Patient Engagement Requires Right IT Tools

Paul Cerrato, writing in Information Week, thoughtfully discusses how IT tools can help (or hinder) practices to engage patients in their care (and meet Meaningful Use requirements). He makes the point that engagement tools that look good in a controlled laboratory environment often fail when put into service in the messy day-to-day world of sick patients, anxious families, harried providers and overworked staffs. That's why it is critical to select tools that have proven themselves in large-scale, well-designed evaluations in real-world settings.

http://www.informationweek.com/news/healthcare/policy/240003073#

Managing chronic conditions through automated patient engagement

Thanks to the good folks at PhysBizTech for publishing my little screed on using health information to engage patients. Insomniacs among you can find it here.

Patient Engagement in the US and Abroad

Robin Osborne and David Squires from The Commonwealth Fund just published a survey of almost 19,000 patients from 11 developed nations (including the US) to see how engaged they are in their health care.  The US scores were fair-to-middling, better than Norway, Sweden and Canada, but nearly as good as the UK and Switzerland.

Remarkably, the US did very well on "Follow-up and Support Between Visits" for patients with a chronic condition: 77% said they could easily call to ask a question or get advice and 31% said that their health care professional contacts them to see how things are going. Although 31% was the best of any of the countries, it is not a very good showing at all. Clearly, this is a big opportunity area both at home and around the world.

What good is being engaged? The more engaged patients are, the higher the reported quality of care and the less likely they are to experience a medical error. Coupled with other, prospective, evidence that engagement improves medical outcomes and lowers costs of care, and this is a very big deal, indeed.

Osborn R, Squires D. International Perspectives on Patient Engagement: Results From the 2011 Commonwealth Fund Survey. The Journal of Ambulatory Care Management 2012;35(2):118-28

You can read the article here.

Informatics for Consumer Health

Informatics for Consumer Health is a consortium of federal agencies seeking to empower providers to manage care and increase the ability of consumers to gain mastery over their own health. Their web site offers news on health informatics from the academic literature, upcoming events and funding opportunities. It seems directed primarily to academics and IT professionals, but health care providers and patients might find it useful as well.


Enjoy!

More care means lower costs?

The Commonwealth Fund recently published one of their very excellent issue briefs titled Paying More for Primary Care: Can It Help Bend the Medicare Cost Curve? by James D. Reschovsky, Arkadipta Ghosh, Kate Stewart, and Deborah Chollet. This paper reports on a simulation model of the effects of improving reimbursement for primary care services (as Medicare did last year). Based on data showing that more primary care leads to lower total costs via lower rates of hospitalizations and other expensive services, the authors conclude that "promoting primary care can help bend the Medicare cost curve."

Other than rationing, getting patients into primary care is just about the only known way to reduce utilization. There are many ways to increase use of primary care services (such as automated systems to increase engagement between patients and providers), but none of them will work if there aren't enough primary providers. There is clearly a shortage of primary care providers now and it will only get worse as demand grows in the future due to improved insurance coverage and an aging population. If primary specialties aren't made more attractive by increasing payments (and lowering administrative burdens, too, while we are at it), we will never see an end to the health care cost crisis.

Is Disease Management Dead?

Archelle Georgiou thinks so. Her very well-written post (on her own blog here and on Managed Care magazine here) is a thoughtful obituary. She puts the time of death last November, when the New England Journal published Nancy McCall and Jerry Cromwell's report on the CMS disease management pilot program (N Engl J Med 2011; 365:1704-1712). The various DM programs showed little or no benefit, but they cost CMS $400 million. Yes, I agree: disease management, as we know it, has bought the farm and ought to be buried.

Dr. Georgiou offers several quite cogent reasons for DM's failure. The most compelling is that DM as implemented has drifted from the format and target audience originally proven effective in clinical trials in the 1990's. Again, I think she is spot on.

