Healthcare Disruption

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Mayo Transform 2016: Change

There was method to the madness, but the feedback for John Hockenberry, host and moderator of this year’s Mayo Clinic Center for Innovation Transform Conference at the first night reception was that the keynote was a bummer.

And it was. This year’s theme was change, and the keynote highlighted three key areas where we need fast and effective change: climate, diet, and early childhood education.Mayo Transform logo

Will Steger, a lifetime adventure and outdoorsperson and founder of Climate Generation, kicked things off with a dire warning that it was no longer possible to make a living running sled dog tours because the Arctic is melting. This was followed by Karen Watson who talked about the successful DrinkUp campaign to combat the challenge that 75% of Americans are chronically dehydrated from consuming sugared beverages instead of water. The campaign was focused on driving people to reach for bottled water instead of soda, and while this seemed counter to the first session on climate change, she cited that 22 million Americans have no access to potable water so bottled water is a good choice for them. Next up George Halvorson from First 5 California and former CEO of Kaiser Permanente talked about programs the state of California and KP have created for early childhood health and education, noting that the years from 0-3 were crucial for childhood development, and that a child of a working mother is read to for 1,500 hours during this period while the child of a typical Medicaid mother (who could be working) is read to for 30 hours during this period. This year 51% of children will be born to Medicaid mothers.

DrinkUpWhile both DrinkUp and First 5 provided solutions to the problems they raised, the overall impact of the keynote was depressing. While the intention was to catalyze people to change the schedule left us had the tools for making change delivered in sessions on days 2 and 3, which left us to drink our sorrows at the opening night reception (and not with bottled water).

Moving into days 2 and 3 of the conference, we did get tools for thinking differently, and the first session on day 2 provided richly in this area with Roger Martin, former dean of the Rotman School making the case for using both scientific method and rhetoric, and in particularly pointing out the short comings of scientific method if you want to innovate, in particular that it only looks at past data and does not imagine a future. Denny Royal of Azul 7 asked us to get out in nature for creativity, inspiration, pattern matching, by using biomimicry to use nature’s solutions for pressing problems, like how Sharklet used the natural antibiotic properties of sharkskin as inspiration to create a substance that naturally repels bacteria, or considering how to create adhesives that work better when wet, like the silk of the Cadis Fly, and could be used internally during surgery instead of our crude methods today like stiches or stapling. Teri Pipe, of ASU led us on a meditative path by asking us to notice what was happening in this moment, and apply these skills to build compassion and reduce stress in delivering care.img_0055

The day 2 keynote provided us with tools for imagining things that don’t exist, have the courage to quiet our own cleverness and learn from nature, and be resilient and empathetic. Given the day 1 keynote, this was just the antidote to embark on the rest of the conference.

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

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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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Patients As Designers Of Their Own Health

Seattle’s grassroots healthcare community continues to gain traction with a new meetup for patient-centered design. Last week’s meeting was generously sponsored by MCG a subsidiary of Hearst Publications who are quite active in the healthcare world with content and education. The panel discussion featured Dana Lewis, a patient-maker who is active in the open source movement for diabetes care and built her own artificial pancreas, Christina Berry-White from the digital health group at Seattle Children’s, and Amy London, Innovation Specialist at Virginia Mason. The group talked about how to effectively get feedback from patients, and how patient hackers like Dana can take poor design into their own hands build tools they need, and ultimately influence large healthcare companies, in this case device manufacturers.

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Dana, Christina, and Amy, photo credit Alina Serebryany

The panel had great advice for understanding and developing products and improving processes for patients, as well as for soliciting feedback from patients. Here are a few of my takeaways.

Tips for developing products and process

  • Understand patient’s goals and desires. Often the goals of the hospital or health system are not the same as the patient’s. After meeting with a group of patient advocates one Virginia Mason surgeon realized that the only outcome that really mattered was whether the patient had a positive experience.
  • Let patients customize their views and experiences. Amy talked about a particular chart where she wanted to see the graph rising to show increasing blood sugar and another user she talked to wanted to see the graph lowering to show insulin lowering and a need for intervention. Amy was confused by this view but created her open source artificial pancreas interface to enables people to choose their own view, and the result was that people who had diabetes looked at it the same way Amy did and parent-caregivers of diabetic children wanted the second view. Which brings us to the next point–
  • Differentiate between users. Patients often have different requirements than their caregivers, whether that’s parents caring for a child or teen, or adult children caring for a parent. As well, the clinical workflow shouldn’t dictate the patient experience.
  • Get feedback early. Amy mentioned meeting with a device manufacturer who showed her an almost ready for release glucometer that was intended to fit in the pocket. She quipped “you obviously didn’t test this with women’s pockets.”

