Helping the Measurement of Patient Experience Catch Up with the Experience Itself

A passenger is pinged moments after exiting their rideshare vehicle with a request to “rate your driver” using a simple 5-star rating. A few extra typed comments offer detail and context — completed in just moments. The same person, now exiting a doctor's appointment, receives no such alert. Instead, weeks later, they receive a mailed survey consisting of 30, or more, questions spanning a range of content: getting an appointment, interactions with reception staff, communication by the clinician, and the cleanliness of facilities. It's not just that the survey relies on an ability to recall and report on these long-ago interactions and how they felt—it’s likely the response is the only item that person will physically mail in weeks, if in the end it is mailed at all.

In an increasingly digital world where real-time ratings and just-in-time feedback have become routine across a variety of industries, how can healthcare adapt and evolve?

Speeding Up the Current Standards

While the status quo of measuring patient experience provides rigor through validated measures, it has failed to keep up with modern digital interfaces and misses an opportunity to become much more proactive. The strategies currently used do not represent the changing landscape of consumer experiences and expectations.

Examination of the origins of patient experience surveys provide insight into why this process has been slow to evolve. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) was developed by the Centers for Medicare & Medicaid Services (CMS) in order to provide a publicly available, standardized instrument and methodology to capture patient perspectives and compare institutions. ¹ The survey must be administered by a CMS approved third party vendor. Since 2002, HCAHPS has played an integral role in payer assessment programs, the Annual Payment Update for Inpatient Prospective Payment System and in the Value Based Purchasing Program. Over 18 years, HCAHPS questions have remained largely unchanged as has the mode of delivery to patients (e.g. paper). ² CAHPS surveys are now required for home care services and ambulatory surgery. These ties to value-based payment strengthen hospitals’ commitments to antiquated methodology and benchmarking. Further, CMS control over which vendors may administer mandatory CAHPS may stifle innovation in how health systems react to their patient populations. CAHPS surveys have been developed for emergency care, home care, hospice, ambulatory surgery, hemodialysis and office-based practice, but these are not CMS “required” or tied to reimbursement.

Evolving from these standard approaches cannot be a “flip of the switch” moment where the old practices are abruptly abandoned and new technology is launched. Rather, digital surveying can be appended to the current standards to test, learn, and iteratively grow. Incorporating a hybrid model to sit alongside HCAHPS would allow institutions to continuously compare and evaluate across health systems, while novel approaches could explore a new frontier of patient engagement.

The Flexibility and Immediacy of Digital Technology

Patient experience leaders can reimagine methods of patient engagement and data collection in the digital era, as adoption of technology continues to accelerate across the globe and within healthcare. Doing so will move healthcare toward real-time service recovery and patient insights.

What is there to gain? Digital engagement provides a dynamic and customizable approach to engage patients, with options for timing, mode of delivery, and the content itself. Varying methods of reaching patients through digital technology exist including text messaging, mobile surveys, video testimonials to name a few. Text messaging has become one of the most widely used formats for digital communication and engagement. Text messaging is fast, scalable and can be completed from virtually any location. It is also, as opposed to pen and paper, a modality to which we are accustomed to respond immediately. This may improve response rates and accuracy, with less reliance on memory and the barriers associated with completing and returning a physical document. Digital surveys include platforms providing a web-based format to answer more structured questions and can be completed on smart phone devices which are increasingly common across demographics. ³ For those without access to, or who are uncomfortable with digital messaging or surveying captured on smart phones, automated-calling provides an alternative.

These digital methods can be increasingly deployed alongside traditional survey methods to enhance the understanding of patient journeys. ⁴ Digital methods can be tailored toward specific units of analysis along the patient journey, and would move away from a one-size-fits all approach. The standard of asking patients to comment on their appointment making experience, check-in, physician visit and check out all in the same breath, for instance, can be split and delivered separately to more accurately understand these distinct touchpoints. Less dense, low-touch engagement, when brought to scale, would provide health systems with a data driven approach to identifying key points across spectrum of care. Breaking apart the components of care and following patients with shorter and targeted questions would offer more specificity in identifying pain points in patient experience, and focus efforts towards areas of need. What remains underexplored and critically important is how to best time these surveys to capture meaningful experiences and to balance the delivery cadence as to not overwhelm patients.