What should we do to improve outcomes and reduce costs going forward? Many of the ideas being proposed appear promising, but have less of a justification than the currently-employed versions of DM have. We just wasted billions of dollars and many years by failing to use the evidence base correctly. It doesn't seem wise to me to abandon the requirement for solid evidence before we invest again. Rather, we should take steps to ensure that we use technologies and programs that are evidence-based AND that we employ them as close to tested as possible.

What are those technologies and programs? Classic disease management for heart failure patients has been proven effective many times and should be retained. Use of automatic systems to support chronic disease patients (and their providers) are very low cost and have also been proven in large randomized studies. Lowering co-pays and barriers to access for essential medications and services is another strategy with a large evidence base.

Let's not throw out the evidence-based baby with the DM bathwater.

The psychology of exchanging health information with patients

How does exchanging health information work to improve health? Getting the facts about your favorite subject (you!) is extraordinarily motivating. It is the reason why actionable communications like those embedded in effective patient outreach systems work. Here's a nice review of the psychology by Joe Kvedar at Connected Health: Self-Quantification as a Driver of Behavior Change

QR Codes for communicating with patients...

QR Codes are those funny little black and white squares that look like a checkerboard with a screw loose. They can contain a surprising amount of information. For instance, here is the URL for this blog:

If you scan this code with you phone, you will be directed ..... right back here.  You can also do text. This one contains some words of wisdom from Mark Twain:



QR Codes are starting to be used in marketing (I've seen them on posters and flyers), but now that smart phones are so ubiquitous, they provide an option for sharing information with patients (an others). If you turn their medication list into a QR Code, they can scan it right into their smart phone and have it handy whenever. Here is a 6-minute video from the folks at Skyline Family Practice, in Front Royal, Virginia with some examples:

(http://www.youtube.com/watch?v=FSBIXSk4nbg for the non-scanning crowd)


Have fun scanning!

National Medical Home Summit

Benjamin Littenberg, MD, Chief Medical Officer at Patient Engagement Systems to Discuss Advanced IT for Primary Care at the National Medical Home Summit The Fourth National Medical Home Summit, the Leading Forum on the Development and Implementation of the Patient Centered Medical Home, takes place Sept. 20-21 in San Francisco Media Contact: Christine Dunn Savoir Media (617) 484-1660 cdunn@savoirmedia.com Burlington, VT - September 16, 2011 - Benjamin Littenberg, MD, Chief Medical Officer for Patient Engagement Systems, a health-care technology company that provides solutions for improving primary care for people with chronic diseases, will be presenting "Advanced IT for the Medical Home: Engaging the Patient" at the Fourth National Medical Home Summit in San Francisco later this month. At the conference, Dr. Littenberg will discuss how information technology, when applied strategically and purposefully, can create engaged patients and be a key difference maker for PCMH efforts. Dr. Littenberg's presentation will include research that demonstrates that successful patient engagement improves outcomes and saves money. "The future of healthcare is evolving and primary care delivery is changing, making engaging with patients more important than ever to the financial and clinical success of the primary care practice research. The Medical Home model will help this evolution happen, but the right information utilities need to be in place to engrain new methods of health improvement," said Dr. Littenberg. Dr. Littenberg's Mini Summit presentation at the National Medical Home Summit will take place at 2:15 p.m. on Wednesday, Sept. 21. The Fourth National Medical Home Summit is being held on that day, as well as on Sept. 22, at the Grand Hyatt in San Francisco, California. Patient Engagement Systems provides technology solutions that have been demonstrated to improve coordination, compliance and the overall management of chronic conditions by supporting physician decision-making and communication with their patients. Physicians who work with Patient Engagement Systems have found that the technology extended, and expanded, their capability to provide high-quality, cost-effective, and consistent medical care -- ultimately improving health outcomes and reducing expenses. Patient Engagement Systems' technology is the only patient centered clinical solution that has demonstrated effectiveness in a National Institute of Health (NIH) funded study. The National Medical Home Summit is the leading forum on the development and implementation of the patient centered medical home (PCMH). The Summit, a hybrid conference and Internet event that is sponsored by the Jefferson School of Population Health, will bring together the leading authorities and practitioners in the medical home field to discuss how the PCMH model is working, where it has proven outcomes, how it is evolving, and how it fits into plans for delivery system reform. The conference will present the key building blocks of the medical home model, and four major medical home themes -- IT, care coordination, patient engagement, and the medical home workforce. Each of these topics will be discussed in depth in separate mini summits. For more information about the National Medical Home Summit, visitwww.MedicalHomeSummit.com For more information about PES, visit www.patientengagementsystems.com About Patient Engagement Systems® Patient Engagement Systems® technology enhances patient engagement by fostering communication between patient and caregiver, and by delivering decision support to health-care providers. The PES system has been proven in a National Institute of Health clinical trial to improve health outcomes and reduce costs. The patent-pending PES technology uses automated reminders, alerts, flow sheets and population reports to help health care providers better care for their patients, and patients better manage their chronic conditions. PES has been used by thousands of patients with diabetes in Vermont, New York, California and Texas. Clients include municipalities, private hospital systems, physician organizations, and managed care organizations. For more information about Patient Engagement Systems (PES), visit http://www.patientengagementsystems.com.

