HIT-Driven Patient Engagement Is A Bust – Effective Patient Engagement Begins With The Doctor-Patient Relationship

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I hate saying I told you so.  But to quote myself…”patient engagement is a physician-patient communications challenge and not an HIT (Health Information Technology) challenge.”

Just take a look at the Mayo Clinic’s patient portal experience which was discussed at a HIMMS 2013 and reported on in HIT industry press.

The Headline

Mayo Clinic Struggles To Meet Stage 2 Meaningful Use Thresholds For Engaging Patients.

Always innovating, the Mayo Clinic some three years ago introduced a web-based portal to share information with their patients.  During that time some 240,000 patients have signed up for online accounts.  That’s pretty impressive.  But there’s a problem.  A BIG PROBLEM.

Build ItAccording to Eric Manley, product manager of global solutions at the Mayo Clinic, they are having a hard time “getting more than 5% “of all the patients who registered with the patient portal to actually use it.   You see in order to meet Stage 2 Meaningful Use requirements, and enjoy the benefits that come with meeting this criteria, people actually have to use the portal to access their own health information.  You just can’t build a portal and in Mayo’s case have fewer than 12,000 unique patients actually use it.    Actually you can…hospitals and physicians do it all the time…they just can’t get incentive payments for their efforts.

 So What Went Wrong?

It’s not like the folks at Mayo haven’t tried.  Mayo’s patient portal offer all the requisite techie gizmos – giving patients access to their medical record, lab results, appointment schedule, and lots of health information.  They also recently introduced their first patient-directed mobile health app call “Patient” which makes it easy for people to access their health information online.   Mayo even has a Center for Innovation to figure this kind of stuff out.

Upon reflection Manley admits that “simply making services available doesn’t cut it,” he said. “Unless you are engaging patients, you won’t meet meaningful use requirements. [Messaging and other mechanisms] need to be a part of your practice.”

But Wait – I Thought Patient Portals, EMRS and Health Apps Were Patient Engagement Strategies?? You Mean We Need To Do More?

Manley is quoted as saying that “patient engagement has been a part of what Mayo has done for a long time, meaningful use, especially Stage 2, is a catalyst to kick it up a notch.”

Let’s face it.  Meaningful Use maybe a good way to get providers to adopt badly needed HIT improvements – but it not a great way to force patients to “engage” with you.   Here’s why.

1)    Forcing patients to do anything is wrong and antithetical to the whole idea of patient-centeredness…even if you think it is in the patient’s best interest. Meeting Meaningful Use seems to take precedence over what the patient wants.  Manley is quoted as saying “just having it [information and portals] out there isn’t enough”…”It’s making the patient use them.”

2)    Patients want to engage with other people regarding their health, particularly their physicians. Health after all is an intensely personal and social affair.  Mobile health apps and email just can’t give patients want they want – to be listened to and understood.  Plus 85% of people want face-to-face access to their physician when they want it.  Patients know that HIT threatens to get in between them and their doctors.

3)    The content on most patient portals is not particularly relevant or engaging after the first 10 seconds….at least from the patient’s perspective.   After all, cognitive involvement is a prerequisite of meaningful engagement and it tough to be interested and spend time thinking about information that is not in context (of a medical encounter), you don’t understand, find boring, completely inaccurate or irrelevant.

So What Is The Solution?

There’s no question that if done right patient portals can and do work.  One need look no further than Kaiser Permanente, Group Health and the VA for great examples.  The key to their success…and hopefully every provider’s success…is integration.

Health care for us patients occurs within the context of social relations with our physicians.  To be engaging…the information you want to share with us needs to be relevant to us from our perspective, come from our physician and be integrated into our overall care plan.    Only then will we have the trust and confidence that the information is ours…and is something we need to pay attention to.  We focus on our health while we are in the doctor’s office…if you really want to engage us…do it there.

That’s my opinion…what’s yours?

21 Comments

  1. Isabelle says:

    Hi,
    As a VA patient I can tell you most people use the portal for one thing, to renew their scripts. You can’t use it to communicate with your provider, they don’t check their messages. At my profile page I’m told I am overweight (my BMI is 20) and I need to make appointments for 3 screening tests that I am already up to date on. My Healthy Vet is a great portal but is it used in a meaningful for the most part.
    Isabelle

    • ZibdyHealth says:

      Isabelle’s comment prove our position. Patient won’t use any portal unless they get benefit….not their provider.

    • Isabelle,

      Thanks for your comment. A favorite quote of mine – I made it up – is that “the fastest way to disengage, deactivate and disempower any patient is to ignore what they have to say.”

      I am sorry to hear of you experience with the VA.

      Steve Wilkins

  2. ZibdyHealth says:

    We agree with it….Just look at PHR from Australia. They tried this and still less than 5% people used them but we disagree that PHR are threatening doctor-patient relationship. It is more about lack of patient engagement because “the content on most patient portals is not particularly relevant or engaging”. People need to think about few things before they ask users to adopt their technology or approach.

