A Tougher Nut to Crack Than Had Been Expected: The Hard Realities Around Patient Engagement

It’s often said—perhaps lazily by some—that the concept of “patient engagement” is a “soft” concept—a sweet, fuzzy, indistinct notion that idealists and marketers love in healthcare precisely for its indeterminacy. Just what does it mean to “engage” with patients, anyway? Indeed, the term is used so broadly and in so many ways, that at times, it seems to be stretched beyond any tangible meaning.

The reality of the complexity of executing on the concept of patient engagement was plainly observable in the wonderfully nuanced discussion on it held last Wednesday, Oct. 7, the Health IT Summit in Chicago (sponsored by our sister organization, the Institute for Health Technology Transformation, or iHT2). IDC Insights’ research director, Cynthia Burghard, led a lively panel discussion, joined by Krishna Ramachandran, chief administrative officer at the DuPage Medical Group, a 500-physician, 70-location multispecialty group based in the Chicago suburb of Downers Grove; Tom Scaletta, M.D., chair of Emergency Medicine at Edward Hospital, in the Chicago suburb of Naperville; and David Kaelber, M.D., Ph.D., M.P.H., chief medical informatics officer at MetroHealth System, Cleveland.

To begin with, panelists ended up parsing definitions—something that inevitably, and probably necessarily, happens, around as complex and nebulous a concept as “patient engagement.” Both Edward Hsopital’s Scaletta and DuPage Medical group’s Ramachandran emphasized that they see patient engagement and patient experience as separate—though of course, related—phenomena. And Ramachandran noted that, in his medical group, “Engagement, we slice into three buckets: we have the healthy patients; we just need make sure they’re OK and healthy; we have the rising-risk patients; and the high-utilizing patients. And we need to apply a high-touch form of engagement with them.”

“Patient engagement becomes very tactical, and happens in five or ten different places in an organization,” Burghard noted. “In other industries, there are chief customer [experience] officers, but they are different from healthcare.” Then, she asked panelists to enumerate some of the ways in which their organizations were tackling patient engagement. As MetroHealth’s Kaelber reported, “We’re trying to take a very strategic approach; but there are not a lot of models out there for us to follow,” he noted. “It’s one thing to ask, don’t we want to engage patients more? And everyone says yes,” he said. “But then you have to figure out how to make it happen tactically, and so we have this big vision, but it’s being executed in little tactical pockets. On the technology side, we have our personal health record portal and direct patient messaging. And then we have the people side of this. And you only want to throw resource-intensive operations and programs at patients who are already resource-intensive.”

Clearly, even within one organization—MetroHealth System—the approaches to patient engagement end up being broken down into “little tactical pockets,” as Kaelber noted. The same situation is the reality on the ground at DuPage Medical Group, where Ramachandran notes that “We have a director of patient experience who pulls the program together, with support from the board and CEO, but then with tactics to make sure we’re operationalizing this within our workflow. And we have MyChart within Epic, and our CEO made it a goal to get patients active on MyChart, and a whole bunch of tactics came out of that. And about 50 percent of our patients are active on MyChart now. So that’s an example,” he said, “of how tactics formed out of strategy are operationalized in the organization.”

In other words, engaging in patient engagement means creating an entire system of processes, many of them IT-facilitated, to engage patients around their care—particularly, of course, patients with chronic illnesses. But because there is no single or even clear roadmap as to exactly what to do or how to do it, the leaders of medical groups, hospitals, and health systems are more or less finding their way in the dark on this.

So where should patient engagement “sit” in a patient care organization? Is it part of population health management, care management, and case management? Connected to the patient-centered medical home? A function of physician office staff? Allied to marketing? All of the above, or even none of the above? As some of the discussants in last week’s panel discussion noted, they and other organizations are hiring “directors of patient experience,” and similar titles, in order to get closer to patients. The challenges there are multiple. To begin with, there never have been real positions like this before, so what does the role look like, and to whom does that person report? And where should the funding come to support such a position? Does it even make sense to create a separate role in this area, or should patient experience awareness be embedded in all functions of a patient care organization? (Many healthcare consumers might be surprised to learn that only a very few organizations in healthcare even have such positions to begin with; as IDC’s Burghard noted in the session, other industries have had customer experience gurus and doyens for many years.)

I think at a very fundamental level, patient engagement is one of those concepts that is incredibly important but that at the same time is amorphous and in practice, extremely difficult to pin down. What’s more, as everyone is discovering, transforming the concept into a practical reality is turning out to be far more complex and challenging perhaps than anyone ever expected.

In addition, the leaders of patient care organizations aren’t the only ones swimming in this ocean: the leaders of health plans have been at this for a very long time already, in fact. As Stephen Ondra, M.D. senior vice president and chief medical officer at the Chicago-based Health Care Service Corporation, which encompasses the BlueCross BlueShield plans of Illinois, Montana, New Mexico, Oklahoma, and Texas, had said in his keynote address the day before on Oct. 6, he and his colleagues are committed to enhancing the healthcare consumer experience. “What can we do to facilitate provider success?” Ondra had asked. His answer? “Provide information, identify and promote technology, develop and use quality measures and cost measures, and focus on the member experience. Right now, we have a healthcare system that’s efficient and convenient for itself. We need to make the system efficient and convenient for consumers.”

What’s more, health plan leaders like Ondra (who has worked on both the hospital and health insurer side, so he absolutely knows what he’s talking about here) are determined to get closer to healthcare consumers (or plan members, or patients, or whatever one calls them), in order to prove their value in the emerging healthcare system and be seen as more than just “claims processors,” as he referenced in his address last Tuesday. So there’s competition in the engagement arena along multiple dimensions to begin with.

In sum, the concept of patient engagement is turning out to be a harder nut to crack than anyone had perhaps expected. But if anyone’s going to crack that nut, my bets are on the leaders of the smartest medical groups, as they are the closest to patients on an ongoing basis, and they’ve got the clinicians who are most involved in patients’ care.

Doubtless, healthcare IT leaders will absolutely need to be key facilitators of patient engagement efforts, and conveners of all the discussions in this crucial area. And once again, as in so many other areas of endeavor in healthcare, the pioneers in this arena are figuring this out as they go, because no path—certainly no practical path—has ever been laid out for them until now.

So it will be fascinating to see how all this plays out in the next few years in healthcare. As I say, my bet is on the leaders of the most pioneering multispecialty medical groups to figure out how to truly engage patients—patients, plan members, consumers, people, whatever term one wants to use—in their care and in their health, because of their deep and sustained involvement in the care of people. But the exact characteristics of any particular, successful patient engagement initiative will likely look quite different from one patient care organization to another, in any case. So, stay tuned: this story is bound to have many chapters.