Adherence

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4 Reasons Why the Future of Health IT is Serverless (AWS re:Invent 2017 wrap-up)

The big theme at AWS re:Invent 2017 was serverless computing. Whether deploying microservices in containers using ECS, Kubernetes, or Fargate, or building systems using Lambda that connect to serverless relational databases like Serverless Aurora or DynamoDB, Amazon is rapidly moving to remove “undifferentiated heavy lifting” common to building and deploying software applications.

Healthcare has historically been slow to move to the cloud. Some of this stemmed from spotty HIPAA eligibility, and from a desire of health systems not to be the first to break new ground. Today, however, many of the barriers have been cleared away: serverless technologies like Lambda and ECS are already on Amazon’s HIPAA-eligible services list with many more likely to come in the future.

There are many benefits to serverless architectures, including faster time to market, lower operating costs, and lower complexity. Here are 4 compelling reasons why serverless systems are uniquely positioned to thrive in healthcare:

Improved Security

The HIPAA security rule contains a number of requirements for server security. You’d be hard pressed to find a list of security recommendations that doesn’t start with patching your servers. Indeed, over the last year unpatched servers have led to several major security incidents and breaches. There are many (poor) reasons why people don’t patch. Failure to patch machines promptly is a significant risk vector.

With serverless systems, this risk vector goes away.

https://www.csoonline.com/article/3075830/data-protection/zero-days-arent-the-problem-patches-are.html

In actuality, the risk is not entirely removed; instead you’re selling it to Amazon. Underneath serverless technologies, there are still servers running operating systems. However, the bet that you’re making is that Amazon has this down to a science across their millions of servers in a way that other IT departments can’t match.

 

Governance and Compliance

HIPAA mandates a set of administrative controls that govern things like access control and auditability. This is another area that is already baked deeply into serverless architectures.

AWS contains a strong policy-driven identity and access framework in AWS IAM. This is a core component of serverless architectures to control access at every step in the architecture. Applying the ‘least privilege’ principle with IAM roles naturally limits the “blast radius” if a service does become compromised. And because policies are all held in one place, it’s easier to see and control which accounts have access to what.

Auditability and robust logging go hand-in-hand, and if serverless architectures do anything, they generate a ton of log data. Each service, from AWS Gateway routing request to VPC delivering network traffic, to Lambda services handling requests, to S3 getting and setting bulk data is heavily logged, with most logs aggregating into either S3 or CloudWatch Logs. Several of the re:Invent sessions this year explored novel ways to report on this data using tools like ElasticSearch (note: the AWS-managed ElasticSearch Service is not yet on the HIPAA eligible list), and even automatically detect anomalous usage patterns using Kinesis Analytics.

Finally, AWS Artifact organizes all of the compliance documentation for Amazon’s part of the shared-responsibility model, including things like your AWS Business Associate Addendum (BAA), and access to SOC2 audits.

All of this stuff is just baked in, and there’s hardly any work needed to make use of it.

 

Availability and Scalability

While the security and encryption parts of HIPAA get most of the attention, it also contains provisions for ensuring availability, business continuity, and emergency mode operations.

Capacity and availability is something that used to be hard to plan in the days of individual server instances. A well-designed serverless architecture, by contrast, encourages robust-by-design implementations that can scale based on actual usage. Deploying across multiple data centers (AZs) is the default. Deploying across multiple regions is easy. This once again removes a common source of error and failure and gives solution builders tools to build “internet scale” systems that deliver three, four, or more 9’s of availability.

And in the unlikely event that there is an outage, backup and restore is also easy. Relational (Aurora) databases automatically perform backups, and backup/restore support for the DynamoDB document database was announced at re:Invent.

 

Increased Interoperability

Healthcare data has often been locked into data silos inside EMRs and other proprietary systems-of-record. Additionally, the quantity of data has meant that health systems need to undertake massive data consolidation and data warehousing projects to begin to recognize the value stored in this data.

At the same time, in recent years, there has been an explosion in patient-generated data. Vast quantities of activity tracking data, medication adherence records, blood glucose measurements, and patient reported outcome data (to name a few examples) sits collected but underused and uncorrelated.

In modern serverless architectures, patient data from inside and outside the four walls of the clinic can be easily collected and stored in large-scale data lakes like S3 where it can be easily aggregated, cleaned, transformed, queried, and reported on. HIPAA regulations are easily fulfilled, with HIPAA-compliant encryption at no additional cost just a button-click away (or sometimes a few buttons if you want to manage your own encryption keys). Control over who can access and use this data are returned to governance groups and clinicians based on business requirements and policy rather than obscure formats, closed databases, and network firewalls.

 

Wrap Up

At Wellpepper, we help healthcare providers deploy interactive care plans to their patients, so we take our data security and compliance responsibilities seriously. We were an early adopter of the AWS cloud back when EC2 and S3 were the only services available under the HIPAA umbrella, but things have changed! Following AWS’ announcement earlier this year that Lambda is now HIPAA-elegible, we’ve been looking more seriously at serverless system design, and we like what we see.

This is the future that anyone building solutions in healthcare IT should be excited about.