Tips for collecting feedback

  • Build it into the product. Christina from Children’s mentioned that when they switched from reams of paper to an iPad-based tool for patient on-boarding forms the physicians wanted to stop using it because it did not immediately integrate with the EMR. Luckily the tool had a feature to survey users on whether they preferred using it to paper, and the answer from parents was overwhelmingly yes. The digital health team showed these results to the physicians, and the tool stayed in place.
  • Be creative when soliciting feedback. Children’s knew from experience that parents and patients were reluctant to give them negative feedback after a lifesaving experience like an organ transplant, so they used techniques that are often used in brand market research: analogies. For example, they asked teens to describe a digital tool as a car, and found out that their tool was like a pick-up truck to them: useful but utilitarian.
  • Use patients to collect feedback. Patients are also often intimidated to provide direct feedback to healthcare professionals as they see them as authority figures. At Virginia Mason patients who have already had a successful joint replacement visit post-surgical patients to find out how they are doing, and talk about their own experiences. Patients are a lot more candid with each other, and Virginia Mason was able to benefit from understanding the questions they asked the peer ambassadors and incorporate that information into formal programs.
  • Ask the questions at the right time. If you want to understand post-operative experiences ask within a few weeks of the actual experience, not 6 months later.
  • Be aware of selection bias. Patients who volunteer for focus groups are often those who have the time and money to be able to do so. Your feedback may be skewed towards retired patients, and those who are not hourly workers. Consider how you will cast a wide net.

Lots of great advice at this event, much of which we already incorporate into our processes and products at Wellpepper, although I definitely got some new ideas and it’s great to see the community coming together to share best practices. My only disappointment with the event was that with a title of Patients as Designers, I expected to see more patients on the panel. While there was a last minute cancellation of a patient-maker, it would have been amazing to have Children’s and Virginia Mason bring one of their patient-designers to be on the panel. Maybe next time?

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

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Intelligent Disruption in Healthcare

Two recent webinars tracking recent trends and outlooks on the future of digital health presented interesting perspectives on how the healthcare industry is evolving, but also trigger some concerns about such advancement. The first webinar, Digital Health Tech Vision 2016, hosted by Accenture Consulting, featured Kaveh Safavi, M.D, J.D. (Senior Global Managing Director of Accenture Health) and Jane Sarasohn-Kahn (Health Economist, Industry Advisor and blogger at Health Populi) addressing their prediction of the top five digital health trends in the coming year:

  • Intelligent Automation – the merger of humans and artificial intelligence in a health setting (citing an intriguing example of a company integrating AI into a therapy setting).
  • Liquid Workforce – technology enabling the application of healthcare across geographies.
  • Platform Economy – an economy based on multiple technologies to platform architectures that allow them to work together.
  • Digital Trust – the importance of ensuring patient information isn’t shared improperly by those who have legal access to it.
  • Predictable Disruption – industry leaders agree that the nature of healthcare services will change faster in the next ten years than the last thirty

The second webinar was the MobiHealth News Digital Health 2016 Midyear Review, featuring Brian Dolan (Editor-in-Chief of MobiHealthNews) and Ryan Beckland (CEO and Co-Founder of Validic), who spoke about the past year in digital health, including key acquisitions, policy news, and the importance of patient generated health data in the future.

Both webinars addressed the fact that there is significant consumer demand for digital health innovation. Patients want a more seamless and efficient experience that gives them a better “life-health balance” and does so inexpensively. From the physician point of view, MobiHealthNews pointed out that doctors have about seven minutes on average to spend in person with a patient, most of which is spent doing data entry on a computer, so physicians are looking for solutions that enable them to be more “present during care” and not miss out on any important clinical information. As for healthcare systems, the Accenture webinar touched on the “Predictable Disruption” trend, noting a recent poll showing 86% of healthcare executives feeling pressured to “disrupt” their business model or face disruption from the outside (e.g. companies like Wal-Mart, Apple, Google, and financial service firms are entering the healthcare space).

