Traditional methods of digital patient engagement by healthcare providers typically entail a patient portal where patients can access their health records, look at test results or refill prescriptions. There has been data to indicate patients are interested in digital health tools, such as mobile apps, yet industry data also indicates that patient portal usage remains fairly low.
As previously reported by Healthcare Informatics, a Harris Poll survey released in June found that only 9 percent of 2,000 polled adults use a portal to set up appointments, with 13 percent of millennials using portals to book appointments. The Harris Poll survey found that more consumers are using portals to get test results (23 percent) and to get prescriptions and refills (11 percent). Almost a third of respondents (29 percent) report using a portal to look at their current health data.
Additionally, a survey by NEJM Catalyst, which is part of the NEJM Group that produces the New England Journal of Medicine, found that most healthcare organizations are still in the pilot or planning stages for the next wave of patient engagement in order to increase patients’ meaningful participation in their own care. According to that survey, 88 percent of healthcare leaders surveyed said their organizations currently use or have plans to implement a patient portal, but with regard to other approaches such as patient-generated data, social networks and wireless/wearable devices, and it seems most efforts are still in pilot or planning stages.
According to Brian Eastwood, a lead analyst with Chilmark Research, a Boston-based health IT research and advisory firm, the current model for patient engagement—the patient portal—is outdated, does not encourage behavior change and should be replaced with a broader engagement technology model. During a recent webinar, Eastwood addressed the need for broader patient engagement tools and presented findings from a recent Chilmark insight report examining how to use technology for improved engagement.
In the report, Chilmark researchers contend that market pressures as well as government regulations force consumers to take more responsibility for managing their health and paying for their healthcare. However, “effective, easy-to-use tools for helping consumers choose the right high-deductible health plan, find the right in-network physician, and make the healthiest choices are few and far between,” according to the Chilmark report.
Patient portals typically are built by electronic health record (EHR) vendors to serve as patient engagement tools, but compared to other digital tools that consumers use on a daily basis, the patient portal is outdated, according to Eastwood. “Even the most advanced portals pale in comparison to the multimodal experiences offered by familiar firms such as Amazon, Apple, Facebook, Google and Netflix,” he said.
“If you look at the typical patient engagement model at healthcare organization, they implement the portal and hit the bare minimum metrics, and move on,” Eastwood said, while also noting that portals are not optimized for the type of care that organizations want to provide moving forward. Patient portals are typically tied to a health system, not the individual, and don’t encourage behavior change, he said.
“[Portals] are systems are record, they are not systems of engagement. Portals capture information about episodes of care but they are not built for coordinated care and are inadequate for population health management,” he said.
Outlining why current patient portals fall short of meaningful patient engagement, Eastwood said patients with chronic conditions might have 10 specialists and 10 different patient portals and the information in a patient portal does not include what patients do in between care episodes. “It’s a disjointed model and doesn’t encourage engagement. It's not optimal for coordinated care that a lot of healthcare organizations are moving toward in the transition to value-based care,” he said.
Eastwood sees the healthcare industry moving toward a model where engaging with patients as consumers is the first step down a road that includes education, activation and empowerment. “The end goal is to create an environment where patients can change their behavior for the better, feel like advocates and feel a shared responsibility to live healthier lives,” he said.
While there are digital health tools that address the education and activation phase of the model, he asserted there are currently few tools on the market that empower consumers. “The ones that do are outside the larger healthcare system. This is a challenge that a lot of organizations are facing, and will face, as they try to transition to more coordinated care and more value-based care,” he said.
There are a multitude of factors that will make replacing the current patient portal platform with a new technology platform very challenging. According to Eastwood, those challenges include multiple entry points to healthcare, limited IT resources, a long learning curve and healthcare’s perpetual pilot phase for technology innovation.
Additionally, healthcare organizations need to develop engagement tools for patients across the care continuum from healthy individuals to at-risk to simple chronic and then further to episodic/procedural and finally complex chronic/acute patients. “Healthcare organizations really need tools to address these complex patients who are the largest constituents of the healthcare costs,” he said.
One particular challenge facing healthcare delivery organizations in patient engagement efforts is the evolving nature of care teams. Besides the clinical care team, there is also the holistic care team, including mental and behavioral health, physical therapy, long-term care and nutritionists, and then the community care team, which is comprised of home care and non-clinical services, with Meals on Wheels as one example, Eastwood said.
“Consumers likely interact with the community care teams far more often than the clinical care teams. Yet the same time, as you move across this care continuum, use and access to electronic health record (EHR) data diminishes. The community care teams are looking at economic information, personal data, social and behavioral and wellness data. The person scheduling the Meals on Wheels is probably not using EHRs,” Eastwood said. “Healthcare organizations looking to improve engagement and make it more broad need to consider what sort of systems and touchpoints these members of the care teams have and consider beyond the traditional means of accessing clinical data.”
