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Could Providing More Context Reshape Healthcare Consumer Choices? One Survey Says It Could

November 7, 2017
by Mark Hagland
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Survey results released by the health technology company Grand Rounds point to new opportunities to shift healthcare consumer choices through contextualized information

What, precisely, is the practical relationship between perceptions of quality and perceptions of price or convenience, on the part of healthcare consumers? And to what extent does the presentation of data influence healthcare consumer perceptions? Those were questions that researchers at Grand Rounds, a San Francisco-based healthcare technology company that helps employees identify and access quality physicians, wanted to explore, as they executed a consumer survey earlier this fall, the results of which they released on November 2. In fact, what the Grand Rounds researchers found was that survey respondents who typically prioritize appointment availability were four times more likely to sacrifice availability in favor of clinical expertise when presented with information in physician profiles in provider listings that were contextualized rather than simplistic.

In announcing the results of the survey on Nov. 2, Nate Freese, Grand Rounds’ senior director of data strategy, said, “This survey shows that if presented with contextualized information about a physician, people will choose a more qualified physician over one that is more convenient, in a significant way. Further,” Freese added, “based on our findings, traditional metrics like patient ratings, prescribing rates, and volume of patients seen were not nearly as compelling to respondents as more qualitative, contextualized statements about a doctor’s clinical expertise. Understanding how people choose their doctors is critical to our mission of matching people with high-quality providers for their needs,” continued Freese. “If consumers are willing to sacrifice convenience for the sake of quality, there is an opportunity to help them understand when it may be worth traveling further or waiting longer to get the best possible care.”

In the survey, conducted online and via email during September, 1,100 Grand Rounds covered members were broken into two cohorts: one that reviewed traditional physician profiles and one that viewed novel, more contextualized profiles. The version of profiles seen had a profound impact on people who said they typically choose doctors based on appointment availability or travel convenience. Of people who said they typically prioritize availability, only 14 percent made their physician choice based on clinical expertise if they saw the traditional profiles. In contrast, 69 percent of these same people made their choice based on clinical expertise if they saw the contextualized profiles. In fact, the switch to contextualized profiles made these respondents almost as likely to prioritize expertise as respondents who, when initially asked what matters to them when looking for a doctor, cited strong credentials/training.

One example of the different types of listings was provided in the blog that Freese wrote about the survey results. In that blog, he gave contrasting examples of “traditional profiles,” versus “profiles in context.” The sets of profiles involved the fictional “Dr. Williams” and “Dr. Harris.” In the traditional profiles, Dr. Williams was described as being 10 minutes, or 5 miles, away from the consumer, while Dr. Harris was 20 minutes, or 12 miles away. Under the “clinical expertise” category, Dr. Williams’ profile read, “Headache patients: Dr. Williams sees more headache patients than 60 percent of other similar doctors. Opioid prescribing: Dr. Williams writes 15 opioid prescriptions per 100 patients seen. Meanwhile, for Dr. Harris, the clinical expertise description read thus: “Headache patients: Dr. Harris sees more headache patients than 80 percent of other similar doctors. Opioid prescribing: Dr. Harris writes 5 opioid prescriptions per 100 patients seen.”

Meanwhile, the “profiles in context” read very differently. For Dr. Williams, the “clinical expertise” description read thus: “Low expertise: Dr. Williams sees headache patients regularly. However, she frequently  prescribes medications that can actually make symptoms worse.” For Dr. Harris, it read, “High expertise: Dr. Harris sees headache patients regularly  and uses treatments that are known to be the most effective at treating headache symptoms.”

Following the release of the survey results, Freese spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding those results, and their implications for healthcare leaders. Below are excerpts from that interview.

To begin with, could you explain a bit more about Grand Rounds and what your organization does, to our audience?

Yes. Grand Rounds uses data to connect patients to highly qualified doctors. Using data to match that member to a doctor who specializes in care for that particular type of patient. We’re all about helping patients to find the highest-quality doctor for them.

So your firm acts as a service provider to employers?

Yes, we’re a benefit to employees. We help to support employees/plan members who have questions about their healthcare benefits.

Can you comment on the differences between the contextualized and the traditional profiles?

Yes, It’s obviously a subjective term. But the traditional approach was simply to provide objective numbers and ratings. Where a rating fits. Contextualizing means taking a more qualitative stance. Rather than just volume of patients seen, adding in whether that is a valuable metric or not. And rather than just showing a prescribing rate, instead of just prescribing rate, also other data.

