Patient Engagement Improves Safety and Quality of Care – For SOME

Patient Engagement Helps Doctors
Provide Better Care


There are a couple of interesting and seemingly unrelated articles in the May 2013 issue of Health Leaders magazine that address patient engagement at entirely different levels and with entirely divergent results.

The first (“Opening Up to Patients“) is about the 12-month trial of the OpenNotes program in three hospital settings with vastly different patient populations.

The OpenNotes program allows patients to access their physicians’ notes about their treatment and alerts them by email as new entries to their medical records are made. This is meaningful patient engagement with tangible benefits for patients and their doctors alike – as opposed to frivolous “patient satisfaction” measures like valet parking and fancier hospital accommodations.

User response to this trial of increasing patient engagement was over-the-moon positive. At all three hospitals, 99% of patients said they wanted to continue using the patient engagement system – an unheard of response. Over two-thirds of patients reported they were more engaged in their care, understood their medical conditions better, and were more compliant with their treatment regimens.

And doctors who were fearful that increasing patient engagement would increase patient demands on their limited time found their fears unfounded. In fact, many acknowledged that patients found errors in their records that were corrected, improving the safety of their records and their medical care. Basing healthcare decisions on the correct information obviously benefits everyone involved, including physicians themselves – whose malpractice risk is lessened when errors are caught and corrected before any harm ensues.

Medical staff leaders at Boston’s Beth Israel Deaconess Medical Center (BIDMC) voted unanimously to extend the OpenNotes program beyond the initial 12-month trial period. The patient engagement program will be rolled out to all its patients who are registered online by the end of this summer.

Engaged Patients Lower Malpractice Risk

Although my own online patient portal with my provider group doesn’t yet include OpenNotes, it does afford me easy access to my test results and easy communication with physicians involved in my care. The doctors I’ve connected with online have been responsive and seem to welcome the modifications to my treatment plan that our back-and-forth communications produce.

The OpenNotes program enhances this further by creating opportunities to clarify what may have been a misunderstanding of patients’ medical history or symptoms. Patient engagement like this becomes an opportunity to set the record straight so patients’ treatment plans are based on the correct symptoms and closer to optimized care.

And having patients more involved in their treatment decisions inherently lowers their doctors’ malpractice risk since they’re bearing less of the responsibility for the choices made.

In other words, patients are adding real value to the quality and safety of their own care – and their doctors are recognizing and valuing this.

Sounds like a win-win outcome and one of the few “feel-good” stories in America’s troubled healthcare system (see Our Healthcare Sucks for more on this), does it not?

Engaging Some Patients
While Disengaging Others

Here’s where this feel-good story turns sour, at least in large part.

It turns out not all of the three hospital trial sites had as glowing results in testing the OpenNotes system as BIDMC. The OpenNotes experience of the Geisinger Health System in Pennsylvania was also highly successful and popular, but not quite as universally beneficial. Health Leaders quotes that their chief innovation officer, Jonathan Darer, M.D. (great name for an innovation officer!) found that 2-8% of patients “Felt some kind of negative impact. Some felt offended, some felt more worried.”

Still, 87% of them read every note generated in the OpenNotes system by their caregivers. As Dr. Darer commented, “87% of patients doing anything is just remarkable”.

But it’s the third hospital in the trial – Harborview Medical Center, a safety net hospital in Seattle – where the reality of our “two Americas” (much as I hesitate to resurrect that phrase) sets in. As the Health Leaders report put it:

“Harborview Medical Center, the safety net hospital, faces logistical and budgetary challenges before it can expand its use of OpenNotes.”

Get it? The medical centers with the best-insured patients can afford this crucial and long overdue innovation in patient engagement and the poorer safety net hospitals that rely mostly on low-paying Medicaid and local tax support cannot.

What Safety Net?

This brings me to the second article in Health Leaders (“Compounding the Uncompensated Care Problem“) about the impact on safety net hospitals in states that refuse to expand their Medicaid programs as prescribed under Obamacare.

Last year’s Supreme Court decision upholding the constitutionality of Obamacare also gave states the right to opt out of this core component of expanding insurance coverage to millions of uninsured Americans. Right now, 14 states have yet to opt in to expanding Medicaid in their states.

The problem for safety net hospitals in these states is the federal “disproportionate share” payments they now receive in lieu of Medicaid payments for serving a disproportionate number of uninsured patients are scheduled to be phased out under Obamacare. Expanded Medicaid coverage is expected to take their place – unless, of course, a state chooses not to expand its Medicaid program.

This will leave these already financially strapped hospitals with dramatic revenue cuts that will cause many to go out of business, much less worry about instituting patient engagement programs like OpenNotes.

All of this points to an even wider divergence in America’s healthcare system going forward – at least in many states most in need of closing this gap, not expanding it. Instead of the closer-to-equal healthcare envisioned under Obamacare, its die-hard opponents are ensuring precisely the opposite for millions of Americans who happen to live in the wrong states – a two-tiered system of over-treatment for the well-insured and barely adequate to inadequate care for the uninsured.

Third-World America

Their healthcare lot – already resembling that of third world countries in many parts of America – is about to get much worse if they live in one of these states that refuses to expand its Medicaid program.

And as the Health Leaders report notes, better-funded hospitals in these states will also suffer the ripple effects of these short-sighted, politically-driven choices.  Since they’ll have fewer safety net hospitals to fall back on, they’ll have to absorb more bad debt expenses that will add to the pressures on hospitals’ continuing profitability as Obamacare is implemented over the coming months and years.

The hospital lobbying pressure this is generating will likely convince some of the 14 states still holding out to opt in and expand their Medicaid programs – 90% of the cost for which the federal government is obligated to pay. But you can bet some will stick to the party line and refuse to do so – making patient engagement innovations like OpenNotes a mute point for their millions of victims.

And make no mistake – “victims” is the operative term.

Update: Contrary to my optimism when this was written that some of the 14 states then denying Medicaid expansion would reconsider, that number has instead swelled to 24 states. That’s a lot of Americans – millions – being denied healthcare for purely partisan political reasons. I reiterate – our healthcare sucks, especially if you’re poor and live in one of these so-called “red” states. If you do, maybe it’s time to move.

John Lynch: John Lynch was founder and CEO of Medical Diagnostics, Inc. - twice named to Business Week's "Best Small Companies" in America. He's since founded MedSmart Members to publish consumer health education publications.
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