Content uploaded by Christopher A Longhurst
Author content
All content in this area was uploaded by Christopher A Longhurst on Jul 06, 2020
Content may be subject to copyright.
Available via license: CC BY 4.0
Content may be subject to copyright.
By Ming Tai-Seale, N. Lance Downing, Veena Goel Jones, Richard V. Milani, Beiqun Zhao, Brian Clay,
Christopher Demuth Sharp, Albert Solomon Chan, and Christopher A. Longhurst
Technology-Enabled Consumer
Engagement: Promising Practices
At Four Health Care Delivery
Organizations
ABSTRACT
Patients’journeys across the care continuum can be improved
with patient-centered technology integrated into the care process.
Misaligned financial incentives, change management challenges, and
privacy concerns are some of the hurdles that have prevented health
systems from deploying technology that engages patients along the care
continuum. Despite these sociotechnical challenges, some health care
organizations have developed innovative approaches to engaging patients.
We describe promising technology-enabled consumer engagement
practices at two community-based delivery organizations and two
academic medical centers to demonstrate the approaches, sociotechnical
challenges, and outcomes associated with their implementation.
Leadership commitment and payer policies that align with the
quadruple aim—enhancing patient experience, improving population
health, reducing costs, and improving the work life of health care
providers—would encourage further deployment and lead to greater
consumer engagement along the care continuum.
The original aims of the federal
meaningful-use legislation for the
development and dissemination of
health information technology in-
cluded patient and family engage-
ment.1,2 While consumers book flights and make
financial transactions from mobile devices, their
health care experience varies remarkably de-
pending on the degree to which patient-centered
technology is integrated into that experience.
It has been over twenty years since some pa-
tients gained secure online access to their health
information, such as laboratory test results, by
way of patient portals tethered to institutional
electronic health records (EHRs).3–5These por-
tals are intended to provide patients and their
caregivers with timely electronic access to their
health care information. Recent enhancements
enable patients to also enjoy the convenience of
scheduling appointments online, securely mes-
saging their care teams, and reviewing clinic
notes.6Many patients can access these tools
from their mobile devices. Requirements
for privacy and security pose challenges for
usability,3,4,7,8 however, and call for creative sol-
utions that would reduce user burden without
compromising security.
While most portals are optimized for outpa-
tients, an increasing number of health care or-
ganizations are implementing these solutions in
the inpatient setting, where patients have unmet
information and communication needs9,10 and
also value having some control over their physi-
cal environment.11 Patient-centered technology
deployed in this setting can help meet those pa-
tient needs by identifying the care team and pro-
viding real-time access to test results, medication
information, and hospitality amenities.4,5,12 The
literature is relatively silent, however, on how
health care organizations can improve hospital-
doi: 10.1377/hlthaff.2018.05027
HEALTH AFFAIRS 38,
NO. 3 (2019): 383–390
©2019 Project HOPE—
The People-to-People Health
Foundation, Inc.
Ming Tai-Seale (mtaiseale@
ucsd.edu) is a professor in the
Department of Family
Medicine and Public Health at
the University of California
San Diego (UCSD) School of
Medicine, director of
outcomes analysis and
scholarship at UC San Diego
Health, and director of
research at UCSD Health
Sciences International,
in La Jolla.
N. Lance Downing is a clinical
assistant professor of
medicine at the Stanford
School of Medicine and
program director for the
Stanford Program in
AI-Assisted Care, both in Palo
Alto, California.
Veena Goel Jones is medical
director of digital patient
experience and a pediatric
hospitalist at Sutter Health
and an adjunct clinical
assistant professor of
pediatrics at the Stanford
School of Medicine.
Richard V. Milani is chief
clinical transformation officer
at Ochsner Health System in
New Orleans, Louisiana.
Beiqun Zhao is a National
Library of Medicine/National
Institutes of Health
biomedical informatics fellow
and a general surgery resident
at UC San Diego Health.
Brian Clay is a chief medical
information officer at UC San
Diego Health and a clinical
professor of medicine at the
UCSD School of Medicine.
March 2019 38:3 Health Affairs 383
Patients
&
Consumers
Downloaded from HealthAffairs.org on March 04, 2019.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
ity features of inpatient care while enhancing
patient and family engagement in the care proc-
ess.13 Hospitals have been encouraged to bridge
the digital divide (the differences in use of digital
technology between patients of different ages,
races, incomes, and education levels)14 by pro-
viding technological solutions to all patients.
However, it is relatively unknown how patients
and families may use hospital-provisioned mo-
bile devices to control their inpatient rooms and
access the inpatient patient health portal.
The goal of this article is threefold: to describe
consumer engagement technology projects at
four institutions, including two integrated deliv-
ery networks (Ochsner Health System and Sutter
Health) and two academic medical centers (Stan-
ford Health Care and University of California
[UC] San Diego Health); highlight the sociotech-
nical challenges and lessons learned (positive
and negative) from these efforts; and synthesize
the case studies in the context of patients’jour-
neys across the continuum of care, comparing
them and suggesting directions for advancing
consumer engagement.
