Healthcare Disruption

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Is Seattle Ready For A Seismic Shift In Healthcare?

The plans to open the Cambia Grove, a health care innovation center, were first announced about this same time last year at the 25th Annual Governor’s Life Sciences Summit. Nicole Bell, executive director of Cambia Grove was then quoted saying, “Why couldn’t we be for health care what we are for coffee, aerospace, for online retail and for independent rock-and-roll?”IMG_2081

A year later and timed perfectly to coincide with the 17th Annual National Institutes of Health (NIH)/SBIR/STTR Conference, Cambia Grove announced results from the 9 page “Report on Health Care Innovation in Washington State.” This report effectively established a baseline for the economic impact of health care innovation sub-sector in Seattle. Based on the numbers, it seems as though Seattle is poised to compete with rival health care hubs like Boston and the Bay Area.

IMG_0412Here are a few of the more impressive stats. Pay levels are for this sub-sector of this industry are 8% higher than average with $2B in compensation, not to shabby. Apparently these employees are amazing rock stars with 300% more productivity than an average worker and they create $6.8B in direct output?!?!? With this astounding productivity that 8% doesn’t seem like quite a commensurate salary increase.  While there are 22,500 jobs across the state, it is not surprising that over 80% of them are concentrated in Seattle. After Nicole Bell revealed these report highlights, she commented that it would make sense to create or convert even more jobs in to this thriving job sector. I guess we bike riding, coffee drinking, online shopping, wearing jeans and Tevas to work Seattlites must really be on to something here.

I am absolutely thrilled to have taken a path that is leading me into this new sub-sector of healthcare innovation and start-ups where evidently I’ll be working in the land of serious overachievers. As a RN, I’m no stranger to long hours and hard work. Coming from traditional healthcare institutions where the norms are grueling 12-hour shifts, you literally have to ask someone if you can go pee because you can’t leave your patients unattended and you learn to ingest your lunch in under 5 minutes.

IMG_0413As much as working in traditional healthcare has taught me clinically, I couldn’t imagine moving into a healthcare IT analyst role after completing my Masters degree in Clinical Informatics. I imagine if I stayed, I’d probably end-up stuck in a cube trying to unscramble the EHR mess or analyzing already broken workflows attempting to integrated a new piece of technology that never went through any real usability testing by actual healthcare workers who would be suing it. Having used both Epic and Cerner products, I was like “I told you so!” after reading articles about the recently published JAMA reporting the lack of adherence by EHR vendors to conduct usability testing. I digress. My point is I’m waiting with bated breath for the lagging traditional healthcare industry to get the swift kick it needs by the younger, more ambitious and more productive innovation sub-sector. The report is effectively calling out to health innovators in Seattle that the time for a seismic shift is now…in healthcare, hopefully not literally a seismic shift in Seattle. Either way, Seattle Health Innovators prepare yourselves, let’s get ready to compete with Boston and the Bay Area.

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

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P4 Medicine, How You Can Live To Be 100

I was fortunate enough to be on the guest list for the event, “An Evening Discovering Scientific Wellness” hosted by Arivale at Chihuly Garden and Glass this past week.  The space was packed with over 600 guests, which included: students, scientists, nurses, entrepreneurs, investors, doctors, schoolteachers, software engineers and really anyone with an interest in being part of a new transformation in healthcare.   My fascination with what Arivale plans to do originates from three different perspectives: as a scientist with an undergraduate degree in Neurobiology, a healthcare provider (Registered Nurse) and most currently as a graduate student in Clinical Informatics with a penchant for technology. Arivale plans to bring together all of my interests in science, clinical data and technology to create a personalized plan to optimize wellness.

Be forewarned, P4 Medicine (Predictive, Preventative, Personalized and Participatory), is not for the squeamish.  Maybe you have seen the funny coffee table book “What’s Your Poo Telling You?” Well, now it can tell you more than you ever imagined. Arivale, a new Seattle start-up co-founded by biomedical pioneer Leroy Hood, MD, PhD, actually aims to analyze your microbiome (the polite word for poop and/or the bugs inside you) as one part of their unique approach to transform how we think about our health.

