Five Things Healthcare Can Learn from Project Management

Posted on May 20, 2013 by

Physicians have traditionally been individual thinkers and doers.  Healthcare in general has been generally slow to adopt proven successful methods of processes and technologies employed with success in other sectors of society.  Medical training from medical school through post-graduate education has been traditionally focused on the individual.  Hospitals these days are driven by regulatory issues surrounding patient care.  In reading about project management (PM), I have noticed that much of what I did as a practicing physician fit into standard PM teaching.  However, it helps to frame a discussion around PM today in the context of healthcare, because of how fragmented care delivery is.

1.    Collaborative interaction is a key component to success.  It fosters constant and open communication, multidirectional input, and conflict resolution as it occurs, not when it is too late. Team management of patients is something which is catching on, but is not universally practiced.  Multidisciplinary hospital rounds including pharmacy, nursing, discharge planning are important to identify patients at high risk of readmissions, improve the relay of consistent and accurate information to the patient and caregivers, improve documentation, and indirectly improve patient satisfaction and efficiency. Collaboration and communication among personnel in the operating room is especially important and  in one study  “Communication failures in the OR …occurred in approximately 30% of team exchanges and a third of these resulted in effects which jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.”  Electronic health records and their interoperability are being implemented to facilitate collaborative interactions among different technologies and providers. There are even intra-office communications problems which have negative outcome implications for patients. There is a long way to go on that front, mostly due to non-technical issues.

2.    Planning, execution and management are other important fundamentals of PM.  Key to this is the project manager.  ‘Ownership’ of the patient from a supervisory standpoint is important.  A patient with multiple co-morbidities and chronic diseases (especially in ED and ICU patients) might commonly have multiple physicians and other providers involved in care.  Communications among team members in the ICU is important to not only resolve conflicts among ICU team members, but to improve care at the time of discharge from the ICU.  Reevaluation of the patient at certain milestones (on admission, important relevant tests, significant change of clinical status, pre-discharge, etc) with the entire team is important for clinical decision-making, communications to family members, and transfer of the patient to an outside facility.

3.    Sharing a vision is paramount in any team project. Goal alignment and vision as well as support from the managers all constitute part of the foundation for ongoing good morale and thus execution.  If the hospital, physician, and others have different visions, the patient will not be receiving the best possible care.  I always surprised people by saying that my biggest decisions were based on what would benefit the patient.  They were invariably the right decisions.

4.    Technology today plays a role in all project management; however it is never a solution.  Project management uses technology as tools in projecting costs, keeping track of personnel, timeline milestones, efficiency and budgets.  Hospitals and providers are using more and more technology to collect, analyze and reference information.  Technology in all instances needs to be considered and utilized as a tool and not a solution.  Though the implantation of a pacemaker might be a solution to a patient’s problem, the monitoring of that device wirelessly for evaluation of device system function and the patient’s arrhythmia status are tools to support that solution. Good medical apps are potential tools which can be used for reference, patient self-monitoring, and disease management.  They do not serve as a substitute for a physician or other healthcare provider.

5.    Costs matter.  Hospitals and others are today looking more at costs and less at the revenue side of budget planning.  Bundled payments, decreasing reimbursements, and the dissolution of fee for service models have all driven this shift.  The purchase of medical equipment and devices has seen a drastic shift in processes as well as players. Project management preaches minimizing scope creep (which invariably raises costs).  In the same vein, healthcare must minimize cost creep.  In order to do so might mean examining some (the less clinically impactful and more regulatory-laden) provisions of the ACA.

I did not intend to give a seminar in PM, but merely to frame a discussion around the idea that healthcare changes can come about without fundamental changes. Some are accomplished with institution of principles of PM, and some require cultural shifts in education, roles of providers, relative emphasis of technology, and most importantly with who is most important, the patient which should be at the center of all major healthcare PM decisions. 

