In my previous blog I pointed out the benefits of engaging patients in their own healthcare as well as how to measure the level of engagement of the patient. In this blog I will look more closely at specific competencies needed by physicians and practices to optimize patient engagement. As noted in “Patients, Providers, and Systems Need to Acquire a Specific Set of Competencies to Achieve Truly Patient-Centered Care” of the February 2013 issue of Health Affairs these competencies will be necessary to achieve the Triple Aim of the IHI—better outcomes for the patient, better population level outcomes, and lower costs.
There are several distinct types of engagement between the patient and providers. There are:
- Face-to-face between physician and patient
- Face-to-face between clinical staff and patient
- Engagement between non-clinical staff and patient
- Engagement between all three of the above and patient using health information technology (HIT)
Effective face-to-face engagement between physician or non-physician provider and patient requires several skills. First the physician must be able to assess the capacity of the patient to be engaged and how willing the patient is in making decisions that affect his or her care. The competency of patients to be engaged varies according to gender, age, education, culture and severity of disease. Physicians need to be aware of these for each patient. Besides having varying levels of competencies in being engaged patients have varying levels of desires to help in making decisions. According to the Health Affairs article above, “Patients vary in the roles and degree of control that they want to assume in decisions about their medical treatment. Although some patients are naturally inclined to participate, others may prefer that their physician direct their care.” A tool that can measure the level of patient engagement is the Patient Activation Measure, discussed in last month’s edition of this newsletter.
Besides being aware of the patient’s capacity to be engaged the physician must be an effective communicator. The physician needs to be able to explain the patient’s condition in terms that the patient can understand as well as clearly explain the choices that the patient has without bias. The physician needs to be a good listener and respond to the patient appropriately. I have found a very good source of videos that simulate discussions between patients and physicians concerning cancer diagnosis and treatment; the simulations can be easily adapted to other patient-physician discussions. The topics covered are:
- Essentials
- Empathy
- News
- Transitions
- Pearls
Each topic has several examples. These streaming simulations can be found at http://depts.washington.edu/oncotalk/videos/.
Engagement must extend beyond face-to-face encounters between clinical staff and patients. This is especially true of patients with chronic conditions. For best outcomes patients are engaged by nursing staff acting as case managers. These managers are proactive in contacting patients to see that they understand and are following through on care guidelines provided by physicians. This is especially recommended to see that patients are following medication orders. According to a 2012 study published in the Annals of Internal Medicine, about 50% of patients do not take their medication as prescribed. Case managers can also help in connecting patients to community resources, such as dieticians or mental health providers.
Patients engage with more than clinical staff. They also engage office staff. These encounters should be patient-centered. Check-in and checkout should be efficient and pleasant. Patients should receive notice of all test results, even the negative ones. Staff, both clinical and non-clinical, should design processes involving patient encounters that are consistent and effective. This not only improves the patient experience, and ultimately the health outcomes, but also helps the practice avoid risks, such as lawsuits and poor social media posting from disgruntled patients.
Another developing source of engagement with patients is through health information technology (HIT). Eligible providers who are involved in the CMS electronic medical records meaningful use program must satisfy several new forms of engagement through the EMR. For instance, physicians must provide a secure portal to exchange messages with patients. Patients need to be able to access their medical records and be able to download them in order to share them with a third party.
The Office of the National Coordinator for Health Information Technology is actively promoting ways for patients to engage with their providers in order to improve their health and the healthcare that they receive. The strategy for doing this is termed the “Three A’s”. The three prongs for doing this are to increase patients’ Access to their health information, to enable patients to take Action with that information and to shift Attitudes so that patients and providers think and act as partners in managing care through HIT. Enabling access is primarily through the meaningful use stages of EMR adoption so far. The National Coordinator is fostering the development of e-health tools and apps that make use of data from the EMR’s. One example of this is the development of tools that make use of data in the Blue Button program of the Department of Veterans Affairs. The National Coordinator is also partnering with providers in pilot programs. One is with Geisinger Health Systems; the program there allows patients to improve the accuracy of their health records. Much more information is available for patients and providers at the HealthIT.gov website.
Avenues for engaging patients in their own care are developing rapidly. The beginning of all such engagement is with the physician or non-physician provider. This is the keystone of all successful engagement. Along with this providers can and should try a variety of methods. If your group is a patient-centered medical home you will get best results and returns with care a manager or coordinator. Providers should also work to insure that non-clinical processes such as check-in and notification of test results are efficient and consistent, striving to improve patient satisfaction. Doing so will result in better returns and better health, as well as avoiding unnecessary risks. Engagement with e-health tools will become more common and providers should become familiar with them.