Is It Time to Totally Rethink the Concept of Patient Engagement? | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

Is It Time to Totally Rethink the Concept of Patient Engagement?

May 30, 2018
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Dr. Katherine Schneider’s challenge to her audience in Philadelphia speaks volumes about the challenges ahead around the evolution of the patient engagement concept

It was fascinating to listen to the keynote address presented by Katherine Schneider, M.D., CEO of the Delaware Valley Accountable Care Organization (DVACO), a fortnight ago on May 21, during the Health IT Summit in Philadelphia, sponsored by Healthcare Informatics. As I reported here, Dr. Schneider, under the session title, “Patient Engagement Is Not an App,” “offered attendees a bracing view of the challenges facing patients and their families as they navigate the U.S. healthcare delivery system.”

As I wrote, “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.”

First of all, kudos to Dr. Schneider as a speaker. She was able to captivate her audience through her approach to her narrative, keeping attendees in suspense until the “big reveal”—when she was able to share that family member A was her dog, and family member B was her husband. And guess who had the well-coordinated, patient-friendly care delivery experience? Yup, her dog.

But beyond that, Dr. Schneider made a bunch of great points about patient engagement, on a broader level. “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.” Per engagement, she noted, “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.”

The key here is that Dr. Schneider urged Health IT Summit attendees to work with her to begin rethinking the whole concept of patient engagement. The problem, as she pointed out, is that “[W]e want patients to be loyal. But that’s peripheral to how we can engage patients better to be part of their own care team.”

And therein lies the rub. Clinicians and administrators in healthcare largely continue to think of “patient engagement” in the same way that they think of “consumer loyalty,” and also in the way that they think of “patient compliance”—Mrs. Smith is filling her prescriptions, take her medications as directed, and following her doctor’s orders. But that’s a very superficial way to think of this, given A) the tiny percentage of time that patients/healthcare consumers actually spend with clinicians; and B) the explosion in chronic illness in the U.S. The reality is that, in order for Mrs. Smith to become “fully engaged,” she’s going to have to do more than “follow orders” and continue to see the same doctors and nurses.

In fact, Dr. Schneider told her audience, what really engages her around her health is engagement with her community—the neighborhood she lives in, in Philadelphia, among other things. And her community, of course, is where she lives, 24/7/365. And, as she also noted, apps alone won’t do it. There has to be a human connection—and, though she didn’t say it explicitly, a process connection.

And the many-millions-of-dollars question is this: in the shift in U.S. healthcare from a fee-for-service-based payment system to a value-based payment system, where does this concept of patient engagement fit in, really? Because on some level, it’s got to. One arena in which this will inevitably play out will be in the context of care management, within the framework of accountable care organizations (ACOs), and other value-based contracting arrangements—in which, frankly, it’s in the economic interest of providers to engage with their attributed patients in certain ways. What’s exciting is that the patient care organizations whose leaders are architecting new forms of care management, are developing multidisciplinary care teams that really are engaging more fully with their patients, beyond the much-noted nine minutes that the average physician actually spends with her or his patient during a patient visit. And that means nurse case managers, nurse practitioners, physician assistants, dieticians, social workers, pharmacists, and others, are all becoming more active and involved with patients; the burden doesn’t just fall on physicians—and everyone knows it can’t.

So in the emerging value-based healthcare, there is a new dynamic beginning to become more common, one in which entire care teams are engaging with patients. And that’s where that engagement is inevitably going to take place.

There’s a further wrinkle here, too, in that health plan leaders want to become more engaged with their plan members. That’s a different level of engagement—one that’s possible, but even more complex, given the mistrust that many plan members feel towards their health plans (often justifiably). But that level, too, is going to need to emerge going forward, for everyone to become successful.

In short, if Katherine Schneider’s dog can receive patient-centered, well-coordinated, engaging healthcare, why can’t her husband? Dr. Schneider’s question, posed implicitly in the form of a challenge, was the perfect question to ask at the Health IT Summit—and would have been, anywhere in U.S. healthcare.