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Posted in digital health, healthcare economics, Healthcare IT, healthcare reform, medical apps, remote patient monitoring, technology, telehealth, wireless health | Tagged , , , , , , , , | Leave a comment

Remote Patient Monitoring will Lead Value-Based Healthcare

Posted on April 24, 2013 by

Traditional health insurance reimbursement to providers (though payment is a more appropriate word) for healthcare services and products is at the root of our healthcare crisis.  Our traditional fee for service system in the USA rewards hospitals and providers for doing more (and more costly) procedures to patients. Some interesting findings from a study from Harvard Medical School  were that the higher the cost of surgery, the greater the likelihood of complications and the more out-of-pocket a patient with Medicare or private insurance paid, the more complications were reported. In addition, if a patient paid for the surgery fully out-of-pocket or through government-funded Medicaid, the likelihood of complications was lower. The Affordable Care Act, which introduces newer payment models including bundled payments, is creating an economic environment which is conducive to the widespread use of remote patient monitoring (RPM) for recently discharged hospital patients and those with chronic diseases. RPM will be most focused on vital signs monitoring for cardiac and pulmonary patients and diabetes monitoring.  Larger opportunities abound for weight management, medication adherence, and preventive medicine.

Recent institution of Medicare payment penalties for hospital readmissions is probably the most immediate impetus for the interest by healthcare systems in RPM. Studies at Johns Hopkins University and Geisinger Medical Center are just a few which demonstrate this utility of RPM.

RPM, will, in addition, foster other offshoot benefits of its technology. Firstly, I believe it will accelerate interoperability of disparate digital monitoring technologies, EHRs and patient portals. The ability of different technologies to talk to each other and to EHRs is at the heart of potential benefits of electronic health data.  Secondly, it will change the culture of healthcare to shift the focus from the provider to the patient. Data emanating from patients will de facto involve patients more than they are now in their own care. Seeing the data will educate them and facilitate self-management (to detractors of the concept of self-management, patients have been self-managing diabetes for decades). RPM will increase interest in (and hopefully use of) patient portals which will be mobile hubs of patient health records and communication. But I digress (something I usually don’t do, but RPM has so many ramifications).  This will also herald an introduction into the use of mobile apps by patients, recommended by providers. The issue surrounding reimbursement for health apps in general will also be resolved as it follows the path of RPM.

Organizations adopting RPM now are those who already have value-based or bundled payment systems or who realize that determining the ROI of technology in healthcare can be complex and that the predictable prevention of penalties is a good starting place. Improving longer term outcomes of RPM certainly needs more study.

While RPM is not new, its place as a leader of technology in the new payment system healthcare space is. RPM is well-suited for bundled payment systems because it is not just a technology. It involves the creation of processes and changes in workflow around the technology, some of which are home-based and some office and hospital-based. The success of RPM depends upon physician champions who will design these processes, and devise alert self-management, provider notification and treatment algorithms. RPM, via technology, can be the door to better provider-patient communication, more meaningful office follow-up visits, and increased caregiver participation.  Nothing I’ve said here is earth shattering news. I meant to bring the discussion of RPM to a practical level about why it is here, needs to be utilized now and where it fits in to existing strategies. Let’s all welcome it.

 

Posted in digital health, health insurance, healthcare economics, Healthcare IT, healthcare reform, mobile health, remote patient monitoring, technology, telehealth, wireless health | Tagged , , , , , , , , , , , , , , , | 2 Comments

Five Imperatives of Patient-Centric Healthcare

Posted on April 3, 2013 by

In previous posts I discuss how patient-centric care differs from patent-centered care and how patient empowerment must precede patient engagement.  I would like now to delve into what I consider critical elements of patient-centric care. They all involve technology to various extents.

1.    There must be buy-in from providers. I am including payers, healthcare systems as well as clinical providers in this category.  While I realize that much of healthcare is devoted to satisfying legal and regulatory mandates, there is great opportunity to improve the care experience (and dare I say outcome) of patients by changing the focus from provider to patient.  Physicians do care about their patients.  However, they are finding less and less time to devote to direct patient care. This same situation will repeat itself with non-physician providers as they assume more responsibility for patient care. Unless physicians support efforts to provide patients with tools to increase self-management, patient-centric care will not succeed.  Care must be seen as a partnership.  Patients are not seeking a substitute for their physician.  They are seeking a substitute for the unreturned phone calls, insecurities about whether to call in the first place, and tools for navigating the healthcare ecosystem.  If physicians support them in these endeavors, they will be seen more as partners. This will not, unfortunately, change overnight because of the historic delay in changes to the culture of medicine.

2.    Patients need great portals.  Patient portals are the ultimate patient-centric tool.  They can become the epicenter of the patient’s care universe.  All of their physicians and providers can communicate with the patient across healthcare system and technological barriers. The ideal portal can house different EHR system information, communicate with language translation, act as a hub for patient education, instructions, navigation, and allow providers to communicate with each other about a given patient. In addition, and most importantly, it will allow the patient to change relevant information real-time. This can be critical when it pertains to allergies, medication, diagnoses, or change of clinical status.  This will definitely not change overnight even though the technology is here.  Interoperability issues, the low expectations and mandates of the government fueled by resistance from physicians, and burgeoning competition (with attendant technical disparity) of portal vendors are all barriers easily overcome.

