Five Imperatives of the Ideal Digital Patient Education Tool

I’ve previously discussed what I consider the five imperatives of patient-centric care.  One of them was quality patient education and monitoring tools.

  1. Tools must reflect health literacy. Health literacy is defined by the Department of Health and Human Services as “…the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”  Health literacy is a problem which must be addressed across all areas of healthcare.  Consider hospital consent forms for admission and procedures or the ubiquitous HIPAA law notification form where someone might commonly be asked to “just sign here” with the expectation that it won’t be understood anyway. Though simple in concept, health literacy of labels and documents is difficult to achieve by pharmaceutical companies in their own labeling to patients/consumers.  This challenge arises because of the paradoxical regulatory requirements the government places upon these industries.  There is an admirable movement afoot to have these labels accommodate health literacy considerations.
  2. Digital tools must be accurate and interactive. Accuracy of information implies that it is current, factually correct, and follows, if applicable, the most recent professional society guidelines.  Therein lies the devil is in the details factor which is most important to both patient/caregivers and healthcare providers.  It has been previously recommended that professional medical societies become proactive in developing and reviewing apps.  This activity would speak to the mission statements of these organizations by promoting both education and standards for quality care.  At this time there is no easy alternative to address this issue.  Third party medical publishers can certainly play an intermediary role in providing content.  Accuracy of digital educational material is probably the most critical aspect of the adoption of mobile technologies from the viewpoint of the purchaser whether it is a patient or provider. The interactivity of the app is relevant to patient engagement which by definition must be an active process. Interactivity is also important as it can serve as a metric of patient engagement, and even potentially as a patient care quality improvement metric.
  3. Patient education tools must be delivered at the point of engagement. The point of engagement  (POE) is where the need for these tools is most needed and the opportunity for their most significant impact to be made. It need not be the point of a provider-patient interaction.  It is where the most questions will be formulated by patients or caregivers who are often too overwhelmed with information to ask. This POE is more appropriate for the patient’s navigation of the healthcare system which involves so much more than the office visit to the physician or hospital, otherwise known as the point of care.
  4. The tools must be interoperable with electronic health record systems.  The ability for the educational tool to interoperate with the EHR is important for a number of reasons.  I look forward to the day in which these digital education tools are literally prescribed electronically by the provider the same as a prescription.  Doing so incorporates them into the EHR as a significant and respected part of the patient’s care. These tools should also become part of the patient portal, that interactive part of the EHR which patients have access to.
  5. Educational tools must be designed with the caregiver in mind. There is no solution to the crisis in healthcare which will be successful without considering the caregiver.  Educational tools must be able to be accessed by caregivers (if so directed by the patient or health POA).  One of the benefits of digital tools is that they can be shared seamlessly with caregivers. Some tools will be directed specifically towards caregivers who are taking care of patients without digital technology capabilities or adequate literacy to review them alone.  Others will hopefully be directed to the caregiver as support tools in caring for the patient or for they themselves (who are well-known to be vulnerable to problems generated by the stress of caregiving).

Both patients and caregivers have expressed a desire to receive more digital tools. Digital patient education tools are an increasing focus of Pharma  and patient education content developer/marketers.  It is time to put theory into practice and deliver what people want and deserve.

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Patient Satisfaction is not Patient Advocacy: How Digital Health Technology can Help

Editor’s note: While the format of this piece is doesn’t conform to the ‘five points’ you normally see, the ties to clinical and digital remain. We will return to the usual format in the next offering.

Patient advocacy and patient satisfaction are both popular terms these days, but they are far from synonymous.  Patient advocacy is defined by Wikipedia as “An area of lay specialization in healthcare concerned with patient education about the use of health plans and how to obtain needed care.”  This is considerably narrower than what I consider a more appropriate description by Trisha Torrey, “patient advocacy regards any activity which ultimately benefits a patient…it can apply to caregiving for an individual patient, to groups that develop policies and advice that help patients, to government groups that develop legislation to improve systems or processes for patients.”

Patient Satisfaction   While patient satisfaction might intuitively seem to have a simple definition, it is now defined by a conglomerate of defined metrics.  These metrics are a flawed reflection of patient advocacy for a number of reasons.  Firstly, the government surveys are available only in English, Spanish, Chinese, Russian and Vietnamese in the mail format and in English and Spanish in the telephone and Interactive Voice Response formats. Clearly one can imagine the resulting lack of survey response rate as well as the underestimation of patient satisfaction from this literacy barrier. There are tools such as real-time language translation of healthcare materials in any language.

With regards to the timing of the distribution of the HCAHPS survey, “…Sampled patients are surveyed between 48 hours and six weeks after discharge, regardless of the mode of survey administration. Interviewing or distributing surveys to patients while they are still in the hospital is not permitted.” I would submit that average (and perhaps most) patients are not be able to recollect in sufficient detail enough information after six weeks of a prolonged hospitalization to provide meaningful input to such a survey.  A real-time HCAHPS survey tool  on a mobile platform would be ideal. An objection the government might raise is the prospect of patients reluctant to criticize the care that they are presently getting. While this is quite reasonable as an assumption of human nature, it defies logic. Why do hospitals employ patient ‘advocates’? Are they merely for risk reduction or do they really care to take immediate corrective action? They should not in that case have it both ways with regards to real-time surveys.  The survey results are not returned to hospitals for many months and therefore timely corrective measures are not possible.  Not surprisingly, hospitals are strategizing to improve patient scores.

