Healthcare Disruption

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Healthcare is part of our supply chain: The Boeing Company

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

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

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

Washington Hospitals, Boeing Strike ACO Deal

Boeing Signs Shared Savings Deal With Washington Hospitals

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

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

Finding the Defects

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

Understanding Cost Drivers

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

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

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

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

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Improving Healthcare Quality, Costs, and Outcomes in Washington State

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

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

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

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

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

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

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

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

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

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

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

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White Coat, Black Art

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

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

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

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

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

 

 

Posted in: Healthcare Disruption, Healthcare transformation, Lean Healthcare

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Using Homecare For Positive Change in Healthcare

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

The State of Washington

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

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

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

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

The Penn Center for Community Health Workers

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

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

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

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

Panels on Technology Innovation and Practice Solutions

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

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

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

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

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Support for Telemedicine in Rehabilitation

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

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

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

Instead what they showed was:

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

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

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

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

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

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

Patient benefits

Telemed costs

 

 

 

 

 

 

 

 

Benefits that the team saw were:

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

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

 

Tele-rehabilitation: A New Frontier In Geriatric Rehabilitation”

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

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

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

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

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

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Cautious Optimism In Spinal Cord Research: The Model T Stage

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

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

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

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

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

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

Man walking in exoskeleton

Man walking in exoskeleton

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

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

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

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

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

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

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

Posted in: Healthcare Disruption, Healthcare Technology, Rehabilitation Business

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

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

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

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

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

The Problem with Information Dissemination

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

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

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

Barriers to Implementing New Methods from Research

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

Barriers can include:

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

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

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

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

Organizational Barriers

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

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

So should we give up?

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

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

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

Methods that won’t effect change

  • Pamphlets
  • Total quality measures
  • Lectures

Methods that will effect some change

  • Patient driven or mediated
  • Conferences

Methods that will effect real change

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

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

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

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

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Adopting Technology in Healthcare for the Right Reasons

Regulations, process, and records keeping are all important parts of managing health IT; however, when implemented without a strategy focused on patient and business value, they can create headaches for CIOs, not to mention patients and healthcare providers. This was an emerging theme Institute for Health Technology Transformation Conference held in Seattle at the end of August.

IHT2 Summit in SeattleThe conference featured speakers from across major healthcare organizations. Mayo Clinic CIO Chris Ross gave the final keynote which summarized many themes of the conference and provided direction for the future. He described Mayo’s tradition of using industrial and process engineering to deliver on Mayo’s promise of team-based integrated care. Viewed through this lens, imperatives to integrate EMRs, adopt ICD-10 and attest to Meaningful Use became opportunities that aided the business, and enhanced patient care. However, he was clear that while these projects were necessary, they were not sufficient by themselves to achieve Mayo’s vision. He went on to describe projects underway to optimize the workflow for their clinicians, in one instance reducing the amount of time doctors spent using IT tools from 30 minutes to 5 minutes per patient. He also described the vision of having hundreds-of-millions of lives under Mayo’s care, and the patient-centric model that they were following to achieve this. This included projects like delivering the Mayo app deeply integrated with Apple’s HealthKit technology.

Ross also asked his peers to consider the move to electronic records keeping to be a move to digitizing the healthcare industry to keep pace with the innovation available in other industries instead of a regulatory requirement. He envisions a system where a unified data platform provides digital care and knowledge management and recording keeping is a by-product of that system.

Focusing on the right strategy was also a theme in a talk by Dr. Nick Wolter of the Billings Clinic. Wolter described a 1993 merger with Deaconess that nearly bankrupted the organization. The merger was focused on regulatory and process integration while ignoring the vision for the new organization. In 1997, with financial losses posted, they hired turnaround experts who focused on physician leadership development. By 2005 they had established a vision to be best in the nation for patient safety, quality, and service. In 2010 Billings Clinic added value to their mandate and are looking closely at ACO metrics to make sure they are delivering on these promises.