Clayton Lewis, CEO and co-founder of Arivale, introduced co-founder Lee Hood (who probably needs no introduction in Seattle) as a visionary man who “speaks about the future in the present tense.”  Dr. Hood described how Arivale evaluates samples of blood, saliva, microbiome, genetic sequencing and Fitbit data to give participants an entirely personalized set of actionable health data. The fundamental piece is a personal coach who will create a tailored wellness plan.  Not only will the coach call each month to check-in and guide the participant but, they will also integrate any new data and make adjustments to the original plan.

After hearing Arivales pitch, I do question how they plan to deal with the FDA and providing P4 medicine complete with health recommendations to consumers. This is not entirely dissimilar what 23andMe tried to do 2 years ago marketing Personal Genomic Services directly to consumers and shortly thereafter, the FDA required them to stop. Since then, 23andMe has gone through several rounds of R&D and now has the official blessing from the FDA. Along with the FDA approval of 23andMe earlier this year, the FDA also announced two important pieces of regulatory information making the path for other companies like Arivale easier.

  1. FDA is [sic] classifying carrier screening tests as class II. In addition, the FDA intends to exempt these devices from FDA premarket review.
  2. The FDA believes that in many circumstances it is not necessary for consumers to go through a licensed practitioner to have direct access to their personal genetic information.

Why is P4 Medicine so important? The crowd of at least several hundred let out a collective murmur of surprise when Dr. Hood dropped the factoid, ‘living to be 100 is going to be new norm for children being born into the next generation’. He jokingly followed with, “We want to get you to 100 and then you are on your own.” He pointed out that while our genetics may give us the predisposition for certain diseases, they don’t necessarily define our health.  If genetic variants are known, you can do something about them. Arivale wants to provide people with meaningful, personalized diagnostic information so as to optimize as many aspects of their health as possible.  The goal is to make those 100 years of life full of vigor, fitness and optimal health.

Next, two of the original 100 Arivale pioneers took the stage and spoke about their experiences.  The first woman explained her diagnosis of a ‘suspect immune system’ and not having enough T-cells.  This came along with a daily dose of antibiotics and lot of ‘no’s’ to activities she enjoyed such as long distance running.  The microbiome testing revealed that the antibiotic was not wiping out her endogenous gut flora.  Based on genetics, hiking in the woods, not long distance running, was the best exercise for her.  With Arivale, she realized her body was resilient, adaptive and was able to literally ‘start trusting her gut.’  In describing her experience with Arivale, she ended by saying, “Instead of seeing myself as a sickly, non-running person, I now see a person with a diverse life, a diverse gut and an adaptive life.”

The second woman opened by recounted her entertaining experience of giving birth during the 2nd quarter of the Superbowl last year. Her motivation to join the current cohort of 300 Arivale participants, was due in part to optimize her health but she also wants to be around as long as possible for her child. She is part way through the program, has received stellar results on her blood work and just the day before received her genetics phone call. Her genetics revealed a moderate risk for obesity and that her body had difficulties disposing of toxins. Going forward, Arivale will make recommendations on for life style changes based on these revelations.

Patient engagement is one of the newer buzzwords in healthcare and Arivale really gives it a new spin. We are entering a new era where people have access to the data and tools available to truly be active participants and take more control over their health outcomes.  We can no longer lay the blame on genetics because as Arivale is proving, we can now make informed decisions that can alter the expression of our genes and help us to achieve our wellness potential.

After the presentations were over, I went to the Info table to see how I could be part of this second set of 300 beta participants in the Greater Seattle area this fall. Sadly, it is not free this time around, the cost is now $1,999.