 

Relevant Content from AWS re:Invent 2017

Adopting Microservices in Healthcare: Building a Compliant DevOps Pipeline on Amazon ECS

What’s new in AWS Serverless 

Simplifying Healthcare Data Management on AWS 

Building a Secure and Healthcare-Compliant Platform for Adopting a Cloud-First Strategy using AWS 

American Heart Association: Finding Cures to Heart Disease Through the Power of Technology 

 

 

Posted in: Adherence, Data Protection, Healthcare Technology, Interoperability

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Are Women Better Surgeons? Patient-Generated Data Knows The Answer

As empowerers of patients and collectors of patient-generated data, we’re pretty bullish on the ability for this data to show insights. We fully admit to being biased, and view things through a lens of the patient experience and outcomes, which is why we had some ideas about a recent study that showed female surgeons had better outcomes than male surgeons.

The study, conducted on data from Ontario, Canada, was a retrospective population analysis of patients of male and female surgeons looking at rates of complications, readmissions, and death. The results of the study showed that patients of female surgeons had a small but statistically significant decrease in 30-day mortality and similar surgical outcomes.

Does this mean that women are technically better surgeons? Probably not. However, there is one sentence that stands out to a possible reason that patients of female surgeons had better outcomes.

A retrospective analysis showed no difference in outcomes by surgeon sex in patients who had emergency surgery, where patients do not usually choose their surgeon.

This would lead us to believe that there is something about the relationship between the patient and the provider that is resulting in better outcomes. We have seen this at Wellpepper, while we haven’t broken our aggregate data down by gender lines, we have seen that within the same clinic, intervention, and patient population, we see significant differences in patient engagement and outcomes between patients being seen by different providers.

Some healthcare professionals are better than others at motivating patients, and the relationship between provider and patient is key for adherence to care plans which improve outcomes. By tracking patient outcomes and adherence by provider, using patient-generated data, we are able to see insights that go beyond what a retroactive study from EMR data can show.

While our treatment plans, and continued analysis of patient outcomes against those treatment plans go much further than simply amplifying the patient-provider relationship, for example with adaptive reminders, manageable and actionable building blocks, and instant feedback, never underestimate the power of the human connection in healthcare.

Posted in: Adherence, Behavior Change, big data, Clinical Research, patient-generated data

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In Defense of Patient-Generated Data

There’s a lot of activity going on with large technology companies and others trying to get access to EMR data to mine it for insights. They’re using machine learning and artificial intelligence to crawl notes and diagnosis to try to find patterns that may predict disease. At the same time, equal amounts of energy are being spent figuring out how to get data from the myriad of medical and consumer devices into the EMR, considered the system of record.

There are a few flaws in this plan:

  • A significant amount of data in the EMR is copied and pasted. While it may be true that physicians and especially specialists see the same problems repeatedly, it’s also true that lack of specificity and even mistakes are introduced by this practice.
  • As well, the same ICD-10 codes are reused. Doctors admit to reusing codes that they know will be reimbursed. While they are not mis-diagnosing patients, this is another area where there is a lack of specificity. Search for “frequently used ICD-10 codes”, you’ll find a myriad of cheat sheets listing the most common codes for primary care and specialties.
  • Historically clinical research, on which recommendations and standard ranges are created, has been lacking in ethnic and sometimes gender diversity, which means that a patient whose tests are within standard range may have a different experience because that patient is different than the archetype on which the standard is based.
  • Data without context is meaningless, which is physicians initially balked about having device data in the EMR. Understanding how much a healthy person is active is interesting but you don’t need FitBit data for that, there are other indicators like BMI and resting heart rate. Understanding how much someone recovering from knee surgery is interesting, but only if you understand other things about that person’s situation and care.

There’s a pretty simple and often overlooked solution to this problem: get data and information directly from the patient. This data, of a patient’s own experience, will often answer the questions of why a patient is or isn’t getting better. It’s one thing to look at data points and see whether a patient is in or out of accepted ranges. It’s another to consider how the patient feels and what he or she is doing that may improve or exacerbate a condition. In ignoring the patient experience, decisions are being made with only some of the data. In Kleiner-Perkin’s State of the Internet Report, Mary Meeker estimates that the EMR collects a mere 26 data points per year on each patient. That’s not enough to make decisions about a single patient, let alone expect that AI will auto-magically find insights.

We’ve seen the value of patient engagement in our own research and data collected, for example in identifying side effects that are predictors of post-surgical readmission. If you’re interested, in these insights, we publish them through our newsletter.  In interviewing patients and providers, we’ve heard so many examples where physicians were puzzled between the patient’s experience in-clinic or in-patient versus at home. One pulmonary specialist we met told us he had a COPD patient who was not responding to medication. The obvious solution was to change the medication. The not-so-obvious solution was to ask the patient to demonstrate how he was using his inhaler. He was spraying it in the air and walking through the mist, which was how a discharge nurse had shown him how to use the inhaler.

By providing patients with useable and personalized instructions and then tracking the patient experience in following instructions and managing their health, you can close the loop. Combining this information with device data and physician observations and diagnosis, will provide the insight that we can use to scale and personalize care.

Posted in: Adherence, big data, Clinical Research, Healthcare Disruption, Healthcare Research, Healthcare Technology, Healthcare transformation, Interoperability, M-health, patient engagement, patient-generated data

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Evaluating A Patient Engagement Solution

In the past year, patient engagement has evolved past pilots to enterprise-wide deployments, and standards are emerging to evaluate patient engagement platforms. We definite patient engagement platform as a comprehensive system to enable patients to participate in their care, follow treatment plans, and get support from their care team. These patient interactions may occur outside the clinic or inside the hospital setting or clinic. What’s key is that they occur on the patient terms, and the patient device.