So let’s take an example from the survey itself. A traditional approach to the prescribing of opioids would be the rate per 100 patients of a doctor’s prescribing opioids. The patient’s question there is, so what? So, what we did was saying that prescribing above a certain threshold, we said, this doctor prescribes above the norm. For your reference, in the blogpost, we have profiles displayed.

And, as you and your colleagues found, in shifting to providing contextualizing profiles of the physicians, the percentage of consumers who are willing to sacrifice convenience for a perceived clinician quality differential goes from 10 percent to 69 percent. What does that say?

That percentage change is related to the patients who had said that appointment availability mattered more than quality. The traditional narrative would be that patients optimize for convenience, not quality. But this shows that even those patients who optimize for convenience, will go for quality, if there’s a substantial payoff for quality; but traditional metrics have not been able to elicit those responses.

The emergence of the empowered healthcare consumer has been heralded for quite some time now. I wrote a cover story 20 years ago saying the empowered healthcare consumer was right around the corner. Will it happen now?

Yes, I think that there’s a huge shift about to occur, but it won’t occur overnight. Simply getting people to look for information is the biggest challenge. What we found here is that when patients see the information, they will react to it. Now, we regularly survey consumers; and they’re consistently looking for consumer reviews.

One fascinating aspect of all of this is that many outcomes measures have been published publicly for a number of years now, for example, hospital outcomes posted on state hospital association websites. But until recently, consumer behavior doesn’t seem to have moved significantly because of that. But is it your sense that these kinds of information might now make that difference?

That’s right; take that example of hospital ratings. The healthcare system naturally gravitates towards hospital ratings, given that hospitals are large institutions. From the researchers’ perspective, it’s easier to manage data on hospitals, because the databases are bigger, and easier to work with. But patients want to know about their own providers—the specific OB they would use, for example. And so it’s not that patients aren’t willing to travel for quality; it’s just that those hospital-level metrics don’t resonate with them.

What needs to happen to activate healthcare consumers, in this context?

At the simplest level, we need to provide consumers with metrics that will resonate with them.

What needs to happen in the industry next, in terms of motivating healthcare consumers?

I think the biggest difference in the situation now is the movement towards value-based care, which is about incentivizing the provider side of the industry to do the right thing. Here, we’re talking about… consumers aren’t incentivized on their own to see the providers who provide the highest-quality care. You’re really talking about the element of behavioral change, or meeting patients where they are. I look at where patients naturally go to find doctors. It’s, ask a friend; or go to your company’s website, and there’s a doctor-finder. And there’s a huge opportunity to change the information that’s offered at that doctor-finder website. That’s the biggest thing that will lead to consumer change.

What should healthcare IT leaders be thinking now, as they consider these evolving changes in consumer-facing data and information?

First, there’s the message that people are willing to sacrifice convenience for quality. That’s a controversial assertion. To the extent people are, that’s an opportunity to really guide them towards high quality. I think the biggest thing that will be difficult for your audience, and really for everyone, is that moving towards more qualitative and subjective statements, in a public domain, isn’t going to be easy. It’s totally defensible to put up objective numbers. Saying that these prescribing actions might not be in the patients’ best interest, might be challenged. You have to be cautious; on the other hand, there’s a huge opportunity cost to simply sticking with the status quo.


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Who Isn’t Using Patient Portals? New Study Sheds Light on Portal Use

December 12, 2018
by Heather Landi, Associate Editor
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About two-thirds of adult patients did not use an online patient portal in 2017, and research indicates vulnerable and disadvantaged patients are less likely to use these technology tools, according to a study published in the November issue of Health Affairs.

Technologies such as online patient portals, which provide secure internet access to medical records and test results in addition to email communication with providers, can improve health care quality. And, evidence thus far shows that access to online portals increases patients’ engagement and adherence and may reduce unnecessary utilization and spending.

However, while the majority of adults in the United States believe that online access to personal health information is important, disparities in portal access exist.

“Findings from multiple studies that analyzed different population groups, including nationally representative samples, consistently show that members of racial and ethnic minority groups, older patients, and people of lower socioeconomic status are less likely than others to access an online portal,” the study authors wrote. The study was led by Denise Anthony, professor of health management and policy and sociology in the Department of Health Management and Policy, University of Michigan School of Public Health. Anthony and her co-authors also note that “inequities in access to new and beneficial technologies can exacerbate existing disparities in health.”

