The Patient Engagement Pyramid

This blog post was originally published in 2012. Two years later, patient engagement is even more in focus as patient portals are launched in response to Meaningful Use requirements and as the opportunities for population health management are pursued through coordinated care delivery. As part of The American Academy of Ambulatory Care Nursing’s curriculum on Care Coordination and Transition Management, there is an excellent discussion on Population Health Management. The concept of a Patient Engagement Pyramid is referenced in this content. For those interested in ordering the AAACN materials, please visit

Accepted wisdom for transforming the quality and costs of health care includes as a central pillar the concept of “patient engagement,” the need to involve patients more fully in their health and wellness. It’s part of effectively caring for an aging baby boomer generation, better chronic disease management and the evolution to preventive care. What should the provider be asking of the ubiquitous electronic health record in enabling meaningful patient engagement?

The answer may lie in reinterpreting a familiar model Abraham Maslow commonly referred to as The Hierarchy of Needs. This model, depicted as a pyramid, demonstrates that individuals seek to fulfill a set of needs that begin with the most basic such as food and shelter and eventually lead to an ideal state of self-actualization. Each level must be first satisfied before people begin addressing the next higher level.

Patients who are truly engaged make positive choices for their health and wellness every day, enabling the system to move to a culture of prevention as opposed to treatment. The capabilities of electronic health records can help patients follow an engagement path that leads to a wellness equivalent of self-actualization. Lets consider what a Patient Engagement Pyramid could look like and the implications for an EHR at each stage.

The Patient Engagement Pyramid

The pyramid starts with recognizing patients as consumers of healthcare services. Without this there can be no interaction and therefore no opportunity for future engagement. This is perhaps the most fundamental challenge for the majority of EHRs today. The EHR is a technology conduit for care – a fundamental part of the overall delivery of the healthcare services that the patient is consuming. The EHR therefore cannot be just provider and practice-facing. An integrated patient-facing component is required.

With this in place, the engagement process can begin by providing patients access in new and more convenient ways. This is the Connected Patient and in its patient-facing components, the EHR needs to provide ways to connect patients to the practice so that test results, appointment scheduling and information can flow more easily.

With greater connectivity defined by what is convenient to the patient consumer, not just the practice, the Contributing Patient can emerge. At this level of the pyramid, patients are not just connecting to information and administrative tasks but are also contributing to the documentation of their health. An EHR needs to offer a patient health record where patients add and maintain important information on allergies, immunizations, and medications with access for the doctor to integrate into his or her charts.

Patient’s profiling and sharing of their health information can lead to something stronger – The Conferring Patient. This patient is someone who actively seeks out her care team with questions, information seeking education and insight. The EHR must facilitate relationships through multiple touch-points that complement and extend the traditional office visit. These touch-points need to reflect how patients interact with others in their daily lives. On the web. Via email and instant messaging. By video. Convenient, fluent and relevant communication channels. At this level of patient engagement the tools are being used for medical guidance and clinical consults. The EHR needs to have the robustness to manage these in a HIPAA-compliant, secure manner with the ability to seamlessly integrate these communications into a comprehensive and even multi-media electronic medical record.

At the peak of the pyramid is the Challenge-Setting Patient. The confidence and desire to manage one’s health and set wellness goals spring from access to the right medical information, and the medical and moral support from the care team at the right time and through the right channel. The challenges can include diet, exercise, weight and more. At this level the EHR should have the capability to integrate data from health devices that a patient may be using to monitor key biometrics. The EHR must be able to take this information and present to both patient and, if desired, the care team in the form of wellness dashboards that can help monitor and visualize progress and motivate healthy behaviors. The EHR’s patient portal can even facilitate the sharing of a patient’s challenges at her discretion with friends and family through embedded social media links. At this point, the patient is fully engaged or self-actualized in her health and wellness in a meaningful way, with the EHR as one of the daily tools supporting them.

Wellness should be something more than the absence of illness or disease. It is about a state of mind, demonstrated by sustained commitment to prevention and healthy behaviors. The key is starting the wellness journey. Practices should consider their EHR as a tool that can assist patients to become more engaged in their health and ask themselves how capable their selected technology is in helping their patients progress through the Patient Engagement Pyramid.

About the Author
Stephen Armstrong

Stephen Armstrong is senior vice president for Hello Health, the revenue generating EHR platform for primary care practices supporting practice vitality through patient engagement.