Here’s a checklist to get you started, and you’ll find in this check-list why your EMR will not deliver a compelling patient engagement experience.

  • Engagement: The first job of a patient engagement system, is of course, engaging patients. You should expect significantly better uptake in user interactions from a patient engagement system than from your patient portal. What percentage of patients login and use the platform? Do they show the ability to engage patients over time? Are there statistics for engagement for different patient demographics?
  • Usability: Patients are consumers, and their expectations for usability of your application are the same as for any other application on their devices. Can you deliver an experience on par with great consumer applications? Can patients of all ages and abilities use the application without help?
  • Multi-modal Interactions: This is a fancy way of saying that the system needs to support different ways of interacting with patients, for example, SMS, email, web, mobile application, and emerging technologies like voice. Can the system deliver patient interactions in ways that are appropriate for the patient and the content?

multimodal patient interactions

  • Interoperability: Your patient system will need to interface with other systems, like your EMR, scheduling, referral management, and possibly even billing systems. Interoperability needs to be built in from the initial design of the system. Does the patient engagement system have an API? Does it charge extra for application integration interfaces? If the answer to either of these is no, you don’t have an interoperable.
  • Scalability: Scalability takes two forms. Does the system help you to scale care? Can you see more patients, or see patients more efficiently because they can self-manage? Does it provide recommendations for providers and alerts that are at the right level for the interactions? The second form of scalability, is in interventions. Point solutions may address one type of intervention very well, but both patients and health systems need to manage multiple problems. Does the system scale to any type of intervention?

You’ll notice that this list does not include HIPAA compliance: that’s a given. Security and the protection of PHI are table stakes that any good system can show you before you start the rest of the evaluation.

In addition to the technical and usability criteria, your patient engagement solution needs to deliver on value. Determining value will be different for each organization, but we have some tips to help you make the case for yours.

Posted in: Adherence, patient engagement

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Telehealth 2.0: Our picks for Orlando

File-2016-3478-2017_ATATradeshow_1920_25I am really looking forward to heading to Orlando for the American Telemedicine Conference, aka Telehealth 2.0. Seattle has been under a rain cloud this entire year, and I want to see the sun. I’m also looking forward to sharing our findings in using asynchronous mobile telehealth for remote rehabilitation with patients recovering from total joint replacement. I’ll be speaking with our colleagues from Hartford Health, Reflexion, and Miami Children’s Hospital on Sunday during the first breakout sessions. Hope to see you there!

In addition to the topics about legislation and regulations, it’s great to see these sessions on value, quality, and new treatment models. Here are some of Wellpepper’s picks for the conference.

Sunday

Monday

Tuesday

Now with all this great content, networking and a talk to prepare, when will I see the sun?

Posted in: Adherence, Behavior Change, Health Regulations, Healthcare Disruption, Healthcare Legislation, Healthcare Policy, Healthcare Research, Healthcare Technology, patient engagement, Telemedicine

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Population Health and Patient Engagement: A Reckoning Is Coming

Population health and patient engagement should be best friends. To draw conclusions for population health, you need a lot of data, and patient engagement that is, patients interacting digitally with treatment plans and healthcare providers, generates a ton of data. Population health tries to analyze the general to get to the specific and identify patients at risk. Patient engagement starts with the specific patient, and with enough data recorded by those patients, can find general trends.

With patient engagement, the information is real-time. With population health it is backwards-looking. Population health has the richness of the medical teams notes and diagnosis but it is missing the patient perspective. Patient-generated data will have diagnosis if it’s part of a treatment plan prescribed by a physician, but it won’t have the full notes. A blurring of the boundaries between population health and patient engagement presents a way forward to greater insights about both individuals and groups, and can make population health actionable at the individual patient level by providing personalized instructions (with or without care managers).

However, to get to this desired end-state, we need to clear some obstacles, first of which is the idea that patient engagement generates too much data for physicians.

Yes, an individual physician does not want to see or review each data point that a true patient engagement solution generates. However, this information can be extremely interesting to the patient, especially when looking for trends to help self-manage a chronic condition so it is worth enabling patients to collect it. For example, looking at whether certain foods trigger arthritis, or whether certain activities trigger headaches. However, to draw conclusions like this, you must record a lot of data points and in real-time, and this makes physicians nervous. They have enough to do, and not enough time to do it in, so this data cannot add to that workload.

As well, patient-generated data is messy, which can be intimidating, especially in an industry that is looking for deviations from norms. The challenge with patient-generated data is that it can uncover that the long-tail is actually longer than previously thought, that there are sub-groups within previously thought to be homogeneous groups of patients with a similar condition. In the long run, this will result in medical breakthroughs and personalized medicine. In the short run this can be difficult to deal with in the current systems.

the long-tail is actually longer than previously thought

Does that mean that we shouldn’t collect patient-generated data? Not at all. Helping patients track their experiences is a great first step to self-management. Knowing whether they are following a treatment plan, and what their experiences are with that treatment plan can help healthcare systems determine the impact of their instructions outside the clinic.

Although physicians don’t want all this data, healthcare organizations both providers and payers, should want it. Other industries would kill for this type of data. Data scientists and population health managers at health systems should be clamoring for this valuable patient-generated data.

