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Outcomes and Self-Reported Patient Experience: How Social Media is Driving Change

This week the NEJM published an article by Manary, Boulding, Staelin and Glickman “The Patient Experience and Health Outcomes”. This article examines the question “Do patients’ reports of their health care experiences reflect the quality of care?” The authors examine the fact there is little if any consensus on this topic. Some studies show there is no relation to quality of care and is associated with poor outcomes. Other studies found better patient experiences, more than adherence to clinical guidelines, are associated with better outcomes. This is an excellent review and in part speaks to the growth of social media and patient’s involvement in their care.

The money shot in this article is this line “…studies have shown that patient-experience measures and the volume of services ordered are not correlated: in fact, increased patient engagement leads to lower resource use but greater patient satisfaction.” I realize this is not improved patient outcomes but it is about patients being self actualized around their healthcare.

This finding speaks volumes to social media and the topics addressed during the Sunday evening chat at #hcsm. Patients involved in their own healthcare effect cost and are more satisfied with their care. When we address the problems we want to solve we are more involved and take greater control over our lives. As involved active patients we become advocates for our healthcare as well as helping others seek solutions to similar problems.

There is more we can do to improve and increase patient engagement in order to realize improved outcomes, greater satisfaction, and lower cost. We can drive patient’s to become more healthcare active, aid them in learning about their health.

This is not something we randomly apply to any patient. It is something that becomes part of the exam and the in-office visit. The physician should be performing a brief needs assessment on all patients. Damn, it’s not like we are not being handed reams of paper at a visit to fill out. A short assessment to determine where the patient resides on his/her self-learning continuum, where they turn to for knowledge, what are the health problems they want to solve, and do they want to be part of an office based community?

Let’s be real, we will never get near 100% participation but we will realize small committed groups of patients and that demographic will tell us about other groups within our practice. It will drive patient changes and improve outcomes. Changes we can drive in one group will translate to other groups. And this becomes self-actualized through the reality of social media and learning. These patient success stories will be shared and will drive new entrants within a practice.

This trend will not continue on its own without some help. It may be largely driven by the economy and the fact many more Americans are unemployed and struggling to pay their healthcare premiums. Now is the time to leverage what is happened to create deep links to behavioral changes and improved outcomes. Simple small steps at the office level one practice at a time will reap great benefits. Today not tomorrow.

Expanding the Market for and Use of Social Media

The past five years has seen a huge growth in healthcare interest and knowledge seeking behavior at the consumer level. This has been driven in part by the vitriolic discussion and debate over the Affordable Care Act (i.e. Obamacare), online, and digital availability of healthcare information, social media, and a very active healthcare professionals using online as ways to communicate and improve care.

I want to look at two issues. As more consumers and healthcare professionals step into a more active role in their healthcare through social media, online, communities, etc. are we expanding this audience? And are we seeing improvement in outcomes?

A recent article titled “Mind Blowing Digital Health Statistics and Trends” the data they are sharing is quite frankly mind blowing. Here are some statistics:

According to recent study, the number of adults in the US (ages 18+) using mobile phones for health information grew from 61 million to 75 million this year, while tablet adoption nearly doubled from 15 million to 29 million.
64% of healthcare extenders believe that technology has impacted the quality of interaction with patients
80% of Internet Users look online for health information
32. 20% search for health related content on mobile devices
33. 23% use social media to follow health experiences of friends
34. Health related Google searches are up 47% from last year
35. 81% of consumers click on a sponsored link when looking for health information
88% of physicians would like patients to be able to track or monitor their health at home
1 in 5 internet users have gone on line to find someone who shares their health concerns and 1 in 4 with chronic conditions

We can add to these trends the proliferation of branded Web site such as Pfizer’s Hemophilia Village. Which are creating patient centric communities of practice. Places where patients sharing similar illnesses or needs for knowledge can share and learn from like-minded seekers of information.

I would characterize these trends as decentralized with many small segments identifying with specific issues and problem solving. If you follow me or have seen my Tweets you know I advocate that adults learn when they are seeking solutions to problems they are having. This can include family members as well.

Are we seeing?

