Providers Are Held Accountable. Why Aren’t Technology Vendors?

As healthcare shifts from fee-for-service to fee-for-value, hospitals and physicians are increasingly being held accountable for outcomes by the government, payers and patients. Historically, provider organizations only had to meet performance criteria to earn a pay-for-performance bonuses or hospital certification, but with the arrival of Accountable Care Organizations (ACO), Meaningful Use and other programs, payment is now based on to quality of care rather than quantity of services.

Health information technology (HIT) systems are able to track physician actions and measure outcomes down to the individual patient level and allow organizations to closely monitor the quality levels of a given physician. These same tools should be able to monitor the performance of the vendors who are there to support these clinicians. With patient engagement solutions, for example, vendors claim they can help improve HCAHPS scores, treatment adherence, patient outcomes, and reduce costs, but have no evidence to back it up.

Vendors should be willing to commit to their patient engagement promises, present proof showing improved outcomes and face some financial risk for failing to deliver.

Global accountability

Since patient engagement was included in the Centers for Medicare and Medicaid Solutions’ Meaningful Use of Electronic Health Records program, it has become a popular buzzword. Every HIT vendor claims to offer tools to assist providers with this important clinical quality issue, but no one is holding anyone accountable.

Part of the problem is patient engagement lacks a standard definition. The ambiguity allows publishers of diabetes fact sheets to call it patient engagement when a newly diagnosed patient is handed a 100-page binder of information that is more likely to become a doorstop than an interactive engagement tool. Likewise, call centers that remind patients of their appointments, in-room entertainment systems, or printed discharge instructions, could also erroneously be called “patient engagement.” The reality is handing someone a piece of paper is not engaging them in their care. When the industry talks about patient engagement, they mean motivating patients to take an active role in their care to drive outcomes. A piece of paper will not change their care. Calling someone may help them show up for an appointment, but is unlikely to change their behavior and better control their chronic condition. What specific outcomes are improved by these activities? Can it even be measured or shown to deliver a return on investment?

Delivering results, not promises

This is the era of buyer beware. Provider organizations should demand proof statements—not promises—from patient engagement vendors. If organizations want to make patient engagement a part of their care process, then their technology partner should support the needs of everyone who delivers and receives care across the continuum. Can you truly engage someone “across the continuum” from a hospital bed, when roughly 90 percent of patient encounters occur outside the hospital setting [1]?

Organizations need engagement partners with longevity that deliver case examples showing how their solutions have improved clinical quality and/or financial performance across all care settings. These vendors also need to be able to support their claims with assurances that if they fail to meet expectations, the provider organization won’t be at financial risk.

For a patient engagement initiative, organizations need a comprehensive enterprise-wide solution that imparts actionable information to patients and then measures the impact. This doesn’t mean providers should just put information in front of patients, but rather present it in a way that they understand and will take action on it.

Comprehensive outcomes-driven engagement needs to track not only the delivery, but also the consumption of information, which then enables the measurement of impact – on individuals and populations of patients. True technology-driven patient engagement has already been proven effective in numerous provider organizations where data analyses have demonstrated it results in higher HCAHPS scores, reduced length of stay, fewer malpractice claims, the list goes on…

Technology cannot and should not replace physicians’ skills, experience and face-to-face interaction. However, technology can and should be held accountable as a partner. A provider organization would never hire a physician who refused to be held accountable for their performance, so why should they invest as much, if not more, on technology that won’t offer the same?

Jordan Dolin is the founder and vice chairman of Emmi Solutions, a pioneer of outcomes-driven patient engagement.

22 replies »

  1. May I politely take issue with this, as an engineer? I have some thirty years of experience in product design. The responsibility of a system designer begins and ends with making a system (or product) that meets the specification that was input to the design process. Thus, in the case of systems used by medical practitioners, they need to be specified by those practitioners before they ever get near a design facility. If the systems work to specification and do not meet customers needs, the responsibility then lies with the people who specified the system in the first instance – not the designers. Furthermore, in my opinion, it is ONLY the medical profession that can and should specify such devices and systems – not engineers who know nothing of medicine. I would be more than happy to discuss this further.

  2. It is not just about the technology and or the forms that impact patient engagement. It is also the philosophy and culture. Are providers ready for engaged patients that show up with pages from the web with hypothetical diagnosis already? Are our systems ready for patients to engage the way “They” want to’ phone for mom and dad, text for the college student.

    In addition to thinking about technology we also want to think about the soft stuff of patient engagement.

  3. I agree with Jordan that the efficacy of a healthcare technology platform that reports performance criteria lies in its ability to meet measurable goals. Federal programs like MU and PQRS probably serve as strong reference points to define such goals. Real evidence that the technology actually delivers on its promise is hard to come by, unless we are able to track metrics like increase in physician adoption, or reduction in reporting time. Our work with Holzer may be of interest http://bit.ly/1brenAh.

