“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.’” In his April 2017 blog post, Kevin Volpp, MD, PhD, suggests that we need to think more about how to design our delivery systems to fit the needs and expectations of patients rather than those of providers. In other words, to maximize the payoffs, we should tailor interventions to the relevant characteristics of target populations. In this commentary, we extend Dr. Volpp’s point and argue that although it may be obvious that one size does not fit all in patient care, intentional efforts to customize care further by tailoring it to the relevant characteristics of individual patients and engaging patients more extensively in decisions about their own care could result in a number of positive payoffs.
In the business world, the logic of “mass customization” has been used to guide companies’ efforts to connect their products more directly to specific customer wants and needs by allowing customers to choose certain attributes of the products being offered. Auto manufacturers, for example, encourage potential customers to choose such attributes as color, engine size, interior finish, and communication capabilities online, allowing them to “customize” their purchase. The manufacturing logistics are handled through sophisticated information technology (IT) protocols, and the possibility of choice engages the customer in the process. Similarly, Levi Strauss provides customers with a “custom fit” option through which measurements are taken digitally and transmitted to the production site, after which the jeans are produced and then shipped directly to the customer’s home. The customer receives a pair of jeans that “fits,” presumably better than a pair bought off the shelf.
The logic of mass customization more recently has moved from products into the realm of services. With the emergence of increasingly sophisticated IT capabilities, customization is becoming widely used in many service industries, such as financial planning, legal services, and education, with the goal of offering equal or better quality at lower cost. In the worlds of both products and services, mass customization seeks to empower frontline staff and their managers to develop tailored services to meet the diverse and changing needs of their customers at near mass-production prices. In health care, the logic of mass customization is being applied in two distinct, but related, ways: (1) in the development of tailored therapies and interventions based on genetic profiles and (2) in the organization of provider enterprises to ensure more effective communication and coordination, both internally and between and among different providers in the patient trajectory.
Developing Customized Care
Efforts to develop customized care must be designed around a deep understanding of what happens at the ground level along the patient pathway and must incorporate patient engagement by focusing on such things as shared decision-making, definition of appointments, and self-management, all of which are elements of a “build-to-order” approach.
Soliciting active feedback also can help to anticipate patient needs and promote necessary adjustments in the organization of work. Such efforts foster the ability of patients to incorporate their own priorities while minimizing complexity and the burden of choice, arguably leading to both quality improvement and cost savings.
The process of improving a targeted pathway according to the logic of customization and then spreading the knowledge gained from such an effort within a delivery system, however, is not accomplished quickly or easily. Such improvements require well-planned and carefully orchestrated investments of time and energy by leaders, middle managers, trainers, and frontline staff. These investments will help to ensure three preconditions for the successful implementation of customized care.
Preconditions for Developing Customized Care
1. Defining Patient Profiles. To offer customized care, distinct categories of patient profiles have to be built. In the business world, product consumption patterns typically are used as a criterion for the exploration of consumer behavior and as the basis for consumer relationship management, a practice based on the premise that building a positive relationship with a consumer over time produces value that an episodic approach ignores. This practice needs to be adapted for more sophisticated use in health care.
In the world of health care, this effort relies primarily on new clinical and genomic criteria that form the basis for precision medicine, supplemented by additional data describing the patient’s socioeconomic context. For instance, medical as well as social vulnerability criteria can be applied to tailor the management of elderly patients according to their degree of vulnerability or disability. There is also strong demand for alternative medicines and therapies as well as for care that complies with religious practices or cultural customs and traditions. The ability to categorize patients according to both individual characteristics and a wide range of social context information, combined with the ability to link this information to priority outcomes, would be a major step toward customized care. The availability of multiple language capabilities is perhaps the most elementary form of cultural customization, but as more is learned about the healing process, other forms may well be introduced.
2. Leveraging IT. IT makes large-scale customization possible by facilitating the use of large volumes of data to help build patient categories at relatively low cost and through real-time execution. Remote exchange of regular data via online portals and apps personalizes the provider-patient relationship. For example, in the case of patients with cancer, a portal enables nurse navigators and physicians to exchange information about treatment with oral chemotherapy, allowing side effects to be managed more effectively and doses to be adjusted more precisely. And digital sensors (e.g., those in connected devices, mobile apps, etc.) operate a variety of warning indicators. Any significant and sudden change in a given indicator can be transmitted to the health professional, who can then rapidly adjust the patient’s pathway. These examples only scratch the surface of IT applications that can enhance customization.
3. Training in Customer Service Competencies. A face-to-face relationship can contribute to the quality of customized service by enhancing aspects such as customer satisfaction, trust, loyalty, and commitment. Patients tend to be very attuned to the health professional’s “bedside manner” and to such dimensions as empathy, clarity of expression, and listening skills. These attributes, in combination with clinical expertise, can give the patient the sense that his or her own unique situation is being recognized and taken into account as care is being given. Their absence, in fact, may well slow the healing process. While it is certainly the case that face-to-face interaction is resource-intensive and costly, IT-based substitutes have yet to be developed. When they are, substantial cost savings will be realized.
In the meantime, some companies (e.g., Circles, a division of Sodexo) and hospitals (e.g., Riverview Medical Center) have developed concierge services designed to meet the unique nonclinical needs of individual patients. Customer service competencies are required both on the front line and in the back office of any work organization. Nurses represent the front line in the provision of health care services and, as such, need training that goes beyond the purely clinical. They can then become advocates for the spread of customization across the organization.
The Benefits of Customized Care
How does customized care produce value? Through customization, cost savings can be obtained by targeting relevant actions and suspending or curtailing unnecessary actions, thereby avoiding waste, an important cause of spending in the U.S. health care system. For example, efforts to prevent food waste in hospitals by using personalized menus have been demonstrated to reduce the quantity of food needed by one-third while improving patient satisfaction, with the latter representing a competitive advantage for the hospital.
Another example is in patient transportation. New apps, developed by companies such as Ride Health, allow patients to get rides to and from their appointments conveniently and on time, helping to maximize efficiency at the treatment site. Customizing transportation increases patient engagement by removing what, for some, is a significant barrier to getting the right care at the right time and place and helps to improve capacity management at the point of service. As a result, long-term cost savings will be realized as the number of missed appointments is reduced and care is thereby improved.
A third example is the development of apps to help patients manage their medications more effectively. These apps, tailored to the medical needs of individual patients, can help to improve the health status of both individuals and populations by increasing the probability that patients will follow their prescribed courses of medication and by allowing for the adjustment of medications as indicated. Moreover, earlier and more focused identification of “complex” patients should help health care organizations design more appropriate organizational responses, including reduced use of emergency room and inpatient care.
Finally, patients are likely to embrace customization because it is focused on their individual needs. Proof of concept has been developed in other sectors. If the purchaser of a new car can specify certain attributes of the vehicle being purchased, or if the purchaser of a new pair of jeans can get them “built to order,” why can’t similar logic be applied to engaging patients more directly in their own health care experience by encouraging healthy behaviors through individually tailored routines, facilitating regular app-enabled monitoring of health status by providers, and, in so doing, enabling individuals to develop a sense of personal responsibility for their own health? An effective and sustainable business model for care customization most certainly will be built and will help to orient patient engagement efforts. Today the technology is there. Innovative prototypes are being developed and tested. Truly customized care is just around the corner.
This article originally appeared in NEJM Catalyst on June 21, 2017.