Ochsner Health System
Ochsner Health System is a not-for-profit inte-
grated delivery system in Louisiana that serves
over 700,000 patients a year. Ochsner employs
over 1,200 physicians and operates over ninety
clinics and twenty hospitals, assuming varying
degrees of financial risk for approximately
30 percent of the patients seen.
In 2015 Ochsner focused on reengineering
care between office visits for ambulatory care
patients with chronic disease. Because Louisiana
ranked fourth in the nation in hypertension
prevalence, Ochsner first sought to develop a
new model for delivering chronic disease care
to patients by leveraging technology and sharing
information with the goal of improving hyper-
tension control rates.
In the initial pilot in New Orleans, Baton
Rouge, and Covington, patients with uncon-
trolled hypertension were enrolled in the Hyper-
tension Digital Medicine Program through or-
ders from their providers. Patients completed
online surveys through MyChart (a widely used
patient portal product sold by Epic Systems) that
evaluated diet, physical activity, health literacy,
medication adherence, patient activation,15 so-
cial determinants of health16 (including medica-
tion affordability, number of people living in the
home, and caregiver support), and depression.
Along with clinical data from the EHR, these
patient-reported data were used to create a
unique patient phenotype for each patient and
guide individualized interventions. Patients
were provided with an electronic blood pressure
device that transmitted home blood pressure
readings directly into the EHR as they were tak-
en. To meet the needs of many patients who were
unfamiliar with digital tools, Ochsner created
the O Bar, modeled after service bars in comput-
er stores, at primary care sites. The O Bar pro-
vides initial setup of the home blood pressure
device plus health education, training, and tech-
nical support in the use of connected home de-
vices and health apps.17 Patients were asked to
take no less than one blood pressure reading per
week. If the care team had not received a reading
for eight days, patients would receive an auto-
mated text alerting them that a blood pressure
measurement was needed.
Doctoral pharmacists and health coaches are
integral members of the care team—called an
integrated practice unit—that provides patient
education, drug management, and lifestyle rec-
ommendations as per hypertension treatment
guidelines. In addition, custom visual tools were
developed within the EHR that describe the
patient’s social determinants,16 trending blood
pressure over time, hypertension-related co-
morbidities, patient activation level,15 health
literacy, and relevant lab results that assist in
optimizing the effectiveness and efficiency of
the care team. Care team members contact pa-
tients by phone and review screening results and
treatment options for improving blood pressure
control. Patients are encouraged to work with
the care team to cocreate the treatment plan
by choosing among various lifestyle and medica-
tion options.18 Besides direct contacts by the care
team, patients receive monthly reports by the
patient portal and postal mail that describe their
progress to date, along with additional tips to
create better control.
Compared to propensity score–matched con-
trols who received usual care, at six months digi-
tal medicine patients had more blood pressure
measurements recorded in the EHR (93.0 versus
1.6) (exhibit 1). They had more frequent inter-
actions with their care team, or clinical touches
(130 versus 12). Furthermore, they demonstrat-
ed greater medication adherence as measured by
the proportion of days covered, a leading method
used to calculate medication adherence at a
population level.19,20 Medication adherence im-
proved 14 percent among patients in the digital
medicine program and declined 2 percent
among patients in usual care. Digital medicine
patients also achieved greater blood pressure
control (79 percent versus 26 percent) and ex-
hibited higher levels of satisfaction (84 percent
versus 72 percent). Moreover, primary care
physicians experienced a 29 percent reduction
in the number of in-clinic visits from participat-
Christopher Demuth Sharp is
chief medical information
officer at Stanford Health
Care and a clinical associate
professor at the Stanford
School of Medicine.
Albert Solomon Chan is chief
of digital patient experience
and an investigator at Sutter
Health and an adjunct
professor at the Stanford
Center for Biomedical
Informatics Research,
Stanford School of Medicine.
Christopher A. Longhurst is
chief information officer and
associate chief medical
officer at UC San Diego
Health, and a clinical
professor of medicine and
pediatrics at the UCSD School
of Medicine.
Patients
&
Consumers
384 Health Affairs March 2019 38:3
Downloaded from HealthAffairs.org on March 04, 2019.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
ing patients, thus reducing their workloads and
enabling greater access for other patients (data
not shown).
In 2016 the program was expanded to all
Ochsner locations, and it now has over 3,000
active participants. Furthermore, it has created
the infrastructure for additional programs in
managing other chronic diseases, including
diabetes and chronic obstructive pulmonary dis-
ease. Patients and providers alike have found the
program to be life changing. The chair of primary
care told coauthor Richard Milani: “This has dra-
matically changed how we approach chronic dis-
ease care. We forgot what help looked like until
this program.”
