with Ian Worden, MBA, MHI
CIO LifeNexus

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Patient Experience vs. Patient Engagement

What is the “patient experience”? 

The Beryl Institute, a global community of practice and premier thought leader on improving the patient experience in healthcare, defines the patient experience as “the sum of all interactions, shaped by an organizations culture, that influence patient perceptions across the continuum of care.”

Similarly, the Robert Wood Johnson Foundation describes the patient experience as “comprised of research reports and administrative information that reflect quality from the perspective of patients by capturing observations and opinions about what happened during the process of health care delivery. Patient experience encompasses various indicators of patient-centered care, including access (whether patients are obtaining appropriate care in a timely manner), communication skills, customer service, helpfulness of office staff and information resources.”

How is the patience experience measured?

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).  The HCAHPS Survey is the first national, standardized, publicly reported survey of patients’ perspectives of hospital care.  HCAHPS is a 27-item survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience.

CMS publishes HCAHPS results on the Hospital Compare Website four times a year, rolling the oldest quarter of patient surveys off and the newest quarter on each time. Since 2008, HCAHPS has allowed valid comparisons to be made across hospitals locally, regionally and nationally.

What is the driving force behind improving the patient experience?

Value Based Purchasing (VBP) incentive payments.  The Hospital Value-Based Purchasing Program is a Centers for Medicare & Medicaid Services (CMS) initiative that rewards acute-care hospitals with incentive payments for the quality of care they provide to people with Medicare.

Hospital VBP incentive payments to hospitals will come from the regular fees Medicare pays hospitals through its Diagnosis-Related Group (DRG) system. Hospitals participating in Hospital VBP will have their base operating DRG payments for each patient discharge across all hospitals reduced by a small percentage each year.

Taking into account the reduction in base Diagnosis-Related Group operating payments to hospitals (1 percent for Fiscal Year 2013), CMS estimates that roughly half of participating hospitals will receive a net increase in payments as a result of this rule, while the rest will receive a net decrease in payments.

The Fiscal Year 2013 Hospital VBP Program consists of two domains including 1) Clinical Process of Care and 2) Patient Experience of Care.  For FY 2013, these weighted values are 70 percent for Clinical Process of Care and 30 percent for Patient Experience of Care.

The Patient Experience of Care score is the sum of a hospital’s Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) base score and that hospital’s HCAHPS Consistency score.  The Experience of Care domain is broken out into eight equally-weighted dimensions:

  • Communication with Nurses
  • Communication about Medicines
  • Communication with Doctors
  • Pain Management
  • Cleanliness and Quietness of Hospital Environment
  • Responsiveness of Hospital Staff
  • Discharge Information
  • Overall Rating of Hospital

What is patient engagement?

To my knowledge, there is no common definition of patient engagement.  I believe patient engagement can be defined as a person’s sustained participation in managing their health in a way that creates the necessary self-efficacy to achieve physical, mental and social well-being.  This means that healthcare delivery must entice a person to actively participate over the long-term while fostering health related self-efficacy which yields meaningful physical, mental or social benefit.  In only this way can healthcare organizations depend on the active and sustained participation required to improve clinical outcomes.

This definition clearly differentiates the patient experience from patient engagement.  Whereas the patient experience is based on the patient’s perception of quality, patient engagement is based on the patient’s active and sustained participation in managing their health.  The patient experience is about perceptions and patient engagement is about actions and behaviors.  A patient can conceivably be satisfied with their healthcare experience while  having minimal engagement.

How is patient engagement measured?

Medicare and Medicaid EHR Incentive Programs Proposed Stage 2 Meaningful Use Criteria.  CMS published in the Federal Register the proposed rule which would specify the Stage 2 criteria that eligible professionals, eligible hospitals, and critical access hospitals must meet in order to qualify for Medicare and/or Medicaid electronic health record incentive payments.  Among the many topics addressed in the proposed rule are patient and family engagement measures.

The proposed Stage 2 patient and family engagement measures focus providers and/or hospitals on:

  • Making visit/inpatient information available to patients timely and online
  • Presenting visit/inpatient information in a manner that leads to patients viewing, downloading or transmitting the information
  • Providing patient-specific education resources
  • Promoting patient and provider interactions that lead to patients sending secure messages to their provider

Providing the ability for patients to access and exchange information online seems like a basic, reasonable and early step towards engaging patients.  However, I believe it falls woefully short as an overall measurement of patient engagement.  The proposed patient information access and exchange in and of itself does not create patient engagement, rather,  it creates a channel where patients can engage in some aspects of managing their health. Even when providers meet the proposed Stage 2 measures they will still be saddled with the more complex task of actually fostering patient engagement.  So, the really hard work lies ahead for providers and hospitals.

What is the driving force behind improving patient engagement?

The Patient Protection and Affordable Care Act (PPACA) Payment Reform.  The PPACA has many provisions related to payment reform.  These reforms include Medicaid & Medicare payment adjustments, payment reductions, incentive payments, bonus payments, bundled payments and shared savings programs.  Payment reform is increasingly shifting away from fee-for-service to performance based payments.  As such, improved healthcare delivery models have significant dependence on the active and sustained participation of patients post their hospital or provider visits in order to achieve financial targets.  Higher levels of patient engagement will be essential to achieving targeted health outcomes that trigger additional reimbursement.

For example, let’s look at Accountable Care Organizations (ACO).  The CMS.gov website describes ACO’s as groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.  The key to this payment structure is to generate healthcare savings through better healthcare delivery which then can be shared between the ACO and the government.  Generating these savings will be significantly dependent on patients actively participating in the management of their health as a means of driving down cost through reduced utilization of services.


Both the patient experience and patient engagement are emerging variables in healthcare reimbursement.  The patient experience is about perceptions and patient engagement is about actions and behaviors.  Payment reform  is creating a greater dependency on improving patient engagement for hospitals and providers.  Healthcare organizations are faced with the daunting task of re-engineering healthcare delivery to improve the patient experience and patient engagement in order to meet their financial objectives.

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