How to Launch and Grow a Successful Patient Engagement Strategy

As the CEO of Axial Exchange, I've witnessed the same buzzword phenomenon more times than I can count. Last year, Patient Engagement was the new religion. In fact, Time Magazine called it the Trillion Dollar Pill. This year, Aetna pulled out of their Carepass Consumer health data initiatives and Gartner recently published that Mobile Health Monitoring is entering the "Trough of Disillusionment". In the consumer space, Apple Healthkit (and IWatch) and Google Fit are garnering unbelievable press. Are these inconsistent events? Not at all. We are at the nexus of rapidly widening functionality and falling prices of consumer technology meeting up with the traditionally slower moving domain of medicine and health. Bringing these trends together will not only benefit those that already watch their health, but those that are the most costly and traditionally intransigent population: those with chronic health issues. The bridge? Patient engagement. 



What is patient engagement exactly and why does it matter? At Axial, we define patient engagement as the process by which patients become invested in their own health. Health systems with effective patient engagement programs provide patients with the information and tools needed to take control of their care. From Meaningful Use to Value-Based Purchasing, patient engagement is a key feature of payment reform and is instrumental in readmissions reduction, HCAHPS, and patient loyalty. Engaged patients not only have better outcomes, but engaged patients are better business. 

The best health systems not only offer electronic access to patient health records, but also provide the resources patients need for the day-to-day management of disease. For example, a health system might offer its diabetic population digital tools for capturing and reviewing glucose readings. The most effective patient engagement programs offer these tools via the device of the patient's choice: desktop, tablet, or smartphone. 

The other important factor is that we are a nation of chronic disease--we don't die from smallpox; we are sick for multiple years from heart disease, diabetes, and COPD. And yet our health systems are still largely focused on the times when the patient is in the hospital or physician's office--that .1% of the time. If patients are to take charge of their health, then health systems and plans must meet them where they are--and that would be their mobile devices. 

Studies show that hospitals offering these types of personal health resources are more effective at reducing costs and improving health outcomes than are hospitals that do not offer them. For example, a Commonwealth Funds-supported study demonstrated that patients with the lowest engagement generated 21% more health costs. (1) In another study, patients suffering from depression were given interactive engagement tools. These patients showed a 33% increase in antidepressant medication adherence, decreased overall depression scores, and a 61% increase in satisfaction. (2)

  • Myth: Patient Engagement is an IT Project
  • Truth: Patient Engagement Starts From the Top

Fear is a great motivator; so let me blunt. There are significant leading healthcare organizations that are far down the path of incorporating a patient engagement strategy into their everyday practice of medicine. For the winners, it's more than a program; it's a cultural change. Some of the most well known organizations get plenty of press coverage in this arena; Kaiser and Geisinger, for example. These organizations do not consider patient engagement a program; they consider the patient the center of the healthcare system. Driving that kind of cultural mind shift can only start from the top. When you look at organizations that scored at the top of the Becker's Hospital / Axial Patient Engagement Rankings, there is a definite pattern of profitable steadily expanding hospitals. Of the top 100 hospitals, Intermountain had nine hospitals in the list and the Mayo Clinic had seven. 

At Axial, we see a clear delineation in our data in patient engagement between those institutions where clinicians are driving a program with measurable clinical results than those where Marketing or IT is leading the program (though of course, they are crucial participants) 

Recommendation: The CEO should make the patient the top priority and begin a multi-year program to address this, naming key clinical staff to manage various parts of the initiatives. There should be clear, measurable objectives, such as the percent of patients engaged in self-care and total cost of care for certain diagnoses.

  • Myth: I tell the patient what's wrong with them and what they should do to improve, but they don't listen!
  • Truth: No one wants to be sick. However, patients only retain about 11% of what they hear in the hospital and 25% -40% in the physician's office.

There are two main parts to getting a patient engaged over the long term; teaching them, their families and caregivers, and tracking their health. If you've ever watched Grey's Anatomy or House, you can't help but marvel at the actors' ability to reel off long lists of medical terms. But in the shows, the patient then gets a compelling, simple explanation in English. In real life, that's often not the case. Language and educational barriers are numerous. Most medical literature is written at a tenth grade level, and even college graduates have been shown to only be able to process at a sixth grade level when they are in the hospital. 

