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Flexible Care for Independent Aging: Don’t Dumb It Down!

I had the pleasure of participating on a panel on technology for aging, along with Honor founder Seth Sternberg and CareTicker founder Chiara Bell during the HX360 event at HIMSS 2016. (HX360 is a “conference within a conference” focused on innovation and C-suite leadership.) The panel was hosted by Jeff Makowka, Director of Market Innovation for AARP, and ranged from topics on entrepreneurship and whether there is a venture rush to technology for aging now to approaches for delivering care for aging in place.

Interestingly, all three panelists were inspired by personal experiences to found our companies. For me, it was poor discharge instructions and lack of continuity of care when my mom was released from 6 months in a long-term care facility. For Seth and Chiara, it was trying to figure out how to enable their parents to age at home. It’s a classic entrepreneurial model to experience a problem and try to find a solution to it, provided the market is big enough, and this market certainly is based only on demographics of the aging baby boomers. Seth and I both made the leap from technology, Seth from Google, and me from Microsoft, and Chiara from a long history in healthcare and homecare.

We were much sharper in real life.

We were much sharper in real life.

Honor’s $20M in funding lead by Andressen Horowitz is proof that Silicon Valley is paying attention to homecare, which can be viewed as important from two aspects: first we need innovative and new thinking to approach these challenges, and second these solutions could require a lot of money. (Although I would posit that we need patient capital in this space, something that Silicon Valley is not always known for. Interestingly, the same week as the panel Dave Chase and Andrey Ostrovsky posted a piece on why Silicon Valley does not belong in homecare. Maybe they should be on next year’s panel.)

The three panelist companies took similar approaches in using technology to scale and empower the people in the process, both patients and caregivers. For Wellpepper it’s about empowering the patient to follow their care plans and get remote support from the healthcare team. Honor and Careticker are more focused on the patient and their homecare team, whether that is professionals or family members. What was similar in the approach was providing information in real-time to the people who need it, and treating everyone in the process with respect. Honor does this by ensuring homecare workers are paid a living wage. Careticker does this by recognizing for people to age in place, the family caregivers need the right information and supports and Wellpepper does this with patient-centered and highly-usable software that is not dumbed down for the aging.

We were perhaps the outlier on this panel as our solution is not aimed specifically at the elderly. However, you could say we are the most representative of the way we need to approach the challenge: we need solutions that are designed with empathy, putting the patient first, and are not categorizing people into “young” and “old.” Well designed solutions and products should can address a broad spectrum of users, and we need to treat those aging in our population as another audience in this spectrum.

Posted in: Aging, Behavior Change, Healthcare Disruption, Healthcare motivation, Healthcare Technology, Healthcare transformation, M-health, Managing Chronic Disease, Patient Satisfaction

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Cross-Fit for Healthcare: An HX360 Workshop

At the recent HIMSS 2016 conference in Las Vegas, Robin Schroeder-Janonis, Wellpepper’s VP of Business Development,  and I were up early for cross-fit. Not the total body workout you may expect, but a workout nonetheless in the session “Innovation Cross-Fit” facilitated by Leslie Wainwright, Molly Coye, Gregory Makoul, and John Kutz. The cross-fit in this session referred to cross-organizational teams, the type required to implement innovation in healthcare and the workout took the form of a workshop where participants determined how big of a lift it would be to implement a new innovation.

Each table was comprised of a cross-section of senior healthcare leaders including CIOs, CEOs, business development, innovation leaders, IT, and marketing/communications. As a warm up, we were asked to evaluate the effort to implement a new innovation from a number of axes including user experience, implementation, stakeholders, path to scale, and opportunity. Our table was asked to evaluate the Proteus Discover Platform, a new category of ingestible medicine. We were given a high-level brief of Proteus and set loose.

In evaluating the “lift” for Proteus our group took into consideration a number of factors. First, while the population that would receive the ingestible medication would be relatively small, the legal and privacy impacts could be huge. As a result, we ranked higher complexity on user training and stakeholders, particularly with respect to medical users who would need to explain how the medication worked. Implementation costs were low as there was no IT involvement and no new hires, and only some new hardware required.

Here’s an example of the scorecard from our table:

Cross-Fit For Innovation

The next step was to map the implementation journey by adding steps in the process and stakeholders involved at each step. Our group started with the process steps and added stakeholders after the initial process was mapped out. Others fully explored each step before moving on to the next in the process. We found that there were a few stakeholders missing from the provided stack, for example although this was a medication we didn’t have a sticker for pharmacists, and that we had stakeholders participating in multiple process steps: patients and end users for example were seen at multiple stages.

In this stage the interdisciplinary teams brought their own experiences and filters to the table, which resulting in a more inclusionary process. For example, marketing representatives suggested that although the board of directors was not required to approve the implementation because the budget was so low, that they should be on an FYI list before any press releases related to using the new technologies. Operations people pointed out that procurement was left out of the process initially, and yet they’d have to sign the contracts and issue the POs.

Here’s what the process looked like from my group:

Innovation Journey Map

Finally, groups presented to each other, and this is where things got really interesting, as you can see the approach differed significantly across groups. Our group heavilty weighted the beginning of the process while another used iteration to get the same effect. Another group’s results showed that organization was the driving principle.

IMG_2559 IMG_2558

 

For me, the top takeaways from the session were:

  • Don’t be surprised how quickly a group of individuals with completely different backgrounds and experiences can coalesce to get a job done.
  • Innovation takes a cross-disciplinary team.
  • Making sure the right stakeholders are involved at each step is important, and consider that stakeholders aren’t necessarily decision makers, but they can also be people who need to be informed about the project.
  • The more time you spend in the first part of the process the easier the actual implementation
  • Conferences need more interactive sessions like this but it would also be an easy activity for a team within a health system

Posted in: Healthcare Disruption, Healthcare transformation, Lean Healthcare

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Our Picks for APTA CSM 2016

APTA CSM 2016Wellpepper CTO Mike Van Snellenberg will be at APTA CSM in Anaheim this year, and here are a few of the sessions you might see him at. If you want to be sure to see him, book a meeting.

As usual we’re following sessions about healthcare transformation, patient experience and patient centered care, patient reported outcomes, and interventions that include technology. With the conservative care and physical therapy being an important part of new bundles like CMS’s Comprehensive Care for Total Joint Replacement, these are hot topics as well.

Here are a few session picks from Wellpepper.

