Digital Engagement: How Serious Are Hospitals?

Digital health is a fast moving area of growth, with healthcare organizations and a range of companies investing to meet changing consumer demands, increase access, and reduce costs of care. Twenty years ago, online patient portals began electronically connecting patients with their clinical care teams and providing access to certain elements of electronic health records (EHRs). Today, 95% of acute care hospitals enable patients to view elements of their health record online, and 67% enable secure messaging with clinicians ¹. Nonetheless, digital engagement has not widely taken off as it has in other industries, with only about 40% of patients reporting electronically accessing their health records or electronically engaging with their clinician offices ². Prior research has shown that digitally engaged patients lead to both clinical and organizational efficiency improvements. ³

The reasons for why adoption has been sluggish are not completely understood, but are suspected to be a combination of limited awareness, a perception of low value, or difficulty in accessing the tools. Data show that active encouragement on the part of clinicians and staff is a significant driver of adoption. ⁴ But how do healthcare organizations frame digital engagement, and what guidance is available for patients? To answer these questions, Lee and colleagues conducted an illuminating exercise of collecting published information from hospitals related to digital engagement, and more specifically to the usage of secure messaging services. ⁵

The research, drawn from a comprehensive analysis of 200 randomly selected acute care hospitals across the USA plus the Veterans Health Administration (VA), showed that portals were readily accessible from the hospital homepage only 65% of the time. Among the reviewed hospitals that offered secure messaging, not using the portal for urgent matters was the most common guidance, identified readily from 78% of hospitals. Expectations for turnaround time for secure messaging were identified from two-thirds of these hospitals. Forty-two percent of these hospitals provided guidance around patient behavior, and most focused on inappropriate behavior (68%) rather than appropriate behavior (32%). The VA portal had among the most comprehensive user information, including print and online frequently asked questions.

Lee and colleagues also identified that it was difficult to obtain additional information in the form of brochures or pamphlets about the patient portal. The process of requesting information led the investigators through a series of different departments that undoubtedly reflect the variation in management practices of portals across hospitals. We suggest this finding highlights the diversity of how hospitals manage portals and who has responsibility and oversight for that experience, whether marketing and communications, clinical informatics, information technology, or other administrative units.

Together, these findings tell an important part of the story of patient portals and the state of digital engagement with healthcare institutions. Currently, patient portals are often an “add-on” service, built on top of other clinical or organizational work with little consideration to its overall potential and risks. The paper suggests that hospitals writ large may be struggling with broader digital strategy to support patient care. For many clinicians and their staff members, secure messaging does not serve their needs and sits atop other mediums of engagement such as in-person visits and in-bound telephone calls. On another note, given that most secure messaging currently is not reimbursed, clinicians remain concerned around time management, responding to inquiries and messages often after full and busy clinical days. In addition to time, clinicians also are concerned around liability or of missing an urgent clinical symptom. Given these two common concerns with patient portals, it is not surprising that information about secure messaging is difficult to find, and when present, it focuses more on guidance around “what not to do” rather than how to positively engage.

If we are to fundamentally move healthcare into the digital area, our tactics today related to digital engagement must evolve. Three things must occur to achieve more widespread engagement. Firstly, enough information and transactional capabilities must exist to make the time investment by patients worthwhile and scalable. For example, sharing clinical notes through portals (OpenNotes) provides patients with much more detail about their clinical care, diagnoses, and treatment plan. While clinicians were initially concerned around time management and questions by patients, less than 5% of doctors reported spending more time outside of visits following enrollment of OpenNotes. ⁶ Moreover, patients with lower educational attainment reported bigger benefits than those with higher educational attainment. ⁷ Secondly, we must encourage patients to join us online, and design processes that facilitate enrollment. When doing so, we must ensure that we provide added value along the way, whether as more consumer-centric services in the form of asynchronous visits, timely prescription refills, or guidance around a medical concern. Third, our digital services must be patient-centric and designed to be more friendly and intuitive to use, rather than, as what has been identified by Lee et al., crafted around compliance and policies. Patients may not know when a concern would be considered “serious” by a trained healthcare provider, but they are seeking advice about next steps in their care. Facilitated by technology, we must continue to find ways to meet those needs while not placing all of the responsibility on patients to triage their concerns.

The VA serves as an exemplar, being a leading telemedicine provider in the USA, encouraging patients to take advantage of full access of their health records, and developing multiple applications and even online chat tools to serve their patients. Newer entrants into the healthcare market that are providing digital first care are growing. For instance in the UK, Babylon Health has partnered with the National Health Service (NHS) to launch NHS at Hand, a mobile application that combines secure messaging, an AI symptom checker, an on-demand video visits, and physical primary care clinics. ⁸ In the USA, several new entrants, from 98.6 to Amazon Care, are offering either virtual first or text-based primary care services. This trend is changing the modalities of engagement with individuals. In traditional settings, access to care services is delivered primarily in the traditional brick-and-mortar office. In the digital space, care is delivered instantaneously anytime, anywhere.

Undoubtedly, hospital, clinician, and patient stakeholder groups must work through several thorny issues along the path of digital transformation. Security, privacy, safety, access, and equity are but some of the challenges that face digital engagement. Providing expectations around response and turnaround time of messaging is a necessary first step to help guide patients in how to digitally engage with care providers. We must continue to identify best practices and workflows to support our patients and our staff. Newer services with artificial intelligence or advanced computing that help patients navigate care services must continue to have risks assessed to understand where they can appropriately be used. ⁹ We must advocate for alternate business models, and we must fight for appropriate work–life balance such that secure messages are not being read at the end of an otherwise full clinical day. To realize this goal, we need to move from managing digital as an “add on to care” to placing digital in a more central role in our work.

For now, if hospitals are serious about digital transformation, making information about digital engagement readily available, developing clear ownership, and finding solutions to reduce the friction for engagement are key initial steps. The work by Lee and colleagues provides an objective assessment about the present state of digital engagement across hospitals, and highlights opportunities for hospitals to do better.