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

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Disruptive Innovation to Improve Mental Health Care

Health Innovators Collaborative, University of WA Bioengineering
Dr. Jurgen Unützer, Chair of UW Psychiatry and Behavioral Sciences

The Health Innovators Collaborative seminar that I attend last week by Dr. Unutzer gave me an emotional whirlwind, which is ironic because the subject was mental health. That afternoon I innocently put my boots on and galloped down to the university in my VW Beetle and waited for the seminar to begin by eating an apple in the front row. I had no idea what was in store for me in the next 60 minutes or so. I would have cowardly slumped down into my chair if this was a talk taking place outside of Washington… because I am so ashamed about how we brush our mental illness folks under the rug. My jaw almost dropped in shock; we are ranked 48 out of 51 to have the correct resources available for our mentally ill with only 20 psychiatrists in Rural Washington. Dr. Unutzer argued that we spend more money on preventing auto accidents and homicide, when the rate of suicide is much higher- there is a suicide every 15 minutes in our country and 2-3 a day in Washington.

IMPACT- Collaborative Care Model

After giving us such somber news he talked at great lengths about ‘working smarter’ in order to close the gap of inadequate mental health professionals. One of the largest treatment trials for depression, Improving Mood–Promoting Access to Collaborative Treatment (IMPACT) was spearheaded by Dr. Unutzer and his colleagues. They designed IMPACT to function in two ways; “The patient’s primary care physician works with a mental health care manager (can be a mental health nurse, social worker etc.) to develop and implement a treatment and the mental health care manager and primary care provider consult with psychiatrist to change treatment plans if patients do not improve.” The IMPACT study was started over 15 years ago when the use of EMRs and video conferencing were just starting to become ‘mainstream’. Therefore in a way this study was the forerunner in utilizing a multi-based ‘high tech’ mental health patient care platform; population registry/database (tracking tool of patients PHI, treatments, etc.) psychiatric consultation (video), treatment protocols and outcome measures (I feel I am writing about Wellpepper!). The video consultation takes place between the patient and a remote psychiatrist typically after treatments protocols are administered in the primary cares office with little or no patient improvement. This is imperative especially in Washington where half of the counties don’t have a single psychiatrist or psychologist.

There is a great JAMA article written on the outcomes of the IMPACT program (I am proud to say I did my homework on the positive slides presented and not the slippery slides) that really nails out the particulars in the normal scientific journal fashion. As always I shot to the bottom of such article for the ‘results and conclusions’ because I knew this one was going to be great, I had a sneak peak last Wednesday. After a year 45% of the 1801 patients studied had a 50% or greater reduction in depressive symptoms from baseline compared with 19% of usual care participants! Furthermore this study reduced healthcare costs; $6.50 saved for every $1 invested, with the most being saved in inpatient medical and pharmacy costs. In conclusion having a system that provides population based care, that is patient centered, has target treatment solutions, and is evidence based leads to more efficient modes of getting a patient in and out the door with positive results.

I exhaled what a clever man you are Dr. Unutzer to present your slides in such an order, from negative/scary to positive/uplifting, it’s almost like you are a psychiatrist and now how the mind works, oh wait you are!! Thank you for a wonderful talk, it was superb and always nice to learn something new!

Next seminar is “Bad Language, Worse Outcomes” with Jeremy Stone, MD MBA on November 3.

Posted in: Healthcare Disruption, Healthcare Research, Healthcare Technology, Healthcare transformation, Interoperability, Outcomes, Seattle, Telemedicine

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You Could Get Well Here: Touring Mayo Clinic

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

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

Spirituality is part of health at Mayo

Spirituality is part of health at Mayo

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

Mayo Clinic Center for Innovation Tour

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

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

A few innovative examples include:

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

    How Patients Experience Services

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

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

Mayo Clinic Center for Healthy Living

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

IMG_2373

Yoga studio with a view

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

The living wall

The living wall

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

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

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

More pictures of the Center for Healthy Living.

