Ian Worden, MBA, MHI, PMP Healthcare CIO and Patient Engagement Advocate

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1 BETTER PATIENT ENGAGEMENT Ian Worden, MBA, MHI, PMP Healthcare CIO and Patient Engagement Advocate CONTENTS Introduction 2 The Path to Increased Patient Engagement Lies in the Definition 3 Defining Patient Engagement and its Growing Importance in Healthcare Economics 5 Is Technology the Solution to Improving Patient Engagement? 6 Summary 8 About the Author 8 References 9 INTRODUCTION The concept of patient engagement is increasingly touted by pundits, healthcare reform, and technology vendors as one of the primary keys to improving the cost and quality of healthcare. If you are involved in the payment or delivery of healthcare, in almost any capacity, you have undoubtedly heard the term patient engagement. The list is vast of initiatives or projects launched under the guise of patient engagement. You have quite possibly been asked by your organization to participate in such efforts as improving patient engagement in the form of launching a patient portal for Meaningful Use incentive eligibility, improving participation in wellness programs, improving HEDIS measures, or participating in the rollout of patient centered medical home models. The goal of this whitepaper is to take a step back from the urgency of action to review and understand some basic ideas and concepts of patient engagement: What is patient engagement? Why does it matter? What is the role of technology in patient engagement? This whitepaper is comprised from several key blog posts from and is meant to be a primer on the topic of patient engagement. The Path to Increased Patient Engagement Lies in the Definition One significant challenge with improving patient engagement lies in the lack of a standard and correct definition for the term patient engagement. How do you go about improving patient engagement if you cannot effectively articulate what patient engagement means? Before exploring a proposed definition that may ABOUT THE AUTHOR Ian Worden is a thought leader on patient engagement and author of the blog Better Patient Engagement (www.betterpatientengagement.com) and manages the Linkedin Group, Patient Engagement Innovation Exchange. For him, the pursuit of improving patient engagement is a personal and professional passion. For almost a decade Ian has held senior leadership roles (CIO, SVP, VP, Director) for healthcare organizations focused on personal wellness, health advocacy, gaps in care management, disease management, case management, substance dependence, discharge planning, nurse triage, primary care, emergency care, and specialty care. Ian holds a Master of Healthcare Innovation in the College of Nursing and Health Innovation from Arizona State University and a Master of Business Administration in Healthcare Management from Colorado Technical University. linkedin.com/in/ianworden Linkedin Group: Patient Engagement Innovation Exchange 1

2 unlock the improvement process, let s look at several organizations and publications that have floated definitions or descriptions of patient engagement. A 2012 NeHC Stakeholder Survey found the following responses when it asked How are you most likely to describe patient engagement? 64% patient uses educational material and online resources to learn about better health or their own health condition 58.7% patient uses tools and resources to manage his or her medical record and other health data 41.3% patient feels comfortable challenging doctor when something doesn t seem right or when explanations are not clear 38.4% patient feels comfortable discussing health issues and questions with doctor or nurse face-to-face 38.4% patient communicates with doctor about changes in health status in a timely way US Department of Health and Human Services: EHR Incentive Program Introduction of Patient and Family Engagement : As the second of five health policy priorities, this policy priority aims to improve patients understanding of their health and related conditions so they take a more active role in their health care. It also encourages the involvement of patients families, as many patients depend on their support Center for Advancing Health Actions individuals must take to obtain the greatest benefit from the health care services available to them. Health Affairs Health Policy Brief Patient engagement is a broader concept that combines patient activation with interventions designed to increase activation and promote positive patient behavior, such as obtaining preventive care or exercising regularly. Health Affairs: Analysis & Commentary Choice Architecture Is A Better Strategy Than Engaging Patients To Spur Behavior Change - Although there is no widely accepted definition, engagement generally captures the notion that patients are involved in the process of their care actively processing information, deciding how best to fit care into their lives, and acting on their decisions. In most cases I would suggest that the definitions of patient engagement are defined too vaguely to drive effective process improvements. In other cases, such as the US Department of Health and Human Services EHR Incentive Program, I would suggest that the definition is defined too narrowly. Let me offer a definition of patient engagement that I believe can be used to more effectively increase patient engagement. linkedin.com/in/ianworden Linkedin Group: Patient Engagement Innovation Exchange 2

