The Prescription for Patient Engagement

Patient engagement has been dubbed the blockbuster drug of the 21st century. Proponents point to studies suggesting it improves care, saves lives and cuts costs. Data are so persuasive that policymakers have addressed patient engagement in Meaningful Use measures and the Affordable Care Act via quality metrics in accountable care organizations (ACOs) and medical homes. Yet, the prescription for patient engagement entails far more than pill popping. Patient engagement reframes medicine and requires providers and patients step into new roles. Is your practice up to the challenge?

The time is ripe

The definition of patient engagement continues to evolve; the fundamental concept focuses on patients’ empowerment and direct involvement in their healthcare. There are myriad IT, management and infrastructure ways practices can launch the patient engagement process. While there is no one-size-fits-all solution, most providers can identify approaches that dovetail with their needs and goals. The first step may be making the case.

With countless challenges facing healthcare, why has patient engagement burst onto the agenda now? It ties together two primary needs—improving quality and decreasing cost. “The level of technical brilliance isn’t producing the kind of outcomes that we expect,” explains Jessie Gruman, president, Center for Advancing Health (CFAH). Many behaviors that contribute to health outcomes, such as smoking cessation, diet, exercise and medication adherence, take place outside of the physician’s office. Patients control them.

A provider’s technology, knowledge and experience are for naught, continues Gruman, unless the patient follows through.

The growing consensus that patient engagement drives success spurred policymakers into action. Consider:

  • Multiple stage 2 Meaningful Use measures address patient engagement, including provision of patient-specific education resources and use of a patient portal.
  • ACOs will be measured by patient engagement strategies such as physician communication, access to specialists, health promotion and education and shared decision-making.

However, patient engagement transcends health information, says Kate Berry, CEO of the National eHealth Collaborative (NeHC). “Success requires leveraging health IT tools to help patients better manage chronic conditions and monitor their health.”

She cautions providers against falling into the trap of a tech-centered approach to patient engagement. “A lot of providers are deploying the next whiz-bang technology—the personal health record, the patient portal, believing ‘if we offer it, the patients will come.’”

It’s not that easy. Technology sans strategy or culture change may set the stage for failure. Providers need to understand the whys and hows of patient engagement and how to encourage it to create a new culture between providers, families and the care team, says Berry.

Patient engagement strategies may go against the cultural grain of some providers or it may impact efficiency or earnings. A physician may believe he or she is not paid to explain test results to patients, notes Berry. “We all want to do what’s best for patients. But sometimes that’s not best for the department,” says Alexander J. Towbin, MD, director of radiology informatics at Cincinnati Children’s Hospital Medical Center (CCHMC).
What’s more, patients themselves can be a barrier.

Patients may be reluctant to question a provider, with age, culture and background affecting patient-physician communication. Patient-education materials are often written at a reading level beyond most U.S. adults, hindering knowledge and engagement.

The motivation to spur change among providers and patients may be on the uptick. Although current reimbursement models and financial incentives may deter patient engagement, both public and private plans are shifting to performance-based models that will encourage providers to boost their focus on outcomes. In addition, as patients pay a greater portion of the costs of care, their approach to responsibility for care will change.

Beyond the basics

Beware the Barriers

RAND Corporation has identified 3 barriers to shared decision-making
1. Overworked physicians
2. Insufficient provider training
3. Clinical information systems that fail to adequately track patients

Progress on the patient engagement front may be hindered by a lack of understanding. Patient engagement has rapidly ascended into healthcare hegemony, and it’s a sharp turn from the status quo for many patients and providers. Thus, there is no clear map for getting from A to B.

NeHC has developed a patient engagement framework to help organizations navigate the patient engagement process. “It can be helpful to think in terms of a progression of capabilities that stretches from sharing information to helping people navigate the system to providing EHR access to patient-specific education materials to building ehealth tools patients can use to enable generation of health data into the EHR to developing a fully connected healthcare community,” says Berry.

Creating a connected healthcare community takes time and may begin with small steps that are easy to overlook. Most people are healthy most of the time and without frequent contact with the healthcare system often don’t understand how healthcare works, says Gruman. The unknowns include the basics such as what to expect during and after an exam, who to talk to if there is a problem with the appointment and how to transfer images to another provider.

NRAD Medical Associates, an imaging center in Garden City, N.Y., aims to streamline the process for patients by providing registration materials online, which can make it less overwhelming when a patient arrives for a biopsy or follow-up imaging. The practice also provides print, online and video information about various imaging procedures, says Geraldine McGinty, MD, MBA, partner.

CFAH has identified 43 behaviors, divided into three categories, required to optimize healthcare. Some behaviors like managing diabetes or asthma are lifelong. Others, like learning how to manage an oxygen tank or knee-replacement rehabilitation, are situational. Gruman dubs the final category “just do it,” which includes finding a doctor and navigating the patient portal.

Although Meaningful Use stage 2 and 3 measures stress patient portals, Gruman cautions overreliance on the portal to communicate with patients, citing a patient pain point. “The CT exam is scheduled for 11 a.m., but the patient portal instructs me to arrive an hour early to drink contrast. Is the appointment at 10 a.m. or 11 a.m.? Be explicit about preparations, and don’t depend on the patient to read the portal. I will, but my 87-year-old mother will not.”

Rules for rads

Some radiologists, given their minimal contact with patients, may let patient engagement slide off the to-do list. That’s likely a mistake. There are a host of strategies that imaging practices can use to achieve the healthcare trifecta: improved care, reduced costs and enhanced patient management.
For some practices, the basics provide an ideal starting point. “Imaging is a service,” Gruman points out. “A businesslike approach to service can make it easier for office staff and physicians.” For instance, providing print and online information about how to transfer images to another provider and email confirmation of transferred studies could eliminate multiple phone calls.