According to Eastwood, a broader engagement model would focus on a collaborative patient health record that builds on longitudinal patient health data including social determinants of health and data from the holistic and community care teams to make the model more bi-directional.
Moving forward, there are a number stakeholders who could drive innovation in developing broader patient engagement models, with the primary stakeholders being patients and healthcare providers, especially those participating in alternative payment models such as accountable care organizations (ACOs) and the comprehensive joint replacement (CJR) bundled payment program as well as integrated delivery networks (IDNs) and even non-traditional care settings such as retail, telehealth and payer-provider organizations. Additionally, payers and providers could drive the innovation including large and self-insured employers and Medicare or Medicaid, Eastwood said.
“Payer organizations and their employer clients who are working with larger populations of members with increasingly diverse care needs and insurance needs see the value for more coordinated care, which begets a more interactive engagement process than the transactional way of doing things,” he said.
Secondary stakeholders include vendors that design EHR systems and care and condition management tools, he said.
Eastwood projects that providers and vendors moving forward to develop a new, broader patient engagement model will likely experience what he called “short-term pain.”
“There are a growing number of entry points and point solutions. Even with consolidation, the point solutions that consumers use to access the healthcare system will get bigger. We need to try to connect to these solutions in some way and integration is the best we can hope for,” he said.
Furthermore, return on investments on such efforts remains a mixed bag, he said. “Shared risk has demonstrated some efficacy but other efforts are too soon to tell. Wellness programs are longer-term investments aiming for the long game, so trying to decide one year out if a wellness program works is not conducive to making the program work,” he said.
Engagement programs and models are still evolving, he continued, and healthcare organizations will need to decide if they are focusing on loyalty to a program or care management. And, providers and payers also have different engagement needs, with payers focused on price, quality and cost while providers are addressing different engagement needs for patients, namely, convenience, education and loyalty. “These are not entirely competing interests, but they are not completely complimentary either,” he said. “Organizations need to sit down and figure out how to bring these strategies together.”
Despite the myriad of challenges, Eastwood also projects that such efforts to develop broader engagement models could, in three years, result in long-term gains. For patients, it could mean access to their collaborative health record and a more seamless, multimodal experience with the healthcare system. “The customer experience will improve,” he said, also noting that patients will have more active participation in their health and wellness and better self-management of their care.
Looking at the market outlook to 2020, Eastwood estimates that in the next three years the industry will start to see the evolution in patient relationship management (PRM) with partial device integration and partial engagement among larger and regional healthcare delivery organizations and midsized payers and employers, though these efforts at integration will still lack social determinants of health (SDoH) data.
By 2020, he forecasts the start of what he called “PRM 2.0” with full device integration and near-full engagement and partial integration of SDoH data. He also projects these efforts will begin to trickle down to small and rural healthcare organizations.
In these efforts to develop broader patient engagement, Eastwood also believes there will be leaders in the industry who will emphasizes customer loyalty along with a push to value-based care with high visibility, large scale patient engagement programs. Then there will be followers, he said, who will emphasize value with a push to care management and their efforts will be medium scale with high volatility. Finally, there will be the organizations he called “waiters,” and these organizations will emphasize strategy and value and will push to grow, or get acquired, and their efforts will be small scale with high uncertainty.
In sum, Eastwood offered a number of recommendations for healthcare organizations to transition to broader patient engagement models.
“For engagement programs to work, you need to align technology, experience and the business model and define the value proposition. For example, if the customer experience is still lacking and your apps are crashing, it’s not going to work and your engagement efforts will fail. So technology, experience and the business model need to be closely aligned,” he said.
He continued, “One of the key ways to do that is to figure out what you’re trying to accomplish with your engagement model. Are you focused on loyalty, on care management or are you just focused on demonstrating that you can engage with your population?”
Once an organization defines its value proposition, the next step is to find like-minded collaborators, “such as vendors of health IT solutions or payers in your area to start making that engagement model a reality,” he said.
Eastwood also suggested that healthcare organizations push beyond short-term convenience. “Push beyond low-acuity care to more coordinated care, and the way to do that is to emphasize a consumer-centric design into engagement solutions you develop and roll out. You need to understand how consumers use them, make it convenient for them in the goals they are trying to achieve and the overall healthcare needs they have, and make it simple without taking away from the clinical efficacy. It needs to be something that they will stick with as much as the social media apps on their phone,” he said.
“That will plant the seed for behavioral change,” he added.
Eastwood cautioned that these efforts will take time while also encouraging healthcare organizations to “think big.”
“A small step is better than no step. And many organizations are in pilot phases to test out new modalities of engagement to see if they work to help drive down A1c levels and increase physical activity, for example. But, at the same time, I think organizations need to look at the big picture. Think about why you are doing these things—the ultimate goal is to help people make better decisions and live healthier lives so they don’t have to spend a lot of time in high acuity care organizations,” he said.