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The Future of Mobile Healthcare is Like a Warm Marshmallow

As we look towards a new year, we thought it was time for a few predictions:

  • Patient satisfaction will be the most important focus of the Triple Aim
  • Patient reported outcomes will be combined with full-body scanning for key signs
  • Emotional health will be as important as physical health, and mobile health companions will focus on both
  • The standard 10-point pain measurement scale will still be in active use
  • Mobile healthcare will move on its own, and even fly

Big Hero 6 logoHow do we know this? Big Hero 6: Disney’s treatise on the future of healthcare delivered by robots. Okay, maybe it’s about the bond between brothers and how ordinary brilliant scientists can become superheroes but given that one of the main characters, Baymax is a personal health companion, we believe Disney is also trying to tell us something about the future of healthcare.

Baymax is a huggable robot and personal health companion who can scan, diagnose, and treat humans and cannot be ‘turned off” until his patient is “fully satisfied with his or her care.” Baymax takes the patient satisfaction pillar of Triple Aim to the extreme. He can also do kung-fu, packs a mean punch, and can fly.

Baymax: I fail to see how flying makes me a better healthcare companion.

Hiro Hamada: I fail to see, how you fail to see that it’s awesome!

Baymax is activated when he hears someone say “ow” and uses a standard 10-point pain scale to first identify problems. Given his ability to review vital signs by scanning, we have to assume he’s asking this question for the emotional benefit of patient rather than a real data point.

Baymax: Hello. I am Baymax, your personal healthcare companion. I heard the sound of distress, what is the problem? On a scale of 1 to 10, how would you rate your pain?

Baymax Big Hero 6

Like a futuristic country doctor, Baymax understands that a patient’s health and well-being is affected by his or her emotions. At one point he tells his young charge:

Baymax: “It is all right to cry, crying is a natural response to pain.”

While he is only activated in response to injury, once Baymax is caring for a patient, he anticipates future issues, and is aware of what’s happening before the patient.

Baymax: “You have sustained no injuries. However, your hormone and neurotransmitter levels indicate that you are experiencing mood swings, common in adolescence. Diagnosis: puberty.”

He is also prepared for health emergencies.

Baymax: “My hands are equipped with defibrillators. Clear!”

Unfortunately, in this situation, the patient was using a figure of speech about having a heart attack, and this is one central problem with this future mobile health: Baymax is naïve and doesn’t understand human emotion. As well, in his desire to help he asks his young patient if certain activities will make him feel better even though they are potentially ill-advised. Baymax 2.0 will need to have some situational learning skills and not confuse patient satisfaction with the “customer is always right” motto.

However, like a real healthcare provider, Baxmax has taken an oath not to hurt humans and he fuBaymax hug Big Hero 6lfils this to the best of his ability, even when the humans try to get him to do otherwise.

So what is Disney trying to tell us about the future of mobile health? Based on the example of Baymax, we’d say in the future it needs to be:

  • With you when you need it
  • Focused on the needs of the patient
  • Summoned by the patient
  • Comprehensive
  • Focused on patient satisfaction
  • Huggable

The last one can’t be underestimated. One of the great appeals of Baymax besides his childlike naivety, is that he looks like a giant marshmallow. Mobile health needs to be patient-friendly and approachable. People don’t like to be reminded that they are sick and medical apps with medical names too often do this. For us at Wellpepper, we have a dog as our logo for this reason. We want to be approachable, friendly, and supportive to patients. We’re going to be with them on their mobile devices so they’d better want to have us there with them, just as Hiro has Baymax.

Happy Holidays from all of us at Wellpepper! All the best for 2015.

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

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Texting to Better Health

This post is guest authored by freelance journalist Fiona Hughes.

Can text messaging improve patient health outcomes? Judging from presentations made during a seminar at the sixth annual mHealth Summit held in Washington D.C. Dec 7-10, the answer to that question is a resounding YES.

In a seminar entitled “Evidence, Challenges and Successes in Text Messaging Programs,” three speakers discussed their unique experiences using text messaging (SMS) programs to improve health outcomes for patients. Key to any success, all three noted, was patient engagement to empower patients to cultivate and sustain positive lifestyle behaviors.

Wellpepper's Secure Text Messaging

Wellpepper’s Secure Text Messaging

But why use SMS? The answer is obvious. Almost everyone owns a cell phone. In fact, 90% of American adults own a cell phone, according to the Pew Research Center.

Seminar speaker Vanessa Mason, a strategist with ZeroDivide.Org, provided even more compelling statistics: 81% of cell phone users text, 97% of texts are read, 78% of cell phone owners make less than $30,000 a year. These stats may explain why SMS is rapidly becoming a means to reach out to diverse populations because of the low cost and ubiquitous nature of mobile devices. Other studies have shown that for low income populations a mobile device is their only way of accessing the Internet.

Dr. Stephen Agboola, a research fellow at the Boston-based Centre for Connected Health, presented his findings from a 2-arm randomized controlled trial called Text to Move, which sent personalized text messages to improve physical activity (PA) among patients with Type 2 diabetes. According to Dr. Agboola, PA is one of the more difficult behaviours to change among Type 2 diabetics.

Patients in the intervention group were sent 60 messages a month for six months (one in the morning, one in the evening) of practical educational and motivational information tailored to a 4th grade level (e.g. sample morning message: As of 08:27 AM, you were active for 45 minutes – 75% of your goal. Reply HELP for help…)

Dr. Agboola, who has expanded the trial to four more health centres associated with Massachusetts General Hospital, noted that the low cost and design of the messages makes it possible for the program to be easily scaled across a diverse patient population regardless of age, educational, economic or ethnic background and sustained over a longer period of time.

Results of the Text to Move included 3-pound weight loss in the intervention group, a significant decrease in HbA1c, an increase in average daily step counts and 78% program engagement.

Dr. Agboola’s conclusion: “Text messaging can be used to improve patient outcomes.”

***

In his brief presentation, business and research analyst Troy Keyser of the Centre for Connected Health compared various techniques in participant recruitment in texting health intervention in a clinical setting.

He cited the example of Quit Now, a free service to help people live tobacco free. Techniques used to get patients to enroll included postcards left in the clinic (1.6% conversion rate); An opt-in text (200 messages were sent, 7 patients enrolled for a 3.5% conversion rate); and finally a provider-led approach (126 patients were asked to enroll by their physician, 126 enrolled for a 100% conversion rate).

***

ZeroDivide’s Vanessa Mason expanded further on enrollment methods and offered a how-to-guide for text messaging (recruitment, operational needs, technological specifications, content development, evaluation). Some key points included:

  • Assess target audience
  • Involve patients in message content
  • Segment messaging as necessary
  • Evaluate patient expectations, needs and skills
  • Assess self-management goals
  • Encourage peer support for participation
  • Reinforce positive behaviours to support health goals
  • Mason’s full report “Texting for Better Care Project” can be viewed at zerodivide.org. It examines text messaging interventions for health care delivery in the safety net for underserved populations.

Mason shared the story of ZeroDivide’s work with church congregations in Atlanta, Cleveland, Columbus and Dallas that are using SMS to improve health outcomes for Africa-American women. According to the Pew Research Centre, Latinos, African-Americans and people between the ages of 18 and 49 are more likely than other demographic groups to access health information on their mobile devices.

The two grassroots programs — Mobilize-4-Fitness and Text4Wellness — use culturally appropriate SMS to provide information about physical activity, nutrition and wellness. The initiatives specifically target female congregants between the ages of 19 and 55.

“Given that many African-American women see being part of a faith-based community as a bedrock to their social lives, this is a great opportunity to leverage the assets that are already in their church, including fellow congregants and the health ministers, to achieve better health outcomes,” Mason writes.

Final results of these programs will be published in May 2015.

One issue, important to all health organizations that want to use texting with patients for clinical purposes, PHI protection, was skirted by the panelists. One said that no PHI was sent back and forth, however, this is doubtful if a patient is sending their outcomes. SMS holds great promise but information must be sent in a secure manner.

As the digital revolution shakes up the healthcare system and changes the way medicine is practiced, it’s not hard to imagine SMS becoming a standard tool for physicians to engage patients to help them manage their care. But it’s important to be mindful of the digital divide affecting underserved communities, especially in the U.S. healthcare system, which — as ZeroDivide noted in a recent report on eHealth in underserved populations — is known for its “persistent disparities in quality of and access to care.”

 

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

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Choosing the Right M-Health Tools for the Job

“People will share about their diarrhea on Twitter but they won’t use an app called ‘Diarrhea Near Me” said John Brownstein, Director of the Computational Epidemiology Group at Children’s Hospital Boston and founder of HealthMap, on why patient reported outcomes alone won’t solve our data problems in healthcare.

The third day of the M-Health conference coincided with the first day of the Global MHealth Forum, and the keynote presented the most aspirational view of the three conference keynotes.