This high demand for digital health solutions is certainly good news for any companies operating in the space, especially in light of regulations pushing the industry more towards value based care. But is it good news for patients?

With such multipronged pressure facing hospital systems, a concern might be that in trying to keep up with the industry, they too quickly install digital health solutions that aren’t adequately designed for interoperability with other technologies and EMRs and in doing so, could make the patient experience worse. The American Medical Association CEO recently commented on the influx of “ineffective” and “mixed quality” digital health products, going as far as comparing them to modern-day snake oil, and Dr. Sachin Jain, the CEO of CareMore, said that most remote monitoring solutions are not currently working because they aren’t adequately integrated into a system of care, and are just “bolted on” to a current system.

In such a fragmented market, it will be important for healthcare systems to take the time to make decisions based on how well these solutions can integrate with the current systems and EMRs (which aren’t patient-facing, but need to integrate with these new technologies for a seamless patient experience), work with other digital products within the system (achieving the platform economy mentioned by Accenture), and enhance the patient and physician experience and interaction. Perhaps then the industry can claim a new trend: intelligent disruption.

Posted in: Healthcare Disruption, Healthcare Technology, Healthcare transformation, Interoperability, Patient Satisfaction

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Different System, Same Challenges: Long-Term Care Perspective From Canada

Kristin Helps, our Director of Client Operations, and I had the opportunity to speak about delivering Empathetic Care for Seniors Through Technology at the annual BC Caregiver’s Association Conference in Whistler, BC. The BCCPA is the representative body for long-term care, skilled nursing, homecare and retirement facilities in the province of British Columbia in Canada. These types of facilities are mostly privately run, by both for-profit, and charity organizations, as opposed to acute care which is run by provincial and regional authorities. While this was a BC organization and conference, delegates came from across the country, and ranged from individual home care works, to facility owners, to university professors and researchers.

For the most part we heard similar challenges to those encountered in the health system in the US:

  • Communication between care settings
  • The struggle to deliver patient-centered care
  • Decreasing reimbursement for homecare
  • Enabling staff to operate at the top of their license

At the same time, people expressed a desire to age in place, and the health system wanted to be able to support this. While 80% of Canadians cited wanting to die at home, only 40% actually do.

One of the big differences we noted at this conference was that speakers and participants were calling on the Federal government to step in and fix many of the problems in a way that we don’t often see in the US. Another difference was that participants were looking globally for solutions to challenges, particularly in dementia care.

Looking Globally for Dementia Care

This was our first time at this conference and veterans told us that the previous year was quite focused on analytics, while this year the focus was on dementia care. While not primarily our area of expertise at Wellpepper, we heard about a number of innovative initiatives to improve care, including a novel approach by the government of Japan. Japan decided to characterize dementia as a social problem rather than a medical problem and trained bank tellers and grocery store clerks to recognize the signs of dementia. It was thought that these people were most likely to see problems, for example if someone was unable to understand how to pay bills or buy groceries. Considering that many with early onset dementia are quite successful at hiding changes from their loved ones, this idea is quite interesting. It also puts the responsibility for care back into society rather than relying on medical facilities that often distance the rest of us from the challenges of aging.

Basketball courts at Aegis Living Seattle

Basketball courts at Aegis Living Seattle

The Butterfly Household Model of Care, which was initiated in the UK, but has been implemented in Alberta with some success, is another novel idea. People with dementia often don’t know what day it is or what they had for lunch, but they do have vivid internal experiences, often remembering happier times of their lives. Butterfly Households are designed to stimulate people with dementia with bright colors, and also to stimulate memories with areas designed to invoke feelings of the past, for example an ice cream shop or an area with old photographs. The idea in a Butterfly home is to meet patients where they are, and caregivers report much joy in delivering care and significantly fewer of the violent behaviors often associated with dementia.

While not a designated Butterfly Home, you can see some of these techniques in action at Aegis Living in Capitol Hill, Seattle. Here are a couple of pictures from when I visited last fall. In an outdoor area they have a car and a garden shed designed to stimulate conversation and fond memories, and an old-gym styled basketball court, where you can shoot hoops sitting down.

