Patient engagement will be tough task for health tech

The buzz phrase in health care IT these days is “patient engagement,” as medical providers figure out how to meet the May 2014 deadlines set by federal regulations known as ONC Meaningful Use Phase 2 (MU2). The notion is the patients — rechristened “consumers” — will take active stewardship of their health, using personal health repositories (PHRs) like Microsoft HealthVault to track information, mobile apps and sensors like the FitBit or Withings blood pressure monitor to adjust their activities into healthier patterns, and patient portals to interact with their doctors and nurses on a regular basis if they have chronic conditions (the ones that cost the health system the most money after care for the aged).

There are many wonderful ideas and pilot projects for such patient engagement tools, as well as slick patient portals in place at advanced providers such as Kaiser Permanente. But as I saw last week at the Healthcare Information and Management Systems Society (HIMSS) conference, there’s a huge gap between the vision and what we’re all likely to see.

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What you can expect in the near term

As health care providers, their IT staffs, and the vendors work their way through the issues in delivering on the patient-engagement promise, with the ongoing prodding of the feds, all patients can expect to be able to make appointments, see and refill prescriptions, and see most lab tests (though not necessarily with any interpretation of their meaning) in the next year via Web-based patient portals set up by their providers or perhaps insurer. Increasingly, a mobile app or website will also be available for the same functions.

Many people will also be able to have email exchanges within these portals — but not to their personal email accounts. This is due to privacy rules that impose a higher burden of security on electronic communication than on the paper copies you often get from the doctor, even when the information is the same.

What you likely won’t see are online consults (known as e-visits), online diagnostic tools for common maladies, integration with PHRs, integration with your own consumer-grade monitoring apps and devices, integration across multiple providers (primary care providers, medical specialists, dentists, and eye doctors), or full access to your medical records, much less the ability to flag anything for correction. You might be able to add your appointments to your personal calendar on your smartphone or computer; then again, you might not.

There are three major reasons for the gap I expect we’ll see between the intent of patient engagement and the reality:

• An economic model where health care providers lose if patient engagement actually happens
• A strong ignorance of how apps and websites work today by the health care IT and medical staffs tasked with developing them
• An aversion to the full concept by a significant percentage of doctors, who now hold the most power in the majority of health care organizations

An economic model that rewards keeping people sick

Through what’s popularly known as Obamacare, the feds are trying to change health care delivery so that it focuses on wellness — preventing injury and illness — rather than on illness. Problem is, doctors and hospitals are paid to treat illnesses, typically for each procedure they perform. Doctors aren’t paid to engage with patients, whether to read emails or look at patient-generated data such as from home monitors. This means the IT systems being designed to encourage patient engagement may often do just the minimum.

As an example, I learned last week at the HIMMS 2013 conference that one pilot project of at-home wireless glucose monitors at several hospitals reduced readmission rates for diabetics between 19 and 65 percent, thus cutting care costs and reducing serious episodes of illness. But several hospitals discontinued the effort when the pilots were done because they saw their admissions decline, noted Dr. Wayne Guerra, a physician who relayed the findings at the conference. (Guerra, marketing chief at mobile health app maker iTriage, is involved in the creation of the Mobile HIMSS Roadmap, which is meant to help hospitals deliver on patient engagement via wireless and mobile devices.)

Admissions are where health providers make their money. The feds know this, which is why Obamacare is changing the incentives. For example, Medicare reimbursement rates for a follow-up in-person consultation will be $165, but $195 if over the phone or through electronic means such as patient portals. That’s a small step to change the incentives, but it doesn’t pay for regular communications via electronic means. And, Guerra notes, “doctors are avoiding electronic due to the high cost and complexity of the electronic communications systems. They tend to use the phone or do in-person for the follow-up.”

Likewise, “providers aren’t paid to use the data from personal devices, so the economic issue hinders formal use,” said Dr. Mohamad Ali, the Mobile HIMMS Roadmap task force’s chairman and an assistant medical director at Wexford Health Sources in Pennsylvania. There are also legal issues as to how providers should treat patient-supplied data — basically, at what point does it become part of the formal medical record and thus data that the provider is liable to monitor and act on? The MU2 regulations don’t address the economics or legal issues. The result is that the current system “discourages patient self-monitoring and participation,” says David Wierz, another road map task force member who is also principal of the health IT consultancy OCI Group.

