In a recent commentary on the American Public Media program Marketplace Money, Francis Frei discussed the failure of self check-out at supermarkets. Her insightful commentary is clearly based on both personal experience as well as her professional knowledge of operations management and customer behavior (she is a professor at Harvard Business School). The piece is excellent and I recommend listening to it whether you’re thinking in “e-pateint mode” or just interested in why those darned checkout lanes are so ineffective.
I think there are parallels between the failure of the self check-out lanes in grocery stores, and the failure of many patients to embrace engagement. After all, I hope readers of this blog realize that they are in the minority. The majority of patients are not e-patients and the majority of providers are not welcoming of e-patients. And, as a provider, I recognize that I can’t force my patients to become e- patients and to participate with me in assuring their best health. Why not? Perhaps we’re falling in to the same trap as the super markets.
The principle points raised in Dr. Frei’s commentary are that customers will only embrace self-service when it provides something they want and when the technology is intuitive. She described how the grocery store self-service lane failed to address these issues, foisting the work of checkers on the customer without adding value to the experience. As anyone who has used one can attest, the machines are not intuitive to use. Nobody wants to struggle to scan items and type in codes while other customers wait impatiently. Dr. Frei described a potentially more successful self-service technology. A new system is presently in testing where customers are issued hand-held scanners to use while shopping. In addition to registering the price and creating a tally, the scanner displays information about each product so that the customer can see it at the point when they are deciding to buy. This is a system that both saves time/money at the cash register and adds value that customers appreciate.
What is the lesson for providers and patients? As providers strive to empower patients through new health information technology, whether offering self-service or encouraging self-care, we frequently transfer work from our office to the patient. Patient portals allow one to make an appointment, request a medication refill or get a referral. Remote monitoring collects weight, blood pressure and other physiologic information. But, if the technology and processes are not designed to give people something that they want, it will not be effectively used. Right now, blood pressure and weight metrics are transferred to a doctor’s office, and the patient gets a call back from a health coach or nurse. Appointment requests go in to the black hole of the provider’s office and its status is not available. Self-service is thwarted, and self-care and patient engagement remain elusive.
I know what I think would constitute valuable self-service at my doctor’s office, but wonder what others think. What constitutes useful “self-service” at the doctors office? Are there value-added self-service functions that will enhance engagement and self-care?
I’m probably not the right person to answer this because I love the self check-out machines at the grocery store. I also know at least one store where there’s a line at the self-checkout machines, so not sure I agree with the statement that they are failing.
I’d love to enter my medical history and demographics data from home, on my computer the day before I have my doctor’s appointment. I’d love to pay my copayment and online.
I’d like to use the time before the doctor gets in the room to enter the chief complaint by myself on a terminal and to review my EHR data, maybe add my own comments to it.
I’d like to be able to send my FitBit data so that the weight measurement, activity, etc. would actually have some data behind them and I can have a really meaningful discussion with the doctor.
I’d like to be able to send the doctor my own self-diagnosis, the info behind it and discuss it in the appointment.
I’d love to set an appointment by myself from a list of possibilities.
I’d love to have follow-up email/messaging conversations with my doctor about: anything I forgot to mention, test results, questions about drugs or other prescribed self-care, side-effects.
There’s so much we patients can do to help… and some of us would even scan out own barcodes.
Thanks for the teaser, great article!
Wonderful Ideas! this is an incredible start. thanks
“Transmission” is the most important feature of a practice portal. Even those of us that don’t or can’t be bothered to interact with the technology can be served by advocates, family members, commercial services, second opinions, etc…
The technology to securely connect one Web portal to another is all over the Internet. We need to demand it of our providers and regulators.
Excellent piece and thanks! Love your analogies and they are so on target to me.
What am I hoping to see? Perspective on my personal history, over time, in context, as compared to peers. E.g. charts that help me track correlations of symptoms and meds and tests etc so I can sort my own outcome stats.