Patient-generated data is usually collected in real-time so it may be more representative of the actual current population. The benefit of real-time collection is that further exploration of the actual patient experience is possible and can be used to prevent issues from escalating. With backwards looking data whatever was going to happen has happened, so you can only use it to impact new groups of patients not current groups.Patient-Generated Data

Finally, patient-generated data is less likely to be siloed, like clinical data often is, because the patient experience is broad and often messy and crosses clinical department thresholds (or more simply, patients are usually treated for more than one issue at a time.) Being relatively new to market, patient-engagement systems are built on modern and interoperable technology which also makes accessing data for analysis easier.

So where will we end up? To our team at Wellpepper, it seems inevitable that influencing and understanding patient experience outside the clinic. If you are making decisions for an individual patient with only a few clinical touch points, this is a very thin slice, often with a specific clinician’s specialty lenses on the actual situation. While healthcare systems are currently dipping their toes in the water on collecting and analyzing this data, if they don’t embrace the whole patient, patients will vote with their feet and pocket books towards organizations that are data and technology driven.

Posted in: Adherence, big data, Healthcare Technology, Healthcare transformation, Interoperability, M-health, patient engagement, population health

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Is Connected Health Entering The Mainstream?

I’m just back from Parks Associates 3rd Annual Connected Health Summit. The summit, which began with a focus on consumer health and devices, is broadening to include the consumer experience in all digital health. Most attendees were from technology, payer, and device industries rather than healthcare organizations, and I was struck that a lot of the discussion of about the data from devices, predictive analytics, and natural language processing was beyond what we’re seeing in implementation in healthcare industries today.

Evolution of Digital Health

Evolution of Digital Health

Possibly because Parks Associates focuses on consumer data, and also that the conference has been consumer-device focused in the past, attendees and presenters included telecommunications companies, and even home security companies. This was my first time at the conference but from the data presented by Parks it seems as though digital health, and consumer focused health has become accepted as inevitable and mainstream. A few examples include ADT, the home security company talking about in-home sensing to enable seniors to stay in their homes longer, and Wal-mart talking about meeting healthcare consumers where they are. All of this is a far cry from traditional healthcare delivery. There was also a belief that digital health and the digital health consumer touches everyone from seniors, to the example that for many homeless people their most prized possession is their mobile phone.

Top takeaways:

  • There is no silver bullet for mobile health, digital health, or sensors.
    • Personalization is going to be key as the drivers for engaging in health are different for each person
  • There is no digital health consumer. Segmentation is very challenging in this market. Parks Associates Research identified 4 consumer groups, and 14 segments within those groups.

Digital Health Segments

  • Technology is currently out-pacing implementation possibly due to a slower transition to value-based care than the speed of consumer technology adoption.
  • People are sometimes consumers and sometimes patients, and this is not mutually exclusive.

From Fee For Service To Value-Based Payments

I had the pleasure of participating on a panel on moving to value-based care with Dr. Alexander Grunsfeld, Chief of Neurology from our customer Sentara Healthcare, and Angie Kalousek  from Blue Cross/Blue Shield of California. Too often value gets lumped into the idea of bundles versus fee for service, instead of considering the triple aim of healthcare and delivering the best patient experience and outcomes cost effectively. Fee for service remains the stumbling block to value-based care and organizations have to straddle two worlds when considering implementing two programs. Those who can effectively cross the chasm from fee-for-service to value-based care will be the ones who succeed in the long run, and especially those who consider options before they are legislated to do so.

Crossing the chasm from fee for service to value-based payments

Crossing the chasm from fee for service to value-based payments

Our headache management project with Sentara started from the need of one neurologist to manage his caseload. He had too many patients and not enough data, and needed a way to identify patients that needed the most help and also to enable patients to self-manage their headaches. Interestingly, though although the problem that he was trying to solve was focused on access, in a fee-for-service world, initial appointments are compensated at a higher rate that follow on appointments, so decreasing the need for follow on appointments could actually increase revenue. In an exact opposite scenario, this project has caught the attention of those in Sentara’s health plan, Optima, and they are looking to use this patient self-management to decrease ER costs by enabling patients to better self-manage.

Audience poll on in-home care

Audience poll on in-home care

Posted in: Adherence, Behavior Change, Healthcare Policy, Healthcare Research, Healthcare Technology, Healthcare transformation, M-health, Managing Chronic Disease, patient engagement

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Cardiac rehab is effective, but patient-centered care needs to actually be patient-centered

With CMS’s new Cardiac Bundle, cardiac care (especially post-acute care), is the next service line to go under the microscope. As with total joint, variations in outcomes and costs are often seen in post-acute care so looking at how that care is delivered is key. For any bundle to be successful, engaging patients and ensuring their participation in follow up is a driver of success.

I have to admit, I haven’t read the bundle specs yet, just the news on the bundle. According to Becker’s Hospital Review’s “10 things to know about CMS’ new mandatory cardiac bundle”, the bundle includes provisions to test cardiac rehabilitation services, with 36 sessions available over 36 weeks. However, according to this article from NPR, although cardiac rehabilitation is proven to be effective, most people don’t participate. If you read through the comments on the NPR article (ignoring the trolls of course), you’ll start to see the reasons: cardiac rehabilitation care is built around the needs of the people providing the rehabilitation, not the patients.