While there are many digital tools which can improve patient satisfaction including communication tools, patient portals, and the ideal patient education tool, the idea that patient satisfaction is a metric and separate from patient advocacy must be dispelled. Patient satisfaction as a driver for provider payment continues to be debated.

Patient Advocacy  Patient advocacy is distinctly different from patient satisfaction.  It is grass roots driven and not top-down regulatory driven.  It is not a popularity contest, but a movement which has interests in digital technology ranging from patients’ rights to their own electronic record data to online patient support groups.

Analogous to the government wanting to believe that payment penalties for 30 day hospital readmissions has something to do with patient outcomes, patient satisfaction scores do little for significant patient advocacy issues. It is time for the public, patients and caregivers to see the difference between financial metrics and real patient and caregiver issues.

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Five Mobile Health Technologies Providers Need to Implement NOW

This marks my first post since the sudden death of my chronically ill mother last month. The journey as her caregiver solidified what I believe should be priorities for the adoption of digital health technologies. There are currently many mobile technology tools directed towards the healthcare sector, with the industry experiencing explosive growth.  However, true rubber meeting the road adoption is lagging behind market expectations. Some challenges have been addressed; there is now a reimbursement mechanism for remote  chronic care management, proposed legislation for the expansion of telehealth, and the entrance to the market by Apple, and Samsung.  Barriers to their adoption include awareness by both the public at large and providers, cost/prioritization by strategic decision makers and challenges in the realization of interoperability. I will discuss five areas which can provide an impact in care and are available immediately.

  1. Scheduling: Finding a physician and scheduling an office visit are among the first tasks on the mobile health app wish list for many people. ZocDoc answered that call first.  The business model is a physician-purchased subscription.  Given the significant percentage of physicians who are employees of health systems, many potential customers are not subscribing.  There is huge potential if enterprises subscribe. Other players include docASAP and
  2. Billing: Mobile apps can improve efficiencies on the provider as well as patient sides.  Apps which assist in medical coding with ICD-10 will be important useful tools at the point of care.  Others permit for easier payment transactions.  The increasing transparency of prices in healthcare has led to development of consumer comparative shopping
  3. Patient satisfaction survey tools: Hospitals and physicians are now rated via patient surveys. These survey results have direct Medicare financial payment implications. The surveys are mailed to patients after discharge or office visit (often very much later).  It is often difficult for patient to recall their experiences. In addition, the results are made available to the provider almost a year later, delaying corrective actions. If these surveys were available on a mobile app,  I submit that there would be a higher return rate for the surveys and more rapid corrective measures as a result of more timely feedback.
  4. Mobile clinical trials: The ability to recruit more appropriate patients more rapidly via social media and wearable sensors using mobile technology has revolutionized the way we can conduct clinical trials. Tracking patients via mobile, collecting more accurate data and adverse events can all lead to improved study subject safety.
  5. Messaging: Quite a few secure ‘HIPAA compliant’ messaging apps have hit the market. The value of this technology lies in the potential for financial savings (improved discharge times, decrease in tests ordered), patient safety, and patient/caregiver satisfaction. Perhaps the historical decrease in interactions between hospital-based and office-based providers can be reversed with good messaging tools.

Healthcare enterprise C-Suite executives need to expand their horizons with respect to mobile health technologies. Organizations like MGMA and professional medical societies can be influential in this regard. The advent of bundled payment reform will, in my opinion, expedite the adoption of technologies which will decrease provider costs which is now the real ROI focus.

Disclosure: The author is an advisor to Parallel 6.


Posted in clinical trials, digital health, digital health technology, EHR, FDA, health insurance, healthcare economics, Healthcare IT, healthcare reform, healthcare vendors, informatics, medical apps, mHealth, mobile health, patient engagement, remote patient monitoring, smartphone apps, technology | Tagged , , , , , , , , , , | 2 Comments

Five Ways Professional Medical Societies Can Speed the Adoption of Mobile Digital Health Tools

There have been many stated roles of professional medical societies, including standardization of care (best practice), promoting public health, and improving leadership in medicine.  All of these roles can be facilitated with digital health technologies. Most professional societies are recognizing the benefit to their members of all types of digital tools including mobile apps.   One organization founded by the American College of Physicians, interestingly named  AmericanEHR describes itself as “…A free online resource designed to aid the medical community with the selection, implementation, and effective use of health information technology and electronic health records. AmericanEHR Partners was founded by the American College of Physicians and Cientis Technologies and is supported by 16 medical societies and five health IT organizations with a combined membership of more than 720,000 clinicians, representing over 65 percent of physicians in the U.S. It does not endorse any electronic health record vendor.”   One would naturally question whether this is a veiled targeted trade organization for EHR vendors. But it does highlight two points; Industry recognizes the potential market growth for digital technology via professional societies, and professional societies recognize the importance of digital tools to their members. Professional medical societies can markedly accelerate the adoption of mobile health tools in a number of ways:

