As a physician, I have been frustrated by countless patients who simply failed to participate in their own healthcare. We providers know better than anyone the true lack of meaningful “Patient Engagement” in today’s society. While our patients routinely accept responsibility for non-health decisions (financial, career, child rearing, etc.), when it comes to their own health, Americans shy away from “ownership.” One needs to look no farther than non-compliance with prescription medications, which is estimated to contribute to greater than 100,000 deaths and 10 percent of hospitalizations annually (at a cost of $289 billion). And don’t get me started on our population’s diet, exercise habit, or limited participation in preventative care and screening activities. Type II diabetes is reaching epidemic levels with obesity and heart disease close behind.

We providers want to drop our stethoscopes and cry out, “What do you want us to do?” After all, the truth is that we spend virtually no time directly caring for our patients (usually only hours annually, at most). We can’t drive to every patient’s home and force their pills down their throats, weigh our heart failure patients daily, and replace the processed carbohydrates on their plates with fresh vegetables. The situation is analogous to motor vehicle crashes. The government has legislated that auto manufacturers include seat belts in their vehicles and that all drivers and passengers wear those seat belts. And yet every year, tens of thousands are injured and killed in car crashes simply because they fail to buckle up. It’s the same with patients. If they don’t participate in their care, there’s only so much that even punitive federal legislation can do to improve the quality and cost of healthcare.


Better clinical outcomes

The data is clear: Engaged patients have better clinical outcomes and lower costs of care.  Engaged, educated, and empowered patients are the key to dramatically successful healthcare reform. So why start by targeting providers to improve the value of care? There are several reasons. One is that the general patient population is both enormous (in reality, everyone is a patient or future patient) and heterogeneous in terms of medical status and health-related behaviors. Thus to devise, let alone implement, large-scale patient level reform is extremely challenging. Providers, on the other hand, are a relatively small, homogeneous (in terms of care delivery) group. In a nutshell, targeting us is more likely to rapidly result in some level of quality and cost improvement, albeit much less impactful than would be achieved via successful Patient Engagement.

It is also important for providers to admit and accept that there is significant room for improvement when it comes to the care we deliver. Preventable medical errors kill 400,000 patients annually and seriously injure 10,000 every single day. These numbers are entirely unacceptable and represent a significant opportunity where we providers can directly advance our commitment to “First Do No Harm.”

But in the end, solving the Patient Engagement riddle still holds the key to consistent, proactive, preventative, cost-efficient, high quality healthcare. Providers (individuals and systems) must first understand their specific patient population. And by understand, I mean appreciate that your population is actually comprised of multiple sub-populations. Validated instruments, such as the Patient Activation Measure® (PAM), allow you to rapidly, easily, and objectively stratify your population along a spectrum of engagement. Multiple studies demonstrate that patients with higher PAM scores demonstrate healthier behaviors (in terms of diet, exercise, blood pressure, cholesterol and HgA1c control, etc.) than those with low scores (who utilize your ER and are hospitalized more frequently, including soon after hospital discharge). Such credible tools are useful to evaluate the success of your engagement strategies, as even small score increases are associated with meaningful value improvements.


Three sub-groups

But stratifying your patients by engagement level is not enough. Just as EHRs haven’t solved our patient care problems, technology alone won’t truly engage and educate our patients. The human touch is critical. Only when provider-patient interaction is combined with technology will we significantly and consistently improve our patients’ ownership of their health. But physicians, hospitals, and other providers have limited human and financial resources. To best allocate those resources, you should not only stratify your patients by engagement level, but also categorize sub-populations defined by a common, major engagement obstacle. This requires you to rely on your own experiences in caring for the individual patients, as well as on records of their past care. In my experiences, there are three major such sub-groups.

Think of the tanned surfer holding a surfboard with a shark bite-shaped piece missing. He tells the newsman that he is so committed to riding the waves that he is willing to be killed by a shark if that’s the risk. All providers have cared for Shark Surfers, patients who understand but choose to ignore the serious risks associated with their behaviors. Allocating engagement resources to Shark Surfers (like the cirrhotic who refuses to quit drinking) is usually pointless.

Credit Carders approach life with an “enjoy now, pay later” attitude. For example, an asymptomatic diabetic who may see his or her health risks as only “possible” and “in the future,” while routine blood glucose sticks and daily medications are “real,” “now” burdens. But this large sub-population can be engaged when doctors, nurses, social workers, and others take the time to personally speak and work with them and their families. Understand their future plans (retirement, travel, kids’ graduations, grandchildren), and then to explain (using targeted educational materials) the real risks those future plans face if their behavior doesn’t change. Engaging Credit Carders is a repetitive process that must involve the extended care team and family, along with technology.

