As an orthopedic surgeon, I always strive to help my patients understand that healthcare is a two-way street. Even if I do my best work and the surgical procedure goes without a hitch, outcomes can be highly variable, and the patient must do their part to foster a healthy recovery.1 Fortunately, modern technology now offers us a variety of simple, convenient tools for engaging patients and encouraging them to take their medication, attend therapy and come to follow-up appointments. In many cases, the better patients adhere to their treatment protocols, the more likely it is that positive outcomes will result.
Background: How engagement drives adherence
Becoming an engaged, adherent patient doesn’t happen instantly on the day of the surgery. Post-op engagement is heavily influenced by the patient’s existing attitudes and behaviors.
A patient’s understanding of their role in the care process, as well as their possession of the knowledge, skill and confidence to manage their health and health care, is known as patient activation level.2 Increasingly, patient activation is becoming recognized as a key health measure associated with improved clinical outcomes and patient experience.2,3
For instance, one study found that higher patient activation scores correlated with higher attendance and engagement in physical therapy after spine surgery.4 More activated orthopedic patients also experienced a greater degree of decrease in post-op pain and disability.4 Another study found that after a total joint arthroplasty, orthopedic patients with higher activation levels experienced better pain relief, decreased symptoms, improved mental health and greater satisfaction than their less activated counterparts.5
Overall, higher activation levels have been associated with better clinical indicators, more healthy behaviors and greater use of preventive screening.2,3 There is also limited evidence linking them to decreases in costs.2,3 Researchers have suggested that the greater the activation level, the greater the odds of a positive outcome.3 This is likely due in part to the fact that more activated patients use healthcare resources more effectively and engage in more positive health behaviors compared to less activated patients.3 Meanwhile, less activated patients are much more likely to have unmet medical needs and delay medical care.2
Research is also emerging to show that healthcare providers have the ability to increase patient engagement and activation, which in turn can help improve outcomes.2,3 A 2017 cross-sectional study on chronic disease patients found that the quality of the doctor/patient relationship significantly impacted the patient activation level, which, in turn, impacted patients’ reported medication adherence.6 The researchers concluded that patient engagement may play an important mediating role in improving activation and treatment adherence.6
Increasingly, providers are being called to adopt systematic approaches to help increase patients’ participation in their care process, with the goal of driving more effective, efficient healthcare.2 In this article, I’ll look at a variety of strategies and tools I use in my orthopedic practice to foster patient engagement and treatment adherence in my patients post-surgery.
Before the operation: Laying the groundwork
The patient’s mindset before the surgery is an important factor in determining the patient activation level, which in turn has the potential to influence how they will behave after surgery.4-5 Because of this, I aim to make my patients active participants their care process.
Next year, I’m planning to implement the modmed® Kiosk app, which will allow patients to enter their information on an iPad in the waiting room instead of filling out intake forms. This will allow them to see key information in their record every time they visit, such as medical, social and family history, medications, allergies and review of systems. By seeing the data that I’m working with and realizing that they’re held responsible for its accuracy, patients will be encouraged to keep it thorough and up to date. This, in turn, can make them more likely to use our patient health portal and other patient engagement tools.
In addition to helping engage patients, modmed Kiosk will help us shorten wait times. In fact, some practices using it have saved as much as 15 minutes per new patient. Instead of manually re-entering all the data, staff will simply be able to review and accept patient changes into our EHR system, Modernizing Medicine®’s EMA™ for orthopedics.
In the exam room, I already use EMA on the iPad to document exams quickly and give my attention to my patients rather than turning my back to type at a computer. By facing my patients and making eye contact as I tap through the exam, I have more meaningful conversations with the patient and avoid making them feel left out.
Thanks to EMA’s efficient interface, which is built by orthopedic surgeons, gaining extra time with patients doesn’t have to come at the expense of staying late to chart. EMA anticipates my next move and automates time-consuming documentation tasks, so I can move through the visit fast and am often done documenting before the patient leaves the room.
By cultivating strong patient relationships and making patients feel that they’re part of the care process, I can help foster a mentality of engagement and activation from the outset. Moreover, through the careful attention I provide, I strive to show patients that I care about their wellbeing. This, in turn, can help give them confidence that following my advice is truly in their best interest. Enhancing patient interaction with EMA also makes it easier for me to engage in shared decision-making with my patients, which has the potential to improve not only engagement but also quality and satisfaction.7
Another orthopedic patient engagement tool I use to help improve satisfaction and post-op treatment adherence is patient education.
