Adherence

Archive for Adherence

Simple Patient-Centered Design

At Wellpepper, we work hard to make sure our software is intuitive, including working with external academic researchers on randomized control trials for people who may have cognitive or other disabilities. This is both to make sure our software is easy-to-use for all abilities, and to overcome a frequent bias we hear about older people not being able to use applications, and also to provide valuable feedback. We’ve found from these studies, the results of which will be published shortly in peer-reviewed journals, that software can be designed for long-term adherence, and this adherence to programs can lead to clinically-meaningful patient outcome improvements.

User-centered design relies on three principles, all of which can be practiced easily, but require continual discipline to practice. It’s easy to assume you know how your users or patients will react either based on your own experiences, or based on prior knowledge. There’s really no substitute for direct experience though. When we practice user-centered design, we think about things from three aspects:

Immersion

Place ourselves in the full experience through the eyes of the user. This is possibly the most powerful way to impact user-centered design, but sometimes the most difficult. Virtual reality is proving to be a great way to experience immersion. At the Kaiser Permanente Center For Total Health in Washington, DC, participants experience a virtual reality tour by a homeless man showing where he sleeps and spends his days. It’s very powerful to be right there with him. While this is definitely a deep-dive immersion experience, there are other ways like these physical therapy students who learned what it was like to age through simple simulations like braces, and crutches. Changing the font size on your screens can be a really easy way to see whether your solution is useable by those with less than 20/20 vision. With many technology solutions being built by young teams, immersion can be a very powerful tool for usable and accessible software.

Observation

Carefully watch and examine what people are actually doing. It can be really difficult to do this without jumping in and explaining how to use your solution. An interesting way to get started with observation is to start before you start building a solution: go and visit your end-user’s environment and take notes, video, and pictures.

Understanding what is around them when they are using your solution may give you much greater insight. When possible we try to visit the clinic before a deployment of Wellpepper. Simple things like whether wifi is available, how busy the waiting room is, and who is initiating conversations with patients can help us understand how to better build administrative tools that fit into the clinician’s workflow. Once you’ve started with observing your users where they will use your solution, the next step is to have them test what you’ve built. Again, it doesn’t have to be complicated. Starting with asking them how they think they would use paper wireframes or voice interface testing with Wizard of Oz scenarios can get you early feedback before you become too attached to your creations.

Conversation

Accurately capture conversations and personal stories. The personal stories will give you insight into what’s important to your users, and also uncover things that you can’t possibly know just by looking at usage data. Conversations can help you with this. The great thing about conversations is that they are an easy way to share feedback with team members who can’t be there, and personal stories help your team converge around personas. We’ve found personal stories to be really helpful in thinking about software design, in particular understanding how to capture those personal stories from patients right in the software by letting them set and track progress against their own personal goals.

Doctor’s often talk about how becoming a patient or becoming a care-giver for a loved one changes their experiences of healthcare and makes them better doctors. This is truly user-centered design, but deeply personal experience is not the only way to learn.

To learn more:

Check out the work Bon Ku, MD is doing at Jefferson University Hospital teaching design to physicians.

Visit the Kaiser Permanente Innovation Center.

Learn about our research with Boston University and Harvard to show patient adherence and outcome improvements.

Read these books from physicians who became patients.
In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope, Rana Adwish, MD
When Breath Becomes Air Paul Kalanithi, MD

Posted in: Adherence, Aging, Behavior Change, Clinical Research, Healthcare Technology, Healthcare transformation, patient engagement, Patient Satisfaction, Research

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Voice.Health Shows The Promise of Conversational Interfaces

“By embracing voice, healthcare has the opportunity to leapfrog technology from other industries” John Brownstein, PhD, Chief Innovation Officer, Boston Children’s Hospital

Dr. Brownstein was speaking in shared keynote at the Voice.Health summit about why he and other healthcare innovators are so pumped about the opportunity for voice in healthcare. On a later panel Shivdev Rao, MD from UPMC Enterprises described what makes voice a natural fit.

75-80 percent of the signal in a hospital is voice-driven
Shivdev Rao, MD, Vice President, UPMC Enterprises

The one-day concentrated pre-day at Connected Health focused on all things voice tech in healthcare and was kicked off by Klick Health founder and CEO Leerom Segal, who talked about the factors that made this time ripe for voice in the tech industry overall. Putting technology in context is exactly what’s needed at more healthcare events versus a sometimes myopic view of healthcare technology.

So why is voice having a moment?

