In the past, the AMA published an article questioning the merits of patient portals — the primary tool for engaging patients. Rob Tennant, senior policy adviser with the MGMA-ACMPE, the entity formed by the merger of the Medical Group Management Association and the American College of Medical Practice Executives raised the fundamental issue: “The business case just hasn’t been made.” I’ll attempt to make it.
Perhaps the best evidence of the business case is when industry visionaries/organizations/leaders such as HIMSS (the professional association for healthIT), Aetna and Kaiser Permanente have made significant investments in patient engagement.
I’ve excerpted a couple sections of Pam Dolan’s article on the topic to set context and then I will address the business case. The patient portal benefits assume that it’s more than a simplistic silo’ed patient portal tethered to an EHR since they are broadly available. [Disclosure: My company, Avado, is one many patient engagement companies.]
This is why I would call it the patient portal & relationship management system or simply patient relationship management system to distinguish it from traditional limited patient portals.
Soon, physicians planning to collect incentive pay for the second stage of the Centers for Medicare & Medicaid Services’ meaningful use bonus plans not only have to implement the technology, but also ensure at least 5% of their patients use it. The rule, some medical organizations say, will force physicians to decide if the incentive money is enough of a return on what could be a very costly investment. Practices can earn up to $44,000 per physician over five years from Medicare, or up to $63,750 over six years from Medicaid if they meet meaningful use. Starting in 2015, practices must demonstrate meaningful use annually or face pay penalties. Proposed meaningful use stage 2 requirements said physicians had to make available to patients a portal that would offer them the ability to access, print, share or download their records, and make sure that at least 10% of their patients use the technology. The final rules reduced that requirement to 5%, but many physician organizations say the requirement is unfair, because meeting it involves factors outside of their control. The American Medical Association and other medical societies recommended that the portal requirement and other patient-driven measures be optional.
Much of the patient portal technologies meant for small practices are sold as third-party add-ons to EHR systems but lack the necessary capabilities to meet the meaningful use requirements. Vendors are now looking at ways of offering the patient portal feature, given the new regulations. And, according to Tennant, some are exploring creative ways of making them more attractive to physicians.
Assuming practices move beyond low-value patient portals, the benefits are clear.
One group applauding the new regulations is the National Partnership for Women & Families. Christine Bechtel, vice president of the NPWF, said in a statement that the rule “recognizes the essential role that providers and their staff play encouraging patients to use this online access.”
It’s clear this desire is rippling through to providers as this quote from a leader of the trade association for the healthIT industry demonstrates.
Mary Griskewicz, senior director of ambulatory health information systems for the Healthcare Information and Management Systems Society (HIMSS). Griskewicz agreed, saying she expects that physicians will hear more requests from patients for such access as more aspects of health reform take hold and patients become more engaged in their own care. HIMSS will spend the next several months looking at ways care will be affected by the technology, she said.Meanwhile, physicians also should ask vendors some pointed questions, Griskewicz said.
However, Griskewicz cautions that they apply more scrutiny than they had when it was simply the throw-in tethered patient portal they were getting with an EHR.
“You’re going to ask those questions before you sign the contracts or before you do the upgrades and the updates: ‘What is this going to do for our practice? How is this going to help with patient outcomes or the administrative burden overall? Can this truly return our investment to us?’ ”
In a highly dynamic arena, it will be risky to have traditional patient portal built on a client-server model as it will get rapidly out-of-date unless the vendor is frequently updating the software AND the provider takes their latest upgrades. My experience has been both are usually absent — traditional healthIT vendors has 18-36 month product cycles and it’s burdensome financially for providers to keep up on the latest vendor version. In contrast, cloud-based systems are always up-to-date.
Patients Portals Have Been Like Pre-Google Web Search
Before Google, web search was largely a low-value afterthought on web portals dominant in the late 90′s (AOL, MSN & Yahoo). Likewise, patient portals have typically been little more than a “marketing checkbox” that have demonstrated little clinical or financial value to healthcare providers (there have been exceptions such as in Denmark and Kaiser Permanente). Just as Google demonstrated, the next generation of patient portal & relationship management systems have dramatically more value.
