Providers often throw up their hands in frustration when they see the same patients repeatedly readmitted to the hospital for behaviors such as failing to take their medications at home or eating a high salt diet when they have heart failure. Many acute exacerbations of chronic disease are from patients having trouble following through with provider recommendations — whether to eat healthy foods, watch fluid balance, take medications, lose weight, quit smoking, or avoid alcohol or other drugs.
Generally, the standard approaches clinicians take to address these issues, such as cajoling or providing information in a brief face-to-face encounter, don’t work. The problem is that providers receive little training in medical school or residency about how people make decisions, how to help patients change their behavior, or understanding or addressing social determinants of health, nor are they trained to think about these issues from a design perspective; in other words, how to create an easily navigable health improvement pathway for the patient.
Imagine a world in which programs rolled out by health plans or health delivery systems were designed to be customized for each individual patient, instead of “one size fits all.” Imagine that these programs were designed for the convenience of the patient, not the provider. In theory, health providers strive for this. But in reality, many of the existing mechanisms by which we provide care, or in which health plans strive to influence patient behavior, were built from one version, scaled up to affect many people.
A system centered around patient convenience would look very different; much of the support for patients would likely happen outside of conventional medical settings. It would address the proverbial “5,000 hours problem,” in which even patients who frequently see a provider put in 5,000-plus hours on care in their own at home, with little oversight or support from their providers. In this truly patient-centered system, providers (or their team members) would provide virtual support to patients through mobile devices of various types to both track behavior and provide useful feedback. Each patient would essentially get a different intervention customized to his or her own life and preferences, as revealed in his or her own experience or in the experiences of others. Much of this would be automated by technology that learns from the successes and failures of each individual and gets progressively smarter and better at customizing.
In our event on “Hardwiring Patient Engagement to Deliver Better Health,” jointly hosted by NEJM Catalyst and Kaiser Permanente Southern California, we explored some of these themes, focusing on designing and tailoring systems to individual patients to achieve high rates of engagement; enlisting social supporters who could help providers and patients improve the health of patient populations; and thinking about a health system more holistically in addressing social determinants of health as well as medical needs. I am particularly excited about the concept of mass customization for health — using a paradigm built by online retailers such as Amazon to provide customers with what they are looking for, sometimes before they even realize it, in determining alternatives presented as choices tailored to each individual.
What if this customization could not only recognize that a patient has diabetes and hypertension, but also extend the trajectory of care by designing and offering solutions to best fit that particular patient’s needs and preferences? This is the type of initiative we should embrace if we want to help our patients engage more easily and efficiently with health care at higher rates.
This blog post originally appeared in NEJM Catalyst on April 13, 2017.