One national study, a March 2017 by the U.S. Government Accountability Office (GAO), found that only about 15 to 30 percent of patients who were offered access to a portal used it, with lower use among people living in rural and high-poverty areas.

“To identify appropriate levers that can be used to address inequities in online portal access, policy makers and providers must have a clear understanding of who is and is not accessing portals, as well as the reasons for not accessing them,” the study authors said.

For the study, titled “Who Isn’t Using Patient Portals and Why? Evidence and Implications from a National Sample of U.S. Adults,” researchers analyzed information about 2,325 insured respondents to the nationally representative 2017 Health Information National Trends survey to examine characteristics of patients who do not use portals and the reasons why they don’t them. By identifying who is not using portals and why, the researchers sought to uncover barriers and reduce disparities.

The study indicates that about two-thirds (63 percent) of insured adults with a health care visit in the previous 12 months reported not using an online patient portal. The research indicates that nonusers are more likely to be male and age 65 or older, have less than a college degree, not be employed, live in a rural location, be on Medicaid, and not have a regular provider.

These factors, along with race, were also related to whether a patient reported receiving an offer to use a portal.

Relative to females, males had significantly higher odds of not being offered access to and not using a portal, the study indicates. Members of racial minority groups (specifically, non-Hispanic blacks and non-Hispanics of other races—including Asian Americans, Native Americans, Native Hawaiians, and Pacific Islanders) had significantly greater odds of not being offered a portal. Among only those who were offered a portal, these groups reported rates of using a portal comparable to the rate of non-Hispanic whites.

The study also found that people with only a high school diploma or less were significantly less likely than those with college degrees to have been offered access to a portal. Patients with Medicaid insurance were significantly more likely to report not having been offered access to a portal and not using one, compared to people with other insurance.

Patients who lacked a regular provider were significantly more likely to report not having been offered access and not using a portal.

When evaluating reasons why people did not use a portal, the researchers did not find evidence of disparities in technological barriers. The reasons patients gave for not using portals included the desire to speak directly to providers and privacy concerns, both of which require recognition of the important role of provider communication and patient-provider relationships, the study authors note.

The study authors conclude that healthcare providers will need to address patients’ privacy and security concerns to enhance provider-patient communication.

“Reducing disparities in portal use will require that providers, particularly those serving vulnerable populations, communicate with all patients about portal use and have the capacity to discuss these technologies with patients,” the study authors wrote.

“Health care providers and plans can increase patients’ use of portals and narrow disparities in that use through direct communication about the benefits of portals, while also addressing patient-specific needs and concerns. Such interventions will require recognition that providers’ communication with patients takes time—an extremely scarce resource in clinical practice today,” the study authors concluded, while also noting that careful monitoring of who is and who is not using new technologies, and why, and designing technologies to address patients’ needs, will help ensure that such innovations do not exacerbate disparities but rather lead to improvements for all.

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AMIA, AHIMA Call for HIPAA Modernization to Support Patient Access

December 7, 2018
by Heather Landi, Associate Editor
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Modernization of the 22-year-old Health Insurance Portability and Accountability Act (HIPAA) would improve patients’ access to their health information and protect their health data in a burgeoning app ecosystem, according to two leading health IT industry groups.

During a briefing on Capitol Hill Wednesday, leaders with the American Medical Informatics Association (AMIA) and the American Health Information Management Association (AHIMA), health informatics and health information management experts discussing how federal policies are impacting patients’ ability to access and leverage their health data.

While other industries have advanced forward with digital technology and have improved individual’s access to information, and the ability to integrate and use information, such as booking travel and finding information about prices and products, healthcare has lagged. Healthcare has not been able to create a comparable patient-centric system, AMIA and AHIMA leaders attested.

“Congress has long prioritized patients’ right to access their data as a key lever to improve care, enable research, and empower patients to live healthy lifestyles,” AMIA president and CEO Douglas B. Fridsma, M.D., Ph.D., said in a statement. “But enacting these policies into regulations and translating these regulations to practice has proven more difficult than Congress imagined.”

“AHIMA’s members are most aware of patient challenges in accessing their data as they operationalize the process for access across the healthcare landscape,” AHIMA CEO Wylecia Wiggs Harris, Ph.D. said. “The language in HIPAA complicates these efforts in an electronic world.”