    1. Is content simple enough for average person (grade level 8) to understand it?
    2. If and when user comes to their portal how much time they will need to spend on it to get any benefit?
    3. This benefit has to be about patient not healthcare cost, providers payment (meaningful use), etc.. It has to be make a user feel that they are better off after using their portal.

    We looked hard at this issue so we took utility approach for PHR. When a user interacts with our platform they get useful information in 10-30 seconds. Our goal is that every time our user interacts with our platform they should get some benefit. We do not need to be a social networking site and make our user spend 30 minutes on our platform. We are taking search engine approach.

    Please try us out and give us feedback….we have a long roadmap which will make ZibdyHealth more exciting in future.

  3. nick says:

    I agree – its more about the relationship than the technology. My wife communicates very effectively with her pain management doc via email.

    • Nick,

      Thanks for your comment. Glad to hear it. HIT, including secure email, works in the context of good doctor-patient relationships. Where the doctor knows the patient isn’t going to abuse or overuse HIT service and the patient knows that the doctor is going to reply in a timely fashion.

      Your wife is a bit unusual at least according to the statistics. Only 9% of people in the US report using E-mail to communicate with the doctors as your wife does. This despite the research showing that 80%+ of consumers say they would use use secure email to talk with their doctor if available. Then you look at Mayo which offers secure email and they can’t get even 9% of registered members to use it. Something is wrong with this picture.

      Steve Wilkins

  4. I totally agree. I see 6 clinicians with 4 EMR’s and 3 portals. All separate, non integrated. None include the health goals I’ve established with my team (family and clinicians): Weight loss, pain relief, no depression, continuing to play music, good sex life, no falls, good sleep. A cherry would be integrating the tracking I now do on a spreadsheet. I would use the portal if it did this. I use emails with all my team. Works great.

  5. family doc says:

    Excellent, excellent post. I wonder how many billions are being spent on these portals that accomplish so little?

    Watch for the inevitable unintended consequences: patients not being allowed to communicate with their doctor’s office except through the portal; a fee if you demand to speak to a human being; and so on.

  6. Carolyn Thomas says:

    Hello and thanks for this overview. This is sobering for all the tech hypemeisters out there who view “technology” to be a synonym for “engagement”.

    For a truly dreadful example of a worse-than-useless patient portal, read Donna Cryer’s recent eye-opening personal account after she found out (purely by accident) that her hospital even HAD a patient portal. Donna blogs at DC Patient: http://www.dcpatient.us/2013/03/portal-hypertension/

    Stephen, can you provide us a link to Eric Manley’s 5% quote? All I’ve been able to find online are general references to his HIMSS comments.

    Regards,
    C.

  7. Deb S says:

    Stephen, One (of many) concerns regarding Patient Engagement is the teen population and privacy issues NOT addressed by the majority of EHRs or portals. Consider the minor consent (mature minor), minor on judicial bypass and emancipated minor. Add variability of state and federal laws based on each of the above – it gets quite complicated for any covered entity to even consider web-enabling the 13-17 + year old population. The 2014 Certified Edition requirements do not address this population. Here is just one example of the conundrum as it relates to CA law (at least in 2011):
    http://www.teenhealthlaw.org/fileadmin/teenhealth/teenhealthrights/ca/CaMinorConsentConfChartFull11-11.pdf
    Besides just saying NO access to teens; I’d appreciate knowing if any covered entities have the ability to address the above based upon their EHR/Portal capabilities in compliance with HIPAA Privacy and Security Omnibus Rule 2013. Thank You.

  8. Don Logue says:

    The problem is with implementation. Do we not now use email instead of snail mail? Facebook instead of letters and the telephone? The problem is with our healthcare institutions failing to catch-up to the consumer with appropriate interface models, not vice versa. I asked my physician if could communicate by email though his practice’s patient portal and the response was “yes” but good luck getting him to read it. When I asked him for the required PIN number to allow Quest Labs to upload my reports to HealthVault, he had no idea of what I was talking about. Hospital systems are either going to have to catch-up or be bypassed by other delivery models that engage and empower the patient.

    • Don,

      Great points. There’s no question that health care providers are behind the times with respect to the adoption of new information technology..but the so are a lot of their older patients. I get this notion that doctors are hoping they can last long enough in the pre-e-mail era hopefully long enough to be able to retire rather than adapt.

      Steve Wilkins

  9. Michelle Batt says:

    What a great post! Peoples’ comments have touched on a variety of helpful things to consider here:
    > need to ensure there is relevant, useful content for patients to use > integrate doctors further into implementation process, to personally invite patients to use portal or if not the doctor, then maybe the nurse/assistant can even show the patient the portal and how it can be used before they leave (I know that’s crazy amount of time but this is sometimes necessary)
    > need to have process in place for immediate/quick response if/when patients’ ask questions or post there

    I’d like to add a few thoughts: Across many industries, health included, we struggle with the implementation and adoption part of new technology/tool launches.

