On Monday morning, May 21, during the Health IT Summit in Philadelphia, sponsored by Healthcare Informatics, Katherine Schneider, M.D. CEO of the Delaware Valley Accountable Care Organization (DVACO), based in the Philadelphia suburb of Villanova, offered attendees a bracing view of the challenges facing patients and their families as they navigate the U.S. healthcare delivery system.
Under the session title, “Patient Engagement Is Not an App,” Dr. Schneider illustrated her theme through a complex, multi-partite personal story about her family’s experiences with well-coordinated and poorly coordinated care.
Cleverly, Schneider contrasted the experience of family member “A”—a family member who had experienced very well-coordinated, patient-friendly care for an urgent condition—with that of family member “B,” who had experienced extremely uncoordinated care delivery that was frustrating to “B” and to the entire family. After going through the experiences of both family members, she revealed to the audience that “A” was her family’s dog, and “B” was her husband, who also happens to be a physician.
In the case of her husband, she noted, “His symptoms involved some scary visual defects, including blurred vision. Since he did not have a regular ophthalmologist, he went online and looked for an ophthalmologist who took his insurance and was convenient. The ophthalmologist saw him, and referred him immediately to a world-class retinal specialist who was able to see him quickly. It was determined that he needed surgery,” she said. “He was told to get a cardiology clearance, told to get a physical with his primary care physician, and to get some lab work done. All of those things followed no practice guidelines,” she noted. “His outpatient surgery was so low-risk physically that he didn’t even have to take off his socks and shoes.”
Katherine Schneider, M.D.
Further, Schneider said, speaking of her husband, “He tried to get in to see his PCP for a preop physical. His regular physician wasn’t available, and he saw a wonderful covering physician. But when he went to get the bloodwork, there was some confusion because it was a covering physician, and so he had to do it twice. There was no clarification around what a cardiology clearance meant. And these are all wonderful docs. But he had to make 15 phone calls and scramble to get care coordination. He was given a wonderful educational sheet explaining his problem at a sixth-grade-type level, but of course, he went on Google to find everything out.”
Schneider went on to say that “My husband wants you to know that all his care was wonderful. He was very brave for having his stuff sucked out of his eyeball. He’s an MD-JD. But he had to do his own care coordination. But you can imagine if we were an elderly couple with some cognitive impairment.” What’s more, she said, “With my dog, I felt I was embraced, and I didn’t have to worry about anything. It was a wonderful experience. Some people would say, well, that’s because one of these is insured and one isn’t. So is the dog’s experience better because it involves an elective, out-of-pocket experience? I would argue that that’s not the case. Why can’t we provide a nice, well-coordinated experience for people?”
So, Schneider said, “Now, we can talk a bit about the framework. Neil used the word ‘friction,’” she said, referring to Neil Gomes, chief digital officer and senior vice president for technology innovation and consumer experience, at Thomas Jefferson University and Jefferson health (Philadelphia), who had spoken immediately prior to Dr. Schneider, on the topic, “The Digital Future Now: How We Can Build a Transformative Digital Future for Health and Learning Today.”
“The goal is to reduce the friction in healthcare. That’s where people get frustrated, and there’s a lot of waste,” Schneider said. “And this word ‘engagement’ is probably the most overused word in healthcare now. And, if you do a Google search, you can ask, how often does a word appear in common language? It was actually quite common in 1800, because it referred to battlefield engagements,” Schneider noted. “It also means engagement in terms of mutual promise or engagement. We sometimes feel in healthcare that it’s like battlefield engagement; we hope it doesn’t have to be at a marriage level. We hope that it’s about patients feeling like they are a part of this team, and probably the most important part, in terms of patients engaged in their own health. Sometimes, we use the term in terms of loyalty—we want patients to be loyal. But that’s peripheral to how we can engage patients better to be part of their own care team.”
What’s needed, Schneider said, is “a patient-centric view of health engagement. Where are all the levers to get me engaged in my own health? Maybe the insurer? There may be a wellness vendor. The employer. The public health community. By the way,” she said, “I live in central Philadelphia, where the life expectancy is about 30 years longer than in North Philadelphia, something that’s really shameful. So anyway,” she said, pointing to a complex diagram on the screen, “this shows all the stakeholders involved. And when it comes to framing this in terms of apps, it’s overwhelming, right? The wellness vendor has an app; the insurer has an app; the health systems have apps. There’s an app for a telemedicine visit. And actually, I’m on the page of my local public health agency. And then I’ve got all my health apps for my phone. So the point is, this is kind of overwhelming. These are all wonderful, but they don’t talk to each other. I tried to get my wellness app to talk to my tracker applications. My tracker didn’t have a link to my wellness app, but I could do an indirect chain, or I thought so, but it didn’t work.”
Meanwhile, Schneider asked, “So, what really helps me with my health? This is what engages me in my health: one is my community. I live in a wonderful community in Rittenhouse Square. There’s a farmer’s market. I have four vegan fast-food restaurants where I can get vegan takeout. There is actually a McDonald’s on my block, but it’s always empty—except for the homeless people and the tourists. The vegan fast-food restaurants have longer lines, actually. And here’s a photo of the bikeshare program within a block of my house. Many things have helped me to get healthier, including family and friends.”
The bottom line? “It's better to have something simple that’s accurate,” Schneider said. “So let’s think for a moment about how to engage people. We’ve got people who are healthy, those at risk with unhealthy behaviors, and those who are chronically ill. And we’re actually not doing too badly” as a healthcare system “with the acutely and episodically ill. And both my family members’ experiences were around acute care. But how do we get people to engage in their health, around unhealthy behaviors? How many of you are good at putting time and effort in something that won’t give you pleasure, but will help you eight years down the road? None of us are good at that.” And, she said, there’s a process gap involving the fact that, for example, most diabetics will only see their doctors fewer than four times a year. The key, she said, is this: “We need a consumer-centric view of health engagement. We need to target tools not at what your health status is, but on moving you along into better health. And only a small minority” of those with chronic illnesses “are really empowered people who actually own it. How do you get others to join that group? There are a lot of strategies to move an individual along, and that’s where we’ve really got the most potential.”
And, she noted, going back to the beginning of her speech, “That’s my dog’s story—the story of a team that’s well-integrated, and which meets all of my needs within a 90-minute visit.” What is needed, she said, is “taking the barriers away for the patient,” and helping teams “to do this right. And, in that,” she said, one of the biggest barriers we have is the fee-for-service system, which does not support any of these models” of truly integrated care delivery and care management. “APMs”—alternative payment models—can provide the environment to change care models. The point is personal: health engagement is really the ultimate in personalized medicine. You can have identical twins with the same genome, but very different attitudes and behaviors.”
Meanwhile, Schneider asked, “Where does technology fit in? Technology should be some of the means to an end. So, the message here is that there is hope; there certainly is a lot of opportunity, and it’s a really exciting time for technology to break down barriers. And our motto at the DVACO is, keep calm and keep your foot on the gas.”