During the visit, the EMA EHR automatically generates orthopedic patient education handouts for me alongside my note and bill. These handouts include wording from the treatment plans I’ve documented. I also have access to context-aware patient education for medications, allergies and diagnoses, which displays in the patient's preferred language, if available.
For prescriptions, EMA uses my selected diagnoses and prescribed medications to generate patient-specific handouts that explain how and when to take the drug. When medication savings offers are available, EMA can even add them to the handout. From there, I can choose whether to modify the handout, print it or send it to the patient through the patient portal.
These patient education handouts can be very convenient not only for informing patients about disease processes, but also for encouraging them to fill medications and educating them on surgery prep and post-op treatment. This could potentially help improve both adherence and satisfaction. For instance, one study found that surgical patients are more likely to follow physician instructions when provided simple medication instruction sheets.8
In a systematic review of preoperative orthopedic patient education in hip and knee replacement surgery patients, researchers found evidence that preoperative patient education may be able to reduce preoperative anxiety.9 According to another systematic review, preoperative anxiety is the most common predictor of post-surgery dissatisfaction, so reducing anxiety through patient education could potentially help improve patient satisfaction.10
The patient portal as an engagement hub
After laying the groundwork for engagement during the visit, I use technology to stay in touch with my patients and help keep them involved through the surgery and recovery process. One particularly important way in which I do this is by using EMA’s orthopedic patient portal.
In addition to accessing patient education materials, patients can use the portal to view test results, suggest updates to their records, request refills and use secure messaging to ask me questions without having to call my office. Meanwhile, I can use it to check in with my patients, answer questions and remind them of upcoming appointments.
Overall, the patient portal can deliver information that educates the patient on the importance of adhering to treatment, while giving patients an easy way to ask about solutions to issues that may be hindering their adherence. When my staff or I follow up with patients regularly through the portal, we believe it helps them feel more connected to my practice, while letting them know that I’m keeping tabs on their progress and adherence.
There is growing patient demand for online patient-physician messaging. One study found that such messaging can increase quality of care due to increased patient-physician communication.11 Another study looking at portal usage noted that orthopedic surgery patients were initiating online portal conversations more often in orthopedic surgery than in almost any other specialty measured.12 Over the course of the study, the use of messaging in orthopedics continued to grow.12
To aid my efforts in meeting this demand and providing quality service that helps me engage my patients, responsiveness can be key. One way I’m better able to respond quickly to my patients at my own convenience is through mobile orthopedic EHR tools.
Going mobile for faster responsiveness
My orthopedic EHR includes a mobile app for Android and iPhone, called PocketEMA™, that I can use to view patient information, such as past medical history, chief complaints and review of systems, from virtually anywhere I have an Internet connection. In the operating room, the app can be used to view notes in real time.
Outside the OR, it can be used to respond to patient portal messages quickly from wherever you are, helping increase your patient responsiveness. For instance, you can check your messages while you’re in line at the store instead of having to set aside time to sit and answer them at your computer.
Another key application of PocketEMA in helping improve adherence is the ability to simply tap the patient’s phone number to call them. If I need to refer to their chart before or during the call, I have it right at my fingertips. This can be an important way to check in with patients. For instance, one study found that following up with post-op total knee arthroplasty patients about their home exercise routines in structured phone calls helped improve adherence.13 After the call, I can leave a quick note in the app documenting the communication, so I don’t have to remember to document it when I get to the office the next morning.
Sometimes, when I call a patient using PocketEMA, I find out that they need to switch medications because they’re experiencing an allergic reaction. Other times, I open the PocketEMA app to see a patient refill request or a secure message from my staff saying that a patient has called my office to request a refill. In both situations, instead of waiting until I’m back in the office, I can promptly send a prescription or refill to their pharmacy with just a few taps on my phone.
This can be important for maintaining adherence because it’s—quite understandably—very difficult for a patient to take their prescribed medications when they can’t physically tolerate them or have none left. Patients appreciate my ability to respond quickly, and it shows them how important it is to me that they have and take the medication they need.
Prescription adherence: Finding a better pill to swallow
When I’m back in the office, EMA provides me with additional ePrescribing tools that help me promote and monitor patient medication adherence.