IMG_2370

The Nutrition Pantry

Guests learn to prepare healthy meals in this kitchen

Guests learn to prepare healthy meals in this kitchen

Rest with a view

Rest with a view

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

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

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

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

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

 

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

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Accountable Care and HealthIT Strategies Summit 2015: Still early days

Patients and providers both need to be empowered to deliver on the promises of the Affordable Care Act. That was the major theme and takeaway of the recent “Accountable Care and Health IT Strategies Summit” that I attended a few weeks ago in Chicago. I would add to this sentiment that IT needs help to implement technologies that empower these end-users. While not underestimating the importance of making sure technology is secure, and scalable, with too much focus on the back-end, IT can miss an opportunity to help deliver real value and change by putting tools in the hands of end-users.

Since value-based payments require health systems to be able to impact patient behavior outside their four walls, technology (and therefore IT departments) have the ability to play a greater role in helping to monitor and manage patients, and scale healthcare providers. Access to real-time data can also help identify issues and impact patient behavior before small problems turn into big ones.

While some of the stories and sessions at the conference were promising, I came away with the impression that we are still in really early days, and the leaders in this care transformation are willing to take leaps without having all the data. Considering that even with data, it still takes 17 years from innovation to transfer from research to clinical best practice, it seems that some amount of faith is required for this healthcare transformation.

In no particular order, here are a few of my notes from the 2-day conference.

Theme: Population Health 2.0: Accountable Care, Big Data and Healthcare Analytics

Population Health seems the furthest along in this transformation both in the way care is delivered and how technology supports care. Participants on this panel from Partners, Geisinger, and Hackensack University Medical Center, along with population health vendor Wellcentive debated the differences between Population Health 1.0 and 2.0. They even tried to see the future with Population Health 3.0.

Population Health 1.0 was seen as identifying risk and gaps in care, and attempting to plug those gaps. Although many organizations are still in this stage, some haven’t even gotten there yet. The panel saw themselves moving to a more evolved state of Population Health where data is used to drive better care, while responsibility for population health moves to the individual primary care physician rather than being managed in aggregate by remote care teams. However, this type of shift requires engagement by both the patients and the physicians which is still a work-in –progress.

The representative from Geisinger stressed for an effective implementation of population health, a multi-disciplinary team needs to be assembled that includes both clinical and IT. Wellcentive agreed and added that analytics need to be in the hands of end-users so they can make informed decisions.

The panel was also asked to speculate on Population Health 3.0: historical data, data driven decisions, and patient empowerment through data from sensors and surveys were all seen as key.

Honestly, my biggest takeaway from this session is that while some organizations may be claiming it’s time for Population Health 2.0, many haven’t gotten to 1.0, and no one seems to be in agreement on the definitions of each stage. Given today we already have the ability to collect survey and sensor data in the context of care, it seems like we are already have the tools for Population Health 3.0. But, we haven’t implemented the technology to address Pop Health 1.0 & 2.0 to achieve value…..so how can we even look to addressing the road to 3.0?

Theme: EMRs and Enabling Technology for ACOs

Another major theme that arose across many sessions at the conference is the limitations of current technology to support the infrastructure of new models of care. While organizations are looking for the EMR to be the Holy Grail, it’s a challenge as most EMRs are built to support older models of care, specifically around billing and reimbursement. Renown Health’s Accountable Care Organization, in Northern Nevada, will look to EPIC to solve some of their technology care needs, but realizes the need for M-health and other care coordination technologies to move up the stack, and exist separately from the EMR will be required.

Many of the participants are either trying to collect and track ACO data in the EMR or build their own systems to engage patients that fed data back into the EMR. Others acknowledged that new systems to directly engage patients need to be built on new technology stacks, although surprisingly one panelist on the Connected Care – How Trends in mHealth, Wearables and Connected Medical Home are Shaping Healthcare keynote boasted about 20-30% engagement rates with paper surveys. Yes, paper.

Theme: Engaging Patients and Providers

For ACOs and the ACA in general to be effective, the consensus at the conference was the need to enable both patients and providers. Adding individual providers into the mix seems to be a bit of a shift in thinking, and one that we’re supportive of at Wellpepper. We know that a key driver of patient adherence is the relationship between patients and providers. With our system, a good provider can influence patients to be over 85% adherent to their treatment plans. Some key ideas at the conference were providers may still need to be convinced of the need to influence patients directly, and that showing them data is the way to do that. However, the method of communication to that patient needs to connect in a way that is of their everyday life routine.