Greater illness associated with aging Americans: Need to solve problems
Easier access to healthcare knowledge and information: Easier to solve problems
Greater interest in improving our collective healthcare ‘footprint’ starting at a younger non ill state of health: Wanting to avoid problems

I would present that it is a combination of all three but, the most important consideration is are we seeing a change in behavior and outcomes? Are we turning a corner on self-management of healthcare? Are we driving down the cost curve? Do we have a more knowledgeable public? How can we expand this segment to do two tasks, add more consumers to self-driven learners and help those seeking knowledge to dive deeper and change behavior?

Our next task should be to wrap SM around smart outcome driven strategies while measuring outcomes to see which strategies work the best with which goals.

Best Buy and WebMD: Sharing a Reality

Scott a good and dear friend made an off the cuff comment that was like a song that says it all.

We were speaking about online health sites and I mentioned WebMD. Without skipping a beat Scott said WebMD is the Best Buy of online healthcare information. I couldn’t agree more. I’ve been hocking for a year or more that it’s not WebMD but MyMD. That is where real healthcare learning should take place, at the intersection of patient and physician, the smallest discreet healthcare environment of learning.

Best Buys positions itself as the all knowing customer centric resource for technology. And they can charge more because they are all knowing. Best Buy doesn’t really get that their customers were bright, tech savy, and can smell higher priced products. Best Buy is the place to go to test drive products and buy elsewhere. How tech savy are you when you have a huge inventory of CDs and DVDs. When was the last time you bought a CD? The Best Buy Logo is 20+ years old. Best Buy is fading before our eyes. It is a relic of a different time. Even buying Napster was two years to late. The tech consumer is learning, changing, and adapting as fast as an upload to Dropbox or Sugarsync or iCloud. And this knowledge is being used daily.

Are healthcare consumers moving as fast with their knowledge uptake as the technorati? Yes and no. Consumers/patients are doing more research online and using social media to improve their healthcare knowledge. That fact is clear. The HCP may be part of the problem but, that will change because there is a critical mass of smart health savvy consumers happening. As consumers/patients improve their knowledge (remember a medical degree and residency doesn’t happen in a year or two) they will begin to see through WebMD. WebMD will become a resource like Wikipedia but not that source where they uptake knowledge, reflect on it and apply it. WebMD will become a minor visit to underpin learning. And let us not forget the consumer sees that WebMD exists for the single purpose of mass marketing readership on placed press releases and articles to gather ad click throughs.

As Best Buy goes so will WebMD. Consumers/patients want to be part of a care team, a learning team. They do not want to interact with a thing controlling the distribution of learning. They want share in discovery and change. But the HCP needs to begin to take charge of learning. They are trusted, respected, and have the knowledge.

Creating a Networked Imagination in Healthcare One Patient at a Time

Web 2.0, social media, and the movement from interpretation to participation can best be witnessed in how blogger/Twitter/G+ is not simply transferring knowledge or information but creating a community with reader’s and their shared experiences. I want to continue my look at the work by Thomas and Brown ‘Learning for a World of Constant Change’ Homo Sapiens, Homo Faber & Homo Ludens’ specifically moving from passive participation to active participation and what it means for healthcare.

Today all of us can participate (let’s call this learning) with writers, thinkings, film makers, and more by leaving comments on a blog, posts on our personal digital media (e.g. Twitter links, Gooogle + posts, etc) linked back to the authors posts, Twitter chats, podcasts and more. This is different from traditional media and learning (broadcasts, lectures, reading). Thomas and Brown state ‘learning was a function of absorbing (or interpreting) a transmitted message’. In this new media we find the learner engaging with information, using it more broadly in a social context. Thomas and Brown call this ‘productive inquiry’.

Productive inquiry is associated with John Dewey He associated productive inquiry with the ability to engage the imagination. This new media “has enabled the fusion of network technology, communities of interest, and a shared sense of co-presence…’ Thomas and Brown call this ‘networked imagination’ which is a type of social and collective participation, think #hcsm. Learning is taking place in a social context. It is more effective than passive participation because it speaks to the learners needs.