  1. They can develop their own apps. Mobile apps developed by a professional medical society can serve many purposes. Many are already doing this but at a basic level. They can be reference guides, sources of publication highlights, breaking clinical, regulatory or other medical news.  The real excitement lies in interactive patient engagement tools.  These can potentially facilitate better patient outcomes by incorporating accepted practice guideline recommendations to both provider and patients (see below).  Apps can be tailored to communicate specialty quality measures.  The simplification of regulatory requirements in digestible and user-experience friendly ways in a mobile app format would be very attractive to providers. They want to do the right thing but also have little time or easy way to understand most of them.  This then becomes a win-win situation.
  2. Support development of digital health technology KOLs. Professional societies already have organizational leadership training initiatives but also need to foster development of what I would call Digital leaders. These are people who can spread the ideals of the organization to not only members but to patients and the public at large via social media. In addition, physicians want to interact in more ways than the traditional annual sessions or regional meetings. These interactions would occur in more personalized ways.  It’s time to utilize digital tools in ways other segments of the population do. Digital KOLs are thought leader members who already navigate digital media for professional purposes and understand the landscape of opportunities and barriers to digital health technologies adoption.
  3. Serve as quality evaluators of mobile apps. A professional medical society acting as an endorser of third-party digital health tools has obvious potential for conflicts of interest.   However, this need not be the case. A Society can vet apps with respect to data accuracy and whether they conform to practice guidelines. They can also encourage clinical studies of mobile apps. The time for conference sessions devoted to mobile technologies is here. Peer review evaluation of studies will add credibility to the technology.  Reliability and accuracy are among the biggest concerns (as well as privacy and security-see below) of users of medical apps.
  4. Create patient engagement tools. A natural place for the design and endorsement of patient engagement tools is the group which developed specialty practice guidelines. Ideally one would love to see both a patient-facing app as well as a provider-facing app. The rationale is obvious. The user experience or UX is totally different for the users. The patient app would be designed with sensitivity to health literacy with perhaps even a language translation feature. It would, with simple educational and instructional guides permit patients to more easily navigate their medical journey as their provider would like. Conforming to practice guidelines allows for metrics to be collected and potentially be applied to quality measure programs.  This data would be more reliable than other types because it is generated directly from the patient (or caregiver). On the provider side, the tool can simplify the guidelines with easy to convey actionable educational and treatment points.
  5. Work with regulators to incorporate mobile technologies into reimbursement, quality measure, and population health initiatives. There is an incredible delay between the development of technology and regulatory issues surrounding it (I am not referring to the FDA approval process which is actually relatively short).  If this time frame were shortened, then technology could lessen the burden on providers, by integrating mobile data from the patient engagement apps discussed above into the EHR and/or the required data registries.
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Five Ways Digital Communication Tools Can Improve Health Care

Many of the problems plaguing healthcare today, specifically errors in patient care, reside in poor communications.  How many of us need to listen to the entire recorded message tree when calling a doctor’s office or healthcare facility, only to not reach the intended person and as a result giver up trying? Why is it that most people when leaving an office visit do not know their diagnosis or how to take their prescribed medication? How can we best engage patients whose native language is not English? How do we best engage all patients? I will discuss five types of digital tools which address clinical needs.

  1. Patient handoff tools. Discontinuity in patient care in the hospital or other care facility is necessary. Strictly speaking, a handoff is the transfer of role and responsibility from one person to another in a physical or mental process.  An excellent study from 2005 examined multiple areas of communication surrounding the patient handoff.  The authors argue for a combination of verbal and written communication.   According to the Agency for Healthcare Research and Quality (AHQR), components of an effective handoff strategy should reflect the acronym ANTICipate:
  • Administrative data (patient’s name, medical record number, and location) must be accurate.
  • New clinical information must be updated.
  • Tasks to be performed by the covering provider must be clearly explained.
  • Illness severity must be communicated.
  • Contingency plans for changes in clinical status must be outlined, to assist cross-coverage in managing the patient overnight.


The role of technology in the patient handoff process is clear. The implementation of one handoff program as reported in the New England Journal of Medicine last year reduced the rate of preventable adverse events by 30%.  There are different types of handoff tools which might vary in complexity, specialty, and effectiveness.*

  1. Caregiver tools. There is finally now focus on technology for caregivers. This makes perfect sense since caregivers are more likely to be digitally connected via smartphones and apps, though at a logistical disadvantage.  Technology enables surveillance (both figuratively and literally) of loved ones.
  2. Language tools. Obviously language becomes a critical barrier when the subject of patient engagement is discussed.  The legal framework for language access in healthcare settings is not new.  What is different is the significant increase in cultural diversity of the USA.  The combination of this diversity as well as the increase in patients with chronic diseases increases the imperative of health literacy for all patients.  The lack of adequate language translation might be the difference between life and death.  This critical gap has been addressed by multiple translational services, some enabled with video conferencing.  One unique company in this area is SpeechMED which utilizes mobile technology for all aspects of healthcare.*
  3. Telehealth. In a previous post I discussed how I believe telehealth will change healthcare. It will close gaps in healthcare. These gaps include gaps of access due to rural/remote geographical regions or lack of available physicians in certain medical specialties.  Telehealth can keep patients in touch with their usual healthcare providers and specialists without an in-person visit.
  4. Patient-provider messaging tools. Many questions patients have can be answered quickly via messaging. We are used to messaging people in other aspects of our daily lives.  Communication tools allow for more prompt responses and will I believe facilitate the rebirth of the patient-physician relationship which has all but disappeared in the harried world of the 15-minute office encounter.  People have questions they recall when they leave or think of after a discussion with a caregiver or other healthcare provider. There are many such tools in use and the most utilized fall into the category of patient portal provided by the EHR vendor.