Before I prescribe, I’m able to see formulary information and real-time dollar estimates for each medication based on the patient’s insurance. EMA lets me compare up to five drug alternatives and three delivery channel options, helping me choose the most clinically appropriate treatment at the most affordable price. EMA also searches for eligible electronic coupons and automatically sends them to the pharmacy, if available.
Many patients don’t fill medications simply because they can’t afford them, so these prescription price transparency tools are key for helping promote fills while reducing pharmacy callbacks to my office. Plus, discussing the benefits and affordability of different drugs with the patient is another way to help make them feel valued and involve them in their care process.
To keep an eye on the use of riskier medications like opioids, I use EMA’s Prescription History tool to instantly import the patient’s prescriptions from community pharmacies where available and add them to their record. I can see not just what was prescribed, but also when, how much and whether it was filled. This helps me monitor patient adherence as well as prevent over-prescribing and adverse drug events. Plus, it decreases the chances of data entry errors.
If I see that a patient has recently filled an opioid prescription from another provider, I’m inclined to speak to them about it and consider whether other alternative medications might be useful for controlling their post-surgery pain. After the surgery, if a patient hasn’t filled a medication I’ve prescribed, I can send them a patient portal message about it or have my staff call them.
The value of orthopedic appointment reminders
Unfortunately, even if patients are diligent about taking their medications, some have busy lives and are unable or simply forget to come in for appointments. One study found that one-third of orthopedic trauma surgery patients did not attend their first clinic appointment after surgery.14
To help prevent this from happening, Modernizing Medicine offers me the ability to send personalized text, email and phone reminders before each appointment through their Patient Reminders service. It includes on-demand messaging to selected groups of patients, so if I suddenly have to leave the office one afternoon, I could send updates to the affected patients telling them to reschedule. In addition, Patient Reminders sends automatic follow-ups to no-show patients to see if they’re interested in rescheduling.
While many patient engagement tools are still being researched, there is already a large body of evidence supporting the effectiveness of patient text and phone reminders.15-22 Dozens of studies and systematic reviews have concluded that they significantly increase appointment attendance and even medical compliance.15-22 Plus, they can be more cost-effective and less labor-intensive than the traditional method of having staff members phone each patient.17 One systematic review reported that they can be “a simple and efficient option for health services to use to improve service delivery, as well as resulting in health benefits for the patients who receive the reminders.”18
In another systematic review, researchers examined60 studies on SMS reminders as a health intervention and found improved outcomes in 77% of the studies.19 Moreover, treatment adherence increased in 40% of the studies.19The reminders were also linked with decreased amounts of missed medication doses, more positive attitudes towards medication and decreased interruptions to treatment.19
Finally, a 2018 study in knee ligamentous reconstruction patients found that patients who received automatic electronic follow-ups after orthopedic surgery had significantly greater follow-up compliance compared with patients who received traditional follow-ups.22
Patient satisfaction surveys: showing you care
After the appointment, Modernizing Medicine’s Patient Survey service also offers me the option to send patient satisfaction surveys via text and email. The act of completing a survey may not in itself improve a patient’s treatment adherence, but it can reinforce to the patient that I’m committed to their care.
Each survey response can help me identify what my practice is doing well and what could be improved, so I can deliver an even better experience for the next patient. By delivering top-notch service, I can help improve patient satisfaction and retention. Plus, if patients are happy with the care I provide, they just might be more likely to follow my treatment advice.
Conclusion
As we’ve seen, treatment adherence after orthopedic surgery can be a key factor impacting patient outcomes. Increasingly, research shows that increasing patient engagement can help increase adherence, which is why I’ve adopted a variety of patient engagement tools in my practice.
Ultimately, whether or not you have the right technology at your fingertips can make or break your patient engagement initiatives. With a powerful orthopedic EHR, patient portal, mobile physician app and more, Modernizing Medicine has been my practice’s trusted technology partner, helping us achieve success in promoting post-op treatment adherence.
If you’re interested in seeing some of these solutions for yourself, I highly recommend filling out the form on Modernizing Medicine’s contact page.
References
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2 Hibbard JH, Greene J. What The Evidence Shows About Patient Activation: Better Health Outcomes And Care Experiences; Fewer Data On Costs. Health Affairs. 2013;32(2):207-214. doi:10.1377/hlthaff.2012.1061.
3 Greene J, Hibbard JH, Sacks R, Overton V, Parrotta CD. When Patient Activation Levels Change, Health Outcomes And Costs Change, Too. Health Affairs. 2015;34(3):431-437. doi:10.1377/hlthaff.2014.0452.