HealthMap, which was recently acquired by Booz Allen, focuses on mining public data to predict epidemics and to chart the course of infectious diseases. We’ve seen this before with Google Flu Trends, but HealthMap goes beyond what people are searching for crawls over 200,000 websites globally including social media networks, news, government sites. HealthMap uses natural language processing to take it a step further by comparing this data to satellite images to see whether quarantine is working. While HealthMap considers itself a public data set for health, Brownstein is clear that partnerships with private sector are the only way to scale health programs, and that these programs must have a business model. Texting for health scenarios that partner with carriers are a good match. The carriers are looking for new customers, and SMS programs have proven to be very effective in developing countries. In a twist on that model, Orange partnered on a program in Liberia where health workers got free data access to any government health information sites and then used their own data for Facebook and Twitter, capitalizing on human nature that while we might buy our devices for work we spend a lot of time goofing around on them.

Validating Clinical Data To Reinvent Medicine

The second half of the keynote was a panel discussion focused more on how to deal with all of the medical data coming in, and reflected some of the concern and disappointment with sensors and quantified self movement. Even though the hype and funding for these activity tracker and sensor companies does not seem to have cooled off, there are a few issues that the healthcare industry has identified:

  • Too much data that we can’t make sense of. We haven’t previously been capable of tracking people’s vital signs 24/7 during daily life so it’s impossible to know what a “normal” data set looks like.
  • The novelty of trackers wears off after you calibrate. We’ve written about this before. Once you know how many steps something is or how many calories you’re burning, you don’t need to keep wearing the tracker.

Of course, there is also the often-cited issue of doctors not having the time, interest, or financial incentives to look at all this data.

The solution was to look at tracking in context of a care path or a specific issue, and to figure out how to provide insight along with the data both for the consumer and for the healthcare provider. Panelist Bryan Sivak, CTO of the US Department of Health and Human Services said he didn’t just want to know that he slept poorly but why he slept poorly. Sivak also outlined what he saw as the barriers to MHealth really taking off:

  • Questions of data ownership
  • Privacy and data protection issues
  • Standards of care
  • Incentives for providers
  • Design for clinician workflow

None of these are particularly new or daunting, which again points to the need for solid implementation and adoption evidence from m-health vendors.

James Levine, Professor of Medicine at the Mayo Clinic, wanted more thought put into what data we use and why, and provide the example that many over the counter blood pressure readings are not valid. Levine would like mobile health applications evaluated by the following criteria.

  • What is the medical benefit?
  • Is it cost-effective? What is the return on investment?
  • Is data interoperable? Is data protected?
  • Can you analyze the data the application collects?
  • Can you take action if you need to address something based on patient entered data?
  • How is it reimbursed?
  • Is it constantly improving based on patient input?

Teri Pipe, Dean of ASU College of Nursing, and as the moderator pointed out the only nurse on a panel at the conference, said that the promise of m-health is being able to know when to bring a patient into a clinic for treatment, and allowing them to stay at home when they want it. We would add to that, how do you help them manage when they are at home. She also felt that mobile health held great promise in the hands of nurses who can prevent ER visits from the field while being connected to the healthcare system via mobile. Teri used the example of fire departments having nurses on staff to treat minor trauma and injury onsite rather than sending people to the ER.

This was our first MHealth Summit, although it was the 6th annual, so we can’t compare to previous years. It seems like the overall tone was of cautious optimism. Attendees, panelists, and presenters all firmly believed in the promise of mHealth but there was not enough demostratable evidence, and certainly not enough examples of health systems, payers, and m-health companies overcoming the barriers we have in the market. Hopefully, as the first day keynote asked, 2015 will be the breakout year for MHealth, and we’ll see more success stories, ROI, and clinical validation at the summit next year.

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

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Will 2015 Be the Breakout Year for M-Health?

While on the one hand, many are proclaiming 2015 to be the year that M-Health finally becomes mainstream (and certainly CMS’s announcement that they will pay $42 per month for remote care for chronic diseases helps with that), the opening day keynote at  the M-Health Summit last week at the Gaylord National Harbor Convention center, seemed to suggest we are in the trough of disillusionment.

In particular Walgreens Chief Medical Officer Harry Lieder and Partner’s Center for Connected Health Director Joseph Kvedar were pragmatic to almost pessimistic about how mobile health would be adopted by consumers, healthcare systems, and payers. While being realistic about how mobile health can help, who can benefit, and who will actually pay for it is a conversation we all need to be having, the tone of the opening day keynote was not so much about celebrating successes but shoring up the audience to continue the good fight.

Walgreens CMO, Lieder outlined four areas where he thought that M-Health could have an impact across the care continuum:

  • Health, fitness, and well-being
  • Self-diagnosis
  • Acute care
  • Chronic care

Source: M-Health Summit

He then went on to debunk the myths of the quantified-self, that is that consumers will take their health in their own hands if presented with information. He also talked about why wellness is not popular with insurers and employers: the impact of wellness programs is generally only in the long-term, for example 10-20 years, and most employers and insurers hope that any individual won’t be their problem for that long. Taking the short term approach, Lieder said there were really only two ways to have a successful m-health startup today: enable people to bill for an existing CPT code or show significant cost savings to the healthcare system in 12-18 months. This is the current reality of the healthcare system, but certainly not how we’re going to drive change. CPT codes are backward looking not about new ways of delivering care, and while ROI needs to be forthcoming, managing patients over their lives needs to be the goal of the healthcare system.

So with this grounding in the somewhat depressing realities of today’s situation, Lieder then announced that Walgreens has partnered with MDLive to offer in-store telemedicine visits. Their recognition that consumer health alone doesn’t change behavior and that patients need support prompted the introduction of this new service, Lieder said “We need people available behind the device to change behavior.” If you can’t fix the system, reinvent it! One speaker called pharmacy the “last mile” that is, the patient loses connection to the health system at the pharmacy so brining the health system to the pharmacy might be the solution.

Joseph Kvedar of Partners.org asked if 2015 would be m-health’s coming out party but said that until applications hit certain key criteria we won’t see widespread adoption. He asked that application builders make m-health apps usable, social, personalized, and with relevance to everyday life. From a patient’s perspective applications should know the patient, engage the patient on his or her terms, and empower the patient. Kvedar did not seem to think that applications had nailed these things yet, especially in the area of usability and that we don’t get this right (and soon) m-health will “go down as another tech bubble.”

Joseph Kvedar

Source: MHealth Summit

M-health has had a lot of hype, and while this keynote provided some grounding in the reality of the market today, it seemed that this might have been a better keynote for the second or third day. Day one, it would have been nice to hear some success stories. After this keynote, I attended a session where one medical researcher spent most of the time explaining how she knew better on how to build good software than anything out there. We m-health entrepreneurs definitely need to get better at telling our success stories. It seems the press to date has been too much hype and not enough clinical substance and ROI to make our case.

At Wellpepper, we predict that if m-health companies can show real clinical evidence, tell real patient stories, and find partners in the ACOs and other organizations that are passionately trying to change healthcare in this country, then 2015 really will be the breakout year for M-Health, and next year’s keynote will see us out of the trough of disillusionment and firmly into real value.

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The Connected Patient Is Here

After either a realistic or pessimistic Day 1 keynote, depending on whether you’re a glass half full or half empty kind of person, Day 2 at the MHealth Summit started with a difficult topic but a much more inspiring message and continued with presentations stressing that patients are already connected and engaged. A bonus for those of you who are counting (XX in Health, Halle Tecco), is that ¾ keynote speakers on this day were women.

Confronting Mental Illness Online

First up was Jen Hyatt (@jennyhyatt) CEO and co-founder of Big White Wall, and online community for mental health. Big White Wall provides an online community for people who are mentally distressed and sometimes suicidal. Jen relayed a heart-breaking story of a possibly preventable suicide, if the person had just had an anonymous place to share what he was feeling. Big White Wall provides a community of people who are trying to self-manage their mental distress with support from clinical process and staff. It does so confidentially and anonymously. Anonymity is a key part of how Big White Wall works. People are more comfortable sharing when they know they won’t be judged and sometimes talking to a machine rather than a person can provide that, to illustrate, Hyatt shared the story of the young autistic boy who made friends with Siri. Hyatt has compared the accuracy of the data behind Big White Wall to predict depression and suicide risk to that of standardized tests, and says that interactions on Big White Wall provide enough information to be as accurate as the tests. Considering the difficulty of getting people to take these tests, and especially those who might not be seeking help for mental illness, this holds great promise for the power of patient (or people) generated data.

Serving the New Connected Patient

Source: MHealth Summit

The connected patient is already here, and she’s a millennial says Janet Schijns, Vice President of Global Verticals and Channel Marketing at Verizon. Schijns used a recent ER visit by her daughter, a college student to elaborate how patients are outpacing hospitals when it comes to digital care. Schijns daughter sprained her ankle badly, while waiting for a nurse to return with discharge instructions, she had already found and watched a video on how to navigate the world on crutches, ordered groceries online so she wouldn’t have go out, and researched how she would be able to get around campus. Schijns posits that healthcare organizations are spending dollars in the wrong areas online because they don’t really understand what patients are looking for. She talked about how patients are creating their own content through community sites like Patients Like Me and filling in gaps in the information the healthcare system is providing.