Obamacare is changing the economic model in stages, with the goal being that providers are paid a flat annual fee per patient, which is supposed to encourage wellness care by making it too expensive to let patients fall ill — the opposite of today’s predominant fee-for-service model. But even organizations committed to the change will find it tricky to navigate the shift, as big-dollar treatment revenues disappear and an annuity payment takes its place, noted Julie Vilardi, a nurse at Kaiser Permanente involved in its technology transformation efforts. It’s the same problem IT vendors face in moving from selling big-ticket software and systems to selling cloud services: There’s a cash flow gap, often when the necessary investment in the new technology is biggest.

Ignorance of today’s technology and user base

I heard it multiple times at the HIMSS conference: “Who will train patients how to access the patient portals on their computers?” Many in health care — both in IT and in the medical provider ends — seem to have missed the last decade, the rise of electronic banking and e-commerce (which aren’t that different from patient portals), the universality of the Web, and the rise of mobile devices and apps.

“The patients already know this; it’s health care that needs to catch up,” Vilardi said. Her organization has 6 million members, two-thirds of whom use Kaiser’s patient portal to email their caregivers, make appointments, refill prescriptions, and even choose their doctors. The federal MU2 requirement is that 5 percent of patients have such electronic interactions each year — a percentage that was reduced from the original but still-low 10 percent target.

Yet in session after session, I heard the assumption that users were too stupid or ignorant to use such systems. At the same time, while slick mobile apps and Web portals were demonstrated all over the HIMMS show floor, I saw multiple health care organizations demonstrate their own ignorance about current technology — the very people designing the systems for patients to use.

For example, almost every patient portal lets users schedule appointments, but the do-it-yourself organizations that described their efforts hadn’t considered how to ensure those appointments were on patients’ own calendars. The issue hadn’t occurred to those whom I asked about how a patient would remember the appointment set up in the secure, sign-in-required portal. The answer, of course, is to generate a file using the established iCalendar (.ics) standard that users click or tap to add the appointment to add to their calendars, whether in Microsoft Outlook, Google Calendar, Apple Mail, Android Email, BlackBerry Mail, Windows Phone Mail, or even Lotus Notes. Airlines and other travel services use it, but these people were oblivious.

The calendar issue is a small example — from an admittedly small sample — but the dozen practitioners and vendors I spoke with at the conference said it was a representative example of the disconnect between those deploying patient-facing technology systems and the real world today. The same phenomenon has led to all those IT-developed apps that business users hate because they “don’t get it.” It’ll be interesting to see if all the personal health apps and devices coming to market will create a similar phenomenon in patient engagement as mobile devices and apps have done in the business world at large (the consumerization phenomenon). Strict privacy rules and proof-of-efficacy mandates may make it harder for a BYOD-like phenomenon to take root in health care.

The (uncomfortable) shift in power

At session after session, doctors and nurses lauded Obamacare’s notion of inclusion of patients as partners in their health care. But a survey released at the conference suggested there’s a lot more convincing to be done, at least of physicians. Most agreed that patient engagement is a good thing — to a point. Most wanted to limit what medical information patients could see about themselves, and few wanted to deal with patient-generated data.

Doctors have been treated as deities in American culture since the 1950s, and the “doctor knows best” prestige will be hard for many to let go. To be fair, doctors are ultimately responsible for the care provided, so they, in fact, have to know best. But why that should mean limited patients’ information is unclear.

The feds seem to think limited information is a bad idea, so the agency pushing Obamacare rules — the ONC (Office of the National Coordinator for Health Information Technology, part of the federal Health and Human Services Dept.) — has been encouraging widespread adoption of the Blue Button, a technology developed by the Veterans Affairs Dept. The VA was a pioneer in electronic health records and continues to be on the leading edge. The Blue Button is a badge on the VA’s website that, when clicked, lets patients access their entire medical records, in essentially a data dump aimed for transfer to other providers. A follow-on effort called Blue Button Plus makes the data both machine- and human-readable; it also defines a transmission standard to enable sharing with personal health records systems.

Physicians may want to limit what medical information patients can access about themselves, but Blue Button Plus shares the whole thing under the belief that knowledge is power, and patients will do better when doctors explain the information rather than keep it to themselves. There’s talk that the ONC may mandate that electronic health records (EHR) systems implement Blue Button Plus as part of the Meaningful Use Phase 3 requirements now being developed.

Over time, as the economics, technology savvy, and culture all change within the health care industry, we should see more sophisticated forms of technology-based patient engagement. “It will be like online banking: slow adoption at first, but then it exploded,” says Mac McMillan, CEO of health care security consultancy Cynergistek. After that initial slow start, “people will likewise rapidly adopt patient portals and at-home technology.” As was the case with online banking, the early systems probably won’t be that great — but will get better over time.

This article, “Patient engagement will be tough task for health tech,” was originally published at InfoWorld.com.