We are currently challenged by a healthcare system problem. Too often patients only communicate with their provider to receive episodic care; we need to emphasize the importance of the provider-patient relationship in preventative care.

The election of President Obama in November 2008 marked the beginning of the health reform era in the United States. Since his election, several legislation, including the American Recovery and Reinvestment Act of 2009 (ARRA) and the Health Information Technology Economic and Clinical Health Act (HITECH Act), have been passed to address the inefficiencies and depreciating quality of health care delivery within our health care system. The underlying costs of the healthcare system are exploding. Our nation currently boasts a health care GDP of nearly 17%[i] and an uninsured population of over 50 million (which includes an estimated 10 million non-citizens).

Whether we argue that health expenditures or inefficient quality are responsible for increased healthcare spending and disparate health outcomes, our current performance on economic and health quality indicators show a need for reform. But can we achieve healthcare reform without including patients at the table?

Patients remain the most underutilized resource in our health care system. If we want to optimize prevention and wellness, we must improve patient involvement and understanding of their health care. Health reform and embracing new technologies won’t be successful if patients aren’t engaged.

Why patient engagement?

Patient engagement is the process of involving patients in the management of their health care in order to satisfy their healthcare needs.  Examples of patient engagement include documenting patient preferences, discussing healthy lifestyle behaviors, and the use of new technologies, like patient portals, to facilitate patient-provider communication.

It is important that we look to patients as partners in their health care management, and not placing prejudice on their ability to understand “just what the doctor ordered.”

One of the recommendations from the Using Open Innovation to Reinvent Primary Care project addresses the need to engage patients and hold them accountable for the management of their healthcare. Similarly, at Working Together Towards a Healthier Generation: The Implementation of Health Reform, the Metropolitan Washington Public Health Association’s 2011 Annual Meeting, Dr. Mohammad Akhter, Director of the District of Columbia’s Department of Public Health, spoke about the need for patients to understand what health care reform means to them.

This requires a cultural shift where the patient, in collaboration with the physician, takes the initiative in managing his/her care.

Just because health reform promises to place a health insurance card in the hand of every citizen and documented person does not guarantee that patients will use this coverage. Health insurance coverage without patient engagement will not lead to the outcomes we hope to see (i.e. better care coordination, controlled hemoglobin A1Cs, etc.) As the old adage goes, “you can bring a horse to water, but you can’t make him drink…”

Recognizing the importance of patient engagement in care delivery, there are a number of tools being introduced to help transform the way we deliver care. Recent discussions celebrate the use of mobile or software applications to facilitate ongoing communication between the patient and health care provider. Whether we rely on the use of mobile applications of electronic records, the use of technology provides an opportunity to merge the disparate words of health IT and patient engagement in care delivery.

What’s all this about health information technology?

E-health technologies, such as the electronic health record, can improve patient engagement. The electronic health record is a longitudinal archive of a patient’s medical history. It has the ability to offer providers immediate access to their patients’ medical records. Empirical data on the clinical effectiveness of the electronic health record suggests that this technology can help improve care coordination between providers caring for the same patient and ensure that providers educate their patients with up-to-date, relevant information on managing their care (see reference links below).

E-health technologies, if implemented, can transform the way health care is currently delivered by vastly improving health providers’ ability to involve patients in the care management process.

Reference Articles

1. Gustafson DH, Hawkins R, Boberg E, Pingree S, Serlin RE, Graziano F, Chan CL (1999) Impact of a patient-centered, computer-based health information/support system. Am J Prev Med 16(1):1-9.

2. Poon EG, Keohane CA, Yoon CS, et al. (2010) Effect of Bar-Code Technology on the Safety of Medication Administration New England Journal of Medicine 362:1698-1707.

3. Resnick HE, Alwan M (2010) Use of health information technology in home health and hospice agencies: United States, 2007 Journal of the American Medical Informatics Association 17(4):389-395.