Webinar: Advanced IT for the Medical Home: Engaging the Patient

Advanced IT for the Medical Home: Engaging the Patient    A special conference for senior executives & administrators from physician groups, emerging Accountable Care Organizations, health systems, Patient Centered Medical Homes, health plans, and government agencies.   To register for this interactive, 45 minute webinar, please click here. System Requirements PC-based attendees require: Windows® 7, Vista, XP or 2003 Server       Macintosh®-based attendees require:  Mac OS® X 10.5 or newer  Answers to Your Specific Questions If you have questions on our webinar and/or webinar formats, please contact us atmarketing@ptengage.com Webinar Date:  Monday, October 3rd Time:  12:00 pm Eastern Primary care is at the core of most every major initiative for health care reform - not the least of which is the Patient Centered Medical Home. The PCMH model will succeed or fail depending on how well primary care providers can engage their patients in a coordinated, continual, and directed pattern of care.  Information technology, when applied strategically and purposefully, can create engaged patients and be a key difference maker for PCMH efforts.     Benjamin Littenberg, MD FACP will share his experience as a practicing physician, academician, and information scientist about how primary care delivery is changing, and how engaging with patients is more important than ever to the financial and clinical success of the primary care practice.  Focused Discussion Attendees will learn: · How well the medical home model orients itself to patient engagement · How primary care physician-lead groups have implemented technology solutions that support PCMH criteria · What research and standard practices have established about how patient engagement improves the overall clinical experience and what that means for Medical Home providers · What are the anticipated impacts - risks and rewards - of PCMH on how providers and patients interact Seminar Speaker Benjamin Littenberg MD, FACP  Henry and Carleen Tufo Professor of Medicine, Professor of Nursing, Director of General Internal Medicine Division of General Internal Medicine, University of Vermont Chief Medical Officer, Patient Engagement Systems, Inc. Dr. Littenberg is the Henry and Carleen Tufo Professor of Medicine, Professor of Nursing and Director of General Internal Medicine at the University of Vermont. He received his medical degree from Case Western Reserve University and trained in internal medicine at Hartford Hospital in Connecticut. He was a Robert Wood Johnson Clinical Scholar at Stanford University before becoming Assistant Professor of Medicine at Dartmouth. Following an appointment as Associate Professor of Medicine at Washington University in St. Louis, he assumed his present position in 1999. Dr. Littenberg practices General Internal Medicine in Burlington, Vermont. His research interests center on technology assessment and quality improvement. Recent projects include new ways to measure quality of care in cancer, novel strategies for reporting test results to patients, better approaches to antibiotics in sinusitis, safety improvements in outpatient prescriptions, and strategies to address health literacy. In Vermont, Dr. Littenberg has been active on the Board of the Vermont Program for Quality in Health Care. He has developed statewide registry-based approaches to quality and safety improvement with the Vermont Breast Cancer Surveillance System and as Principal Investigator of the NIH-funded research grant for the Patient Engagement Systems Diabetes Information System which engendered Patient Engagement Systems.           Patient Engagement Systems 89 Beaumont Ave. Given Courtyard, 4 South Burlington, VT 05405 (802) 656-4576  About Patient Engagement Systems® Patient Engagement Systems® technology enhances patient engagement by fostering communication between patient and caregiver, and by delivering decision support to health-care providers. The PES system has been proven in a National Institute of Health clinical trial to improve health outcomes and reduce costs. The patent-pending PES technology uses automated reminders, alerts, flow sheets and population reports to help health care providers better care for their patients, and patients better manage their chronic conditions. PES has been used by thousands of patients with diabetes in Vermont, New York, California and Texas. Clients include municipalities, private hospital systems, physician organizations, and managed care organizations. For more information about Patient Engagement Systems (PES), visit http://www.patientengagementsystems.com.

