A thousand channels, and nothing’s on. “Patient engagement” has become an increasingly used buzzword in which healthcare finds itself awash. Yet little around patient engagement has been operationalized into any sort of enduring clinical reality. In part, this is due to the lack of convergence, until recently, of three major and arguably requisite ingredients: 1. A practical, operational definition of patient engagement that allows us to measure it continuously and treat it just as we do a vital sign, 2. A manner by which to connect the two most important parties in the patient engagement equation -‐ the patient and physician – between visits in a way that is clinically compatible and meaningful, and 3. An incentive that helps honor and reward a key missing ingredient – the physician -‐ for the time needed to promote engagement directly with his or her patients. We will discuss these three elements and highlight two current pilot studies that are beginning to break through these barriers.
Use of the term “patient engagement” in the media and the gray literature (Figure 1), and in the peer-‐ reviewed literature (Figure 2), has skyrocketed in recent years. One of the biggest problems with the term “patient engagement” is that although many conceptual definitions have been put forth, very few operational definitions exist that can help us turn ideas into action. Without a common currency of exchange for this thing called patient engagement, we are limited in terms of what we each believe it is, and what we can do to promote it. As Stan Berkow eloquently stated in his March, 2014 Huffington Post blog, “While everybody wants patient engagement, nobody really knows what it is or how to measure it.”1 We chase our tails looking for a good thing, not knowing how to get there, or whether we’ve arrived.
Why pay doctors for patient engagement? The concept of paying for engagement is not new. A number of studies have explored offering financial incentives from health plans to members (who are often patients) for engaging in healthful behaviors.4 5 Unfortunately, these studies have had mixed results, and it’s unclear if any long-‐term behavior change can result. Why is this? The answer may be simple. Who amongst us, if asked to engage with an entity or organization rather than a trusted person, is likely to sustain engagement? Engagement is not optimally facilitated through an administrative program; nor is it merely achieved by having a patient log in through a portal. It is created through a contextual experience with a trusted individual – often our doctors -‐ around a health-‐related issue to achieve a goal. Substantiating this concept is a study on patient engagement by the National Institute for Health Care Reform that stated, “Lesson one is that people trust their doctors, and if it’s anyone else that the patient is not familiar with, the outreach does not work.”6 One reason among many that the task of engagement has been relegated to organizational and programmatic activities, rather than to the physician him or herself, is that the physician has neither the protected time, nor the efficient tools to proactively reach out to patients in an enduring and sustainable way.
Pay-‐for-‐engagement (P4E) is a new reimbursement model that aligns physician compensation with patient engagement. Rooted in the principles of Narrative Medicine7 and Relationship Centered Care,8 P4E incentivizes a strong doctor-‐patient relationship, promotes the inclusion of actionable patient-‐generated data, and serves as an economic catalyst to capacitate new proactive, longitudinal, and contextual practice in medicine.9 The P4E model directly compensates doctors for the time, attention, and care they provide in the context of patient engagement, which includes activities such as proactive communication, monitoring, analysis, and interventions that take place outside of (and between) traditional episodic visits.
In this model, compensation may take the form of a one-‐time payment based on activities sustained through an acute recovery period, or it may be a recurring payment for continued proactive management of a chronic condition. In either case, the emphasis is placed on the immediate importance of sustaining a strong doctor-‐patient relationship, as opposed to tying the reward to a distant outcome metric that may or may not be achievable. The P4E model anchors the broader ideals of patient engagement in the pivotal trust relationship between doctors and patients, encouraging new methods of communication that extend the partnership beyond the boundaries of the exam room, and into the enduring context of day-‐to-‐day life.
The Impact of Proactive Communication
As described by Laura Landro in the Wall Street Journal, communication in the physician-‐patient relationship has long been thought of as a “soft” science, but is increasingly understood to be at the root of many of health care’s failures and rising costs.10 Bre a kdow ns in physicia n -‐pa tie nt com m unica tion a re cite d in 40% o r m o re o f m alp ractice claim s. Research by Texas State University and the University of California has shown a 19% higher risk of non-‐adherence among patients whose physicians communicate poorly than among patients whose physicians communicate well.11 The notion of a communication partnership sitting at the heart of patient engagement is further reinforced within the framework of Relationship-‐Centered Care, which recognizes that the “nature and the quality of relationships are central to health care and the broader health care delivery system.” 8
P4E aims to be a catalyst for this doctrine by directly remunerating physicians for fostering partnership with their patients, particularly for activity that may lie outside of and between traditional clinical encounters.