What does this mean for healthcare? I think we need to look at what it is happening to the average American and how they are using the web. And how this behavior is shaping current healthcare so we may capitalize on it.

You’ve seen the data on how Americans use the internet for healthcare related data here Americans are using the internet to find answers to healthcare problems they are seeking solutions to here. Americans are sharing healthcare knowledge with each other. Americans are using mobile devices to search for health information. In short and unsurprisingly Americans are going online, joining social networks, and sharing knowledge to manage their healthcare. These learners are engaging in their healthcare through the creation of networks of healthcare knowledge and information. They are doing it patient to patient, HCP to HCP, and in some cases HCP to patient. Web sites and publishers are focusing on getting health related information to consumers in an easily digestible fashion quickly.

Historically HCP have been trained in traditional learning, absorbing a transmitted message. This works well as witnessed by the skill and expertise of our medical professionals. They leave medical school and residency as well trained as any in the world. And as HCPs continue their training in pretty much the same vain with CME lectures, online, grand rounds, etc. And further, HCP do access networks of other HCP and colleagues to learn. They to are part of this online healthcare revolution ‘networked imagination’.

So we have patients engaging in ‘networked imagination’ in healthcare. We have HCP trained in a traditional fashion, message sent message received and moving toward active participation in social media as they enter into practice. What we don’t see here is the overlap of physician and patients in a way where the HCP is taking the lead in becoming that trusted resource for the patient. Leading this productive inquiry. Becoming a valued network for the patient not just a parental figure.

HCP need to move away from the idea that patients uniformly want a simple transfer of information or knowledge. ‘You have HTN and you need to take this.’ Because you know a majority of your patients will go do a http://duckduckgo.com/search HTN and the medication and find 20 other patients taking the medication with opinions and ideas. And if they feel welcomed they will call or come into to discuss it with you. Are HCP ready to create participation in order to manage interpretation?

Let’s look at ‘You have HTN and you need to take this’, as part of a productive inquiry. This is not shocking to the patient, you’ve told your patient they are moving toward HTN. Both of you are prepared. What’s to keep you from handing that patient a single 8″x11″ sheet of paper with some URLs to links and PDFs on the topic of HTN and the medication that you have selected based on good evidence? Nothing. What is to keep you from adding a short paragraph about each URL or PDF as your abstract? Nothing. And you can do it with the following direction: a) Fill the Rx, begin your regimen, and read the information. b) Read the information, fill the Rx, and begin your regimen or c) Read the information don’t fill the Rx. I will see you in two weeks to follow-up with you on the medication, side effects, what you’ve read, and answer your questions.

You have engaged this patient in a social context on a clinical topic. You are now occupying the learning receptors of patient and managing their expectations. This is not you waiting to react. It is you leading a networked imagination in healthcare one patient at a time.

The Aporia and Epiphany of Learning, Healthcare & Social Media

My one trick pony reprise: social media is just one shinny toy in a box of other equally shinny toys (i.e. tactics). You’re drinking the Kool-Aid if you believe SM in and of itself will solve the healthcare crisis, change outcomes, improve patient care, and save money. Throwing a Twitter hashtag at healthcare without a strategy, goals, and metics is like wearing flip flops in a blizzard.

In my view social media is a tactic best suited for education and learning. It offers those who apply it a robust tactic for learning about, learning to be, and learning to become active and engaged consumers and providers of healthcare.

I am reading and digesting ‘Learning for a World of Constant Change’ Homo Sapiens, Homo Faber & Homo Ludens’ by Douglas Thomas & John Seely Brown. You can read the PDF here and it is well worth it if for nothing else the rich tapestry of ideas about learning in todays complex ever changing world. (Just consider how many links to new information are tweeted on your timeline in an hour, a day a week)

The authors state, rightly so, that we cannot possible keep up or engage with the sheer volume and flux of [healthcare] knowledge occurring today.

In the 20^th century it was learning about. You accessed and learned skills and knowledge. Think slide lectures, didactic, reading, watching, etc.