3.    Quality patient education and monitoring tools.  There are many patient education and monitoring tools out there. Because of lack of reimbursement (isn’t it always about the money), there has been little adoption of health literacy appropriate education technologies.  A patient-centric healthcare system would place both of these categories of technologies at the highest of priorities. They can both be tied to the portals described in the prior section.. I would certainly want to see outcomes-based evaluations (which wouldn’t take long or millions of dollars to accomplish) of these tools (though intuitively one could imagine patients who receive instructions via a mobile device to be NPO for their procedure the following day being more compliant, resulting in less cancelled procedures). I would refer the reader to the immediately preceding posts on remote patient monitoring to become familiar with how these technologies can foster patient-centric care.

4.     Patient-centric care must involve a caregiver.  There is always a need for caregiver involvement.  Even if a patient has full mental faculties, emotional and possibly logistical support is often needed.  I saw many high level corporate executives as patients who had a significant other accompany them to visits or who called furnishing otherwise non-communicated critical information or questions.  Not uncommonly emotional upset surrounding an acute or chronic condition cloud factual retention.  The need for emotional support is borne out by the success of online communities even if they are anonymous like Treatment Diaries or others like Wego Health.

5.    Attention to advanced directives.  Most people think advanced directives are instructions to be conveyed to a physician in the ICU when things are grim. This is probably the biggest misconception about advanced directives. Others include thinking that they are irrevocable or immutable. I believe that advanced directives should be discussed in middle school health classes. They shouldn’t be made instantaneously and should be well thought out.  Directives go way beyond the trite “Do not Resuscitate.’  Advance directives are more relevant and personal to all than many medical issues on network news, yet get little public attention.  They are the most personal of decisions and therefore should be made by the individual before being incapacitated, not by someone else after the fact. They must be portable not papers in a safe in the bank.  There is actually an app for that called My Healthcare Wishes.  Providers must discuss this with patients early on in care delivery, so that options are explained, contemplated, and directives established.  A 20-minute visit for a problem-focused encounter or follow-up visit is not going to be the right forum for this.  Physicians and patients both must be incentivized (not monetarily necessarily) to address advanced directives.

These are only a few, what I consider significant ways in which one might approach designing patient-centric care.  What are your thoughts?  As a matter of disclosure, I have no financial relationships with any companies mentioned in this post. 

Posted in mHealth, technology, smartphone apps, mobile health, informatics, healthcare vendors, education, healthcare reform, telehealth, medical apps, remote patient monitoring | Tagged , , , , , , , , , , , , , , | 7 Comments

#DigitalHealth: Remote Patient Monitoring Part 3: The Ideal RPM System

Posted on March 29, 2013 by

Remote patient monitoring may serve patients who are in the post-acute care phase of recovery from a hospitalization as well as those with chronic diseases.  Monitoring may consist of communication tools or measurements of medication adherence, glucose measurements for diabetics, oxygen saturation measurements for those recovering from pneumonia or who have chronic lung or heart disease, symptom reporting, and vital sign measurements, and other potential parameters. Most important to consider is that these tools must be used in a context of a comprehensive approach to monitoring. A strategy regarding workflow and dedicated human resource support needs to be designed prior to implementation. Once implemented on a small-scale initially, it needs to be reexamined with an eye on identifying pain points in logistics, communication, and outcomes.  The following consist of what I consider five characteristics of an ideal RPM system, however individual needs might vary.

1.    Single vendor for all technologies.  There are currently vendors which can furnish multiple technologies and even some with more than an organization or healthcare system might want. Be careful about a one size fits all proposal. Consider whether it would be of benefit to have the technology provided by a wireless carrier or not.

2.    Easily implemented and unobtrusive to the user.  Anyone who has experienced difficulties with setting up a new TV or smartphone understands frustrations with technology implementation. Considerations for assisting the healthcare system, Senior living facility, and the individual user are an important point of an RPM business plan.  If the tool is difficult to set up or significantly gets in the way of daily activities of living, it will not be utilized. Involving a caregiver with instructions is crucial in this regard as well.