 Email Is Our Killer Application

Christine Paige, Senior Vice President of Marketing and Internet Services from Kaiser Permanente helped all m-health entrepreneurs in the audience breathe a sigh of relief when she said that Kaiser was not going to get into the m-health app business and instead focus on working with companies that help them improve the patient provider relationship. Paige called email Kaiser’s killer app for two reasons, one is that patients are not able to absorb key information when they’re in the clinic, especially if they’ve had a difficult or surprising diagnosis and second because they want convenience and a connection to their physicians. Kaiser’s patients who engage online are healthier, and only 1/4 emails results in a doctor’s office visit.

While personalized medicine is a hot topic these days, Paige warned against personalization trumping patient privacy and the risk of personalized recommendations being wrong. That is, patients using technology trust their physician with the information, but not necessarily if an application starts intervening and providing recommendations based on that data.

While the day 2 keynote was optimistic about the promise of m-health, it was definitely cautiously optimistic. Patients and providers are still feeling their way through the role of technology in communication and automating care.

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

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Healthcare is part of our supply chain: The Boeing Company

The Health Innovator’s Collaborative sponsored by the University of Washington and the WBBA is entering it’s second year and continuing to gain momentum bringing together providers, payers, and health innovators from education, public sector, and industry to discuss hot topics in health. This week marked the second talk in the new season, delivered by Greg Marchand, Director of Benefits and Policy Strategy at The Boeing Company.

BoBoeing is a data-driven company that makes big bets and takes big risks to bring their products to market. This philosophy extends to how they provide employee benefits, and Marchand and team have taken a data-driven approach to healthcare benefits. In the same way that the principles of lean, data-driven decision making, and cost/risk benefit drive decisions across Boeings supply chain, the same rigor has been applied to healthcare benefits. Marchand knows that Boeing’s human resources are a key part of their success and wants to ensure they are working at optimum productivity. The best way to do that is to make sure they are healthy and that they receive the best benefits available. Quality, innovation, advocacy, and service are the influencers of Boeing’s strategy and the differentiators of their benefits.

Boeing made headlines for their “ACO” approach where they contract directly with healthcare providers and negotiate for service and Marchand came to the Health Innovator’s Collaborative to describe how they did it and why this is the model for the future.

Washington Hospitals, Boeing Strike ACO Deal

Boeing Signs Shared Savings Deal With Washington Hospitals

Boeing-Marchand2Marchand kicked off his talk with a personal example of a “defect” in the healthcare system, to his mind a result of healthcare organizations not having a consumer focus. A few years ago, his wife needed to make a doctor’s appointment for their child. She called for an appointment and was told that she could book a time two weeks from that day, which happened to be a Tuesday. Depending on whether you’re going to see a specialist, 2-weeks could be considered an acceptable wait time for an appointment, however, that wasn’t the problem. The problem was that if she wanted to book an appointment for another day, say 2 weeks from Wednesday, she’d have to call back on Wednesday to book it. Marchand asked the audience to try to imagine what might happen to a retailer like Nordstrom if they used this archane booking system for their personal shoppers. The system had a flaw, and it’s this type of flaw that Marchand and team are on a mission to correct.

boeing-marchand4To do so, they have partnered with UWMedicine and Swedish/Providence in Washington State to provide care for Boeing employees. They also rely on Cleveland Clinic as a Center of Excellence for cardiovascular care. While Marchand says that he doesn’t want employees to have to travel for care, he also wants them to have the most effective care, which is what drove the partnership. (You could tell that this statement was specifically aimed at attendees from the event’s host: the subtext being that it was possible for them to win this business for Boeing.) Boeing’s “triple aim” is quality, experience, and cost with the goal of improving the employee experience and passing any savings as a result of the new ACO model onto employees. Their expectation is that healthcare partners have these same goals and the same data-driven approach. The challenge for Marchand is the need to find partners in all states where Boeing has employees. While Boeing has a lot of clout with $2.5B in annual healthcare spend covering 500K employees, they don’t have the same economies of scale in all states based on employee number. (ACOs looking to pilot new ideas and test data-driven approaches should definitely consider reaching out to work with Boeing: they are looking for solutions.)

Finding the Defects

Marchand’s focus is on continually improving defects in the system and that includes the patient/provider relationship: making sure patients do what they are supposed to do. It also includes using the appropriate forms of communication and care for the situation. Here he gave two examples: using a house call service from Seattle-based Carena for non-emergency issues, especially with children, and being able to email or text your doctor with simple questions, like how to deal with side effects from prescribed medication. Both of these examples provided a higher level of service to the end-user and also lower costs to the entire system. A Carena house-call is 1/3 of the cost of an emergency room visit and email and texting is more efficient and less expensive than a phone call and most certainly than an office visit.

Understanding Cost Drivers

From all the data analysis, Boeing understands very well where its largest cost drivers are coming from and ways to improve, and from Marchand’s talk it was clear that they were very much in the driver seat in pushing their healthcare partners to innovate. Areas of focus include improving the usability of patient communication tools, managing population health, providing easily actionable data for the clinical team, and using the most appropriate and cost effective methods for care. Marchand gave the example of how incentives need to be better aligned to spend money on physical therapy rather than back surgery: again a situation where the patient experience is dramatically improved and costs are lowered, however incentives must be aligned because today, hospitals make more money on surgery than preventative care. Boeing and the ACO vision of the future changes that of course.

The Q&A portion of the event was quite lively and extended far beyond the allotted time. One notable question was about why other employers are not taking the same approach as The Boeing Company. Marchand wishes they would but acknowledged it’s a lot of effort and certainly the data-driven approach is in Boeing’s DNA. As well, only the largest companies have the resources for this type of undertaking.

If you’re in Seattle and interested in the massive changes coming in health and looking for a community of like-minded people plus lively debate, then we recommend you check out the series. Talks are the first Tuesday of every month. We’ll see you there!

Posted in: Healthcare Disruption, Healthcare Technology, Healthcare transformation, Lean Healthcare, Seattle, Telemedicine

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Improving Healthcare Quality, Costs, and Outcomes in Washington State

Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has. Margaret Mead

Naysayers who can’t see how healthcare is going to move from a fee-for-service to an outcome and value-based model should look at the work being done by organizations like the Institute for Healthcare Innovation, the American Board of Internal Medicine Foundation’s Choosing Wisely program, and The Bree Collaborative.

Last week, I attended a meeting of the Dr. Robert Bree Collaborative, an initiative in Washington State spearheaded by Governor Christine Gregoire in 2011 and named in memory of a physician who focused on cutting back use of inappropriate medical imaging in the state. The goal of the collaborative is:

“…to provide a mechanism through which public and private health care stakeholders can work together to improve quality, health outcomes, and cost effectiveness of care in Washington State.”

Dr. Robert Bree CollaborativeMembers represent some of the top healthcare organizations in the state, as well as representatives from government, and payers. All meetings are open to the public, and the public is encouraged to attend and provide comments. (At the meeting I attended, most of the public seemed to be made up of healthcare industry folks like myself, although there was one attendee who spoke both as a physician and as a patient.)

The Collaborative’s mandate is to tackle four topics per year for quality and process improvements with the aim of statewide adoption in healthcare. Previous recommendations have included those for total joint replacement which is a hot topic due to new Medicare fines for readmission and lumbar spinal fusion, another hot topic due to the rising costs of back pain to employers, health systems, and in lost productivity. Recommendations include not just process recommendations and standardized ways to track outcomes, but also how to deliver care in a bundle. Payers like bundles because they provide some predictability to costs. Patients like bundles for the predictability of costs but also what they can expect from their care. Bundles pose the greatest challenge for providers, as often many of the services are provided by different organizations, for example skilled nursing or specialized physical therapy. Often surgeons are not even employed directly by the hospital where the patient undergoes a procedure. In this situation the hospital or healthcare organization needs to play quarterback and make sure the other organizations are staying within cost and quality guidelines. Add into this the fact that outcomes are so dependent on patient behavior and you can see what a tall order the Bree Collaborative, and organizations like it, have taken on.

At last week’s meeting topics included updates from groups focused on End of Life Care, Addiction/Dependence Treatment, as well as, an update from the state of Washington on state-wide measures to track quality and outcomes. New initiatives that were approved for 2015 workgroups included Coronary Artery Disease, Prostate Screening, Opioid Use, and Oncology. If you are a patient, provider, or payer stakeholder with an interest in any of these topics, you may want to subscribe to The Bree Collaborative’s newsletter to stay abreast of the workgroup’s progress and any recommendations.

