Analysis of the first NEJM Catalyst Insights Council survey on the Patient Engagement theme. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.
METHODOLOGY AND RESPONDENTS
In February and March 2016, an online survey was sent to the NEJM Catalyst Insights Council, which includes U.S. health care executives, clinician leaders, and clinicians at organizations directly involved in health care delivery. A total of 340 completed surveys are included in the analysis. The margin of error for a base of 340 is +/- 5.3% at the 95% confidence interval.
The majority of respondents were clinicians (44%), followed by clinician leaders (32%) and executives (25%). Most respondents described their organizations as hospitals (38%) or health systems (17%). These hospitals were predominantly midsized (32% had 200–499 beds) or larger (49% had 500 or more beds).
Only 9% of respondents indicated that their major affiliation was with a physician organization. Those physician organizations tended to be big — 75% had 100 or more physicians.
Nearly three-quarters of the organizations (72%) were nonprofit, with the remainder of respondents coming from for-profit organizations. Every region of the country was well represented.
In recent years, there has been a shift toward a greater role for patients in health delivery. We are all aware of the greater focus on shared decision-making, patient satisfaction scores, information on provider price and quality to patients, and the use of incentives embedded in benefit design (such as high-deductible health plans) that put the onus on the patient to behave like a consumer and assess the value of different health services they could receive.
But how do we define engagement? What are typical ways in which it is measured? Do clinicians think their patients are engaged? What can be done to improve this?
In this first NEJM Catalyst Insights Report on patient engagement, we describe results of a recent survey that collects insights from health care executives, clinician leaders, and clinicians from around the United States. We surveyed our Insights Council, a group of distinguished and experienced leaders, to better understand the landscape of patient engagement, ranging from a working definition of the phrase to which strategies they feel are most helpful (and which are not).
When asked their definition of patient engagement, most respondents highlighted the following components. Patients are:
- Interested in participating in choices about their health care
- Responsibly taking ownership of those choices and adhering to their care plans (ideally co-created with providers)
- Taking an active role in improving their health
These definitions illustrate the important role of the patient, both in health behavior and their interaction with the health system. Yet a strikingly low percentage of patients — per the assessment of the council — are highly engaged: 42% of respondents indicated that less than a quarter of their patients were highly engaged, and more than 70% report having less than half of their patients highly engaged. Executives were more negative about patient engagement levels than were other respondents; 54% of executives said that less than a quarter of their patients were highly engaged. Only 9% of survey respondents overall reported high rates of engagement in a large share (more than three-quarters) of their patients.
These results highlight the challenges in front of us; while having patients who are engaged with their health and with the health system is important, low rates of engagement appear to be the norm.
A further challenge is that while the majority of Council members — 86% — report that their organizations use systematic tools to collect this data, most regard their current measurement approaches as, at best, only somewhat effective.
Respondents viewed internal surveys of patients as the most effective, but only 33% of respondents see them as completely or mostly effective. This does raise the question of whether better tools are needed to assess engagement, perhaps involving real-time assessments of behavior as opposed to surveys.
Council members have strong opinions about which interventions work, and which do not. Fifty-nine percent of respondents support having members of the care team (physicians, nurses, or other clinicians) spend more time with patients. Clinicians felt more strongly than executives about more time spent with patients (66% vs. 51%); when asked about the biggest challenge to improving patient outcomes, clinicians cited not enough time with patients (57% clinicians vs. 32% executives).
When people advocate for “time spent with patients,” it naturally leads to the question of how this could be afforded, given the high existing cost of health services in the United States. New health financing arrangements that shift from fee-for-service to health systems bearing financial risk may make it possible for clinicians to spend more time with higher-risk patients, but only if they spend less time with lower-risk patients. A shift toward asynchronous communication using emails, better use of physician extenders, and approaches like “automated hovering” with wireless devices could help.
Fifty-four percent of survey respondents believe that shared decision-making is another most effective strategy.
Other approaches, such as working with health plans to provide incentives to improve their health (24%) and giving patients information (23%), received limited support. This may reflect a general lack of comfort in working with health plans and a lack of success with previous efforts to educate patients to motivate behavior change. The use of wireless devices (5%) garnered less support than we expected. The explanation may be that the current use of wearables is still quite limited, and clinicians haven’t seen data showing improvements in chronic disease management. In addition, there is evidence that without engagement strategies, technology alone is unlikely to change behavior for higher-risk patients. There may also be concerns about how all these additional streams of data will be handled and about the burdens they could impose on clinicians.
We view this survey as providing health care executives, clinical leaders, and clinicians with some baseline information on patient engagement.
The survey highlights that respondents view engagement levels among their patients as low and recognize that how engagement is measured is inadequate, and it suggests that we haven’t yet discovered optimal ways of achieving high rates of sustained patient engagement. This is a rapidly evolving field, and what is regarded as ineffective today — such as remote monitoring devices — may be viewed very differently in the future, as new technologies and service models that take full advantage of them emerge. In the coming months we will search for evidence of effective approaches to both measurement and the achievement of successful engagement among patients. We are also interested in highlighting approaches that don’t work, as both kinds of examples can highlight important learnings for the field.
VERBATIM COMMENTS FROM SURVEY RESPONDENTS
How do you define patient engagement?
“Patient being an active participant in their care. This would include asking questions. Being respectful to the staff and Dr. Following instructions such as bringing in all medications to every visit. Showing up on time.”
“Patients that take some sort of action in their care. I see it as a catchphrase for everything from a marketing perspective to another IT pitch.”
“Patients either calling us or answering our calls, making and keeping appointments — both initial and follow-ups.”
“Effort to make healthy lifestyle changes, compliance with meds, realistic advance directives, and priority in value.”
“Supporting people to more fully understand their situation, the options available to them, and the steps they can choose to improve their lives.”
“Patient participates in his/her own health objectives, takes medications, maintains reasonable weight, exercises.”
“Patients considered part of the care team, able to self-advocate for their care without fear of retaliation.”
“Patients are informed about how the system works, participate in decision making, and are interested in giving feedback to foster improvement.”
“Patients who are interested in their own health and show at least some signs of activation to actually improve it.”
“Patient involvement in choosing among options and, more importantly, following recommendations for therapies/lifestyle changes when prescribed.”
“Exercise 30 minutes a day and shop in the periphery of the supermarket.”
“Use patient portal.”
Join the NEJM Catalyst Insights Council and contribute to the conversation about health care delivery transformation. Qualified members participate in brief monthly surveys.