Lahey Hospital and Medical Center in Burlington, Mass., offers another patient engagement model. The hospital launched its no-cost Rescue Lung, Rescue Life lung cancer screening program in January 2012. During the planning and implementation phases, a team of specialists, including radiologists, radiation oncologists, internal medicine physicians and pulmonologists, provided gratis services to develop the program.

The team focused on supporting the patient engagement efforts of primary care providers. “It’s important to have them engaged because that’s where screening discussions occur. Primary care providers are in the best position to gain informed consent,” explains Andrea B. McKee, MD, chair of radiation oncology.

The need to support primary care led the steering committee to develop a CME campaign to educate primary care providers. The program included educational talks, literature and a letter that reviews salient points to discuss with patients. The committee boosted primary care providers’ support for its program via a Lung-Rads reporting system.

“Primary care physicians wanted reassurance about how findings would be managed. Lung-Rads operationalizes the National Comprehensive Cancer Network guidelines [by integrating follow-up recommendations into the report],” says McKee. Thus, primary care is not responsible for determining follow-up recommendations.

Lahey also supports primary care physicians and patients with lung navigators who assess patients’ eligibility for screening CT, conduct quality assessment and follow up with patients to evaluate their experience in the program. Lahey complements physician outreach with patient-specific strategies, including a four-page FAQ that addresses the risks and benefits of screening and directs patients to a free smoking cessation program.

Open communication is emphasized throughout the process. Screening reports are distributed to the primary care physician, patient and lung navigators, who check whether or not patients have any post-screening questions.   

The patient engagement effort has gathered steam, says McKee. Primary care providers lobbied for the lung cancer risk assessment to be incorporated into the EHR to systematize the program and automate screening recommendations, alerting providers to patients eligible for screening. “Now physicians are assured that they are discussing screening with all patients who might benefit.”

Communication and collaboration also play a central role at CCHMC. Although the question of whether or not radiologists should deliver results to patients and their families remains a topic of debate, the radiology department has pioneered a difficult news process that includes the referring physician and expedites patient care.

If a radiologist detects a tumor during a study, he or she contacts the referring physician to determine how the clinician would like the news delivered. The provider may be patched through on the phone or the radiologist may deliver the result. In most cases, immediate delivery of results means the child can be admitted and treatment started.

In difficult cases, the radiology department turns to a point person to assist the family. “As soon as a parent hears his or her child is sick, the parent stops hearing the physician,” says Towbin. The point person takes notes for the family, directs them to the next location and helps to keep other children occupied as parents address the needs of the patient.

Like Lahey, CCHMC has tweaked its IT systems to support patient engagement. “We define critical results differently and very broadly. It’s basically a result that’s important to someone.” That means the acuity score is based on factors beyond a STAT order. The parent may be exceptionally anxious or need to pick up other children. “We put the patient at the center of the workflow. Sometimes that runs counter to what’s best for the department, but in the end, it’s best for the patient.”

Similarly, McGinty has embraced some patient engagement strategies that seem to defy conventional practice management. Although most physicians might guard their cell phone numbers like Fort Knox, fearing that patients would abuse the privilege, McGinty shares her number readily with breast biopsy patients. “I’ve never had a problem, and I have had situations where I’ve been able to manage bleeding after a biopsy at home by phone.” In one case, the patient avoided the cost and inconvenience of a trip to the emergency room.

She shares additional benefits of proactive communications with patients. “The more we engage with patients, the more they understand the value and limitations of what radiologists do.” Difficult conversations become a bit easier when the physician has established personal contact either individually or through the practice website, she continues.

Breast biopsy patient Pam Berger agrees. With a family history of breast cancer, Berger is diligent about screening. Her go-to provider was a large mammogram mill that delivered same-day results. But when the result was a cyst that required 6-month follow-up, the tech was unable to answer Berger’s questions or provide access to the radiologist.

Berger sought a new radiologist and found McGinty. She reviewed the prior exams and performed a mammogram before diagnosing a fibroadenoma that required biopsy. “She was clear in communicating what it was, what it wasn’t and how she would approach it.” The approach helped Berger feel empowered and confident to take charge of her health. In other words, she became engaged in her care.

Patient Engagement Stat Sheet
  • 8-21% – costs among patients with the least skills and confidence to actively engage in healthcare compared to patients with highest activation levels
    Health Affairs, February 2013
  • Patients receiving enhanced decision support to review treatment options and provider-patient communication by trained coaches showed:
    - 5.3% costs
    - 12.5% hospital admissions
    Health Dialog, Power to the Patient
  • 4th-6th grade – reading level recommended by the American Medical Association and National Institutes of Health for patient-education materials
  • 9.3-14.1 – grade level scores for patient-education materials from 16 specialties
  • $106-236B – annual cost of inadequate health literacy to U.S. economy
    JAMA Internal Medicine, May 20
  • 61% – U.S. adults who would use a medical device to check their condition if it sends information to their doctor electronically
  • 2 out of 3 – consumers who would consider switching to a physician who provides secure online access to their medical records
    Deloitte: 2011 Survey of Healthcare Consumers in the U.S.
  • The activated patient is twice as likely to avoid a readmission and less than half as likely to experience a medical error.
    AARP Public Policy Institute: Chronic Care: A Call to Action for Health ReformNemporep