Sutter Health
Sutter Health is a not-for-profit health care
delivery system that serves over three million
patients annually. In response to consumer de-
mand for care opportunities beyond the office
setting, in 2001 the Palo Alto Medical Founda-
tion, a Sutter Health affiliate, became the first
health system in the nation to implement
MyChart, Epic Systems’vendor-based patient
portal.7Sutter’s experience provides lessons
learned about engaging patients, addressing un-
intended consequences as portal engagement
matures, and ultimately the positive clinical ben-
efits of such engagement.
In contrast to the national experience, where
only a limited percentage of patients use patient
portals,21 as of July 2018 over 79 percent of pa-
tients seeking ambulatory care at Sutter Health
had enrolled in the portal. Systemwide engage-
ment of all stakeholders is key. Executive
commitment is exemplified by inclusion of en-
rollment tracking on a dashboard. Clinical oper-
ations leaders track nursing staff performance
on enrollment of patients during clinical en-
counters. Peer review reports transparently
show patient portal adoption rates per clinician.
Delivering tangible patient and clinical value is
critical to sustaining engagement. One of the
most important functions provided by a patient
portal is enabling patients to securely message
their clinicians and supporting clinicians to an-
swer them in a timely way.7,22 Initially, patients
were asked to pay a $5 monthly fee to use the
messaging function, and 13 percent of patients
who were enrolled in the portal paid the fee and
engaged in secure messaging. A survey of portal
users suggested that 65 percent of these patients
had reduced one or more office visits annually,
and over 70 percent were satisfied with the mes-
saging service.5,22
In response to market competition, Sutter re-
moved the monthly user fee for secure messag-
ing for Palo Alto Medical Foundation patients,
increasing the messaging-eligible population
from 13 percent to 100 percent of enrolled pa-
tients. Sutter used a three-pronged approach to
enable clinicians to respond in a timely fashion
to the anticipated increased volume of messages.
First, to support change management, multiple
town hall meetings were held to engage clini-
cians in developing solutions. Second, medical
assistants or nurses were tasked with addressing
patient messages first when appropriate, and
clinical guides for addressing common patient
message themes were provided to clinicians.
Third, to recognize the value of the work provid-
ed by the clinicians, an incentive program was
established to reward the answering of messages
within one business day. In 2011 the average
response time dropped to about four hours, de-
spite a sixfold increase in messaging volume.
Patients used the portal to exchange almost six-
teen million secure messages with clinicians in
2017, and over 90 percent of patient-initiated
messages were answered within one business
day.
Other components of Sutter’s patient portal
include online appointment scheduling,
automated wait-listing of appointments, and
booking of same-day video visits for low-acuity
Exhibit 1
Six-month outcomes for patients of Ochsner Health System enrolled in the Hypertension
Digital Medicine Program, compared to those for propensity score–matched patients in
usual care
SOURCE Authors’analysis of outcome data for patients of Ochsner Health System enrolled in the
Hypertension Digital Medicine Program over three years. NOTES The program is explained in the text.
Clinical touches include outpatient visits; patient portal communications between provider and
patient; letters, calls, and texts; and patient-generated health data transmitted to the health team.
All differences in outcomes between the two groups were significant (p<0:05 for percentage of
days of medication adherence, explained in the text, and satisfaction; p<0:01 for all other differ-
ences). BP is blood pressure.
March 2019 38:3 Health Affairs 385
Downloaded from HealthAffairs.org on March 04, 2019.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
conditions seven days a week. The wait-listing
function enabled wait-listed patients to see pri-
mary care clinicians fifteen days earlier and to
see specialists twenty-six days earlier than ini-
tially scheduled. The number of video visits for
low-acuity conditions has grown eightfold since
launch in March 2018.
To help patients engage in self-management of
their health, patient-centric decision support
tools concurrently alert clinicians in the EHR
and patients in the portal to address screening
and disease monitoring concordant with
evidence-based recommendations. Guideline-
concordant reminders of hemoglobin A1c moni-
toring among patients with diabetes improved
the rate of A1c test completion by 33.9 percent
(p<0:01).23 In a clinical trial of online disease
management delivered via the patient portal,
patients with previously uncontrolled diabetes
had a significant reduction in HbA1c at six
months, compared to usual care (a reduction
of 1.32 percent versus one of 0.66 percent;
p<0:001).24
Sustainment of patient engagement is facili-
tated by a dedicated service center that provides
support twelve hours a day, five days a week. In
2017 there were over 400,000 customer service
support encounters with patients via phone,
chat, and email to facilitate continuous access
to the portal. An average of approximately
450,000 unique users log into the portal
2,500,000 times per month.
Stanford Health Care
Stanford Health Care is a not-for-profit multihos-
pital health system that includes more than 100
affiliated faculty and community-based clinics.
As Stanford Health Care grew from a single ter-
tiary medical center to a regional health system
with community primary and specialty care, dig-
ital engagement with patients became increas-
ingly important to provide efficient access to
administrative services, connect with patients
between visits, satisfy a growing demand for ac-
cess to health data, and enable remote monitor-
ing of high-risk patients.9,25 Stanford’s priorities
were to increase patient portal enrollment and
usage, enable patients to access their own medi-
cal data and records, and monitor and respond to
patients’symptoms between visits.
