The common refrain in health care circles is that most “people won’t become engaged in care until it’s too late.” But there are those who do get engaged with significant impact. What determines success? As behavioral scientist BJ Fogg says, start with “What behavior do we want people to do?” Then work on making the process simple, easy and something that can be triggered. It helps to pick a simple behavior that people are already trying to do: Take medications on time? Setting up an appointment?
While selecting the when and where is a matter of finding things people are already trying to do, the ability to get attention of the people who will actually be engaged depends largely on what they are experiencing, how receptive they are, and what influences them. Once you have a good idea about targets and actions, you can move on to what tools and channels might be most successful as part of a messaging strategy.
If this sounds a lot like marketing, you’re right. It’s no mistake that Cleveland Clinic apps that integrate with “My Chart” are part of their digital marketing strategy.
Whether we engage, and how we engage is about context
Dave Chase says in his Forbes piece “7 Habits of Highly Patient Centric Providers” (highly recommended):
“I ask the audience which hospital they’d choose if given the choice between one where patients have an 88 percent reduced risk of dying of a cardiac-related cause when enrolled within 90 days of a heart attack, compared to those not in the program, clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent versus others that didn’t have these outcomes.”
In this case, of course, the choice is obvious. It’s a relatively easy situation to predict success. The motivation is clear and strong: staying alive. The very real chance of dying from a heart attack tends to get people’s attention and increases their willingness to engage. As PatientsLikeMe CEO Jamie Heywood said last week at The 2013 Healthcare Experience Design Conference, “People mostly don’t want to die.”
Meeting people where they are already trying to get engaged and find answers will increase the odd of success of an engagement initiative.
Heart disease and cancer might be among the candidates for an initial patient engagement strategy, with an immediate impact in people’s lives.
Putting Engagement in Context
Once motivations and patient niches have been identified, it then becomes a matter of delivering those people the right message in the right channel, also just like a good marketing campaign.
To access deeper layers of patient engagement with different patient populations, it’ll require deeper levels of understanding of motivation and communicating the right messages. Heywood brought up Maslow’s Hierearchy of needs in the same speech, which is worth a review to think about the different kinds of context that exist for patients and consumers.
— Marie Connelly (@marieconnelly) March 25, 2013
Maslow as an Engagement Spectrum
Maslow’s hierarchy is well known in advertising and may be useful to consider when we think about who is likely to benefit from patient engagement. Those that don’t have needs fulfilled at the bottom of the pyramid, the physical level, like those with a fear of dying, may be the ones most likely to become engaged patients.
You might think people go on PatientsLikeMe because of social interaction, level 3, but the data-centric success of PatientsLikeMe, and Heywood’s comments, suggest many of them go there because they don’t want to die or they no longer want to be in pain. They’re looking for solutions, they’re looking for answers to a very serious problem, and want to see measurable results.
On the other end of the spectrum, near the top of the pyramid in self-actualization, we might place the early-adopter quantified selfers, a small, but growing and highly engaged group that sees engaging as part of being their best.
In the middle, most people might not pay much attention to health care. As health care data strategist Dave Clifford says, “I don’t think that most people perceive the healthcare system as anything other than ‘there if we need it to be’ and as a result…from an HIT perspective most of the people in the middle of the spectrum just don’t exist…we need to consider what a learning healthcare system can tell us when our classrooms are full of A students and D students and the rest of the class is ‘skipping school.'”
How to get the folks skipping school to attend healthcare “class?” There’s a broad spectrum in between where making engagement “fun, playful, sexy, scary” to use Lygeia Ricciardi’s terms, mixed with quantifiable results could have real public health impacts, but it will take real time, effort and resources.
I suspect Maslow may provide some insights into meeting people where they are in the middle, around level 3 and social. Weight loss could be one example. We might not lose weight to be healthier, but we’ll do it to be more attractive and we feel we have a chance at success. These are important considerations for building engagement strategies for chronic diseases and the promises of big data in health care as we eventually move toward the middle.
There are many schools of thought on motivation. For a great summary, I highly recommend Michael Wu’s article on how motivation relates to gamification and consumer engagement. I’d also add Economics Nobel Prize Winner and Psychologist Daniel Kahneman’s “Thinking, Fast and Slow,” “Nudge” by Thaler and Sustein, and “Connected” by Fowler Christakis to the reading list on attention and decision structures and how they might be applied to health scenarios.
Where to Start
Last week on a Collaborative Health Consortium call, a provider leader involved in HIEs who is moving to a new quality-based payment model asked, “How do we start (with engagement)? How do we know what will work?”
The expectation seemed to be that he should buy an off-the-shelf tool (perhaps driven by HIMSS and vendors, all of whom seemed to have a “patient-engagement solution.”)
But engagement is about more than a tool as illustrated above. While opening up and sharing data is a good start, ultimately, who engages and the value they see in their data depends as much on their internal motivation as to anything external. Each person has different motivations and contexts within which they’ll want to engage the health care system. And, to be an effective “patient-centered system,” we’ll need to address each one.
In the next part of this series, I’ll explore nudging, and why engagement is a two-way street, more pull than push.