Patient-Centered Care

Exercise and Diabetes: Tools for Integrating Patient-Directed Practice

The Customer Experience in Health Care: The Game Changer, Part 1

Words Mean Things: How Language Impacts Clinical Results

Acute Care Productivity Measurement, “What about the Patient?” The Time has Come to Shift to a Value Based Measurement System

Technology

Wearable Technology Meets Physical Therapy

Virtual Reality and Serious Game-Based Rehabilitation for Injured Service Members

Tracking Outcomes

Changing Behavior Through Physical Therapy: Improving Patient Outcomes

Functional Reconciliation: Implementing Outcomes Across the Continuum

Using Outcomes Data to Improve Provider, Patient and Payer Engagement and Demonstrate the Value of Your Services

Healthcare Transformation and New Models of Care

Exceptional Care and Profitability in Light of Health Care Reform for Patients with Chronic Musculoskeletal Pain

The Complicated Hip: A New Debate

Emerging Issues in Medicare and Health Care Reform, Part 2

Bundled Payment Implementation for Primary Total Joint Patients

Managing Patient-Centered Care in a Changing Reimbursement World

Health System PT’s Leading the Transition to Value-Based Health Care

Posted in: Adherence, Health Regulations, Healthcare Disruption, Healthcare motivation, Healthcare Policy, Healthcare Research, Physical Therapy, Prehabilitation, Rehabilitation Business

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Hot topics of 2015 from the Wellpepper Blog: It’s All About Value

As we get ready for big changes in 2016, especially in the world of value-based payments, let’s take a quick look at our most popular blog posts of 2015. Not surprisingly, they are related to changes coming with bundles and value-based payments, and the role of patient-reported outcomes and patient engagement.

In no particular order, here are our most popular blog posts from 2015.

From Wellpepper CTO, Mike Van Snellenberg.

http://wellpepper.wpengine.com/decreasing-the-patient-survey-burden-for-total-joint-pros

From Wellpepper, VP of Business Development, Robin Schroeder-Janonis

http://wellpepper.wpengine.com/does-healthcare-need-a-call-to-minga

And from Wellpepper CEO, Anne Weiler

http://wellpepper.wpengine.com/value-based-bundles-for-total-joint-the-glass-is-more-than-half-full

And from Wellpepper Business Analyst, Liz Zampino

http://wellpepper.wpengine.com/2016-the-year-of-telehealth

 

Posted in: Health Regulations, Healthcare Disruption, Healthcare Policy, Healthcare Research, Healthcare transformation, Outcomes

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Digital Health and the Influence on Healthcare: Wearables, Telehealth, & Treatment

Things are looking up in the world of digital health at least this was the view from “Digital Health and the Influence on Healthcare: Wearables, Telehealth, & Treatment.” The WBBA held their last event of the season with a panel on digital health, hosted by Russell Benaroya, CEO of Everymove, and featuring Dr. John Scott, Director of Telemedicine at UW Medicine, Davide Vigano CEO and co-founder of Sensoria, Mike Blume, independent healthcare consultant, and myself. I’d characterize the overall event as being optimistic and realistic, both from the panel and the attendees.

Digital health event

It was a dark and stormy night

No one said that the road to digital health was easy or fast, but the consensus that things like moving to the cloud, and the acceptance and adoption of patient-driven digital care is reaching a turning point.

Both Sensoria and Wellpepper’s business models are made possible by the cloud. For Sensoria this was the ability to process millions of datapoints coming from their wearable technology. For Wellpepper, this is our ability to rapidly implement solutions working with department heads facing a particular challenge in patient engagement and outcome tracking and improvement. Dr. Scott remarked on the dramatic drop in the cost of telemedicine solutions over the years he’s been an advocate and solutions due to both Moore’s Law and cloud computing over his tenure running telemedicine at UW.

Sensoria's Quantified Socks

Sensoria’s Quantified Socks

As well, although Dr. Scott highlighted how telemedicine was limited by arcane reimbursement models that did not allow for patients to receive telemedicine consults in their homes, he and other panelists discussed that they were not waiting for billing codes to do the right things in using technology to deliver better care. As usual, the Affordable Care Act was seen as a big driver as patient-centered and digital care.

Possibly because there were two ex-Microsoftees on the panel (Davide and me) a cloud-based platform approach was touted as the best way to both collect, analyze, and sort the data that came in directly from patients. In the case of Sensoria and Davide, this was to look for trends and patterns coming from sensor-integrated clothing, and in the case of Wellpepper it was to collect patient outcomes in the context of care and compare these across patients, procedures, and healthcare organizations.

This view led to a discussion about the proliferation of data, and everyone agreed that digital health has the ability to overwhelm health systems with data that they are currently not prepared for. EMRs are not set up to include sensor or patient-reported data, and as Dr. Scott pointed out, physicians are not looking for every data point on a patient, only the anomalies, like glucose out of range.

One audience member asked about whether healthcare organizations had an overall data strategy, and whether digital health data should be collected as part of that. It’s an interesting idea to consider but it seems like it’s still a long way off in healthcare. Does your organization or CIO have an overall data strategy? It seems that quality measures and the need for patient reported outcomes are introducing new requirements for data, but this is at the departmental or initiative level. Grappling with questions like this will be important as connected devices, digital, health, and patient reported outcomes enter the mainstream.

Posted in: Health Regulations, Healthcare Disruption, Healthcare Policy, Healthcare Research, Healthcare Technology, Healthcare transformation, M-health, Outcomes, Telemedicine

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Reverse Innovation: What We Can Learn From Global M-Health

Whenever possible at conferences, I try to attend at least one session that is outside my particular area of focus and expertise. While almost everything at the recent HIMSS M-Health was relevant, global health is a bit outside the target for Wellpepper right now. Attending a few sessions on M-Health got me thinking about similarities between some of these initiatives and the situation at home.

Global M-HealthWhen we started Wellpepper, we got a lot of feedback on our mobile first strategy, not all of it positive. We believe that people have an emotional connection with their mobile devices and that when people’s mobile devices ask them to do something they generally do it which is why we optimize our patient experience for mobile. Concerns were that people of lower socio-economic backgrounds or older people would not be able to use the technology.

We and other startups have found this to be untrue, and given the success of mobile programs in the developing world, it seems that this is a red herring of an argument as m-health initiatives are successful with people with widely varying literacy levels and for whom this is often their only connection with technology. Basically if people with low tech literacy can engage in their health through mobile devices in the developing world, we’re pretty sure everyone can in the US as well. In the developing world, mobile infrastructure has leapt over landline infrastructure. A similar thing has happened for lower income people in the US: they are more likely to only have Internet access through a smart phone than through a computer and home Internet connection.

The session “Innovative Content & Mobile Delivery Tools: Driving Healthcare Utilization & Coordinating Care” covered a number of private and public partnerships to bring culturally relevant and timely information health issues related to childbirth to women, caregivers, and families in Africa. There were a number of similar initiatives involving different players in different countries both not-for-profits and telecommunications companies. Rather than recapping one initiative this post is a survey of some of the learning and best practices from a few different ones.

Most projects were either focused on preventing unwanted pregnancies and also reducing child mortality. Really two sides of the same coin: making sure women and families had the information and resources they needed to care for their children. Information needed to be localized to the needs of the audiences that included mothers, mothers-to-be, midwives, and others caring for pregnant women, and their spouses. Customized content was key, for example, nutrition advice needed to address what was available in each country, and medical advice for the types of caregivers that were in the area, not always licensed medical professionals.