While patient portals have grown in function-
ality, sign-up rates are often low owing to rigor-
ous but onerous identity verification processes.
To facilitate enrollment, Stanford automatically
verifies patient identity during portal enroll-
ment using a process similar to credit verifica-
tion, in which the patient answers a series of
questions based on publicly available data such
as the most recent home addresses instead of
standard in-person verification. Stanford also
developed a novel method to issue a text-based
instant invitation to sign up for the patient portal
directly from the EHR to the patient’s mobile
phone. In combination with effort by front-office
staff, these automatic processes have led to
72 percent enrollment overall and 87 percent
within primary care—among the highest in the
nation.
Stanford customized its EHR-based patient
portal, the Stanford MyHealth application, to
provide novel features such as technology that
automates patient check-ins upon arrival at a
clinic and provides an indoor navigational tool
to enable patients to find their way around the
hospital. The custom platform also allows pa-
tients to access their health data via mobile
and web-based apps, including laboratory, radi-
ology, and pathology information that was pre-
viously difficult for patients to obtain despite a
legal right to these data.
In an effort to expand patients’access to their
own health information,6Stanford shares doc-
tors’notes with patients across virtually all pro-
viders, with the exception of mental health care
providers. This functional enhancement has led
to high readership rates, with nearly 35 percent
of all doctors’notes viewed by patients overall
and 42 percent within cancer and primary care.
This patient-facing feature required intensive
change management to overcome physician anx-
iety. The doctor’s note has historically been a
provider-centric document, and though patients
have legal access to their record, enabling online
access for patients is a relatively new concept. To
generate support, Stanford engaged providers
on multiple fronts, including physician leaders
(for example, the chief medical officer and de-
partment chairs), front-line physicians, and
their full multidisciplinary care teams. Upon
implementation, providers voiced virtually no
negative feedback, and there was no noticeable
increase in patients’concerns.
Recognizing that emotional distress is com-
monly unidentified among patients receiving
treatment for cancer, Stanford implemented a
process to systematically survey such patients
for unaddressed symptoms, distress, and needs
through the patient portal as a standard element
of visit preparation. Positive responses triggered
clinical decision support to remind clinicians to
offer supportive services, addressing unmet
symptom-driven needs. A spectrum of examples
was uncovered—from minor transportation is-
sues to major financial hardship, and from
anxiety to suicidality. In a survey of 54,000 pa-
tients with cancer, about 40 percent of the
roughly 13,000 patients who responded re-
Patients
&
Consumers
386 Health Affairs March 2019 38:3
Downloaded from HealthAffairs.org on March 04, 2019.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
ported experiencing distress. These responses
precipitated more than 6,000 referrals for psy-
chotherapy, case management, nutrition, and
other services. In all, this process engages the
patient in preparing ahead of the visit, informs
the care team of unmet needs, and helps patients
connect with their care teams.
UC San Diego Health
UC San Diego Health maintains two geographi-
cally separate hospitals with a combined capacity
of 808 beds. It employs almost 9,000 staff and
physicians, with over 30,000 discharges and
750,000 outpatient visits annually. In 1996 it
implemented a home-grown patient portal called
PCASSO,3,4 and in 2008 it rolled out an EHR-
integrated patient portal.
In its newly constructed 364-bed Jacobs Medi-
cal Center, in 2016 UC San Diego Health hard-
wired inpatient rooms to embed digital technol-
ogy for engaging patients during their inpatient
stays. Tablet computers in each patient room
give patients access to room controls (lights,
shades, thermostat, and entertainment system),
educational content, and an inpatient patient
portal (MyChart Bedside, from Epic Systems).
From their beds, patients can access test results,
photographs of their health care team, a sched-
ule of medications and upcoming procedures,
and prescribed educational materials.
To understand the take-up of room control
features and the inpatient portal on tablets,
UC San Diego Health studied 3,411 inpatient
stays (excluding 789 newborn stays) between
September 1 and November 30, 2017. In two-
thirds of the stays, patients used the room con-
trol feature, and in one-third, patients accessed
the inpatient patient portal (exhibit 2). After
multiple factors were controlled for, logistic re-
gression analysis suggests that the odds of using
the inpatient patient portal among room control
users were 1.65 times greater than the odds for
patients who didn’t use the tablet for room con-
trol. This suggests that the tablet has served as a
conduit that nudged more patients to use the
patient portal.
It is worth noting, however, that patients used
the inpatient patient portal differentially by age
and race, even after service areas were controlled
for. The odds of using the portal among non-
white patients were 0.84 times the odds among
white patients. Compared to younger patients,
older patients also had lower odds of using the
portal (odds ratio: 0.64).