Although this is certainly not an exhaustive review of the topic, technology communication tools in healthcare will become part of our routine.  The concept of these tools is no longer something from outer space.  Communication is a phenomenon older than mankind itself. What technology does is make it more convenient and should never be seen as a replacement for traditional human interactions.  As I say, technologies are tools which only become solutions when incorporated into a humanistic context.

*Disclosure: The author is an advisor to MEDarchon which makes Quarc, a healthcare communications tool and SpeechMed.

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Five Reasons Why the Future of Clinical Trials Utilizing Mobile Technology is Here

In a previous post I discussed both the merits and needs for the use of mobile technologies in clinical trials. Recruiting patients via social media is now a reality and has been a topic of discussion in many forums, including mainstream medical journals.  There is no question that online patient support groups serve unique purposes. There are regulatory issues involved in this arena.  However, new regulatory frameworks need to be developed in the age of digital and mobile trials with considerations to technology and patient populations. To be more specific, mobile technologies have unique issues to address. Crowdsourced clinical studies  have been recognized as an emerging aspect of clinical research for years. Even funding for medical research has found its way to the masses.  Regardless of changes in the paradigm of conducting trials, patient safety must always remain a priority of study designers and investigators (whether organizational or subject investigators). The subject of health literacy is extremely important today. It is recognized as a major determinant of patient engagement. Health literacy is a critical factor in pharmaceutical and device labeling and is paramount to user experience of a mobile health app of any kind.

Improving patient recruiting, retention, and data collection should be the priorities of any mobile technology in this space. I am going to discuss why we can and need to adopt mobile technologies for clinical trials now.

1. Corporate giants are paving the way. Apple’s ResearchKit is a pioneering effort to accomplish many objectives. Its present offerings will not cure heart cancer (though arguably, if optimally utilized in association with other tools by both providers and patients it might prevent them). What it will do is to markedly increase awareness and enthusiasm of the public as well as the healthcare provider community to participate in clinical trials. ResearchKit’s present apps are primarily geared for wellness, with monitoring via smartphone sensors initially, but the satisfaction of participating in research and the sense of empowerment that participants will experience will pay huge dividends with regards to more disease-oriented research down the line. In addition, and not to be minimized, it will facilitate the adoption of mobile technology in general in the wellness and healthcare arenas.

2. The technology is here. One might intuitively think that a clinical trial mobile app might simply consist of a technology limited to data and symptom entry. But the dynamics and workflows of all phases of a clinical trial make that a recipe for poor recruiting and lack of patient engagement and thus retention. Parallel 6 is a company which utilizes patented technology in its end to end mobile clinical trial technology for improving both the recruiting and retention of study subjects. In addition, pharmaceutical companies are realizing the power of crowdsourced studies.  This is illustrated by the partnership deal between Genentech and 23andme.  These kinds of partnerships themselves spawn proliferation of mobile clinical trials.

3. Traditional evidence-based medicine is no longer considered infallible. As I have previously reported, there are significant cracks in the foundation of evidence-based clinical trials.  Some of these cracks may be due to well-publicized gender bias possibly related to recruitment practices (see below). These biases have been recognized by the FDA and stressed as a priority of attention in the recruiting of study subjects.  Social media as a source of study subject recruitment has multiple appealing aspects. It can facilitate recruitment of patients with rare diseases who reside in widely dispersed geographical regions. One study found that patients who are actively engaged in the use of social media for healthcare information are 60% more likely to have participated in a clinical trial compared to the general population. Clinical trial recruitment via social media can potentially decrease gender bias, leveling the clinical trial subject playing field. Amy Ohm, the CEO of Treatment Diaries, a large and successful online cross-disciplinary collection of support groups states that 73% of the site’s participants are female.

4. Traditional clinical trial research is becoming financially unfeasible. The cost of clinical trials is discouraging both sponsors and healthcare enterprises from conducting traditional clinical trials. The cost of even a market-approved medical device trial for a new indication is tens of millions of dollars. The cost of clinical research nurses and coordinators has become prohibitive for institutions except those most famous or endowed. Although most research today is sponsor-driven, research by physicians in smaller hospitals and organizations is cost-prohibitive. Mobile technology can potentially assist in this regard. Even clinical research organizations (CROs) are looking to decrease costs and improve efficiency. The cost reduction projected for each phase of a trial in multiple disease state areas with the use of mobile technologies has been estimated in a recent report by the Department of Health and Human Services. “In Phase 1, the highest savings are $0.4 million (immunomodulation and respiratory system). The savings range from $0.5 million (cardiovascular) to $2.4 million (hematology) studies in Phase 2. In Phase 3, the highest savings that can be expected from the adoption of mobile technologies is $6.1 million (pain and anesthesia). Finally, the range of savings in Phase 4 studies is $0.7 million (genitourinary system) and $6.7 million (respiratory system).”

