One of the core principles of healthcare reform is that
consumers of healthcare (patients & their caregivers) would take an
increasing role in collaborating with their healthcare providers in making
decisions about their care. This would result in lower healthcare costs, as
consumers would in general select lower costs options for care &
potentially choose to receive less care (i.e. at lower cost) than their
provider might choose without this collaboration. It would also lead to
improved outcomes because the consumer would be more deeply engaged in the
content of their care & might be more consistent in following treatment
regimens, for instance being more consistent about taking medication for
chronic conditions such as diabetes. This principle is made concrete in the
Meaningful Use criteria for Stage 1 & Stage 2 on patient access to their
healthcare data & in the efforts & programs such as patient-centered
medical home and the patient portals made available by many provider &
payer organizations.
Recently, however, there appears to be evidence that
consumers (patients, people) are less engaged in their care then they were
previously, & that the underpinnings of this engagement in Federal programs
have also been de-emphasized. A recent survey by Deloitte Center for Health
Solutions[1]
found that 1 in 3 healthcare consumers were not actively engaged in their own
healthcare & that 2 in 5 consumers were less actively engaged in their care
in 2012 than in 2008. In addition,
several other reports found that consumers don’t want to be making healthcare
decisions & don’t feel as if they, or their caregivers, family etc., have
the information or the understanding to make them[2]
The question then becomes: what can be done to re-engage
people in making decisions, in collaboration with their providers &
caregivers, about their healthcare? Several paths have been proposed including:
- Qualification for Stage 1 & Stage 2 meaningful use (CMS) incentives – As originally proposed, both Stage 1 & Stage 2 of the CMS meaningful use criteria had patient engagement requirements in the form of making healthcare information directly available either as electronic copies of healthcare records or through electronic access. Unfortunately, while provision of electronic copies of selected information is still required (>50% of patients within 4 business days, Stage 2), the provision of electronic access by patients to their healthcare records is no longer required for either Stage 1 or Stage 2. This greatly reduces the effectiveness of the meaningful use requirements with respect to re-engaging patients.[3]
- National eHealth Collaborative (NeHC) Patient Engagement Framework – The NeHC framework is roughly aligned with the meaningful use guidelines before they were dialed-back by the ONC. For “Stage 2” it emphasizes criteria such as:
o
Availability of quality & safety reports on
providers, hospitals, etc. along with patient ratings for same
o
eTools for care plan management & secure
messaging (to provider)
o
integration of EHR & patient’s PHR
o
electronic sharing of patient information with
other providers(HIE & secure messaging)
o
patient generated EHR data
o
eReferral coordination, &
o
ambulatory & hospital record integration
Given the misalignment of this
framework with current proposed meaningful use criteria, it is unlikely that it
will have the desired impact on engagement.
- PCMH – A set of guidelines for the improvement of primary care through the use of care teams & better coordination for continuity of care & care transitions. These guidelines were first proposed by professional medical organizations (American Academy of Pediatrics & others). There are several certification or recognition programs including the AAAHC accreditation & NCQA recognition program. At this time, less than 5% of providers in the U.S. have PCMH accreditation or recognition, although the program is influential.
- Patient Portals – With a few exceptions, most “patient portal” efforts have been actually focused on either information gathering for provider or provider’s staff, administrative functions such as making appointments or both. Kaiser & Geisinger are usually pointed at as examples of patient portals that have been successful because they are focused on patient needs. However, even these have been the subject of much criticism. Portals are criticized because they: don’t allow access to the entire record, don’t facilitate portability of PHI, don’t allow for patients to change or correct information, don’t allow the integration of PHR with clinical records etc. Patient portals have the possibility of facilitating engagement, but their relatively low adoption rate & lack of real patient-centered capability limits their effectiveness at this time.
These approaches, & others currently underway, to enable
patient re-engagement are based on a set of ideas that patients will engage
with their healthcare organizations & providers through the means defined
by meaningful use & efforts such as the NeHC framework, namely by reviewing
copies of their EHR records (or extracts of them), secure messaging with their
providers, generating their own PHRs etc. Operating as a medical home allows a
healthcare organization to provide more opportunities for patient engagement as
many of the guidelines pertain to care continuity & transition that
includes the patient & caregivers as part of the process, but the
interactions are still mostly limited to conventional means, as with the
meaningful use & engagement framework(s) reflected in the design of patient
portals.
The fact is that consumers (patients, caregivers) already
are engaged in finding information, making decisions about & managing their
healthcare through public social media & through use of healthcare-directed
apps on smart phones & other devices. There are close to 6,000 health &
fitness smart phone apps & an immense amount of healthcare-related activity
on social media sites such as Facebook, YouTube, Twitter & Google+. A
survey last year by the pwc Health
Research Institute[4]
found that over 50% of the age group 18-24 had posted personal health information
(PHI) on social media sites & that 80% of them would share PHI & that
90% would trust healthcare information discovered on social media sites. In
contrast, 45% of people 45-64 would be likely to post PHI, but 56% of them said
they would engage in healthcare activities discovered on social media sites.
The 25-44 year old group was, as might be expected, intermediate between the
other two groups.
Social media is not the only new element of the technology
& media fabric where this & even higher levels of engagement are
current. The same is true of online gaming of all kinds & use of health
& fitness apps on smartphones & other devices. This type of engagement,
especially in the critical 18-25 year old demographic, must be utilized in order
to have consumers re-engage with their healthcare. The hypothesis is that
alignment of clinical workflows & doctors’ communications with patients with
public social media, gaming & use of apps can facilitate patient
re-engagement. The real trick will be how to do it (see Part 2 of this post).
[1]
The U.S. Healthcare Market: A Strategic View of Consumer Segmentation. Deloitte
Center for Health Solutions. ©2012
[2]
Meill & Ericson. The Trouble with Treating Patients as Consumers. http://blogs.hbr.org/cs/2012/01/the_trouble_with_treating_pati.html
(accessed 3 June 2013),
Nease, R.F., et
al. Choice Architecture is a Better Strategy than Patient Engagment to Spur
Behavior Change. Health Affairs, 32(2):242-249. 2/2013
[4]
Social Media “Likes” Healthcare – From Marketing to Social Business. pwc Health Research Institute. April
2012.
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