A 2015 HIMSS study found that chief information officers and chief medical information officers believe that they drive their hospital’s patient engagement efforts because it is likely to have a strong technical component. But as Chicago-based HIMSS Executive Vice President Carla Smith noted in a recent interview, clinicians and patients beg to disagree. They see patient engagement as a high-touch thing. “But the clinicians say the patients need to take more responsibility for outcomes and the patients say the clinicians need to be driving it,” she adds. All three groups see different barriers, according to the survey. Many CIOs say attitudes and expectations of providers and patients are a problem, while providers see time demands and training as barriers, “so we have many steps to walk together to figure this out,” Smith said.
As HCI Editor-in-Chief Mark Hagland noted in his report on the Health IT Summit in Chicago, held in October 2015 and sponsored by the Institute for Health Technology Transformation (a sister organization to HCI under the Vendome Group corporate umbrella), whenever clinical and healthcare IT leaders come together to discuss the subject, they inevitably begin parsing definitions around a concept as complex and nebulous as “patient engagement.”
In a panel discussion at the Health IT Summit in Chicago, Krishna Ramachandran, chief administrative officer at the DuPage Medical Group, a 500-physician, 70-location multispecialty group based in the Chicago suburb of Downers Grove, emphasized that patient engagement and patient experience are a separate but related phenomena. Ramachandran noted that, in his medical group, “Engagement, we slice into three buckets: we have the healthy patients; we just need make sure they’re OK and healthy; we have the rising-risk patients; and the high-utilizing patients. And we need to apply a high-touch form of engagement with them.”
A common refrain heard these days is that health systems have a tactical approach to patient engagement but not yet a strategic one. Also in the Chicago panel discussion, David Kaelber, M.D., Ph.D., chief medical informatics officer at MetroHealth System in Cleveland, reported, “We’re trying to take a very strategic approach, but there are not a lot of models out there for us to follow. It’s one thing to ask, don’t we want to engage patients more? And everyone says yes,” he said. “But then you have to figure out how to make it happen tactically, and so we have this big vision, but it’s being executed in little tactical pockets. On the technology side, we have our personal health record portal and direct patient messaging. And then we have the people side of this. And you only want to throw resource-intensive operations and programs at patients who are already resource-intensive.”
During a recent eHealth Initiative presentation, executives from two large health systems — Partners HealthCare in Boston and Geisinger Health System in central Pennsylvania — talked about their evolution in thinking about patient engagement and their efforts to create portfolios of tools to help patients manage their conditions.
Joseph Kvedar, M.D., vice president of Connected Health at Partners HealthCare, said his thinking about how to approach patient engagement has evolved as he became aware of how addicted so many of us are to our smartphones. Connected Health had actually had some trouble getting patients with chronic conditions to engage in remote monitoring programs that required them to make an effort. In one study, people who had to push a button to send device data every day were 75 percent less likely to upload their data than a control group where submitting the data was made automatic, he said.
Joseph Kvedar, M.D.
“The simple act of pushing a button was less engaging,” he said. “So I came away asking myself why do they check smartphones 150 times a day, but I can’t get a sick person to push a button once a day to improve their health? That was the day I decided to try to make health as addictive as your mobile phone.”
Kvedar, who recently published a book called The Internet of Healthy Things, said one change they made at Partners was to try to make any intervention be more positive about the patient’s life. “We lecture patients about negative consequences of behavior down the road, and it just doesn’t resonate with people,” he said. “We are looking to find ways to make it more relatable, such as telling them they will have more energy when around their grandchildren or be able to travel more.” He gave an example about a text messaging program for pregnant women called OB Texting: “If I know your due date, I can predict a lot of things about you for the next nine months or so. We set up routines to send out messages to folks who sign up for this program. It has been very effective.” Of women who responded to a survey about using OB Texting, 74 percent said it helped them to learn to take care of themselves and their babies, and 85 percent said they felt supported by the OB team.
Kvedar called mobility in health a game changer. “We have never had a situation where there is something in the palm of the patient’s hand that is always on and connected. It is a new world where you can message people through an app or text in a very contextual way,” he said. “We just have to figure out how to weave our health messaging into that power of picking up the phone to check things and I think we will have a winner on our hands.”
Chanin Wendling is director of Geisinger in Motion in its Division of Applied Research & Clinical Informatics. Geisinger in Motion promotes the effective use of technology to initiate patient and provider activation across the healthcare delivery network. She said that in evaluating new technologies that might be valuable in clinical care, she looks for ones that excite people and make them more interested in their care and more likely to adhere to care plans. “I want to meet patients where they are,” she said. “We are not trying to get them to do something that is not natural for them.”
At Geisinger, how technology is used to engage patients falls into three main areas: getting them to understand their health; enhancing the time they spend with the clinical team; and tools to help them manage chronic conditions.
She notes that the effort really has been an evolution at Geisinger. “We did not start out with a big bang and one technology platform,” Wendling said. It has grown over time based in part on consumer adoption of technology. Geisinger tries to follow what consumers are already doing. “When text messaging and mobile apps became popular, it gave us an opportunity to take advantage of that,” she said.
Geisinger was an early adopter of a patient portal back in 2001. To make the patient’s office visit more valuable, they are prompted through the portal to do a pre-visit update, completing and reviewing information. “Were also part of Open Notes,” she said, “so we ask them to go back and look at doctor notes from previous visits.”
A few years ago Geisinger added some text messaging programs around topics such as weight management and has been adding mobile device solutions.
“We have these pieces,” Wendling said. “The question is how do we bring them together into a portfolio of tools to manage your condition?” The portal is the foundation to help patients understand their condition. “We are working on integration with wearable devices, she said. “Although patients may want to give us lots of data, we want to ensure that providers are getting the data they need. If you have somebody who is at goal in terms of treatment, you may not need to get data from them on a regular basis, just things that are outside the range,” she explained. “But if you have a diabetic, and you are trying to figure out appropriate dosage of insulin, then regular glucose readings could be very important.”
One new area Geisinger is exploring involves electronic books. It has developed one for patients going through lumbar spine surgery and made it available through iTunes University. “It’s like a course you might take,” she said. It has photos of staff and an app about the lumbar spine. It links to the patient portal, so the patient can stay connected with information in their medical record. “With e-books we can enable interactive features and video, which make the material more interesting and engaging,” Wendling said.
Looking to the future, Wendling said Geisinger wants to be more retail-focused and think about patients as individuals. “We tend to look at populations and think about what we need to do for diabetics. But we look at them as a group rather than Shannon and Joe and Ed and Alex, who have unique styles, motivations and behaviors. And what we would ultimately like to do is deliver an individualized approach,” she explained. Technology would enable this, but technology would not always be the answer, Wendling added. “If you understand the patient’s communication preferences and motivations, you can use those in terms of how to approach the patient. Some would like telehealth; others want to talk to people face to face. The theory is that if we make it personal, patients are more likely to see it as a partnership and they will have better outcomes because they are onboard with the plan we have constructed with them.”