Exchanging Health Information to improve medication adherence

Getting the right medicine into the right patient at the right time is a particularly challenging problem in outpatient care. Consider the required steps:

1. Prescriber selects the right medication
2. Prescriber prescribes the right medication
3. Patient carries the paper prescription to the pharmacy
4. Pharmacist interprets the written prescription correctly
5. Pharmacist selects, packages and labels the medication correctly
6. Patient returns to pharmacy
7. Patient receives the correct package
8. Patient takes the medication as prescribed
9. Patient requests refill at appropriate time
10. Return to Step 5

There are lots of variations on this scheme depending on insurance, expired prescriptions, need for clarifications, etc, etc., etc. A big one recently is that Step #3 is sometimes replaced by a network connection with quite high reliability.

There have been a number of studies on "secondary non-adherence" in which the pharmacy records identify patients who don't get refills (Step #9). There have even been some analyses of patients who drop off their paper prescription but fail to pick up the medicines (Step #6). However, until recently, the gap between prescribing and dispensing the first unit (Steps #3, "Primary Non-adherence") has been very difficult to study because of the lack of information exchange between the prescriber and the dispenser.

Marsha A. Raebel and the good folks at the Kaiser Permanente Institute for Health Research in Colorado just published an article in The Journal of General Internal Medicine about using health technology to identify those patients who need help in getting their first fill. They looked at over 12,000 new electronic prescriptions for  blood pressure, cholesterol or diabetes. Overall, about 7% failed to pick up their first medication, even though these patients had pretty good insurance coverage.

It is not clear yet why these folks don't show up to pick up their pills. Nor is it clear exactly what should be done about it. However, it is clear that this kind of health information exchange between prescribers and pharmacists should trigger an alert to someone inside the system: "This patient is not getting the intended care - call them and find out why!!"

Characteristics of Patients with Primary Non-adherence to Medications for Hypertension, Diabetes, and Lipid Disorders

Marsha A. Raebel, Jennifer L. Ellis, Nikki M. Carroll, Elizabeth A. Bayliss and Brandy McGinnis, et al.

Journal of General Internal Medicine Online First™, 30 August 2011

Empowering patients with data

I've been thinking more and more about the idea of engaging patients in their own care as the means to improve quality and reduce costs. Today I see that Farzad Mostashari, Director of the Office of the National Coordinator, is thinking along the same lines:

"The meta principle is putting patients at the center of information flows, literally. Achieving that means freeing the patient data, empowering patients by raising awareness that they can access their own data and teaching them to learn from it."

Perhaps the time has come....

Is it better to prescribe or negotiate?

Engaging patients in their own care means more than just giving them a handout or teaching them how to care for their feet. The tough part is motivating them to stay engaged for the long run. This is especially difficult when they have depression which itself induces dis-engagement from the world.

Exercise is an effective treatment for depression. It is also inexpensive and has positive benefits in other spheres of health such as weight control and heart disease prevention. However, it is notoriously difficult to get depressed patients to start exercising and to keep them engaged. One reason might be that the recommended duration and intensity of exertion can seem daunting. (30 minutes on the treadmill!!!)