The old discharge process did the equivalent of sending patients to a foreign land, gave them directions in a second language and then pushed them out the door towards their destination (the best health possible given their condition). Instead, a modern patient relationship management system recognizes that the equivalent of a GPS is needed. This ‘healthcare GPS’ would be able to remotely monitor the patient’s progress toward full health, could communicate with them if they were off track and generally help them navigate their health journey without forcing them back to the office for further direction.
One of the leading thinkers in healthIT, Shahid Shah, outlined how systems must expand to incorporate the patient in an article in a HIMSS publication.
“It will be nowhere as easy for existing legacy EHRs to simply retool their current platforms, like they did for MU.”With that said, Shah outlines nine ways future EHRs need to support ACOs.
1. Sophisticated patient relationship management (PRM). According to Shah, today’s EHRs are more document management systems, rather than sophisticated, customer/patient relationship management systems. “For them to be really useful in ACO environments, they will need to support outreach, communication, patient engagement, and similar features we’re more accustomed to seeing, from marketing automation systems than transactional systems.”
Healthcare Finally Moving Beyond Wang/Prodigy Model
It has become clear that one of the reasons there is tremendous waste in healthcare is there are too many silos that don’t communicate with each other. Reflecting these silos, healthIT vendors operated in a similar model to Wang or Prodigy (younger readers may need to Google those organizations). That is, one company supplied all of the technology from top to bottom. Until now, healthcare has largely missed what has happened on the Internet. Consumers are given access to systems they never had access to before whether it’s for booking airline tickets or buying products (saving a lot of money for the companies, in the process). This gives consumers greater services and the businesses offering these products and services can plug in a wide array of technology solutions into their back-end without those front-end systems having deep knowledge of the back-end systems. Unfortunately, many healthcare providers are stuck with whatever one vendor can provide. It’s the equivalent of still being dependent on Verizon/AT&T for smartphone app stores versus Apple or Google’s smartphone app stores. Even heavily-resourced Verizon couldn’t succeed and announced shutting down their app store.
As we enter the era of nimble medicine, this will impair their ability to reinvent themselves and put their enterprise at risk. We have seen with other countries that the shift from a reactive “sick care” model to a proactive health-focused system has resulted in a significant reduction of the number of hospitals. Only the strong and nimble survive. As we have seen in nature, monocultures aren’t as resilient as more diverse ecosystems.
The business case
I use the mnemonic MAAAP (“map”) to summarize the business case for the ‘healthcare GPS’. A modern patient portal such as a Patient Relationship Management system enables the following items:
Marketing & market share
Accountable model success depends on patient engagement
Avoiding vendor lock-in
Market share & marketing
The following are some examples of marketing and market share benefit with a smartly deployed patient portal & relationship management system:
At a practice level, some practices are gaining 20% of their new patients via their web publishing (social media, etc.). A doctor in Missouri explained this in more depth here. A PRM system allows providers to create content once and publish it as narrowly (e.g., internal to the practice) or broadly (Twitter, public website, etc.) as they would like. With information that isn’t patient specific, it can be shared with cohorts of patients (e.g., new treatment options for COPD patients) whether they are current or prospective patients. It ends up saving the doctor’s precious time while also serving as a point of differentiation versus non-communicative providers. As I’ve said before, communication is the most important medical instrument of the future.
At a health system level, there is an immense opportunity to use patient relationship management systems to provide a service to both affiliated doctors and health professionals as well as with prospective patients. It’s analogous to what American Airlines did decades ago providing their Sabre system to independent travel agents. They delivered value to independent professionals and got loyalty in return. Even when the playing field was leveled (i.e., a system from one airline could book flights on any airline), there is a market share halo effect where the agent books more with that airline. Likewise, a health system can provide modern patient portal functionality that addresses key needs for the affiliated provider such as addressing Meaningful Use requirements and patient communication tools. The system can have built-in hooks into the health system even while providing a tool that works with any other health system (or HIE).