From our experiences delivering post-acute care plans, as well as talking to payers and providers we’ve learned a few reasons why patients don’t follow up with their outpatient care:

  • Distance: In cardiac cases, patients are taken to the closest hospital, but this may not be the closest to their home or work. In other post-acute scenarios, they may have gone to a center of excellence that is also at distance.
  • Time commitment: These programs often require multiple days of treatment a week. Not everyone has the flexibility to take off work.
  • Timing: Programs are usually offered during 9 to 5, to accommodate the needs of the providers. Patients might prefer evening or weekend programs. We talked to one provider that focuses on lower income patients. People in hourly wage jobs don’t get to choose when they take breaks and their breaks are usually 15 minutes, and maybe 30 minutes for lunch. It’s next to impossible for them to attend in-person sessions.
Francis Ying/Kaiser Health News

Francis Ying/Kaiser Health News

The NPR article keyed in on these within the one example of Kathryn Shiflett (a healthcare worker herself!) whose distance and work hours (4:30 AM – 3:00 PM) pose a significant barrier: “She lives an hour away and is about to start a new job. Cardiac rehab classes happen Mondays, Wednesdays and Fridays, with sessions at 8 a.m., 10 a.m. and 3 p.m.”

While the bundles are definitely driving the right behavior in focusing on patient outcomes rather than procedures, they need to go further to promote patient-centered care. In this case, that should be testing new models like mobile health or community-based rehab programs that are adaptable to the unique needs of different patient groups.

Posted in: Adherence, Healthcare Disruption, Healthcare Legislation, Healthcare motivation, Healthcare transformation, Occupational Therapy, patient engagement, Patient Satisfaction, Rehabilitation Business, Uncategorized

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Wellpepper to attend The Beryl Institute Patient Experience Conference in Dallas!

I will be traveling to the great state of Texas for my first Beryl Institute Patient Experience Conference next week. The Beryl Institute is a global community of practice dedicated to improving the patient experience through collaboration and shared knowledge. They define patient experience as the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.

As a first time attendee, I am thrilled to be part of this community that is inspired to improve the patient experience. It will be a great 3 days of networking, education and sharing of ideas on how we, as a healthcare community, can make a difference in patient care.This shift to patient centered care has been coming for quite some time. Now that value-base reimbursement is starting to take shape, this conference could not be timelier. Since I will be an attendee and not an exhibitor (yea!), I will be able to get in the trenches with leaders of patient experience, quality and transformation from major health systems from across the country.

There are so many sessions that touch upon all aspects of patient experience and engagement, it’s a bit overwhelming. But, here are the sessions that peaked my interest.  Hope to see you there!

April 13, 2016
Opening Keynote: Dr. Ronan Tynan – Recording artist, physician and champion disabled athlete

Breakout Sessions I
Patent is Not a Consumer – Here’s Why
Leveraging Physician Engagement in Patient Experience Improvement Efforts
Evolving to a Patient-Centered Team-Based Culture – Engaging the Healthcare Team

April 14, 2016
Keynote Day: Cynthia Mercer – Senior Vice President & Chief Administrative Officer – Mercy Health

Breakout Sessions II
Removing Complexity from the Post-Acute Patient Experience
The Role of the Built Environment in Improving Patient Experiences and Outcomes

Lunch & Learn
“I’m There to Efficiently Help People”: How Our Busiest Clinicians Balance Productivity and Patient Experience
The Role of the Built Environment in Improving Patient Experiences and Outcomes 

April 15, 2016
Keynote: Montel Williams – Talk Show Host and MS Awareness Champion

Breakout Sessions III
Digital Engagement of Discharged ED Patients is a Must
The Impact of Cultural Diversity on Patient Experience

Breakout Sessions IV
Enhancing Patient Experience and Engagement Through Technological Innovation
The Patient Financial Experience: A Link to Satisfaction, Payment and More.
Closing Keynote: Kelly Corrigan – Author, Philanthropist and Breast Cancer Survivor

Conference program full packet can be found here

If you will be at the conference too, please contact Robin to schedule a meeting.

Posted in: Adherence, Healthcare transformation, patient engagement, Patient Satisfaction, Telemedicine

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mHealth and big data will bring meaning and value to patient-reported outcomes

Anne Weiler
Wellpepper, Inc., Seattle, WA, USA
Correspondence to: Anne Weiler. CEO, Wellpepper, Inc., Seattle, WA, USA.
Email: anne@wellpepper.com
Abstract: The intersection of widespread mobile adoption, cloud computing and healthcare will enable patient-reported outcomes to be used to personalize care, draw insights and shorten the cycle from research to clinical implementation. Today, patient-reported outcomes are largely collected as part of a regulatory shift to value-based or bundled care. When patients are able to record their experiences in real-time and combine them with passive data collection from sensors and mobile devices, this information can inform better care for each patient and contribute to the growing body of health data that can be used to draw insights for all patients. This paper explores the current limitations of patient reported outcomes and how mobile health and big data analysis unlocks their potential as a valuable tool to deliver care.