Overall, the conference presented some early wins in the shift to ACOs and value-based payments, but showed that we still have a long way to go and a lot of opportunity to improve care based on data. That said, this was the first conference I’ve been to where IT was front-and-center at the table and able to drive change if they wanted to. We have an opportunity to leapfrog old ways of doing things and implement new systems that have focus on the patient and provider, and are based on data to drive better outcomes. I for one am excited about this new opportunity and how it will change the way we deliver care in the future.

Posted in: Behavior Change, Health Regulations, Healthcare Disruption, Healthcare motivation, Healthcare Technology, Outcomes

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

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

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

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

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

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

Patient Record on Parking

Patient record in parking garage of major health system

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

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

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

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

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

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

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

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

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Personal or Population Health? Big Data or Small Data?

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

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

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

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

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

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

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

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

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Advancements in Diabetes Research: A Salon Dinner for JDRF

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

Derek Rapp

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

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

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

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

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

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

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

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

Canlis Private Dining Room View

Canlis Private Dining Room View, Source Seattle PI

Posted in: Health Regulations, Healthcare Disruption, Healthcare Research

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ResearchKit: The Tip of the Iceberg

In March, during the much-anticipated Apple Watch keynote, Apple carved out a few minutes to announce ResearchKit, a system to enable faster and easier healthcare research. The announcement was received positively, some even saying that the announcement was bigger news than the Apple Watch itself! Within a week, one of the early apps, MyHeart Counts, had enrolled 11,000-patients, an enrollment pace and efficiency unheard of in the healthcare community. Without a doubt, Apple has the opportunity to bring the power of numbers to healthcare.

What It Is

ResearchKit is an SDK (Software Development Kit) containing presentation logic and user interface components for gathering healthcare research data on an iPhone. It can gain informed patient consent, present surveys (whether existing clinically-validated surveys, or novel surveys for a particular study), and also use the sensors on the device to do things like measure vocal tremor, conduct a 6-minute talk test, and measure motor reaction time.

Building a new research app with ResearchKit-powered is a fairly standard mobile app development project. The ResearchKit components certainly accelerate the process, however you will still need an iOS developer, and you will need to follow all the usual software development steps of requirements gathering, design, implementation, stabilization, and then releasing through the App Store. The SDK was recently open-sourced on GitHub. Since most of the SDK relates to the user interface, ResearchKit really only helps with iPhone app development, which some have pointed out may give rise to a sample bias.

Image of an Iceberg

(Original source: National Ocean Service Image Gallery)

 

What It Is Not

More important than the development of the mobile app, though, it all of the infrastructure behind the app that allows the data to be securely transmitted, stored, aggregated, and analyzed by researchers. In systems of this kind, the scale and complexity of the underlying data service layer is usually considerably larger than the user-facing data collection app. This is especially true in healthcare, given the compliance overhead imposed by regulations like HIPAA.

On this dimension, ResearchKit has no immediate answer. Given Apple’s privacy-centric stance on data collection and aggregation and the sensitivity of the data, they are unlikely to build a cloud service offering for ResearchKit. As such, it will be up to individual researchers to build their own systems, at least until other software vendors move in to fill this need.

 

The Iceberg

Much like the proverbial iceberg where only 10% of the whole is visible, Apple’s ResearchKit is a beautiful, if small, slice of user interface that hides a large and complex underlying platform needed to actually deploy healthcare research apps.