Patient Engagement and Doctor Engagement
While emphasis has lo n g b e e n placed on engaging the patient, an argument can be made to actively cultivate physician engagement as well. At the frontlines of the U.S. healthcare system, doctors are bearing the brunt of regulatory upheaval, technology adoption, and reimbursement reform. As delegates of the healthcare system at large, doctors are often the targets of frustration and resentment, stemming from systemic inequities that are often beyond their control. This has created a tenuous climate for physicians and taken a toll on job satisfaction, stress, and perhaps quality of care.
In this challenging context, how do we motivate the doctor to take that extra step towards patient-‐ centeredness when his or her schedule demands more and more? With the emergence and proliferation of secure electronic messaging through patient portals, physicians are increasingly being tasked with managing high-‐volume electronic in-‐baskets without any additional reimbursement. In one study, over 75% of physicians reported that lack of reimbursement was a barrier to engaging with their patients through secure messaging. 12 A 2003 policy paper of the American College of Physicians entitled, “ACP Analysis and Recommendations to Assure Fair Reimbursement for Physician Care Rendered Online,” urged the Centers for Medicare & Medicaid Services (CMS) to reimburse physicians for electronic care delivered through emails and electronic consultations.13 Former CMS Administrator Donald Berwick suggests that “communication between clinicians and patients can be far easier and multimodal, making the former mainstay of care -‐ the “visit” -‐ only one among the ways to get and give help, and not often the best one, at that.”14 Gradually, CMS has added billing codes that may make reimbursement for telehealth (also called non face-‐to-‐face care) possible in limited contexts including transition care management (TCM) codes, and chronic care management (CCM) codes,15 but there is still a long way to go. As Crotty et al. indicated in their recent Health Affairs article, “As the use of secure messaging becomes more prevalent, a mechanism for reimbursing physicians and accounting for the workload of electronic messaging will be important.” 16 Crotty further indicates that most payers continue to use fee-‐for-‐service reimbursement systems that don’t include compensation for time spent on patient email, with the gloomy forecast that this is unlikely to change in the foreseeable future. P4E, however, specifically challenges that barrier.
By focusing a financial incentive on engagement -‐ the act of participating in an important activity -‐ P4E aligns patient, physician, and payer incentives. Pay-‐for-‐engagement demands proactivity, whereas fee-‐for-‐service is reactive by design. P4E is also fundamentally different from pay-‐for-‐performance and other value-‐based models that tie physician compensation to downstream process of care measures, efficiency standards, and quality metrics. And although P4E is a departure from traditional reimbursement models, it is not mutually exclusive and can be combined with almost any framework. As such, P4E can complement popular incentive programs such as Patient Centered Medical Home and Accountable Care Organizations, which emphasize coordination and share a similar patient-‐centered philosophy.
The Era of Patient-Generated Health Data
If we are to expect physicians to respond positively to reimbursement for engaging their patients, we should equally expect that the engagement take a form that is both meaningful for the patient and efficient and highly actionable for the physician. Biomedical sensors, mobile health apps, and bluetooth-‐enabled devices are rapidly becoming integrated with each other and with clinical systems through interoperable frameworks. Apple’s HealthKit is just the most recent entrant to this space. There are so many patient engagement related data streams demanding the potential attention of the physician, that the doctor simply can’t take them all in, and as a result, often chooses to take none of them in at all. The call for engagement is everywhere, but in the clinic, there is not a drop to drink.
In this era of patient generated health data, increasing opportunities for engagement and communication carry the risk of burying the physician under an abundance of data that are so voluminous that the actionable bits are hidden like the proverbial needle in the haystack. Ultimately, if we are going to use technology, SMS, secure messaging, and sensor-‐based devices to enable patients to track and share their own health data, we must provide the data in filtered, meaningful, and actionable formats to members of the care team. Using patient-‐reported outcome metrics such as those being developed by the Patient Reported Outcomes Measurement Information System (NIHPROMIS.org) for subjective metrics, and using smart algorithms to interpret objective data, we can reduce inbound noise to the clinician, render the data both efficient and actionable, and thereby facilitate physician engagement.