But I know at this point that is like wishing for a world wide web circa 1986.
I love the scanners when–I have no fruit which needs to be weighed, when everything I purchase is pre-packaged, when I have no questions of the clerk, the ability to pack my groceries in the tiny space allotted, and when I am reassured in advance that the check-out machine won’t be one of those “we’re having trouble with today.” As a patient, I would love to have ALL my labs sent to me in advance of my doctor’s appt, have access to records from other doctors, have a way to show a trend in some measurement across a year or two–which does not mean him flipping back and forth between 8 pages to see if my name-the-value is really going up or down in comparison to the meds I am taking. Just saying.
Self-service health care will become standard practice. As health insurers continue to incent their members to meet wellness markers and the expense of doctor office visits, the shortage of PCPs, patients/consumers will do routine tasks inconvenient locations with new technologies.
Self-service kioks at retail, provider offices, airports will be common and so will devices that attach you smartphones. Performing one’s own blood pressure, weight/BMI, blood sugar will be standard.
Consumers are demanding better service, more information and want to be in control of their medical records. They want to see how their health compares to others like them.
The physician community needs to be the group innovating in this regard. Their patients will love them and they will have more time to spend on patients that need more complex care mgmt.
For me, there is nothing more empowering than self-service.
Marcee, I agree with you — I love being able to participate in my own health care — and that of my family as well. But I also have an advanced degree, come from a family of health providers, and have worked with scientists and physicians for most of my adult career. I wonder how people who don’t have this much background cope — clearly, e-patients are a remarkably efficacious group of people.
My experience hanging out in waiting rooms and talking to friends is not that they aren’t smart or even willing, but they already feel overwhelmed by current responsibilities — becoming an active self-care health manager makes their eyes glaze over. I can’t really blame them since so few resources exist that would help a patient make a decision — just as the NIH publishes clinical guidelines for health providers, I would love to see a similarly robust resource developed for patients that would help them make health decisions. So many of the “symptom” trees available on a variety of websites so frequently point to “go see doctor” that I wonder what the point of having any other option is?
When my son was diagnosed with “developmental delays” of an unspecified cause, we got to spend 3 1/2 years in various therapy sites and I spent a lot of time talking to parents and providers alike. One of the places was desperate to find teaching information on autism that was appropriate to a largely high-school-educated, rural agricultural community. The NIH is a nice place to start, but even that was relatively difficult for most parents to understand.
Eventually, of course, as they learned the terms, they became much better co-participants, but the first 6 months, when they are asked to make all sorts of treatment decisions, parents were overwhelmed, scared silly, and just plain out of their depth. While I shared their emotional responses, I felt helpless to aid them in understanding the neurological basis of behavior underlying their sons’ disorder.
Not only could I access the primary literature (I work at a large university), I could read and understand it, and this was enormously comforting to me. More importantly, the training I received en route to this level of education meant I could accept that my son’s delays were neurological in nature — the fact of the brain and science were not new and the frame within which to understand them was well-practiced.
This is the thing I find most difficult to overcome with patients — it isn’t simply a matter of learning how to do something or what something means, but of accepting a framework within which to think about health that is essentially scientific at heart. Before self-serve kiosks become a reality that actually contributes to health care, patients will needs to adopt a different way of thinking about health.
Actually I wouldn’t mind some self service health care, especially considering that I’m currently uninsured. I read a lot of my ex’s lecture notes and text books when she was in med school, discussed her classes or clinical rotations daily, and have a pretty good handle on my routine needs. I’d be be pretty happy if I could order a few routine labs, abx for my typical ear infection, some imaging, etc. without involving a physician or other provider. I don’t think society as a whole would be better off but it might work well for me.
> Actually I wouldn’t mind some self service health care,
> especially considering that I’m currently uninsured.
Increasingly – including by my own experience – I’m certain we’ll see a wide range self-service options, to be purchased by people outside the establishment. Why? Because increasingly the establishment is pricing itself out of the game.