While the costs of tablets were relatively low in
the context of building a new state-of-the-art
hospital, scaling up the use of tablets was not
Exhibit 2
Patient characteristics associated with use of bedside digital room control and inpatient patient portal on tablet
computers in inpatient settings at UC San Diego Health
Used bedside
room control
Used inpatient
patient portal
Sample size
(N=3,411) No. % No. %
Odds ratios of using
inpatient patient portal
Used bedside room control 2,242 2,242 100 815 36 1.65***
Sex
Male 920 700 76 316 34 1.06
Female 2,491 1,542 62 781 31 Ref
Age (years)
Younger patients (2–64) 2,694 1,713 64 898 33 Ref
Older patients (≥65) 717 529 74 199 28 0.64***
Race
White 2,009 1,286 64 652 32 Ref
Nonwhite 1,402 956 68 445 32 0.84**
Hospital service area
Obstetrics and gynecology 1,599 860 54 488 31 Ref
General medicine 475 378 80 192 40 1.56***
Bone marrow transplant 241 228 95 165 68 4.65***
Critical care 78 27 35 27 35 1.51
General surgery 456 419 92 118 26 0.72**
Medical specialty 79 14 18 17 22 0.86
Neurology 113 70 62 16 14 0.42***
Surgical subspecialty 370 246 66 74 20 0.60***
SOURCE Authors’analysis of data for 2017 from UC San Diego Health on inpatient stays. **p<0:05 ***p<0:01
March 2019 38:3 Health Affairs 387
Downloaded from HealthAffairs.org on March 04, 2019.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
as simple as flipping a switch. Integrating pa-
tients’tablet use into clinical staff work flow
can be challenging.26 Keeping information on
the care team up-to-date and reflected in the
tablets can also be difficult. This can be particu-
larly difficult for academic medical centers where
residents provide significant patient care. In-
cluding residents’information and pictures in
the care team profile will require nontrivial ef-
forts. Continued engagement by clinical staff
with patients and the allocation of resources to
provide technical support to clinicians is neces-
sary to transform the inpatient care setting from
a traditional clinician-centric culture to a pa-
tient-centric culture.
In early 2018 UC San Diego Health, along with
Ochsner, became one of the first organizations
to adopt a new digital tool produced by Apple27
that makes it possible for patients to integrate
data from multiple sources—for example, their
personal devices and multiple health care deliv-
ery organizations from which they receive ser-
vices, in addition to the data from their primary
health care organization. A UC San Diego Health
survey of the first 425 users of the tool suggested
that 90 percent of these early adopters reported
improvements in understanding their own
health; sharing health information with care-
givers, family, or friends; and facilitation of con-
versations with clinicians.28
Patient portals are being leveraged to further
improve transparency of patient priorities to
clinicians at UC San Diego Health, and also at
Sutter. In a study funded by the Patient-Centered
Outcomes Research Institute, patients are invit-
ed to contribute to setting ambulatory care visit
agendas, using the patient portal to inform their
primary care physicians of their top priorities
before their visits.29
Discussion
As patients enjoy more user-friendly technology
in nonhealth areas of their lives, they expect the
same type of consumer-friendly technology in
health care. The innovations from the academic
and community-based delivery organizations de-
scribed in this article mirror some of the modern
conveniences available in the consumer market-
place. The online appendix exhibit describes and
summarizes the technology-enabled consumer
engagement approaches at the four organiza-
tions as patients encounter health care providers
at home, in outpatient clinics, and in hospitals.30
While each institution stands out in particular
areas, no institution has adopted these tools and
processes in all areas.
At home, consumers expect to be able to sched-
ule appointments online, securely message their
care teams, and review clinical results. All four
organizations have implemented these features
in the patient portal, with 45–79 percent of their
patients using them. User interface redesign has
enabled some of the organizations to authenti-
cate users in real time, thereby greatly removing
friction in patient portal enrollment. Notably, all
four organizations have adopted OpenNotes—
which, while engaging patients,6brings unique
physician change management challenges.31
Two of the organizations (UC San Diego Health
and Sutter) are going further, with funding from
the Patient-Centered Outcomes Research Insti-
tute, to examine the potential impact of improv-
ing transparency of patient priorities to clini-
cians using the patient portal.29
Several organizations have home monitoring
using patient portal technology. The provision of
transmittable blood pressure and weight moni-
toring along with a physical service bar or digital
service center enables access to these valuable
technologies for patients with chronic condi-
tions. All four organizations are also offering
virtual care32 that is accessible through mobile
patient portal applications or online.
In the clinic, consumers are being offered
way-finding technology on their mobile devices.
Mobile check-in offers the convenience of
“saving your spot in line”and the ability to pri-
vately complete previsit questionnaires, as well
as directly paying for services without needing to
interact with any clinic staff.
