Five Reasons Why Population Health Management Matters

The term Population Health has replaced patient engagement as the latest buzzwords in healthcare. There are a few reasons for this. It is a necessary evolutionary strategy born out of the worsening epidemic of chronic diseases (obesity, diabetes, hypertension, and others). It is also the foundation of a new payment model.  Population health is best defined in an article in the American Journal of Public Health by Kindig and Stoddart as “…the health outcomes of a group of individuals, including the distribution of such outcomes within the group…The field of population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two.”  Of related importance is addressing disparities in healthcare as contributors to outcomes. As patient outcomes become a metric for value based healthcare payment models, the focus of providers is shifting to preventive medicine, less testing and procedures, and helping people manage their own lifestyles as much as their chronic condition care. Addressing epidemic levels of chronic diseases as a matter of public health (as was done in past centuries in efforts to address infectious diseases) may seem appropriate on the surface, but presents problems concerning civil rights and other regulatory bodies.

  1. It is about people. An interesting overview of the potential roles of the Center for Medicaid and Medicare Services (CMS) in population health management (PHM) is given in an article in the New England Journal of Medicine. It describes the importance of healthcare between visits to providers, issues around provider scope of practice, necessary partnerships with private industry, and other issues. The article conveys a realistic assessment of the magnitude of the challenges involved in such an undertaking. It will not be something addressed with a single program, entity, or technology. A population is composed of individuals. Many will share common chronic diseases for which treatment guidelines are in place. Others will be at high risk of developing these chronic diseases. Within these groups lie factors which cannot be approached in a cookie cutter fashion.
  2. It creates a new and questionable way of paying for healthcare services. While population health outcomes are a laudable goal of payment models, there are limitations to what an individual healthcare provider can accomplish. One cannot force a patient’s change lifestyles or medical regimen adherence. Tools which improve adherence and lifestyle can be ‘prescribed’ but many need to be proven and adoption will take years before a (potentially) positive financial impact is felt, for which payment models should take a huge back seat to patient outcomes as a focus of PHM. What does not need to be proven are benefits of changes in lifestyle (which can be facilitated with motivational messages, coaching, and financial incentives). As with all policy changes, the devil is always in the details. Will a physician in a solo or small private practice who is exempt from having electronic health records be held to the same metric standards of PHM as a large physician ACO? Will physicians in geographical areas of high and low rates of obesity or significantly diverse ethnicities be held to the same outcomes metrics? Questions remain as to whether PHM will actually change the delivery of care itself by physicians. According to a report by The Rand Corporation the implementation of other newer health care payment models have resulted in huge increases in non-clinical administrative burdens without a significant change in face to face care changes. I would submit that better access to relevant data (via excellent analytical tools) reviewed and managed by informaticists (recently approved as an internal medicine subspecialty) with technology providing accurate and filtered actionable data is a better way to effect change in care. The implementation of deep and customizable (according to clinical profiles, geography, genetics) patient population registries with analytics and EHR interoperability seems to be an appropriate first step.
  3. It is a potential equalizer for providers and patients. EHRs were touted to decrease divides among populations by providing data which can result in the delivery of more equitable care. This hasn’t happened because of the inability of EHRs to collect data from multiple disparate sources, facilitate data searches, provide good analytics and to proscribe strategies for PHM. EHRs have the potential to improve patient care if improvements in the user experience of providers via easy to use interfaces and customizable data collection and analysis take place. Patients on the other hand desire, deserve and are not offered portals with good visuals, are mobile, and provide information which they feel will be useful to their clinicians. Patient use of portals presently has been sadly predominantly limited to encounters of minimal quality meeting Meaningful Use criteria which enable providers to receive incentive payments.
  4. It provides a new focus for innovation and investment. As with all new initiatives in healthcare, PMH presents opportunities for innovation and thus investment in products and services designed to provide the necessary infrastructure and tools to support it. Adoption of tools which provide a perspective (via good registry and analytics) on what is ‘going on out there’ (outside of the enterprise) as well as others connecting the public as consumers and patients to providers is the minimum goal we need to first achieve. According to the 2015 HIMSS Leadership Survey, 38% of respondents said they had PHM tools in place and 51% said their organization improved population health based on IT tools. Two-thirds stated that their organization was increasing its IT budget this year. However, according to a KPMG poll, 38% of respondents described their PHM capabilities as in their “infancy.” Investment by enterprises in analytics is critical in these efforts. The technology is here. Putting the pieces together (see below) and adopting them involve shifting cultural, economic, and internal political forces.
  5. It requires a multidiscipline team and portfolio of technologies. There is no single organizational department, process or technology which can address PHM. The varied needs of the spectrum of individuals in a population and requirements of different enterprises necessitate diverse strategies, goals, and utilization of human and material resources. As stated previously on this site, technology is not a solution but only becomes such when incorporated into processes and human workflows which accommodate it.  Predictive analytics,  proscriptive analytics,  excellent remote patient monitoring tools,  customized and EHR-integrated connected clinical business intelligence,* and intuitive user interfaces* all provide elements necessary for successful PHM. Partnerships among technology vendors, public and private healthcare stakeholder sectors, and between patient advocacy and provider groups need to occur for success. It will take investment and creative strategies to design the most economical,efficient and effective PHM initiatives.