And as I read these comments, my mind went back to the magazine our visionary founder, Tom Ferguson MD, founded in 1976: Medical Self-Care. Here’s our August 2010 post about it – a 1978 interview in Mother Earth News.
Of course I hope that as reform continues to roll out the American healthcare industry will become less corrupt and financially untenable. I just spent 11 days overseas, where everyone gets care, people are generally healthier, and it all costs 1/3 less than what we have here.
Anyway yeah, self-care!
I recently used a new patient health form portal and left some acerbic feedback on how poor the user design was — and I LIKE technology. “User experience/design” is a significant problem and is doubly so when the provider’s vocabulary is what is used on the form. This particular portal used what looked like 8 pt font on a crowded screen in low contrast colors — it had a poor style sheet associated with it.
I work with health providers and premeds, so I understand what is meant by “What is your complaint today?” — but I still react negatively to the language! I want to explain that I am not complaining; I am seeking health care as part of my normal routine. If this is what is typical of patient portals, then I would agree that using them will not likely serve even the independent patient (I like self-checkout, too — my husband hates it).
I also worry about a gap between increasing patient independence and what some patients really want: a human being who will listen to their needs. My mother-in-law is like this — even if she could, she would never use a self-serve patient function b/c she depends on physicians for social interaction. Yes, there will be people who would use self-serve health care, but my guess is the population would be mostly comprised of those who are highly educated with strong self-efficacy, those with chronic conditions who eventually become experts in their own way, and those who cannot afford face-to-face health care, even for routine wellness care. Is that population of people large enough to motivate the larger health industry to develop a sufficiently broad set of tools to make it economically feasible for patients and health providers alike?
That is very significant idea and knowledge.It is better us what we use for medical check up. It very new machine for that check up.So i am very satisfied to know the information.
It’s little wonder that self-checkout at markets hasn’t worked. The machines are a kludge of technologies and processes, none of which were designed specifically for self-service. It’s just what’s available cobbled together. After a lot more failure I’m fairly confident that better devices will come along, but only after much better design (think Apple vs most electronics) and after a much more complete standards-based infrastructure evolves to make it work. How long did it take just to get barcodes to become ubiquitous?
We’re in a kind of Cambrian Explosion of citizen-centered technology (I reject the term “patient”) for health awareness and thousands of entrepreneurs are diving in to get a piece of the booty. Just yesterdayh I spotted an article from a couple of months ago about a partnership among Ford, Microsoft, Healthrageous and others to develop technology for health information services and data-gathering built into Ford cars. It’s called “Doctor in Your Car.” Sensors would be busy gathering your biometric data while you drive and schlepping it up to Microsoft Azure cloud services and Healthvault. Because Ford “cares about the well-being of its customers” (yeah, right) they’ll be able to do things like manage their asthma or diabetes in their car! Likely another kludge.
Dr. Frei’s remarks about customers being receptive only to things they want to do is well taken, but a statement from the guy at Ford responsible for the doc-in-your-car project, Gary Strumolo, is revealing:
“Strumolo recalls a famous anecdote about Henry Ford, who once was said to remark that if he asked his customers what they wanted, they would say ‘a faster horse.’ ‘We’re trying to create something that they don’t necessarily know they want,‘ Strumolo says. ‘But hopefully once they experience it they won’t be able to live without it.’
Ah, a marketers wet-dream.
Like the Cambrian era, I suspect that 99.9% of what we see now in the e-health and mobile-health field are going to go extinct or simply be mutations along an evolutionary path to a more radically transformed system. To my mind the current technology frenzy is the best lever we have for opening up the current health care system.