For hospitalized patients, institutions are in-
creasingly looking to empower patients by pro-
viding access to inpatient patient portals that can
facilitate communication; provide easy access to
hospitality amenities; and deliver education to
advance safe, coordinated, and dignified patient-
centered care.12,26 Further patient engagement
enhancements can be built upon the early suc-
cesses in uptake of room control features to
transform the culture of inpatient care setting
from clinician-centric to patient-centric. While
hospital-provisioned devices are an equalizing
enablement for many patients, patients with un-
met needs because of older age, nonwhite race,
and serious illnesses should receive additional
individualized support—not only for physical
comfort, but also for meaningful engagement
in their care at levels consistent with their pref-
erences and needs. It is important to prevent
overdependence on technology that could exac-
erbate perceived isolation and patients’unmet
needs for human connection and interaction.9
Additional research is needed to assess the im-
pact of room control features and inpatient pa-
tient portals provided on tablets on outcomes
that matter to patients and families during their
inpatient stays and beyond.
Patients
&
Consumers
388 Health Affairs March 2019 38:3
Downloaded from HealthAffairs.org on March 04, 2019.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
Policy Implications
Federal resources have facilitated consumer en-
gagement by health care delivery organizations.
For example, Sutter leveraged funding from
meaningful use on some of its digital consumer
engagement tools. Other organizations used
grants to purchase initial equipment for televi-
sits. In 2018 the four organizations implemented
interoperable personal health records capabili-
ties using the open Apple Health Record appli-
cation programming interface.28 In addition to
empowering patients to aggregate their records
from multiple health systems, this will enable all
four organizations to attest to meeting 2018
stage 3 standards for meaningful use in the Cen-
ters for Medicare and Medicaid Services’Merit-
based Incentive Payment System.
The long-term sustainability and scalability of
these initiatives depend on payers’commitment
to the quadruple aim—enhancing patient expe-
rience, improving population health, reducing
costs, and improving the work life of health care
providers.33 Organizations may lack incentives
to scale virtual visits, for example, in a fee-
for-service environment—despite recognized
benefits of virtual visits in preventing avoidable
emergency department visits and hospital ad-
missions, increasing the capacity of mental
health care providers, and allowing for telemo-
nitoring after hospital discharge.34 Private
payers require documentation unique to video
visits. The field is evolving, however, as Medicare
will begin to reimburse providers for conducting
video visits, reviewing brief communication
technology–based services such as virtual
check-ins, and remotely evaluating recorded vid-
eo or images submitted by the patient.35
Although Medicare has created a new mecha-
nism to pay for team-based care, it charges
patients a 20 percent monthly copayment for
remote monitoring and chronic care manage-
ment services. Ochsner decided to not bill the
Centers for Medicare and Medicaid Services for
its Hypertension Digital Medicine Program,
although it included chronic care management
and remote monitoring, because Ochsner did
not want to increase its patients’financial bur-
den. Its success in significantly increasing
the rate of blood pressure control, medication
adherence, and satisfaction with care among pa-
tients, however, has resulted in payment from
commercial insurance in recognition of its per-
formance. When payers benefit from providers’
use of technology to engage patients and its sub-
sequent savings, payers should share the savings
with the health care delivery organizations.
A direct business case for patient engagement
cannot always be made, however. Indeed, most
of the strategies described here do not directly
contribute to revenue and are often costly. It is
difficult to quantify the value of patient satisfac-
tion in a competitive health care market and hard
to gauge patient engagement—let alone its mon-
etary value. However, in many metropolitan
areas there is increasing competition among
health care systems, and consumer engagement
is an important differentiator and may even be a
basic requirement. Despite lack of direct finan-
cial benefit, these four health systems have in-
vested in consumer-facing technologies to better
connect with their patients, reduce the friction of
obtaining care, and serve the needs of patients.
The technology-enhanced journey to a patient-
centered world is achievable with organizational
commitment to implementing patient-centered
care. Use of digital tools to enhance consumer
engagement and transparency could not only
improve patient health outcomes and experience
with care, but could also grow health care organ-
izations’market share. ▪
The authors thank Jeremy Sutton, James
Read, and Lisa Moore for their support.
Research reported in this article was
partially funded through a Patient-
Centered Outcomes Research Institute
(PCORI) Award (No. IHS-1608-35689-IC).
NOTES
1HealthIT.gov. Meaningful use [In-
ternet]. Washington (DC): Depart-
ment of Health and Human Services;
[content last reviewed 2019 Jan 9;
cited 2019 Jan 30]. Available from:
https://www.healthit.gov/topic/
meaningful-use-and-macra/
meaningful-use/
2Carman KL, Dardess P, Maurer M,
Sofaer S, Adams K, Bechtel C, et al.
Patient and family engagement: a
framework for understanding the
elements and developing interven-
tions and policies. Health Aff (Mill-
wood). 2013;32(2):223–31.
3Masys D, Baker D, Butros A, Cowles
KE. Giving patients access to their
medical records via the internet: the
PCASSO experience. J Am Med In-
form Assoc. 2002;9(2):181–91.
4Masys DR. Effects of current and
future information technologies on
the health care workforce. Health Aff
(Millwood). 2002;21(5):33–41.
5Halamka JD, Mandl KD, Tang PC.
Early experiences with personal
health records. J Am Med Inform
Assoc. 2008;15(1):1–7.
6Fossa AJ, Bell SK, DesRoches C.