  4. I agree with Al Lewis that using some relatively arbitrary “engagement” as a metric of quality health care is obscene. It is simply one more aspect of the system to game. Physicians are reasonably bright, and if you pay them to document some aspect of an encounter they will find a way to document that aspect. Instead pay for true outcomes, or at least some objective proxy for an outcome like BP, HbA1C, LDL, etc. Don’t pay for a simple documentation of an exchange of information.

  5. @shannon

    Go ahead and blame the users. Gee, the administration was complaining that I did not use my pen and paper correctly!

  6. During an interaction with one of many computer techs i have had to engage with recently, i suggested that if computer companies were subject to the same requirements of competency as medical folk – they would be perpetually defending themselves against “malfunction” suits …

  7. Part of the problem, I think, is the term “engagement”. It sounds so one-sided and operational, rather than bringing patients/consumers into two-way relationships. Why would a patient be startled by an email about stage IV cancer? Or call after hours about an abnormal but not significant lab value? It’s because they have not been adequately prepared. I have heard more often from patients who have had sleepless nights waiting for a test result than concern they’ve gotten a test result too early. There are few test results that are incidental – usually, you’re looking for something and patients should be understanding that as well. When that happens, we will realize ePatient’s Dave’s vision where we “let patients help”.

  8. My point exactly! We have spent over a decade learning how to truly “engage” patients in a way that prompts an action or changes a behavior. There are 2 things which i now know to be true, 1) when done correctly, patient engagement will improve clinical and financial outcomes. and 2) it’s really, really hard to engage patients. It requires a deep understanding of communication methodologies, health literacy levels, cultural sensitivities and individual learning styles.

    There are organizations who have done the work and made the investment. Their solutions will have been shaped by the market and they more than likely have the outcomes data that you would want to see. While there is no common definition of what constitutes “patient engagement,” there does seem some agreement on what it’s not.

    It seems to me that anything that could potentially find its way into the hands of a patent is now being categorized as engagement. For example, a post card explaining that you are ready for an annual physical or the folded brochures stacked at the front desk in the physicians’ office are both now being described as patient engagement solutions. Organizations that provide telephonic appointment reminders are now positioning themselves as “engagement platforms which span the continuum of care.”

    While I’m sure that the products described above meet some specific needs of certain organizations, presenting them as comprehensive engagement solution is misleading. Technology and sheets of paper are both tools that can be leveraged to convey information. Where the rubber meets the road is in knowing that the information was received and if it in fact had any impact.

  9. This is an excellent post. It is not at all uncommon to hear health IT vendors claim all the time that their widget is the cure to what ails the system, but when pressed, it’s easy to see that they often have few or no metrics for success. Worse still, they don’t think that the accountability flow ought to extend to them. After all, they’re just tools in the process…the real levers for engagement are clinicians, and if they can’t get patients engaged, then that can’t possibly be the IT vendor’s fault.

    And, while we’re at it, let’s lasso wellness vendors, too. No segment of the health care marketplace has been so empowered by health reform but is so devoid of any kind of common sense accountability framework.

  10. I am shocked, shocked, that EHR vendors are not being held accountable. That never happens in disease management or wellness, where engagement is defined very strictly as: whatever the vendor wants it to mean.

    And, yes, handing out pieces of paper and/or making phone calls that get answered in any way other than a machine count as engagement.

    Measuring engagement itself is a fool’s errand. If patients are indeed being engaged, it should show up in things like readmissions, fill rates, ambulatory care-sensitive admissions etc. THAT’s what tells you whether someone is engaged.

  11. First off, I’m thrilled that my piece is promoting this conversation. I agree with most all of what Ross has written here, and feel it is critical that this type of discussion takes place on a broader scale.

    Of course I agree that presenting difficult information, such as a cancer diagnosis, should never be done electronically. Technology is just another tool that clinicians can use to make the care process more effective and efficient. Since founding Emmi Solutions 12 years ago, I’ve heard every form of support as well as every form of pushback. More often than not, people will go to extremes in order to demonstrate their point which is, in my opinion, not additive to the conversation – not that anyone has done so in this conversation, but take the following scenario as an example:

    A few years back I was in a meeting at a large health system and a senior clinician asked me if I honestly believed our “computer toy could actually change the behavior of a non-compliant diabetic.” My response was “of course not,” and that it was never our intention. Instead, I explained there are millions of asthmatics who don’t know how to use their inhaler properly and an interactive engagement platform is the perfect way to teach them. The same can be done for a newly diagnosed diabetic who is not completely sure how to inject insulin.

    Patient engagement should never be intended to replace the role of human interaction. Rather, it should supplement the care process. In light of the current economic state of the healthcare industry, we need tools to extend the reach and efficacy of caregivers. Every industry is utilizing technology to support their processes and has figured out how to apply it appropriately. For example, airlines will have a person call you if your flight is canceled but will simply text you if it has been delayed. This allows agents to be available on the phone to help you get on another flight. The same concept can be applied to the healthcare industry. Wouldn’t it be advantageous to make physicians more available to spend as much time as needed with patients?