 

 

 

Posted in: Healthcare Disruption, Healthcare Technology

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Something old, something new, something borrowed, something blue

As someone, (most likely French philosopher Blaise Pascal ) once said, “I would have written a shorter letter but I didn’t have time.” Stanford Professor Dr. Arnold Milstean started his talk for the Health Innovator’s Collaborative on “Providing Better Care With Less.” with a variation of this, saying that if he knew his topic better he would only have 4 slides instead of the 8. Those 8 slides represented so much practical data-driven advice and highly quotable and provocative statements like

“1/3 of healthcare spending could be cut without affecting anything except the quality of life of the providers.”

that it’s hard to imagine how rapid fire the content would have been with only 4 slides. Mistean took us along a path to define goals in healthcare transformation and then apply some simple formulas to affecting that change.

To determine some generally agreed upon principles for healthcare improvement, Milstean and team reviewed policy, research reports, and employer and payer surveys. The team found that getting to a 1% annual increase in quality, with a 30% reduction in costs, and a 2.5 percentage point long term increase in spend (less than GDP) would suit most policy recommendations and were therefore to be considered reasonable goals. To bring about this level of change, Milstean recommended implementing an “Old, New, Borrowed, Blue” strategy, which has nothing to do with marriage: it’s just a catchy and easy way to categorize some common sense thinking.

Old: Take a methodical review of existing evidence. As anyone who’s spent much time in healthcare research will tell you, there are a wealth of studies and best practices out there. Given that it takes 17 years to get from research to clinical practice, rather than starting a new study, reviewing what’s been done and implementing best practices is a better way to go.

New: Use technology to automate assessment, help with decision support, and improve workflow. Being at Stanford and working on multi-disciplinary teams lead Milstean to believe that the area healthcare could benefit most from “new” is in healthcare IT. In other industries the move to electronic records produced 2-6 percentage points in productivity improvement after 10 years. Healthcare, with only recent moves to electronic medical records, is just at the beginning of this and hasn’t seen the rewards yet. As well they have just scratched the surface of the digital opportunities.

Finding Outlier Physicians

Finding Outlier Physicians

Borrowed: Look at examples from other countries best practices and figure out how to implement locally. Milstean gave the example of a city in Finland where the time from stroke identification to tPA injection at an ER was 17 minutes. With each minute of time after the onset of stroke representing the death of 1.9 million braincells, emulating the Finnish model can have real impact on quality of patient life and long-term costs. (The average “door to needle” time in the US today is 60-75 minutes.)

Blue: Focus on human-centered design. Too much of healthcare is not working at the most basic human level, which as it turns out is the place where better and cheaper care resides. Here, Mistean showed a chart of “outliers” physicians who delivered a high-level of care at lower costs than their peers. It turns out what these physicians did differently was at the human level. They truly cared for their patients and looked at the whole patient, not the disease or not the specific incident. These primary care physicians acted as quarterbacks when their patients were managing complex issues with specialists. They cared, caught issues, and also motivated patients to participate in their own care.

The Impact of Blood Sugar on Parole Hearings

The Impact of Blood Sugar on Parole Hearings

While the formula is simple, it takes a lot of effort to change the system. Some are organization issues like the number of people involved in making any decision. One hospital, trying to implement a new program, took 3 months to get to the kick-off meeting due to the number of people involved in scheduling. The other issue is the human factor in creating repeatable systems. Here, Milstean used an example from the legal world, where judges were less likely to grant early release when their blood sugar was low. Comparing this to medicine, is remembering that everyone thinks that they are delivering high-quality care, but you often need data to convince them otherwise, and that you need to repeat, repeat, repeat to get to a precision that can cancel out the human factor. As a result, Milstean believes that computer science and behavioral science are two keys to making the big changes we need to improve quality and lower costs in healthcare.

 

 

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

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There’s No Silver Bullet: Reducing Avoidable Readmissions

Last week I had the opportunity to attend the Institute for Healthcare Improvement’s two-day training on “Reducing Avoidable Readmissions” training here in Seattle.

Reducing Avoidable ReadmissionsI’ve got some good news and some bad news. The bad news first according to this leading organization in healthcare quality improvement, there is no silver bullet. The good news is that there are a number of small practical steps to improve insight, quality, and patient experience.