3.    Must have optimized population alerts and superimposed personalized alerts.  Optimized alerts are those determined from evidenced based medicine, professional societies, or physicians associated with the customer.  In addition, these alerts should be customizable for the individual patient whose baseline measurements or variations might be atypical.  Both of the above should result in alerts to non-physician healthcare providers which are actionable only. What this means is that measurements which do not prompt a provider to recommend a change in course of treatment or other action should be stored but not transmitted. There might even be different levels of alerts which, after verified, are conveyed to the physician or other provider which ideally via an algorithm, would prompt different actions.  The aim is to minimize false positive alerts while maintaining a high degree of specificity.

4.    It needs to be a closed loop system.  This refers to every alert being addressed with an interaction. This might be a human interaction (phone call) or algorithmically determined digital message with instructions. It also refers to a follow-up afterwards to determine adherence to the instructions.  This system must be bidirectional to work. There also needs to be a human component to discuss symptoms and interact with patients with limited capabilities.

5.    there must be seamless integration with PHR and EHR.  The incorporation of data into the PHR and EHR is imperative. This is a logical progression of collection of data. It must be filtered so as not to clutter an electronic file with endless unimportant data points. It must be in an easily identifiable part of the electronic record.  It must be able to be shared with the caregiver and all designated providers in an interoperable fashion.

     Hopefully the Telehealth Promotions Act of 2012 will be approved in this Congressional session and pave the way for widespread adoption of these technologies which are sorely needed.  It is up to both industry and adopters to optimize implementation and utilization and to create outcomes measures which might translate to health and financial ROIs.

 

Posted in mHealth, technology, mobile health, informatics, medical devices, telehealth, digital health, FDA, remote patient monitoring | Tagged , , , , , , | Leave a comment

#DigitalHealth: Remote Patient Monitoring, Part 2- Operational Models

Posted on March 25, 2013 by

In my previous post, I discussed some generalities of remote patient monitoring (RPM).  The current value of the RPM market is estimated at $10.6B. There are diverse clinical and non-clinical environments in which RPM might be utilized.  The healthcare ecosystem is becoming a continuum of care more than discrete silos of acute care and various post-acute care settings which must interact with each other in order to result in better outcomes and prevent hospital readmissions.  These are the motives for the institution of RPM along this continuum. There are different models of deployment of RPM which affect investment by providers, ROI of the process, and logistics and workflows which I will discuss.

1.    Monitoring performed primarily by the individual. This would include glucometers, blood pressure recordings, weight scales, and other accessories to smartphones or computers which via wireless communication transmit and store measured data points. The patient can then present the data to a healthcare provider or have it sent electronically. This allows for the direct flow of data from the patient to the provider. There is little investment from a financial perspective in this model.

2.  Monitoring  by the vendor.  In this model, the technology vendor itself provides technical data support and acts as an intermediary between the patient and provider. This was the original model adopted for RPM of implantable cardiac rhythm devices. This type of model might involve partnering of the monitoring company and a wireless provider such as seen between Intuitive Health Inc. and ATT&T. The cost of monitoring in this model is built into the cost of the technology if used with Medicare reimbursement because of safe harbor law restrictions.

3.    Monitoring by a local healthcare system.  A local healthcare system might perform its own monitoring.  In this model, non-healthcare providers might take directives from physicians who set alerts and algorithms to treat patients based on data received if necessary. This logistical model also facilitates integration with the patient’s EHR. Patients can also call in and discuss related symptoms with the providers and appropriate follow-up appointments made if necessary.

4.    Centralized healthcare system monitoring.  Countries in Europe have large academic institutions performing RPM regionally for smaller hospitals and unaffiliated healthcare providers. They are equipped to handle the 24/7 coverage as well as possibly the clinical expertise (as seen with implantable cardiac devices for example) not otherwise available.

5.    Other third party commercial monitoring centers.  There are a growing number of companies performing RPM.  Some offer physician expertise (professional component) as well as the technical component of monitoring.  These companies might have an advantage of 24/7 coverage over small hospital-based monitoring centers.

There are advantages and drawbacks of all the above-mentioned models, and there might be others not discussed.  The lack of reimbursement for RPM might slow adoption, however the most significant impetus for the recent uptake in use has been the hospital readmission penalty policy. It remains to be seen which operational and business models fair economically better than others and more importantly, which ones produce better short and long-term patient outcomes.