  • Compute power necessary for processing the large amounts of data that voice creates and requires is now available and relatively inexpensive through cloud offerings from Amazon, Google, and Microsoft
  • Devices are cheap and ubiquitous
  • We’re already trained to expect instant answers but starting to be sensitive to the impact of screen time
  • Voice is seen as more accessible to broader groups
  • And of course, voice is being used as a Trojan horse for commerce (at least by Amazon), for Google it’s for more data

In addition to panels on clinical and consumer impact of voice in healthcare, there was an immersive experience with examples of voice technology in different healthcare settings including clinic, hospital room, operating room, senior home, and an actual home living room. We participated on the consumer panel, and showcased Sugarpod (in the living room since there wasn’t a bathroom.) During the course of the day, and in the keynote at least a hundred potential uses for voice in healthcare were explored. At the same time, participants didn’t shy away from challenges either, like using voice for the wrong purposes like converting pages and pages of web content, or the challenges for people with hearing, cognition, or speech problems to use the devices, all of which can be mitigated with thoughtful voice interaction design, accessibility design, and user testing.

Clinicians have particular concerns about voice. From UPMC, Dr. talked about the challenges of any new and shiny technology in healthcare

As well, similar to what we’ve seen with other technology starting with the real problem of EMR screen time but also including mobile outside the clinic to machine-learning and artificial intelligence, clinicians are concerned about any technology getting between them and their patients. From Robert Stevens, Executive Director and Head of Digital for Novartis summed up what he had heard from physicians “I don’t to be usurped by a smart hockey puck at patient point of care.”

We’re bullish on voice, and agree with Brownstein, that embracing this technology puts healthcare on the cutting-edge technology-wise. It’s also an opportunity for new players, as the incumbents have not proved themselves capable of embracing consumer or end-user centric design that voice requires. We’re also still firmly in the “voice and” camp, looking at voice user interface as one of a number of tools for engaging patients as part of a comprehensive overall digital strategy. Planning and delivering on  a context-aware omni-channel adoption strategy for digital health is another way healthcare has an opportunity to evolve with the overall technology and consumer markets who also haven’t solved this thorny problem.

If you’d like to talk about how to deliver a consistent and engaging omni-channel experience that improves patient outcomes, get in touch sales@wellpepper.com

If you’re interested in voice, check out our other blog posts on the topic:

Posted in: Adherence, Healthcare Social Media, Healthcare Technology, Healthcare transformation, M-health, patient engagement, Patient Satisfaction, Voice

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Digital Transformation in Pharma: Digital Pharma West

Like the rest of the healthcare industry, the pharma industry is also grappling with lots of data, disconnects from end-users, and shifting to a digital-first experience while grappling with ongoing regulatory and privacy challenges. Actually it’s pretty much what every industry is grappling with, so the good news is that no one is getting left behind in this digital revolution.

In pharma though, the division between commercial and R&D creates both delays and lags in implementing new technology and the regulatory challenges cause specific issues in communication with both providers and patients.

Last week, I was invited to speak at Digital Pharma West about our work in voice-enabling care plans for people with Type 2 diabetes, and also how our participation in the Alexa Diabetes Challenge enabled us to engage with pharma. It was my first ‘pharma-only’ conference, so it was interesting to contrast with the provider and healthcare IT world.

If you think that there are a lot of constituents who care about digital health in provider organizations, pharma rivals that. For example, there was a discussion about the value of patient-facing digital tools in clinical trials. While everyone agreed there could be real value in both efficiencies of collecting data, and engaging patients and keeping them enrolled in trials, a couple of real barriers came up.

First the question of the impact of the digital tools on the trial. Would they create an intended impact on the outcomes, for example a placebo effect? Depending on how the “usual care condition” is delivered in a control group, it might not even be possible to use digital tools in both cohorts, which could definitely impact outcomes.

Another challenge with digital technology in randomized control trials is that technology and interfaces can change much faster than drug clinical trials. Considering that elapsed time between Phase 1 and Phase 3 trials can be years, also consider that the technology that accompanies the drug could change dramatically during that period. Even technology companies that are not “moving fast and breaking things” may do hundreds of updates in that period.

Another challenge is that technology may advance or come on the market after the initial IRB is approved, and while the technology may be a perfect fit for the study, principle investigators are hesitant to mess with study design after IRB approval.

Interestingly, while in the patient-provider world the number of channels of communication are increasing significantly with mobile, texting, web, and voice options, the number of touch points in pharma is decreasing. Pharma’s touchpoints with providers are decreasing 10% per year. While some may say that this is good due to past overreach, it does make it difficult to reach one of their constituents.