Putting it all together
Returning to our opening paragraph, achieving engagement is about: being able to implement an operational definition of engagement, giving the right people (physician and patient) the right tools (convenient, efficient, actionable) to enable them to execute on an ongoing, contextual care plan, and providing incentives (reimbursement) that honors the work involved in maintenance of engagement.
We can illustrate the pay for engagement model in action by describing two pilot studies underway in California in which a large national payer, and a medical malpractice carrier are reimbursing orthopedic surgeons for successfully maintaining a target level of patient engagement over episodes of peri-‐operative care. Although results from these pilots may not be known for 1-‐2 years, better outcomes and lower costs of care as functions of patient engagement are among the most interesting results that may emerge. Certainly, the findings of these studies may have significant translational implications to other medical specialties.
In these pilot studies, patients are enrolled in procedure-‐specific electronic care plans that consist of schedules of automated electronic check-‐ins served through HIPAA compliant, secure messaging (such as secure email). These automated check-‐in requests, coming directly from the physician to the patient, honor that unique trust-‐relationship and contain mutually agreed upon reminders, guidance, care instructions, and calls to actions. Pre-‐operatively, these may include tasks to get medical clearance, guidance to make medication adjustments, suggestions to prepare the home for post-‐operative recovery, and reminders to arrange for a ride home after surgery. All of these activities focus on the notion that the best post-‐operative outcome is achieved through the best pre-‐operative preparation not only by educating the patient about what to expect, but by providing timely reminders about clinically important actions that can be taken. Following surgery and after discharge, the automated schedule of ongoing electronic check-‐ins may include messages of encouragement, guidance, and symptom assessment through validated scales to monitor clinical concerns.
(1) Operationalizing engagement: In a model in which there is a mutually agreed upon schedule of valued activities, the execution of which can be measured digitally, engagement as a continuous vital sign is measured as a running percentage of electronic care plan actions carried out by the patient. But engagement is not capped by those activities that are pre-‐scheduled. In the pilot studies, a patient who goes above, by proactively carrying out more than only those scheduled items, will increase his or her engagement. The first of the two pilots has already achieved high degrees of engagement, particularly – and interestingly -‐ among those individuals in the 65-‐75 year old age cohort.
(2) Making engagement clinically compatible and meaningful: Through automation, the physicians in the pilot are enabled to concurrently manage many patients asynchronously between visits with minimal impact to their clinical workflows. Through analytical algorithms, exception-‐based rules surface the patients with clinical concerns -‐ the “needles in the haystack” -‐ to the attention of the care staff and/or the physician, and similarly provide reassurance that the majority of other patients are on track.
(3) Creating incentives: Real reimbursement based on real engagement metrics honor the physician for engaging with his or her patients, especially so for the ones requiring attention due to questions or evolving clinical concerns. By treating poor engagement as a vital sign, practices can proactively reach out to low-‐ engagers. And by having a finger on the pulse of patients between visits, practices can intervene earlier than ever before for those patients who develop clinically concerning issues.
Many companies including HealthLoop, Wellbe, Ginger.IO, Conversa, and RoundingWell (just to name a few), are entering the space of the digital, asynchronous visit, connecting patients and physicians in increasingly meaningful ways. P4E, developed in part by Dr. Jordan Shlain, founder of HealthLoop, is a new and powerful approach to bringing patient engagement into clinical reality. With the emergence of meaningful digital metrics of engagement, and with the recognition by more and more risk-‐bearing entities that engaged patients have better outcomes and lower costs, the incentives of patients, physicians, and payers may increasingly align. And when that happens, we may finally be turning the corner on the promise of a blockbuster.17
1. Berkow S. Only Talk Patient Engagement When Activation Is Involved. Huffington Post [Internet] 2014 [cited 27 Oct 2014];
2. James J. Health Policy Brief: Patient Engagement. Health Aff (Millwood) 2013;1–6.
3. Hibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res 2004;39(4 Pt
1):1005–1026.
4. Sandy LG, Tuckson RV, Stevens SL. UnitedHealthcare experience illustrates how payers can enable patient engagement. Health Aff Proj Hope 2013;32(8):1440–1445.
5. Hibbard JH, Greene J. The impact of an incentive on the use of an online self-directed wellness and self- management program. J Med Internet Res 2014;16(10):e217.
6. Yee T, Lechner A, Carrier E. NIHCR: High-Intensity Primary Care: Lessons for Physician and Patient
Engagement. 2012 Oct. Report No.: Research Brief No. 9.
