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.
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.