While the projects were shown to work, sustainability was key. There needed to be benefits to the telecommunciations companies that were providing free texting between expectant and new mothers and providers, and access to video content. There are definitely benefits for the telecommunications companies, which included:

  • Customer loyalty. By supporting women and families in this crucial time, the telcos were able to let them know that they would be with them through thick and thin and supporting them in important life events.
  • While the phones were provided for this particular educational program, people started using them for other activities which provided a revenue stream for the telecommunication companies.
  • Lack of churn. Many women were repeat users of the program when they had their second child.

Content for Global M-HealthChallenges of the programs mostly revolved around content. Creating and managing content was a big cost for the non-profits involved. Video content was seen to be best as it didn’t require a high-level of literacy, but keeping content both culturally-relevant and up-to-date was a challenge. As a result, one organization provides a free content library for front-line health workers.

In addition to the similarities of access to information, the content problem is also one we see here. However, the difference is an abundance of content for patient treatment plans. Each organization has their own content and best practices. During the session, I thought that donating care plans and instructions to some of these not-for-profit might be an interesting way to solve this problem, collect more feedback on care plans and accessibility, as well as give back.

Posted in: Healthcare Disruption, Healthcare motivation, Healthcare Research, Healthcare Technology, Healthcare transformation, M-health

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Postcards from HIMSS M-Health 2015

HIMSS M-HealthIt’s been a busy couple of weeks at Wellpepper with both the AAKHS annual conference and HIMSS M-Health Summit at the Gaylord Convention Center in National Harbor where Wellpepper was honored to have won the Venture+ Pitch along with CirrusMD. This was our second year attending the conference and we noticed that the hype for digital health is a bit lower and perhaps that represents market maturity. It could also be that organizations are in the thick of implementation and don’t have the success stories to tell yet. We believe in digital health and are rolling up our sleeves so will take this feeling that we are moving to incremental change as a positive sign.

Venture+: The Market Is Maturing

We participated in the Venture+ Pitch last year as well which was won by fellow our fellow Springboard Alumna Prima-Temp. Prima-Temp was the clear winner last year, already raising their Series B. However, there were a ton of startups with only an idea. This year the criteria was that startups have revenue before applying, and the competition was held in two parts, the first an invitation-only session where 11 startups pitched and panelists talked about the market opportunity in general, and then a final round with 4 excellent startups and really tough questions from the judges. We were a bit earlier on our journey than a couple of the other startups in the final pitch so were honored to be recognized along with CirrusMD.Clinic of the Past and Present

Interestingly the startup area on the tradeshow floor was almost entirely made up of a new class of startups. So, while the market for M-Health may be maturing somewhat, there are still new entrants attracted by the promise of disruption.

Incremental Progress and Show Me The Evidence

I was only able to attend Day 1 Keynotes, and I heard that the Day 2 keynotes were great, especially by Shahram Ebadollahi of IBM Watson Healthcare. On Day 1, with the exception of an excellent presentation from Dr. Wood from Mayo Center for Innovation (disclosure: as part of winning the Mayo ThinkBig challenge we have the opportunity to work with CFI for the next year), most of the presentations were quite low-key. The main problem was the voice of the patient was missing: the focus was on initiatives or technology. I timed it. 1.5 hours into the keynote and we heard the first end-user story, and it wasn’t really a patient, it was a blind runner who used FitBit.

Dr. Wood shook everyone out of complacency and called out for a faster adoption of healthcare innovation, pointing out how basic things like patient treatment rooms have not changed dramatically in the last 50 years. He asked the audience to consider going beyond patient-reported outcomes and consider the outcomes that matter to patients. What would the system look like if we paid for health rather than healthcare, and we paid based on people being able to reach their own self-defined goals? Digital health is an enabler of this new system, but really, it’s about taking a patient or people-centered approach to health and to care.

What Patients WantAgain, maybe it’s a sign of market maturity, but the conference this year seemed more evolutionary rather than revolutionary. Themes from previous years were expanded on. For example, Judy Murphy of IBM talked about how consumer expectations expectations are fueling demand for m-health. People expect the same level of transparent and always available technology to manage their healthcare as they get from any other consumer experience.

HoneyBee and IPSOs announced the launch of the Global M-Health Survey which also pointed to ubiquity and consumer expectations and desire for M-Health. (The final survey results will be available in Q1.)

In a number of sessions Apple Research Kit was heralded as a major breakthrough for clinical trials. While the speed with which Research Kit was able to sign up study participants is certainly turning traditional research recruits on its head, the same limitations are still there: no HIPAA-compliant server infrastructure and selection-bias for those with more expensive devices. Interestingly, one of the greatest benefits for researchers seems to be the standardization of the informed consent process. (Note that Duke University will be open-sourcing the platform infrastructure they built in recognition that not all organizations have the skills and resources to build something like that.)

Interesting, how what was deemed such a major innovation at the time of release (less than a year ago), also seems a bit incremental. Again, we will take the glass-half full approach and say that we are reaching a market maturity where the gains are more incremental, although at next year’s conference we would really like to see more clinically-validated mobile health applications, and also more patient stories, preferably told by the patients themselves.

Posted in: Healthcare Disruption, Healthcare motivation, Healthcare Policy, Healthcare Research, Healthcare Technology, Healthcare transformation, M-health

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Value-Based Bundles for Total Joint: The Glass Is More Than Half-Full

The bundles are coming! The bundles are coming! While many health systems have been delivering care in value-based bundles for some time, the broad implementation of bundles was made a reality when the Centers for Medicare and Medicaid announced the Comprehensive Care for Total Joint proposal to go into effect in early 2016. Navigating this new world, was the focus of the session “The Business of Total Joint Replacement: Surviving and Thriving” at the American Association of Hip and Knee Surgeons annual meeting. This was one of the best sessions we’ve attended on this topic: both realistic and optimistic about the opportunity to impact patient-centered care and change. This is a long post because the session was jam-packed with information, and I was only able to attend the first part. Heads must have been reeling for those who were fortunate to attend the entire 5-hour session.

The session was kicked off by Mark I. Froimson, MD, MBA EVP and Chief Clinical Officer of Trinity Health who took questions from the audience to start the day to ensure that their needs were addressed. A survey of the room showed that roughly half of the attendees were surgeons or physicians and the rest of the audience was comprised of included administrators, nurses, and physical therapists involved in care. This was apropos as much of the theme of the conference was about how care teams will need to work together across settings in a new patient-centered model to deliver on care.

Questions fielded showed that the audience had done their homework and included concerns about business models and outcome tracking for revisions. The Baby Boomer’s desire to stay active has resulted in earlier joint replacements which means revision surgery in the future. Audience members were concerned that revisions wouldn’t have as strong outcomes and they would be penalized by that. Participants from smaller organizations asked whether there were other metric tracking schemes they could participate in to offset the Meaningful Use incentives if they weren’t able to participate. (We have an idea: how about reimbursement for engagement with digital patient treatment plans?) Complex cases were also of concern: the system needs to ensure that systems will not be penalized for complex case that may also have weaker outcomes. Without risk adjustment for complex cases which are more likely be done at large in-patient facilities rather than ambulatory surgery centers, some organizations could be unfairly penalized.