4Skolasky RL, Mackenzie EJ, Wegener ST, Riley LH. Patient activation and adherence to physical therapy in persons undergoing spine surgery. Spine (Phila Pa 1976). 2008;33(21):E784-91.
5 Ring D. CORR Insights®: Higher Preoperative Patient Activation Associated With Better Patient-reported Outcomes After Total Joint Arthroplasty. Clinical Orthopaedics and Related Research®. 2015;473(8):2698-2699. doi:10.1007/s11999-015-4274-1.
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7 PatientEngagementHIT. Using Shared Decision-Making to Improve Patient Engagement. PatientEngagementHIT. https://patientengagementhit.com/features/using-shared-decision-making-to-improve-patient-engagement. Published May 18, 2018. Accessed November 21, 2018.
8 Surgical patients more likely to follow medication instructions when provided simple instruction sheet. ScienceDaily. https://www.sciencedaily.com/releases/2014/06/140617091742.htm. Published June 17, 2014. Accessed November 27, 2018.
9 Aydin D, Klit J, Jacobsen S, Troelsen A, Husted H. No major effects of preoperative education in patients undergoing hip or knee replacement--a systematic review. Danish Medical Journal. 2015;62(7):A5106.
10 Smith MJ, Choma TJ. Patient satisfaction in musculoskeletal medicine. Current Reviews in Musculoskeletal Medicine. 2017;10(2):207-211. doi:10.1007/s12178-017-9403-x.
11Mcgeady D, Kujala J, Ilvonen K. The impact of patient–physician web messaging on healthcare service provision. International Journal of Medical Informatics. 2008;77(1):17-23. doi:10.1016/j.ijmedinf.2006.11.004.
12Shenson JA, Cronin RM, Davis SE, Chen Q, Jackson GP. Rapid growth in surgeons’ use of secure messaging in a patient portal. Surgical Endoscopy. 2015;30(4):1432-1440. doi:10.1007/s00464-015-4347-y.
13 Lin F, Chen M, Li P. Influence of structured telephone follow-up on patient compliance with rehabilitation after total knee arthroplasty. Patient Preference and Adherence. 2016:257. doi:10.2147/ppa.s102156.
14 Whiting PS, Greenberg SE, Thakore RV, et al. What factors influence follow-up in orthopedic trauma surgery? Archives of Orthopaedic and Trauma Surgery. 2015;135(3):321-327. doi:10.1007/s00402-015-2151-8.
15 Lin H, Wu X. Intervention Strategies for Improving Patient Adherence to Follow-Up in the Era of Mobile Information Technology: A Systematic Review and Meta-Analysis. PLoS ONE. 2014;9(8). doi:10.1371/journal.pone.0104266.
16 Free C, Phillips G, Watson L, et al. The Effectiveness of Mobile-Health Technologies to Improve Health Care Service Delivery Processes: A Systematic Review and Meta-Analysis. PLoS Medicine. 2013;10(1). doi:10.1371/journal.pmed.1001363.
17 Koshy E, Car J, Majeed A. Effectiveness of mobile-phone short message service (SMS) reminders for ophthalmology outpatient appointments: Observational study. BMC Ophthalmology. 2008;8(1). doi:10.1186/1471-2415-8-9.
18 Guy R, Hocking J, Wand H, Stott S, Ali H, Kaldor J. How Effective Are Short Message Service Reminders at Increasing Clinic Attendance? A Meta-Analysis and Systematic Review. Health Services Research. 2011;47(2):614-632. doi:10.1111/j.1475-6773.2011.01342.x.
19Kannisto KA, Koivunen MH, Välimäki MA. Use of Mobile Phone Text Message Reminders in Health Care Services: A Narrative Literature Review. Journal of Medical Internet Research. 2014;16(10). doi:10.2196/jmir.3442.
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21Car J, Gurol-Urganci I, Jongh TD, Vodopivec-Jamsek V, Atun R. Mobile phone messaging reminders for attendance at scheduled healthcare appointments. Cochrane Database of Systematic Reviews. August 2008. doi:10.1002/14651858.cd007458.
22 Shu HT, Bodendorfer BM, Folgueras CA, Argintar EH. Follow-up Compliance and Outcomes of Knee Ligamentous Reconstruction or Repair Patients Enrolled in an Electronic Versus a Traditional Follow-up Protocol. Orthopedics. 2018;41(5). doi:10.3928/01477447-20180828-02.