A grade-school English teacher of mine would write a little guide on the chalkboard at the beginning of our expository writing lessons:
Say what you’re going to say; Say It; Say what you said
Coming off another HIMSS, that lesson reminds me of the patient engagement market today, where it seems we have heard some things being said, and then being said again and again. We have been sold on the transformative promise of more proactive patient populations, fueled with education, armed with their own data, and empowered to become interactive with a connected fleet of software and hardware. Tools for medication adherence or doctor communication continue to be sold as silver bullets to bring down costs of care while improving outcomes; Scalability via SaaS and enterprise IT means that patient engagement can serve as a lynchpin in population health management. Around the corner, a safety net of Bluetooth and wireless devices promises to catch us when we fall.
Yet as John observed in his recap, there is very little out there today that suggests these solutions are mature enough to work as advertised in the real world, not just on the HIMSS tradeshow floor. With all fronts – payers, providers, device makers, and more – claiming to engage patients, the market has become a jumbled jungle with diminishing clarity around strategy – how solutions work together, what settings or populations are best suited for what products, and where one begins the patient engagement process.
However, the squawky chaos of HIMSS is nothing new, and neither is the immaturity of the patient engagement market. So beyond all of the countless patient engagement rah rahs on the expo floor, we did see a few faint signs of progress amidst the following trends, based on our conversations with a dozen or so health IT vendors, clinician leaders, and tech entrepreneurs.
EHRs Look Inward
EHR vendors are at last developing moderate to advanced functionality with their portals (refills, secure communication, education, scheduling), with improved UX/UI that is starting to conform to consumer tech standards. However, the bulk of their efforts in advancing patient engagement over the coming year will be moving “in” to the delivery system rather than “out” towards the patient.
This makes sense, as EHRs have the deep reach into HCOs to advance provider-centric functionality and optimize the patient engagement workflow. In particular, we saw abundant attention on care planning/management tools that generate task lists, discharge plans, medication lists, and so on (possibly a result of efforts to streamline workflow, as Cora described yesterday). Cerner and Epic are leading the pack in optimizing patient engagement workflow for clinical end-users (e.g. tying in medication refill tools or simple note entry based on patient interactions).
These are welcome improvements that will do much to enable better patient engagement down the road, yet:
A) they appear to remain limited to a select test-bed of all-Epic or all-Cerner deployments, or for that matter, any other EHR-system and
B) they still focus heavily on point of care workflow, signaling that EHRs may be the bottleneck when it comes to reaching out to patients between or after visits.
There are exceptions to every norm however, and PracticeFusion’s announcement of two health monitoring partnerships with AliveCor and DiaSend was an encouraging acknowledgement that the EHR can and should become more than a point of care documentation system.
HIEs Look Backward
HIE vendors are looking to build out patient portals and care coordination applications as they transition from building pipelines to demonstrating value. While this represents progress for that market, after seeing a leading vendor’s demo and speaking with leadership from two others, we are not quite ready to celebrate.
Instead of looking ahead, HIE vendors are looking at MU2 and assembling a new crop of anemic patient portals that allow VDT and little else. If HIEs really want to get involved with patient engagement in a truly meaningful transformative way and generate value, they ought to tackle a problem that nobody was talking about at HIMSS: consolidating payer and provider patient portal data to create a unified, longitudinal patient record. (Editor’s note: In our ongoing research of the HIE market (we’ve been tracking this market since 2008), Naveen’s finding is not at all surprising. The primary culprit to the lack of rich patient engagement tools among HIE vendors is simple, there has been very little customer demand.)
Maybe HealtheWay’s new CareQuality initiative will be able to bridge that gap (with Medfusion’s presence serving as a reassuring sign that patient portals might one day benefit from this work). However, given how long it’s taken Commonwell’s work to translate into real world improvement, coupled with patient data taking a backseat to provider data, we won’t hold our breath to see (and feel) results anytime soon.
Mobile Players Look Forward
Sadly, most enterprise vendors are limiting their present mobile strategies to optimized web, leaving tools like GPS, Bluetooth, accelerometers, wearables, and more on the table. Realizing that EHRs aren’t going to come knocking on their doors anytime soon, mobile plays of all types have taken these integrations on themselves. On the device side, companies are also going to market using an array of channel partnerships that range from traditional disease management call centers to Qualcomm’s ecosystem to bundling with personal emergency response system (PERS) targeted at the senior market to TelCo resale plays. We learned of one major partnership between a biometric device maker and a large MCO, and see continued growth on that front despite little buzz on the topic at HIMSS.