Invoking memories at Aegis Living Seattle

Invoking memories at Aegis Living Seattle

To find out more about the topics in this post:

Bank Tellers Act Serve as Caregivers in Aging Japan

BC Caregivers Association

Butterfly Household Model of Care

Aegis Living Capitol Hill Seattle

If you’re interested in learning more about our talk on delivering empathy through technology, contact us.

Posted in: Aging, Behavior Change, chronic disease, Healthcare Disruption, Healthcare motivation, Healthcare transformation, Managing Chronic Disease, Seattle, Uncategorized

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The Consumerization of Healthcare

While Healthcare is sometimes criticized as being behind other industries when it comes to technology, being behind this can have advantages. The first is that early adopters in other industries have worked the kinks out of new models like Saas or not-new models like single-sign-on. The second is that you can understand how technology and usage might evolve by seeing what happened in other industries, and the third is that you can skip steps in technical evolution and potentially move faster. This is what’s happening with the Consumerization of Healthcare IT, as evidenced by the proliferation of mobile and consumer-facing health technologies, topics at a few key healthcare events I’ve attended lately, and conversations I’ve had with senior healthcare leaders.

The concept of consumerization is the idea that consumer perceptions, expectations, and consumer technology can have an impact on an industry. This sometimes results in direct applications, like “it’s Uber for ambulances” or “Netflix for CPE credits” but more frequently it’s a subtle shift in thinking.

When I was working at Microsoft preparing for the launch of Office 2010, the consumerization of IT was a major theme of the release. We talked about the influence of the expectations of end-users on the tools they used every day: users were always on and always connected and they expected the same of their companies. We talked about the impact of BYOD on security and also the expectations to be able to communicate and collaborate from anywhere. The same is happening in healthcare today. Patients and physicians alike want to be able to communicate in the ways they communicate elsewhere and wonder why they can’t. They want applications that are as easy to understand and interact with as those on their phones.

One health system CIO I spoke to recently envisioned providing a “productivity stipend” and enabling all his staff to use whatever type of computer and smartphone they wanted. He would make sure they kept patient-health information secure but they would be responsible for choosing and maintaining their devices. Where BYOD was seen as a threat back in 2010, it’s now an opportunity. (I checked in with some of my former colleagues and they are seeing BYOD for phones but not computers, so this CIO is ahead of the industry pack and could even be seen as an example of skipping a step.)

When we started Wellpepper a little over three years ago, people commented on how patient-friendly and patient-focused our software was, and how it was a shame because it didn’t really matter what patients thought or what the patient experience was. (Not everyone said this, but we did hear it more than you’d hope.) Today, leaders in the industry are laser-focused on the patient/consumer experience. There are a number of reasons for that, which are both carrots and sticks.

  • Meaningful Use, while not always driving the best technology, has put an emphasis on communicating electronically with patients
  • High-deductible plans have made patients into consumers, carefully evaluating the service and value they can get for their healthcare dollars
  • New technology players like ZocDoc with online scheduling and MDLive with telemedicine delivered at Walgreens have trained people to expect on-demand services
  • New care delivery players like Iora and Zoom+ have set expectations for wellness and preventative care, and have attracted healthcare professionals who want to practice differently
  • We are all consumers. These supercomputers in our pockets and the constant connection and sharing they provide, and the ease of use of the applications that run on them have trained us to expect the same in our healthcare whether we are patients or providers.

At two recent conferences, I participated in conversations about the consumerization of healthcare service and tools. At the annual Health Evolution Partners Summit in Laguna Beach I had the opportunity to participate in a workshop where we were asked to imagine what it would be like if healthcare were run by customer-focused brands like Nordstrom, Amazon, Apple, and Uber for example.

@griotsyeye draws the consumer revolution in healthcare

@griotsyeye draws the consumer revolution in healthcare

At a local Seattle event hosted by the University of Washington Foster School of Business and sponsored by Providence Healthcare and Premera, I participated on a panel with Bill Frerichs, VP of Clinic Operations from Zoom+ and Paul Stoddart, VP of Marketing for Providence, and hosted by Curtis Kopf, VP of Customer Experience, Premera Blue Cross. We had all joined healthcare from other industries: Bill from running Target’s Store Operations and Paul from Microsoft, like me. We had all had personal experiences that had moved us into healthcare to try to change the system from within. Similar to many that choose healthcare as a career from day 1, we had become vocation-driven.

