Patient Engagement

Engaging Patients Using Digital Technology — Learning from Other Industries

Article · June 5, 2019

Excellent customer service is at the heart of high-performing organizations. In industry sectors outside of health care, a competitive focus on service drives organizations to create new products and services that meet the needs of consumers. First-rate customer experiences enhance consumer loyalty, retention, and recommendation to others, all of which enhance sales revenues. The financial and reputational success of companies rests on their ability to engage customers in appealing ways. In recent years, digital transformation outside of the health care context has been the cornerstone in trying to deliver excellent customer service and improve consumer engagement.

Within health care, excellent service and engagement also matter deeply, but health care earns surprisingly poor grades when it comes to patient experience. Patients with high health care needs are especially vulnerable to poor service. Even the generally healthy, who interact with the health care system infrequently, can find the experience vexing. The contrast with other service industries could not be starker. As people encounter more appealing and convenient digital services in all other walks of life, the disparity between their experiences with health care and with other services will continue to grow. It is far easier to book a complicated international holiday online than to book an appointment with most doctors.

There are also many new and exciting patient-facing technologies available on the market including implantable glucose monitoring devices, Bluetooth-linked inhalers, and smart watches that can detect cardiac arrhythmias. Health care organizations, however, are slow to adopt these technologies at scale, with the main barriers being lack of financial incentives, funding, and interoperability between these devices and electronic health records.

We know that health care is distinct from other services in important ways, but its unique features should not stand in the way of outstanding service for patients and their caregivers, nor should they justify settling for mediocrity. For health care organizations, outstanding service can produce reputational benefits including patient loyalty, recommendations, and referrals, but the benefits do not stop there. Hibbard and Greene illustrate that patients who have better experiences and are more engaged in their care, more likely to adhere to treatment, and may have better health outcomes. Conversely, patients who experience bad service may be less likely to follow up with clinicians and adhere to treatments. The desire to achieve better health outcomes — a primary goal of any health system — should motivate health care organizations to produce an outstanding patient experience.

To understand what health care organizations can learn about offering patients a better experience from consumer-focused companies outside of health care, the authors (two physicians with years of experience practicing in and studying two distinctly different health care systems in the U.K. and the U.S.) conducted research through a review of the literature, as well as both formal and informal interviews. We highlight the key lessons that consumer-focused industries can offer health care (the section immediately below) and offer insights gleaned from our own research (the third and fourth sections below).

How Have Other Industries Improved Customer Experience?

Respond to incentives to innovate, even if consumers don’t demand it.

Consumer-focused companies face strong incentives to innovate. To gain market share, remain competitive, and retain customers, companies develop new and better services, enhance convenience, and reduce costs. Service and design in other industries rely on constantly reassessing customers’ needs and taking advantage of new digital technologies to deliver.

The incremental evolution is well illustrated by banking, which used to require consumers to wait in line at a bank for simple financial transactions. The automated teller machine (ATM), introduced in the 1960s, did not spread until the 1980s. Subsequent innovations now allow consumers to make these transactions on a smartphone app at any hour, anywhere in the world. At every stage, consumers did not demand the next stage. They were not aware that ATMs or smartphone banking were even possible. The onus was on the bank to improve the consumer experience, and reimagining service delivery offered consumers an option they didn’t anticipate.

Keep a human focus.

Consumer-focused companies have come to recognize that digital services are more likely to succeed when they extend or enhance human relationships rather than replace them. Online shopping and banking have become the norm for some people, but the option of carrying out these transactions over the telephone or going to a brick-and-mortar outlet persist because some people prefer those approaches in some situations. Another example is the gaming industry. Online gaming has been found to enhance and promote social interaction and improve communication skills; people can connect with their friends and peers online and also take the opportunity to connect with other players across the globe. As patient-facing technologies become more commonplace, this concept can be employed to help connect communities of patients, both as an adjunct to face-to-face meetings and to form connections with a geographically diverse online community.

The use of multiple modes of communication, including face-to-face, telephone, and real-time chat functions, enables people to match services to their preferences and caters to the needs of all consumers rather than just a market segment.

Create appealing digital interfaces for consumers and enable standardized data exchange.

Consumer-focused companies have succeeded by standardizing protocols for exchanging data. In some instances, companies within industry sectors have collaborated to develop shared digital platforms. The banking system SWIFT and the airline reservation system Sabre enhance the consumer experience by standardizing the exchange of data to enable consumer transactions and reduce the need for other humans to carry out transactions. Investing in these shared platforms has enabled the gradual introduction and layering of new capabilities on top of the platforms. Participating firms could benefit through increased revenue and lower cost despite competition within their industry sectors. Meanwhile, consumers have also reaped the benefits. Handheld banking and travel planning have been a natural extension of the underlying data exchange platforms. Some companies, such as Amazon.com and Uber, have created new consumer experiences by building their own digital data exchange platforms, thereby disrupting incumbents like retail stores and taxi services.