5. Mobile can improve trial safety and efficiencies in clinical workflow. With the collection of more data in real-time, the improved efficiencies produced with mobile technology might theoretically improve patient satisfaction, study subject retention, and the aforementioned cost to study sponsor and investigators.  In addition, earlier reporting of adverse events might translate to safer patient outcomes.  I truly look forward to pharmaceutical and medical device companies, CROs, payers, and healthcare institutions saving money which can be better utilized with the use of mobile technologies for clinical trials.


Posted in digital health, EHR, FDA, healthcare economics, Healthcare IT, medical apps, medical devices, medical education, mHealth, mobile health, remote patient monitoring, smartphone apps, technology, telehealth, wireless health | Tagged , , , , , , , , , , , , , , , , | 2 Comments

A New Paradigm for Digital Pharma: The Digital KOL

A digital strategy is important for Pharma to remain relevant.  The need to connect with both patients and providers via digital formats and via mobile devices has been dictated by the successful penetration of these types of marketing, educational, and engagement tools in other aspects of our daily lives. Healthcare providers expect this evolution in the workplace as well.

Pharma’s traditional collaboration with KOLs has been successful. The quickest way to facilitate adoption of a Digital Pharma model of interaction with providers is to utilize the KOL, who, like a traditional KOL is a trusted and respected leader. There is a need for physicians who champion online interactions, realize the value of social media, and are familiar with best practice digital and mobile health technologies to be involved in new industry initiatives. These initiatives include furnishing needed information to both providers and patients based on evidence and experience.

The business model Digital Pharma has heretofore been one of a direct to patient/consumer play. It is well-appreciated by industry that it is hard these days (if not impossible in many circumstances) for Pharma clinical liaisons (Pharma reps most trusted by physicians) or r other agents to engage physicians directly due to organizational policy restrictions, lack of available time in between those 15-minute patient visits, or worse, at the scrub sink or OR lounge.  I would submit that these encounters need to be redesigned to be one of a ‘pull’ by the physician and not a ‘push’ by industry. Digital both allows for and encourages new business models.   What if a provider could, by way of a digital profile created, determine what individualized type of encounter was preferred (in-person, secure text message, email, safety alert, published clinical study results, or a combination thereof)?  This would save huge pieces of marketing budgets for industry while creating focused high value proposition interactions based on provider preference. Digital KOLs will be utilized to help design, implement, and lead adoption of content and presentations (both static and live).  This would amount to an Amazon type one stop ‘shopping’ of Digital Pharma education for providers. These ideas are admittedly out of the box. But physicians are thirsty for meaningful information and data provided by Pharma while requiring convenient and trusted means of obtaining it.  Digital KOLs will be helpful in creating awareness and presenting the value proposition of digital to their peers at professional society meetings.  The FDA just presented its Guidance document on Pharma and social media.  This should only serve to enhance the industry’s digital presence, not discourage it as some have hinted.

Digital as a DTC strategy needs to close the patient engagement loop.  I submit that the only way that can happen is with involvement of clinicians.  There is a historically low mistrust of the industry by the public.  Healthcare providers must be involved.  They are the ones who have the relationship (strained as it may be in 2015) with the patient. In addition, no digital technology is a solution. It only becomes a solution in the context of human interactions and processes built around it.  Therefore, the technology necessarily involves a provider. Otherwise these tools never become solutions.

There is presently much industry buzz about quite a few prescription drugs going over the counter (OTC).  This will necessitate significant efforts devoted to patient education focused on safety and self-management. There are great opportunities in this arena for digital technologies. The delivery (‘prescribing’) of digital tools to patients can take place with results monitored by both providers and industry.  KOLs in this space are needed in this critical time of creating awareness not just of products, but of ways in which digital interactions between industry and providers will take place. Scientific liaisons, sales and technical support personnel will still be critical players in the process, but the means of interactions will evolve. Clinical trials are moving into the mobile technology arena (see Parallel 6). Physician KOLs need to help pave the way for this new model as well.

Pharma is doing progressively more marketing research and marketing via digital technology. The use of mobile devices is catching on in the industry (see Prolifiq) .  Digital health advertizing is big business (see McCann Health and InTouch Solutions).  Other targets of interest are online physician (Doximity, Medscape) and patient (Treatment Diaries, WEGO Health) communities, general social media sites (Facebook, Twitter), and even electronic records companies (Practice Fusion).  I believe that the use of physician KOLs can markedly increase the success of these strategies. Many physicians do not encourage patients from seeking medical information online. They would if they had better tools to utilize.  Therein lays the value proposition as a win-win for Pharma.  KOLs will be provider champions of prescribing digital tools (including appropriate online sites, apps, and other tools). Ultimately, the primary objectives of better provider-patient, industry-provider, and industry-consumer relationships, improved patient outcomes we constantly hear about can be facilitated with the use of excellent digital tools.