    Please forgive the business/airline example I’m about to give here (I never worked there but have travelled quite a bit!), but it’s a good one. When airlines first introduced the self service kiosks at airports, nobody wanted to use them. People didn’t “trust” them, they wanted to speak to a live person to make sure they were checked in and all was well. It took a fairly extensive adoption and training strategy that the airlines were not initially prepared for, but they eventually developed. It took years of training, reinforcement/repeat involving the front line folks, that I’m sure was grueling for them (still not everyone using them, but adoption rates are way up).

    In no way are these airline kiosks the same or even as important as health information on a patient portal, but I always think of that example when I see/hear any organization implementing new customer focused technologies/tools.

    I realize that time is not readily available for many doctors, nurses, staff in medical facilities, but the “personal approach” tactics might really help build the adoption needed/desired. My 82 year old mother, who has a wonderfully sweet “doctor crush” on her thoracic surgeon (he helped cure her lung cancer), listens to every word out of his mouth. If he showed her an online tool, during the appointment, I guarantee she would go home and try it out herself (and she is not too computer savvy!) This time investment is a long-term consideration (don’t see payback on these systems in short or even medium term).

    I am sure the Mayo Clinic is working on this implementation and adoption strategy. What an amazing place that is. While I don’t want to be there for medical reasons (though I’ve spent plenty of time as a patient and also support/advocate in hospitals in the Mid-Atlantic area), I would love to visit and see all the great patient experience work “in real life.”

    Thanks for writing this and getting the discussion going!

  10. I am a family nurse practitioner in a unique practice and integrated technology such as email and online scheduling long before portals were available. Approximately 98% of my subset of patients utilize both. Most rave about the accessibility. Obviously, I answer personally (I have no staff). The greatest challenge to continuing is privacy laws. The portal is an option that meets HIPPA requirements but has drawbacks. Various portals offer differing features- some clunky, some missing. And all require that extra step of logging in just to get email.

    On the topic of patients wanting face to face connection with their provider… my patients may be an anomaly, but they prefer a more seamless connection that includes the ability to have phone, skype, and email visits and more general, though personalized, information ‘pushed’ to them via email and website posts.

    I don’t disagree that we focus on our health while in our provider’s office, but we will never advance our health as a nation until we are expand that focus into our daily lives. I think our primary care providers need to lead in that goal and regulations that interfere should be relaxed to a more practical level.

    With that said, the trend towards employment of providers by hospitals (the current Kings of the medical industrialized complex), is creating a disconnect between providers and patients. Being a doctor (or nurse practitioner) is just a 40 hour week job now for employed providers. Hospitals will soon employ 75-80% of physicians if I have my stats right- whereas 5-6 years ago, it was 20%. As an employee, what incentive is there to engage with patients- they are not “your” patients… they are the hospitals’ “customers”. Even if the desire is there, who could truly engage with the volume of patients that primary care providers have to see in the current traditional model- 25-30 per day!

    The problem isn’t with the technology, its much deeper. We must find ways to support independent practices who choose not to be consumed by the hospital or to kowtow to ACOs that dictate inefficient and obstructive methods. We must focus on patient goals and outcomes (in relation to cost) as tools for evaluating the effectiveness of care rather than one-size-fits-all criteria that promotes cookie-cutter medicine. And it is mandatory that the system allow the provider and the patient the luxury of time to build their relationship together!

  11. Christina says:

    I believe it is about the strategy, user-centric design and integration. Just plugging in the EHRs portal only gives you health record information and perhaps some messaging. That isn’t enough for truly engaging patients, especially those with low health literacy levels or needing support across the entire care continuum. Enterprise-wide portals are a better solution and allow for the integration of the health record, social networks, transactions, personalization, widgets, a variety of communication channels and more.

    One example of what I suggest is outlined in this case study on MD Anderson Cancer Center’s PreCare. http://towerstrategies.com/our-work/md-anderson/ The pre-registration process isn’t something usually included in EHR portal products, but it is certainly a great starting point for establishing a great patient experience.

    • Christina,

      I like the Pre-Care piece for MD Anderson. They never had that when I took my wife there for Stage 4 Lung CA in 2004.

      Steve Wilkins

      • Christina says:

        Stephen: Implementation across each of the clinics began last August and it will be fully implemented in the next couple of months. I truly wish the technology or innovation had been in place for your wife!

  12. R Johnson says:

    Love the article, great critique. Wonder what your take on HealthTap is, it’s not affiliated with a hospital or HMO like Mayo/Kaiser/ClevelandClinic but appears to be filling the “gap” in physician/patient engagement in HIT environment.

    • Rahman,

      Thanks for the kind words.

      HealthTap appears to simply be another webMD but of the “lite” variety. It’s a content or fulfillment play not an engagement play. Content, if relevant, is engaging to people who are already engaged in their health like the people that would use HealthTap. Heck they have thought through the issue and came up with a question…suggesting a high degree of cognitive engagement already.

      Steve Wilkins

  13. If you want a patient portal to engage patients just include the hospital progress notes or office notes for the patients to read and make comments! What hospital or doctor office has the guts to do that?

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