Link to full article can be found here

Posted in: Adherence, Healthcare Technology, M-health, Telemedicine

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APTA Combined Sections Meeting Wrap Up

Walking the floor at APTA CSM 2016 Anaheim, CA

Last week, I attended the American Physical Therapy Association Combined Sections Meeting (APTA CSM) in Anaheim, CA. The show was well attended by about 18,000 Physical Therapists and professionals in related roles. The packed house meant lots of energy, a few full sessions, and long lines for coffee at the two overwhelmed Starbucks kiosks in the nearby hotels. Wellpepper started out in physical rehabilitation, so it was great to be back in the company of many talented ‘movement system experts’ and associates working together to gain knowledge in order to achieve best practices for healthcare systems, patients and/or caregivers.

I attended a number of sessions, mostly focused on the shift to value-based payment, and outcome measurement. The healthcare value equation has penetrated deep in this community. I saw the same basic slide in at least 3 talks:

* This formula has been widely discussed by Michael Porter and others.

I attended two presentations on outcome measurements by Beth Israel Deaconess Medical Center (BIDMC) and Johns Hopkins. Both organizations spoke about the task of adopting outcome measurements in an acute settingand their thoughtful deliberate steps to take research-based measurement techniques and apply them into clinical practice;BIDMC’s applied the Knowledge Translation framework, and Hopkins’ applied the Translating Knowledge Into Practice (TRIP) initiative. There were many similarities that both organizations encapsulated in their task of adopting outcome measurements; both organizations had to fight against “don’t give me more documentation work” attitudes, worked cross-functionally with PTs, nurses, physicians and administrators to gain support for their plans. And both adopted process measurements to observe the rollout of outcome measurement tools and practices. Furthermore both had some crossover in the specific measurement tools they used (e.g. AM-PAC / 6 clicks).Another common thread I believe important to note was the development of practical tips and tricks for how to make it easy to capture data into their EMRs that weren’t always designed to capture this kind of data (real nuts-and-bolts stuff like how to copy and paste boilerplate text).

Finally, armed with data on patient functional outcomes, Johns Hopkins shared some of the work they were doing on risk-stratifying patients to help control costs. In a world where Post-Acute Care costs represent one of the largest and most variable cost centers for many procedures, this is critical. The quantity and richness of this data is something I hadn’t seen presented at this conference before. Here is real objective data on how real patients progress through their care journeys that can be used to at the individual level to have an informed conversation with the patient and provides fantastic optics into the most important work product of the healthcare system: making people better.

I was struck that both presentations concluded that measuring outcomes was less of a technical feat than an organizational one. It is, as Michael Friedman a presenter from Johns Hopkins articulated, “About culture change more than anything.”

Throughout the conference, there were also mentions of Patient-Reported Outcomes (Oswestry, HOOS, KOOS were frequently mentioned – thankfully ones that Wellpepper supports!) My sense was that these are still not as widely deployed and not as consistently measured to have made their way into any of the mainstream presentations. As Wellpepper and other companies keep pushing to measure (and improve!) the patient journey with patient reported outcomes, I expect this will change in the coming years.

The one disappointment I had from the conference was that the excellent session on the Patient Experience was not better attended. Jerry Durham (a minor celebrity in the PT world!) introduced a panel of 2 patients to present on their experiences and lamented that often the Triple-Aim objectives are reduced to a Double Aim, ignoring the patient experience. So we had the excellent chance to learn and hear real patients talk. Both patients were both doing great thanks to their Physical Therapists, but both talked about the significant failings they’d seen in their medical practitioners (of all stripes). In a string of wrenching, quotable sound bites, one said “I couldn’t have gotten this bad without the help of PT”. It’s a shame that despite the healthcare rhetoric about putting patients first that more attendees didn’t put this into practice and take the opportunity to learn from some honest patient-driven conversation.

All told, this was a good conference, notable for the increasing use of patient data to measure and improve. If the attendance for CSM 2017 in San Antonio is anything like this one, let’s hope for more coffee and more chairs!

Posted in: Adherence, Healthcare Disruption, Healthcare Technology, M-health, Telemedicine

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Our Picks for APTA CSM 2016

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

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

Here are a few session picks from Wellpepper.

Patient-Centered Care

Exercise and Diabetes: Tools for Integrating Patient-Directed Practice

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

Words Mean Things: How Language Impacts Clinical Results

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

Technology

Wearable Technology Meets Physical Therapy

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

Tracking Outcomes

Changing Behavior Through Physical Therapy: Improving Patient Outcomes

Functional Reconciliation: Implementing Outcomes Across the Continuum

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

Healthcare Transformation and New Models of Care

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

The Complicated Hip: A New Debate

Emerging Issues in Medicare and Health Care Reform, Part 2

Bundled Payment Implementation for Primary Total Joint Patients

Managing Patient-Centered Care in a Changing Reimbursement World

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

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

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Reducing Readmissions and Costs for Total Joint Replacement

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

Patient Record on Parking

Patient record in parking garage of major health system

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

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

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

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

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

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

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

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

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Reducing Avoidable Readmissions: Transfer to Home

While studies show that discharge to home can be best for patient recovery from surgery, this is an area where communications and continuity of care often break-down, risking readmissions. The idea of a patient-centered medical home where the patient is at the center receiving consistent care from a group that can bring in specialists is intended to solve some of this problem, but better communications between healthcare organization, primary care physician, and patient and the patient’s care team can go a long way to improve discharge to home without requiring an entirely new model.

This post is part of a series recapping a recent training from the Institute for Healthcare Improvement’s course on Reducing Avoidable Readmissions.

