Enabling More Self-Service in Healthcare

The New England Journal of Medicine recently published a commentary by Asch, Nicholson and Berger about facilitating self-service in healthcare. They argue that our existing approaches to transform healthcare (alternative payment systems, high-deductible insurance plans, iPads serving as digital transformation) has not done very much to improve the value we get for the money we spend. Other industries have used technology to enable the operational changes to enhance productivity. They define facilitated self-service as “consumers can handle most of their needs without help, but some needs require a higher level of service.” They recommend: 1) abandoning legacy payment systems based on how and where care is delivered, 2) moving past state-based regulation of licensure and insurance, and 3) expanding the regulatory expertise, processes and capacity for ensuring that self-service approaches to health care meet the safety and effectiveness standards we expect for drugs, devices, clinicians and organizations.

Facilitated self-service could support the quadruple aim (enhance the patient experience, improve population health, reduce costs and improve the work life balance of healthcare providers). When I interact with other industries, I appreciate those companies that help me get what I need without engaging an employee. I appreciate the ability to complete the task on my own and the company spends fewer resources managing customers like me. Employees focus on helping customers facing problems that require the employees’ expertise and emotional intelligence.

“Facilitating self-service” is a different frame from the current “virtual care” paradigm in health information technology. Rather than pushing more interactions with physicians online, enabling self-service could empower patients to make meaningful healthcare decisions on their own or through friends or non-physician guides. Unlike care coordination or care management (activities driven by an external entity with some patient consultation), self-management starts with the patient who is provide enough information to make an informed decision. The patient can then seek out whatever resources necessary to translate those decisions into actions.

What health behaviors might be most appropriate to consider first for “facilitating self-service?” In 2012, Goetzel et al. identified 10 modifiable health risk factors linked to over 20% of employer-based spending: depression, blood glucose, blood pressure, body weight, tobacco use, physical inactivity, stress, cholesterol, nutrition and eating habits, and alcohol consumption. These risk factors encompass primary prevention as well as chronic disease management. Self-guided internet-based cognitive behavioral therapy is more effective than usual care for individuals with symptoms of depression. Group-based education lowered A1C and body weight compared to usual care or individual education. Groups led by a health professional were more effective than peer-led interventions. Self-monitoring of blood pressure was associated with better control only if paired with systemic medication titration or lifestyle counseling. I was unable to find a meta-analysis of studies evaluating the effectiveness of self-service approaches to help patients manage their own weight, tobacco cessation, physical activity, stress or dietary behaviors. A recent Cochrane review was unable to draw definitive conclusions about text message-based interventions for medication adherence to address secondary prevention of cardiovascular disease. Chronic pain management may also benefit from self-service. A health system or payer might consider addictions beyond tobacco, alcohol and food.

From a health information technology perspective, self-service seems converge on building a killer app. Pooja Chandrashekar identified the following characteristics of an effective healthcare app:

  1. High patient engagement – including real-time engagement, usage reminders, and gamified interactions
  2. Simple user interface and experience – pictures instead of text, reduced sentence length, and inclusive, nonclinical language
  3. Transdiagnostic capabilities
  4. Self-monitoring features – enable users to periodically report their thoughts, behaviors and actions to increase emotional self-awareness

What additional information would we need to verify that patients aren’t receiving lower quality care with a self-service model? Since definitive outcomes like total mortality or blindness that matter to patients take decades to develop, we will need to track intermediate outcomes that may be closely related to these definitive outcomes. Self-service models rely on patients being engaged with the healthcare system and have some insight into when they may need additional assistance from a healthcare team member. Although most Americans expect individuals to choose whatever guidance they might require for financial decisions, this “caveat emptor” attitude for managing our retirement savings, we may be more concerned about applying this approach to healthcare, especially if taxpayer dollars pay for each individual’s “poor” choices.

Patients could be stratified across different permutations of risk and engagement. Patients at high risk for complications, but low engagement will need different approaches than patients at low risk for complications and high engagement. Until we have more effective tools to increase engagement, patients with low engagement may need to be redirected toward existing provider- or health system-facilitated services. The approach implies that individuals with low self-efficacy or engagement may be associated with a higher risk of developing complications or adverse health events. Reliable markers of self-efficacy, engagement and willingness to change may be more important than a genomic profile or any other “omic.” Vasiljevic et al. suggest people from lower socioeconomic strata have lower levels of health-related self-efficacy. This lower level of health-related self-efficacy could be contributing to higher rates of unhealthy behavior (i.e., diet, physical activity and medication adherence in smoking cessation). We in healthcare must restrict any efforts to link engagement with health care premiums or patient payments.

Self-service in healthcare offers a different way to approach challenges around quality, value, employee fatigue and consumer experience. The framing asks different questions and suggests different tactics to help patients take better care of themselves. Although this is some work to translate these ideas into reality, the work is doable and results can be measured.