Our Methodology

The authors conducted interviews with 24 executives of patient and consumer advocacy groups, consumer-focused companies not involved directly in health care, health care delivery system leaders, and digital health technology start-ups.

To identify potential interview subjects, we first relied on a literature search, followed by informal interviews. We used snowball sampling to maximize contacts and ensure we were capturing the most active members in this arena. Interview subjects were from Boston, California, New York City, Seattle, and Utah.

Prior to interviews, a screening call was done to ensure suitability of the participant/organization for the study. Each participant was sent a consent form prior to the interview that included a description of the project, the purpose of the interview, and the rights of the participant.

The first set of interviews was conducted with representatives of patient and consumer advocacy groups. Participants were selected using convenience sampling, subject to the inclusion criterion that they were a national organization representing patients or consumers. The interviews were conducted face-to-face or via telephone and analyzed using NVivo; the themes established following coding helped to further develop the interview guide for the next set of interviews.

The second set of interviews was conducted with leaders of integrated delivery systems (Boston Children’s Hospital, Providence St. Joseph Health, Kaiser Permanente, Mount Sinai, University of Utah Hospital, and NewYork-Presbyterian) and consumer companies not directly involved in health care (Yelp, Google, BlackRock, ProPublica, LinkedIn, and Amazon).

We list a series of examples of lessons gleaned from our interviews as well as from our experience as doctors under “Lessons for Health Care” immediately below. While none of the lessons is groundbreaking, the principles underlying them are seldom applied in the setting of health care, which is a missed opportunity to improve patient care.

Lessons for Health Care

Experience-enhancing digital solutions are under development for health care; in fact, in the U.S., digital health funding has exceeded $3 billion over the past 6 months. But despite good intentions, many of these solutions fail to solve problems or enhance the patient experience. Instead, solutions are often designed without a clear idea of the patient’s needs and wants and no real plan to involve patients in the design process from the start through concept, development, testing, and production. This results in a product that often negates the concept of “patient-centered care,” with lack of uptake and little hope for return on investment for developers or investors. It’s pretty simple — if the technology doesn’t meet the patient’s needs or enhance their experience, it won’t be used!

Patient-facing digital technology solutions could improve the patient’s experience of health care if health systems, doctor groups, and entrepreneurs take advantage of the insights from consumer-focused industries. We see several ways health care could improve patient experience:

Evaluate whether patients value new services; then, focus design around their needs and wants, rather than those of clinicians.

Commercial companies with an unrelenting focus on the customer examine the problems customers face and create solutions to those problems. The service being delivered to meet the patient’s needs is far more important than the technology that delivers the service. Convenience and simplicity are central to success. Technology designed for health care is often clunky, difficult to navigate, and lacks the design elements that are offered by other industries. Burdensome technologies, such as patient portals requiring complex log-ins or apps needing laborious data inputs by the patient, do little to improve the experience of health care.

Health care apps are often designed in a way that they become a constant reminder of a patient’s condition, and at times, this reality can’t be escaped. The apps lack features that reinforce a positive interaction with the technology; this, along with emerging research on the abandonment of fitness trackers, does not give much optimism. However, if technology can improve the experience for patients using strategies such as gamification, encouraging engagement with other patients, and making it easier to communicate with clinicians and share information, the content would effectively be more appealing. As a result, technology solutions may have more staying power and aid in therapeutic adherence.

Make the content more engaging.

A trusting patient-clinician relationship is a core feature of health care. Some commentators suggest that digital technology can completely replace personal interactions with clinicians. However, consumer industry experience suggests that successfully meeting the needs of customers is a matter of matching the communication channel to the customer’s preferences — an “omni-channel” approach. In health care, this would translate to the patients having the option to consult a clinician in person, by telephone, or using telehealth, depending on the situation. A central challenge for digital technology developers is to anticipate the moment-to-moment demand and make these options readily available to patients and the family and friends assisting in their care.

Apps such as Yelp and TripAdvisor invite users to share reviews, offer recommendations and ratings, and share pictures, among other offerings. This makes the app interactive and enjoyable to use, helping the consumer engage better with the content.

Imagine new ways of accomplishing tasks for patients and clinicians.

Uber and Seamless offer instructive examples of altering the way people travel or order food by delivering on-demand services directly to the consumer. To replicate this in health care, we need to reimagine service delivery without the constraints of current workflows. Replacing existing processes with digital processes is not a trivial task and implies swapping an incumbent process with a digitized form, which is not always the right answer; the answer lies in thinking about the bigger picture in the way that a service is delivered. Is the service meeting the needs of patients and clinicians? What can be done to improve the experience, and can digital technology help to improve it? These are fundamental questions to be asked before employing any alternatives to current services.