Risk-sharing

Dr. Fromison handed the session over to the extremely optimistic Kevin J. Bozic, MD, MBA, Chair of Surgery and Perioperative Care, Dell School of Medicine. While value-based the goal of bundled payments is to improve outcomes and lower costs, Dr. Bozic spoke directly to the audience about the value for them: in the current fee-for-service model, the best surgeon gets paid the same as the worst. There is no incentive for efficiency. In the new model, surgeons that can deliver better outcomes at lower costs will be rewarded accordingly.

Interestingly though, the team-based medicine approach and the focus on surgical prep and post-operative care, means that it’s not clear which physician in the team will see the benefits of performance bonus: the primary care or physiatrist, the anesthesiologist, or the surgeon. This will be interesting to watch play out. In the past some surgeons considered their work to be finished after the surgery and others stepped in for post-acute care. As well, there was discussion about how to get hourly workers in the care team on board and aligned with the new models. As we’ve talked to countless organizations and individuals about the move to value-based payments, the common theme is that the patient outcome driven approach is better for patients: perhaps this can be the rallying cry for alignment.

This team-based partnership is not just within an organization or care team. Since 40-50% of costs of a total joint replacement are in post-acute care, surgeons and health systems must partner with post-acute care facilities. We’ve observed this trend directly with both inpatient and outpatient rehabilitation joining health systems and creating new ACOs to share risk.

Dr. Bozic handily turned the negative connotations of risk-sharing on their heads, when he was asked whether these new models were just a measure to shift risk to the providers. His answer was a positive “Yes” and encouraged the audience that providers were really the only ones who could manage performance and appropriateness of care. Note that payers still bear the risk of who gets a disease (although with more health systems focusing on wellness this could change), while providers bear the risk for the outcomes. Because of this, Bozic recommended that a strong physician needed to lead the change and own the bundle implementation within a health system.

Outcomes, Outcomes, Outcomes

Today with the focus on outcomes it’s hard to believe that a surgeon from Massachusetts General, largely seen as the father of outcome tracking, was run out of town and eventually lost his license for suggesting that physicians should track and be accountable for the outcomes of the interventions they performed.

Refreshingly, Dr. Bozic asked the audience to go beyond standardized outcome tracking as it relates to reimbursement, and consider which outcomes matter most to patients. We’re excited about this idea as we track outcomes both based on standardized outcome measures like the HOOS and KOOS (and soon the Hoos Jr & Koos Jr) but also at the task level and soon based on the patient’s own goal.Outcomes-mobile.screen4.jpg Outcomes-mobile.screen5.jpg

Without data transparency and sharing, improvement can’t happen. Finding out where the waste is in the 100-300% variation in inpatient total joint cost is key. Dr. Bozic is suspicious of organizations that boast that they are better than average on all measures: he believes that they are actually are unaware of their flaws and not driving a culture of continuous improvement.

We’ve been at surgeon-focused conferences before, and the booths that were busiest were those promoting joints and surgical instruments. Dr. Bozic told the audience they needed to be evaluating vendors that could help them collect, measure, and act on outcomes, which was music to our ears.

Patients and Prevention

The third speaker was Dr. David Halsey, MD from Vermont, who echoed many of the themes of the previous speakers, especially in the need for outcomes, but also posited a question we haven’t heard before, Dr. Halsey asked who better to do population health for arthritis than orthopedic surgeons? In our travels, we think that both physiatrists and physical therapists might want to join in that population health management, however, if it starts with the surgeons then they would be more incented to try other approaches before surgery, which can be accomplished through preventative care. Preventative care includes patient education and shared decision making and requires new tools to involve and engage patients in their care. It also includes making the patient’s goals front and center to improve care, and understanding and managing their expectations. Today’s patients have higher expectations to have a high level of mobility post surgery, and a low level of pain. Physicians need to engage with patients both to understand and to manage their expectations.

Moving Forward

While we’ve heard some people grousing about the squeeze that is being put on orthopedics through the CCJR, this glass-half-full group sees this as an opportunity for orthopedists to lead the way and actively engage with CMS. Data collection and transparency are the way to do this, and the current tools (aka EMRs) don’t cut it. (While this is our message at Wellpepper, it came directly from the speakers: times are changing!) Expectations are that other specialties will follow the total joint guidelines, spinal surgery is considered to be next, so orthopedists have the opportunity to set the standard for how value-based bundles are implemented in their organizations, while collecting and analyzing real-time data and leading an interdisciplinary team of course. Onwards! We’re ready!

Posted in: Health Regulations, Healthcare Disruption, Healthcare Policy, Healthcare Technology, Healthcare transformation, M-health, Outcomes

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You Could Get Well Here: Touring Mayo Clinic

Mayo Clinic Center for InnovationDuring the recent Mayo Clinic Center for Innovation Transform Conference, attendees had the opportunity to take tours of various Mayo facilities.

I was able to tour the Center For Innovation, where we will be working periodically over the next year as part of our prize for winning the Mayo and Avia Think Big Innovation challenge, and the Center for Healthy Living. A third tour, of the new Well Living Lab was sold out before we could get tickets.

Spirituality is part of health at Mayo

Spirituality is part of health at Mayo

The Well Living Lab is a research center where the health impacts of daily living can be tested. For example, researchers expect to study the impacts of air quality or lighting in office buildings on employee health. Tour organizers told me that the paint was still drying on the center as they start the tours so I’m sure we’ll be hearing more about this innovative center in the future.

Mayo Clinic Center for Innovation Tour

The Center For Innovation houses two main areas, one a clinical space where real patients and care teams can test different types of exam room configurations and equipment, and the other more like a typical software or design office. Pictures were limited in this area, so you’ll have to imagine from my descriptions.

All the walls in the clinical space are magnetic, enabling different types of room configurations on the fly. Even the artwork is affixed with magnets, so I suppose it’s possible to also test the effect of different artists as well. When medical teams work out of the CFI space, they are testing not just the patient experience but whether these new configurations make teams more productive or collaborative. The CFI has found a number of improvements to care are possible with better room configuration, and noted that clinics and exam rooms have changed very little since the 1950s.Human Centered Design

A few innovative examples include:

  • A kidney-shaped table encourages more collaboration and communication between doctors and patients
  • Separate consultation and exam rooms offer many benefits in both communication and efficiency. Patients are less stressed, more able to absorb information, and ask questions in a consultation room rather than sitting on a table in an exam room. Two physicians can share one exam room when there are two consultation rooms and therefore they can see more patients in only 1.5 times the space of a normal exam room.
  • An open plan office where all of the care team, nurses, medical assistants, schedulers can work encourages team collaboration and also empathy as each member has much better insight into what the others are doing.
    How Patients Experience Services

    How Patients Experience Services

At the CFI, we learned about projects that have recently been completed (although they were mum on work in progress), like a project to overhaul post-discharge instructions for total joint replacement. This is a hot topic lately as CMS moves to value-based bundles for reimbursing these procedures it’s even more important to manage care outside the clinic, and do to that patients need to understand what they need to do. This is a topic near and dear to our hearts at Wellpepper.