The guidelines for digital engagement have remained vague and hold entities responsible for maintaining privacy and security, ⁵ CMS and The Joint Commission have acknowledged the power of digital modalities and underscore the need for secure platforms. ⁶ Disparities in access to telemedicine or “higher-tech” approaches have inspired the use of “lower-tech” solutions such as text messaging to drive clinical monitoring. ⁷ This invites an opportunity to use these solutions to receive patient experience survey data. The ubiquity of text messaging may improve engagement across patients providing a broader sample and opportunity to address racial, ethnic, and gender equity challenges. Text messaging is widely used across the U.S. and provides a mechanism to reach a wide swath of patients quickly and invites a rapid, concise response.

Adapting Digital Data to Become Actionable Data

Just-in-time data collection creates a dynamic arena for patients, and their caregivers, to provide quantitative and qualitative feedback. Real-time patient insights could drive forward performance measurement, enhance the monitoring of quality improvement initiatives, and provide an opportunity for proximal service recovery. Classic surveys limit responses to classic scores or quantitative scales. Smartphone capabilities allow patients to contribute their experience through audio, video or photographic content to describe what they are seeing and feeling in the moment. These images and videos provide a window in the eyes of the patient and can act as powerful motivators for inquiry and change. A photo of a dirty exam room or a positive video testimonial highlighting compassionate care provides much more actionable and contextualized feedback across systems. The information collected through digital methods combined with advanced analytic and reporting mechanisms support a more patient-centered and robust method of understanding the patient experience. As more patients use devices to capture images and moments within healthcare, health systems and policy makers will need to ensure protection of staff privacy, patient privacy, and ensure sensitive information remains secure. Allowing patients to capture photos and provide feedback through various digital formats could provide an alternative, rich source of information but must be balanced by appropriate protective mechanisms.

Technical Troubles

As health systems begin to incorporate technology into patient experience surveys, the uptake may be rapid, but must include an intentional assessment of trade-offs and short falls. Short-format digital surveying has key limitations important to patients, caregivers, clinicians, and health systems. The illustrative example of the rideshare oversimplifies the approach as healthcare experiences often include a team of individuals in varying environments. A two-week hospital admission likely cannot be rated on a simple 5-star scale, but digital methods could begin to emphasize and highlight key areas of operational improvement and provide rapid-cycle feedback for quality improvement efforts. Technologic divides exist across race, gender, age and financial status and though access to the internet and a smart device is expanding, key racial and other demographic groups may need intentional outreach. Text messaging offers more flexibility in reaching these individuals as opposed to web-based interfaces, but trends in engagement must be continuously assessed for diversity in representation. Finally, these digital surveys must move toward a standardized structure in order to provide conceptual benchmarking comparisons either within or between healthcare organizations. Many institutions have either begun to explore or launch their own versions of digital patient engagement surveys, yet validation across surveys and against the standard of care remains underexplored. These individual efforts provide opportunities to assess pilot experiences and inform larger, national policies aimed at modernizing patient experience data collection and engagement.

Improving the patient experience has been associated with higher adherence to clinical guidelines, lower risk-adjusted mortality, and lower readmissions, ⁴ underscoring the urgency to modernize our survey methods. Much of the “care” within healthcare has utilized technology. The use of telemedicine has dramatically increased and has connected patients to providers across visit types. ⁸ Wearable devices have been used to monitor and motivate health behaviors. ⁹ Text messaging programs engage patients to improve medication adherence or monitor symptoms. ¹⁰ The technologic gains for clinical care have not crossed over for eliciting and responding to patient feedback. Digital methods can help facilitate communication and garner feedback aimed to improve care and promote just-in-time service recovery.