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What this patient engagement infographic shows is that none of the ways health care professionals defined in the survey works very well. That is not the same as saying that patient engagement does not work. It will work if executed properly between the provider and the patient. Engagement can not be "delegated" to a web portal, personal health record, or informational brochure as many would have you believe.Steve Wilkins
Thanks. You may be a pedestrian reader of my blog...but I sense from your comments that there's nothing pedestrian about your background and training. Do you mide sharing a liitle information about yourself? You can e-mail me separately if you would care to firstname.lastname@example.org.Thanks.
I should have also mentioned, Steve, that I appreciate that you and others are doing this work and are actively seeking to improve patient care and engagement, my suggestions notwithstanding. I appreciate the difficult obstacles inherent in social science and policy, and I'm grateful that you and others contend with them.
In light of some of the other comments posted, I thought I'd reiterate that I find the column "Does it work?" unhelpful. The unnecessary dichotomization of variables is all too common in medical research (which I'm tempted to put in qualifying quotes). That column and the "evidence" column suggest that the author believes in a silver bullet rather than recognizing that each of these initiatives might work to a certain extent or only in combination with other efforts. It seems to me that this infographic connotes a common short-coming in the methodological and statistical training received by medical researchers. (Moreover, the cited evidence often seems insufficient to assert the inefficacy of the assessed methods.)
Hi:I think this infographic is very interesting. (However, at the risk of sounding nit-picky, uploading a new version without typos might be a good idea.)I was especially interested in the part of the infographic stating that certain interventions "don't work." Especially in the area of online information.First, I think taking a close look at other research not published in peer-reviewed journals would be a good strategy. (While peer-reviewed is the gold standard, it may fall down in digital health given the rapid and daily changes in this area.) Also, many of the references cited here (at least based on the date of publication) are out of date given the rapid expansion of digital/social tools over the past few years. In addition, the conclusions here don't take into account the multi-dimensional nature of online information consumption by patents. While some patients certainly look at recommended resources, they are researching conditions online for many reasons. Their state of mind toward the information and stage of illness may have an influence on whether they decide to initiate or sustain behaviors based on information consumption. (Here's a good reference focusing more on the "whys" of health information consumption - http://pbeye.info/59X.)In addition, the research may not account for the role content delivered via computers and other media play in behavior change. BJ Fogg over at Stanford has suggested that content can play a role in supporting the three factors that spark behavior change: ability, motivation and triggers. Again, the infographic does not take this fully into account.I certainly agree that we need to learn more about exactly how online/digital content impacts behavior change. (In fact, we've called for it quite forcefully in this ebook (http://pbeye.info/justify). But, I think it is important to fully account for the dynamic and multifactorial nature of online content consumption and how it fits into other social/enviornmental factors that influence behavior change.
The 3rd infographic (re: methods of patient engagement that "don't work") seems to suffer from an undefined criterion for what constitutes "not working". It seems to me that a low prevalence of usage is not evidence that the method doesn't work, and phrasing it that way seems to mischaracterize the evidence you provide.
Good comment Kari. People creating wellness plans happens today with their acupuncturists, chiropractors and other alternative providers. In many cases paying the bill 100% out of pocket. That's healthcare! Indeed those visits are typically 50 minutes, with a solid 15-20 minutes of that time 1:1, face-to-face conversation about what's going on, feedback from last visit, how to move forward. For patients, is it the fact that they're paying for care themselves, choosing the practitioner themselves that makes the difference in engagement? I wonder what chiropractors, dentists, accupuncturists etc are doing differently on their end?
I hope to return later to say more but I want to take issue (aside from the many typos in the poster) with the thinking in the "does it work" table. You can't say "No" without explicitly identifying what the supposed purpose was, line by line.What do YOU mean by "patient enagement," exactly? If I use online resources to learn about my condition, and I learn, on what basis do you say that didn't work?I'm so sick of hearing of clinicians who feel "Patients don't know anything - they're lazy slugs" and then seeing this kind of response when patients DO show interest and put out effort to learn. I'm not saying anyone on this post is that way, but it's a giant red flag when I hear anyone say "Patients doing research doesn't do any good."More later, I hope. And, poster-maker please fix the typos - it makes it look like you're not a careful thinker. Ahem.
Actually, there's almost nothing in the NCQA criteria for a PCMH that acknowledge the patient's perspective. It's primarily about collecting the data that CMS and large insurers want
To Steve: I wonder what the data show related to your statement that we are beginning with the patient. When we look at the criteria for judging a Patient Centered Medical Home there are many many items that look at the structure of medical care which theoretically hold the patients health perspective in mind. AND there is tremendous evidence that it is beneficial to work the with patient's own perspective and goals regarding OUR goals of lower blood pressure, or better blood sugar control. But I am hard pressed to find data that STARTS with the patients perspective of what is important in their health and judges the health care on how well we help them meet that.. If folks are interested in this subject we are starting a simple list serve conversation about patient's goals.- join in.. http://lists.sonic.net/mailman/listinfo/patientsgoals
This is a great infograph and parralled to what we, as a patient engagement focused Health IT firm, are seeing first hand.
@Ellen, that's a really good point. I wonder if we'll see a paradigm shift to people wanting to create a wellness plan with their physician rather than only visiting a physician to cure an ill. Now that would be "healthcare!" If that shift happens, we'll also need a shift in how the typical office visit plays out; it may take more than 15 minutes.Also, I wonder if there are more current studies about patients using educational materials and online information. Seems to me we've seen an increase in the ePatient since 2003.