Other projects included exer-gaming for seniors, and Project Mars named as a challenge to completely reimagining the Mayo Clinic experience as though they were building a new Mayo on Mars. This experience spans pre-visit to post visit and includes patient care and the patient’s experience in the physical space.

Mayo Clinic Center for Healthy Living

The Center for Healthy Living is an impressive new facility in the middle of Mayo campus. The Center is focused on proactive and preventative experiences for people who want to take action managing their health.

IMG_2373

Yoga studio with a view

This may include executives who believe health and fitness is a competitive business advantage to people diagnosed as pre-diabetes who are motivated not to become diabetic, to people wanting to regain health and strength after cancer treatment. The Center takes a wholistic approach, and guests (as visitors are called) frequently book a week-long package that includes physical assessment, diet, and stress and spirituality consultations.

The living wall

The living wall

Consultations on diet include cooking classes and nutritional information including how to read labels and understand what’s really in your food.

The Center also houses a spa, which is apparently a best kept secret in Rochester. Throughout the center the design is calming, including floor to ceiling windows and a living wall, and it really feels like a place you can get well.

Clients are sent home with specialized treatment programs and recommendations to support their lifestyle changes permanently. The Center has only been open for a year, and ideally will seen clients coming back year over year for a tune up. It’s definitely a place I’d visit again.

More pictures of the Center for Healthy Living.

IMG_2370

The Nutrition Pantry

Guests learn to prepare healthy meals in this kitchen

Guests learn to prepare healthy meals in this kitchen

Rest with a view

Rest with a view

Posted in: Behavior Change, Healthcare Disruption, Healthcare motivation, Healthcare Research, Healthcare Technology, Healthcare transformation, M-health

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Telling Stories & Busting Myths at Mayo Clinic’s Transform 2015 Conference

We’re just back from Mayo Clinic’s excellent Transform Conference 2015. What struck us about the conference was just how fun it was. Bring together a group of people who are passionate about changing health, and put them in an innovative setting, and some magic happens.Mayo Transform 2015

Here are some other highlights of the conference that made it a stand out:

  • The Host: NPR host John Hockenberry was the MC for the entire conference. His ability to ask hard questions and also provide consistency across the themes and panels was fantastic. He was also able to talk about his own experiences as a patient from an early accident.
  • Mayo Transform THINKBIG Innovation ChallengeStorytelling: The power of story was on showcase from Minnesotan playwright Kevin Kling, to the Pecha Kucha talks, and even the ThinkBig Innovation Challenge, which featured real patients telling their stories to find a match with a startup. The two winning startups (disclosure: we were one of them) also both featured real stories that inspired founders to start the companies. In connecting with other attendees, everyone had a personal health story to share, even though attendees were in the healthcare industries it was the personal stories that resonated the most.
  • Diversity: Very low incidence of panels that were all white men. And not token diversity, these people are leaders in their fields and incredibly inspiring, like Dr. Nadine Burke Harris, founder of the Center For Youth Wellness, and expert on early adverse childhood experiences (ACES) and how they impact future health.
  • Mayo Transform ConferenceMyth Busting: Myths were busted all over the place. Here are some examples:
    • While 10% of people cause most of the costs in healthcare, we’ll all be in the 10% at some point, in the same way that we are in the 10% of spend for other life events like weddings, buying houses, or paying for education.
    • Shame and ritual can both be powerful motivators. Positive reinforcement has it’s place but we always think we’re perfect in the future so today sometimes we need shame to get us to do things we don’t want to. This was from behavioral economist and head of The Center for Advanced Hindsight at Duke University, Dan Ariely.
    • Free telehealth is cost-effective. Or this could also be subtitled: proactive, preventative, and accessible care is cheaper. This is from Oscar CEO Mario Schlosser.
    • Price transparency is not just for patients: how can providers evaluate treatments or drugs if they are unaware of the costs.
  • The Mayo Clinic: It was our first time visiting, and we loved the tours of the Center for Innovation, and the Center for Healthy Living. More on those in a future post.His Holiness, The Dalai Llama
  • Interactivity: From maker labs and nurse maker projects, to the ability to spend time with every speaker immediately after they talked, it was a hands on type of conference. The entire conference was live-streamed as well, and the top tweeter was watching from home!
  • His Holiness, The Dalai Llama: Yes, he was visiting Mayo.

 

Posted in: Healthcare Disruption, Healthcare motivation, Healthcare Technology, Healthcare transformation, Outcomes, Patient Satisfaction

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The (Little) Things That Matter To Patients

Outcome measurement is top of mind for all of us in healthcare these days, and there’s been a lot of talk about whether measures drive the right behavior, with some examples of how patient satisfaction measures can create a “Disneyfication” of the healthcare system, which at its worst, results in animatronic nurses reciting scripts and patients demanding the amenities of a 5-star hotel. When managing towards patient satisfaction in the extreme results in a “patient is always right” mentality and additional or unnecessary procedures are performed on demand we need to question whether “patient satisfaction” or outcomes should be the goal. However, the patient experience with and in a healthcare setting impacts their desire and ability to recover, and therefore can impact outcomes.

Small and not so small things that focus on the patient experience, not in trying to win at patient satisfaction measures, but in really thinking about what will make patients comfortable and cared for to help them heal. At a recent talk at Seattle’s Cambia Grove, a physician who had recently joined Iora Health described their clinics as “places you could actually get better.” Compare how spas are designed to inspire you to health versus your average doctor’s office. A lot of healthcare offices feel like places you could get sick, and they often are.

In their annual report on patient outcomes, Hoag Orthopedics offers patient stories. I was struck by how fondly these patients recalled their hip replacement experiences. There is no way a hip replacement can be pleasant, but Hoag delivers such a high quality of care and for these patients, the hip replacement provided a release from constant pain and function back. As a result, the entire experience was positive.

That got me thinking about my own experiences as a patient and those of my loved ones, and which ones felt that way and which didn’t.

Similar to the Hoag patients, I had a really positive experience when I had an appendectomy, in Russia no less! A few things stand out for me about the quality of the experience:

  • The hospital was extremely quiet and in a city of 13 million this was no small feat. Noise in hospitals is often cited as the number one complaint for patients impacting satisfaction scores, and has recently become a top priority for hospital administrators. Compare the noises of a spa to the noises of a hospital and consider which one you’d want to recover in.