A team of researchers from the University of Nottingham just published the intriguing results of a controlled trial in which they compared the effects of exercise of preferred intensity with exercise of prescribed intensity in thirty-eight women living with depression. The women who chose their own level completed more sessions and had better mental AND physical health at the end of the 12 week study.

The study is quite small (only 38 subjects) and may not be the last word on this issue, but the idea certainly warrants further investigation. It suggests that engaging patients in decisions about the dose of the treatment is effective at keeping them in the treatment. And, that's better than getting them on the "right" dose.

Pragmatic randomised controlled trial of preferred intensity exercise in women living with depression. Patrick Callaghan, Elizabeth Khalil, Ioannis Morres, Tim Carter. BMC Public Health 2011; 11:465

Smartphones for Health? A survey

Last month, Consumer Health Information Corporation released the results of a survey of 395 smartphone consumers. It was a good first effort to dig into a very murky, but important question: how will folks use their smartphones to manage their own health? 


They reported a number of findings:

• 74% of smartphone apps are abandoned by the user before they use it 10 times.
• Most health apps do not comply with public health guidelines.
• In spite of these failings, most consumers were willing to pay a few dollars for the app.
• Respondents preferred text messages over other methods of getting health reminders.

This last finding is a bit problematic. Apparently the survey included only electronic methods of communication (phone calls, e-mails, app messages, etc.). However, none of these methods has ever been shown to improve health outcomes or lower costs. On the other hand, personalized first class mail is quite effective and has been proven in large scale clinical trials to change patient behavior for the better.

I guess that's what happens when you survey cell phone users on Facebook - they tell you they like using cell phones! But whether health apps will truly change our health awaits a more rigorous evaluation, including a large randomized clinical trial.

Patient Portals and Equity

Mita Goel, David Baker and the good folks at Northwestern University report in the Journal of General Internal Medicine about use of the patient portal in their large, academic practice in Chicago. Of 7,088 patients invited to open an account on the portal, 69% enrolled. However, older patients and minority patients were significantly less likely to use the technology.

Once they were enrolled, race and ehtnicity didn't seem to be associated with how the patients used the portal. However, younger patients were less likely to initiate a request for refill or advice, perhaps because they have fewer medical issues. Likewise, men used the system less than women, reflecting the general tendnecy for women to seek health care more often than men.

The good news for engaging patients and exchanging health information is that over 2/3 of patients in this large, complex population took the opportunity to enroll. Patients want to connect. The bad news is that it might not help resolve the racial and ethnic divides that continue to bedevil health care and American society - it might even make them worse.


Goel M, Brown T, Williams A, Hasnain-Wynia R, Thompson J, Baker D. Disparities in Enrollment and Use of an Electronic Patient Portal. Journal of General Internal Medicine 2011; Online first at http://dx.doi.org/10.1007/s11606-011-1728-3

Sharing Information and Patient Engagement

The original motivator for electronic health records and exchanging health information (way back in the dark days of the late 20th century) was to make it easier, safer and cheaper to take care of patients.  The push came largely from managers looking to reduce the transaction costs of care and providers trying to reduce the administrative overhead of care so they could spend more time dealing with patients.

However, the more I deal with health information systems, the more I see that the best and highest purpose is not for management or even professional use. Rather, it is for patients. Giving patients their own information, (in the right format, via the right medium, at the right time, and from the right source), does more than enable them to make better decisions, it engages them in their care. It motivates them, educates them, energizes them, and empowers them. Whether any specific bit of information is, by itself, critical to the patient's care is not the whole story. The mere act of sharing the information with the patient turns the patient from a passive passenger on the health care bus to the driver, choosing the destination and calling the stops.

What happens when you engage patients with chronic care by sharing their personal health information with them?
1) They like it. Really, really a lot. HIE with patients is a big satisfier.
2) It generates scheduled care, notably primary care.
3) It reduces the need for urgent and emergency care and hospitalizations.
4) It saves a huge amount of money.

(Oddly, it seems to do all this without improving the patient's disease control, their physiologic state. The mechanism for this is unclear, but more on that later.)