In Western Washington, a new purchasing coalition made up of employers with less than 5000 people has formed. The Northwest Healthcare Purchaser’s Coalition is hoping to drive better outcomes and lower costs by combining the purchasing power of many smaller employers. In particular this group is working with local payers and providers Western Washington to try to lower the costs of back pain by implementing Bree Collaborative Workgroup recommendations at the community level. This means both clinical adoption within local healthcare organizations but also public education and awareness about recommendations for reducing back pain.

Going back to the quote from Margaret Mead that started this post, there is no doubt that The Bree Collaborative members are thoughtful, committed, and working for change. Possibly the one thing that is missing is more voices from citizens. All meetings are open to the public. If you have personal experience either positive or negative, especially around care, outcomes, and costs for any of the topics that the Bree is tackling, you’d be welcome at the next public forum. See you there?

And if you’re not in Washington State, there are initiatives like this going on across the United States. Not all are as friendly to the general public, but it’s our health and everyone needs to find a way to participate.

Posted in: Health Regulations, Healthcare Disruption, Healthcare transformation, Seattle

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White Coat, Black Art

Dr. Brian Goldman, photo source: http://www.cbc.ca

If you’re interested in an informative and entertaining podcast that explores medicine warts and all, we highly recommend subscribing to Dr. Brian Goldman’s “White Coat, Black Art.” Dr. Goldman is a Toronto ER physician and living in the land of socialized medicine with a less litigious population enables him to speak more candidly about taboo subjects like doctor’s errors. That said, the first time he admitted medical mistakes while extremely cathartic for him and his patients, caused a furor in the physician community with concerns about future lawsuits. Interestingly, Dr. Goldman noted that admitting mistakes and apologizing made patients and families less likely to sue.

You can hear about this at “After the Error.”

Another more recent podcast that caught our attention was on Lean Healthcare. (Featured is the hospital I was born in, in Kitchener, Ontario.) Interestingly, only days after the episode was aired the government of Saskatchewan pulled the plug on their $40M lean overall of the system. While some significant quality improvements have definitely resulted from a lean healthcare approach, we have noticed that the expense of lean processes are sometimes prohibitive for initial projects. That is, the people and process costs of lean might make the overall project more effective and efficient but the startup costs are high. Ironic isn’t it? Of course Toyota hasn’t been upholding the quality standards they have been known for recently either. I suppose this is why in software development, lean is also equated with agile. It’s not good enough to look at making sure your processes are effective, you also need to understand how to implement quickly and cheaply. Not an easy proposition.

You can listen to White Coat, Black Art live on CBC and CBC streaming or on demand podcasts on CBC’s website.

 

 

Posted in: Healthcare Disruption, Healthcare transformation, Lean Healthcare

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Using Homecare For Positive Change in Healthcare

The week before last, I was fortunate to be invited to attend the Collaborative for Integrated Home Care Aid Innovation Symposium: a group of committed individuals and organizations that passionate about improving healthcare through home care. The goal of the summit, organized by the SEIU union for healthcare workers was to apply the “Triple Aim” principles to home care. With the realization that our current systems cannot support the increase in chronic disease and the aging population, the group was looking for innovative solutions through people, process, and technology, that could provide preventative care and follow-up care in a community setting.

The State of Washington

Washington State CareBill Moss, Assistant Secretary for Aging and Long-Term Support, kicked off the day with a sobering look at the statistics for Washington State. While the number of people in nursing homes has declined by 7,000 since 1993, and more people are cared for in their homes, which provides a better quality of life, the complexity of health issues affecting the population has dramatically increased. In addition to being the preference of patients, at-home care is less expensive. If today we had as many people in long-term care facilities as 1993, it would cost the state an extra $200 M annually, so that’s good news.

Recognizing this benefit, but also understanding the increasing complexity of patients, provides a starting point for improving and supporting the role of home care workers to support more people aging at home. While return-on-investment studies are few and far between, the general understanding of participants is that keeping people out of long-term care facilities can provide financial subsidies to people in long-term care. For example, for the annual cost of one person in a nursing home, $17,500, three patients can be cared for in their homes.Medications Taken By Clients in Washington State

Clinical Care Needs for Washington StateTo support these home care workers and their patients, new training needs to be developed to address some of the top health risks and preventative medicine including nutritional needs, fall risk, and mobility support. By helping people improve their health, we can save money and also improve quality of life.

Continuing on the data wallow, Lili Hay a researcher with Milliman, an independent consulting and actuarial firm, shared a deep dive into the situation in Washington and the complexity of patients that require home care, for example 40% of Medicare patients take 5 or more medications and most have more than one issue.

The Penn Center for Community Health Workers

Next up, Casey Chanton, a social worker and project manager at the Penn Center for Community Health Workers in Philadelphia talked about a unique program for training community leaders as health workers. In dealing with patients from low-income, high-health risk neighborhoods, physicians and patients had both expressed frustration with the gap between what physicians prescribed and the reality of patient’s lives. Physicians might tell a patient to eat a low sodium diet while the patient would be getting most of their meals from a food bank and have little or no control over what they ate. Both felt helpless to bridge the gap. Enter the community health worker. The program trained natural leaders from within these high-risk communities. These leaders visit patients in their homes and help them get the support they needed within the constraints of their own lives.

Not surprisingly, most of the issues were not medical but related to their living situations, income, and access to services. The best recruits to be community health workers were people who listened more than they talked and were non-judgmental. They helped patients set goals that were attainable by using patient-centered goal setting coupled with achievable steps.

Results of the program are impressive and really speak for themselves:

You can learn more about the center and the program here: http://chw.upenn.edu/

Panels on Technology Innovation and Practice Solutions

The next two sessions were panels, one on technology innovation and the second on practice options. There was too much good information for me to summarize everything, so I’ll stick to the major themes.

  • Post-acute care costs are the fastest rising and most variable care costs, so finding a way to manage them is key.
  • Technology is not the solution, people and process are the solution, but technology can help.
  • People of all ages and socio-economic backgrounds can be use technology (although possibly not EMR interfaces—this isn’t a reflection on the people 😉 )
  • If we could start from scratch designing a health system, we would never have designed the siloed-system we have today.
  • Issues of care coordination are causing post-acute care to be the fastest rising cost in healthcare today, even though readmissions are falling
  • Homecare needs to be structured around outcomes not having homecare workers check off task lists
  • Even if the payment models aren’t there yet, we need to take best practices and move forward.
  • Even if all the research isn’t in, we need to take best practices and move forward.
  • Even if healthcare administration isn’t ready for it, we need to take best practices and move forward.

During the panels and Q&A we heard from a few of the homecare workers in the audience about the impact they’ve had on people’s lives because they do what’s right and not what’s required. Particularly striking was the story from a woman who talked about caring for one of her patients who needed to go into a nursing home temporarily after surgery. The nursing home was understaffed so the homecare worker visited her patient there multiple times a day to make sure he was being turned in his bed. She did this because she cared about her patient and she wanted to make sure when he was released back into her care he wasn’t in worse condition than when he entered the nursing home. Rather than consider the negative aspects of this anecdote, let’s look at the amazing resource that exists in home care workers who spend more time with patients than their medical professionals and sometimes their families. That was the point of the day: what can we do to help scale this valuable resource and empower them to help patients even more.

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

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Support for Telemedicine in Rehabilitation

Recognized barriers to telemedicine in rehabilitation, for example, the need for hands on intervention, a lack of billing codes, and not enough studies on cost-effectiveness, did not damper the enthusiasm for the potential of the field and the inevitability of future interventions at American Congress of Rehabilitation Medicine annual conference in Toronto. Presenters in numerous sessions demonstrated the many benefits of tele-rehabilitation for patients, providers, healthcare systems and payers.

Two sessions we attended, “Use Of Telemedicine In Spinal Cord Injury And Pressure Sore. A Pilot Project “ and “Tele-rehabilitation: A New Frontier In Geriatric Rehabilitation” debunked many of the common myths of telemedicine including:

  • Concerns about patient privacy
  • Ability of seniors to use telemedicine
  • Diminished care quality

Instead what they showed was:

  • Patients were more than willing to invite the video into their homes
  • Seniors and people with severe disabilities can use technology with the right support
  • Care quality can be improved by telemedicine

However, even with solid data presented in all of these sessions, presenters joked that telemedicine still largely suffers from a disease called “pilotitis”, that is never progressing past the pilot stage and a proliferation of pilots.

The Use of Telemedicine In Spinal Cord Injury And Pressure Sore: A Pilot Project

Norwegian Health SystemThis session showcased another great example of an interdisciplinary team, common at this conference. This team was from Norway, as they called it “land of trolls and polar bears.” Norway has a total area of 385,252 square kilometres and a population of 5,109,059 people (2014). 84% of the population has smart phones. Like most countries other than the US, they also have socialized medicine. Telemedicine was first introduced in Norway in 1980, so the fact that this project was still a pilot points to some of that “pilotitis.”