While it’s easy to come up with ideas for how healthcare can improve by looking at the customer focus from other industries as we did in these two sessions, for example, taking a concierge model like Nordstrom’s personal shopper or pattern-matching what’s important to each patient like Amazon’s “people like you also bought”, or using data to predict pregnancy like Target, it’s important to remember two things. First, if history of adoption of technology is any indicator, healthcare will evolve like other industries and will move to the cloud and more end-user and patient-friendly tools. It’s already happening. And second, that we need to remember the goals of healthcare while transferring best practices from other industries, and emulate only what’s best in healthcare settings: compassion and care, not greed and a ‘gig-based’ economy that is sometimes the focus in other industries. As well, while patients want to share data with their care teams, they want this data protected and used appropriately. Those who question the status quo, embrace change, and yet do it while remaining true to the ideals of healthcare should be the winners in this new consumerized world.

Posted in: Healthcare Disruption, Healthcare Technology, Healthcare transformation, M-health, patient engagement, Patient Satisfaction

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Patient Engagement Goes Mainstream: 5 Observations from HIMSS 2016

A walk through the trade show floor, and a glance at some of the sessions at HIMSS, quickly indicates that patient engagement is everywhere, which is great because an empowered patient is key to improving outcomes and lowering costs of care. There is still a lot of noise in this space however, with anything from wayfinding applications to billing services being billed as patient engagement. Let me set the record straight: making sense of things that are very confusing and often poorly designed, like hospitals and healthcare billing is not patient engagement, it’s explanation. That said, there are many innovative companies and healthcare organizations who are taking patient engagement seriously.

Here are 5 impressions or things heard at HIMSS about patient engagement and the state of healthcare IT:

  1. There are a lot of solutions in this space/competition is good. While there may be companies that have joined the space because patient engagement is a hot topic, real competition shows a real need and market.
  2. Clinical workflow does not equal patient engagement. True patient engagement solutions are designed around the needs of the patient.
  3. Engagement does not equal alignment. While this was said about physicians it’s also applicable to patients. A surgical patient can’t help but be engaged, but are the patient and physician aligned on the patient’s goals.
  4. Healthcare IT is emerging from the EMR era. Meaningful use drove widespread adoption of EMRs and monopolized IT resources for the past X years. IT is now ready to take a seat at the table and proactively suggest solutions to the clinical side of the house.
  5. People are asking how a solution is different rather than why they need a solution. This is a huge shift: at our booth we spent a lot less time explaining what we do and how we do it.

We’re looking forward to what the next year will bring. It seems like we’re at the starting blocks for some real value-based implementations of patient engagement solutions.

Patient Engagement Hits The Mainstream

Posted in: Healthcare Disruption, Healthcare Technology, M-health, Outcomes, patient engagement

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

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

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

We were much sharper in real life.

We were much sharper in real life.

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

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

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

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

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Cross-Fit for Healthcare: An HX360 Workshop

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

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

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

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

Cross-Fit For Innovation

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

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

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

Innovation Journey Map

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

IMG_2559 IMG_2558

 

For me, the top takeaways from the session were:

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

Posted in: Healthcare Disruption, Healthcare transformation, Lean Healthcare

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

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

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

From Wellpepper CTO, Mike Van Snellenberg.

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

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

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

And from Wellpepper CEO, Anne Weiler

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

And from Wellpepper Business Analyst, Liz Zampino

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

 

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

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Does Healthcare Need a “Call to Minga”?

ihi-logoIn the most recent months, I have experienced a lot of “firsts” since I have joined Wellpepper. Although still in healthcare, I have ventured into the patient engagement space which has opened up a whole to new world. This technology is evolving in the marketplace with the charter of quality, value and engagement, specifically around the patient. This is one of the reasons why I joined Wellpepper…..we are about improving the patient experience.

Attending the Institute for Healthcare Improvement National Forum in Orlando (IHI) last week was another “first”. This conference was focused around how we change and improve healthcare for the patient. There was a real sense of community at this conference among the attendees. Everyone was focused on the patient and how to better serve and improve outcomes.