So let’s keep asking these questions, and finding process solutions over time—because we’ll need to find those solutions, in order for everyone—very much including patients/healthcare consumers—to move forward together into the future. It will be fascinating to see how this plays out; I have no doubt that the leaders of some of the most pioneering patient care organizations in the U.S. will find some answers to these questions sooner rather than later.

2018 Seattle Health IT Summit

Renowned leaders in U.S. and North American healthcare gather throughout the year to present important information and share insights at the Healthcare Informatics Health IT Summits.

October 22 - 23, 2018 | Seattle


PCCI Combines Predictive Modeling, Patient Engagement to Address Pediatric Asthma

August 16, 2018
by David Raths
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Over three years, effort leads to 31 percent drop in ED visits and 42 percent drop in admissions for pediatric asthma cohort
Steve Miff

The Parkland Center for Clinical Innovation (PCCI) in Dallas has spent the past three years developing and testing predictive models to identify children at risk for asthma exacerbations. Combining those models with clinical and population health interventions has led to improved outcomes, says PCCI, which is now turning its efforts to pre-term births.

This targeted population health effort was funded by Parkland Community Health Plan, the largest Medicaid plan in the Dallas area. PCCI has eight clinicians on staff, including two pediatricians by training. “They intuitively knew that for the population we are serving pediatric asthma is typically not well managed and is a high-cost condition,” said Steve Miff, president and CEO of PCCI.

A deep-dive analysis of the data for the health plan identified areas that had the largest expenditures and where there was the most variation in care and potential overutilization for services, such as emergency room visits for asthma, he said.

“We had to understand the disease itself and where these children receive care in the community.”

PCCI has built a predictive model to risk-stratify the children into different cohorts based on the likelihood that their asthma condition would exasperate over the next three months and likely require emergency department visits or hospitalizations. The model itself uses claims data, EHR data, social determinants of health information, which might include gaps in insurance coverage. “We also ingested and used data from EPA sensors in the community about air quality,” Miff said. That has been only marginally useful so far because the sensors are not specific enough to be able to attribute to an individual,” he said, “so we are working with local universities and some companies that are deploying sensors to get data on air quality that is more real-time and more specific.”

Part of the project involves being more proactive with clinicians and patients.  It sends alerts to the 21 physician practices involved before visits with these patients. Because the payer is involved, the case manager at the health plan gets a risk-stratified list of patients. The risk manager use that to focus on the very high-risk cohort, Miff said.

“We also engage directly with the children and families themselves in their home,” he said. “We enroll the very high-risk cohort into a texting program.” They receive texts multiple times per week with reminders about upcoming appointments, reminders about the need to take their medication, and ongoing education about their condition so it stays top of mind. “What is cool is that they 70 percent rated it very useful in a survey, and over a 12-month period, we saw only 15 percent attrition, which is pretty fantastic when you think about the frequency of engagements.”

Miff said that over the last three years, this has proven to be an effective way to engage individuals. “We have expanded the number of clinics and individuals involved and we have continued to refine the model.

He pointed to some key improvements: The program is saving the health plan around $6 million per year in costs for this population. “Contributing to that is that we have seen a 31 percent drop in ED visits and we have seen a 42 percent drop in in-patient admissions for the population,” he said.  Alerts embedded in clinicians’ EHRs and monthly progress reports have led to up to 50 percent improvement in asthma controller medication prescriptions and a 5 percent improvement in the asthma medication ratio.

PCCI also did a cross-market analysis to compare apples to apples with other Medicaid insurers. The overall Dallas-Fort Worth Medicaid managed care market saw ED visits decline 5 percent over the past three years in a similar population. The overall market is making progress, Miff said, but a similar cohort within Parkland Community Health Plan had a 31 percent drop.

PCCI also found that the children most actively engaged with texting had even better outcomes in terms of reduced ED utilizations.

PCCI did have a cohort of high-risk children they could not get engaged via the texting program. They designed a pilot to use Amazon Echo Alexa as a personal assistant and a group interaction to gamify this process for those individuals. The Echo is programmed to ask questions about their asthma. The children win together as a group if they participate on a regular basis and their knowledge about their condition improves. “The results are not in on that pilot in terms of how long they stay engaged,” Miff said, “but it is an interesting way to engage them in the home.”