The driver for this particular project was two-fold: improve patient care by enabling patients to stay in their home, extend the reach of specialists to rural areas. Both are common reasons for telemedicine, and also can help lower healthcare costs in this case by decreasing transportation of the patient to a medical center located a few hours away. This particular intervention focused on helping Paraplegic patients manage pressure ulcers. Due to both cost and patient preference, patients with spinal cord injuries are being released earlier from hospital. However the risk of developing a pressure ulcer is greater and local healthcare support often does not have the expertise needed.

In this case, a team from the hospital would check in with the patient via video conference through a web camera at the patient site. Now, here’s where we debunk the myth of patient privacy. The patient in this case was so happy with the remote support and care he received that he agreed to have the recording of his sessions shown at the conference. For those unfamiliar, pressure ulcers occur in intimate locations like the buttocks. The team did a great job of showing how they manage to capture high-quality video over speeds as low as 256k and keep the privacy of the patient protected by positioning the camera only on the ulcer with no identifyiable patient visuals. (The video presented in the session was not for the faint of heart though.)

Patient benefits

Telemed costs

 

 

 

 

 

 

 

 

Benefits that the team saw were:

  • Cost-savings from decreased hospital stay
  • Decreasing travel exhaustion for the patient
  • Supporting the nurses in the community and helping them improve skills
  • Time-saving as the patient was always ready at the exact appointment time
  • Continuity of care, although interestingly, summer vacations caused some discontinuity and showed that this is not ensured simply by having Telemed.

Some best practices they identified included making sure that all introductions were completed for context, safety, and dignity before starting the examination, excluding personally identifiable information from sensitive video, and working with an interdisciplinary team to deliver results.

 

Tele-rehabilitation: A New Frontier In Geriatric Rehabilitation”

This session reinforced the need for telemedicine to support patients in their own homes. Dr. Helen Hoenig from Veterans Affairs described the gap between what the patient was able to do in the hospital and what they were able to do at home. For example, one veteran was released from the hospital proficient at using a walker but had no way of getting into his house because of the large number of steps. Having the veteran capture photo and video and send it for review (a method known as “store and forward” or “asynchronous telehealth”), enables staff at the hospital to provide advice and programs that are more applicable to the veteran’s real home situation.

Another example was of a patient who was given a shower chair and taught to use it during occupational therapy sessions at the hospital. When he returned home, it was obvious that the chair didn’t fit in the shower, and needed to be replaced with a bench. During the next video telemedicine session, the veteran practiced getting in and out of the shower using the shower bench while the occupational therapist coached remotely. (Unlike our Norwegian example, this person was fully clothed on the video.)

Veterans Affairs spends up to $6000 per person on home renovations for disabled veterans who need it. Having occupational therapists who are able to see the home remotely and help the veteran navigate it, as well as provide suggestions for modifications can help maximize the benefit of spending this money.

Our favorite part of this session was the presentation by Nancy Latham from Boston University who shared preliminary results from their study using Wellpepper and FitBit to keep activity levels high for people with Parkinson’s. People with Parkinson’s often see a dramatic decline in activity levels. However, the healthcare system has little or no support for long-term exercise needs. This randomized control trial had one group receiving the usual care condition which was an in-person visit and exercise prescription. The m-health group received an in-person visit but their exercise program was assigned using Wellpepper for their program with custom video, reminders, and messaging with a physical therapist. They were also given a FitBit. The results are extremely positive for exercise adherence, self-efficacy, patient satisfaction, and most importantly outcomes, judged using the 6-minute walk test. Stay tuned for early 2015 when we’ll have the final results to share with you. If you’d like to see the preliminary results, contact us.

Posted in: Health Regulations, Healthcare Disruption, Healthcare Technology, M-health, Rehabilitation Business, Telemedicine

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Cautious Optimism In Spinal Cord Research: The Model T Stage

You probably saw recent news about a novel new treatment for spinal cord injury that enabled a man with a severed spinal cord to walk. Cells were cultivated from olfactory cells and implanted in his spine. While this is a phenomenal outcome, medical professionals were slightly more cautious.

It is premature at best, and at worst inappropriate, to draw any conclusions from a single patient,” said Dr. Mark H. Tuszynski, director of the translational neuroscience unit at the medical school of the University of California, San Diego quoted in the New York Times article about the case.

Why the caution? Well first off it’s one patient. Dr. Tuszynski warned that this example might lead others with spinal cord injuries to have false hope. In rehabilitation medicine in general, and spinal cord research in particular it’s stressed that there will need to be many specialized approaches based on each patient’s situation. Earlier this month we heard similar caution from V. Reggie Edgerton, the John Stanley Coulter Award Lecturer at the ACRM conference in Toronto.

We’re at the Model T stage” said V. Reggie Edgerton, during the lecture, referring to spinal cord research. “We’re learning new physiological concepts on how we control movement and previously held beliefs are beginning to be challenged. New technology will help us take advantage of these new understandings, like for example, that the spinal cord can learn.

Automaticity is key to what we’re now learning about spinal cord rehabilitation. Automaticity is the “ability to do things without occupying the mind with the low-level details required, allowing it to become an automatic response pattern or habit. It is usually the result of learning, repetition, and practice.” (Another way to consider the concept is that the only way to get a thought out of your brain is through movement, so if this didn’t become an automatic response, we’d too many thoughts going on at any one time to hear ourselves think. ;))

It had been thought that once the spinal cord is severed from the brain, this automaticity is lost. However, in experiments with animals with severed spinal cords, fully functional humans, and humans with spinal cord injury, Dr. Edgerton and team, successfully triggered the spinal cord to cause movement in the legs. That is “the spinal cord knows how to walk.”

Man walking in exoskeleton

Man walking in exoskeleton

An even more compelling result from the studies is that while in the humans without spinal cord injury who were tested, the movement of the legs was involuntary based on neuro-stimulation, one of the rats that had a severed spinal cord was seen ‘walking’ toward a food source in front of him when his spinal cord was stimulated. From these two breakthroughs, the team was able to extend the study to humans with spinal cord injury. Dr. Edgerton showed an extremely compelling video where a Parapelegic man was able to stand and balance while catching a ball, but only during the time that the stimulation was applied. Similarily another patient is shown moving his leg while the stimulation is applied, demonstrating that the neuro-stimulation is able to make the connection between brain and spinal cord. The spinal cord, however, does need to know what to do to begin with which is what was shown in the studies using people without spinal cord injury, that is that the spinal cord has movement memory “built-in.”

Interestingly the first human with spine injury subject took significantly longer than later subjects to move his leg. Researchers think that this is because later subjects had heard of his success, and therefore expected it to work, while the first subject was extremely doubtful.

This amplification through neuro-stimulation is able to reengage the automaticity and enables rather than induces movement. What these studies tell us is that the system has placidity for years after the injury and that if you provide the spine with proprioceptic information, it knows what to do with it. Dr. Edgerton refered to this in those of us who are not paralyzed as “the spine is just being nice to the brain when the brain tells it what it was going to do anyway.”

The stimulation only worked up to a point, and subjects seemed to know intuitively what that point was. Too little stimulation and there is no response, too much stimulation and there is a loss of control.

Robotics will play a key part in this type of recovery. For example, adding the stimulation to an exoskeleton.

Dr. Edgerton cautioned that there is a long road ahead and still a lot of research: this study was only done with 10 subjects. However every one of those subjects gained voluntary control. He also stressed, similar to most of the presentations we were able to attend, that there is no “one size fits all approach.” Care and care teams will need to be specific to the type of injury sustained and the needs of the patient.

Regardless, the research that Dr. Edgerton and his team did shows that we need to redefine “completely paralyzed”: paralysis is no longer an all or none proposition, which is truly amazing. Thinking back to the Model-T analogy, one can hardly what it will be like when spinal cord innovation reaches the Tesla level.

Posted in: Healthcare Disruption, Healthcare Technology, Rehabilitation Business

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Pre-habilitation: Effective Preventative Medicine for Rehabilitation

If an apple a day keeps the doctor away, what can a knee bend do? The American Academy of Orthopedic Surgeons recently answered this question with the results of a new study of the impact of physical therapy on surgical outcomes for hip replacement. The answer: “Prehabilitation reduces the need for perioperative care by 30%.” Amazing results, especially considering that total joint replacements will increase by 400% by 2030 according to the academy. Considering that post-acute care costs are the fastest rising and most variable, an investment in pre-habilitation can pay off huge dividends. Based on data from the AMA and CDC we’ve estimated that a 10% decrease in post-acute care costs could help realize $4.3B in savings over this same period. The AAOS study showed that patients who received pre-habilitation saw a decline in up to $1,215 per patient in perioperative care, due to a decrease in costs for skilled nursing and home care. Given that total joint replacement costs vary from a low of $6000 to a high of $30,000, providing pre-habilitation and a means for patients to be adherent is a very easy way to get to this 10% decrease. If you’d like more information on how we calculated these costs contact us.