3 Patient engagement is a person s sustained participation in managing their health in a way that creates the necessary self-efficacy to achieve physical, mental and social well-being. Let s dive deeper into the key terms and their implications to this definition of patient engagement: Participate the fact of taking part, as in some action or attempt. Patient engagement begins with the recognition that patients must be willing to participate in the management of their health. Sustain to keep up or keep going, as an action or process. A patient s participation must be sustained over some period of time in order to achieve the desired health related benefits or participation. Manage to bring about or succeed in accomplishing, sometimes despite difficulty or hardship. A patient s sustained participation should be coupled with the readily available and easily accessible tools, processes and resources required to manage their health. Self-Efficacy the belief in one s capabilities to organize and execute the courses of action required to manage perspective situations. A patient s sustained participation coupled with the tools, processes and resources should be designed to foster the skills, knowledge and confidence required to manage their health. Well-Being a good or satisfactory condition of existence. A patient s sustained participation coupled with the tools, processes and resources, designed to foster self-efficacy should yield improved personal well-being. The reward for participation should far exceed the effort to participate and be relevant on an individual by individual basis. linkedin.com/in/ianworden Linkedin Group: Patient Engagement Innovation Exchange 3

4 Patient engagement defined in this way allows for patient engagement improvement efforts to be deployed, measured and evaluated with an understanding of the inter-dependencies and elements that drive patient engagement. This is an important distinction because definitions that are too vague or too narrow may lead to claims of successful improvement without actually achieving the right type of patient engagement required to improve health outcomes. Successful improvement on anything but all elements of patient engagement will ultimately fall short of expectations. Correctly defining patient engagement allows organizations with the aim of improving patient engagement to assess their current offerings, services and healthcare delivery from the perspective of those inter-dependencies and elements that drive patient engagement. Do we garner enough participation from our patients? If not how can we improve participation? Do they continue to participate? If not how can we get them to sustain participation? Are we deploying the right tools, process and resources that strengthen participation and make it easier to manage their health? Is sustained participation with our tools, processes and resources building sufficient self-efficacy? How would we know? How would we measure? Is our approach designed to result in improved well-being? Etc. The path to increased patient engagement is in properly defining patient engagement. Defining Patient Engagement and its Growing Importance in Healthcare Economics Patient satisfaction, patient experience, patient-centered, patient engagement, it is all the same, right? It would certainly be a logical conclusion as the terms are often used interchangeably. However, patient engagement is significantly more than creating a healthcare experience that is patient-centered in an effort to improve satisfaction. Patient engagement is considerably more complex than the preceding terms and is becoming an increasingly important variable in the financial performance of hospitals, providers and payers. Patient engagement can be defined as a person s sustained participation in managing their health in a way that creates the necessary self-efficacy to achieve physical, mental and social well-being. This means that healthcare delivery must entice a person to actively participate over the long-term while fostering health related self-efficacy which yields meaningful physical, mental or social benefit. In only this way can healthcare organizations depend on the active and sustained participation required to improve clinical outcomes. However, improving patient engagement is a complex, multidisciplinary, multi-functional endeavor which leaves this critical issue ambiguous, fragmented and largely under-managed in many healthcare delivery systems. So, what does patient engagement have to do with the financial performance and healthcare economics? linkedin.com/in/ianworden Linkedin Group: Patient Engagement Innovation Exchange 4

5 Healthcare reform and other environmental factors are rapidly positioning patient engagement as the new economic engine of healthcare. In 2010 more than 1 in 4 hospitals generated a negative operating margin. Hospitals and providers are expected to experience even greater financial pressures as reimbursement increasingly shifts away from fee-for-service and more towards performance-based reimbursement. Healthcare reform is placing significant weight on performance-based (outcomes) reimbursement via penalties, fee reductions and incentives. As such, improved healthcare delivery models will have significant dependence on the active and sustained participation of patients post their hospital or provider visit in order to avoid incurring preventable, low to negative margin, fee-for-service encounters. Patient engagement will also be essential to achieving targeted health outcomes that trigger additional reimbursement. Hospitals and providers are not the only stakeholders dependent on improved patient engagement. Healthcare payers also stand to benefit from the active and sustained participation of their members or beneficiaries. Healthcare payers are motivated by the opportunity to reduce healthcare costs while improving member or beneficiary health status, satisfaction and retention. In response to these environmental factors most hospitals are increasing their focus and efforts on improving the patient experience as primary strategy to achieve revenue targets and mitigate financial risks. In fact, in a 2011 HealthLeaders Media report, 92% of healthcare executives surveyed had improving the patient experience as in their top five priorities and in a 2010 HealthLeaders Media report 99% agreed strongly or somewhat that improving the patient experience would drive referrals, volume and revenue. While this approach is directionally correct it will likely be insufficient to protect and grow revenues because satisfaction does not necessarily equate to better health outcomes. A USA Today analysis of Medicare data found that despite being well-liked by patients, more than 120 of the top U.S. hospitals have death rates for heart attack, heart failure or pneumonia significantly higher than the national average. Being satisfied with your healthcare experience is not synonymous with being engaged in your healthcare and this simple reality leaves hospitals, providers and payers increasingly exposed to financial risk. Is Technology the Solution to Improving Patient Engagement? There is certainly a rising interest in the topic of patient engagement. A quick Google Chrome search of the term patient engagement reveals 6.7 million results. The interest in patient engagement has surely been influenced by The Centers for Medicare & Medicaid Services (CMS) release of the final meaningful use stage 2 rule in late August Additionally, the National Coordinator for Health IT, Dr. Farzad linkedin.com/in/ianworden Linkedin Group: Patient Engagement Innovation Exchange 5

