When wearable trackers were introduced, Joseph Kvedar, MD, thought the technology would solve one of healthcare’s thorniest problems: Getting patients to choose healthy disease-fighting behaviors, such as walking after dinner instead of sitting on the couch.

Research on patient engagement indicates that people who are actively involved in managing their health tend to have better health outcomes than those who are less engaged. They are also less likely to visit the hospital or emergency department, spending fewer health dollars.

Patient engagement is considered a linchpin in preventing and managing chronic diseases and conditions, which account for 86 percent of U.S. health spending. But Kvedar, vice president of Connected Health, Partners HealthCare, quickly learned that enlisting patients is not as simple as recommending a one-size-fits-all fitness tracker or smartphone app. While some people are motivated by charting their daily activity or food intake, many are not.

“Most people are not wed to their step count the way I am fascinated with it,” Kvedar says. “I’m one of those people who really enjoy numbers and tracking. But for most, feedback loops alone are not compelling.”

According to a 2016 survey by Gartner, the abandonment rate for fitness trackers is 30 percent. Patient portals have fared even worse. While 88 percent of hospitals offered portals in 2015, only 15 percent of patients used them, found a report from the U.S. Government Accountability Office. Evidence is also mixed on whether these tools positively impact health outcomes. A 2018 meta-analysis found no significant impact on six outcomes, including weight and blood pressure, among patients who used remote monitoring tools.

Rather than being deterred by these less than stellar results, Partners HealthCare and other healthcare organizations pushing for increased engagement are building on lessons from behavioral psychology, user-centered design and other fields to address past mistakes and deploy second-generation engagement tools.

Make it compelling

One reason patients avoid portals and abandon activity trackers is that the tools often are not compelling enough, Kvedar says. “Every minute, our brains are focused on something,” he says. “For our health to be compelling, it has to displace something else, whether that’s a game of Candy Crush or something you’re doing at work.”

Based on years of work developing technology-enabled care programs, Kvedar has identified three factors that help make connected health tools compelling:

  • Make it about life. “If my communication to you is, ‘You’ll have a heart attack in 10 years if you don’t get your high blood pressure under control,’ that’s much less compelling than focusing on relevant, near-term goals like being more productive at your job,” Kvedar explains.
  • Keep it personal. Algorithms can pull in many types of data (e.g., location, weather, wearable data) to send personal motivational messages to patients.
  • Include a social element. Known as the sentinel effect, most people try harder to achieve health outcomes when they know they’re being monitored, particularly by someone whose opinion they care about, such as a physician or family member.

Partners Connected Health incorporated these principles into a software program that encourages people with type 2 diabetes to be more active. Initially, the algorithm incorporated four data streams: activity levels from wearable trackers; location; weather; and the patient’s interest in being active, as measured by the transtheoretical behavioral model (i.e., precontemplation, contemplation, preparation, action, maintenance).

An initial study found that the software got patients walking more, which improved their blood sugar levels compared with a control group. “Each day, personalized, contextual messages were sent, encouraging enrollees to be more active,” Kvedar says. “For instance, the software might send a message like, ‘Tomorrow is going to be rainy, and we noticed that when it’s rainy you’re not as active. Here are three things you can do indoors to be more active.’”

The program continues to be tweaked. Messages initially sent by text are now pushed out via a mobile app, for example, and additional data from users’ smartphones, such as song lists, are also being used to further personalize messages. Partners Connected Health is working with Samsung to develop the next generation of personalized digital and mobile solutions for health and wellness.

Location, location, location

“I think the key to engagement is really understanding where people are at,” says Judith Hibbard, research professor, Health Policy Research Group, University of Oregon. “They’re not all ready to be proactive about their health and take charge.”

Hibbard developed the patient activation measure (PAM), which assesses patients’ knowledge, skill and confidence for managing their health. A PAM survey, licensed by Insignia, can be given to patients to determine where they fall on a four-level activation scale:

  • Disengaged and overwhelmed
  • Becoming aware but still struggling
  • Taking action
  • Maintaining behaviors and pushing further

Hibbard believes digital health technologies are better at engaging people who are already involved in their own health management. “People who are less activated have little confidence, and you need to help them develop some basic skills,” she says. “You probably want to use your staff to reach out to less activated patients.”