 

Posted in digital health, FDA, Implantable Defibrillators, informatics, mobile health, remote patient monitoring, wireless health | Tagged , , , , , , | 2 Comments

#DigitalHealth: Five Fallacies of Remote Patient Monitoring

Posted on March 15, 2013 by

As defined in Wikipedia, remote patient monitoring (RPM) is: “a technology to enable monitoring of patients outside of conventional clinical settings (e.g. in the home), which may increase access to care and decrease healthcare delivery costs.”  I was a pioneer adopter of RPM as a BETA site for Medtronic’s Carelink wireless system which monitors implantable cardiac rhythm devices (defibrillators and pacemakers). RPM has gained significant attention because of recently mandated penalties for hospital readmissions for certain diagnoses (myocardial infarction, congestive heart failure, stroke, and chronic obstructive lung disease).  RPM is seen as a way of remaining in physiologic contact with these patients who might be managed at home via care systems. There are conflicting study results regarding the utility of remote monitoring preventing hospital readmissions. Some studies show no decrease in hospitalizations, and others with significant benefit.

1.    All remote monitoring is the same. There is no standard definition for RPM.  Some studies utilizing only telephone interviews have been called RPM. Other RPM technologies use body sensors which deliver data from the person’s body in an automated fashion into a server and/or a smartphone via an app, and/or an EHR.

2.     All remote monitoring is reimbursed.  RPM of implantable cardiac rhythm devices has been directly reimbursed for many years in the USA.  In fact, when it was first approved for reimbursement by CMS, it was approved at a higher level than in-office follow-up.  Many years following USA approval of reimbursement, European countries are still variable with regards to reimbursement models.  Besides RPM of implantable cardiac rhythm devices, – Not directly reimbursed but is an approved adjunct under the Home Health Resource Groups of the Prospective Payment System (HHRG PPS).

3.    Patients and physicians will welcome and embrace remote monitoring.  My first foray into remote patient monitoring introduced me into the psychological aspects of the technology as much as the bells, whistles, and clicks entailed in performing it. The first pushback from patients is that the technology is replacing the physician, and eliminating the patient-physician relationship. If the technology conveys true benefit to patient care (implantable cardiac device monitoring leads to early discovery of arrhythmias and even led to detection of an eventually recalled defibrillator system wire).  What patients should know is that with any type of well-designed and thought out RPM system they will be more connected both literally and figuratively with their provider.  Interestingly according to the 2012 Study of mHealth by Ruder Finn, 33% patients would like their physician to use a mobile platform for RPM to alert them of serious medical problems.  The first reaction from physicians is that they will be deluged with useless generated data, and that the data will remain in cyberspace without them knowing about it. The first reaction is addressed with good design, with actionable (and customizable) alerts and a workflow system employing non-physician providers.  The second concern is addressed below.

4.    Remote monitoring should be totally automated. The most effective RPM systems have some sort of human interaction involved in closing the monitoring loop. This is advisable for a number of reasons. There needs to be individualization of programmed parameters and alerts. This will allow for actionable alerts that are both meaningful from the provider’s standpoint and beneficial to the patient. Data cannot e managed in a vacuum. There will be false positive and negative readings which must be correlated to the clinical condition of the patient in order to result in optimal management.  Caregivers should be involved in the loop as well.

5.    Remote monitoring is only for recently discharged patients. It is no secret that RPM has both garnered and generated extraordinary attention because of Medicare penalties for hospital readmissions.  Regulatory requirements have driven much of digital technology adoption in the past decade. This includes EHRs, tools to determine and improve patient satisfaction, and patient portals. This is sad insomuch as one would hope that providers would invest in improved patient outcomes independent of mandates, following the tech adoption leads of the retail and finance sectors, focused on customer satisfaction and transaction outcomes. That being said, one would hope that the theoretical improvements brought to patients vis a vis decreased rehospitalizations (though 30 days is hardly a measure of long-term success) could extend to all relevant patients (those not hospitalized with chronic illness as well as those beyond the 30 day discharge period).

I have witnessed firsthand the dawn and benefits of RPM over time.  I look forward to the partnerships of RPM, mobile health, health IT, and non-tech patient-centric care. 