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Five Imperatives of User Experience (UX) Design in Mobile Health Technology

The Wiki definition of UX design is “the process of enhancing user satisfaction by improving the usability, ease of use, and pleasure provided in the interaction between the user and the product.” UX design success in mobile health technologies depends upon the achievement of including the best in reliability, usability, privacy and safety, content, and pleasurable experience. I will discuss what I think are five important issues in achieving the ideal mobile technology user experience, specifically for those technologies hoping to enter the healthcare (versus consumer) market.

  1. Clinician involvement in development. I first realized the importance of UX design when working on an interoperability project in 2004 between remote monitoring data from implantable cardiac defibrillators and my electronic health record (EHR) company. The EHR programmer and I worked together with an interesting dynamic as he had no clinical background and I had no CS expertise. The UX design was dictated by me, the user. The programmer had no idea in what order or visual format (pages, tabs, etc) was expected by the clinician for optimal UX. This was not a patient-facing mobile technology where attention to UX design is critical to success. I was therefore not surprised to see poor UX design by mobile health app developers in 2010.  The lack of clinician involvement in development of mobile health technologies continues dominate the landscape today notwithstanding vendor promises of achieving better patient outcomes at a lower cost and better patient experience. Expert clinician input is necessary on a number of levels. It assures accurate and reliable content. It leads to a better UX for the clinician with regards to how data is obtained, presented and incorporated into clinical workflow.
  2. Patient and caregiver involvement in development. Just as clinician involvement is important in the development phase, so is that of the patient and/or caregiver who are the data sources. If they are not engaged by good UX design, the technology never takes off and no one even knows why. Many patients don’t manage their medications, appointments, or data because they might not have a smartphone. That shouldn’t be a reason not to recommend an app, digital patient education or device tool. A caregiver (typically younger and digitally connected) will likely be more able to engage the product. I have witnessed this many times in my own practice when recommending a digital tool. There is a workflow to being a patient which differs from that of the provider.  It consists of incorporating the digital interaction with activities such as timing of medications, physical activity, or even those unrelated to healthcare. The content and visual displays to patients are necessarily different.  The same mindset of developers which marginalizes clinicians invariably sees the patient as a passive recipient of this tool. The proverbial ‘build it and they will come’ works neither for provider nor patient. The true value of patient involvement in development is easily seen if small incremental alpha testing is performed along the way.
  3. Less is more. The value of an app is simple, intuitive, and pleasurable interaction. Crowding a screen with data or words is counterproductive. If the app is about patient data, meds, or appointments, then these must take up the vast majority of the screen. Efficiency of the presentation, interaction, and feedback are important to a good UX. There must be age, healthcare and educational literacy, and ethnic language appropriateness.
  4. Privacy and security in the background. A better user experience might occur at the expense of less personal data privacy. A social community has been a component of successful health apps. It can however create (in the absence of chosen anonymity) a great experience at risk of privacy. This is usually made clear with a disclaimer and many participants are willing members anyway.  The aggregation of pooled or anonymous data is considered by some a breach of privacy or ownership. These issues are presently the subject of ethical, legal, and business discussions. Lack of privacy or security is often not discovered until after a breach.  This has been seen in HIPAA violation cases involving large healthcare providers and payers and cases of large retail companies. Not all people share the same concern for or desire similar levels of security and privacy. Measuring satisfaction of security level is not easy to say the least. The app must provide the highest level of security which also allows for the best UX. People may opt out of sharing data, identity, etc. but the ‘opt out’ option must be presented.  
  5. Creation of a sandbox enjoyable to both play in, revisit, and benefit from. UX design should make it enjoyable to experience the app utilizing a humanistic and empathetic slant. Empathy is sorely lacking in medicine today. It is potentially the biggest factor in a good physician-patient relationship. It is a large part of the attraction of online patient support groups. Social community interactions around the focus of the app incentivizes users to experience as much of the app as possible as well as return to it after it is downloaded (something done in only 10% of health apps in current use). Medical apps can potentially have a very unique place in digital health by impacting what we value most in life, health.

The UX design part of medical app development is very much underappreciated today. It is more than a first impression. It is akin to a good learning experience in school. If it sparks the enthusiasm of a student, it can mean the difference between dropping out and graduating with honors. For more on what constitutes good UX design in healthcare, I would suggest this review from a HIMSS workshop on the subject.