The theme of pre-habilitation was also prevalent at the recent ACRM annual congress in Toronto, consider it the preventative health of rehabilitation, which literally means the act of restoring something to it’s original state. If you can decrease the amount of damage done in the first place, restoring it to the original state becomes easier or at least if you don’t see complete recovery, you see better outcomes. Two sessions at the conference explored this concept where there was known risk of damage: one focused on pre-habilitation for cancer patients that would need to undergo surgery, and the other a focused study on adults with lower back pain who were at risk of declining.

Effect of Diet on Outcomes for Cancer Surgery PatientsOne session focused on pre-habilitation for patients undergoing cancer surgery, and was striking both for the outcomes and for the collaborative and interdisciplinary team. The session, “Improving Outcomes With Multimodal Prehabilitation in Surgical Cancer Patients” was notable both for the outcomes presented and for the strength of the collaborative and inter-disciplinary team that included led by Dr. Carli from McGill University that included physicians, dieticians, and physical therapists. The team presented the results of their randomized clinical study that showed that a prehab program including strength training, exercise, diet, and nutrition counseling could decrease hospital stays by ½ a day and that the strength training helped patients compensate for surgery-related weakness perioperatively.

Patients were given either just nutrition counseling or nutrition counseling plus a whey supplement or a placebo. Patients with nutrition counseling sustained their levels in the 6 minute walk test before and after surgery. Patients with both nutrition counseling and the whey supplement improved their distances in the 6-minute walk test after surgery.

Together the strength training, nutritional counseling, and protein supplements improved patient surgical outcomes. Ideally, nutrition counseling was recommended to begin at cancer diagnosis, but at the very least pre-surgery. This study proved that there are modifiable patient risk factors before surgery that can improve outcomes.

Exercise for Lower Back Pain in SeniorsA second study outlined by Dr. Gregory Hicks from the University of Delaware  in the session “Novel Ways to Improve Mobility and Physical Function in Older Adults: A Targeted Intervention Approach”, looked at whether stabilizing trunk exercises could prevent decline in high-risk seniors. Interestingly, the presenter X pointed out, any studies involving trunk muscle stabilization had purposely excluded adults over 65 so there was no evidence of the impact. In this study, the control group was given the usual care condition of heat, ultrasound, massage, and stretching. The second group was given trunk muscle training and Neuromuscular Electromagnetic Stimulation. Unfortunately, the second group had low adherence to their programs, and were not happy to miss out on heat and massage. This probably says more about the need for patient education and engagement than anything. In many studies strengthening exercises have proven helpful, but not if you can’t get patients to do them. Regardless, patients in the trunk muscle group had a 17% higher rating on the top 3 functional limitations that they had reported as being most important to them at the outset of the study and their exercise self-efficacy was expected to continue to improve over time.

While the results were positive, Hicks outlined some of the limitations of the study, including the exercise adherence but also pointed out that patients had different outcomes based on the physical therapist delivering the treatment and based on how closely they identified with the pre-defined outcome measures that were used in the standard tools (OSWESTRY). This brings up an interesting point about how to deliver care.

While research has proven that proactive activities, like improving diet or exercise, can improve outcomes, patients, and by that I mean humans, are subject to human nature, which is not always doing what’s in our own best interest.

There are ways to change this within the care delivery system to help patients adhere to their treatment plans:

  • Making sure patients understand what they are being asked to do
  • Making it easy to follow instructions
  • Fostering a positive relationship between patient and healthcare provider

Adapted from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624/pdf/tcrm0103-189.pdf

These principles are fundamental to our Wellpepper patient engagement solutions and help us get over 70% patient engagement. We’re pretty excited to see the opportunities for these types of solutions to be used in pre-habilitation scenarios that are proven to improve outcomes.

Posted in: Prehabilitation

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Should Patients set SMART or MEANING(ful) Goals?

Goal setting provides incentive, improves adherence, and helps measure progress. Right? Maybe. Presenters in the session “Goal Setting in Rehabilitation: Theory, Practice, Evidence” at the annual American Congress of Rehabilitation Medicine conference in Toronto were consistent in their believe that goal setting is important for rehabilitation but also pointed out a lack of evidence and a distinct lack of consistency in application. It seems that goal setting theory in healthcare has been largely borrowed from business and sports, and while it makes sense that goal setting should help patients, there is not a lot of decisive evidence and there is a lot of debate on how goals should be set.

Does goal setting work?

A survey of the clinical research on goal-setting in rehabilitation showed that goal setting didn’t improve physical function, however it did improve patient self-efficacy. Evidence was inconclusive on whether goal setting affected motivation, adherence, or engagement. However, the overall analysis showed a statistically significant difference in favor of goal setting. The issue is how goals are set and could setting them differently improve care.

How are goals set?

Currently the usual care condition for setting goals is having healthcare professionals set them instead of patients. The problem with this is that the goals may be SMART, but they are not meaningful for the patients. There is often a mismatch between patient and physician goals: physician goals are often functional goals and patient goals are quality of life or aspirational goals. Since goal seems to have a bigger impact on intrinsic factors, like efficacy and possibly also satisfaction, it seems that patient-directed goals would be more effective.

The following are “SMART goals” adapted to apply in rehabilitation. However, the speakers adapted them slightly to apply more directly to rehabilitation. (Assignable rather than achievable.)

Specific, measurable, assignable, realistic, time bound
 
 

How should goals be set?

Goals that help a patient connect with their care plan are preferred, for example, goals that fit the following criteria.

MEANING goal setting

 

While presenter Kath McPherson from the Auckland Institute of Technology argued that patient goals could be vague and also asked why goals had to be realistic: wasn’t it better that the patient continued to hope and work towards something, William M. M. Levack the concept of helping patients set “fiduciary” goals. That is, guide the patients goals based on the situation more initially and less as the patient gained autonomy. To illustrate this he used the example of Mr Roberts a blind diabetic amputee who had a goal of going home to live. If Mr. Roberts’ goal were the only thing taken into consideration, it would ignore the realistic factors that might not make this possible, for example, his wife’s ability to care for him. As such, a better approach for goal setting for Mr. Roberts was to consider a number of factors including:

  • The values and preferences of the patient
  • Clinical judgment of the healthcare professional
  • Time and resources required for the goal
  • Likely consequences of pursuing the goal

For Mr. Roberts, this approach would look like this:

value pluralism in goal setting

The takeaway from these sessions was the necessity to link the clinicians small functional goals with the patients big aspirational goals. Functional goals are necessary and will measure progress but aspirational goals are what drives patient self efficacy which is so important for recovery.

 

We think a lot about goal setting and patient reported outcomes at Wellpepper. Patient reported outcomes are great tools to show progress and also validate clinical efficacy but they must be linked to patient’s goals for real impact. We’re working on some interesting ways to do this through our technology and are excited to be able to share this with the rehabilitation medicine community.

Posted in: Adherence, Behavior Change, Healthcare motivation, Healthcare transformation, Occupational Therapy, Rehabilitation Business

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Pushing, Pulling, Nudging and Tipping Healthcare Evidence Into Practice: Highlights from ACRM

We’re just back from 2 weeks on the road visiting Wellpepper customers and also attending the Annual Congress of Rehabilitation Medicine conference in Toronto where our research partners at Boston University presented the preliminary results from a study they’ve been working on. We’re so pleased and impressed with the results, but if you weren’t at the Congress, you’ll need to wait until November when we can share final results with you.

In the meantime, you can follow our recaps from some of the sessions we were fortunate to attend atIMG_0325 the conference. While the conference was heavily research-based (subtitled, “Progress in Rehabilitation Researchers), most researchers were affliated with teaching hospitals so that research could be put into practice. Also striking about this event, compared to many other healthcare conferences, is the team-based care and interdisciplinary nature of the presentations. Most presentations features care or research teams that included professionals with varying backgrounds including physicians, surgeons, dieticians, registered nurses, physical therapists, and occupational therapists. Another striking difference was that while everyone was striving toward repeatable outcomes, rehabilitation medicine requires a level of personalization that is specific to each patient’s ability.

Keynote: Pushing, Pulling, Nudging and Tipping Evidence Into Practice: Experience From the Frontline Implementing Best Practices in Rehabilitation

Dr. Mark Bayley from University Health Networks, and the University of Toronto kicked off the ACRM conference with a challenge to researchers to shorten the distance between research and implementation using techniques from other disciplines. His talk highlighted the challenges and provided solutions in a snappy and entertaining manner.

The Problem with Information Dissemination

To illustrate the problem, Dr. Bayley launched the talk by describing with the 386 year path from when Vasco da Gama observed scurvy in his ship’s crew to the implementation of vitamin C (or citrus juice in particular) as a protocol in the British navy. Although da Gama’s crew recovered from scurvy when given citrus fruit in India, the connection somehow was not made, and there’s a long history of sailors dying from scurvy, until the first ‘clinical trial’ when James Lind ran a 6-armed comparative study at sea and proved that citrus or vitamin C cured scurvy. Another 40 years passed before the British Navy adopted citrus as a standard.

Lest anyone in the audience start to feel smug about advances from scientific discovery to implementation today, Dr. Bayley revealed that it currently takes discoveries and new methods 17 years to get from research to implementation. He then spent the rest of the talk providing concrete suggestions that researchers could use to try to change this.

