Q&A: Eric Dishman on patient engagement

Eric Dishman

Eric Dishman, Intel Fellow and director of health innovation and policy for Intel's Digital Health Group, has been working on issues around patient engagement – and the technologies that enable it – for more than 20 years.

Healthcare IT News spoke with him recently about the challenges to getting people more involved in their own care, the value of mobile health devices and patient portals, and his vision for a future with more empowered patients.

How have you seen the approach to patient-centered care evolve over the past few years? In a way, it's started to evolve with the whole mHealth movement. And the focus on consumer apps. That's certainly brought a lot of attention to the possibilities of patient-centered health. I'm a little concerned about the way it's going in that regard, though, because there's a lot of hype and very little reality.

I go to the mHealth conferences, and I'm the first person who will stand up and believe – and we have prototyped at Intel a range of mHealth solutions – I am absolutely convinced that the role of the smartphone in our life, it's going to be a coaching tool, it's going to be a diagnostic tool, it's going to be a reminding tool, and you're certainly seeing applications built out from that.

But people will say to me, 'There's 65,000 apps for health in the iTunes store.' But I say, '12,000 of them are diabetes apps, maybe six of them have ever been downloaded more than once, and two of them have been used continuously.'

When people go to iTunes, they're downloading Angry Birds. Yeah, you never see anything in the Top Ten list of most downloaded anything that's a healthcare app. And then if you look at usage, as opposed to downloads, it's even lower. So, directionally, it feels like there's all this attention, there's the 2.0 movement and patient-centered hype. But what no one's done yet is fundamentally change the role the patient is supposed to play, in terms of doctor-patient interaction.

We're approaching it at Intel from a different direction. We've been studying team-based care models from around the world. Forget the IT for a moment. Let's figure out – in France, in Germany, in the U.S. – where are good team-based care models where patients themselves are treated as a legitimate and trained member of their own care team. And there are some – not a lot, but there are some of these models we can learn from.

If that's the sort of seed, and you're forming the foundation of a new kind of expectation of the relationship between patient and doctor, then how could you use IT tools to enhance that relationship?

Because it's really about the relationship, and not the IT tools, but right now I feel like there's so much attention on the apps that are coming out. Until you really change the patient-physician relationship, and expand the care team to the patient, the family member, the neighbor, the untrained volunteer health workers, the nurse, the nurse practitioner, the doctor – when you can orchestrate among those, using social networking tools, reminding tools, online education and coaching, then it starts to be interesting.

So, as a technology company, we've kind of taken the opposite approach, studying people and then looking at how IT can scale things up.

Obviously, policymakers feel this is an important area, and they're making a big push to bring the patient more into the fold: Meaningful use Stage 2 puts patient engagement more at the forefront. But ultimately there's only so much IT can do. And then it's up to Joe Q. Public out there to take responsibility for his own health. And that means undoing the hundred years of patient passivity that we have trained people to live. It's a big challenge. I've been doing cancer patient advocacy for 22 years now. And the first thing you have to do is teach people not to come into their healthcare as some sort of passive automaton.

And not, quite frankly, to adopt this kind of entitlement mentality that says, 'Good care means everything thrown at me but the kitchen sink.' And undoing that expectation, particularly in the U.S., has been a big challenge.

Starting next year, in 2013, Intel employees will have some skin in the game, not just to adopt a consumer driven health plan, but to show that they're making meaningful progress toward health goals they make with their doctor, they will take a percentage of the savings we eke out of the program because of that.

For all this talk of bundled payments and ACOs, until the patient is part of the care team, and gets some reward, and there are carrots that can be customized to you, I don't think you're going to change a lot. There's a lot of talk about patient centered care, but it doesn't feel very patient centered.

What are some of the things you're perhaps a bit pessimistic about at the moment? I'm pessimistic that there's all this talk of care coordination, and meaningful use of electronic health records, and no one has asked the fundamental question of what are the standards for a care plan?

If you go into your physician in the U.S. today and you ask for a copy of your care plan, I'll bet fewer than 1 percent of them would be able to give you one.

If you're being discharged from a hospital where you've been for the past two weeks, there's a copy of your care plan. Everyone in the hospital has been using it to get you out on time. But once you walk out and walk into the office of your primary care doc … as an advocate, I tell people to ask for their care plans, and the physicians sort of look at them like, "What in the world are you talking about?"

There are, through AHRQ and other organizations, examples of standardized formats for care plans. But if we're really serious about behavior change, if we're really serious about coordinated care, how can you really accomplish any of those unless there's a care plan that says 'Here are the health goals this patient has for the next six months, year, three years.'

One of the things my policy team is trying to do around the world is say, "Care plan first, and then let the technology sort of reflect that care plan." It turns the EHR into a useful tool for everyone involved. Particularly when you're dealing with people with chronic conditions, or seniors – people seeing an average of 12 physicians.

Do you think there are physicians out there who don't want smart, engaged patients? After all, it makes their job harder, in a way. I think the financial incentives will change. We've been studying physicians around the world for the last decade, and they move from fee-for-service to some sort of salary based payment. Unbelievably resistant at first. Human nature. And then a month into it: 'Oh my god, this is why I went into medicine in the first place.'

The principle we've been trying to instill is called Care Flexibility. And the principle is this: If my physician can make life or death decisions about what scalpel he's going to use to do my kidney surgery. But they're not empowered to make a decision about what modality of care to do as a follow-up – is it secured messaging, is it an in-clinic visit, is it a home visit, is it a virtual visit\

Today we're sort of prescribing that all care should be face to face, and it should be in 30-minute visits you can bill for. It's crazy. We don't have any sort of flexibility in the creation of the relationship between the doctor and the patient. And I think that's one of the things that's kept this variety of tools we've seen over the last decade – mHealth, PHRs – from taking off.

I think there is resistance when you look at it from the filter of the old payment model. And right now there's so much anxiety about an ACO and what it means. But when [doctors] get on the other side of it, and they realize that, 'This patient needs five seconds of care and a quick phone call; this patient need 50 minutes of detailed investigation; and now I've got the modalities to customize care to whatever the patient's need is,' a lot of them will be so happy that kind of factory line mentality of seeing patients is gone, and now it's all about delivering the best quality care.

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