7. Narrative medicine – Wikipedia, the free encyclopedia. http://en.wikipedia.org/wiki/Narrative_medicine , (date last accessed 9 October 2014).
8. Beach MC, Inui T, Relationship-Centered Care Research Network. Relationship-centered care. A constructive reframing. J Gen Intern Med 2006;21 Suppl 1:S3–8.
9. Leonard K. The Rise of Contextual Medicine | HL7 Standards. http://www.hl7standards.com/blog/2013/03/22/rise-of-contextual-medicine/ , (date last accessed 9 October 2014).
10. Landro L. Talking Cure for Health Care: Improve Doctors’ People Skills – WSJ. Wall Str J [Internet] 2013 [cited 27 Oct 2014];
11. Zolnierek KBH, Dimatteo MR. Physician communication and patient adherence to treatment: a meta- analysis. Med Care 2009;47(8):826–834.
12. Kittler AF, Carlson GL, Harris C, Lippincott M, Pizziferri L, Volk LA, et al. Primary care physician attitudes towards using a secure web-based portal designed to facilitate electronic communication with patients. Inform Prim Care 2004;12(3):129–138.
13. American College of Physicians. American College of Physicians. The Changing Face of Ambulatory Medicine—Reimbursing Physicians for Computer-Based Care: ACP Analysis and Recommendations to Assure Fair Reimbursement for Physician Care Rendered Online. Philadelphia, 2003.
14. Liang L. Connected for Health: Using Electronic Health Records to Transform Care Delivery. San
Francisco: Jossey-Bass. 2010.
15. Goodson J, Engel J. Medicare’s Chronic Care Management (CCM) Code: Prepare now for 2015. SGIM Forum. 2014. [cited 3 Nov 2014].
16. Crotty BH, Tamrat Y, Mostaghimi A, Safran C, Landon BE. Patient-to-physician messaging: volume nearly tripled as more patients joined system, but per capita rate plateaued. Health Aff Proj Hope
2014;33(10):1817–1822.
17. Dentzer S. Rx for the ‘blockbuster drug’ of patient engagement. Health Aff Proj Hope 2013;32(2):202.
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Rosener et al’s central premise that patient engagement occurs between two human beings – the doctor and patient – versus technology and patients, is correct. Health care is after all a “social” interaction. All the text messages, patient portals and emails in the world cannot compensate (in terms of engagement potential) for a physician-patient relationship characterized by dislike, distrust or poor communications.
The real challenge for physicians and their stakeholders today is “not how to engage more patients.” Rather the challenge for physicians et al “is how to be more engaging to patients” (who are already engaged
Before a patient shows up in the doctor’s they research their complaints online and with their family/friends. They decide that a doctors visit is necessary and take time to schedule, take time off, and show up for their appointment. While waiting to be seen we make mental lists of what we want to discuss with the doctor.
By definition, people waiting to be seen in the doctors office are engaged in their health. They are 1) interested in the subject matter enough to have schedule the appointment and shown up and 2) they are cognitively and emotionally engaged in the subject of their own health. Showing up constitutes engagement.
Depending upon how engaging the clinician’s “bedside manner” is will determine whether the patient remains fully engaged or becomes disengaged. Most would agree that being interrupted or ignored do not make for an engaging patient experience. Nor does not being able to ask more than one question/visit. The average PCP spends <60 seconds educating patients when prescribing a new medication. Lack of information and health literacy – not a lack of engagement – explains why so many people walk out of the doctor's office not understanding what they were told.
Physicians were taught in medical school that they – not the patient – are in charge of the visit. Their job is to get patients to give them the diagnosis – not be engaged. In fact patients are expected to assume a passive sick role once the exam room door closes which indicates that patients were never supposed to engage in prolonged conversations with doctors.
A clinician's ability "to be engaging" can be measured. My company does it right now by evaluating audio recordings of doctor-patient exam room conversations. We can tell you who does the talking, what is talked about, the role of Health IT, who asks the questions, who sets the visit agenda, who makes the decisions, etc…
Meaningful patient engagement takes place between physicians and their patients beginning in the doctor's exam room. Technology can help enhance that relationship between visits.
Stephen Wilkins, MPH
MindTheGapAcademy.com
“Lower costs for the health care system”
For a health care system run for the benefit of for-profit insurers and their shareholders.
I’ve been involved in a lot of cost-control programs over the years, and I’ve never seen a penny returned to the enrollees.