This blog post provides an overview of the intensive 2-day training, and I’ll follow up with deep dives on a few sessions. Really, there’s enough content for a few weeks of blog posts, so we’ll use this forum to point out some best practices, and capture some of the best insights from the training. As with any training, so much of the value comes from the other participants, so we recommend checking out a training yourself in person. What was amazing about this course is that it brought together healthcare professionals who might not have had the opportunity to meet otherwise, and these different perspectives resulted in actionable takeaways for participants when returning home. Participants ranged from hospital CEOs and other C-level executives, to care coordinators across large and small health systems, primary care, hospitals and health systems, skilled nursing and in rural and urban settings.

Changing Healthcare ParadigmsRegardless of participant, it became clear that information did not flow well between these different healthcare settings, and that each specialty or care location had very little insight into what happened in the other setting. Just bringing these diverse participants together helped them see what could be done to improve patient handoffs and communication across the care continuum. A number of participants expressed how helpful it was to understand the process and constraints that others were seeing. Primary care physicians seemed to be the most handicapped as they had no way of knowing if their patients were admitted to hospital at all.

Sadly, for someone in the digital health field, another key theme that ran across the two days was how many participants felt that their medical records were preventing them from doing a better job on readmissions. The reason for this was two-fold: information did not flow between settings, and it was often too difficult to capture key information about the patient and access it at point of care. Medication reconciliation was cited as the holy grail of patient management but most participants didn’t believe it would ever be possible to get a clear solution to this problem.

Communication with patients was another key theme of the course, both in improving how patient discharge instructions and patient understanding of those instructions were delivered and in asking the patient for feedback. Again, it was a common sense approach rather than a “silver bullet.” Multiple presenters said “The reason your patient readmitted is in the hospital bed” or more simply, “ask the patient why they readmitted.”

Another key focus of the course was on change management within the organization. First understanding and then preventing readmissions requires change within the healthcare organization. Presenters had all led or participated in multi-year change journeys within their organizations and had both battle scars and key strategies for how to motivate and change within a large organization. One most basic tip was “don’t talk about readmissions, fines, or penalties” instead they suggested rallying teams around the benefits to the patients.

Topics that we’ll explore in more detail from the course here on the blog include:

  • Teach back and communicating with patients
  • Care transitions and discharge setting
  • Measuring change

Posted in: Behavior Change, Health Regulations, Healthcare Disruption, Healthcare Policy, Healthcare transformation

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Stroke Rehabilitation is the Poster Child for the Need for Collaborative Care

APTA CSM 2015 Recap: Anne Shumway-Cook Lecture: Transforming Physical Therapy Practice for Healthcare Reform

Speaker: Pamela Duncan, PhD

Interdisciplinary teams and patient-centered care are key to the future of healthcare, and physical therapists attending this keynote of the Neurology track at APTA CSM 2015 in Indianapolis were encouraged to embrace this change. Bemoaning the lag time from research to clinical practice, Pam Duncan suggested that researchers find ways to work with interdisciplinary teams of biomechantical engineers and even private companies to bring innovation to patients faster. She started with the inspiring example of Carol Richards who received the Order of Canada for her work with the interdisciplinary team on the Stroke Network Canada, aimed at decreasing the impact of stroke across Canada.

Source @mdaware on Twitter

Source @mdaware on Twitter

Duncan then told a story to explain her passion for changing post-acute stroke care, involving a personal experience that changed the course of her career. Duncan’s mother suffered a stroke and while Duncan was trying to provide comfort in her mother’s last days, a traveling physical therapist arrived in the hospital room with a goal of getting her mother to get her mother to stand, which was apparently the clinical protocol she was assigned to do. Duncan protested and later spoke to the owner of the physical therapy company that had contracted to the hospital. He shrugged and asked her why she cared since Medicare would pay for the visit. Incensed at the waste of time and money but more furious at the way this care completely disregarded the patient’s best interests, Duncan put aside her plans for opening a private practice and focused research to improve post-acute care for stroke patients.