The culture of healthcare on the part of patients and providers must change. Transformation needs to occur more quickly than regulators expect from changing payment models. There is a stellar quality of leaders already in this field. They must be given the political clout and technology tools to achieve those goals because clinicians and patients will not tolerate the status quo of the 15 minute encounter for much longer. The goals of population health management, if focused on the people and not regulations, commercial successes of vendors, or payer subscriber levels, can be met in some significant degree.

*As disclosure, the author serves as an advisor to  Medivu.

Posted in analytics, communications, digital health, digital health technology, Healthcare IT, medical apps, medical devices, mobile health, patient advocacy, remote patient monitoring | Tagged , , , , , , , , , , , , | 3 Comments

Five Requirements for the Adoption of Genomics as a Digital Health Tool

That digital health technologies will be adopted to address the ills of healthcare systems around the world is a foregone conclusion. The challenges of the cost of chronic disease burden, physician and patient dissatisfaction While awareness of digital health is being created with technologies like patient scheduling apps and telehealth video conferencing, a potentially more profound game changer, genomics is rarely injected into the conversation. The potential benefits of genomics lie in areas of both public health and disease treatment.  Before genomics becomes an integral part of population health management, there remain fundamental prerequisites yet to be realized. As a disclaimer I have no financial interest in any commercial entity this post mentions or links to.

  1. Education of providers. There are only approximately 4000 (Nov. 2014) certified genetic counselors in the USA. A recent study reveals that educating medical students in genomics is woefully lacking. Only 26% of schools in the USA and Canada teach genomics during clinical training years. An interesting study examining awareness of direct to consumer genetic testing found very few primary care physicians knew about and/or were prepared to discuss it. While physicians know the potential benefits of genetic testing for some diseases, they might not be in favor of it to the point of having their own genome determined.
  2. Awareness by ALL healthcare stakeholders. There is lively debate over payment for genetic testing. While there is widespread consensus with regards to testing of certain cancers, there are many issues to be considered with general screening. The company 23andme was stopped by the FDA two years ago from providing health reports based on genetic testing it did for consumers. However, it has found new success partnering with and pharmaceutical companies Pfizer and   Genetech. Although it had to shift business models, the company is bringing awareness via these other channels to multiple healthcare stakeholders.  This is yet another illustration of patients as consumers.   Patients should also be aware that the lack of identification of a sought-after gene of a disease might not be an absolute negative test. The disease (or predisposition thereof) might be on an heretofore undiscovered associated gene.
  3. Scaling the technology. This is not as much a function of the technology itself as it is of awareness and identifying opportunities for the clinical utility of derived data. The day when genomic analysis is done at home and applied in a meaningful way is going to come. Information garnered from such testing not requiring a genetic counselor might consist of a recommendation to discuss with a physician dosing or other changes of a medication regimen. It might be a virtual assistant suggesting that a family member being screened. Scaling this type of technology can result in targeting certain patient populations for new treatments (the consumer can opt-in or out for these protocols) via widespread sources such as social media or EHR charts.
  4. Development of tools and solutions. There are many potential clinical spokes emanating from the genomic wheel. Consider the alteration of genes of other species to facilitate organ donation or drug development based on population genetics.  Pharmacogenomics  involves the identification of biomarkers which can predict non-responders to medications and people prone to adverse reactions.  Implications of these biomarkers have made their way to drug labeling by the FDA.  The use of EHR-derived data for applications related to genomics is intriguing. Advantages of EHR-derived data for genetic research include the magnitude of data, low-cost, and the ability to follow it over time.
  5. Policies and regulations preventing abuse. It is natural to think that there is potential for discrimination against someone due to a genetic test resulting in the identification of genes diagnostic of or having the potential for developing a disease or significant clinical abnormality. What comes to mind is a potentially lethal or mental  illness. This issue has been addressed to some degree for some time now. The government has, via the Genetic Information Nondiscrimination Act of 2008 made it illegal to discriminate against a person in the areas of health insurance and employment based on findings from a genetic test. However, there remain other instances of potential discrimination. Consider life insurance, long-term care insurance or disability insurance which are not covered by the GINA. In addition, there are other drawbacks to undergoing genetic testing to consider.