Researchers are often very focused on publishing, it’s how they are evaluated. However, publishing information and hoping that someone reviews it and sees the value is not enough to drive change into clinical practice. To put this into perspective, Dr. Bayley quizzed the audience on how many articles a healthcare professional would have to read each year to stay on top of all the research. The answer: 7300 or 20 articles each day. Compare this to the 1 hour of reading per week that most practicing healthcare professionals can manage, and you’ll see very clearly why best practices derived through research are often lost and not implemented. With only 1 hour per week for reading, is it any wonder most healthcare professionals get their information from their peers?

Barriers to Implementing New Methods from Research

As well, it’s not enough to provide recommendations but researchers must provide guidelines for how they should be implemented and understand the types of organizational barriers to implementation.

Barriers can include:

  • Individual perceptions
  • Complexity of solution
  • People who will need to adopt the new practice
  • Where the new practice will need to be implemented

Other things to consider are who will deliver the care, what stage of recovery the patient is in, the amount of time available with the patient, and the expected outcomes. Rehabilitation medicine adds an additional level of complexity to writing general implementation guidelines as each stage of recovery is different and requires it’s own care path, and the level of specificity for each is high.
Personal Barriers

When considering the people who will implement the guidelines from the research, many factors will impact their openness and ability to implement, including:

  • Knowledge: Does the person understand the research?
  • Skills: Does the research require the healthcare professional to learn new skills?
  • Social role: Does the healthcare professionals role within the healthcare system give them the authority or autonomy to implement the solution?
  • Beliefs: Do their beliefs in their capabilities or in the consequences of implementing the solution interfere with a successful outcome?
  • Motivation: Are they properly motivated or incentivized to implement the solution? For example, does the way they are compensated cause issues with implementation?
  • Emotion: Are their any emotional beliefs that will interfere with implementation, for example: “this is different than what I learned in school”?

Organizational Barriers

In addition to barriers that may arise through the people who are implementing research, there are many possible organizational barriers to implementation. These include:

  • Practice: How does the new method fit in with what is currently practiced?
  • Resources: Are the right people and skills available to implement?
  • Legal: Are their legal or regulatory issues that could block implementation?
  • Cost: Is it too expensive to implement? Are financial incentives aligned? (Of course the biggest issue here is always “Is it billable?”
  • Physical layout: Does the implementation require a change in the physical layout of the care center?
  • Time: Do staff have adequate time to understand the new procedure? Does the new procedure take longer than the time available?
  • Staff turnover: Can this new practice be maintained if staff change?
  • Equipment: Does it require new equipment to be purchased? Is it in the budget? Is it difficult to learn?
  • Communications: Does the practice require new ways of communicating between disciplines, within teams, and between patients and providers?

So should we give up?

To contrast the almost 400 years to recognize the treatment of scurvy, Dr. Bayley provided the example of how the use of general anesthetic spread thousands of miles from the UK to France and Germany in only a few months, and to widespread adoption within 2 years. Although the knowledge of properties of gases like either goes back further, the main adoption was relatively quick between demonstrations in 1844 and widespread adoption in 1846. The fast adoption stemmed from two factors: it was better for the patient and easier for the surgeon to operate on a patient that wasn’t squirming around.

What makes an invention or a new process sticky is that it’s good for providers and good for patients. (We would add to that in the US, it needs to be good for payers.)

Dr. Bayley then went on to provide some practical and possibly new advice for the best ways to effect change starting with things that don’t work within healthcare settings.

Methods that won’t effect change

  • Pamphlets
  • Total quality measures
  • Lectures

Methods that will effect some change

  • Patient driven or mediated
  • Conferences

Methods that will effect real change

  • Reminder systems (like hand washing)
  • Mass media for patients but will also impact providers
  • Financial incentives
  • Interdisciplinary collaboration

More practically, finding champions and interdisciplinary teams to implement changes, figuring out how the change relates to financial incentives, either the fear of losing money or the opportunity to gain money, and finding opinon leaders to publicize the changeDoctor-Recommeds-ProduceFinally Dr. Bayley introduced the theory of nudges and benevolent paternalism, or the idea that if you can make it easier for someone to do the desired behavior than the usual behavior they will. To illustrate this point, he showed a picture of an escalator and stairs, with an outline of a slim figure pointing to the stairs and a pudgy figure pointing to the escalator. Not quite as cheeky was a UK campaign that had pictures of local family physicians next to the fresh ruit and vegetable aisle asking people to eat more healthily which caused a 20% increase in produce sales.

This was a great talk to start the conference as it provided concrete advice for the presenters of all the great innovations over the next few days to get their advances into clinical practice in a period shorter than the current 17 years, because heaven knows our health system needs the nudge.

Posted in: Behavior Change, Healthcare Disruption, Healthcare motivation, Healthcare transformation, Rehabilitation Business

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Helping Patients Protect Their Own Personal Health Information

Last week I was leaving a meeting at a large hospital when I saw a patient record sitting on top of the payment machine in the parking garage. Incredibly this is the second time that I’ve seen documents left here. People put them down when they pull out their wallets to pay for parking and then walk away.

Patient Record on ParkingThe information the patients left behind included treatment plan instructions – so you can be pretty sure they are not doing their follow up home care – but worse than that it contained a schedule of future appointments with the patient’s name, date of birth, and social security number. Yes, you read that right: a perfect package for anyone practicing identity theft. This was all on a page that was printed directly from the EMR. The DOB and SSN were probably included on the record to verify that the information was for the correct patient, but this could be verified by asking the patient without printing it on a schedule of appointments.

So – first things first – I took the paper records back into the hospital. But afterwards it got me thinking about information protection and privacy, and in particular about the many people who still think that a paper print out is more secure than the cloud.

Although concerns about information protection and privacy are valid, many of the major HIPAA breaches of the last few years have had nothing to do with the cloud and usually are related to human error and not great security practices.

A few examples:

Good protection of patient information is important whether that information is in the cloud, on an internal computer or system, or on paper. HIPAA regulations encourage building good encrypted software, however we also need to have safeguards to protect against human error.

If patient information were in the cloud, the patient would either access the information through a secure portal, email, or application on their mobile device. He or she would then authenticate themselves to receive the information, and would not need to worry about accidentally forgetting their treatment plans sitting on a parking payment machine.

While patients expect to be able to interact with their healthcare providers through portals and mobile applications in the same way they interact with their banks, many healthcare CIOs we’ve encountered are still extremely wary of cloud-based systems. Financial services is another heavily regulated industry that has been able to successfully move to the cloud to better serve its customers.

Wellpepper is a cloud-based application, which in the healthcare world, makes us a business associate and on the hook for any breaches of patient health information. On the hook means that we need to sign a HIPAA agreement with any organization and we have liability for breaches of information. This is a job we take very seriously and we do our utmost to protect all information that flows through Wellpepper. This includes encrypting information at rest and in transit, ensuring strong passwords, and conducting audits of our system as well as making sure we are well-insured.

With Wellpepper, we provide the same level of encryption and safeguards to the patient’s own device as we do on the clinical devices. Information is not stored locally so if a device is lost or stolen there is much lower risk than in the laptop examples. Patient can do whatever they like with their own data. If I want to post my x-rays on the lamppost in-front of my house I can do that. However, that doesn’t mean that a healthcare organization should facilitate me in sharing my personal health information, which is actually significantly easier with paper-based systems than cloud based.

Yes this information would have been transferred over the Internet which could leave it open for hacking but a secure cloud system is no less, and sometimes more secure than internal IT systems which are also vulnerable. The key is to ensure that everyone in the chain, from internal IT to external partners, and finally to the providers and the patients understands the importance of protecting health data, and has the tools they need to do so, whether that’s on paper, online, or in the cloud.

Posted in: Data Protection, Health Regulations, Healthcare Technology, Healthcare transformation, M-health

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Post or Perish? Disseminating Scientific Research and the Kardashian Index

Publish or perish has long been the mantra of academic research. While this used to be limited to peer-reviewed journals, researchers are increasingly needing to include public outreach through social media to their list of communication vehicles. A recent panel at the International Society for Environmental Epidemiology conference this week in Seattle tackled this problem with some practical advice. With a focus on the environmental factors that can impact public health, the researchers at this conference have a definite need to reach a broad audience base not just to justify their grant money but to positively impact public health and the environment with their findings.

Disseminating air pollution effects on public health

Disseminating air pollution effects on public health

Disseminating scientific research to the general population is not an easy task. Media outlets like easy wins and definitive statements, but research results often need the fine print to be fully understood, and the fine print often contains details like study methodology or influencing factors that either are too complicated for the general public or limit the results of the findings to very specific situations. For example, perhaps a drug proves effective but only in left-handed blind mice that could play the tuba. This might be a big scientific breakthrough pointing towards broader benefits, but it’s not conclusive enough for media that want to say things like “New drug 100% effective” not “Drug thought to be effective in tuba-playing left-handed blind mice.”