    Luxury hotel or private hospital, the European Medical Center in Moscow

  • As I regained consciousness in the recovery room, hot air was pumped into my bed—general anesthesia lowers the body temperature, but my first sensation on regaining consciousness was of being in a warm cocoon, this continued to my hospital bed which had a duvet on it. This may not seem like much but for someone who is always cold it made a big impression.
  • I wasn’t able to eat anything but my roommate said that the food was incredible (and in Russia no less)
  • The cost for all this value, including not having a burst appendix or other complications: 2 nights was less than $5000!

Contrast this to my mom’s experience during 6 months in a rehabilitation hospital recovering from a rare auto-immune disease. Blankets were flimsy at best and we supplemented them and the pillows to make her more comfortable—granted this was a long stay and adding comfort and personal items was important. While my mom was in the hospital she started losing her thick and still almost black hair. The physicians looked into whether it was side effects of any of the drugs she was taking. However, when she left the hospital it started to grow back. Her family physician diagnosed the problem: poor nutrition. The food in the hospital was of such poor quality that she lost her hair! Although this hospital had a nutritionist that reviewed patient’s diets, to save money they no longer had food preparation on staff and an institutional caterer brought in food. How did this lack of nutrition impact her recovery? Could she have regained strength and function faster with better food?

Two vastly different experiences with things that may seem tangential to care, but are they really? Think back to when you were a child and were sick. What did you want? Comforting nutritious food, and a cozy blanket. While what was most important in both experiences was treating the original problem: a duvet wouldn’t have helped me much if my appendix had burst or surgery was botched, however, the experience of being warm, comfortable, and cared for definitely helped my recovery. I raved about the experience to a friend who thought I was crazy until she had surgery at the same hospital: she didn’t want to leave either.

The way we are cared for impacts our own recovery, and often our desire for recovery. Patients need to feel confident and cared for and with this, they can take responsibility for their own health.

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Measure What You Manage, With Caveats: Thoughts on Surgeon Ratings

When I worked at Microsoft, we managed by the scorecard. The scorecard was meant to provide key indicators of the business health. If something wasn’t on the scorecard, it didn’t get focus from the worldwide sales and marketing groups, and if a product or initiative didn’t get this focus it would die. The scorecard had tremendous power and was a rallying and focal point for a sometimes unwieldy global organization. So powerful was the scorecard that if any errors were made in how something was tracked, it could drive exactly the wrong behavior.

One year, a metric was introduced to measure sales of a new product, in relation to an existing product. The thought was that the new product was a good “upsell” from the existing product so tracking one in relation to the other was a logical measurement. The intention of the metric was to show the new product growing as it “attached” to the existing product. The metric was calculated as:

Product target calculation

 

The sales teams behaved rationally and stopped selling the existing product, because if they sold the existing product, they had to sell even more of the new product to meet their target since the denominator of the equation kept increasing. They met their targets and got their bonuses, but their behavior was exactly the opposite of what the product teams and the company wanted which was for both businesses to grow or at least for the existing product to stay steady while the new one grew.

Last week, ProPublica caused a flurry by releasing a report of complication data for US surgeons. Using their database you can look up any surgeon and find how their patients fared on average for complications after surgery.

As with any measure, it is fraught with controversy about both the accuracy of the data or whether we are measuring the right things. On the surface complication data seems like it’s a good way to track surgeons, and it is if the complications are caused by surgeon error. The problem is that complications are caused by lots of things including patient behavior (for example not caring for a wound properly or taking too many narcotics and falling down after surgery) or by the patient situation, for example, age or co-morbidities. Looking at complication data alone, as Dr. Jennifer Gunter points out eloquently in her blog post, does not give the whole picture. Dr. Gunter’s mother had two surgeries, one that would be recorded as “no complications” and one full of complications. From the raw data, the first surgery looks like a success with a 7-day hospital stay, and the 2nd a failure with a 90-day hospital stay and many complications. (Note that the 2nd surgery could be counted as a “readmission” which would be counted against the hospital.) Regardless, in this situation data alone does not tell the whole story.

In addition to not telling the whole story, looking at complication data alone can drive the wrong behavior, which is surgeons only taking on the “easy” cases, those who are younger, in perfect health, and have no other diseases, for example diabetes. There are many things that patients can do before surgery to ensure successful outcomes like quitting smoking or losing weight, there are things they can’t do, like get rid of a chronic disease or suddenly shed 10 years. Judging surgeons on only complications can encourage them to “cherry-pick” patients so that they have low complications and high scores. In turn these surgeons will be sought out by the “best” patients, and we could end up with a bifurcated system where the “worst” surgeons (looking only at complications) operate on the hardest cases.

There’s a saying that you can’t manage what you can’t measure. It’s important as well to consider what you are measuring, the behavior that you intend to drive, and the long-term implications of it . Healthcare is making small steps to become more data and outcome-driven and we need to encourage and commend that. At the same time, let’s make sure we are looking at the right metrics.

Posted in: Behavior Change, Healthcare Policy, Healthcare Research, Healthcare transformation, Outcomes

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Reducing Readmissions and Costs for Total Joint Replacement

Last week CMS announced a major new initiative for Total Joint Replacement, aimed at both reducing and reconciling costs. Total joint replacements are predicted to increase at a rate of 30% to 2020. Demographics are the major driver: people are getting joint replacements at a younger age, and may have more than one in their lifetime. On the one hand, more active baby boomers have put greater strain on their joints by running marathons, and on the other an overweight population is putting more strain on their joints just by walking around.

Since the demand is increasing, and the costs fluctuate wildly, up to 100% by Medicare’s estimates, the opportunities to look for costs savings and to reward based on outcomes is key. Like other bundled payment recommendations, Medicare is looking at the 90-day readmission rates and also using a carrot and stick reimbursement approach.

“Depending on the hospital’s quality and cost performance during the episode, the hospital may receive an additional payment or be required to repay Medicare for a portion of the episode costs.”

While private payers often follow Medicare, this is one area where Medicare cites that it is following a trend that has already been piloted in private scenarios, most notably with self-insured employers contracting directly with healthcare systems on fixed-price knee and hip replacements, like the deals Walmart and Lowe’s have struck directly with hospitals.

Screen Shot 2015-07-12 at 4.00.51 PMThe American Hospital Association is also ahead of the curve on this trend, and they published some recommendations in a 2013 report entitled “Moving Towards Bundled Payment.” In it, they also noted the wide fluctuations in pricing between health systems for total joint replacement, and also that 33% of the costs of a total-joint replacement come from post-acute care.

Screen Shot 2015-07-12 at 4.01.13 PM
Our research has shown that a large driver of these costs is discharge setting related. While the majority of patients do better when discharged to home, they were being discharged to skilled nursing instead as a “belt and suspenders” type of back up. Discharging to the right setting, can improve patient experience and lower costs. However discharge to home requires the right type of patient tools. Patients need to have great educational materials, the ability to track their progress, and the ability to get remote help if they need it. This is something we’re passionate about at Wellpepper, and we are working with a number of leading health systems that are moving to bundled payments to help them digitize the pre and post surgical instructions and collect patient reported outcomes. We’d like to be part of the solution for both patients and providers as we move to these new models of care and reimbursement.