Count me out from here on.
Stephen, thanks for your comment. You are absolutely right. The literature shows that often, by the time a patient reaches the parking lot after discharging from the hospital or the clinic, they have forgotten 80% of the instructions provided to them.
So, the idea is to provide the patient the rift information at the right time, in bite sized pieces (rather than just as a large bolus at the time of discharge). Particularly in the case of hospital discharge, this is believed to help keep the patient on track and reduce potentially preventable causes of readmission. One of the pilot studies underway is exploring that specific outcome.
Lower costs for the health care system. Engaged patients have fewer potentially avoidable visits to the emergency room, fewer preventable hospital readmissions, etc. Please see article references such as #2 and #17, or anything by Hibbard et al.
Also in references (#4, #5) are studies in which the payers offered financial incentives to patients who were engaged…So yes, there can be mechanism for profits to get back to patients. The problem with those studies was that the engagement was not between a patient and doctor, it was between a patient and a program or a patient and a third party, and the literature has shown (reference #6) that to get patient engagement, the doctor must be involved, not another party.
So, P4E opens the possibility for every party involved to enjoy benefits and to help keep costs – especially costs around preventable/avoidable utilization – controlled. If your doctor knew every day how you were doing after your visit, and could intervene as soon as there was any sign of problem (rather than intervene only after the problem got much worse), then you could avoid that problem landing you in the emergency room or in the hospital.
I’m a big fan of P4E solutions for another reason: the way patients are discharged from hospitals is all too often inadequate (frankly often atrocious). We know this to be true based upon patient satisfaction levels but also due to sizable number of preventable readmissions. P4E is the means to reduce risk of readmission and now, associated financial penalties.
But don’t believe me… here’s what AHRQ says: “No consensus exists on how to ensure patient safety after hospital discharge, but some evidence indicates that comprehensive, multi-modal interventions may be more effective at preventing rehospitalization than targeting individual components of the discharge process.”
And while there’s no specific evidence that P4E is the exact type of “multi-modal intervention” referenced, intuitively, texting with your doctor is better than being handed a brochure and five pages of discharge instructions to follow. All too often patients simply ignore that junk and end up panicking on what to do, so back to the hospital they go. Or how many times does a patient call their doctor’s office only to be told by the staff or nurse that “I can’t answer that question, you’re going to need to see the doctor.”
The penalties will certainly motivate experimentation and P4E is going to be an approach that many should be willing to try.
“You don’t think any of the savings will get back to the patients, do you?”
My cynical nature says NO because this system is only about higher profits for everyone except the patient, but the ACA is supposed to limit insurance profit % – isn’t it?
Remember, “lower costs” is always a euphemism for “higher profits for United, Aetna, and Cigna.” You don’t think any of the savings will get back to the patients, do you?
“…high patient engagement is show to lead to better outcomes and lower costs.”
Lower costs for the doctor? How is that an incentive? I get you on docs would want better outcomes, but spending 30 minutes with the patient instead of 15 minutes probably would also.
Physicians still make money the same way as they currently do, but they are given an added incentive for engagement because high patient engagement is show to lead to better outcomes and lower costs.
Communication is key and sometime needs a advocate to step in and bridge the gap between the patient and physician. Most of the time it only take an appointment or two to get them going on the same page. It’s a beautiful moment when that happens. http://www.viveesa.com
Being engaged sounds like a lovely relationship but how are the providers going to make money?
What compares to surgeries and expensive relatively useless lab tests and drugs?
Don Levit
these are not computer generated.
They are narratives that are thought out by medical teams.
No off-shoring. Doctors need to be on the other end of the responses to give contextual, exception based information about who they should be worried about NOW…
No third parties. We need to connect doctors to patients directly. Get everyone else out of the way. They are complicit in the Principal Agent Problem.
We need to measure engagement; which is another way of saying ‘communication’.
We wake up and all we do is communicate…all day long….so let’s lubricate the communication, in a meaningful way, between doctors and patients.
It’s good medicine.
One cannot oursource relationships. You can try, but show me where it has succeed. The magic of pay for engagement (via a digital medium) is that you are proactively, contextually checking in with patients that goes right back to the medical team that takes care of you.
Trust is built on being valued and being included….and this is a critical factor in relationship building. Furthermore, where there is trust, there is a higher liklihood to change behavior.
