New blog: Patient engagement. Don’t fall in love with technology too much.

Digital patient involvement can be done, but it is not easy. A recent and rather disappointing clinical trial is just another case in point.

Grätzel von Grätz

Issue 5.4 of Insights features a title story on patient engagement and why there is such a big gap between what everybody is convinced of in theory and what is actually being done in eHealth projects all over the world. Examples of electronic patient records with comprehensive access for patients and properly implemented access policies remain rare, for example, as do app-enabled medical therapies. Why is this the case? Maybe it is because patients are not really taken seriously by many project managers, app developers, and healthcare IT infrastructure providers.

The HeartStrong trial: Something must have gone wrong.

Some weeks ago, Kevin G Volpp and colleagues from Pennsylvania, US, published results of the randomised HeartStrong trial that compared a digitally enhanced medication adherence intervention with regular care in more than 1,500 patients with stable angina, (JAMA Intern Med 2017; 177(8):1093-1101). The trial featured a combined intervention with a wireless pill bottle, a lottery-based financial incentive scheme for patients with good therapy adherence, and a software that enabled the involvement of friends and relatives..

The result was pretty disappointing: There was no difference whatsoever in medication adherence between the two groups. No wonder, then, that the trial didn’t meet its primary clinical endpoint: There was no effect on death or time to first revascularisation, either. The HeartStrong study is important because it was a lage and thoroughly-randomised study. It is easy to show an effect of a digital adherence intervention in a pilot study. But pilot studies are prone to be biased. This one is not biased. Something must have gone terribly wrong, if a combination of three sound adherence-improvement strategies fails to have any effect.

The engagement part is what makes the difference

There are discussions now whether stable angina might have been the wrong disease for such a trial. But why should it? A far more likely explanation has to do with patient engagement and how to do it properly. It is simply not enough to have good intentions and a software development kit. It is not enough to employ a couple of good coders who can provide an app, some product designers who can come up with a pill-bottle that might win the Red Dot Design Award, and a physician consultant who says that medication adherence is terribly important.

The really important aspect of digital patient engagement is the patient engagement part, not the digital part. There is a lot of data out there showing that doctors who are empathetic, who take their time to listen, and who explain treatments properly have patients with better adherence than doctors who rush through their patient contacts, who don’t explain treatments and who lack empathy. Give the empathetic doctors digital tools, and they will even get better. A digital tool handed over by a doctor who is already thinking of something else won’t make a difference.

Technology: Nothing more than a tool

In the aforementioned Insights cover story, the Estonian GP Le Vallikivi says that “eHealth is really not my cup of tea.” She nevertheless came to an eHealth conference and explained to the audience how wonderful it was for a GP to be able to share information with their patients – by means of the Estonian digital health infrastructure, in this case.

Sharing information makes the GP a “gate opener”, and gives the patient a feeling of being in the driving seat to a greater degree than before. So here is a point to remember: Don’t think about what technology can do for you, but think about what you can do for the patient and what the patients really need. Usually it will be about better communication, better access to information and to other resources, and about dealing with individual worries. If there is technology that can help with these issues, great. But technology is a tool, it is not the treat

Philipp Grätzel von Grätz

(Germany) specialises in medicine, health policy and, in particular, eHealth and information technology in healthcare. He is one of Europe’s leading journalists in the field and author of the German book Connected Health.

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