6 Mostashari has been bullish on the topic of patient engagement. More recently The National ehealth Collaborative released the Patient Engagement Framework. Stage 2 Meaningful Use The U.S. Department of Health & Human Services issued a press release titled HHS announces next steps to promote use of electronic health records and health information exchange. In this press release HHS described the meaningful use Stage 2 rule as Stage 2 (which will begin as early as 2014) increases health information exchange between providers and promotes patient engagement by giving patients secure online access to their health information. The National Coordinator for Health IT, Dr. Farzad Mostashari has been quoted as saying Patient engagement is the blockbuster drug of the century. In November or 2012 The National ehealth Collaborative released the Patient Engagement Framework which is a model created to guide healthcare organizations in developing and strengthening their patient engagement strategies through the use of ehealth tools and resources. Meaningful use and tools like the Patient Engagement Framework are beginning to systematize patient engagement. These approaches are heavily rooted in enabling technologies as the gateway to better patient engagement. Technology is undeniably an instrumental component to improving patient engagement. However, technology alone will have minimal impact on improving patient engagement. The Patient Engagement Framework is in essence a healthcare provider road map for implementing ehealth tools to increase patient engagement. The Framework is comprised of 5 phases with each phase building on the progress of the previous phase. Similarly technology focused, the goal of meaningful use is to promote the spread of electronic health records to improve healthcare and is comprised of stages with each stage building on the progress of the previous stage. Improving patient engagement is a complex, multidisciplinary, multifunctional endeavor and as such transcends technology alone. Core concepts essential to improving patient engagement include recognizing that: Patient engagement is a person s sustained participation in managing their health in a way that creates the necessary self-efficacy to achieve physical, mental and social well-being. This means that healthcare delivery must entice a person to actively participate over the long-term while fostering health related self-efficacy which yields meaningful physical, mental or social benefit. linkedin.com/in/ianworden Linkedin Group: Patient Engagement Innovation Exchange 6

7 Self-efficacy is the belief in one s capabilities to organize and execute the courses of action required to manage perspective situations (Bandura, 1995). People with low self-efficacy lower their aspirations and the quality of their performance deteriorates. Conversely, those with higher self-efficacy achieve better performance. All patients require some level of engagement to successfully manage their condition and achieve physical, mental and social well-being. Healthcare delivery systems must be engineered to specifically nurture a patient s beliefs about their ability to organize and execute healthcare related activities. Patient engagement is a people, process and technology issue. Meaningful use and tools like the Patient Engagement Framework are essential elements to improving patient engagement. However, technology must be aligned and balanced with the people and process elements of patient engagement. It is essential that the use of technology entails and reflects an understanding of such aspects as a patient s psychological and socioeconomic status (the people) and the significantly variable actions, barriers, regulation and administration of healthcare delivery (the process). Maximizing patient engagement can only occur in the orchestration of people, process and technology. SUMMARY This whitepaper set out to help inform readers about the topic of patient engagement. If patient engagement is approached in its most altruist sense, healthcare payers and providers will identify robust people, process and technology solutions which are specifically designed to entice and position patients as the stewards of their own health. Arguably the endeavor of improving patient engagement begins with an understanding of what patient engagement is, why it matters and how it is enabled. Of course, the topic of improving patient engagement is too complex to cover in a single whitepaper. Please visit the blog Better Patient Engagement and the Linked in Group, Patient Engagement Innovation Exchange to participate in the ongoing dialog and knowledge exchange surrounding patient engagement. linkedin.com/in/ianworden Linkedin Group: Patient Engagement Innovation Exchange 7

8 REFERENCES NeHC Stakeholder Survey US Department of Health and Human Services: EHR Incentive Program Introduction of Patient and Family Engagement. Center for Advancing Health. Health Affairs Health Policy Brief. Health Affairs: Analysis & Commentary Choice Architecture Is A Better Strategy Than Engaging Patients To Spur Behavior Change. The New Patient Experience Imperative. Patient Experience: Help Wanted. Medicare Data Show Gap in Hospital Performance, Perception. Stage 2 Meaningful Use The U.S. Department of Health & Human Services. linkedin.com/in/ianworden Linkedin Group: Patient Engagement Innovation Exchange 8

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