Thomas and Brown further present that later in the 20th Century value was identified as learning to be where learning was put in the context of systems, identity and the transmission of knowledge. Think patient office visit, infusion lab, patient handouts, WebMD, support groups, etc.

Thomas and Brown further state that in the 21st Century learning is beaming a function of learning to become. We will all need to learn to become over and over. We will need to continuously reinvent ourselves to meet the constant change in information, knowledge, and data. Think changes in treatment, diagnosis, management of diseases and the aging population. Guidelines are changed almost bi-annually.

In this new world of ever expanding content and data where attention is measured in a fruit flies life span we must embrace the key principle in healthcare–life long learning. This is not solely the purview of the HCP but of the patient because it is abundantly clear that patients expect to be part of the care team. And, to become that member they to must engage in life long learning as well in order maximize the benefits of their healthcare professional and improve their own healthcare footprint. And fr the HCP to surrender that learning opportunity to others is a failure in seeing where the puck is going to be.

Over the course of the next couple of weeks post additional comments and thoughts from Thomas and Brown’s paper on learning and relating it to healthcare and social media.

Changing the Office Visit from Transaction to Value Experience

In my estimation a goal beyond the clinical exam of an office visit is to have both the HCP and the patient establish a foundation for better outcomes by managing knowledge and sharing problem solving. In a sense this is a form of shared decision making (SDM) where HCP and patients communicate thus moving the relationship from paternalism to partnership. SDM is labor intensive and best suited to chronic or terminal illnesses. How can the busy PCP change a HC transaction to a learning experience and gain the benefits of SDM?

All practices comprise patients at varying degrees of health status and age. Each segment will reside on a different part of the learning continuum. Say 10 is a highly active involved learner and 1 is a non-learner. The reality is that we can’t expect to move all patients to a 10. The goal is to move patients to be more active in their HC involvement. Say a 2 to a 4 or a 5 to a 6. These small changes can make a difference.

Over the course of six months each patient visit should be accompanied with a short questionnaire to determine where patients reside on the learning continuum.

1. Do you have a chronic illness or a healthcare problem that you are concerned about? Y/N

2. Are you actively learning about your illness or problem? Y/N

3. If you are active in learning what are your sources? (RankInternet

Social media and groups with similar concerns or illnesses
Friends and family
Medical and scientific journals
Support groups
Healthcare professionals

4. If you have a chronic illness or a healthcare problem but are not actively learning about your illness why?

My HCP is my decision maker
I know a lot about it and am managing it well with my HCP
I don’t have the time or desire to pursue this type of information
I never considered learning more

5. If your health is good and you have no HC problems are you interested in learning more about your health? Y/N

These five simple questions will first open an entry point for discussion. The HCP can identify what problems the patient is seeking to solve, are they active learners, where do they learn, etc. The key for moving the office visit from a drive by transaction to a learning experience is knowing where the learner resides and if they want to learn.

The data can be put into a database by disease, interest in learning, and other patient demographics. Once this is completed an educational strategy can be identified by segment or group. Outcomes can be as simple as did the patient at the next visit change his or her opinion about learning? Did they add some new knowledge to their knowledge base? Bottom line: the HCP should be the primary resource for patient learning or the most trusted. With a small effort the HCP can control and manage this knowledge channel

The Office Visit is Not a Drive By

In Digital Tonto’s post ‘4 New Marketing Paradigms’ Greg’s second paradigm is titled ‘From Campaigns to Platforms’. http://tiny.cc/srj2dw His premise is that marketers can no longer just run ads till they wear out; they need to build campaigns that integrate social media, e-commerce, and interaction with the reader/viewer. Marketers are now ‘tailoring the message to past behavior’. I am very found of his closing sentence ‘Brands need to become authors whose stories unfold over time.’ www.digitaltonto.com The brand becomes the connection to reader/viewer not just a feature or benefit.

How does this relate to healthcare? The physician is the brand. The patient is the consumer of that brand. The office visit for a check-up or care for an acute or chronic condition is the ad/commercial. It is where the consumer (patient) interacts with the brand (physician). And historically it is a flat moment where the patient is passive and the physician active. With all the changes occurring in healthcare etc. more patients are becoming active in their health and care. Many physicians are stepping up to meet that half way. But that is not enough and it misses key inflection points. Engagement between physician and patient is becoming the new black and it is up to the physician to lead the way. To in a sense create that learning narrative with the patient.