At the same time, regulations on approved content for both providers and patients means that when content has had regulatory approval, like what you might find in brochures, on websites, and in commercials, the easiest thing to do is reuse this content. However, new delivery channels like chatbots and voice don’t lend themselves well to static marketing or information content. The costs of developing new experiences may be high but the costs of delivering content that is not context or end-user aware can be even higher.

At the same time, these real-time interactive experiences create new risks and responsibilities for adverse event reporting for organizations. Interestingly, as we talk with pharma companies about delivering interactive content through the new Wellpepper Marketplace, these concerns surface, and yet at the same time, when we ask the difference between a patient calling a 1-800 line with a problem and texting with a problem there doesn’t seem to be a difference. The only possible difference is a potential increase in adverse event reporting due to ease of reporting, which could cause problems in the short term, but in the long term seems both inevitable and like a win. Many of the discussions and sessions at the conference were about social media listening programs for both patient and provider feedback, so there is definitely a desire to get and make sense of more information.

Like everyone in healthcare, digital pharma also seems to be at an inflection point, and creativity thinking about audiences, channels, and how to meet people where they are and when you need them is key.

Posted in: Adherence, Clinical Research, Data Protection, Health Regulations, Healthcare Disruption, Healthcare Policy, Healthcare Research, Healthcare Social Media, Healthcare Technology, HIPAA, M-health, Outcomes, pharma, Voice

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Supporting Patient Motivation

What motivates people to improve their health and stay on the right track over time?

This question is on the mind of every practitioner, whether it’s a physician sending someone home with a wound care plan, a nutritionist giving dietary advice to help manage diabetes or a physical therapist providing exercises to get a frozen shoulder moving again. They’re thinking: “Will the patient do it?” To a great extent, the answer to this question determines how successful their treatment plans will be.

Some of this blog’s most popular posts have explored the issue of motivation because it is a major underpinning of patient engagement technology – will the patient use, and stick with, the technology that in turn helps them adhere to their care plans?

The subject of motivation usually starts with a discussion about goal-setting. This process, at least in the medical context, typically begins when the practitioner sets goals for the patient and provides a care plan that tells the patient what they need to do in order to get there. Some practitioners feel this should be motivation enough for a patient. In reality, they know it’s not.

So what is motivation? A great deal of research has gone into the subject, particularly with regard to behavior change. It is most often described as being either extrinsic (outside the individual) or intrinsic (inside the individual). With extrinsic motivation, we engage in a behavior or activity either to gain some sort of external reward or avoid a negative consequence. With intrinsic motivation, we engage in something because we find it personally fun or rewarding.

While these are the two areas most often discussed, there are other, deeper dimensions to motivation, including fear-based and development-based motivators – and these can be either extrinsic or intrinsic. Understanding the interplay among these different forms of motivation is an important element in successful health coaching and in the creation of successful, supportive technologies that assist people in reaching their health goals.

Fear-based motivation comes in two basic flavors: deficiency-based and threat-based. Deficiency-based motivations come from the sense you are lacking in some way. These can have an external, socio-cultural source (just watch any personal care product advertisement: you smell bad, your hair is the wrong color and your teeth aren’t nearly white enough) or an intrinsic source (e.g. internal pressure “shoulds,” self-imposed discipline or overcoming the deficiency of lost health). Threat-based motivations tap into fear at a deeper level. In the world of medicine, this might be a medical incident that serves as a wake-up call, and the threat of disability or death propels a person to make serious lifestyle changes.

Development-based motivation tends to come from the desire for personal growth or self-actualization. It can also be externally sourced (e.g. from positive peer health norms or positive environmental conditions like smoke-free public spaces) or intrinsic – from the satisfaction, pleasure or joy we derive from doing something.

Research has shown that while fear can be a great motivator for getting people started on something, the positive, development-based motivators tend to be more powerful in keeping people engaged and active in behavior change over the longer term.

I believe one of the reasons the Wellpepper patient engagement platform is so successful at driving patient engagement with care plans (70% engagement compared to an average of 20% engagement with portals) is because the Wellpepper team understands this complex motivation dynamic very well and they have incorporated some of the most successful elements from it into their platform. They call it the “3rd approach” and here’s why I think it works.

Wellpepper takes a very obvious extrinsic motivator – the practitioner’s care plan – and turns it into an application that incorporates both intrinsic and extrinsic development-based motivators that keep people engaged over time. There are many layers we could explore here, but we’ll start with a few of the big ones.

Setting aspirational goals: In addition to the functional goals set by the practitioner, Wellpepper provides the ability for patients to set their own personally meaningful, aspirational goals that can support and reinforce their motivation to heal. For example, someone recovering from a total joint replacement operation might set a future vision of wanting to hike to their favorite fishing spot with a grandchild. They can use Wellpepper to set interim goals that lead them toward that vision and can rate their own progress on a Likert scale.