The Medicare proposal is open for public comment for the next 60 days. It’s over 400 pages long, so you may want to print a copy and take it for a little light beach reading.

 

Posted in: Adherence, Aging, Behavior Change, Health Regulations, Healthcare Policy, Healthcare transformation, Outcomes

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The Case for Patient Video in Doctors Visits: Take a Selfie and Call Me In the Morning

The selfie culture and our desire to photo-document every aspect of our lives has started to influence healthcare as well, and patients want to be able to record their doctors visits. The concept is so prevalent that it’s making headlines in the mainstream media.

Patients Press the Record Button, Making Doctors Squirm” from the Washington Post

Why You Should Record Your Doctor’s Visits” from Forbes.

Having a recording of a visit ensures that you don’t miss any information, and you can review it when you get home and are able to provide more attention to the topic. Much of what is said in a doctors visit is missed by patients, by some accounts between 40 and 80% is missed, and an additional half of that information is remembered incorrectly. As we learned during a course from the Institute for Healthcare Improvement, often healthcare providers are not trained in making sure the message is received.

When we ask patients about their experiences, they tell us that they thought they understood the instructions but realized when they got home they really didn’t retain enough or understand enough to comply with the instructions. Patients are often intimidated by healthcare personnel, worried about wasting valuable visit time with questions, or worrying about how what their being told will impact their lives, for example, who will walk my dog when I have my hip replaced? Is it any wonder that the information isn’t landing?

Patient Record on Parking

Patient record in parking garage of major health system

When handout instructions are available, they are often forgotten by patients, or confusing. One healthcare organization we work with conducted an audit of all their patient handouts and discovered that they were at an 18th grade reading level. The recommended reading level for health information is fifth grade, and yet these instructions required a graduate degree!

Patients have a seemingly simple solution to this: record their doctors. Doctors on the other hand have been warned about PHI and HIPAA, so a common ‘workaround’ is to record patients on their own phones. Legal departments hate this because then the patient has a copy of their prescribed instructions but the health system does not. Liability aside, it doesn’t result in good care if everyone is not working off the same information.

Including patient video as part of a HIPAA compliant digital treatment plan is a great way to solve this problem. Patients have a better experience and the health system is able to keep good records.

Patient video can cueing or instructions that is unique to that patient, and they show the patient’s actual experience whether that’s in wound care, using a medical device, or physical therapy. Patients feel a greater sense of connection and accountability to care plans when they are personalized and customized.

For complex instructions like wound care, using medical devices and durable medical equipment, and physical and occupational therapy, patients feel more confident that they can repeat the exercise or instructions at home when they see video of themselves doing it.

There are so many benefits to including custom video as part of a patient’s care plan. The technology is here today, it can be delivered in a HIPAA compliant manner, and it can be stored and easily retrieved. The challenge is that while patients are ready for this, health systems aren’t and the answer is often ‘no’. The risks to the health system, if video is delivered as part of an overall digital patient treatment plan solution are low, but the potential benefits to care are large.

We’ve tracked the evolution of the ‘consumerization of IT’ through other industries. Some have said it can never happen in healthcare, but this is a great example where patients starting to push the envelope and use technology in their care. Let’s hope they are able to convince their doctors as well.

Posted in: Adherence, Health Regulations, Healthcare Disruption, Healthcare Policy, Healthcare Technology, Healthcare transformation, M-health

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Personal or Population Health? Big Data or Small Data?

Seattle Health Innovator's meetupJune’s Seattle Health Innovator’s Meetup topic was on Innovations in Population Health Management. Interestingly much of the discussion from panelists circled back to the individual patient. It seems that much of this was because the great promise of big data analytics in healthcare and automation and economies of scale through electronic medical records have not been realized. The audience consisted of entrepreneurs building solutions in this area, and innovative and entrepreneurial people within health systems.

The event, at the sleek new Cambia Grove healthcare meeting space, was kicked off by Dr. Wellesley Chapman, Medical Director Innovation and Development at Group Health. Dr Chapman set the stage by defining population health in a highly inspirational manner by referring to The Gates Foundation mission that everyone deserves to live a healthy and productive life. Narrowing in a bit more Dr. Chapman talked about the influences of good health on a population. Interestingly, although population health is largely thought of as a health system problem, the formal medical system only has a 20% influence on the health of a population and a person. Socio-economic factors have a much bigger influence, things like building walkable cities that encourage activity and community, access to healthful foods, and education. Unfortunately with healthcare representing 18% of the US GDP, there is a misallocation of funds to the clean up of problems versus infrastructure that will affect the well-being of the whole population. However, even though care delivery is a small part of the overall picture and influencers of health, Dr. Chapman enthusiastically encouraged the audience to do what they could to affect change.

The meet up continued with a panel discussion moderated by former Group Health VP of Marketing and now patient engagement consultant, Randy Wise and featuring:

When considering a population health strategy, key factors the panel felt were important were lead time to implement, expected outcomes, costs to patient and payer, and the overall patient experience. Patients are concerned about the quality of their lives, and this needs to be addressed at the primary care level, however, most health systems do not have a primary care strategy. Primary care is reactive rather than preventative, and reactive care is not usually focused on patient goals. Since the health of a population is so varied, at the primary care level, panelist thought “everything could be considered population health” making it difficult to pinpoint specific solutions for care.

When asked about whether big data was improving population health, panelists were negative to neutral, citing Excel spreadsheets used to review data, and the opportunity to know a lot more about patients. However this again came back to the specific saying that the intervention is all about the relationship between patient and provider and asking whether we are enabling patients to follow through with recommendations. (At Wellpepper, we would say there’s a great opportunity to improve here based on many of the care plans and instructions we’ve seen.)

Seattle Health Innovator's MeetupDr. Levine from Iora talked about his experiences training residents in listening skills and the payoff. Compared to a common approach of telling the patient they have limited time and to focus on the top issue, Dr. Levine advocated listening first, ask the patient to recount all their concerns, make a commitment to truly listen and hold the information the patient provided, and then follow up on the most pressing issues. Although the residents were skeptical, this approach yielded significantly faster follow-up as key information wasn’t being uncovered at a later date.

Events like this provide a great opportunity for those enthusiastic about changing healthcare to exchange ideas, and especially for entrepreneurs to learn practical advice from those in the trenches delivering care and trying new models. The big takeaways are that the promise of big data in healthcare is yet to be realized, and because of that population health tools may not be as effective as they could be. While the focus on patient personalization, customization, and meeting the needs of the individual are key, we need to figure out new ways to scale to solve this great problems in health.

Posted in: Behavior Change, chronic disease, Healthcare Disruption, Healthcare motivation, Healthcare Research, Healthcare Technology, Healthcare transformation, M-health, Seattle

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Advancements in Diabetes Research: A Salon Dinner for JDRF

This past week I had the opportunity to attend a salon dinner at Seattle’s lovely Canlis hosted by Derek Rapp, CEO of the Juvenile Diabetes Research Foundation (JDRF).