OpenNotes and shared decision
making: a growing practice in clini-
cal transparency and how it can
support patient-centered care. J Am
March 2019 38:3 Health Affairs 389
Downloaded from HealthAffairs.org on March 04, 2019.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
Med Inform Assoc. 2018;25(9):
1153–9.
7Tang PC, Lansky D. The missing link:
bridging the patient-provider health
information gap. Health Aff (Mill-
wood). 2005;24(5):1290–5.
8Zhao JY, Song B, Anand E, Schwartz
D, Panesar M, Jackson GP, et al.
Barriers, facilitators, and solutions
to optimal patient portal and per-
sonal health record use: a systematic
review of the literature. AMIA Annu
Symp Proc. 2018;2017:1913–22.
9Dalal AK, Bates DW, Collins S. Op-
portunities and challenges for im-
proving the patient experience in the
acute and postacute care setting us-
ing patient portals: the patient’s
perspective. J Hosp Med. 2017;
12(12):1012–6.
10 Kaziunas E, Hanauer DA, Ackerman
MS, Choi SW. Identifying unmet in-
formational needs in the inpatient
setting to increase patient and care-
giver engagement in the context of
pediatric hematopoietic stem cell
transplantation. J Am Med Inform
Assoc. 2016;23(1):94–104.
11 Wu Z, Robson S, Hollis B. The ap-
plication of hospitality elements in
hospitals. J Healthc Manag. 2013;
58(1):47–62, discussion 62–3.
12 Grossman LV, Choi SW, Collins S,
Dykes PC, O’Leary KJ, Rizer M, et al.
Implementation of acute care patient
portals: recommendations on utility
and use from six early adopters. J Am
Med Inform Assoc. 2018;25(4):
370–9.
13 Kelly MM, Coller RJ, Hoonakker PL.
Inpatient portals for hospitalized
patients and caregivers: a systematic
review. J Hosp Med. 2018;13(6):
405–12.
14 Brodie M, Flournoy RE, Altman DE,
Blendon RJ, Benson JM, Rosenbaum
MD. Health information, the Inter-
net, and the digital divide. Health Aff
(Millwood). 2000;19(6):255–65.
15 Hibbard JH, Stockard J, Mahoney
ER, Tusler M. Development of the
Patient Activation Measure (PAM):
conceptualizing and measuring ac-
tivation in patients and consumers.
Health Serv Res. 2004;39(4 Pt 1):
1005–26.
16 Needham BL, Epel ES, Adler NE,
Kiefe C. Trajectories of change in
obesity and symptoms of depression:
the CARDIA study. Am J Public
Health. 2010;100(6):1040–6.
17 Milani RV, Bober RM, Lavie CJ. The
role of technology in chronic disease
care. Prog Cardiovasc Dis. 2016;
58(6):579–83.
18 Milani RV, Lavie CJ, Bober RM,
Milani AR, Ventura HO. Improving
hypertension control and patient
engagement using digital tools. Am J
Med. 2017;130(1):14–20.
19 Centers for Disease Control and
Prevention. Calculating proportion
of days covered (PDC) for anti-
hypertensive and antidiabetic medi-
cations: an evaluation guide for
grantees [Internet]. Atlanta (GA):
CDC; 2015 Aug 31 [cited 2019 Jan
24]. Available from: https://
www.cdc.gov/dhdsp/docs/med-
adherence-evaluation-tool.pdf
20 Centers for Medicare and Medicaid
Services. 2017 Medicare-Medicaid
plan performance data technical
notes [Internet]. Baltimore (MD):
CMS; [updated 2017 Jun 23; cited
2019 Jan 24]. Available from:
https://www.cms.gov/Medicare-
Medicaid-Coordination/Medicare-
and-Medicaid-Coordination/
Medicare-Medicaid-Coordination-
Office/FinancialAlignment
Initiative/Downloads/MMP
PerformanceDataTechNotes
CY2017_06262017.pdf
21 Anthony DL, Campos-Castillo C, Lim
PS. Who isn’t using patient portals
and why? Evidence and implications
from a national sample of US adults.
Health Aff (Millwood). 2018;37(12):
1948–54.
22 Tang PC, Black W, Young CY. Pro-
posed criteria for reimbursing
eVisits: content analysis of secure
patient messages in a personal
health record system. AMIA Annu
Symp Proc. 2006:764–8.
23 Panattoni L, Chan A, Yang Y, Olson
C, Tai-Seale M. Nudging physicians
and patients with autopend clinical
decision support to improve diabetes
management. Am J Manag Care.
2018;24(10):479–83.
24 Tang PC, Overhage JM, Chan AS,
Brown NL, Aghighi B, Entwistle MP,
et al. Online disease management of
diabetes: Engaging and Motivating
Patients Online with Enhanced
Resources—Diabetes (EMPOWER-
D), a randomized controlled trial.
J Am Med Inform Assoc. 2013;
20(3):526–34.