Research in positive psychology has shown that this kind of personal vision and goal setting is highly successful at sustaining motivation over time. In this case the patient is more likely to complete their prescribed exercises because it leads them toward goals that are personally meaningful about their own healing and about doing something special with someone they love.

Personalized experience: Wellpepper also provides a personalized experience for the patient. Using the same joint replacement example, instead of getting a piece of paper with a series of exercise diagrams or a generic video, the practitioner can record the patient doing their own exercises. Seeing yourself, and hearing the personal comments of the physician or physical therapist as you do it, is not only easier to follow, it feels personal. And, as you begin to improve, when you watch yourself then and now, seeing your own progress can be very satisfying (a powerful development-based motivator).

Adaptive notification: Wellpepper’s patented adaptive notification system means the patient doesn’t get the same generic reminder every day – it changes the notification based on the patient’s progress and level of engagement, keeping the extrinsic motivator relevant, fresh and focused on personal development.

Tracking progress: By enabling people to track progress on their goals and sharing that information with their practitioners, patients tap into positive, extrinsic motivation. Also tracking progress on personal, aspirational goals helps people feel a greater sense of accomplishment and direction over their own developmental outcomes.

While motivation for any one individual can be elusive, the way Wellpepper weaves together the positive extrinsic and intrinsic development-based motivators may be the key to its success in helping patients stay motivated and helping practitioners answer the age-old question: “Will the patient do it?”

If they’re using Wellpepper, chances are, they will.

Jennifer Allen Newton is Wellpepper’s PR lead, and also a Functional Medicine Certified Health Coach. 

Posted in: Adherence, Healthcare motivation, Healthcare Technology, Healthcare transformation, patient engagement, Physical Therapy

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The Secrets of Strong CIO and CMIO Relationships

What’s the secret of a strong CIO and CMIO relationship? Many things including the ability to be adaptable, understand organizational priorities, and deadlines, but most importantly to align on shared goals and purpose.

These were some of the takeaways from the insights shared by CIOs and CMIOs of Confluence Health, and EvergreenHealth at the annual Washington State HIMSS Executive dinner. While the conversation was split between how to foster innovation, and how to manage the demands of an EMR rollout (including the resulting backlog of other IT requests), where the relationship really shone was in the implementation of tools for a shared purpose, in this case tracking and control of opioids to help curb the epidemic we’re seeing in this country.

In particular a project at EvergreenHealth to implement e-prescribing of controlled substances, showed the need for strong CMIO and CIO collaboration. The program is designed to decrease fraud and misuse of controlled substances, but it can also improve patient care. Since it involves both technology implementation and clinical guidelines it’s a perfect example of medical and technology collaboration. In Washington State, where we’re based, the Bree Collaborative also has recommended guidelines for prescribing opioids, that while optional are widely adopted across the state.

We’ve written about this problem before in pain management for total joint replacement. Sadly, an unintended consequence of the pain management question on the HCAHPS survey, is sometimes an overprescribing of prescription pain medication. According to one speaker at the event, 30mg of oxycontin over 7 days is enough to trigger an addiction, and yet often post-surgery up to 30 days of pills are prescribed. We talked to one patient (not a Wellpepper user) who reported taking all of her prescribed pain medication, not because she needed it but because it was prescribed. The first step to solving this problem is with the prescription, and EvergreenHealth’s e-prescription program, combined with locked cabinets in the operating room (the idea is that if you don’t need it immediately, you don’t actually need it), alerts on over prescribing, and programs to substitute suboxone, coupled with behavior health management can all help. As well behavior change happens with the physicians, and a powerful image was the story of a pharmacist who put a bag of unused opioid prescriptions on the table to show that even if they didn’t think so, some physicians may have been over-prescribing.

However there are ways to take it a step further: tracking what the patient actually took outside the clinic, which is why we include a pain medication usage task in many care plans. This activity asks patients some simple questions about their over-the-counter and prescribed pain medication usage, and alerts if the numbers or the length of time is over certain thresholds. It’s in use in care plans that include general pain management, surgical, and neurology (headache management), and provides a view into usage, and the opportunity to reach out and help patients outside the clinic before usage becomes a problem.

We’re strong believers in the ability for patients to record their own outcomes and experiences, and the value of combining this with prescribing and clinical data to close the loop on delivering better care. If you’re interested in learning more, get in touch.

Posted in: Adherence, Behavior Change, Healthcare Legislation, HIPAA, Opioids, Outcomes, patient engagement

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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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