4. Zaia AH, Grant RW, Esteya G, Lestera WT, Andrews CT, Yeea R, Mortd E, Chueha HC. 2008. The Practice of Informatics Application of Information Technology Lessons from Implementing a Combined Workflow–Informatics System for Diabetes Management. JAMIA. 15:524-533.

5. Kwok R, Dinh M, Dinh D, Chu M (2009) Improving adherence to asthma clinical guidelines and discharge documentation from emergency departments: implementation of a dynamic and integrated electronic decision support system. Emerg Med Australas. 21(1):31-7.

[i] “Two Myths about the American health care system.” Montreal Economic Institute. June 2005. Retrieved 2011-04-15.

"I already have a doctor I’m happy with."
One of the main obstacles to health reform has been the resistance of Americans who already have health insurance.  They are pretty satisfied with what they have and frightened that change can only hurt them.  The same is seen in Americans’ attitudes to the primary care shortage.  Most Americans with insurance have a primary care doctor that they are satisfied with.  Where’s the shortage and why should they care?  Why should we invest hundreds of millions of dollars into training more health workers when they already have a doctor they’re happy with?

The truth is that whether you are insured ore nor or have a doctor or not, the primary care shortage affects us all.    The most important affect is that of waiting times which have dramatically increased for all patients.  For example, a recent study showed that the wait times for a non-urgent appointment to see a family doctor were as high as 63 days in many cities.  Long waits extend physical and emotional pain, cause conditions to worsen, delay diagnosis and treatment, worsen outcomes, and cause some people to forgo care completely.   To worsen matters, many people who cannot get an appointment with their primary care provider in a timely manner resort to the Emergency Room where they drive up the cost of health care for us all and delay care for the critically ill.  With non-emergent patients unnecessarily clogging up the ER, the patients who truly need to be seen are neglected.

You may also think that you don’t need a primary care provider.   For example, you may have a cardiologist that you see regularly and she takes care of all your health needs.  Yet, a preponderance of evidence shows that those patients who see a primary care provider who coordinates all their care with specialists have better health outcomes and lower health bills than patients cared for exclusively by specialists.

A Practical Experiment
For those readers who may still be doubting, I’ll suggest a practical experiment.  Call your primary care physician’s office and tell the scheduler that your back has been hurting for a week and you would like to see your doctor.  My bet is that you won’t be able to get an appointment for at least a week if not longer.  Then ask the scheduler when you can schedule an appointment for an annual physical exam.   You’ll probably be given a date several months in the future.  Then tell the scheduler that a family member is considering being seen by your doctor as a new patient.  Is your doctor even taking new patients?  If you’re lucky enough to get a “yes”, ask when your relative can schedule an annual physical.

The Price Paid by Rural Americans
The situation is worse for the over 60 million Americans living in rural America; the primary care shortage is deeper in rural American than metropolitan America.  As part of the “hollowing out of the middle” the US has not invested enough in training primary care providers with an inclination to serve rural communities or in structuring payment systems that incentivize providers to work in rural areas.   A recent study in central Texas on insured patients showed that 25% of them had trouble getting to see a doctor in the last year.    The US relies on rural America for much of its food production and light industry yet rural America is on its own when it comes to their health.

The Coming Wave
If you don’t think there is a primary care provider shortage, just wait until the more than 40 million uninsured Americans finally get insurance and a title wave of previously unmet need lands on the primary health system.   In addition to their pent-up demand, the uninsured tend to be lower income than the insured and have worse health status than middle and upper income Americans of the same age.  Even without the addition of the newly insured, shortages of over 125,000 doctors are being predicted by 2025.  That number will worsen if demand for their services is increased.

So whether you have insurance or not, the primary care shortage affects you.  We need a rapid expansion in the training of all different types of primary care providers, including pediatricians, family practitioners, internal medicine specialists, nurse practitioners, and physician assistants.  Only then will we have enough hands to do the work.