At a time when healthcare consumerism is emerging in all the advanced, industrialized nations, research into the phenomenon is bringing forward new understandings of what consumers need and want. What’s more, the phenomenon of healthcare consumerism is international, indeed, global.
Discussions around consumerism were numerous at the World of Health IT (WoHIT) Conference, held in Barcelona, Spain, in November, and extended across presentations and discussions around patient engagement, health information exchange, and interoperability, among other topics. Among those who has considered consumers, and helped lead research on the subject, is Kaveh Safavi, M.D., J.D., senior managing director of the global health practice in the New York-based consulting firm Accenture. Dr. Safavi, who consults with client organizations in the United States, Europe, and globally, sat down during WoHIT, to speak with Healthcare Informatics Editor-in-Chief Mark Hagland, about this topic. Below are excerpts from that interview.
You and your colleagues have been examining healthcare consumer attitudes, both in the context of the U.S. healthcare system, and in an international context.
Yes, that’s correct. We recently surveyed U.S. healthcare consumers around a number of topics, including access to their EHRs [electronic health records]; and we asked physicians the same questions. What we found was interesting. First, we asked healthcare consumers whether they believed that consumers should full access to their EHRs; limited access; or no access. The results were as follows: 92 percent of consumers believed that consumers should have full access to their EHRs; 7 percent said they should have limited access; and only 1 percent said they should have no access.
Then we asked physicians what level of access they believe healthcare consumers should have, to their EHRs. And only 18 percent of physicians said that they believed consumers should have full access to their EHRs, while 74 percent said they should have limited access, and 7 percent said no access whatsoever.
That’s a huge contrast.
Yes, it absolutely is. And, interestingly, 49 percent of patients believe that they already have full access to their EHRs.
What does the concept of the engaged consumer or patient mean, now, in an international context?
It depends on whether the healthcare system believes that competition should be a part of the healthcare system. In the U.S., we believe that competition for patients is a good thing; it’s a part of our model. Meanwhile, in other countries—ones with public health systems—there’s more of a sense that healthcare is an entitlement. So consumerism in those systems is being driven more as a right issue than as a market issue. When access is driven as a market issue, it tends to focus on things like appointment access. But is access on the consumers’ own terms? That’s a little bit different. We see that consumers are having expectations around things like banks and retail; so healthcare consumers are not looking at this as a competitive issue, but as a service or satisfaction issue. We’ve had a survey result finding that 49 percent of consumers say they would switch doctors over the differential in access. The barriers to switching are high, while the loyalty level is low. So this idea about the experience, separate from just appointment access, is a reflection that consumers want access and care delivery on their own terms. And we in healthcare can’t depend on the idea that healthcare is different.
Is there a conceptual difference in how patient care leaders frame consumers, versus patients? Does it change how providers interact with those who receive healthcare services?
There is a difference, but it’s one with a nuance. There was a false dichotomy for at least ten years. We said, are they consumers or patients? And we’ve discovered that they’re both, and those archetypes interact with each other. So the sick patient in the bed doesn’t know what diagnosis should occur or when, of course, meaning that they don’t have precise or educated expectations around purely clinical issues. But when it comes to a porter taking them to their bed or getting a meal on time, their expectations are very high in terms of service, just as in any other industry.
There’s a term we call “liquid expectations”—the idea that you move expectations from one segment of your life to another. I think that’s a really interesting part of healthcare that we’re starting to recognize as a reality. So if I’m building a healthcare system, how do I address service as a quality? In most industries, they recognize that service experiences are designed based around consumers’ experiences with your product. In healthcare, we don’t do that. We will do polling and try to base how we architect services around that polling, but it doesn’t make sense. We see that time and again, for example, in surveying about what telemedicine should be like—because consumers didn’t know what to expect.
We saw this in the south-central U.S., where they tried the [telehealth delivery-based] system where the physician would drive out to a center; but when patients were cajoled to show up, they preferred it, even though they had said, ‘I don’t want to see my doctor on TV.’ But they ended up loving it, because the doctors suddenly had all kinds of capacity. And from the doctors’ perspective, they were staffing multiple exam rooms, so there was more productivity, if patients didn’t show up. By setting up these centers with remote access, it worked out great. So our industry is struggling, because if it accepts the fact that it has a service opportunity, it doesn’t understand how to fix the problem.
