Correcting critical misperceptions about patient engagement

Jan. 19, 2016
Dr. Peter Edelstein, Chief Medical Officer, Elsevier

Clinicians objectively measure. We implement improvement processes. Then we measure again. We do all this with the aim of increasing value: improving clinical outcomes, reducing costs, and increasing patient satisfaction.

But not when it comes to “patient engagement.”

To many healthcare leaders, integrated delivery network (IDN) administrators, even to doctors and nurses, patient engagement is at best a fuzzy concept. Today’s continually evolving potential threats (reimbursement penalties) and rewards (shared savings) demand strategies founded in “evidence-based” content and clear, specific, measurable clinical and financial outcomes. In this world of objective tools and strategies, “patient engagement” is simply too ambiguous. After all, if we can’t objectively measure it, if we don’t clearly understand its clinical and financial impact, and if we are unable to improve it, there are simply too few resources and not enough time to waste on patient engagement.

But here’s the shocking truth: We can measure patient engagement. And we can understand the (significant) impact of engagement on value. And we can drive improvement. But first, our society must undergo a paradigm shift in who we view as a healthcare “provider.”

Doctors, hospital CEOs, senators, plumbers, electricians, chefs, teachers, your mom, my dad … we must all appreciate that if our society (including our loved ones and our wallets) is to realize the full potential of healthcare reform, we must dramatically expand our perception of who is responsible for our health and healthcare. We must not only accept but embrace the patient as provider. Because the reality is that we will only experience a limited bump in clinical and financial improvement if we continue to define “provider” so rigidly, legislating reform on the backs of traditional providers. Even those suffering from chronic conditions spend only hours annually under the care of a doctor, nurse, or other clinician. Thus, it will only be when a significant percentage of us truly accepts ownership of our health – the way that we own our finances, child-rearing responsibilities, and virtually everything else in our lives – that our society will achieve dramatic and sustainable improvement in the quality and cost efficiency of our healthcare.

The comparison I frequently use is that we legislate seat belt usage, but only when drivers and passengers buckle up do we see a reduction in the physical, emotional, and financial damage that results from auto accidents.

Let’s start with measuring patient engagement. The common perception is that there is no valid way to measure it objectively and repeatedly. This could not be further from the truth. Likely the most frequently utilized instrument to objectify patient engagement is the Patient Activation Measure (PAM). This 13-question survey-style tool was developed through a rigorous process at the University of Oregon by a team led by Judith Hibbard. Now commercially available, the PAM has been repeatedly evaluated in more than 20 countries and languages, with study results published in peer-reviewed articles. The PAM is simple for patients to understand and requires only minutes to complete. Thus, the first critical piece of the puzzle is in place: We can objectively and repeatedly measure patient engagement.

Based on such credible measurement instruments, a nation, state, city, accountable care organization (ACO), or IDN, or even single hospital or ambulatory center, can stratify its patient population into sub-populations based on demonstrated levels of engagement. For instance, the PAM segregates survey users into four high levels of patient healthcare ownership and involvement: Disengaged and Overwhelmed; Becoming Aware but Still Struggling; Taking Action; and Maintaining Behaviors and Pushing Further. Dividing a population into valid engagement-level cohorts is enormously powerful, allowing resource managers to allocate staff, money, and time more effectively and efficiently. Patients on the lower end of the ownership spectrum may be targeted for more frequent and deeper outreach (including personal outreach by nurses or others), whereas populations demonstrating greater engagement may require less frequent and simpler interactions (such as emails or auto-calls).

But the use of the PAM or other patient engagement measurement tools is only useful for resource allocation if there is a clear relationship between engagement and desired outcomes.

And there is.

The evidence demonstrates that engaged patients have better clinical outcomes and lower costs of care. In terms of the PAM specifically, patients with higher scores are more likely to demonstrate a number of higher value behaviors, such as: autonomously seeking out medical knowledge and using medical resources; eating a healthy diet, exercising regularly, and maintaining a healthy weight; controlling blood pressure, cholesterol, and HbA1c; adhering to prescribed medical regimens; better managing chronic conditions; completing prescribed post-operative physical therapy; and participating in preventative care activities. And the correlation between PAM score and patient outcomes holds true on the opposite end of the spectrum: Patients with lower scores are more likely to be admitted to the hospital, utilize the emergency department, and be readmitted soon after hospital discharge (almost twice as likely). And here’s the kicker: Improvement in PAM score has been shown to correlate with meaningful improvement in healthcare value. For example, even small PAM score increases correlate with reduced hospitalizations and increased prescribed medication compliance. Thus, the second piece of the puzzle is in place: There are clear, objective correlations between both static and dynamic patient engagement measurements and value.

That we can measure patient engagement, that patient engagement correlates with desired clinical and financial outcomes, and that improvement in patient engagement translates to improved value is the framework on which sound, impactful patient engagement strategy can be created and implemented. Fortunately, the third and final piece of the puzzle is already both available and continuously improving: HIT solutions that (when combined with appropriate human-to-human interaction) can truly engage, educate, and ultimately empower patients. A limited number of vendors provide creative solutions to address the first challenge, which is true engagement. These impressive, interactive, social media-like products incorporate gaming, captivating iconography, and even humor to rapidly draw their target audience in. Next, the engaged patients and their loved ones have access to evidence-based information to guide them in preventative and health maintenance activities specific to them. Leading patient engagement vendors offer this critical educational material in text and video formats, in the hospital or at home, in multiple languages and in varying educational levels. Finally, more and more interactive products are empowering engaged, educated patients in seeking credible, specific information and appropriately communicating with their providers.

Don’t get me wrong, there is little doubt that HIT solutions that support care delivery by doctors, nurses, pharmacists, and other clinical personnel can reduce preventable deaths and harm. But ask yourself, “How many hours did I spend under the direct care of a traditional provider this last year?” Statistically, people spend their entire lives away from doctors, hospitals, and clinics. We don’t depend on our insurance agent for our driving. Thus, depending even moderately (let alone heavily) on the small population of traditional providers to alter the behavior and activities of the entire population is (to put it kindly) naive. Traditional providers are the seat belts in our healthcare system. Only when the population of patients and future patients (that is to say, all of us) chooses to buckle up will we harness the true potential of healthcare reform.