Digital tools should enhance and not replace relationships between patients and clinicians. A recent survey by Rock Health suggests that patients are much more satisfied using telehealth after a previous face-to-face consultation. Other evidence suggests that patients are more likely to continue using a technology if a health care practitioner has recommended it. Without a recommendation based on a relationship of trust between a patient and a clinician, sustained use of digital technologies will be difficult and their potential value to patients, clinicians, and health care systems undermined

Create industry-wide digital health data exchange platforms that standardize data, communication protocols, and software solutions.

The emergence of disparate proprietary digital health record systems has created barriers to interoperability and challenges for health systems as a whole. To support innovative digital health solutions requires a coordinated effort to create a platform that structures data exchange and provides the data to power new services. As described earlier, competing companies in banking and airline sectors have established cohesive and standardized data sharing infrastructure that can be used for transactions by the companies and their customers. More recently, the concept of “open banking” in the U.K. enables a more seamless way of working, based on common standards that rely on open application programming interfaces (APIs). Consumers can securely share their own financial transaction data with other banks and third parties, resulting in an increase in the number of services provided and an improved user experience. It has also allowed more novel digital-only banks such as Monzo and Revolut to compete with more traditional banking services, making them more agile. Health care could vastly benefit from better data exchange to deliver more innovative services using industry-wide platforms.

Examples of standardization and exchange protocols are just beginning to emerge in health care. Large data and technology firms, including Amazon, Google, and IBM, have pledged to develop their health care tools using standardized technology standards, such as Fast Healthcare Interoperability Resources (FHIR®) created by Health Level Seven International (HL7), to enable consumers and clinicians to securely access personal health data from any clinician in the system and potentially to share the data. This is a significant step toward enabling companies to build the digital services that will better meet the needs of patients and help remove barriers.

Model Examples and Results

Three organizations, Providence St. Joseph Health, Boston Children’s Hospital, and the University of Pittsburgh Medical Center, have started to adopt the user-centered design methods that are pervasive in consumer-focused companies. They collect data about pain points in the system, involve patients and clinicians in product design from the outset, engage designers and technology experts to work closely alongside health care workers, and forge the financial investment partnerships to create and relentlessly improve technology solutions for patients.

All three institutions have created multi-professional teams to improve user design and experience. The teams are composed of UX designers, clinicians, patients, and tech experts. The organizations have also employed individuals who have worked in sectors outside of health care to apply lessons from other industries.

Initiatives like these are yielding results. For example, NewYork-Presbyterian (NYP) carried out a study of 1,500 individuals throughout the U.S. to identify the needs and wants of patients and the public. In 2016, NewYork-Presbyterian introduced NYP OnDemand, a range of patient-facing digital services that includes Express Care, a digital emergency and urgent care program for low-acuity conditions, where patients have the option of a telehealth consult with a clinician after having an initial triage; Digital Second Opinion, a service offering clinical expertise for second opinions to patients around the country through an online portal; and Digital Consults, which connects patients at NYP’s regional network hospitals to NYP hospital specialists, with the option of Digital Follow-Up Appointments instead of in-office visits.

Since the roll out of the Express Care program, waiting times in the ED have fallen, space has been reallocated to higher-acuity cases, and there has been excellent feedback from patients, with a Net Promoter Score of 95, according to our interviews with the organization.

Another success story comes out of Boston Children’s Hospital, where a customer relationship management tool has been introduced to help improve the patient/caregiver experience. A deep dive highlighted the administrative burden placed on families by filling out forms, increased waiting times flowing from this, and delays in confirmation of appointments. The tool allows families to fill out administrative forms ahead of time and be directed to further information on the website as well as videos guiding families on what to expect. Any interactions with the chat function are documented, and this data along with the pre-filled administrative information help inform health care staff prior to the appointment. According to our interviewees, the introduction of this tool has resulted in improved patient experience, decreased waiting times, and increased engagement with the website.

And University of Utah Hospital offers all patients a survey after their care to rate their physician. Patients report on their interactions about their engagement with physicians and the system as a whole; the results are collated, and physician ratings are made public using a star rating system. Interviewees say this has driven improvements in patient experience and patient satisfaction ratings over time and has seen a shift from 5% of physicians in the 90th percentile to 50% of physicians in the 90th percentile nationwide for patient experience, based on a statistically significant number of patient feedback surveys. The feedback facilitates continuous improvements in care and helps ensure that the patient voice is really heard.

In hindsight, it would have been advantageous to have asked our interviewees how they think big tech companies like Apple, Amazon, and Google — all of whom have launched health care ventures — will influence this field. Based on lessons from consumer-focused companies, health care has significant opportunities to improve patient experience using digital technology in spite of some of its unique features. Investment in a standardized health data exchange could enable this patient experience revolution. The fundamental question remains, why are we not doing more to adopt these technologies?

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