As we move care out towards the patients, what should CIOs and CMIOs be thinking about?
The gold standard is changing towards care delivery becoming location-independent, based on where a patient would like to receive care. And it will be a blend of physical and virtual care delivery. If you take a physical experience—an example I gave came from ten years of research. If you look at advanced telemedicine, where you have a high-quality audio-video connection, including where you can do remote blood pressure, stethoscope, otoscope—a study found that in urgent care in Scotland, about 83 percent of patients can be taken care of safely remotely, as long as you have remote equipment. And historically telemedicine was in the 60s in terms of satisfaction. But patients are finding they actually prefer the virtual—they can see the same ear drum the physician is looking at, or hear the same heart sounds. So the choice is, if I have a doctor in front of me in an old-fashioned format, versus a remotely located doctor who has the tools to provide a richer experience, most patients will choose the latter. They want a personalized visit, as opposed to an in-person visit. Technology allows us to change the nature of the visit. And that kind of augmentation offers a huge opportunity to transform care.
So, how can CIOs and CMIOs be strategic about these kinds of potential changes and innovations?
The CIO has really become part of the strategy now. It used to be that the job of the CIO was to be on time and on budget; now, what’s possible is not what the operating executive of the past would even have known. And typically, the business lags the strategy; but typically, organizations follow what’s available. An example: a large U.S. healthcare system identifies the fact that they have 50 different telemedicine pilot projects going on. The enterprise needs to figure out what its strategy is. Are we doing it to improve access? Effectiveness? Affordability? You have to understand the why, and then the what and the how come out of that. A lot of people don’t really understand that. And we tell people, if you don’t have a strategy, every vendor will pull you in their direction.
And the CIO, if they’re not part of the strategy, they’re handed an implementation task, along with the total cost of ownership, and it becomes a gigantic technology maintenance problem. So I always say that having the “why” first before the “what” and the “how,” is really critical.
What should U.S. healthcare IT leaders know about any trends that are emerging right now in Europe and Asia?
We talk about affordability in the U.S., but we primarily think about it in terms of the elimination of unnecessary services. Technology is interesting—if you talk to people in the U.S. and in Europe about things like cognitive computing and AI [artificial intelligence], it prompts them to think about replacing cognitive tasks with technology. But if you have that conversation in Singapore and Japan, they think about robots, because they have a shortage of workers. They’re talking about automating physical tasks, out of necessity. There will be a convergence. Unfortunately, most countries think that the answer to the question lies in changing economic incentives. Every country thinks that changing their economic model to someone else’s, will solve the problem; and that’s emotionally comforting, but false. Healthcare costs go up at the rate of the GDP [gross domestic product] plus 1 to 3 percent in all countries—all countries’ healthcare inflation rate is still their GDP plus 1 to 3 percent.
So the real question is not how much you spend in absolute terms, but how much you’re spending on healthcare relative to your economy. And the reason for that is the cost of labor. Wages will never grow more slowly than your overall economy. And with the aging of populations and the explosion in chronic disease, unless you can eliminate some humans, you’ll never fix that. So we’ve seen in the U.S. GDP plus 2 percent, 1 percent, 1.5 percent. So we haven’t bent the curve, only dented it. Ultimately, all the remaining units of care delivery, even after we’ve taken some unnecessary services and tasks out, we’ll still be in the same place, basically. The service industries in general have lost 0.5 percent productivity, and healthcare is the worst-performing of all industries; it’s lost almost 1 percent productivity. Other industries have either moved tasks to a less expensive person, or a machine, or a customer. So when we said, how do we make healthcare safer? Electronic health records. They’ve made things safer. But they haven’t saved money.
What will happen in the next few years in all this, in the U.S., Europe, and elsewhere?
We’re going to make care more effective and more virtual. That will help us to accomplish both personalization, as well as greater productivity, so you’ll have two forces moving that forward. Meanwhile, advances in cognitive computing and AI will help us perform diagnostic testing more effectively. Diagnosis, treatment, care coordination, ancillary and supportive services, and self-care, all of those things that largely rely still now on the physical world, become possible as you start to think of new ways to bring these technologies to bear. So in the longer term, AI and cognitive computing will have a huge impact on making healthcare more effective and affordable.