Recommendation: Make sure your patients, family and caregivers have baseline health literacy. The patient and their family should have access to the same multi-language care information, regardless of whether they could attend the office visit. Ideally, health care institutions and plans should make this information available to them on mobile devices, so they can consult it whenever they have a question.

  • Myth: People won't take their medications when they're supposed to--or take the right amount. It's not that hard.
  • Truth: It is that hard. On average, individuals 65 to 69 years old take nearly 14 prescriptions per year, individuals aged 80 to 84 take an average of 18 prescriptions per year. (3)

Only 36% of patients correctly interpreted the meaning of "every six hours." (4) 

Medication adherence is the single largest cause of unplanned admissions and readmissions in the United States. Yet, less than 10% of hospitals in the United States send a patient home with 30 days worth of the correct medications. While it is increasingly common to perform a "medical reconciliation", these are typically more for the physician than the patient. There's little to indicate that patients know what the medications are for or how to take them together. 

Simple, visual mobile tools (as opposed to 10 page warning labels) allow reminders and simple visual checks to make sure patients are taking the right medications at the right time. For high risk and elderly patients, adherence can be improved by having a caregiver or pharmacy technician make sure the information is correctly entered into the device, as I do for my mother. Because of the ubiquity of mobile devices, the same information can be used to facilitate medical reconciliations at the provider. A patient doesn't have to be able to load all the information to answer an alarm and match the picture to what they are taking 

Recommendation: Recognize that the same tools that make our life easier outside healthcare can be used to improve adherence. At discharge and follow-up appointments, the medications should be reviewed with the patient and their caregiver. If the health system EHR supports it, that information should be downloaded to the smart phone. 

Which Is More Patient Friendly?

     

 

  • Myth: We Take Biometrics At The Physicians Office; that's enough. Besides, patients can't do it anyway
  • Truth: We're a nation of chronic disease and your patients are with you .1% of the time. Patients will track their health if its "prescribed"

Eric Topol had it right. Soon, physicians will be prescribing an app or a device. The falling cost of wireless devices means that everyone can take the common biometric measurements and see how they are doing. A patient may not know the meaning or difference between their Systolic or Diastolic rates, but they will understand if one of their readings is very high compared to others. If they notate what happened, say, when their blood pressure dropped (skipped breakfast), they can become self-learning, self-correcting patients. 

It is true that not everyone comes to the table with the same motivation or understanding to track their health; the good news is that people still, despite all the press, trust their doctors. If the doctors tell them to measure, they will. That's where the consumer world and medical world catch up. These consumer devices are very adept at providing feedback, reminding patients, or color-coding results. And while studies don't yet show how long people will use these devices, the good news is that from the healthcare provider's perspective, they provide the highest benefit when it is most needed- the thirty days after discharge or other chronic event. 
 

Consumer Tools Work With Hospital Systems 

Recommendation: Make sure patients know what biometrics or symptoms they need to measure or journal and why. Make it easy by using consumer devices and applications. Make sure they note to annotate out-of-range events. Have your staff or care coordinators review the information with the patient as reinforcing behavior, instead of trying to get patient to "describe" how they've been feeling.

  • Myth: It's Too Complicated - My staff is already too busy
  • Truth: Start small with a motivated department- little changes will yield big results

Just as we tell people getting back into exercise, taking the stairs instead of the elevator will yield great results. The same is true for implementing Patient Engagement programs. Some ways successful organizations have started:

  • Employee wellness programs
  • Gestational Diabetes glucose monitoring
  • Fitbits to measure readiness or cardiac discharge
  • Wireless scales to avoid CHF readmissions

These are just a few of the successful samples we have seen. Success breeds success. 

Recommendation: Pick a small high impact area of the health system and get started. Spend the time to take a baseline, suggest process improvement, and test and measure. Because mobile tools are so ingrained in everyone's life outside of healthcare, these kind of changes are readily incorporated into your staff's workflow and your patients' daily lives. 

References
1. Hibbard, J.H. Greene, J. and Overton V. "Patients With Lower Activation Associated With Higher Costs; Delivery Systems Should Know Their Patients' Scores," Health Affairs, Feb 2013: 32(2):216-222 
2. Simon, G.E. et al., "Randomized Trial of Depression Follow-Up Care by Online Messaging," Journal of General Internal Medicine, July, 2011: 26(7) 698-7 
3. American Society of Consultant Pharmacists; Fact Sheet; and FDA; 1996 
4. "Understanding and Improving Patient Compliance," Annals of Internal Medicine, 1984