On the app front, IMSHealth’s recently launched Appscripts platform is positioning itself to deliver on Happtique’s failed promise, not just by curating clinical apps, but setting up a platform for docs to prescribe them to patients. Aetna, a recent darling on the consumer engagement front under their Healthagen and CarePass banners, seemed more of an also-ran this year, with great soundbytes from Mark Bertolini’s keynote belying a suspiciously quiet year save for emergence of the occasional odd story.
Other than that, mobile apps (and startups in general) are still subsisting on a traditional bait-and-tackle, door-to-door growth strategy for delivery system partners and pilots. These apps are at different stages of maturity, but some are proving that the daunting challenges faced by startups, such as clinical workflow or EHR integration, are not insurmountable. One promising trend is that more of these new “startups” seem to be run by seasoned veterans, doctors, and technologists than in previous years.
Conclusions: Signs of Progress
There is no one-size fits all approach to patient engagement, which is the ultimate shortcoming of the portal approach espoused by the Meaningful Use program. Past the immaturity of any particular solution, the abundance of fragmented approaches, and general lack of cohesion on the strategy front, there were small signs of progress at HIMSS this year. We heard how vendors and customers are working together to co-generate care plans and discharge protocols, or forging piecemeal, meet-you-where-you’re-at approaches to disease management that pair a stratification engine with a good old-fashioned call center.
As Rob pointed out, there are changes afoot in the world of post-acute care (where an estimated ~50 percent of providers still lack EHRs) and for whom a mobile app or a web dashboard is an immediate upgrade for patient management. With much of this world situated closer to patients’ homes (rehab hospitals, SNF, VNA, LTC facilities), there is a big opportunity for reminders, virtual assistance, device support, etc., that folks have started to pick up on. As one startup told us, “we’re competing with clipboards out there.” (Boy, haven’t we heard that one before!) We saw creative new uses of old data, from ADT feeds in hospitals to set up ‘project management plans for post-discharge’ to early neuralnet algorithms for a biometric device that disintermediate the doctor to provide patients with analysis of their readings, mere seconds later. More engaging than a portal, if you ask me.
Bringing it all home for me, on my last day in Orlando I happened to run into my former primary care physician, who has since become a HIMSS Rockstar. We caught up briefly outside the press room before he went on his way, off to give a speech and accept a second Stage7 award. I was left reminiscing back to when I saw him last as a patient, over a decade ago. So much has changed in patient engagement since then – EHRs, patient portals, smartphones, wearables. So while progress may appear to be lost amidst a sea of repetitive soundbytes and multi-million dollar displays, we are indeed moving forward. Let’s all remember to be patient.
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I’d suggest that the entire healthcare industry is going to take a decade to get any real engagement. For the most part the industry has had no experience building customer experience, engaging with consumers outside of the care path and has had little interest in an individual beyond a traditional interaction.
While there have been some providers that have focused on window dressing improvements and changes to service operation models for efficiency, none that I can think of can even build a comprehensive and coherent picture of a consumer. Even if started today, it takes massive capital investment, both human and technological, to begin to make improvements. Tesco and Harrahs were pioneers and took a 5-10 years to really see big value, and they were mainly driving more consumption.
Successful engagement is built on top of an infrastructure that allows for interoperability. Until a company can deliver the functionality that TIBCO delivered for ERP, your best consumer engagement is going to come from the consumer goods world, nothing with clinical value.
Even the most integrated systems still can’t get an integrated experience. Just recently a friend was relating his experience with his integrated provider system. They texted him a reminder for an appointment, but he still had to call a customer service center to reschedule rather then deal with it immediately. Needless to say that became a missed appointment.
Thanks for your comment, Gil.
I agree it’s going to take time. If we look at the adjustments being made to EHR to make them more usable for clinicians (the proposed “voluntary 2015 Edition” EHR certification criteria is a good example, along with early rumblings for the Stage 3 NPRM) – many of them are features that would make things a lot easier for patients via portals, if implemented correctly. An example is “Infobutton” standards from HL7 to contexualize complex jargon – currently only being used for CDS, while things like patients’ lab results are still data dumps directly from laboratory HIS (“LDLc SerPl Calc-mCnc<130"…..really??). Blue Button is great, but basic information is often entirely absent from the patient's portal, or as you put it, the comprehensive picture of a consumer's needs is missing.
I'd echo your sentiments about needing only to put on one's patient hat to see the myriad shortcomings of the status quo…we're sure it will get better over time, though the immediacy and obviousness of these issues can make being a patient patient a challenge.