Looking at other cohorts that are costly, have high utilization and are not favorable for patients, they chose pre-term birth as a next target. “Nine months ago, we launched a pilot to look at that population,” Miff said, “and we are rolling out a subgroup of that population looking at gestational diabetes using a similar approach and model.”

“For the sub-cohort on gestational diabetes, we need additional information if we are going to engage with them at home. It is not enough to build these models based on the most recent clinical or claims data or social determinants,” Miff said. “We need more real-time information about their condition, so we have included remote monitoring devices to extract real-time data about three things: blood pressure, blood glucose and weight so we can monitor those.” PCI is designing the predictive models that take those into account. For the general diabetic population, they are focusing on the diabetic foot ulcer population.

PCCI’s impressive results with predictive modeling and patient outreach have drawn interest from other Medicaid plans.

“We are at a point where this is ready to be tested in other environments,” Miff said. “We are in advanced discussions with two other Medicaid plans in other parts of the country, and in advanced discussions with one commercial payer with an employer population to test these models. They will have to figure out to adjust the predictive models and the work flows and the in-home outreach from a technology perspective.”


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Apple Health Records Project Continues to Gain Provider Participants

August 6, 2018
by Rajiv Leventhal
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In the last few weeks, nine more health systems have signed on to support Apple’s new “Health Records” initiative.

The new institutions were announced on Twitter by Ricky Bloomfield, M.D., who is working at Apple as a clinical and health informatics lead.

In January, Apple announced that it would be testing the Health Records feature out with 12 hospitals, inclusive of some of the most prominent healthcare institutions in the U.S. Then in March, Apple tripled the number of health systems participating, from 12 to 39, and announced that the new capability was available to all iPhone users with the latest iOS 11.3 update. Now, as of an Aug. 2 update from Apple, approximately 80 provider institutions are on board with the project.

According to Apple, the updated Health Records section within the Health app brings together hospitals, clinics and the existing Health app, with the aim to make it easy for consumers to see their available medical data from multiple providers whenever they choose.

Consumers who are participating will now have medical information from various institutions organized into one view covering allergies, conditions, immunizations, lab results, medications, procedures and vitals, and will receive notifications when their data is updated. Health Records data is encrypted and protected with the user’s iPhone passcode, Apple officials attest.

In May, Apple also introduced a Health Records API (application programming interface) for developers and researchers. The new API, set to be delivered starting this fall, will enable developers building health apps to individualize experiences, with the user’s permission, based on the user’s unique health history, Apple officials have said.

Related Insights For: Patient Engagement


Patient Portals Commonplace in Healthcare Organizations, Survey Finds

July 27, 2018
by Rajiv Leventhal
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Nine out of 10 healthcare leaders surveyed in a recent Medical Group Management Association (MGMA) poll said that their organization offers a patient portal.

The remaining 10 percent that do not offer one said they are working to implement one soon or have the software as part of their EHR (electronic health record) but it has not yet been implemented. The poll was conducted this week, with more than 1,750 applicable responses.

Also of note, of the 90 percent that offer a patient portal, 43 percent accept patient-generated health data (PGHD) for clinician review. Additionally, 37 percent reported their patient portal does not accept PGHD for review and the remaining 20 percent were unsure.

In an insight article accompanying the survey results, Pamela Ballou-Nelson, R.N., MSPH, Ph.D., principal, MGMA Consulting, noted that while she is an advocate of patient portals, as it stands today, many she has observed “are clunky and offer nothing more than secure message exchanges.” For a patient portal to categorically assist in patient activation, it should include the following five functions, Ballou-Nelson wrote:

  • The ability for patients to view their health data, such as immunizations, lab work and imaging results
  • Online appointment scheduling
  • Online billing
  • Prescription refill requests, which can eliminate the need to make a phone call
  • Data update capabilities, so that patients can upload blood pressure readings and/or other patient generated health data

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