AMIA and AHIMA recommend that policymakers modernize HIPAA by either establishing a new term, “Health Data Set,” which includes all clinical, biomedical, and claims data maintained by a Covered Entity or Business Associate, or by revising the existing HIPAA “Designated Record Set” definition and require Certified Health IT to provide the amended DRS to patients electronically in a way that enables them to use and reuse their data.

According to AMIA and AHIMA, a new definition for “Health Data Set” would support individual HIPAA right of access and guide the future development of ONC’s Certification Program so individuals could view, download, or transmit to a third party this information electronically and access this information via application programming interface. Alternatively, a revision of the current DRS definition would provide greater clarity and predictability for providers and patients.

The groups also noted that a growing number of mHealth and health social media applications that generate, store, and use health data require attention as part of a broader conversation regarding consumer data privacy.

Congress should “extend the HIPAA individual right of access and amendment to non-HIPAA Covered Entities that manage individual health data, such as mHealth and health social media applications, the two groups said. The goal is uniformity of data access policy, regardless of covered entity, business associate, or other commercial status, the group leaders said.

Beyond HIPAA, during the briefing Wednesday, panelists discussed the success of efforts to share clinical notes with patients during visits, including the successful OpenNotes initiative, and recommended that federal officials look for ways to encourage more providers to share notes with patients through federal policies, such as Medicare and Medicaid payment programs.

“More than two decades after Congress declared access a right guaranteed by law, patients continue to face barriers,” Thomas Payne, M.D., Medical Director, IT Services, UW Medicine, said in a statement. “We need a focused look at both the technical as well as social barriers.”

What’s more, AMIA and AHIMA recommended federal regulators clarify existing regulatory guidance related to third-party legal requests, such as those by attorneys that seek information without appropriate patient-direction.

“HIM professionals continue to struggle with the existing Office for Civil Rights guidance that enables third-party attorneys to request a patient’s PHI,” Harris stated. “We recognize there are necessary circumstances in which a patient has the right and need to direct their health information to an attorney. However, AHIMA members increasingly face instances in which an attorney forwards a request for PHI on behalf of the patient but lacks the information required to validate the identity of the patient. As a result, the HIM professional is challenged as to whether to treat it as an authorization or patient access request, which has HIPAA enforcement implications

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Health Systems Work with Epic on Electronic Patient-Reported Outcomes for Oncology

November 18, 2018
by David Raths, Contributing Editor
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With eSyM app, patients will provide feedback to their cancer care team via the EHR

Six U.S. healthcare systems are sharing a $9 million grant to research introducing electronic patient-reported outcomes (ePROs) into the routine practice of oncology providers to improve symptom management and to decrease hospitalizations.

The National Cancer Institute, in association with the Beau Biden Cancer Moonshot Initiative, recently announced the funding of the collaboration, the SIMPRO (Symptom Management IMplementation of Patient Reported Outcomes in Oncology) Research Center. The SIMPRO team will work with Epic, the EHR system used by all six participating institutions, which are New Hampshire-based Dartmouth-Hitchcock, Dana-Farber/Brigham and Women’s Cancer Center in Boston, Baptist Memorial Medical Center in Memphis, Lifespan Cancer Institute in Rhode Island, West Virginia University Cancer Institute, and Maine Medical Center in Portland.

SIMPRO will develop, implement, and evaluate an ePRO reporting and management system through an app called eSyM. Patients’ smart devices will enable a secure connection to their cancer care team via the EHR, and facilitate symptom tracking following cancer surgery or chemotherapy. The study will test whether monitoring the symptoms patients experience and providing coaching on how to manage them can decrease the need for hospitalizations and emergency room visits.

“The opportunity to partner directly with Epic and their resources, to build these tools into our electronic health record, means in the short-term the research is more likely to bear fruit “and in the long-term that successful strategies can be disseminated around the country.” said Dartmouth-Hitchcock Chief Health Information Officer Peter Solberg, M.D., in a prepared statement,

After development and pilot testing, eSyM will be fully integrated into the EHR at each participating center, allowing for direct communication and real-time updates for clinicians who will have access to a dashboard of patients’ symptoms to prioritize outreach efforts and coaching.

The SIMPRO investigators will conduct a randomized trial to evaluate implementation of eSyM from a patient, clinician and health system perspective. Across all study phases, the implementation, adoption, acceptance, and adaptation of the ePRO system will be critically evaluated to promote better delivery of cancer care.



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