Patient Engagement: Winning a Trifecta

Optimized-DavidColbyThe delivery of health care is dominated by individual providers, such as physicians and nurses, and large institutions, mainly hospitals and nursing homes.  It feels like the patient is the little character that sits in the corner of Tom Toles’ Pulitzer Prize-winning editorial cartoons in the Washington Post waving a flag – saying in high pitched voice, “I am here! I am here!” or “I can help! I can help!”  The larger picture seems always to be focused on big discussions in health care – how systems need to change, how providers need to change, how new models will transform care. As a nation, we’ve really neglected that all-important person in the corner who has the most crucial input of all. The patient, according to Leonard Kish, a health IT consultant, is “the blockbuster drug.”

In a recent New Yorker article, Dr. Oz is quoted as saying, “Ultimately if we want to fix American medicine we will need skeptical and smart patients to dominate.”  Several years ago when I was having back problems, my physician said he wanted to talk with me about getting an MRI.  I asked whether he would do anything different after seeing the MRI results.  He paused… and then said, “good question” and “no.”  Sometimes “just saying no” is the best response.  All times it is valuable to have patients engaged in their care.

In the latest issue of Health Affairs, there is evidence on why patient engagement and activation are very smart things to do. Judy Hibbard and Jessica Greene reviewed over 100 articles and concluded that activation (which is one aspect of engagement) is linked to better care experiences and improved outcomes.  In another article, they and Valerie Overton examined over 33,000 patient encounters finding that patients with the lowest activation levels had significantly higher billed costs.

The Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative engages those who provide care, pay for care and receive health care in improving quality of care within their communities.  This program is featured in this issue of Health Affairs which describes how patient engagement is playing out in places as diverse as south central Pennsylvania, Maine, Oregon, and Humboldt County, CA.  It also points out that we need more data, more quantifiable research to help us understand ways we can start moving systematically toward a culture that respects the role of the patient AND knows how to involve patients in the most effective ways.

Other articles in Health Affairs provide insights into the tools that are needed to engage the patient. Dr. Howard Koh, the assistant secretary for Health, Department of Health and Human Services, described the health literacy care model that that combines the care (a.k.a. Chronic Care) model and the Health Literacy Precautions Toolkit.  Others suggested the use of decision aids that are efficacious. Nevertheless, there are barriers to engaging the patient.  Dominick Frosch and his colleagues found that decisions aids are not widely used.  Cultural change must occur; physicians must learn new ways of working; patients must receive enhanced support in decision making; and the architecture of choice must be structured to encourage patient engagement.

It’s incredibly important for the nation to have a resource like this issue of Health Affairs that gathers together much of what the leading minds in health policy are doing and thinking about the patient’s role in better health and health care. So I’m thrilled to see that the discussion is shifting, and starting to define exactly what it means to have the patient at the center of the picture.  The discussion continues online: @ePatientDave and others tweeted under #HA_patients; Judith Hibbard and Jessica Greene have posted on The Health Care Blog; the Robert Wood Johnson Foundation posted patient engagement material on its site.

A growing body of evidence shows that patient engagement produces happier patients, lower costs, and better quality.  What could be better than winning this trifecta?

David C. Colby, Ph.D. the Vice President, Research and Evaluation at the Robert Wood Johnson Foundation and will become the Vice President of Public Policy at RWJF later in 2013.

  • Kwanza

    I think patient’s can become more engaged, I’m not sure if hospitals or providers are ready to be engaged with patients (and caregivers)…

  • McGuckin

    I have researced and published several aricles on patient empowerment as it applies to Hand Hygiene and HAIs. On March 6 I gave a WHO sponsored teleclass on Patient Participation and the tools to start a program in hospitals.It can be viewed at; We have also developed checklists for patients on 8 simple solutions they can learn as a consumer and use when they are in a healthcare setting The Patient Survival Guide: 8 Simple Solutions to Prevent Hospital and Healthcare Associated Infections:

  • EileenCurras

    The reality is the system at least in Florida leaves Patients out of the picture. I became engaged and got a phone call from a hysterical governor of Florida with promises of a visit to be a witness to a signature from him. Nothing yet.

  • Rich

    To me one issue in patient involvement is the ability to offer meaningful feedback other than the “on time appointments,” “pleasant environment,” and “did the provider take time to explain” standard comment categories. With the availability of solid medical information on the internet (one has to know where, of course, to look and trust), a patient and moreover a patient’s advocate can become pretty technically conversant in a relatively short time about medically related issues and risks. In addition, observation of doctor-patient interaction techniques, for example, providing overwhelming information versus substantive information is one provider technique that I have seen used (abused?), somewhat akin to a “snow job.” Or rushing the delivery. Or simply ignoring signals from “lesser providers” (nurses who may be reluctant to directly confront the primary provider) are serious issues that make for a successful outcome vs readmission. Gauging that sort of information is far more valid for me than reports shown in studies like the Wisconsin healthcare quality initiative. Some of these issues were addressed in the book “Unaccountable” and I witnessed play out to the detriment of the patient but getting a voice for them is a key to real quality. Full participation, survey of, and valuing of all levels in, say, a hospital in terms of opinion seeking of each category would be most useful to future patients. In other words, I am agreeing with Kwanza below.

  • Cyndy

    David, all good comments. But until purchasers and providers are as engaged as we want consumers to be, we will still have misaligned wheels on a fast-moving train