Posted in digital health, FDA, Healthcare IT, informatics, medical apps, medical devices, mHealth, mobile health, technology, telehealth, wireless health | Tagged , , , , , , , , , , , | 5 Comments

#DigitalHealth: Patient Engagement Does Not Imply Patient Empowerment

Posted on February 28, 2013 by

Patient engagement is a phrase that is everywhere now. It is part of the vernacular in advocacy circles, government, health technology companies, and payers. It used to signal a new healthcare ecosystem in which the patient is more of a spotlighted consumer; where reimbursement hinges on patient satisfaction, where the shortage of physicians dictates new care paradigms, and where the cost of healthcare must decrease as well as be redirected to wellness and home care from the more expensive treatments of preventable chronic diseases and institutional care. The Center for Advancing Health defines patient engagement as “actions individuals must take to obtain the greatest benefit from the health care services available to them.”  It is defined by an active role that patients play in their own care.

According to the National eHealth Collaborative, the Five Phases of the Patient Engagement Framework consists of:

  1. INFORM ME
  2. ENGAGE ME
  3. EMPOWER ME
  4. PARTNER WITH ME
  5. SUPPORT MY E-COMMUNITY

Each of these phases has a process corresponding to a stage of Meaningful Use.  They are also provider-facing, in much the same way the Patient Centered Medical Home is.  I agree fully with the framework of ‘INFORM ME’ preceding ‘EMPOWER ME’.  But the accompanying narrative (“A healthcare provider in this phase demonstrates basic levels of patient engagement with an emphasis on the use of simple tools that make healthcare more convenient and accessible. This also includes providing patients with standard forms, both printable and electronic, and information about advance directives, privacy and specific conditions.”) implies that a patient will become informed if they can use simple technology tools. I would say that the technology is a tool, not a solution to informing patients. The technology itself must be put into a framework which involves human interactions and ‘EMPOWER ME’ refers to “advanced patient engagement activities through substantive use of health IT.”  If the MU directive only requires 5% of patients to have patient portals, how substantive is it?  Do patients need to wait for this third phase to be empowered?  Should Stage 3 of Meaningful Use be a surrogate for true patient engagement?

Physicians and other providers need more than this framework to begin to engage patients. There needs to be a change in the mentality and culture of healthcare on the part of all stakeholders to empower patients before they become engaged. When my practice hired a nurse practitioner 13 years ago, referring physicians were livid that patients were seen (for routine follow-up, not consultations) by a non-physician. That culture has since changed dramatically, but took many years to do so.  Empowerment or enabling will come simply with the realization of how much one can do with lifestyle changes to improve health and maintain wellness.  This need not take years and should be independent of MU schedules and technology. Patient engagement is more  conceptually restrictive and technology-oriented than patient empowerment.  I submit that patient empowerment can come to those even unwilling or unable to use digital technologies. Without empowerment there can be no engagement. Engagement cannot be passively bestowed upon a patient because technology is available.  Patient empowerment should start in schools. Children are always seeking to become enabled in all aspects of life, and I believe that teaching them how much they can do to keep themselves well will, if done appropriately, yield huge benefits.  I applaud the efforts of the e-Health Collaborative. But we need not wait for MU to mature nor depend upon technology to have patients obtain the respect or responsibilities from others to become empowered, which only takes knowledge and a change of culture.  Patient engagement will require technology including mobile health and other tools.  there is no debate about that. Demographics and economics dictate this. I am a champion of technology.  But for technology to succeed as an integral part of patient engagement, empowerment must occur first.  Critics of engagement and empowerment will say that there are many patients and consumers who do not desire to participate in their care. I realize this and that topic is for another discussion.  The above implies to those who wish to.

Posted in digital health, fitness, Healthcare IT, healthcare reform, informatics, medical apps, mHealth, mobile health, technology, telehealth, wireless health | Tagged , , , , , , , , , | 14 Comments

Five Ways of Achieving Patient Engagement: Part 2: WITH Technology

Posted on February 12, 2013 by

In my previous post I discussed what I believe to be the most important paths to patient engagement without technology. I would like to now follow-up and discuss how technology can promote patient engagement.  This technology might be in the form of a health/medical app, a patient portal, information derived and transmitted via a sensor, or other type of digital health technology.

1.    Technology is always to be utilized as an adjunct tool, not the sole solution.  This is probably the most fundamental consideration.  I chuckle when I hear of a technology presented as a ‘solution.’   Solutions do not occur in a vacuum. Technology must always be incorporated into some process, whether it is limited to the user or spans a network of individuals. Much data might be generated, but if it resides in a magic silo without it being filtered and translated into a meaningful actionable message, it is useless. It is also useless if the following four issues are not addressed.