Recognizing that patients have individualized needs, Atrium Health, formerly Carolinas HealthCare System, is combining remote monitoring using the Twine Health platform coupled with a human health coach. Patients in the health system’s subscription-based primary care practice, Proactive Health, develop care plans with their physicians and meet regularly with a health coach, either face-to-face or virtually, to pinpoint personalized health goals. The plan and goals are incorporated into Twine, which sends patients reminders (e.g., to take medication) and tracks progress toward goals.

Results to date for this tailored coaching approach are promising. In a group of patients with uncontrolled hypertension, approximately 80 percent reached their target blood pressure within 30 days compared with 30 percent receiving standard care.

The customized goals are key, believes Lindsay Deneault, director of commercialization for Atrium Health’s Innovation Engine. “While the clinical care team can recommend a course of action, it’s not really going to stick unless it fits into the fabric of the patient’s life,” she says. “The patients are the only ones who can provide information about their values, preferences, lifestyle, current knowledge about their illness and the progress they’re trying to make.”

Atrium Health also encourages patients in the program to set small, incremental goals (e.g., one vegetable a day), which reflects the “tiny habits” behavioral model developed by Stanford University psychologist BJ Fogg. This approach can help build confidence in those who are disengaged, says Hibbard. “It takes patience and time, but the important thing is to start people on that journey rather than just labeling them as noncompliant.”

Socially proactive

Research by the United Health Foundation shows that so-called social determinants of health, including poverty, unstable housing and lack of social support, influences 50 percent of health outcomes. These factors interfere with a person’s ability to manage his or her own health. “If you can’t feed your family, you’re not going to focus on your insulin shots,” Kvedar says.

However, Kvedar believes mobile health approaches are well suited for helping patients with social and economic challenges, primarily because mobile phones have become ubiquitous across income levels. One study found that 89 percent of homeless residents had a mobile phone, and 60 percent wanted to receive medication reminders via their phones. “The mobile phone has become the new equalizer,” Kvedar says.

At Chicago’s Rush University Medical Center, providers are writing electronic orders for free food, clothing, housing and other resources for patients in need. The orders are automatically sent to NowPow, an electronic database of community-based resources developed at the University of Chicago. A NowPow algorithm searches for the best-matched resource and sends the Rush patient a text describing where and how to access the recommended service.

Rush has integrated NowPow into its Epic EHR using Fast Healthcare Interoperability Resources (FHIR), HL7’s data exchange standard. “In the olden days, people used interfaces,” says Shafiq Rab, senior vice president and CIO. “We use FHIR.”

The technology also tracks whether patients access the NowPow recommended resource and sends reminders when they don’t. In a recent month, 218 Rush patients used NowPow, which can also connect people to smoking cessation and fitness classes as well as other health resources.

Shared decisions

Shared decision making (SDM) is an engagement technique that helps patients make treatment decisions that align with their values and preferences. “It is considered a meeting of two experts,” explains Kelly Reeves, BSN, RN, clinical and quality research nurse, Department of Family Medicine, Atrium Health. “Patients are the experts on their values, goals and preferences, and the providers bring their expertise about the disease and treatment options.”

Several years ago, clinicians, patients and researchers at Atrium Health began developing an SDM approach to help children and parents with decisions around asthma care. Recognizing the strain on pediatricians to incorporate time-intensive SDM during clinic visits, Atrium Health developed an interactive, digital health coaching experience called Carolinas Asthma Coach™, which collects patient-reported outcomes and provides tailored education about asthma, based on clinical guidelines, to set the stage for SDM.

“To help patients and caregivers engage in SDM and their care process, it is key to not only help them understand the underlying disease, but also translate the guidelines in a way that makes sense,” says Andrew McWilliams, MD, medical director of Atrium Health’s Center for Outcomes Research and Evaluation. “Then they come to their visit prepared with questions specific to their situation and values.”

Carolinas Asthma Coach incorporates a sports theme, and uses animation and humor to engage young patients and caregivers. The interactive platform collects key information about a patient’s symptoms, triggers, treatment goals and preferences. This enables the tool to tailor educational messages and produce a personalized “asthma visit playbook” that can be printed out before a clinic visit.

The playbook starts with a list of topics to discuss with the pediatrician, such as whether a controller medicine needs to be prescribed. It also provides an asthma medication decision aid, which pediatricians use to address a patient’s or caregiver’s medication concerns (e.g., side effects, costs).

Atrium Health is working to integrate the tool into its EHR and provider workflows, and partnering with others to pilot and commercialize the solution.

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