Two modest kiosks far in the back of a cavernous HIMSS 2015 exhibit hall symbolized two separate streams of the patient engagement effort as filtered through health information technology (IT).
One featured a Bluetooth-enabled toothbrush paired with a personalized video game to teach kids to properly care for their teeth. Call that approach, “enabling compliance.” Nearby, another kiosk showcased a computerized questionnaire to help patients understand their treatment goals and true feelings about risks and benefits of a proposed surgery. Call that, “better decisions.”
The two approaches can certainly co-exist. Dominating Brush Up: The Toothbrush Training Game doesn’t say anything about how you’d prefer to treat a toothache. Nonetheless, there’s an implicit tension between the two strategies. When Wiser Care, the company with the computerized decision support, promises to bring “clarity to health care decisions,” a question lingers in the air: What happens if the shared decision making bucks what the doctor thinks best?
Given the relative newness of these products, vendors prefer the all-encompassing promise to improve the patient experience. In the part of exhibit floor where the two kiosks were found, an area sponsored by the health technology accelerator HX360, a host of eager entrepreneurs offered their wares.
Employers who’ve raised workers’ insurance deductibles can provide them with doctor-shopping direction through Grand Rounds. The company promises to connect patients with medical experts who are the top 0.1 percent of doctors and provide “a guided experience that gives you clarity on your condition.” Along the way, patients might get text messages from CareWire, checking up on their condition after surgery, or use CareSync to coordinate among patients, caregivers, and clinicians. The patient might also be wearing a Fitbit provided by CipherHealth to manage their exercise and diet — while CipherHealth enables the hospital to monitor that management.
Elsewhere in the exhibit hall, Conversa displayed a clever way to get patient-generated data from digital devices directly into the electronic health record. Meanwhile, as my friend and colleague Jane Sarasohn-Kahn has written, one of the largest exhibits was the Connected Patient Gallery, sponsored by Walgreens. I was struck by participants as diverse as a newly updated, online Merck Manual from the old-line drug company and a kiosk from PatientsLikeMe, the innovative social network that has grown to serve more than 350,000 patients.
Although the evidence is still not in on the effectiveness of these new services, they fill a clear need. Studies cited by HX360 show that just 36 percent of patients describe themselves as “very well-informed” about conditions and treatments and a third leave the hospital unsure who is supposed to coordinate their care.
Patient satisfaction, as measured through CAHPS scores, is increasingly linked to compensation in the inpatient and outpatient environment alike. More importantly, motivating and enabling patients with chronic disease to consistently make the lifestyle changes needed to keep them healthy has gained new importance as payment moves from fee-for-service to fee-for-value. The latter includes bundled payment and payment linked to outcomes. The patient-as-partner has become both a business and clinical imperative.
As a 2013 Institute of Medicine workshop put it, “Prepared, engaged patients are a fundamental precursor to high-quality care, lower costs, and better health.”
Not surprisingly, patient engagement products tailor their pitch to the paying customer — not typically the patient. CareWire promises to “improve adherence throughout the management of care” and thereby “enhance” the bottom line. GrandRounds tells potential provider customers, “We preferentially guide our commercially insured patients to your top physicians.” Even Wiser Care reassures providers that shared decision-making leads to higher patient and provider satisfaction and even helps workflow by starting the treatment conversation from a more advanced place.
Certainly, aligning financial incentives to reward patient-centered practices is a positive change. Moreover, patient compliance with clinical directives is critical when the course of care is appropriate. However, patients can’t take that for granted.
Was the doctor’s decision evidence-based? Tools as diverse as computerized clinical decision support and Choosing Wisely materials for both doctor and patient can help ensure that it was. But simply listening closely also matters. A colleague recently told me of the “non-compliant” diabetic who instantly began taking her insulin once it was switched to an oral dosage that didn’t involve needles. The patient experience is enhanced the most when technological innovation includes a cultural transformation that emphasizes the voice of the patient.
Jan Oldenburg, a recognized patient engagement expert now at Ernst & Young, advised health systems to integrate patients and caregivers into every process. That means proactively using patient and family advisory councils and social media. Most important of all: “Do you take action on what you hear?”
As I’ve previously written, transformation in the doctor-patient relationship must recognize the importance of the medical evidence, the patient’s preferences and values and the doctor’s clinical experience. A striking example of how that might look was provided in a breakout session featuring the Dartmouth Institute’s Dr. Carolyn Kerrigan. Kerrigan, who has worked to integrate patient-generated health data and self-reported outcome assessment into the medical center’s normal workflow, told the story of a patient who had been scheduled months in advance for back surgery to relieve spinal pain.
As the date approached, the spine surgeon realized that he didn’t have a recent self-reported pain assessment. When those results arrived, he called the patient for a candid discussion. Her score on a disability index had declined from a 32 to a 26; the typical surgery patient scored 50+ pre-operatively and in the 30+ range afterwards.
“Together they decided [surgery] didn’t make sense, and her surgery was cancelled,” said Kerrigan, herself a surgeon, adding, “This story remains an inspiration to us.”
Surgeons and a medical center celebrating an expensive operation that never happened? Technology can reinforce that kind of transformation, but clinicians — with a persistent nudge from patients and payers — will have to lead the transformation themselves.