. Because it is people’s health, there is a closer watch on these mistakes and there are huge settlements. What judge won’t give the patient $5 million dollars if the anesthesiologist made the wrong call, because he had a bad night and barely slept. There is lesser of a margin for error in healthcare, and that’s tough. Personally, I think a lot of the bureaucracy and red tape which slows innovation is brought to you by the patient — who blames the government for not taking action; then, when they take action, they say things are moving too slowly. Payers can never win, because they pay for thousands of dollars in care and only are mentioned when they fail to cover something. The only time anyone likes them is when… well, never… despite the fact they make one of the lowest margins in healthcare. That bureaucracy and legalities probably won’t stop. I cannot see patients ever not sue because of a human error or anyone not paying them — because an error in medical care can mean the loss of a life at the hands of a human error which didn’t need to happen. To today’s society, that’s not acceptable.

  • DuvalThinker

    This is only partially
    correct because in fact many patients are not engaged at all in their
    healthcare and those that do see their physician often don’t follow through as
    you have pointed out. While certainly the demeanor of the provider and their
    interaction etc. are important for those
    that show up, it’s how the person engages before and after the visit or for those
    that don’t visit they do those thousands of hours of the year when they are not
    spending the 10 minutes with their provider that are the key. This is where
    apps can play an amazing role.

    Want to change
    behavior, get engagement, mobile phones already have, the average person looks
    at their phone 30 times per day, it’s one of the few items besides a key or
    wallet/purse that you go back for if left inside the house. In fact there is
    now a condition, Nomophobia, the fear of losing one’s cell phone. By the end of
    2012 there will be more mobile devices in the world than people. Over 247
    million people have downloaded a health app and 27% of adult internet users
    track their health data online. Don’t relate well to your provider, maybe
    you’ll do better with your phone, studies have shown that people create
    relationships with their device. This technology is an opportunity to improve
    healthcare and should be leveraged by providers to increase efficiency, engagement
    and improve outcomes in conjunction with provider changes during the few short office
    visits they get a year.

    You are correct that patients have not wanted PHR’s, but the
    number one reason patients don’t take their meds is not that they don’t want
    to, its that they forgot… there are apps for that, Want to educate them to
    make a decision about whether or not they need to see their MD in the first
    place, there are apps for that, need to know when and be reminded to get your
    annual exam, mammogram, colonoscopy, there are apps for that; need to measure
    your blood sugar, there’s an app to remind and track that. These are all useful
    engagement tools. Perhaps a physician
    office might want to use an app to extend the reach of their providers to their
    patients doing just what these apps do and more.

    There are 40,000 health apps and today only 10 are prescribable
    and billable. We are early and the tech is ahead of the system, If done
    correctly great things are possible and should create meaningful and real patient
    engagement that may in fact reduce the need for the visits in the first place.

  • Giacomo Balli

    let’s make an app for that!

  • Simon Sikorski MD

    We do have an App for that – it’s called Medical Blogging, and it’s been around for many years. Just in the past 8 months we had over 200 doctors try out our blogs with our guidance. Patient engagement is achieved every time. We even have a project right now via a physician’s blog that is aimed at improving patient adherence to treatments.

    You don’t need rocket scientists to build patient engagement platforms. Just start blogging. Feel free to reach out to me for ideas how to get started.

  • Jennifer Michelle

    The fact is that the problem on both ends – patient and doctor – is lack of emotional connection. That’s at the crux of the engagement issue. Doctors are burning out in droves because being a doctor doesn’t feel at all like what they dreamed it would, and patients are avoiding doctors/avoiding taking care of themselves/seeking out alternative treatments because the CARE they need is simply not available. Apps are just a tool – if they are used to engage, they can,. If they are used as one more thing the patient has to deal with, despite not feeling understood or like their getting any real help with their problem, apps won’t be effective.

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