Throughout the two-day conference, panelists called out EMRs as a significant driver of physician dissatisfaction. While meaningful use requirements have increased the focus on moving to electronic records, in many cases this is apparently happening without a vision that leverages these transformations to improve physician efficacy and patient care, which is unfortunate as these two areas if provided with appropriate electronic tools could see some of the biggest benefits.

Although there is was definitely a dissatisfaction expressed with the current state of health IT, it was promising to see shifts towards tools that are more focused on provider workflow and patient engagement. Even more promising was the general understanding at this conference that digital healthcare can and should be better delivered. At Wellpepper we’re excited to support this shift to a patient- and value-centered system.

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

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Patient Engagement: From Idea to Proof

In the last year, patient engagement has gone from buzzword to a clinically proven solution to rising healthcare costs. A study published in 2013 in Health Affairs found that engaged patients in the first year of the study were 8% less expensive that non-engaged patients in the base year. As the years progressed and the impact of some of the behaviors of non-engaged patients like diet, exercise, and smoking had a bigger impact, the gap was expected to widen.  Cost drivers were use of emergency room services and hospitalization of these non-engaged patients.medicalperson

“Patients With Lower Activation Associated With Higher Costs; Delivery Systems Should Know Their Patients’ ‘Scores”http://content.healthaffairs.org/content/32/2/216.full?sid=bd3de9e3-8393-4553-bf75-ebb537b75905

At the same time, technology has been heralded as the solution for engaging patients, and the quantified self-movement was the poster child for tracking health metrics. The problem is that the people who were doing all this tracking were pretty engaged to begin with and therefore not representative of the population as a whole. Other solutions used rewards for behavior change, like gift cards or donations to favorite charities. Unfortunately, recent studies have shown that these types of rewards systems are good at enrolling patients in health engagement programs but not good at helping them sustain good habits. http://mobihealthnews.com/35244/study-rewards-boost-enrollment-but-not-sustained-engagement/

personA combination of extrinsic and intrinsic rewards is seen to be much more motivating. Intrinsic rewards are the ones that are built directly into an experience, for example Facebook likes or Twitter retweets. We know from our experience at Wellpepper that a combination of intrinsic rewards coupled with the accountability through a connection with the healthcare provider creates more adherent patients and better outcomes. Our patient engagement rates hover around 70% (compared to 2-3% for some EHR portals), and we have some providers with patients who are 100% adherent to their treatment plans. Look for more news on this topic in the fall of 2014 when we release the results of some clinical studies that use Wellpepper.

Technology for health-related behavior change is still in its infancy. However, with the right combinations of factors that motivate patients, the benefits are clear: better engagement and better outcomes. For patients, using technology for health engagement provides them with convenient and cost effective solutions. There are also benefits across the health system.

Using technology for patient engagement can enable:

  • Remote care and monitoring. This covers both outpatient discharge and aging in place. Enabling people to recover or live at home longer improves their experience and lowers overall healthcare costs. New models of care are also possible as remote communication can employ specialists in different areas of the country or the world.

“There is a nationwide shortage of such critical-care specialists, known as “intensivists,” so the idea is that these doctors can monitor more patients remotely than if they were on-site at a single hospital.” USA Today

  • medical bldgOperating at the top of your license. Predicted shortages of primary care physicians due to an increased demand from more coverage and an aging population are not overstated. Technology that enables physicians to scale their abilities to cover patients by offloading some care and monitoring to other disciplines like nurse practitioners can help ease this burden.

“We use what we call Teamlettes. A group of people assigned to every patient. Administrative, clinical, psychiatric, all of us working at the top of our license, because there’s a lot of stuff done in medicine that can be done at other levels.” Mike Witte, Medical Director Coastal Health Alliance

  • Patient-reported data. Patient-data is already in our systems, from patient interviews, however it’s inputted by healthcare professionals and relies on patient memory of previous events. Enabling patients to enter health data as they experience it can result in more accurate information and also a more efficient in-person visit as the healthcare professional and patient can review what’s been entered rather than trying to remember what happened over the course of several days or weeks between in-person visits.