Genomics is now on the national radar and was recognized in a Presidential speech earlier this year. The potential for huge strides in early disease (or pre-disease state) identification and treatments is clear. Challenges remain in multiple arenas, but I consider the biggest ones the shortage of genetic counselors, insurance payment issues (I know of insurance companies who require a genetic test to qualify patients for a new cholesterol-lowering medication but won’t pay for the test!), and need for more education/awareness of all healthcare stakeholders. I look forward to genomics becoming a larger part of medical education, water cooler talk, and the investment landscape in digital health!

Posted in clinical trials, digital health, digital health technology, education, FDA, Healthcare IT, informatics, medical apps, medical devices, mHealth, mobile health, pharma, remote patient monitoring, technology | Tagged , , , , , , , , , , , , , | 4 Comments

Five Essentials of a Successful Digital Health Technology Initiative

In previous posts I have discussed imperatives of patient-centric healthcare, creating patient engagement, and potential value of various digital health technologies. Apart from these considerations are those involving roles of stakeholders and barriers they face in adopting technologies and optimal models of adoption. Not lost in the technical, regulatory, and clinical issues required to be addressed are business models which need to be created for this nascent industry.  Significant strides have been made in all these areas. However, the farm to table process of digital health technology is not as easily achievable as its culinary counterpart. According to a recent survey, hospitals are either behind their schedule for adoption of a digital health strategy or lack one entirely. I would like to discuss essential elements of a successful enterprise which develops, purchases, and executes adoption in administrative and clinical best practice approaches.

  1. C-suite buy-in. The commitment to the development and adoption of a comprehensive digital health (including mobile) strategy must start with a vision and endorsement emanating from the highest level of administration.  An assessment of ‘Ten Challenges and Opportunities for Hospitals in 2015’ by Becker’s Hospital Review cited population health, shifting volume to value-based payment, regulatory demands, demonstrating the value of M & A to consumers, and physician workforce issues as major concerns.  I find it interesting how digital health technologies can be critical tools of solutions to all of these. Only with support from the C-Suite can an undertaking as far-reaching as digital health find success. The commitment of resources (see below) is dependent upon this support.
  2. Commitment of resources. There is no question that technology-enabled care has the potential to improve healthcare. However, the ability to deliver on promises of improved outcomes has been demonstrated by only a few products, some of which have deservedly been met with commercial success. Proving efficacy and safety is the cornerstone to adoption. Those who recognize the importance of participating as pioneer investigators in technologies which can address their own clinical needs (even at the expense of no immediate financial  or other ROI) will benefit from the experience. Claiming population health is a priority (as most enterprises do today) or stating “We have a digital strategy” is not enough. Defining specific goals and committing resources (human, financial, and material) are necessary. All politics is local and the path to digital strategy success will differ from place to place. Some enterprises do not have the resources to undertake such commitment. Those who have the resources can either serve as blueprints for others or potentially commercialize/outsource them.
  3. Interdisciplinary team participation. Digital health technology must not be approached as a separate silo with regards to strategy or resources. It must become integrated into the enterprise’s overall strategy and function, developed with an interdisciplinary team. If better satisfaction (patient and provider) and care are to be realized, input from all stakeholders at all stages is necessary. IT personnel, clinician (students, clinicians in training, physicians, nurses, and others) champions, basic researchers, behaviorists, mental health professionals, engineers, patient advocates, organizations like HIMSS, and community leaders all can contribute to produce a far-reaching successful strategy. Approached in this manner, the benefits of this teamwork affect bench to bedside medicine, patient population strategies, aging at home initiatives, mental health and other mobile health needs, and ultimately the success of the enterprise itself.
  4. Clinician input. There is a necessary differentiation between the introduction and adoption of technology in healthcare which has to consider clinician input. UCSF has just received a grant from the NIH for an impressive long-term cardiac mobile health study. Projects like this will foster support from healthcare providers because they reflect evidence-based medicine.  Clinicians are necessary because they are advocates for providers as well as patients. Nurses are the most trusted people in healthcare. As the interactive time between clinicians and patients decreases, tools which identify patients at risk, improve communication, increase patient self-management and decision-making, and potentially lead to improved patient safety and outcomes are indisputably desirable. Only with clinician input will strategies thrive.  As long as the adoption of these tools is not mandated and designed well, the chances for success increase.
  5. As healthcare enterprises tackle issues like population health management and outcomes-based payments they should partner with both private business and public sectors. These partnerships arise out of shared objectives, complimentary resources, and a sense of community. Digital health initiatives have resulted in Partners Healthcare, Stanford Health Care and others partnering with public and private entities.  The partnership of Apple, Mayo Clinic, and Epic EHR highlighted the consumer as patient concept. Partnerships with technology developers allows for the enterprise to potentially function as an incubator for tools deemed useful to it but requiring support.  Ultimately an entity which can even commercialize these technologies can be established, becoming a revenue center. Examples of such a model include Montefiore Health System and  Cleveland Clinic.

