We talked to executives, clinical leaders, and clinician members of the NEJM Catalyst Insights Council for a closer look at who should lead patient engagement efforts and the expected impact on quality and cost.
Who should head up patient engagement initiatives?
At Avera McKennan Hospital and University Health Center, a 450-bed tertiary care facility based in Sioux Falls, South Dakota, the Chief Medical Officer and Chief Nursing Officer have been jointly tapped to lead patient engagement.
Avera McKennan’s tasking of the CMO matches 38% of respondents to the NEJM Catalyst report Patient Engagement Survey: Far to Go to Meaningful Participation. Slightly less than a fifth (19%) of respondents said CNOs should head up the charge.
“Both have time devoted as part of their jobs to lead such ventures,” says Nate Miller, MD, an internist and hospitalist at the medical center who is also Chief of the Hospitalist Division at the University of South Dakota Sanford School of Medicine. The CMO and CNO are aided by the Avera McKennan health system, he says, which has a multidisciplinary team devoted to increasing patient engagement.
Staff physicians ranked second in the survey, with 35% of respondents saying they should head patient engagement efforts. At Avera McKennan, staff physicians focus more on day-to-day care but will get pulled in for input on patient engagement at appropriate times. Hospital leadership “will need to involve physician leaders and other groups to help develop ideas,” he says.
Allison Suttle, MD, Senior Vice President and CMO at Sanford Health, an integrated health system headquartered in North Dakota and South Dakota with 43 hospitals and nearly 250 clinics in nine states and three countries, agrees that the CMO “plays a major role in getting better outcomes,” but thinks positions such as Chief Quality Officer and Chief Medical Information Officer also have important contributions to patient engagement.
“I don’t know that there is one person who is fully in charge of patient engagement — it has to be everyone’s priority,” she says. For instance, the CMIO, which some respondents included as an “other” in the NEJM Catalyst survey, can lead patient portal and data collection projects.
Engaging Patients Through Technology
Suttle says buy-in from staff physicians is essential because “patients aren’t going to get engaged unless the physicians want them to.” For example, physicians have to buy into utilization of mobile devices, portals, and other technologies as a way to change patient engagement in their practice, she says.
“The patients that move to digital love it,” she says, adding that Sanford Health has improved patient engagement by offering video visits that allow patients to Skype with a physician, and e-visits that use patient-submitted questionnaires about their health issues to help clinicians diagnose them online.
Sanford has nearly 400,000 patients active on its portal. “We are making sure there is value to the patient so they have a reason to use the portal,” she says.
Patient portals were the top patient engagement initiative in the NEJM Catalyst survey; 88% of respondents said their organizations are currently using or plan to implement portals, and 38% said portals are the most effective tool for increasing patients’ meaningful participation in care.
The Importance of Clinicians
Eric Fleegler, MD, MPH, FAAP, a pediatric emergency physician in the Division of Emergency Medicine at Boston Children’s Hospital, a 404-bed comprehensive center for pediatric health care, says that no matter if you pursue a top-down approach with the CMO or a bottom-up approach with staff physicians and staff nurses, “the individual provider will make or break patient engagement.”
Patient engagement “has to come in a process that is collaborative,” says Fleegler, who is also an Assistant Professor in Pediatrics and Emergency Medicine at Harvard Medical School. “It cannot come as a mandate from above, but rather providers must develop an understanding of what ‘patient engagement’ means in their clinical environment and develop a plan to make their interactions more meaningful and guided by the patient.”
Fleegler is eager for patient engagement to continue to develop in his department so that he can have better feedback about his quality of care. “In emergency medicine, we engage with patients while in the ED, yet we have minimal feedback after the patient leaves. We don’t know how good our laceration care turned out or whether the prescribed medications worked. The only time we know is if the patient bounces back to the ER within 72 hours,” he says. “Patient engagement needs to move beyond the exclusive realm of the clinical encounter.”
The Cost of Patient Engagement
While Fleegler is confident that better patient engagement will lead to better care, like many respondents to the survey, he is not sure there will be a positive impact on the cost of care. In the NEJM Catalyst survey, cost fell considerably below quality in respondents’ ratings of the impact of patient engagement initiatives.
“Much of patient engagement can improve quality of care, perception of quality of care, and . . . health outcomes, but that’s not necessarily going to be fully reflected in cost,” Fleegler says. “Eventually, if patients become more engaged and we do improve their health, we will hopefully see costs decrease.”
Quality and cost must go hand-in-hand, Suttle says: “I don’t think you should ever look at quality without cost.” She says organizations must address quality first and have a target that they expect. But as quality improves, she believes the “natural byproduct” will be lower costs.
Miller also thinks that health care organizations should expect a positive impact on costs. For example, through better patient engagement, physicians can sometimes dissuade families from ordering expensive tests such as CT scans or MRIs when they are unnecessary.
“The focus should be on quality, but the end result will be improved quality with decreased costs,” he says.