In-Depth: A brief history of digital patient engagement tools

By Brian Dolan
07:17 am

Without a doubt patient engagement is one of the more important trends in healthcare and health IT right now. Over the past few years the tools that look to enable patient engagement between providers and patients have changed markedly. It is important to note, however, that the tools themselves are just a small part of the story -- they can go a long way toward improving patient engagement, though. The drivers of the patient engagement buzz are varied, but one big one is the federal government's Office of the National Coordinator's (ONC) Meaningful Use (MU) program, which is beginning to include requirements for very basic patient engagement services. 

Blue Button ConnectorONC's MU Stage II requirements include at least three patient engagement related deliverables of providers. To meet Stage II, providers must give patients clinical summaries after each visit. They must use electronic secure messaging to communicate with patients on relevant health information with a minimum of 5 percent of their patients during the review period. They must also provide patients with the ability to view online, download and transmit information about a hospital admission and give them access to any health information about that patient the providers receives -- within four days of receiving it.

Along with MU, an equally important driver -- or perhaps an even bigger driver -- of the patient engagement trend has been the rise of accountable care models and payment reforms. Under accountable care models, providers are responsible for managing an entire population and their payment is based on outcomes – keeping them well and helping them get better – as opposed to fees for services rendered. As a result, providers are looking for ways to engage patients in their own health between visits to the doctor’s office.

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Before diving into digital patient engagement tools, it's worth pointing to the legacy and -- for most providers -- still most prevalent ways that providers engage patients in their own care. These include paper print outs of their health records; paper printouts of discharge instructions with simple diagrams or descriptions of rehab exercises, medication schedules, and other do's and don't's; reminder phone calls; follow-up phone calls; and in-person visits and face-to-face conversations with care providers. While some digital patient engagement tools look to replace some of these "analog" channels, most aim to augment or complement them.

The "tethered" and "untethered" PHR

When MobiHealthNews first started publishing more than five years ago, online personal health records systems (PHRs) were a big topic. And while many such efforts were only just starting to get off the ground, so-called "tethered" PHRs -- or those controlled by healthcare providers and offered to patients -- had already taken hold at a handful of healthcare systems around the country. In April 2009, for example, Kaiser Permanente announced that its PHR, My Health Manager, already had 3 million users. Just this month -- February 2014 -- the Department of Veteran's Affairs announced that its PHR, MyHealtheVet, was celebrating its 10th anniversary.


Tethered PHRs were already well established at certain pioneering healthcare systems in US in 2008, which is when their foil -- the untethered PHR -- became a popular topic of discussion in health IT circles. Google Health and Microsoft HealthVault were the two highest profile untethered PHRs, but another initiative that focused on employers -- Dossia -- was often mentioned, too. Untethered PHRs were controlled entirely by the patient and it was up to them to figure out how to download -- or more often scan faxed copies of -- their health information from their healthcare providers into their PHR. Google famously shut down its Google Health initiative in mid-2011, citing a lack of adoption. While Microsoft's HealthVault PHR is still up and running, the company hasn't made many announcements or upgrades to it since it lost its high-profile competitor.

Texting breaks out as early mobile health channel

Following the shuttering of Google Health there was quite a bit of analysis about its demise, but during this fallout healthcare systems and -- really everyone working in health IT -- began to turn their attention to the mobile health opportunity, which up until that point had been mostly focused on text messaging programs. While many text-based initiatives had a public health organization behind them, a number of healthcare providers also piloted texts for patient engagement.

Kaiser Permanente announced in 2010 that they would roll out a text message appointment reminder service following a one-year trial. Mt. Sinai Hospital in New York ran a pilot leveraging CareSpeak's text messaging-based medication adherence program for a group of liver transplant patients. After its success powering Text4Baby, Voxiva went on to launch a number of text message-based programs for payers and chronic disease management companies. As smartphone penetration in the US ramped up and over more than half of the population, more patient engagement initiatives began to leverage apps.

Hospitals launch branded apps, EHR vendors consider patients, and the tablet starts to swivel

mayo clinic mycareIn 2011 MobiHealthNews noticed an uptick in the creation of hospital-branded apps that would continue for the next few years. As we reported in our recent "205 Hospital-branded Apps" report, these iPhone and Android apps were developed by or on behalf of hospitals for their patients or prospective patients. As of early 2014 the number of these apps is north of 220. However, few of these apps help users access their medical records, refill prescriptions, or securely message their physicians. At the same time EHR vendors begin to roll out patient-facing apps like Epic's MyChart, which offers many of these features for patients at healthcare groups using the Epic system.

In early 2010 shortly after the launch of the iPad, tablets became a new channel of interest for those looking to implement patient engagement programs. Companies like Phreesia had long tried to enable patient engagement in the waiting room of physician's offices by putting a tablet in the patient's hands instead of a clipboard for registration. A number of companies -- including Seamless Medical -- would go on to try to do the same with iPads in waiting rooms. Tablets were also expected to serve as a better platform for "swivel apps", which are those that providers have on their mobile devices but that they use to explain something to patients. Jiff offered just such a swivel app, called the JiffPad, that then captured notes, animations, and annotations from the interaction between the provider and the patients -- that the patient could then take home with them. Jiff discountinued JiffPad and pivoted into employee wellness. In recent months the Mayo Clinic has shared some early results from an iPad-based patient engagement study with senior aged cardiac surgery patients. Mayo claimed the take home iPads and the companion program had a remarkable 98 percent engagement rate with this population of "70-year-olds on morphine".

Knitting together direct-to-consumer tools with population health platforms

IMS Health AppScriptIn 2013, as the number of wearable health devices, smartphone peripherals, and health apps continued to proliferate, curation became a pressing concern. Many believed that the only way many of the direct-to-consumer health tools available in the market would have an impact was if physicians had a way to prescribe or recommend them to their patients. A number of companies stepped up -- big and small -- to take on health app "prescribing". By the end of the year IMS Health, WebMD, Cigna, and HealthTap were among those companies still working on the problem. IMS Health launched its AppScript platform at the mHealth Summit in December 2013.

As 2014 begins there appears to be a growing number of startups offering platforms that focus on population health management, reducing readmissions, helping the overstressed primary care doctor, and rekindling the patient-provider relationship. These startups' patient engagement tools often include health risk assessments and a series of ongoing followup surveys coupled with a physician dashboard that provides alerts. Healthloop and Conversa are among the growing number of companies with such platforms.

Where these platforms need to go next, once they gain some traction, is into connecting, aggregating, and analyzing home health device data. Where appropriate – that might include everything from activity tracker data from a Fitbit, to weight scale data from Withings, to heart data from AliveCor – and so on. These tools have been with us for a number of years now. I think they are on the cusp of integration with the wider healthcare system.

Health IT’s recent patient engagement focus is direct-to-consumer digital health’s opportunity to finally get plugged into the health system. 


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