There remain substantial barriers to the achievement of digital strategies achieving positive patient outcomes and other laudable goals. They are not insurmountable. Basic issues such as privacy issues need to be addressed.  A recent study demonstrating privacy risks of accredited health and wellness apps in the UK is an eye opener. For this reason the development of some digital health tools by healthcare enterprises themselves is attractive. Greater accountability in the development process in the context of an overall IT privacy and security framework is desirable. In addition, technologies developed (and/or vetted by a dedicated multidisciplinary team) will better address the specific needs of the institution. Most barriers exist as a result of lack of administrative commitment and defined strategy. I look forward to changes occurring because of increasing pressures to all stakeholders.

Posted in analytics, digital health, digital health technology, EHR, healthcare economics, Healthcare IT, healthcare vendors, medical apps, medical devices, medical education, mHealth, mobile health, technology, telehealth | Tagged , , , , , , , , , , , , , | 2 Comments

Five Reasons why Patient Engagement Means Consumer Engagement

In previous posts I have discussed differences between patient empowerment and patient engagement and differences between patient and consumer sensor technologies.  Nevertheless, there are clear threads between consumer and healthcare delivery with regards to adoption of digital technologies. Many of these threads involve the consumer sides of healthcare.  I will discuss below how the patient is a consumer (defined as a purchaser of goods and services for personal use) in the healthcare arena and how viewing a patient as a consumer is transforming healthcare.