Primary care physicians while often the most trusted person in the care team, and besides the patient the person with the best insight into the patient’s overall wellbeing are often out of the loop when it comes to hospitalization. Once a patient is referred to a specialist for surgery the hospital team takes over, and the primary care physician has little insight into what happens, even though when the patient is discharged they are back in the care of the primary care physician. Often the primary care physician has no idea when the patient has been hospitalized or re-hospitalized.

Primary care physicians who were participating in the course expressed both their desire to participate in this post-acute care follow up and frustration at both the lack of insight they had and felt powerless to influence the hospitals.

While the evidence on post-hospitalization follow up visits is mixed, common sense does point to following up with patients as being a good thing to prevent readmissions. However, depending on the model of care, this is either with a primary care physician or a hospitalist. Considering the PCP is responsible for the general health of the patient, moving to reimbursement models where this is possible also seems to make more sense.

 

Source: IHI.org

Source: IHI.org

One example cited was from Capitol District Physicians Health Plan, where physicians were paid to do post acute care follow-ups. The program plus a phone call from a case manager decreased readmissions from 14% to 6%. (Although it would be interesting to know whether the in-person visit or the phone call had the biggest impact.)

As with other sessions in this course, the keys to improving discharge to home were in communication with the patient and patient caregivers around expectations and communication back to the hospitalist or family physician about medication usage at home, and any concerning symptoms. Too often patients understand “You’re discharged” as “You’re better” and miss their responsibilities for doing follow-up care whether that is physical therapy, wound care, or just easing back into activities they participated in prior to surgery. Ensuring patients and their care givers understand that discharge to home still requires follow-up is a key to decreasing readmissions from this setting.

New models of transitional care and intensive care where patients receive personalized follow-up care and regular check-ins with a healthcare professional after hospital discharge were shown to improve overall function in patients, decrease readmissions, and decrease costs. These types of new models become more practical with the carrot of value-based payments coupled the stick of penalties for readmissions. While the overarching goal of decreasing readmissions is about improving patient care, having financial incentives aligned will provide an extra boost.

Continuing with the theme of the course, there is no one silver bullet. There is no one reason that patients readmit. That’s the bad news. The good news is that some basic common sense improvements, like better communication with patients and their care teams can decrease readmissions. We’ll go into more detail on how to improve communications in the next post on this topic.

Posted in: Adherence, Aging, Health Regulations, Healthcare Policy, Healthcare transformation

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Developing Exercise Self-Efficacy for Chronic Disease Patients

APTA CSM 2015 Recap: Use of Mobile Health Technology to Facilitate Long-Term Engagement in Exercise in Persons with Chronic Neurological Conditions

Speaker: Robert Motl, PhD

Managing chronic neurological diseases like Multiple Sclerosis and Parkinson’s is not easy, and made even more difficult by conflicting research on how to treat issues. For many years it was unclear whether exercise was good or bad for people with Multiple Sclerosis: some thought that exercise increased the inflammation that is a hallmark of the disease. Recent studies have shown the opposite however and this talk was focused on how an Internet-based intervention could improve exercise self-efficacy.

Exercise, in addition to providing increased mobility, has been shown to actually decrease depression and fatigue for these patients, contradicting past beliefs. Unfortunately, many physicians don’t discuss exercise with these patients, and to go from a sedentary lifestyle to one that includes activity, especially for someone with a chronic neurological issue requires support and supervision.

The problem is widespread as only an estimated 20% of MS patients in the US are engaging in levels of physical activity that will have a positive impact, and studies show a linear decrease in activity from initial diagnosis over the course of the disease with a systematic decline in physical activity every 6 months.

Bandura's Social Cognitive Theory, Source Ahmed Asim

Bandura’s Social Cognitive Theory, Source Ahmed Asim

When researcher Robert Motl discovered through a Microsoft-sponsored survey that people with MS were more likely than average to have Internet access (96% had access actually) he decided this would be a great way to educate on the benefits of exercise and attempt to encourage self-sufficiency. He designed an Internet-portal and telemedicine based intervention using Bandura’s techniques of social cognitive theory to effect behavior change.

People learn by observing and by doing and confidence is key for self-efficacy. To accomplish this through an online intervention the website featured personal stories and videos from people who had MS talking about how exercise made a difference for them. People need role models for behavior change and it’s important that those models are similar. The impact of these videos was that people were able to think “If they can do it, so can I.”

Patients were also able to set goals and self-monitor them and communicate in chat rooms with other people with similar situations. After the first year, the website was removed, which may seem strange, but it was done to test whether people would continue with the intervention, which they did. At this point the only support they received 1:1 video chat with a physical therapist to help them check-in and maintain goals.

The main takeaways from this session are that with the right tools and support, which do not have to be expensive, people can change a behavior and maintain self-efficacy. At Wellpepper, we have definitely seen this and hope that more studies like this enable better care through technology and through outside the clinic support.

Note that the other half of this talk explored a yet unpublished study that Boston University is doing with Wellpepper. You can get a sneak preview here, and we’ll be publishing more on this in the future.