It's early days yet and exactly how best to share information, which information, and so forth is by no means completely clear. However, there are some very well documented examples that work and are ready for deployment now.

If you would like to learn more about this, you might want to check out a recorded webinar featuring yours truly:

Does Improving Patient Engagement Result In More Appropriate Utilization

View more videos from vermedx

I'll also be doing a presentation at the Spring Managed Care Forum in Orlando on April 15.

Does Improving Patient Engagement Result in More Appropriate Utilization

Please join me for a webinar tomorrow:

Does Improving  Patient Engagement Result in More  Appropriate Utilization?     A special online seminar for senior executives, administrators, practice managers and patient outreach specialists from physician groups, emerging Accountable Care Organizations, Health Systems, Patient Centered Medical Homes, health plans, and government agencies. To register, please click here.                                                               To register, please click here. Answers to Your Specific Questions Have questions on our webinar and/or webinar formats? Please contact us at: marketing@vermedx.com Event Date:  Thursday, March 24th Time:  12:00 pm Eastern The risk-reward dynamic is shifting within healthcare.  Improving patient engagement is widely accepted as a critical foundation for emerging care practices, such as the patient-centered medical home.  As provider-patient interactions evolve, provider groups are realizing more and more that informed, prepared patients lead to more efficient encounters.  This is especially so when managing chronic conditions.  Benjamin Littenberg, MD FACP will share from both academic and actual business cases how low cost, high touch programs can reduce avoidable health utilization and improve patient satisfaction within normal provider practice workflow. Focused Discussion Attendees will learn: · What published, academic research has established about how patient engagement improves the overall clinical experience and what that means for providers? · How large physician-lead groups have implemented technology solutions that better prepare both providers and patients for more effective clinical encounters, and how they measure it? · What are the anticipated impacts - risks and rewards - of pay for performance and health care reform on how providers and patients interact? To register, please click here. Seminar Speaker Benjamin Littenberg MD, FACP   Henry and Carleen Tufo Professor of Medicine, Professor of Nursing, Director of General Internal Medicine Division of General Internal Medicine, University of Vermont Chief Medical Officer, Vermedx, Inc. Dr. Littenberg is the Henry and Carleen Tufo Professor of Medicine, Professor of Nursing and Director of General Internal Medicine at the University of Vermont. He received his medical degree from CaseWestern Reserve University and trained in internal medicine at Hartford Hospital in Connecticut. He was a Robert Wood Johnson Clinical Scholar at Stanford University before becoming Assistant Professor of Medicine at Dartmouth. Following an appointment as Associate Professor of Medicine at Washington University in St. Louis, he assumed his present position in 1999. Dr. Littenberg practices General Internal Medicine in Burlington, Vermont. His research interests center on technology assessment and quality improvement. Recent projects include new ways to measure quality of care in cancer, novel strategies for reporting test results to patients, better approaches to antibiotics in sinusitis, safety improvements in outpatient prescriptions, and strategies to address health literacy. In Vermont, Dr. Littenberg has been active on the Board of the Vermont Program for Quality in Health Care. He has developed statewide registry-based approaches to quality and safety improvement with the Vermont Breast Cancer Surveillance System and as Principal Investigator of the NIH-funded research grant for the Vermont Diabetes Information System which engendered Vermedx.   This event is sponsored and produced by Vermedx, Inc.           89 Beaumont Ave. Given Courtyard, 4 South Burlington, VT 05405 (802) 656-4576 www.vermedx.com       About Vermedx® Vermedx® technology enhances patient engagement by fostering communication between patient and caregiver, and by delivering decision support to health-care providers. The Vermedx system has been proven in a National Institute of Health clinical trial to improve health outcomes and reduce costs. The patent-pending Vermedx technology uses automated blood test reports and notification letters to help providers better care for their patients, and patients better manage their chronic conditions. Vermedx has been used by thousands of patients with diabetes in Vermont, New York, California and Texas. Clients include municipalities, private hospital systems, physician organizations, and managed care organizations. Visitwww.vermedx.com for more information.