  1. Patients have choices. In an excellent article in the International Journal of Health Policy and Management Benjamin Ebert makes a key point: Although healthcare users have multiple identities (patients and consumers), the relative weight of these roles is dependent upon outside factors (users’ personality, state of health, values and respective health care decisions to face).  Patients have choices as to healthcare insurance plans and medical provider and treating facilities (albeit limited in many cases by the health insurance carrier’s ‘network’), assisted living facilities.  One must note, however that the extent of choice is decreasing because of consolidations in healthcare. Patients have choices regarding the purchase of many digital health technologies.  Awareness (on the part of patients as well as providers) and development of more robust, impactful, diversified and integrated technologies will increase those choices in the future. Fitbit, Apple, Samsung, Google, and others are bringing healthcare closer to the consumer side of society.
  2. Patient satisfaction counts. Patient satisfaction is is not a qualitative term equated with patient advocacy.  It is a set of standardized questions (in limited language diversity) in the form of patient surveys  to formulate metrics upon which payments to hospitals and physicians are based. Though patient higher satisfaction scores have been shown in one study to correspond to higher mortality rates and another to higher hospital readmission rates, they are still seen by some as surrogates of care quality. Nonetheless, the fact that the patient’s perspective is considered at all is a step in the right direction for patient advocacy. Patients may have a choice of points of care and therefore these metrics are certainly playing heavily in marketing campaigns.
  3. All stakeholders in healthcare are looking for market share. Whether speaking about payers, providers, other healthcare services or technologies, the rules of a free economy are in play. Market share rules and is the underlying cause of heavy consolidation in the payer and provider arenas. The number of ‘covered lives’ is the goal of payers, ACOs and healthcare enterprises alike. It is the reason for large companies like IBM, Apple, Samsung and others getting into healthcare. Technologies which appeal to patients as consumers will succeed.  Those putting the most effort into user experience (UX) design translating into adherence and potentially outcomes will succeed in the marketplace. What is different about healthcare from the retail business market is that these efforts need to be driven by studies demonstrating good user experience, adherence, and better outcomes (which can be related to efficiency, clinical or other parameters). The days of walking into a C-Suite with the “I’ve got a technology to sell you” are over. Proof of concept is replaced by proof of efficacy. ROI is defined today as cost savings not revenue generation. As readmission penalties and other quality metrics determine fines and payment, this becomes a critical concept. Some see the need of proof of efficacy via trials (though not necessarily long ones) as a chicken or egg situation. However a tool which makes a difference and the right development team will find its way into clinical trials which can involve minimal investment and even be performed totally via mobile technology.  Investors specializing in digital health technologies (beyond the multitudes of local incubators) are going to become key players. Strategies in healthcare are different because the marketplace, margins, and effects on lives are different.  Proof of the momentum of clinical trials is the1247 studies involving mobile health found on gov.
  4. Mobile health technology success hinges on social engagement. Outcomes tied to patient engagement are directly dependent upon the ability of the technology to maintain contact with the patient or caregiver.  A recent study  found that just 36 health apps accounted for one half of all downloads of the estimated 165,000 health and fitness apps available via Apple and Google. Social engagement will be a significant driver of mobile health engagement. Having a mobile health tool with social will increase interactions and therefore the ‘stickiness’ of the tool. Social media began without a business model. It now makes billions of dollars for advertisers and other digital partners. There are many reasons why physicians need to be on social media as professionals. Many of these same reasons hold true for mobile health technologies. Mobile health technologies need to harness the power of social to connect patients to each other via support communities, to hospitals, to Pharma and medical device companies, to non-profit and governmental agencies and to their own caregivers. Granted, it will take time for all these stakeholders in the slow-moving world of healthcare to get to social in a significant way. But it will happen and social engagement on mobile apps will be the forum.  The excuses of regulatory constraints and lack of models by some stakeholders can be addressed with appropriate investment in internal infrastructure and education.
  5. Most mobile health technologies are patient-facing. The fact that most mobile technologies are patient-facing only speaks to the consumer-oriented approach taken for the quickest adoption and financial success (which doesn’t necessarily reflect long-term adherence or profitability).  The emphasis on user experience is paramount. The purpose of the technology needs to be clearly stated and the expected level of patient and/or caregiver participation needs to be explicitly presented. Incentives in the form of gamification and/or healthcare financial incentives by a payer or employer might result in greater adherence. This remains to be proven. If the patient-facing tool is expected to share information with a provider, it is mandatory that the technology is easily integrated (interoperable) with the electronic health record and that only filtered clinically relevant, important, and actionable data reach the clinician.

In summary, digital technologies are only tools. They will be utilized only if they appeal to patients and caregivers. One might consider mimicking development and marketing strategies of some of the most successful retail and finance tools.  Brand loyalty will be established based on the delivery of high quality, reliable, safe, and easy to use tools. There are considerations in healthcare that certainly differ from retail.  However, patients are consumers of healthcare. Use of any technology is still a universal human experience. Technology offered to them needs to reflect this.


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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.

Posted in communications, digital health, digital health technology, health insurance, healthcare economics, Healthcare IT, medical apps, mHealth, mobile health, politics, technology | Tagged , , , , , , , , , , , | 6 Comments

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.

Posted in communications, digital health technology, healthcare economics, language, patient engagement, pharma, smartphone apps, technology, telehealth | Tagged , , , , , , , , , , , | Leave a comment

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 , , , , , , , , , , , , , , , , | 3 Comments