Translating Research to Evidence and the Humble Researcher

With the same vehemence, Duncan described how she believed that over 180 publications she’d made on the topic had done little to advance stroke care, largely due to the difficulty of translating clinical research into practice, and asked the researchers in the audience to change this by developing interdisciplinary teams, questioning all their assumptions, and thinking about the patient holistically, not just from their own discipline.

She asked researchers to be “humble researchers” referencing a column by the New York Times columnist David Brooks and not just set out to prove what they want to be true. Duncan used an example in her own research which disputed a popular belief on stroke recovery and showed that home-based exercise was more effective than treadmill-based. Duncan described herself as still having arrows in her back from that publication.

Best Practices for Stroke Recovery

After lighting a fire for the audience to think about things differently  by saying

“Take off your neuro-plasticity hat and think about patients holistically.”

Duncan continued with specific examples on how to change care. First was to understand the overall situation. 10-30% of stroke patients face permanent disability, something that is not always clear when they are released from hospital within 3-5 days of the incident. She gave an example of a patient who was discharged with care instructions and prescriptions yet when she got home she couldn’t follow them: she discovered the stroke had affected her ability to do basic calculations.

“If you asked if I had discharge instructions I would have said yes, I heard what the nurse said and I showed her I could inject my drugs, and my math deficit wasn’t diagnosed until I got home. I did the things I needed do to get discharged but wasn’t really able to cope.”

This is a clear example of how our current system fails us. It does not support the patient outside the clinic, and yet it’s so much less expensive and more comfortable for the patient to be released to home. Looking at the costs it’s clear that we need to improve home health options.

Post stroke care costs:

  • Acute inpatient care: $8,000
  • Skilled Nursing Facility: $41,000
  • Inpatient Rehab: $14,000
  • Home health: $6,000
  • Long-term care: $62,000

As Duncan put it, “Home health is a dirty word in Washington” yet this where the patient should be. She called stroke the poster child for the discontinuity of care in healthcare as 73% of post stroke readmissions are for other issues not related specifically to the heart. Duncan sees hope though, and called bundled payments the best thing to happen to stroke recovery as providers will have to collaborate across the care continuum.

She sees the benefits as:

  • Coordinated high quality care with seamless transitions
  • One primary metric for integrated care
  • Excellence based on outcomes

The message to physical therapists is that they are uniquely suited to these multi-disciplinary teams focused on patient outcomes. For patients, outcomes are measured by function. For CMS, value is measured by those functional outcomes divided by the cost and physical therapists can deliver on both.

This session was a great kick-off to the conference, which had an overall tone of embracing the changes coming in healthcare and the role of physical therapists in it. As a company providing continuity of care through digital treatment plans and connections with healthcare providers outside the clinic we were inspired to see so many people embracing this change.

Posted in: Aging, Health Regulations, Healthcare Disruption, Healthcare transformation, Physical Therapy

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

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

Presenters:

Mary Altpeter, PhD

Tiffany Shubert, PhD

Clinical Support for Otago

Clinical Support for Otago

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

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

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

Delivering Otago: Calendar view

Delivering Otago: Calendar view

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

Clinical Barriers to Implementation

Clinical Barriers to Implementing Otago

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

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

6-Stage Behavior Change Model

6-Stage Behavior Change Model

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

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

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

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

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

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

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

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

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

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Texting to Better Health

This post is guest authored by freelance journalist Fiona Hughes.

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

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

Wellpepper's Secure Text Messaging

Wellpepper’s Secure Text Messaging

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

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

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

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

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

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

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

***

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

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

***

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

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

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

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

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

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

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

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

 

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

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Choosing the Right M-Health Tools for the Job

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

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

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

Validating Clinical Data To Reinvent Medicine

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

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

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

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

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

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

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

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

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

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

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

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The Connected Patient Is Here

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

Confronting Mental Illness Online

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

Serving the New Connected Patient

Source: MHealth Summit

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

 Email Is Our Killer Application

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

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

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

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

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