2.    It must be used with consideration of health literacy, ethnicity, and language.  The patient experience is a phrase getting much attention these days. While there is little in the way of data correlation between quality and patient satisfaction,  one cannot argue that intuitively if cultural, ethnic and language barriers are addressed with technology tools, the potential for reduced medical errors, better patient satisfaction and perhaps even better outcomes might result.  In searching for such a tool, I found a unique and interesting technology called SpeechMed which incorporates language translation into connected platforms. Improving language literacy will undoubtably improve health literacy. Platforms should also take into account ethnic and cultural differences which might imply utilizing a different user interface for selected populations (as well as ages).

3.  It must include the caregiver. Any technology aimed at self-management needs to take into consideration the caregiver. The importance of technology in assisting caregivers is discussed in a review entitled Family Caregiving and Transitional Care by the Family Caregiver Alliance. The role of technology and the caregiver has also been discussed in a previous post by me.

4.    It must be connected.  I believe that the patient portal is the single most important key to patient self-management. It can serve as a repository for medical records including videos, pdf files, medical apps, and other content. For this piece of the puzzle to be most effective, it must permit connectivity from diverse technological sources. Barriers to this are economic and political, not technological. As the patient portal market and health information exchanges mature (Stage 2 of Meaningful Use which dictates the use of patient portals only requires that 5% of patients have them), I see connectivity becoming less of an issue. The development of open sourced platforms will also help in this regard. The patient portal can thus become the source of convergence of many different digital health technologies.   

5.  It must be endorsed, not despised by healthcare providers.  Technological advances in therapies are expected and even anticipated by many healthcare providers. They are seen as symbols of progressive and modern medicine. Yet due in large part by experiences with EHRs, many providers to push back other types of digital technologies. If technologies are easy to use, are accepted by the patient and caregiver, provide demonstrated benefit, and deal with data in a filtered and algorithmic manner, attitudes would change. As a former practicing clinician who speaks with former colleagues daily, this is not a small barrier.

I look forward to hearing thoughts from readers about these points. Patient engagement is going to be a cornerstone of healthcare in the future.  We must find the best ways in which to achieve it, with both humanistic and technological factors considered.

Posted in digital health, informatics, medical apps, mHealth, mobile health, smartphone apps, technology, telehealth, wireless health | Tagged , , , , , , , , , , | 8 Comments

Five Ways of Achieving Patient Engagement: Part 1: WITHOUT Technology

Posted on February 7, 2013 by

If one looks at communications revolving around healthcare these days, whether emanating from political, healthcare economics, clinical, or technology spaces, the term patient engagement is invariably found as one of the cornerstones of the conversation.  This is no more evident than in the digital health technology space. One would think that patient engagement is only possible by hitching a wagon to the technology horse.  I would like to explore the issue with two posts, the first devoted to non-technical considerations and the second examining best practices of technology utilization in this regard.

1.     Listen to the patient.  Patient-physician communication is the basis for much of what transpires during the tenure of the professional relationship.  Lack of good communication has been cited for medication nonadherence.  William Osler, the father of modern American medicine famously stated that the patient will tell you the diagnosis with the narration of the history. Given the fact that most office encounters today last 15-20 minutes and that patients have comorbidities requiring attention, it is no wonder why many times they are not heard.  The physician is looking at the computer screen clicking off checks. The system is no longer geared towards human interaction and this creates a recipe for poor care, even if unintended.  This is why direct care or concierge medicine is becoming popular.  Both physicians and patients are returning to communicating in this setting. Other solutions need to arise to promote communication. Providing patients with pre-visit guidance in order to organize their thoughts and concerns might help.

2.    Motivate your staff to be as patient-focused as you are. Office and hospital staff should reflect the provider’s patient-focused approach to care. Many times they are too task-oriented and forget there is a patient who is the reason behind those tasks.  If the staff takes on the mindset of a stakeholder in the patient’s care and not just performing a job, the result will be a happier patient. Patient satisfaction surveys (an important part o the future healthcare landscape) will reflect this aspect of the care.  Patient-centered professionalism should be the goal of all ancillary staff.

3.    Demonstrate to the patient that you are an advocate.  Going to bat in front of an insurer for a patient who really needs a specific drug or procedure is something I always felt good about. Spending time on such matters is something physicians years ago (dating myself) went into the field thinking they would have to do.   However onerous, it is what patients need docs to do in critical moments. And patients do very much appreciate this. It is what made me feel good going to sleep at night.