25 Andrade SE, Kahler KH, Frech F,
Chan KA. Methods for evaluation of
medication adherence and persis-
tence using automated databases.
Pharmacoepidemiol Drug Saf.
2006;15(8):565–74, discussion
575–7.
26 Collins SA, Rozenblum R, Leung WY,
Morrison CR, Stade DL, McNally K,
et al. Acute care patient portals: a
qualitative study of stakeholder
perspectives on current practices. J
Am Med Inform Assoc. 2017;24(e1):
e9–17.
27 Apple [Internet]. Cupertino (CA):
Apple; 2018. Press release, Apple
announces effortless solution
bringing health records to iPhone;
[updated 2018 Jan 24; cited 2019
Jan 24]. Available from: https://
www.apple.com/newsroom/2018/
01/apple-announces-effortless-
solution-bringing-health-records-
to-iPhone/
28 Dameff C, Clay B, Longhurst CA.
Personal health records: more
promising in the smartphone era?
JAMA. 2019 Jan 11. [Epub ahead
of print].
29 Patient-Centered Outcomes Re-
search Institute. Comparing three
approaches to improve communica-
tion between patients and their
doctors [Internet]. Washington
(DC): PCORI; [last updated 2019 Jan
4; cited 2019 Jan 24]. Available from:
https://www.pcori.org/research-
results/2016/comparing-three-
approaches-improve-
communication-between-
patients-and-their
30 To access the appendix, click on the
Details tab of the article online.
31 Delbanco T, Walker J, Bell SK, Darer
JD, Elmore JG, Farag N, et al. In-
viting patients to read their doctors’
notes: a quasi-experimental study
and a look ahead. Ann Intern Med.
2012;157(7):461–70.
32 Cheung L, Leung TI, Ding VY, Wang
JX, Norden J, Desai M, et al.
Healthcare service utilization under
a new virtual primary care delivery
model. Telemed J E Health. 2018 Sep
7. [Epub ahead of print].
33 Bodenheimer T, Sinsky C. From tri-
ple to quadruple aim: care of the
patient requires care of the provider.
Ann Fam Med. 2014;12(6):573–6.
34 Leff B, Soones T, DeCherrie L. The
hospital at home program for older
adults. JAMA Intern Med. 2016;
176(11):1724–5.
35 CMS.gov. Proposed policy, payment,
and quality provisions changes to
the Medicare Physician Fee Schedule
for calendar year 2019 [Internet].
Baltimore (MD): Centers for Medi-
care and Medicaid Services; 2018 Jul
12 [cited 2019 Jan 24]. (Fact Sheet).
Available from: https://www.cms
.gov/newsroom/fact-sheets/
proposed-policy-payment-and-
quality-provisions-changes-
medicare-physician-fee-schedule-
calendar-year-3
Patients
&
Consumers
390 Health Affairs March 2019 38:3
Downloaded from HealthAffairs.org on March 04, 2019.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
Tai-Seale M, Downing NL, Jones VG, Milani RV, Zhao B, Clay B, et al. Technology-enabled consumer engagement: promising practices at four health care delivery organizations.
Health Aff (Millwood). 2019;38(3).
Appendix Exhibit. Summary of Tech-Enabled Consumer Engagement Approaches in Four Systems
Care location
Tech-Enabled
Engagement
Ochsner Health
Stanford HealthCare
Sutter Health
UC San Diego Health
At Home
Patient portal
Easy activation,
50% active users
Text based invitation
from the EHR, 72%
active users
Point of care patient portal
enrollment, text based
invitation from the EHR,
online activation, 79%
active users
Call center staff or e-
check-in activation,
45% active users
OpenNotes
2016 System-wide
2017 system-wide
2018, 2 of 5 medical
foundations (Sutter
Medical Foundation and
Sutter Gould Medical
Foundation)
2018 primary care and
multiple specialties
Virtual care
Virtual visits with
Pharmacists/
Health Coaches
Virtual care clinic
System-wide video visits
for non-urgent conditions
Video-visits in primary care
and specialty care
Interoperable patient
health records
iOS application programming interface automates both the retrieval of health record data from multiple
healthcare organizations and the communication of clinical information (such as blood glucose levels from
wearable devices) to those organizations. Patients have View/Download/Transmit capabilities.
Outpatient Clinic
Wayfinding
Email reminder with
external directions to
building
Mobile app, external
directions to buildings
and internal directions
within buildings
Mobile app, external
direction to buildings and
internal directions in one
hospital and one medical
office building
Mobile app, external
directions to buildings
Digitally supported
service
O Bar sets up
transmission capable
BP-monitoring devices
for patients.
Supportive services for
patients undergoing
cancer treatment
Transmission capable BP
and weight monitoring,
personalized health
coaching
Patients’ priorities
transmitted to primary
care physicians before
office visits
Inpatient Hospital
Bedside digital room
control and access to
personal health record
Tablets being
implemented in two
hospitals
Tablets implemented
system-wide
Source: Authors’ analysis of consumer engagement technologies used in each organization.
