Increasing Consumerism in Healthcare Through Intelligent Information Technology
Published Online: December 23, 2010
Seth B. Cohen, MBA, MPA; Kurt D. Grote, MD; Wayne E. Pietraszek, MBA; and Francois Laflamme, MBA
On a Saturday night at 10:15, John, a 45-year-old man with type 2 diabetes, arrives at the emergency department (ED) of his local hospital. John checks in with the admitting nurse and explains his visit. He has exhausted his insulin supply, has forgotten to ask his general physician for a prescription, and is now light-headed. After registering, John sits and waits to be seen.
At 12:45 am, the triage nurse leads John into an examination room to administer a series of tests. Upon discovering that his blood glucose levels are high, the nurse assigns John a bed so that a physician can evaluate his hyperglycemia and determine the appropriate treatment.
By 1:15 am, John ultimately resolves the reason for his visit to the ED, but at a cost that many would consider excessive. John’s health plan likely paid $500 for an emergency intervention that could have cost many times less. One reason for the high cost is that, without access to John’s medical history, the triage nurse needed to administer tests to check for kidney failure, blood pressure, and glycosylated hemoglobin levels. An ED physician dedicated 30 minutes to a nonemergent need rather than focusing on more critical patients. The time John spent in a hospital bed resulted in longer waits for other patients, and the hospital suffered from slower throughput. Also, John spent almost 3 hours of his time resolving an issue that should have required a few minutes of clinical attention. Despite the clear inefficiencies, this scenario is quite common; in fact, approximately 83% of all ED visits could have been resolved in nonemergency settings and at far lower cost.1
One reason this scenario is so common is that many patients do not pay adequate attention to the management of their own care. As a result, payers and providers are increasingly investing in new care delivery models and incentives that encourage greater patient engagement. These players hope to discourage historical patient behaviors that include waiting to react to instructions or largely ignoring the cost of care. Instead, the goal is to create healthcare consumers that, like retail consumers, invest the time in making the right decisions and seek value in the products they purchase. By encouraging this new pattern of patient behaviors—what we term consumerism in healthcare—payers and providers are able to save on costs, improve quality of care, and remain competitive. If John were more engaged in the management of his diabetes, his circumstances would have likely looked different. In fact, it is unlikely that he would have needed to visit the ED. Instead, as an example, John might have relied on a handheld monitoring device to remind him to refill his insulin prescription. Such a device, perhaps offered for free by his employer to reduce emergency care costs that result from inattention, would have alerted John if his glucose levels reached unacceptably low levels. Alternatively, he might have relied on a text message from his pharmacist, triggered automatically due to how much time had passed between prescription refills. Or, if by ignoring his alerts and reminders John still needed care on a Saturday evening, he might have logged into his patient portal to find a pharmacy that was open and able to access his medical profile, or used his iTriage mobile app to identify the closest clinic with the shortest current wait time.
Even if John had ended up in the ED, consumerism tools would have supported a different outcome after his visit. The visit would have been logged in his electronic medical record (EMR). By Monday, the nurse assigned to John’s customized diabetes management program would have noticed the visit after a routine check of his recent activity. The nurse might
then initiate a video chat with John from his home to remind him how to use his handheld monitoring device. This nurse might even encourage him to check in with his company nutritionist and to exercise this month in order to qualify for the discounted premiums offered by his insurance plan.
UNDERSTANDING CONSUMERISM IN HEALTHCARE
As illustrated in this alternative scenario, healthcare consumerism can yield important benefits for both patients and providers. Such benefits can be distinguished in 3 key areas: wellness and prevention, disease management, and care utilization (Table 1). The benefits of consumerism will likely become more relevant due to current industry, consumer, and technology trends.
On the industry side, pressures among payers to reduce costs will require hospitals to provide alternatives to traditional, expensive care delivery models. Some payers, for example, are debating whether to increase copayments for ED visits, which will deter people like John from defaulting to emergency care. Payers also are moving to outcome-based reimbursement, which means that providers will need to manage risk in care delivery. If providers are “on the hook” for specific outcomes, then there is more incentive to involve patients, because they are a major determinant of the delivery outcomes associated with interventions.
There also are industry pressures on the demand/patient side. As a result of recent health reforms, there will be an influx of newly covered Americans who will seek care startingin 2014 when legislative initiatives take effect. Servicing this new demand at a system level through traditional, hospitalbased channels will be increasingly difficult.
On the consumer side, one relevant trend is the rise in costsharing. As a result of escalating healthcare costs, employers are increasingly pushing costs onto consumers in the form of higher deductibles and copayments, and the use of health savings accounts. Recent legislation will likely accelerate this trend as individuals enroll in bronze and silver plans on state health exchanges that entail high cost-sharing with the beneficiary.
Another driver of consumerism is the growth of behaviorally induced chronic diseases. The incidence of diabetes, for example, has nearly doubled over the past 10 years.2 The complex, systemic nature of chronic disease is a key driver of spiraling costs. Part of the solution is greater consumer responsibility, facilitated by new advances in technology.
From a technology perspective, the recent focus on and investment in healthcare information technology (HIT) has resulted in a proliferation of new products and opportunities to engage consumers more effectively. A large driver of this focus on HIT is the American Recovery and Reinvestment Act (ARRA). Passed by Congress in 2009, ARRA encourages meaningful use of technology—through substantial incentives and penalties—among healthcare providers in the United States. The vision of meaningful use is one in which patients are fully engaged in their healthcare, providers have real-time access to all medical information and tools to help ensure the quality and safety of the care provided, and patients are afforded improved access without healthcare disparities.
Not all ARRA requirements have been completely defined. (Only stage 1 ARRA requirements are in place. Stage 2 and stage 3 requirements currently are only recommendations by the HIT policy committee.) However, the requirements do indicate the need to provide patients with an electronic copy of both their health information and discharge instructions at the time of discharge. In addition, providers are required to “use certified EHR [electronic health record] technology to identify patient-specific education resources and provide those resources to the patient if appropriate,” as worded in legislation of ARRA. Other likely requirements (in either stage 2 or 3) will include secure patient-provider messaging, integrated data from home monitoring devices, and access for all patients to personal health records populated in real time with data from EHRs.
Given the emphasis in the legislation on HIT investment and specific applications to improve patient engagement, we believe that ARRA will accelerate the adoption and scope of consumerism in the next few years.
ROLE OF HEALTH INFORMATION TECHNOLOGY
Although the benefits of consumerism extend across care settings and build upon various trends, one theme is constant: the need for robust HIT. The role of HIT is critical because consumerism depends on the ability to interact with information that changes frequently and can be accessed across different settings. Effective chronic disease management, for instance, depends on the availability of up-to-date progress reports that can be accessed by physicians, nurses, and the patient.
Successful examples of consumerism reinforce the need for technology. The Veterans Affairs healthcare system and Kaiser Permanente have leveraged significant investments in HIT, including the early adoption of EHRs, to execute effective care management programs. Regional systems in Alberta, Canada, and Valencia, Spain, have won accolades for their use of technology to encourage greater patient choice, provider competition, and ultimately, greater efficiency.
We believe that 4 technologies in particular enable new, real-time interactions with patients: telemedicine and remote care management, clinical decision support, EHRs, and health intelligence. Coupled with well-designed behavior change programs, these technologies can improve patient engagement (Table 2).
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