Different Drummers are the third sub-group. They include elderly patients (who routinely do not ask questions even if they don’t understand their providers’ instructions) and those whose education, language, and/or culture impede their understanding of care plans. Again, the key to engaging this group is an extended care team with adequate training to successfully evaluate and address educational, language, cultural, and other socio-demographic challenges.

As providers, we all truly want our patients to be engaged. Now that legislation is both directly and indirectly requiring engagement, we must find ways to both effectively engage our patients and to realize an ROI for our engagement strategies. The combination of provider-patient interaction with engagement technology solutions gives us our best shot.


  1. “We providers know better than anyone the true lack of meaningful “Patient Engagement” in today’s society.”

    If patients are as unengaged as your post suggests they are, how do you explain the fact that 82% of adults see their doctor at least once a year … with the average being 3 visits/year … and double that for patients with chronic conditions? True engagement requires cognitive and/or emotional investment of energy in a given subject.

    Before deciding to visit their physician, people have to evaluate whether their medical concern merits seeing a doctor. To answer this question people go online to research their concern … or maybe they talk to a friend or family member. Then people mist make an appointment and take time out of their busy lives to show up for the appointment. While waiting to be seen, people as patient, think about what they want to discuss with the doctor. Depending upon the potential severity of their concern there may also be a fair amount of “worry” on the patient’s part.

    So what about this scenario suggests that patients in doctor’s offices are not engaged? Like so many assumptions that providers make about their patients, the assumption that patients are not engaged is inaccurate … and a bit paternalistic.

    Based upon the evidence, a stronger case can be made that physicians are not very engaging in how they think about, communicate with and relate to patients. Take TX nonadherence … an estimated 20% of said to be caused by poor physician communication with patients .. not because patients don’t “take ownership” of their own health. Consider the fact that physicians on average spend less than 60 seconds teaching patients about newly prescribed medications during office visits..

    Consider the fact that less than 50% of physicians routinely engage patients in shared decision making … a hallmark behavior associated with patient engagement.

    The problem today is not a lack of engaged patient … but rather a lack of physians with an engaging bedside manner.

    • Hi Steve, we have talked about this many times. I think part of the problem is the blind men and the elephant problem. Everyone is looking at patient engagement through a different lens. And, at the same time the healthcare environment is changing so rapidly with digital health tools, Dr. Google, etc meaning that more and more people will seek alternatives to going to a traditional, time-consuming (drive, wait) office visit. Pat

      • Hi Pat … Greetings from Manila. You are correct about people looking at patient engagement from so many different perspectives. Strangely with all the different perspectives out there .. most of which are variations on the HIT-engagement theme … there is only one perspective that really matters. The patient’s perspective. As you yourself wrote about in an earlier post, based up the 2015 HIMSS survey, patients define engagement as driven by relationships and boring things like good communication and personal interaction skills. According to the same survey, physicians tend to agree with patents on the importance of relationships.

        So I my simplistic mind … if you have the two most important stakeholders, in this case patients and physicians, in agreement on the definition of engagement what more do you need? CIO’s have “had their shot” are the technology-driven approach to patient engagement. based approach. Absent a strong physician-patient relationship and a physician with an engaging bedside manner patient portals, text messaging etc. doesn’t work very well.
        It’s time to regroup around what we know patients want … physicians that listen to them, respect what they bring to the table and who take the time to understand them as human beings and not just a disease.
        It ain’t rocket science ….

  2. This does not surprise me at all about ‘Patent Engagement’ or lack of it – lets take a look of a causation – way back when in the 50/60’s my parents took good care of themselves as they knew it – they drank and smoked and ate whatever but were active and they weren’t ‘bothered’ by all these wellness things that didn’t exist – then my people the baby boomers were getting in anything and we survived.

    You even had the ‘old coggers’ who went thru the war and drank but were surprizingly healthy.

    For the next 30+ yrs people were let alone to do whatever – then you had the ‘birth’ of an alarm about heart disease and diabetes and yes they are bad, at about the same time you had the start of these ‘wellness’ programs that sought to help these people get on the road to health – the two problems that I feel happened were – these wellness programs were graduating young people who only had book learning and no experience telling older people that they were doing their lives all wrong – no wonder the resistence

    The second problem that I saw was the these wellness programs didn’t teach about exercising or weight training and if they did they hardly went far enough or these wellness people didn’t understand completely.

    The other problem is failure to listen and understand completely to the patent and the failure to work completely with them – and by this I mean be informed from them and work with them on a 50/50 basis.

    How did I become one of the few – I was born a blue-baby with congential heart disease and had open heart surgery in 1952 and had too many relatives dying too young of heart disease – how did I get started – at age 24, I met a guy who was a bodybuilder and would become a Mr. America who taught me what I had to know and do to achieve maximum health – this culminated in 2014 with a treadmill test in which I passed with flying colors and surprised the md.

  3. That 400,000 people a year killed my medical error has been disproved so often, I can’t believe that it is still trotted out seriously.


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