How Behavioral ‘Nudges’ Help Patient Engagement—and Improve Provider Experience

By Matt Phillion

A new JAMA Network Open study has found that patient engagement technology can significantly increase the number of patients who get, and stay, vaccinated. By using text reminders, automated vaccine reservations, and other techniques like links to vaccine verification, providers can leverage technology to keep patients engaged and healthy as the industry continues to work through the COVID-19 pandemic.

Ascension Health implemented this kind of clinical and operational improvement through patient engagement technology provided by Relatient. The result was increased adherence to the health system’s COVID-19 vaccination policy by 4.9 percentage points.

“Ascension saw their engagement drop-off rate and were trying to understand if some behavioral nudges through technology like text reminders would have a material impact in adjusting that,” says Jeff Gartland, CEO of Relatient.

While the JAMA Network Open study was designed around COVID-19 vaccinations, the factors that got in the way for study participants—distractions, being busy, forgetting about appointments—transcend vaccinations and could have an impact on care anywhere, Gartland says.

He says the positive results from the study are “great validation that these behavioral nudges work—and what’s even more exciting, those same behavioral nudges could be applied in lots of workflows across patient access and patient care broadly.”

Getting patients to come in for annual visits, screenings, or follow-up appointments using effective reminders could put them on the path to improve their compliance.

“Does that simple reminder, at the right point in time to steer people back, [constitute] a material percentage [improvement]? The study points to yes,” says Gartland. “The question is what else is possible, and how often you insert those reminders, what kind of language you use, and how you elevate it.”

A different level of engagement

Patients’ growing familiarity with technology has helped usher in new opportunities for patient engagement.

“Just look at the patients engaging with the ecosystem,” says Gartland. “It’s an entirely different level of engagement when you take down the walls of portals, don’t require usernames and passwords, and reach out to patients in the modality and way they want to be reached.”

Meeting the patient, technologically, where they want to be met is a huge step, he notes. “We all carry a computer in our pocket. That’s where people want to be reached. It’s how we talk to each other,” says Gartland.

Organizations must also make sure, though, that patient engagement methods allow for simple downstream processes for clinical providers.

“If downstream the same [behavioral nudges are] used for certain types of billing, registration, or clinical context, balance becomes important,” he says. “For example, a lot of providers will send out communications for, say, breast cancer screenings, or to come in for a check for diabetes. If you blast that out to a wide audience at the same time, all of a sudden you’re going to become inundated with inbound communications from patients”—and you can expect those communications in all forms, including calls, emails, and in-person visits.

“It’s a balancing act. You can’t just engage with patients for engagement’s sake or nudge for nudging’s sake. You’ve got to put it into context to drive provider workflows and ensure you are equipped to handle the increase in patient engagement,” says Gartland.

That balancing act doesn’t have to be overly complicated. It can be as simple as throttling your messages and knowing what populations and locales you want to reach in a given time span. Using data from the COVID-19 vaccine study, Relatient and Ascension are looking for the right ways to build that balance.

“The race is on for how to use those nudges to improve patient engagement while balancing provider workflow and downstream effects in every practice area,” he says.

Not using tech for tech’s sake

In examining how to best leverage technology for improved patient engagement, Gartland says it’s important to use the right tech for the right situation.

“We as a society tend to think we can throw tech at something to magically improve it, but the reality is there are people and processes that go into making these things work well. This requires thinking about those people and processes upstream and downstream and then leveraging the tech in context of the rest of the design system,” says Gartland. “You want to make sure that you’re thinking end-to-end and execute accordingly.”

In addition, to avoid siloed systems or processes—historically a problem in the industry—It’s important to take a step back before implementing a technology solution. “When it comes to digitizing patient engagement and interaction, the comfort is there, the ability to accomplish it is there, but it’s a matter of how you put it into a system,” says Gartland. “Think conceptually.”

Far beyond the initial use case

With the success of digital nudges to improve vaccination rates, similar technology has applications across the board, including medication adherence, care plan compliance, and outreach before or after appointments.

“Patient education is another area behavioral nudges can help as well,” says Gartland. “We are even seeing opportunities outside the clinical construct and in more administrative or operational situations.” This includes frequently challenging administrative tasks like scheduling, referrals, and follow-ups.

“For example, say I just had my annual visit and my doctor wanted me to go to another provider for a follow-up—nothing dramatic, but just to be sure. They hand me a piece of paper with the referral, and now it’s five weeks later and I haven’t followed up on it on my end,” says Gartland. “It’s simple things like that where behavioral nudges can help. They could send a ‘We noticed you haven’t followed up on that referral. Can we help you get that scheduled?’ message.”

The consumer/patient journey is broad, and Gartland homes in on the appointment component because all roads tend to lead to or from the appointment. Simplifying appointments makes sure patients can show up prepared—and helps them stay on their healthcare journey if it’s going to persist for a while.

Take the act of scheduling an appointment. It’s not just a matter of looking at the calendar for an available time slot. Physicians with a lot of new patients may want to avoid back-to-back appointments with first-timers so their visits don’t bump up against each other and create a traffic jam. Appointments may require special equipment that must be made available in concert with a patient’s visit. And because surgeons are highly specialized, the right specialists may need to be on hand. “These nuances get built into the construct of the simple act of finding time on a calendar,” says Gartland.

Studies have found that about a third of provider capacity goes unused—yet the consumer wait time for an appointment is nearly a month on average. “That juxtaposition is really rooted in the conflict between those rules that providers care about versus the consumer experience we all want,” says Gartland. Relatient’s view is that “making yourself more open and available from an access perspective doesn’t mean having to give up control over all those nuances, preferences, and details that make your downstream life either a breeze or a challenge.”

Right now all those elements exist in three-ring binders, on desktops, or in people’s heads. But if they can be codified into systems so the provider can have control without creating walls around their practice, that opens the path to better care provision.

“This is why I don’t like the visual of the ‘digital front door.’ It becomes a construct between the provider and the consumer, waiting for them to ring the doorbell,” says Gartland. “What we’re really trying to do is say there needs to be a free-flowing relationship, but that doesn’t have to be carte blanche to sit anywhere. What rules and context do you allow for that flow to occur?”

That dichotomy between unused provider capacity and long wait times—multiplied by the 900 million outpatient visits in the U.S. each year—roughens the patient experience and adds pain for providers, especially as the labor shortage and the prevalence of provider burnout grow in significance.

“Tech can create a balance between those worlds, but it needs to be applied correctly so it can be executed on from a people and process standpoint,” says Gartland. He notes that the JAMA Network Open study “is a good example of applying the tech, showing it can have an impact, and then teeing it up for next steps.”

The future of engagement through tech

The next step for using familiar technology to engage with patients through behavioral nudges is building those nudges into very targeted approaches.

It’s not necessarily about volume, Gartland explains. “We’ve seen that with phone and email spam,” he says. “We don’t want to turn this into another opportunity to spam people. It’s about sending the nudges when they will have the most potential impact to steer the patient on their health journey the right way.”

What does that content look like? How short or detailed should it be? And what is the call to action? All of these components help tweak the nudges to keep patients engaged.

“First, we need to understand the behavioral aspect of the content of the message, the modality, and the cadence in a robust way, using data to understand and drive it,” says Gartland. “And second, we apply those concepts across the journey in areas that have material impacts.”

Gartland points out that everyone is on an individualized journey through the healthcare system, depending on geographic location, insurance coverage, social determinants of health, chronic versus acute care needs, and more. “It’s not some generic journey,” he says. “And that’s the next step: applying all these concepts in a more robust, scalable, and ultimately, impactful way.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.