The physician as a brand should look at that visit not as a one time event in a string of events. It is a way to build a brand platform based on patient needs and goals. It is the moment where the physician can determine not just blood pressure but pressure points for knowledge uptake and begin that healthcare narrative. What are the problems/goals/needs the patient wants? How can the physician become the author of a patient narrative? Does the patient leave with an Rx? Or do they leave with a continuum of care based on integration into the brand platform? ‘My physician is a great doctor but he is also doing more then caring for me, he hears me.’

Yes, yes I know, not all patients want to be part of a platform or need to be. The 20 year old patient in excellent health who comes in for a check up is not looking to solve a healthcare problem. And frankly many older patients with chronic HTN are not interested either. What exists is the opportunity to for HCP to take the pulse of each patients’ needs and goals regarding their health and learning styles and to change the office visit from a drive by to an engagement for life. Why can’t patients move from grade school to graduate school in their relationship with their physician over time? Physicians need life long learning. So do patients. I’m getting all misty here http://tiny.cc/93j2dw

And yes dear readers (all three) you re correct, how does a busy HCP achieve this? Stick with me and it shall be shown.

Making The Office Visit a Value Exchange

Sunday night at 9pm EDT the #HCSM chat happens. It is one of the best online healthcare chats that I’ve participated in. It is fast, smart, well facilitated, and with some of the best and the brightest minds I have the pleasure of interacting with. The topics are well considered and examined in great detail. Each discussion drives me to think more and consider the changes occurring in healthcare. If you haven’t participated or lurked and you are interested in healthcare check it out, ” …as the dormouse said, ‘Feed your head’.”

I’m sure I am the most annoying participant with my continuous hocking about SM being a tactic and we need to identify strategies/goals and then overlay a tactic. Can’t help myself Donna and Alan beat me about the head for years to learn what a strategy is and how to use it. Sunday night #hcsm takes me back to sitting in the agency and having account people talk about tactics before they identify a strategy. Backing a tactic into a strategy is putting your shoes on and then your socks.

Sunday morning along with the NY Times I get my mailing from Digital Tonto (www.digitaltonto.com). One of his posts was 4 New Marketing Paradigms: here

Within that post were nuggets that clarified my thinking about those HCSM chats.

Greg the 4 new marketing paradigms:

From Making Contacts to Building Assets

From Campaigns to Platforms

From Awareness to Activation

From Transactions to Experiences

Yes, his post is about consumer media and marketing but let’s get real. We have to think in terms of marketing, communications, and strategies if we are going to meet the needs of patients in this evolving digital world.

It is the patient who is driving a need to know and learn because the www is allowing them in real time to seek solutions to problems they have, classic adult learning. To assume physicians who are struggling to keep up with an ever increasing work load and diminishing returns will jump into social media as a solution without first understanding what is happening is as likely as Mitt Romney is to have a cup of coffee.So we must look at strategies that engage both physician and patients and make that amazing unit of learning (patient & physician) work harder and produce better results. In a word use a strategy to show the physician what’s in it for them.

In the section: From Making Contacts to Building Assets Greg states ‘What’s emerging is the concept of value exchange in the form of owned media assets.’ This is not about using apps and content (tactics) to capture ‘eyeballs’ (think patient office visits). It’s about building assets and creating engagement.

The asset is the physicians knowledge and skill at delivering care. Creating engagement is helping patients replace or complement what they’ve learned at WebMD. Physicians should become MyMD to patients seeking knowledge. Make no mistake, patients trust their physician more then WebMD or they want to. Talk about a ready made gap to close, this is one that can be done.

Take away: The office visit is greater then the sum of its parts. It is a place to begin the ‘value exchange’.

I will examine how Greg’s other models relate to health communications and social media over the next few days. And I will show an example of how to begin that value exchange.