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Five Ways Analytics in Digital Health Tools Will Change Healthcare

There are many reasons cited why digital technologies hope to improve of patient care as well as the state of healthcare itself. They include improving efficiencies, patient safety, and cost. However, as has been seen with the most ubiquitous face of digital health technology, the EHR, these promises remain unfulfilled. One significant barrier to the utility of digital technology has been the heretofore unlinked status of ‘sterile’ data with analytical tools which can bring it into the world of clinical relevance to both the provider and patient. Analytics have been utilized in other sectors of society including retail, social and finance for decades. They drive efficiencies and outcomes at Amazon, IBM, telecoms, FedEx, financial institutions, and sports. Yet the millions of bits of discrete data amassed every minute in healthcare are warehoused in a contextual vacuum. To add insult to injury, even when utilized in hospital patient satisfaction surveys, bundled payment programs, and physician performance measures, the results are transmitted to healthcare enterprises and providers (who are eager to affect improvement based on these metrics) only after months (and up to a year) later. Analytics can be seen as mission control of digital technologies, putting all the pieces together in order to assure ultimate success of the vision. The filtered data needs to be delivered in real-time and incorporated into operational and clinical workflows without having to be mined. Barriers to the adoption of analytics were identified in a joint study by IBM and MIT. The biggest ones were: inability to get the data, the culture does not encourage the sharing of data, lack of understanding of the benefits of analytics, competing administrative priorities, and lack of executive sponsorship. It should be noted that this study was performed in 2010. Nevertheless it is the opinion of this author that these same barriers remain obstacles today. I will discuss some reasons why analytics will ultimately change healthcare.

  1. Analytics will deliver value to electronic health records (EHRs). EHRs were developed to help improve and integrate the flow of clinical information.  However, they were designed as billing tools which also met regulatory specifications.  They do not follow clinical workflows. The American Medical Association has called for design overhaul of EHRs to improve usability.  Clinical decision support is rudimentary and can vary widely in its breadth and depth of use. The discussion of the utility of analytics with EHRs is not new. I suggested what this might look like in healthcare in a piece I wrote in 2011, with pilot studies using predictive analytics have been done.
    1. Analytics can improve clinical workflow. It is intuitive that analytics can improve workflow. Actually determining this by way of metrics has been a challenge. One interesting study from the University of Michigan “focused on measuring clinicians’ ‘time expenditures’ among different clinical activities rather than inspecting clinical ‘workflow’ from the true ‘flow of the work’ perspective.”
    2. Proscribed therapies and digital health tools. Analytics will recommend, based on available data in the EHR (diagnoses, medications, vital signs, results of tests) treatment and discharge plans as well as digital tools for patients (patient education on diagnoses, medication, and follow-up and care instructions. Case managers (as well as the healthcare provider) who have backgrounds in informatics will review these recommendations. This will close the loop as a human element check.
    3. Population health management. ‘Population health’ is currently the buzz phrase for healthcare enterprises. It encompasses preventive health, outreach programs including telehealth, and the use of data to drive health outcomes. Analytics will facilitate this by analyzing real-time data gathered by EHRs, social media, genomics, and mobile health technologies including apps and remote patient monitoring. Crowdsourcing data, whether it is derived from a worldwide or single institutional database is very powerful.
  2. Analytics will transform Big Data into Actionable Data.
    1. Preventing hospital readmissions is becoming a significant focus of healthcare enterprises because of the financial penalties tied to them via CMS. Remote patient monitoring (RPM) is becoming a significant tool in preventing these readmissions by providing continuity of patient-derived data with the hospital, recognizing actionable trending data before it results in a trip to the ER and a subsequent admission to the hospital. One of the unmet challenges of most RPM systems is to incorporate analytics with the technology, offering suggested changes in lifestyle, care, or other instructions to patients and/or caregivers, or changes in the therapeutic plan to the provider.  This is a far cry from the provider receiving a deluge of useless data for analysis.  This type of analytics can also incorporate clinical decision support based on evidence-based medicine.
    2. Use in clinical trials, post marketing of drugs and devices. Analytics can be extremely helpful in the recruitment and retention of patients in clinical trials. There are a few mobile health technology companies in this space. One not mentioned (by way of disclosure to which I am an advisor) is Parallel6 which utilizes patented technology to keep patients and investigators connected. Post-marketing surveillance of medical devices, new pharmaceuticals, and drugs which transition from prescription to over the counter is critical in discovering adverse reactions and other events not captured during controlled (relatively short-term) approval trials or regulated prescribing.
  3. Analytics will be the key to personalized medicine. Only via analytics can we combine the value of population health data and clinical and digital data from an individual patient in an expedited and accurate fashion. Should all patients with the same cancer receive the same treatment regimen? Analytics can potentially readily address variances of diagnosis and/or treatment of a disease based on geography, race, and genomics.
  4. Analytics will decrease gaps/bias in care (geographic, socioeconomic). It is well-known that geographic variations exist in healthcare utilization and costs. Analytics incorporated into EHRs can utilize best practices seen vis-a-vis pooled data such as this to ‘level the playing field’ with respect to both quality and cost of treatment.
  5. Analytics will decrease the cost of care. The use of analytics is readily seen with its incorporation in apps which provide healthcare cost transparency. Analytics can also help patients interested in medical tourism choose a destination. There are apps which allow patients to compare charges for a given procedure.
  6. I do not pretend to deliver the message that analytics is the Wizard of Oz of healthcare, nor that the successful revamping of our broken system lies solely in IT. As described above, barriers to the use of analytics are not technical but cultural. Organizations like Kaiser-Permanente and Geisinger Health System already realize the value proposition of employing high-grade real-time analytics to drive better outcomes and lower costs. It is important for hospitals to realize that remaining in just survival mode is not an option and that a vision of utilizing cost-effective resources such as analytics can be the best investment for success.
Posted in analytics, digital health, healthcare economics, Healthcare IT, healthcare reform, medical devices, mHealth, mobile health, patient engagement, pharma, remote patient monitoring, sudden cardiac arrest, technology | Tagged , , , , , , , , , , , , , | 1 Comment