One audience member, who worked in communications for a large research organization summed up this problem as ‘if a headline meets my criteria no media outlet would pick it up.’ That is, by the time the headline was completely scientifically unambiguous, like our blind mice example, it didn’t seem like news.

The session featured real world examples and best practices from http://escapeproject.eu/ and from the NIH. The Escape project was a multi-year study to evaluate the effects of air pollution from birth to death across a wide range of respiratory and other illnesses. You can understand why getting this information beyond academic readers to the general public is so important.

Some tips:

  • The communications plan needs to be part of the grant-writing process, and for studies that impact public health, you need to think beyond PubMed to the general press and social media.
  • Know what channels your audience accesses. Are they on Twitter or Facebook or maybe print media?
  • Understand what larger story your research is part of and position it within that context. For example, for Escape, it’s the impact of air pollution on health.
  • Understand the implications of your research for the general public. What action do you want them to take based on your findings?
  • Avoid scientific jargon.
  • Make sure you can distill the main message from the study, and as conclusively as possible within the parameters of your research topic.
  • Leverage partner organizations for their press and communications contacts and to disseminate the message. For example, the Escape project used respiratory related health organizations to help spread the word about their findings.
  • Photos can be a powerful way to get attention and disseminate information. Here Escape found that photos of major cities obliterated by smog were very effective to accompany news articles about their study results.
  • Don’t dismiss the Kardashian Index. Some researchers downplay the value of social media because the most popular scientists on social media are often doing the least amount of research and possibly not the best researchers. However rather than making them shy away from social media as a result, the presenters urged the audience to participate more actively to make sure their voices and research were heard. Popularity and valid information do not need to be mutually exclusive.
Do's and Don'ts for Social Media for Researchers

Do’s and Don’ts for Social Media for Researchers

As active social media participants here at Wellpepper, we have a couple of additional recommendations for researchers:

  • Try not to name your study with an acronym. Studies usually have very long names and then acronyms are coined as a short cut. However, they usually don’t convey the actual meaning of the study. “Escape” is an acronym for European Study for Air Pollution Effects. How about “Smog Europe?” ;). A descriptive name with a subtitle is a lot easy for the general public and news media to grasp.
  • Infographics can be a great way to communicate a lot of data-rich information like this one from the NIH about social media influence within a online medical community. Put your contact and study information on the infographic and make it easy for people to redistribute. (We didn’t include the NIH graphic here because it required emailing them for permission.)

Even within the session attendees that represented researchers from across the globe and in all career stages, there was a great digital divide. One young researcher implored her older colleagues to use Facebook to engage with scientists and potential scientists of her generation. She also mentioned that it was a great place to recruit study subjects. Another researcher from Chile talked about the power of social media for collecting data: getting reports from people on the ground who were facing environmental health challenges. This could have been a topic unto itself, and if more deeply explored might have convinced some of the more curmudgeonly audience members who were concerned about the current proliferation of communications channels, lack of ubiquitous digital access, and a worldwide decline in scientific literacy.

In the age of social media, the idea of publish or perish takes on new relevance and meaning, and hopefully scientists and researchers understand that embracing these new ways to engage directly with the general public will amplify the impact of their work.

Posted in: Behavior Change, Healthcare Social Media, Healthcare transformation, Seattle

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A Tale of Two Sensors: Misfit Shine vs. FitBit Zip

On a 5-day back-packing trip in British Columbia, I put two sensors to the test. While neither were designed specifically for this purpose, my impressions are definitely relevant to the usability of the sensors in everyday life.

I’ve been using the FitBit Zip for over a year, and here at Wellpepper, we’ve blogged about experiences with sensors before. We integrated Wellpepper with FitBit for a Boston University study on engaging Parkinson’s patients and so the Wellpepper team all got FitBits to test the product and integration. BU chose the FitBit Zip because it had a long battery life and was easy to sync. They didn’t want study participants to have to worry about constantly charging the device.

For my trip, I decided to also try the Misfit Shine that I received as gift at the XX in Health Conference. I started on the trail with the Shine on my wrist and the FitBit clipped to my shorts. I had two main goals for the devices, which may be different than their intention but I thought they should work for the purpose: to tell time and to know how far I’d gone and how far I had to go until the next campsite.

I have to say, that sadly, I actually needed both devices to accomplish the task and there were problems with each.  The following is my review of how the devices stacked up for telling time, judging distance, ease of use, and form factor.

Misfit Shine

Telling time: The Shine shows you the time by flashing a light at 12, and then flashing the hour location and minute location using lights on a radius, because the time doesn’t advance the “hour” hand stays on the previous time until it hits the next full hour making 6:45 for example, look like 5:45. This made telling time an intellectual exercise. Maybe this was the point, but not being able to glance at the thing on my wrist to find out the time was pretty frustrating. It was also extremely hard to see the flashing lights in bright sunlight. So, for telling time, I’d have the Shine a C.

Misfit Shine

Jewelry? Hmm.

Distance: The Shine uses goals that are awarded according to points. This is so that you can track multiple activities. The problem is that by default it only tracks steps or distance but the reporting on the device is only how complete you are on your goal. This makes it actually impossible to use the Shine for distance tracking without syncing to a cellphone. (I did not bring a cellphone on the trip due to battery life and complete lack of wifi signal.) Tracking Distance: I’d have to give the Shine an F.

Ease of Use: To get information from the Shine, you double-tap it. This in theory is easy but sometimes it didn’t respond or because of the bright sunlight I’d miss what it was trying to tell me. However, syncing with the app was very easy and the app is reasonably usable (although I still haven’t figured out which night sleep tracking is showing). I didn’t find out until after the trip that in order to record other activities like swimming, I was supposed to tell the Shine that an activity other than walking had started. Ease of Use: B+

Form Factor: The Shine is an attractive metal disk. However, it’s on a rubber wrist band so to call it jewelry is a bit of stretch unless you live in Silicon Valley or maybe Seattle. The metal is smooth and pleasing to the touch but I really wish it told you some information when you look at it. Form Factor: A-

Other: The Shine tracks sleep, which is quite interesting. However, I didn’t have this information until after the trip when I synced it with the app. And, as mentioned previously, it’s hard to tell what night it’s showing. For example, it’s Thursday. The sleep tracking I see shows “Today” which I’d assume is “Wednesday night”, “Yesterday” which I’d assume is “Tuesday night” but then “Tuesday” is that “Monday night”? Again, the Misfit Shine feels like it makes me work too hard for the information.

Misfit Shine Sleep

What is restful sleep?

FitBit Zip

I’ve been using the FitBit for about a year, so I know the issues with it a bit better and have many friends that have the FitBit Flex or Zip. I bought I FitBit Zip for my mother specifically because it gives you information without needing to sync to an app. However, since I’ve been using the FitBit for a year, I’ve started running into some issues: I think it’s on its last legs.

Telling Time: Normally, the FitBit would have gotten an A+ in this category. However, after changing the battery and syncing with the phone, as soon as we got on the trail the time somehow changed to 3.5 hours later than the current time. Telling time: D

Distance: This is where the FitBit is awesome. It counts steps and distance. We relied on the distance tracking constantly to track progress on the trip. Distance: A+

Ouch. :(

Ouch. 🙁

Ease of Use: The FitBit wins here too. The display on the actual device shows you everything you need to know, and cycles through steps, time, distance, and an emoticon representing your daily activity by simply tapping the face. You don’t need to sync to the phone to get crucial information. I bought at FitBit Zip for my mother for this reason: simple and easy to use. Ease of Use: A+

Form Factor: The FitBit Zip is light and can easily clip to your clothes. On a backpacking trip it doesn’t matter if you’ve got a funny plastic thing clipped to your pants. In the city, it’s hard not to look like a bit of a dork. Recently, my FitBit lost its protective cover and now has some exposed prongs that have the potential to snag clothes. Also, it’s pretty easy to lose, either from it falling out of the case or putting it through the was on a pair of pants. Form Factor: B (until I get a Tory Burch FitBit.)

Other: The FitBit provides really great weekly summaries of your activity via email. It also enables you to challenge or track your friends activities. Downsides seem to be in durability. Both the Flex and the Zip only seem to last a year (based on anecdotal evidence from friends).

The reason so many friends on this list are “unranked” is that their FitBits have died.

FitBit Friends

The fallen

Neither of these devices were designed specifically with back-packing in mind and the Misfit Shine definitely was built with the assumption you would always have access to a phone to sync, however, it seems that each of them could have worked a bit better ‘off the grid.’ On the other hand, if my FitBit wasn’t approaching the end of its life, it probably would have performed very well.

Regardless even reviewing some of these glitches in the light of daily usage, it still seems we have a long way to go. We’re really just at the beginning of what’s going to be possible with self-tracking. Let’s hope devices get more durable, smaller, and easier to use.

 

Posted in: Behavior Change, Healthcare Technology, M-health

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