NYMC Seminar on Social Media and What I Learned

I attended the April 24th New York Medical College day of presentations on iMedicine- The Influence of Social Media on Medicine. This was an informative and forward thinking event on social media and healthcare. There were 10+ presenters including: Howard Luks, MD, Mark Ryan, MD, Brian McGowan, PhD, Ryan Madanick, MD, Lawrence Sherman, Kent Bottles, MD, and others:

The site is here: http://tiny.cc/wjbndw

Watching and listening I was struck by the depth of knowledge and experience each speaker had specific to SM and how well SM has served each one. As the day progressed I was filled with an overwhelming sense that SM in HC has the power to change, no improve, patient outcomes. Then Kent Bottles, MD spoke and shared the Gartner Hype Cycle. http://tiny.cc/mlbndw and http://www.shockoe.com/blog/trends-in-tech-truth-or-noise/ As he gently put it we may be drinking the Kool-Aid.

The consistent thread throughout all the presentations was the value social media has for physicians, patients, and outcomes. Each presentation spoke to social media not just an important new technology bringing physicians, patients, and healthcare together but showed executing it in new and more productive ways. Five presenters highlight key take away messages:

Mark Ryan, MD @richmonddoc spoke about the long history of personal one to one care delivered by the family physician and how social media can return us to that model and what it means for care.

Natash Burgert, MD www.kckidsdoc.com demonstrated how Tweeter, her web site, and other social media tools changed her practice and improved the care for her patients. She showed how a small investment in time produces durable and important outcomes with parents and patients. She is part of her local community and the community is part of her practice.

Ryan Madanick, MD @ryanmadanickmd presented was how his seeming late adoption of social media was not a barrier. In fact his coming into it as he did provided greater benefits for not just his patients but for his colleagues on both a national and global level.

Howard Luks, MD @hjluks presented the way he integrates a blog, Facebook Page, YouTube Channel, and personal site to educate and engage with patients.

Loring Day a patient spoke about how she was able to improve her care through social media and her physicians (Luks, MD) online presence.

I am highlighting these presenters among the many equally excellent and illustrative ones because they connect the dots in social media and healthcare. Social media in healthcare is about learning. It is shared decision making at a macro level. Patients are adult learners. They want to find solutions to problems they are having. Each of these HCP is offering their patients and colleagues not just places but knowledge. They are providing solution’s patients are seeking directly and indirectly. The physician and the patient is the smallest functional environment of learning and what was shown are ways to extend that beyond and back into the office visit, and ultimately to outcomes. These are communities of practice for the 21^st century built around technology and basic learning.

Kent Bottles, MD www.kentbottles.com is correct, in a way we are drinking the Kool-Aid believing social media is the answer to all out healthcare problems. We will see a period of dissolution with social media in healthcare and the plateau. We will NEVER reach 100% of patients.

My observations:

Social media in healthcare works. It extends what once was to what is and will be, care delivered not top down but together.

Are the audiences seen above a self-selecting small cohort? What can we do to move beyond self-selecting participants? Can we create a push pull?

Can we demonstrate outcomes? What are they?

Performing needs assessments to determine what problems patients are seeking solutions to and where on their continuum of knowledge/learning they reside? This will help to identify others outside the current users of social media. It will also give insight into learning needs that may differ between demographics with the same issue.

Social media is only a tactic, a mere toy. These presenters use social media as part of a strategy that educates, engages, and motivates. This is how a tactic work best, as part of an integrated strategy.

Whether each presenter deliberately identified a strategy or simple found where social media worked best is not up for debate. Social media works in healthcare. The question becomes how do we take these successes and extend it? How do we smooth out the Gartner Hype Cycle?

It is time to approach social media and healthcare in a deliberate fashion, as educators seeking to understand learner needs and problems. In every practice there are 20 year olds in perfect health who have no problems they are seeking solutions to. For them thier physicians social media is about as useful as breasts on a bull.

At the same time there are a slew of 50 something patients with problems who are seeking solutions. With a little planning and work we can improve the percent of 50 year olds who engage with HCP to solve their healthcare problems. It is not WebMD but MyMD. That is where the future of social media and healthcare will meet and improve outcomes.