With an expectation that 25-50% of consumers will be directly buying healthcare, providers need to develop consumer marketing skills. Simply being in an insurance company’s network misses out on the massive segment of the market that is using high deductible health plans. Whether they want to or not, those consumers will become more literate on healthcare choices. Fortunately, the ability to directly reach consumers cost effectively is easier than ever. Health plans have begun a similar transition of having been only B2B marketers and are now B2C marketers marketing items such as Medicare Advantage programs. Leading healthcare providers realize they must do the same to fully serve the population they wish to serve.
As EHRs get broadly adopted, there is a rising issue that people are going to have several user ID and password combinations if the siloization of healthcare continues. The providers who give their patients a universal tool to connect with many healthcare providers will have a distinct advantage over providers who hold their data hostage in their closed systems. With 50 million Americans moving every year, no one goes to one provider their entire life. Even today, there are some noted healthcare systems who hold their patients’ data hostage. Not only can you not take your data with you, they charge stiff per page printing charges for a copy – hard to imagine in this day and age. This will eventually result in consumer backlash. In the meantime, providers who are open can gain market advantage.
One could argue that the absence of robust patient portals has created a huge business opportunity for health information sites. They are, in effect, the de facto patient portal. At one time, people had to completely rely on their doctor as the source of medical information. The strong desire for health information (4th most common activity on the web) has been filled by consumer health information sources. Unfortunately, it has also meant that the likes of Jenny McCarthy (ex Playboy Bunny) are also viewed a sources of health information. This is why doctors such as Natasha Burgert, Howard Luks, Ryan Neuhofel, Wendy Sue Swanson, and many others feel a moral obligation to be a source of reliable, curated information. As a byproduct, it has also been beneficial to them financially.
Providers recognize that there are profoundly new dynamics in a fee-for-value reimbursement model. With the old model, it was natural to optimize for as many visits by a patient as possible. Since providers were only paid when they saw the whites of a patient’s eyes, virtually 100% of the healthIT investment went towards that <1% of a patient’s life when they were in front of a provider. It’s not an exaggeration to say that everything changes in a fee-for-value model, particularly with 75% of all healthcare spending focused on chronic disease. The provider who isn’t prepared for the fee-for-value tsunami will get swamped. The organizations having the greatest success tackling vexing chronic conditions have a key insight. That is, the decisions that most affect outcome in chronic disease aren’t made by the clinical team. Rather, they are made by the patient and/or their family. For example, filling prescriptions, diet, exercise, etc. decisions are made by the patient/family. Thus, having a strong communication framework is paramount to teaming with the patient.
It’s been said that patient engagement is the blockbuster drug of the century. Studies at several health systems have shown dramatic improvements in outcomes when patients are engaged. These outcomes outstrip the most successful drug in history. It naturally begs the question of when, not if, patient engagement itself becomes the Standard of Care all providers are expected to practice.
Healthcare providers spend a tremendous amount of time and money dealing with paper-based forms ranging from intake forms to symptom diaries. Not only does this introduce potential errors when administrative staff keys in information (human error, illegible handwriting), it is a horrible consumer experience and has significant cost.
One orthopedic practice I spoke to is spending $500,000 per year keying in hand-filled forms into their system. To add insult to injury, they affiliated with a system that was using a familiar large healthIT vendor’s system that is known for being difficult to interface. They now have to do double-entry. A modern patient relationship management system can easily eliminate the need for paper-based forms. The ROI can be 20:1 or higher when replacing paper-based systems. In the process, a major patient irritant is removed.
Avoiding vendor lock-in
Providers complain about vendor lock-in strategies. Other industries have long since left the Wang/Prodigy era behind. As we have seen with the Internet, allowing for heterogeneous systems enables competition that drives down software prices while increasing innovation. At a time when myriad new requirements and delivery models are descending on healthcare, it’s clearly impossible for any one vendor to address all of the requirements associated with patient engagement and care coordination. It would be like still using AOL as the only way to get to the Internet.