Posted in: Adherence, Behavior Change, chronic disease, Healthcare motivation, Outcomes

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Translating Evidence-Based Interventions to Practice: Falls Prevention and Otago

APTA CSM 2015 Session Recap: Falls Prevention: Otago Program and Behavior Change

Presenters:

Mary Altpeter, PhD

Tiffany Shubert, PhD

Clinical Support for Otago

Clinical Support for Otago

The fact that a session entitled “Falls Prevention: Otago Program and Behavior Change “ ended up in the Health Administration /Policy track at APTA CSM 2015 reinforces that we have a long way to go on translating outcomes-based research into care plans. Otago is a proven and effective set of preventative exercises and care for community-dwelling yet frail adults which improves balance and prevents falls risk. It was developed in New Zealand, at the University of Otago over 14 years ago, and prescribes a set of balance and strength exercises that the patient completes independently over 12 months.

Recommended physical therapy visits to access, teach, monitor, and kick-start patient adherence are to occur over 6-8 weeks and after that patients are encouraged to self-manage, and herein lies the reason that this session is in health policy and administration: this is longer than most insurance covers, and there are not currently enough incentives for remote patient monitoring. However, according to presenter Tiffany Schubert, Otago shows an ROI of $1.25 of every dollar invested as it prevents patients from falling which results deterioration to the patient and further burden on the health system.

Barriers to implementing Otago in the US stem largely from reimbursement and the current incident-based payment model that does not facilitate managing patients over a long period of time. As a result, Otago expert and presenter Tiffany Schubert presented an abridged version that might be easier to fit into current payment models.

Delivering Otago: Calendar view

Delivering Otago: Calendar view

However she is also on a crusade to collect outcomes data for Otago in the US so that these barriers can be overcome as the barriers are not just reimbursement. Clinicians have preconceived notions that patients won’t adhere to plans. Tiffany challenges these misconceptions by asking “are you sure or is it your patients just don’t understand.” We’ve definitely seen this with patients we’ve interviewed: they do want to be adherent to their plans but they find out when they get home that they forgot or are confused. Otago and systems like it work well when there is remote support for the patient.

Clinical Barriers to Implementation

Clinical Barriers to Implementing Otago

Given that Otago requires a high-level of patient self-efficacy, understanding factors that impact behavior change is key in driving long-term outcomes and adherence. Hence, the second half of this presentation, from Mary Altpeter focused on strategies to help patients develop self-management skills to complete the independent part of the program. One of the big misconceptions, that we hear frequently from healthcare providers (and definitely from many of the sensor and tracker vendors), is that knowledge is sufficient to effect change. It’s not, many other factors weigh in including readiness to change and social influences. Understanding more about the patient’s own journey and the patient’s barriers and readiness to change can make a big difference in this area. Also understanding the patient’s goals is crucial and personalizing their risk of not changing their behavior.

Breaking behavior change down into stages can really help move the patient along a path. In this session, Altpeter outlined a 5 stage model to affect patient behavior.

6-Stage Behavior Change Model

6-Stage Behavior Change Model

Understanding that while your assessment may show that the patient is at risk for falls, the patient may not have internalized this. First step is to plant the seed of doubt while the patient is in what is called the “Pre-Contemplation” stage. You can do this by personalizing the risk.

In a falls scenario, patients are not actually worried about falls risk. This sounds counter intuitive, but patient goals are usually not functional goals they are life goals. (We can attest to this from the goals patients set in Wellpepper.) So, the patient may be worried about losing their driver’s license which might happen if they had limited mobility. This is moving to patient-centered goals from clinical goals which personalizes the risk. Find out what the patient might be afraid of losing and this can start to plant the seed of doubt that they might be at risk for falls.

During the Contemplation phase the healthcare professional can help the patient break down what it might look like to be able to embark on a program. What might be their barriers or sticking points to do so? When might they do it? This isn’t about making a plan it’s about facilitating the patient in thinking that a plan might be possible.

The next phase Preparation, occurs when the patient has demonstrated that he or she is ready to change, and this is where we can examine the nuts and bolts, breaking down what may seem like a daunting task (adhering to a program for 12 years), into something manageable. Here is where you help the come up with plans to overcome the barriers you identified. One key barrier is often fear of relapse: that is that when a patient stops doing the plan, they can’t get back on the wagon, so to speak. Making it okay to “start over” is a great way to encourage patients.

During the preparation phase you may also want to help the patient break down the program into smaller goals and manageable chunks so they can see progress during the program. Also help the patient identify rewards that will help drive their adherence. These are both important steps when helping with a large and often intangible goal.

Action is putting the plan into place. Here your main role is to support the patient, help them continue to overcome barriers, and be a cheerleader to keep them going in the case of a relapse.

The final stage is Maintenance (which includes dealing with Relapse). Pointing out the patient progress, possibly by completing another falls assessment and showing the difference is a great way to reinforce that the program worked and it’s worth continuing. Also ask the patient to remember what fears they had before the program and whether they feel that now. Simply shining a light on their own experience can help a lot here.

With an aging population, and rising health costs, translating valuable and proven research like the information in this session into clinical practice is key. Given that the average time from research to implementation is 17 years, and that Otago was invented 14 years ago, we can only hope to see widespread adoption by 2018. That’s also in-line with CMS’s new requirements for 50% of Medicare spend being for new value and outcome-based models. It’s time right?

Posted in: Adherence, Aging, Behavior Change, Exercise Physiology, Healthcare Disruption, Healthcare transformation, Physical Therapy, Rehabilitation Business

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