    A great first step in this space would be a national standard for what constitutes “Patient Engagement,” and in the interim, a bit more adherence to the notion of “truth in advertising” on behalf of the vendor community.

  12. EHR Vendors are not accountable by law. They have padded the coffers of Congress to influence the printing of laws that do not require them to have their systems validated for safety, efficacy, usability, or interoperability, or to report adverse events or crashes.

    Moreover, the ONC is mostly a cheerleader for HIT, and ignores the importance of interoperability, as witnessed by Mostashafi”s testimony (and his bow tie) to the Senate Finance Committee last week.

    Patient access to records is a joke and a nuisance, for which doctors are not getting paid. A physician friend of mine was called, interrupted from a dinner, as an emergency, after office hours, by an asymptomatic worried patient who accessed personal portal and saw a CPK done two weeks earlier was 205 with the top normal of 200.

    Certainly an example of improved, but abusive, communication. Why did the patient not call during the hours that the office was opened, and why, two weeks after the test???

  13. Data selling and the incentives add to the issues in healthcare. Check out the gamification to exploit it, you can buy a profile of a disgruntled nurse selling medical records, learn how to hack other data brokers data bases and collaborate with them and start all kinds of new web services, you will be a hero it says. Actually the video is very well done. We need to license and excise tax quarterly all data sellers, totally not regulated at all and you don;t know what goes on behind closed server doors when you get an insurer like United that has a couple hundred subsidiaries. No accountability on ethics, just sue and make that money, since they have the former US asst atty general from Minnesota on board now.


    Remember too that a great deal of insurers are also technology companies too that own tech subsidiaries and easy to hide under the radar this way as an insurer and where rules may prohibit playing with one type of subsidiary, send the other “business type” in and we have no idea what data they exchange but they all are needed to put profit down to the bottom line for share holders. Outside the radar…see how many subs you find here and they are not all listed, even at the SEC…the vanishing subsidiary keeps it complex with regulating such vendors and you know insurers modeled it that way or a lot of it.


  14. Interesting post. Excellent comments.

    At this point, I’d settle for objective HIT “usability” metrics. ONC has yet again kicked that can down the road, as they did with the broader HIT “Quality Management System” 2014 CEHRT spec — which they made OPTIONAL rather than a requirement. See §170.314(g)(4)

    “Quality management system. For each capability that an EHR technology includes and for which that capability’s certification is sought, the use of a Quality Management System (QMS) in the development, testing, implementation and maintenance of that capability must be identified.

    (i) If a single QMS was used for applicable capabilities, it would only need to be identified once. (ii)

    If different QMS were applied to specific capabilities, each QMS applied would need to be identified.
    This would include the application of a QMS to some capabilities and none to others.

    (iii) If no QMS was applied to all applicable capabilities such a response is acceptable to satisfy this certification criterion.”

    That is absurd.

    “Vendors should be willing to commit to their patient engagement promises, present proof showing improved outcomes and face some financial risk for failing to deliver.”

    I won’t be holding my breath. And, I bet the boilerplate disclaimer “…[Vendor] makes no express or implied warranty for merchantability or fitness for any particular use…” remains a staple of all EHR contracts.

  15. Let’s hear it for patient engagement. Who could be against it?
    What it means, however, is another question.
    I know of providers who have a typed line on every piece of paper handed to patients that recommends smoking cessation. This enables them to successfully check a box on meaningful use e-templates (with 100% participation!). For all I know, it may help. But I wouldn’t hold my breath.
    What of patients who find e-portals a pain or intimidating? What of the really sick or elderly patients who can’t access them? What of patients in a panic about a tiny rise or diminution in their BUNs who frantically call only to find out it’s clinically meaningless? A lot of patient engagement is for the worried well…..although that does not mean it’s not wonderful and an admirable goal.
    Of course we all want providers and patients to communicate better; we all want patients to receive information as fast as reasonable (but not faster….who wants an email to inform them they have stage 4 cancer?); of course we want to facilitate feedback to providers about symptoms, adverse events, etc. This is without question. But, here’s my point: Until achieve a useful and consistent definition of patient engagement, it’s more about marketing than about healthcare.

  16. athenahealth, a health IT vendor, could not agree more with the proposition that technology vendors should be held accountable for results. That’s why our entire business model is built around that notion. We don’t charge an up-front licensing fee and then walk away until we’re ready to sell an upgrade. Our remuneration is tied to client performance. Stated simply, we don’t do well unless our clients do well. And because we are cloud-based, we are actively engaged with our clients, helping them meet performance metrics and achieve results, every single day. This is particularly important as we move from fee for service to shared savings models.
    Great post. Vendors SHOULD be held accountable. As more doctors realize that a lot of the dead weight in the health IT marketplace will fall away.