June 12, 2013 | Anthony Brino, Associate Editor
Patient engagement is a term Jan Oldenburg, Aetna’s VP of patient and provider engagement in accountable care, didn’t first hear until 2009. But she remembers the concept gradually coming to the fore in the mid-1990s and the early 2000s, as her former employer, Kaiser Permanente, launched a personal health record, and as the importance of active chronic disease management became more apparent.
Fast-forward to 2009, and the HITECH Act-created 17 Beacon Communities set out to experiment with digital health tools and patient engagement in a variety of urban and rural settings, focusing on patients with co-morbidities.
With those experiments wrapping up after three years, the Office of the National Coordinator and the providers and health organizations that worked in those communities have a fair understanding of what can work, and what might not, for using a patient engagement as a route to better care and lower costs. Clinicians and program mangers from two of those Beacons and the ONC shared lessons-learned at the HIMSS Government Health IT Conference.
Bring the right technology to the right patients – and docs
Nancy Maloney, a clinical operations manager with the Western New York Beacon Community, worked with a 40-organization team that was trying to coordinate care for patients in some of the poorest areas of the country, in the eight counties around greater Buffalo. Although the Beacon had some notable successes, such as with nutrition programs, a web-based medication adherence program ended up not working out.
“We started a medication adherence program that we thought was fabulous: web-based, written at a fifth grade level, videos for how to use a glucometer,” Maloney said.
Many of the patients, though, were not computer literate, not confident using the web or didn’t have adequate access. Another problem the Beacon encountered, Maloney said, was with doctors. The web-based medication service wasn’t accessible from EHRs, so physicians would have to use a separate web app for patient medication instructions – another step in the work flow that, however minimal, created extra tasks for already time-strained doctors.
Likewise in rural central Pennsylvania’s Keystone Beacon Community, Geisinger Health System community engagement manager Teresa Younkin ran into the limits of consumer health technology.
Younkin and Geisiner went to health fairs with laptops and wireless cards to try to help show mostly senior patients how to find reputable health information on the internet. “We couldn’t get anybody to touch it,” Younkin said.
“If I come to you with some kind of IT tool, I cannot dictate to you how it’s going to work in your community.”
Use ‘beer and pretzel language’
“Patient-centered outcomes.” “Patient engagement.” “Population health.” What do those terms mean to the typical Beacon Community patient or the typical American patient – say, someone with multiple chronic conditions, like diabetes, asthma and heart disease?
Not much necessarily. And possibly the word population may actually trigger fears of rationing or bring to mind an elitist bureaucracy, because patients want to be treated as individuals, as Aetna’s Oldenburg said.
Geisinger and the Keystone Beacon Community, learned firsthand the importance of clinicians – doctors or nurses – having conversations with patients about chronic disease management, and doing so in “beer and pretzel language,” said Younkin.
One huge for opportunity in patient engagement is for clinicians – and also community organizations partnering with providers – to explain things like nutrition, metabolism and exercise and counsel patients on their habits.
In this and other cases, Younkin said, the phone call – midway between email and in-person visits – may be preferable for some patients, especially those who may be more comfortable talking frankly over the phone as opposed to in-person.
Clinicians entering the realm of health coach may be huge challenge, too, particularly for patients that may never have learned basic nutrition science. But if the nation is going to curb the diabetes epidemic, providers are going to have to contribute to health education and engagement. (And as Aetna’s Oldenburg noted, some are already doing this, such as by hosting farmers markets and healthy cooking demonstrations.)
For HIE authorization, avoid registration overload
A key foundation of accountable care (and care coordination in general) is information exchange, which under HIPAA requires patient consent.
Health systems and HIEs have experimented with opt-in or opt-out consents – framing the choice as either being able to sign up or being automatically signed up unless otherwise opting out. But one variable that may not have been widely considered is how and when the consent is offered.
Doreen Salek, director of case management at the Keystone Beacon Community and an RN at Geisinger, ended up testing a few methods of obtaining consent. She found that universal authorizations at registration, selling the form and cold calling didn’t work.
What did work was using a trusted care team member to explain what the consent form actually meant – that a patient’s information will follow them the next time they seek or need healthcare.