Unlike other conferences I have attended, I was able to participate in several sessions. Even though we exhibited at this forum, attending the sessions provided me with a different perspective on what healthcare professionals are really concerned about and how they are looking to learn from others on how to “fix” it. Again, another “first”.

The atmosphere at the conference was very upbeat and optimistic but there is a transition happening at the helm of IHI. Maureen Bisognano, President and CEO for the last 12 years, she will be retiring after 27 years at IHI. She gave the opening keynote which was very inspirational and echoed the commitment of IHI to improve the quality in healthcare for the better of the patient. Her theme was all about collaboration among the healthcare teams to give care with the patient and not just to the patient. Quality should be everyone’s job and that is why they developed the Breakthrough Collaborative at IHI. This brings together patients, families and health systems to improve the care.

We need to understand what matters to the patient and not what we think matters. In the session, “Thriving in a Value-Based Environment”, Anna Roth, CEO of Contra Costa Health Services, emphasized what matters to patient might not be their health problem but their ability to buy food, pay rent, and job security. So value for that patient goes beyond addressing their health issue but rather access to other life sustaining needs. Furthermore, when you engage with your patients be prepared to act. Lisa Schilling from Kaiser added during this session – “find the problems that really matters and then find an elegant solution”.  This can lead to innovation both from a technology perspective and re-design of care plans for that patient community. As an example, physicians are now prescribing community parks as part of their treatment plans to help address obesity and get their patients moving.

This theme echoed with the other keynote speakers such as Earvin “Magic” Johnson. He was on course with his message of bringing together a sense of community to improve healthcare access and services in the urban cities. He stressed people can make a difference if we just listen to what matters to the community. He has engaged with many charities to address the food deserts that plague our urban cities.  Providing better options to fruits and vegetables will result in healthier communities.

However, the keynote from Craig Kielburger really hit home for me. Craig is the co-founder of Free the Children, an international charity; Me to We, an innovative social enterprise; We Day, a signature youth empowerment event. His journey to where he is today started when he was 12 years old. He was touched by a tragic event with a young Pakistani boy by where he felt compelled to make a difference in children’s lives. Today, he is building schools and empowering our young to make a difference.

So what has this got to do with a “Call to Minga” and healthcare? Craig experienced a “Call to Minga” for the first time more than a decade ago when he and his brother Marc (co-founder of Free the Children) went to Ecuador to build a school with volunteers. Given unforeseen obstacles such as transportation for building materials was difficult and the time to transport was longer than anticipated, his team was falling short of completing the school….in fact, they didn’t even get a chance to start it.  They were two days from traveling back to North American when he and his brother had to explain to the Chief of the village that they would not be able to complete their task. At that moment, the Chief went outside her hut and called “Minga”. The next day, people from surrounding villages ascended upon this village and began to work on building the school and completed it. The “Minga” was a call to action. It is a community coming together to work for the benefit of all.

This is what was happening at IHI, a call to action. We must come together as a healthcare community and work to improve healthcare for patients and overall, our country. Our community consist of caregivers, educators, innovators and the patient. With all the resources available to us, we can have a “Minga” moment. Here at Wellpepper, our “Minga” moment is now. Health systems are hearing the call to action to engage their patient in a fashion that supports their live style along with the technology they use every day.  Our technology allows patients to personalize their care plans that will drive ownership and improve outcomes because we are able to provide them with what matters. This is a “first” for the patient!

Since this is probably my last blog post of 2015, I invite you to consider your call to Minga at your organization for 2016. There is so much we can do together!

Posted in: Health Regulations, Healthcare Disruption, Healthcare motivation, Healthcare Policy, Meaningful Use, Outcomes, Patient Satisfaction

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

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

Digital health event

It was a dark and stormy night

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

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

Sensoria's Quantified Socks

Sensoria’s Quantified Socks

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Postcards from HIMSS M-Health 2015

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

Venture+: The Market Is Maturing

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

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

Incremental Progress and Show Me The Evidence

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

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

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

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

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

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

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

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

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

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

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

Risk-sharing

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

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

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

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

Outcomes, Outcomes, Outcomes

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

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

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

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

Patients and Prevention

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

Moving Forward

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

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

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