Why Home Care is More Important than Readmission Rates: Implications for Digital Health Technologies

The Affordable Care Act added a section to the Social Security Act known which established the Hospital Readmissions Reduction Program. Under the new fines as described in an article by Kaiser Health News, three-quarters of eligible hospitals will be fined in the program’s third year. Fines totaling $428M will be levied from payments of Medicare patients, not limited to those who were readmitted. I first wrote about the role of  role of digital health tools in reducing readmissions in 2011 prior to the program going into effect. Digital tools have been since been developed for providers and offered by entities including the Agency for Healthcare Research and Quality . Technology is being touted as a savior for readmission penalty reduction. But as I have stated many times, technology offers tools which only become solutions in the context of processes involving humans and aimed at solving specific problems. The topic of hospital readmissions is important because no one wants to rebound back into a hospital after a serious illness but popular primarily because of its financial implications. These regulations are part of the historical Medicare-provider cat and mouse reimbursement game that has been taking place for decades. But I digress. Patients and caregivers today are more concerned about what support THEY have when discharged from a hospital as well as that which can help them avoid an initial hospitalization.

Information regarding coverage home care in the USA is available at Medicare and Home Care. An interesting comprehensive overview Home Care Across Europe furnishes information comparing needs and services among nations. Home care is more important than Readmission data because:

  1. It can affect initial as well as repeat hospitalizations. The focus of readmission rates misses the point of what got the patient in the hospital in the first place. The management of a chronic disease is regarded as more important than its prevention (or at least the prevention of its presenting complications). Digital patient education tools might succeed where verbal encounters and/or written materials haven’t. Digital tools in the form of apps are ideally interactive, can easily be shared with caregivers, contain incentives and have a social component.
  2. It applies to people of all ages, not just patients. As we now know too well, chronic diseases are beginning in childhood, linked to unhealthy lifestyle behaviors. Young people are all digitally ‘connected’.  Therefore digital tools are likely the best (and possibly the only) way to engage them.  Addressing chronic disease prevention in young people is the biggest and best investment in healthcare. Addressing the readmission problem, primarily in the Medicare population misses the boat with regards to population health management and the potential for digital tools in other groups. Aging at home should be applied to ALL ages (after all aging, by definition, is a lifelong process).
  3. The implications for the economy and healthcare outcomes are greater. Thinking of hospital readmissions certainly has the patient as a focus, but limiting the readmission time to 30 or 90 days is really not addressing the core problem which is how to institute processes at home which lead to better outcomes. The importance of medication literacy and reconciliation and prompt follow-up appointments are self-evident. Social workers do their best to assure adequate home health concerns are addressed, but they are limited in purpose to meeting regulatory requirements which many times have nothing to do with the patient’s individual needs or ability to meet them financially. The threshold for furnishing adequate care is many times dictated in an all or nothing fashion based on whether the patient is on Medicaid or not.
  4. The market for digital health technologies is greater. People who are not recovering from a recent hospitalization require less acute monitoring. Devices which are directed towards wellness or the prevention of complications of chronic diseases (as opposed to actually managing the chronic disease) have been declared not necessary for regulation by the FDA. This opens the market for less costly (and potentially more impactful) mobile technologies.
  5. The impact on caregivers is greater. According to a report by the AARP Policy Insititute,  the ‘caregiver support ratio’ will dramatically plunge. Between 2010 and 2030, the population between 45 and 64 years old will increase by 1% while those over 80 will increase by 79%. The ratio is expected to drop from 7 potential caregivers for every high risk person (over 80 years old) to 4 to 1. Aging at home is where the rubber meets the road for caregivers. While the patient is recovering from a recent hospitalization, Medicare pays for some home health services (though woefully little with legislation which continues to decrease services). Digital tools including apps will one day deliver informational resources, logistical help with medical equipment, health aid scheduling and visiting nurse assessment and care. While apps today don’t cover much of this, there is a growing group of apps geared to caregivers. Some examples are: Balance: for Alzheimer’s caregivers, Care Zone, Elder 411, and CarePartners Mobile. Online web-based tools include: Apps for caregivers have begun to attract general media attention.  Aging at home is by far a bigger issue for patients and families than readmissions because of the longer-term benefits to all involved.  Sure, readmissions disrupt life but aging at home is what we think about more and deserves more attention.  Payers including the government need to make aging at home, not an institution, the focus of resources and investment.  It’s what Baby Boomers who are becoming seniors of the present and future will demand.
Posted in death and dying, digital health, health insurance, healthcare economics, Healthcare IT, healthcare reform, media coverage, medical apps, mHealth, mobile health, patient engagement, pharma, remote patient monitoring, smartphone apps | Tagged , , , , , , , , | 1 Comment