The essential change needed is to alter the institutions that created the expert-based health system and culture of the 20th century. When physicians succeeded in wresting health practice away from the doctor-moms of earlier times through medical schools, certification, and licensing we ended up with a system where the depth of knowledge needed for medicine was placed exclusively in the hands of a limited number of practitioners.*
Unfortunately, as the medical edifice grew the notion that ordinary people could be made competent to take meaningful responsibility for their health didn’t grow. Health became essentially a bifurcated concept: you are “well” until labeled “sick” through diagnosis and then you fall under the authority of the medical system. Support institutions, infrastructure, and resources to support health-proactive citizens has been very limited. This “cult of expertise” may have been appropriate when access to information and education was very limited. It has been the model for all professions: medicine, law, accounting, investment, IT and others. But that era is fading and something new is not just possible but inevitable.
In the ‘70s I worked for a nonprofit cancer organization that had one set of pamphlets for the public and another for doctors. It was verboten to provide professional information to a cancer patient or family member. (At the time some oncologists didn’t even tell the elderly they had been diagnosed with cancer.) You could get fired for an infraction of the policy. That practice very likely would still be in place today if it weren’t for the internet. It’s gone now, not because the physician-dependent organization changed its policy, but because PubMed and hundreds of other online sources tore down the wall making control impossible.
The role of technology is to expand the information resources available to people in ways they can use. Now an aggressive constituency of adopters is demonstrating that they want and can use beneficially greater information for their well-being. These role-model leaders will show a public — still largely holding the notion that they have no need, no permission, no authority, even no right to medical knowledge — that a whole different order of things is conceivable.
Achieving a new paradigm will take time. The generation now elderly is the generation that would not question doctors or challenge their judgement. Instead they did what they were told out of loyalty if nothing else. I think of them as the Marcus Welby, MD, generation. Baby boomers have a somewhat better perspective about the medical system having been through “Our Bodies Ourselves,” informed consent, second opinions, revelations of medical errors and the economic incentives influencing practices.
I think it’ll take at least another generation before families and individuals fully grasp their responsibility and authority for creating the environment for optimizing health from cradle to grave. To be sure super-experts will always be needed at the cutting edge of research and complex interventions, but hopefully people will learn to use experts appropriately more in relation of advisors and skilled craftsmen. Unwinding the vast legal and economic architecture of the health industry will take a long time, but I think the dynamic of change has the energy.
* Required reading for all: Paul Starr’s, “The Social Transformation of American Medicine: The rise of a sovereign profession and the making of a vast industry.”
> Henry Ford: people would have asked for a faster horse
Well, he was right, eh? Any focus-group-based forecast would have been way off.
> Ford marketer: “hopefully once they experience it they won’t be able to live without it.”
> A marketer’s wet dream
You gotta admit, sometimes that does happen. (*cough*iPad*cough*) And yeah, that’s a marketer’s wet dream. The iPad shows such things are possible AND how rare they are.
At least the Ford guy had the decency to say “hopefully” instead of “We’re certain…”
> at least another generation before families and individuals fully grasp their
> responsibility and authority for creating the environment for optimizing health
> from cradle to grave.
Same for fully changing attitudes throughout the health professions, eh? In my speeches I often say that we’re changing culture – our shared expectations and beliefs about what’s possible – and as with civil rights, women’s rights, gay rights – and that does take a generation.
So I’ve been engaging for a while in splitting out two factors – what needs to change, and what it’ll take to get there. That’s why I wrote that thing the other day about Nudge, Switch and Thinking, Fast and Slow (which you also commented on – I’m going over there now).
Well the paradigm shift seems underway. I saw this post about medical apps available on the iPad. http://bit.ly/HS9BvW The shift is that these apps are available to everyone, not just physicians and on a consumer device. Young people are growing up with medical information at their fingertips. Yet the distinction between doctors and the rest of us remains in the design and the way content is presented. I can’t imagine it will be long until these apps are translated into multiple levels of consumer information (another branch of Google Translate maybe?)for different levels of age, relevance, and current literacy.
In your article it talked about the patients ability to request a referral. Can you please give me the name of a Kioski company that has this capability. Thank you