These examples are engaging the patient in the agenda of the health system.From that perspective the patient is always in a one-down position. Patients are trained that the system knows more about their health condition than they do.. we have to order tests and labs to " find out" what is going on. What would happen if the health system was challenged to get engaged in the patient's reality.. So the individual comes to the doctor with their own goal for what ' healthy living' looks like to them.. and the doctor is responsibile for helping them get to that goal.
Thanks for your comments. Actually the inforgraphic was intended as a response to the simplistic notions of patient engagement cited in the National eHealth Collaborative's 2012 stakeholder survey. Actually it is very easy to identify what works and what doesn't. Health Plan sponsored health portals have been around for a number of years now and their utilization, with several notable exceptions, hovers around 10% of member use. Would you call that a success? Same for PHRs.As for the argument that "giving health information in not enough" I would direct you to the work of Kate Lorig (Stanford) in the chronic care management space. As she put it, giving health information to a chronic disease patient who does not have the self care management skills or self confidence to engage in those skill does not work.BTW, I do happen to believe that there is a silver bullet of sorts that would address the barriers to patient engagement...Steve Wilkins
Fard,You are entitled to your own opinion...but not your own facts. The issue of "information alone is not enough" has been thoroughly detailed in the literature, both peer-reviewed and non-peer reviewed. BJ Foog has done some curious work...but as he told me when I asked him...much of his work has no theoretical foundations of the kind found in more established and validated behavioral models. For more information of the subject from another noted health behavior expert, check out the work of Kate Lorig whose work first turned me on to the shortcoming of "information giving.Thanks for the feedback.Steve Wilkins
Dave,Thanks for your comments. The whole point of the post is that everyone does have a different opinion of what constitutes engagement and that presently engagement is whatever one says it is. If you read the whole series of posts on the subject you would see that I believe that engagement begins with the patient...not the provider. The provider's job is to facilitate and support the level of engagement the patient walks into the office with...and avoid diminishing it or totally deflating it.I can say "no" as to what works and doesn't work since the evidence on each of those point in the posters is very clear. With several notable exceptions, people/patients are simply not using or engaging in large numbers with the interventions being incorporated in provider and payer web portals or the intervention have been shown to be ineffective in behavior change, e.g., information giving.In a recent presentation I made at the National Medical Home Summit, I defined engagement as the act of doing something...usually in support of achieving a specific goal or action. People/patients make a doctor's appointment and show up in the office for a reason...the act of evaluating their concerns (cognition), making an appointment and showing up for the visit demonstrate engagement - doing something purposefully. Providers tend to define engagement in terms of patients doing what they are told or expected to do which as you know ignores the patient's ideas of what constitutes engagement.Feel free to come back anytime Dave.Steve Wilkins
Ironic, isn't it? I would venture to guess that most NCQA-certified practices, even level-3 PCMHs, are still miles from achieving truly patient-centered care.
Ellen,Right on. The whole patient-centered movement is all about beginning with the patient's health perspective in mind.Steve Wilkins
Leaving your predictor/ intervention/ independent variables as well as your criteria/ performance/ dependent variables continuous would allow you to quantify the degree of association (and an estimated confidence interval for the effect size) rather than asserting that the association is all or nothing (e.g., successful vs. unsuccessful).Similarly, your criteria seem to comprise conflated concepts, such as prevalence of usage and the efficacy that results from that usage. The implications for those concepts are different. For example, if the prevalence of usage is low and the efficacy is high, you should work to increase usage. However, if the efficacy is low, the question is whether or not the clinical outcomes are socially significant. (Even a very small effect size in survival rates can be socially significant, especially if the outcomes are cumulative with other interventions.)Few social interventions are panaceas. Just because an intervention is insufficient to solve the entire problem does not mean that it is ineffective. Likewise, a single short-coming in the chain of treatment does not impugn the value of the other elements of the treatment approach (e.g., that low prevalence indicates low efficacy).Overall, the methodological approach and the review of the issue seem simplistic to me. Perhaps you have a better solution, but as a pedestrian reader, I do not see how it strengthens your case to offer less-than-solid criticisms of other options.
Steve:Thanks much for your comment. Let me make this clear. We agree on your main point: information is not enough. We also agree that simply handing information to a patient and leaving it at that is never a good strategy -- especially among patients with chronic conditions.Regarding BJ Fogg's model, yes there are other models, which have been validated under stricter conditions. But it should not be dismissed on those grounds alone. His model is valuable, as it is simple, and easy to apply and test. In addition, the World Economic Forum has selected his model as their model for behavior change. This does not rise to the level of peer-review, but it does indicate that the model is very useful for people trying to spark behavior change via technology.)Also, while I agree that peer reviewed research is the gold standard, relying on second or third level evidence and data is also important to get a fuller picture of the true dynamics of patient online information consumption habits. (As you know, this is done all of the time in clinical practice.) Providing additional context to the data you cite I think would be helpful, as well as looking at data sources that provide a more recent picture of how the online enviornment has evolved.Finally, don't take these comments as a personal attack on you or your methods or your data sources. They are not. I'm simply bringing up ideas and other factors that are worth considering within this conversation. This is all a good thing. Kudos to you for bringing up a very important issue.
Bob,I happen to believe that most PCMH pilots and accredited practices are still in a 1.0 mode where the focus is on EMRs, Registries, embedded care coordinators and team care. There is nothing patient-centered about any of these things...you could even make the case that some of these things run counter to the patient-centered concept. Hopefully PCMH 2.0 will refocus on and around the patient...beginning with physicians adopting a a more patient-centered (vs. physician-directed) style of communicating with patients.