Derek Rapp

Derek Rapp, source http://www.stltoday.com/

Unlike Type 2 or 3 Diabetes, Juvenile Diabetes, or Type 1 Diabetes is an auto-immune disease so while the symptoms are similar to some of the other two types of diabetes, research into causes and prevention is more closely aligned with other auto-immune diseases like multiple sclerosis. Many autoimmune diseases are thought to be triggered by viruses, and there are some thoughts that this is also true for Type 1 diabetes.

Although this was an informal dinner, Rapp provided some interesting updates to the work the JDRF is doing to find the causes and a cure.

Most of the discussion centered around advancements in care, as Type 1 diabetes care is quite onerous for people who live with it, most of whom have onset of the disease in childhood or early adulthood. Rapp himself has one son who has Type 1 diabetes and another who carries the marker, and many of those in attendance had children with the disease. Type 1 Diabetes requires daily blood tests, hawk-like attention to diet, and insulin injections: quite a burden for anyone let alone children and young adults.

Like all areas of healthcare, diabetes care also has the ability to benefit from big data and from personalized data both for research and to provide better control. An example of a medical device breakthrough that works with both types of data is the artificial pancreas, which will ultimately mimic the function of the pancreas to control blood sugar levels.

Another place information flow can benefit is for relatives, which you can imagine is crucial for helping parents help their children. Providing alerts automatically when blood sugar spikes or drops and enabling parents to see how their children are doing when away from them is another benefit of continuous glucose monitoring.

Other advancements that Rupp shared with the group were glucose responsive insulin that waits in the body until there is excess glucose before being deployed. It works by packaging the insulin within the body and releasing based on reading of a “glucose tag.” Another study in progress is encapsulating a device for insulin within cells so that it can be surgically implanted and not rejected by the body.

The audience was visibly excited by hearing about these developments, but their spirits were dampened slightly when Rapp reminded them that it takes $1B and 14 years for a drug to get to commercialization. One guest also asked whether the same drug companies that made significant revenue from insulin were incented to come up with other solutions. However, between the ability of big data to find connections between information and the current speed of genomic research, Rapp was hopeful. He believes that will be possible to prevent Type 1 diabetes before a cure is found.

Canlis Private Dining Room View

Canlis Private Dining Room View, Source Seattle PI

Posted in: Health Regulations, Healthcare Disruption, Healthcare Research

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Telemedicine Requires Optimism and Patience: Dispatches from American Telemedicine 2015

The 21st annual American Telemedicine Conference wrapped up last week in Los Angeles. While there were amazing patient success stories, and a group of people dedicated to the success of telemedicine, it was slightly depressing that after 20 years, there are still people questioning the value and calling for more data as well as no consistent reimbursement except in rural settings. Considering that we can order just about everything at 3am from the couch in our pjs, it’s amazing that we still require sick (and possibly infectious people) to find their way to the doctor rather than offering at-home options.

Here are a few high-level impressions of the event:

  • The exhibit hall was smaller this year. A number of people commented on this, and there seemed to be two reasons. First, there was an impression that this conference was too close to HIMSS for the big companies to get a booth shipped between the two conferences. This is partially good news though: telemedicine has gone mainstream into the biggest health IT conference.

The second reason might have been that some vendors are struggling or have left the market. This is purely based on my observation but I didn’t see as many “all-in-one” hardware and software vendors, which makes sense when video conferencing is available on every computer and every mobile device. As well, vendors that sold “equipment” for telemedicine, like specialty carts were also absent. Vendor consolidation may also have accounted for some of this as well.

So while a smaller tradeshow floor may have indicated a problem at first glance, it also points to market maturation.

  • The reasons for implementing telehealth are changing from purely rural access and access to specialists to consumer preference. However, reimbursement has not caught up with this and most consumer-facing applications are cash-pay by the consumers. Lack of reimbursement despite the evidence supporting telemedicine remains a sticking point. Although I didn’t attend any policy specific sessions, reimbursement came up in every session I did attend.
  • Tuesday morning’s plenary featured a lively debate about consistency in telemedicine. One camp held the position that without consistency of care we could not judge the validity of telemedicine, while the other asked why we would hold telemedicine to higher standards than the current system. While there is something to be said for not making the same mistakes in a new model, it did seem like some of the people in the consistency camp were using this as a reason to stall implementation.

Consistency in Telemedicine

  • A new consumer-facing program by Southwest Medical Associates showed that telemedicine was no-less consistent than in-person, pointing out that antibiotic prescribing rate were identical for UTIs treated via telemedicine or in person. They also discovered that 70% of their telemedicine patients were women, which is not surprising given that women still bear primary childcare responsibilities, and getting to a doctor with kids in tow is not easy.
  • In many cases, telemedicine was not seen to replace rather to augment existing care, especially for chronic disease patients where additional check-ins help them manage care and stay healthy. However, there were other examples of using telemedicine, especially after hours, to treat and triage issues to keep people out of the ER so that the ER could focus on the people who really needed to be there.

We create a nine-to-five system

  • In addition to providing access to specialists and specialty care telemedicine can provide basic access to care. Proponents pointed out that there are many areas of the country, where there is no access to primary care physicians, for example there are 30 counties within Texas with no PCPs. Of course this brings up another sticking point for telemedicine, which is licensure. Without an easy way for healthcare professionals to practice cross-state, it’s hard to solve this problem. In the consumer scenarios this is even more ridiculous, as many consumer-facing telemedicine solutions required that the first check for the patient be which state they resided in. Personally, I’d like to think that if someone has qualified to practice medicine in one state in this country they are competent in another.
  • One of the most touching uses of telemedicine was for pediatric palliative care. There are very few palliative care centers for children, and they are also more comfortable at home. UC Davis Medical Center with the George Mark Children’s House used telemedicine to give families access to nurses remotely. Nurses at first expressed skepticism but were astonished at how much compassion they could share through a video call.
  • Telemedicine decreases no-show rates. Not surprisingly The Cleveland Clinic saw 100% show rates with patients when they did a video follow-up from surgery rather than being asked to drive 100 miles to a visit.
  • Overcoming internal skepticism was often the biggest barrier. Marshfield Clinic physicians didn’t offer telemedicine to their older patients initially because they thought that they wouldn’t want it. Again, not surprisingly they did as older people often have greater challenges getting to the office, especially if they have had surgery or are no longer able drive. The idea that older people don’t want or can’t use telemedicine is another myth that needs to be dispelled for wider adoption.

Looking forward to 2016, let’s hope that the sessions show fewer pilots and more system-wide implementations of telemedicine, an increased focus on patient preference for telemedicine, and a decrease in the regulatory barriers. The best sessions I attended featured real patient stories, while HIPAA is a concern, patients who had positive experiences were more than willing to have their stories told. Let’s hope more of those move us all forward.

For a selection of our live tweets from sessions, see our Twitter feed.

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