4.    Show them your personal side.  Social media is a great way for providers to show their personal side.  This is not to say that personal interactions with patients should take place one on one, but a way in which patients see the personal (and hopefully appropriate) side of their healthcare professional.  I believe Twitter is a better forum for this than ‘friending’ between a provider and patient on Facebook.

5.    individualized self-management.  Patients will partner with providers in their treatment plans with different levels of enthusiasm.  Some patients will require more support than others (motivational and material) and this should be discussed. Discussing patient engagement early on in the relationship is important.  It should also involve a caregiver who might be the one participating in the engagement on a larger scale. A provider who embraces co-management and is seen as both a partner and supporter of the patient will be appreciated.

The above might seem obvious to most people, but in today’s discussions surrounding patient engagement, the humanistic aspects of achieving this are lost in the vision of technology magically transforming how patients react to their medical conditions and to their healthcare providers.

Posted in healthcare reform, mHealth, mobile health, psychology, technology, Uncategorized, wireless health | Tagged , , , , , , | 8 Comments

Five Pitfalls of Designing a Medical App

Posted on January 31, 2013 by

There are an estimated 15,000 medical apps presently on the market and is expected to grow 25% per year according to one study.  There are issues which are common in the development of these apps and other categories of apps. However, some technical and non-technical issues are unique to the sector. As someone who does not design apps, I will offer a perspective which covers topics raised by different stakeholders concerning medical app development which might be of interest.

1.    The motivation for the app development is misguided. Regardless of the elegance, ease of use, enjoyable experience, or other appeal of a health app, if it does not address a specific problem, it will not be considered useful and subsequently not adhered to.  Just monitoring a physiologic parameter, a person’s mood, or collecting data because an app is able to do so is a recipe for failure. People searching for health apps (and health information in general) are likely doing it because of a health problem. Data must be collected and filtered in a way that it translates a message to the end-user, whether that be a patient or clinician.

2.    Lack of clinician involvement.  I am not saying here that clinicians need to be CEOs of mHealth companies.  What I am alluding to is the lack of clinicians’ input at all in the development of many of the technologies.   Technologies do not operate in a vacuum.  There are processes that the technology fits into which might very well need to be totally redesigned around the technology (this is a good thing, for many processes need changed).  These processes may range from someone’s personal schedule to instituting hospital case managers who advise patients on mobile apps. The app cannot be dropped on the lap of a CIO or clinician and be expected to be successful.  Connectivity of mHealth tools will be an important aspect of stage 3 of Meaningful Use adoption. This connectivity will necessitate workflow of data and messaging between patient and clinician.  It is imperative, therefore, to have clinician input into the design of the technology.

3.    Poor attention to usability.  Achieving the final construction of an app must include an in-depth consideration of the experience a user with the need for the app has. According to a guide to evaluating usability of medical apps by HIMSS, usability may be defined as “the effectiveness, efficiency and satisfaction with which specific users can achieve a specific set of tasks in a particular environment.”  I chaired a session at the most recent mHealth Summit on the topic of “What goes into making an extraordinary mHealth app?” which can be found at the bottom of this link.  There are great presentations discussing app design and user experience.

4.    Not knowing the healthcare landscape. Knowing the healthcare landscape is critical to determining a strategy of adoption. What are the available technologies that address this app’s goal? How can this improve or add to them?  Can the technology be used by multiple stakeholders? Might it be best to partner with another company to distribute or co-market my tool? Is my technology more valuable when incorporated into another offering (partnering with another technology)? Is this tool something the payer, provider, or patient would use/purchase (which provides the best/easiest path to sale/adoption)?

5.    Not building to regulatory specifications. It doesn’t matter how much wow factor the app has, if it doesn’t meet regulatory requirements [re: security, HIPAA, FDA (if necessary)], it will need to be reworked as a significant cost. New proposed regulations regarding handling of data from apps might affect development as well and these should be followed in the news closely. Of course the FDA final guidance document is anxiously being awaited.  Aside from regulations, developers might want to look at Happtique’s draft standards for their app certification program.  The final standards are forthcoming.

In summary, building code is a small part of developing a health app if one wants to be successful. It should be seen as a process with many layers requiring attention. Selling an app does not translate to adoption.  Selling a good app improves its chances dramatically. 

Posted in digital health, FDA, informatics, medical apps, mHealth, mobile health, smartphone apps, technology, telehealth, wireless health | Tagged , , , , , , , , , , , , , | 6 Comments