In medicine today, a lot of quality measures are already implemented. These are often determined at an administrative level and include measures such as HEDIS, PQRS, NSQIP, etc. In many settings, physician incentives are tied to performance on such measures at points downstream of the clinical encounter. So to say that the old fashioned doctor patient relationship should be left unfettered is neglecting that that horse has already left the barn. And in truth, some of these metrics have resulted in much better care, better outcomes, and lower costs.
That’s the good news. The down side is that to date, we have not provided the doctor with any tools or incentives to remain engaged with the patient after the clinical encounter (even though most patients would gladly welcome an ongoing contextual relationship). P4E is one such mechanism to do so because it aligns many incentives, and it reduces the disconnect between the encounter and the outcome measure of many of the current metrics that are already in place. There is no “off shore” outsourcing or customer service lines with P4E. P4E starts with the face-to-face encounter, and continues with ongoing electronic check-ins between the same two people – the physician and patient – who had the encounter together. It is an ongoing dialogue between those two parties – not a third party. As the evidence has shown, introducing a 3rd party breaks down the trust relationship between the doctor and patient. P4E honors the relationship between the two most important people, the doctor and patient.
Sorry, but computer generated electronic reminders are not the engagement I was looking for – Granpappy has a point. Why would the doc be paid extra for the computer’s work. Would off-shored (or other) doctor associated chat lines be engagement? The further from the source the worse it gets – just like our food.
I don’t know about the rest of you but my experience with “customer service” chat lines or emails are not handled by anyone with knowledge or engagement – they just read the product manual.
Perry:
I agree with you.
Why should we measure a quality which already should be part of the process?
We want to measure things, for we feel we have a sense of control by doing so.
If the doctor and patient are engaged and they are happy with their relationship, why not have the patient pay the doctor a bonus?
Why not have the doctor provide the patient a gift?
Why get a third party involved?
It merely invites fourth and fifth parties to do the “measuring” and the “adminisrtation.”
Don Levit
??????????????????????
If you read the original post and then my comments, you’ll understand that my scorn is entirely directed at the numbnuts in California who think that sending out spam-like e-mails with a doctor’s name at the end constitutes patient engagement.
The emails follow the face-to-face visit in which the doctor indicates to the patient that there will be follow up together, facilitated by electronic check-in requests (via secure messaging). This keeps the patient engaged in a real personal relationship initiated in the clinical encounter, and these ongoing interactions continue to strengthen that relationship over time.
I’m done with the racist comments on this blog. From now on grounds for banning.
Why don’t you mention your views to the indian specialist you refer your patients to? Just attach a nice note to the patient
Since your views on cusotmer service are so well thought out, maybe try calling your local HMO or cable company and see what kind of customer service you get
I’m confused. It seems like in the course of old-fashioned medicine, the patient would see the doctor, doctor would make an assesment, make recommendations and discuss with patient, the patient would pay the doctor.
Then came all kinds of insurances, HMOs, PPOs, review boards, etc, etc, to decide what is best for the patient (or at least what they will pay for).
Then the government comes up with EHR, MU, PQRS. We have ACOs, P4P now, P4E. The way I see it old-fashioned doctor-patient relationships are being subsumed by all these other entities and requirements.
What we’re looking to do is pay doctors for what they should be doing anyway but they’re too busy doing other required stuff to do now. Amazing.
“These automated check-‐in requests, coming directly from the physician to the patient, honor that unique trust-‐relationship”
That the e-mails described in the California trial could very easily be outsourced to where labor is cheaper and just have the patient’s and doc’s names filled in. Not my idea of a “unique trust- relationship.”
What’s your point about Bangalore, “Granpappy?”
Excellent and important. Many many years ago during physician advisory boards we would hear about how there needs to be pay for cognitive services so physicians could counsel and speak with patient. I’ve completed a post on this “The Office Visit is Not a Drive By”
http://www.bioc.net/blog/2012/5/9/the-office-visit-is-not-a-drive-by.html?rq=Drive%20by
And
“Changing the Office Visit From Transaction to Value Experience”
http://www.bioc.net/blog-2/2012/5/23/changing-the-office-visit-from-transaction-to-value-experien.html?rq=Drive%20by
Let’s see:
If the doc calls the patient and they have a lengthy discussion about medical concerns, that’s not engagement and shouldn’t be paid for;
But if someone in Bangalore sends the patient a boilerplate e-mail with the doc’s name on it, that is engagement and should be paid for.
Got it.