Forward-looking providers have recognized that it is extremely risky to depend on the same vendor for patient-facing systems such as patient portals and relationship management as provider-facing systems such as EHRs. This is a radically different user base and one where more rapid iteration is necessary than is typical of legacy EHR vendors. After all, it’s unlikely that there will be one best way to engage patients and it will be rapid iteration of nimble systems that will win the day. Margit Gur-Arie stated it this way.
It is a different paradigm, and most EHR bashing folks don’t quite get the difference between an interface accessed once a month by a casual user and one that is used 10 hours a day, heads down, by a worker. If your portal can be the shiny, friendly user interface for consumers, it will perhaps make them use it more, and more efficiently than the utilitarian portals designed by those accustomed to servicing providers and have no clue how to engage lay masses of people…
If providers thought there was lock-in when they adopted a vendor’s system, imagine how locked in they’ll be if they also adopt their patient-facing tools as well. Silo’ed patient portals perpetuate the myth that patients only go to one provider their entire life. No one wants to have five different user id and log-ins to piece together their health information. Providers who enable patients to have a full picture of their health information will be at a competitive advantage. John Moore of Chilmark Research wrote about this saying the following:
“I asked one oncologist about HIT adoption at Dana Farber and meaningful use to which he quickly replied: “Meaningful use is the bane of our existence right now.” So I asked further: What problem could HIT really solve for him? He had a ready answer: “Rather than a new patient showing up with a mound of paper records that I must laboriously review, I want a digital version of a new patient’s record with labs, pathology, images, meds, etc. all readily laid out so I can make a more rapid assessment to define a treatment plan for that patient.”
We know from our personal and business lives that strong communication is the foundation that builds trust in a personal or professional relationships. It turns out that communication is the most important “medical instrument”. Increasingly private and public payers are changing their payment systems to reward (or penalize) providers based on patient satisfaction. Of the total amount of time spent with a patient, the clinical encounter is just a fraction of that time. All of the rest of the experience scheduling appointments, entering information into provider’s systems, getting lab results, medication refills, and so on can either be painful and time-consuming or happen with relative ease. Fair or not, it’s the entire patient experience that will drive their degree of satisfaction. Those who are behind the curve on becoming more patient-friendly through modern patient portals and relationship management systems will face penalties that will eat into already-thin margins.
Only those with their head in the sand don’t believe healthcare’s reimbursement model is rapidly getting flipped on its head. There have already been shots across the bow of the healthcare provider ship. For instance, penalties for hospital readmissions and Stage 2 Meaningful Use requirements. Given the degree of urgency around tackling hospital readmissions, it’s not hard to imagine that getting ratcheted up 10x. Most of the rest of the world views hospitalizations as a failure in the system (with a few exceptions such as childbirth) in contrast to the legacy reimbursement model in the U.S. where hospitals are like hotels trying to maximize occupancy. The readmission penalty shot across the bow pales in comparison to what happens when hospitalizations are considered a system failure. The shift from a reactive sick care system to a proactive health system has resulted in >50% reduction in hospital days in places such as Denmark. The surviving health systems optimize for health and realize hospitalizations have a role, but not the central role, in the optimal system.
Let’s face it. Until one operates in a fee-for-value model, the business case is much less strong for patient engagement. In fact, you could argue the opposite. Patients who don’t engage or simply don’t comprehend stay sick and can rack up bills that would make any CFO grin. For entirely rational reasons, the silo’ed patient portals of the past are transactional in nature. For example, a big selling point of most of them is how they allow patients to pay bills online — not exactly what I’d call “patient engagement”. In contrast, patient relationship management systems have their core capabilities focused on communications that optimize the relationship between the patient and their health. In a fee-for-value system, there is a strong business case for that.
David Chase is the CEO of Avado.