“Patient-created, and patient-curated information is the key to the future. We need to build tools that are based on this assumption. They need to be in line with what consumers are accustomed to in other aspects of their lives – they need to work on mobile devices as well as the web.” Robert Rowley, MD 

  • Community support. Engaging community organizations in helping patients, is both beneficial and cost-effective. Community organizations and centers can play an active role in helping people manage their health. Enabling patients to have key health-related information with them outside the clinic can help professionals like fitness or diet coaches engage. Providing the patient with ways to engage around their health in a community setting can help encourage and foster new habits. Medicare is piloting a number of programs designed to increase community involvement and decrease readmissions.
  • Managing groups of people. Websites like “Patients Like Me” and “Ben’s Friends” started as grassroots patient support groups facilitated by the vast reach of the Internet. If patients can meet and discuss their health, healthcare organizations should also be able to facilitate the management of people with similar issues. Technology can facilitate the ability to send similar treatment plans, communication, and tips to groups of people.

This is just the beginning of what’s possible. Technology advances will facilitate new ways of monitoring, communicating, and engaging that we haven’t even considered. We’re pretty excited about how engaging patients can improve outcomes and ultimately result in major positive changes in the health of countries and the way care is delivered. It’s still early days and patients, providers, insurers, and technologists are all still learning but there is so much opportunity to have a real impact.

Posted in: Adherence, Healthcare Disruption, Healthcare motivation, Healthcare Technology, Healthcare transformation

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Big Distances Make the Case for Telemedicine: Recap from the Canadian E-Health Conference

Vancouver Convention CentreJust back from the American Telemedicine Conference, and we took a short trip over the border (and back to the motherland), to the Canadian E-Health Conference in Vancouver, BC. Due to the short timeframe between conferences, it’s hard not to compare and contrast the two, although the healthcare systems between Canada and the US could not be more different. The E-health conference had a broader scope than the ATA conference, with telehealth as a sub-topic and electronic records management featured more broadly, in fact, all the major EMR vendors were there, with the exception of Epic.

Know Me in Powerchart

Know Me in Powerchart

In a session sponsored by Cerner, Island Health CMIO and Acting Executive Medical Director, Dr. Mary-Lyn Fyfe shared their patient-centered approach to EMR implementation called “Know Me.” Island Health Authority has been a Cerner customer for 5 years, and have a robust implementation with plans to extend to patient recorded profiles. Dr. Fyfe talked about how what is most important to patients is not always evident or even apparent to healthcare providers, for example, a patient admitted for heart issues but who is more concerned about who will care for his spouse at home with dementia rather than his own condition. Only by treating the whole patient does Dr. Fyfe believe that healthcare providers can have real impact.

Although telehealth was not more advanced in Canada than what we’ve observed in the US, Canada has real financial incentives for telehealth. Vast distances and sparse populations make delivering a high-level of care in many parts of Canada very expensive. The more that can be done remotely, the better. One group covering First Nations groups boasted that they had delivered nine telebabies, that is babies delivered with the help of a doctor over telemedicine. Another doctor talked about how his being able to coach a medical assistant onsite through a video call prevented a $10,000 emergency helicopter flight. Others talked about the environmental benefits of thousands of car trips of 3-4 hours that were avoided by using telemedicine, not to mention the quality of life improvements for patients. Another benefit of telemedicine that we hadn’t seen cited before was doctor education, this is in the scenario where a local primary care physician calls a specialist and together they meet with a patient. In an in-person specialist care scenario the patient would not see these two physicians at the same time. Having both in the same patient visit enables knowledge sharing between the doctors, for the specialist more context on the patient, and for the primary care physician education about the specialist’s area of expertise and the patient’s condition. You could call this collaborative telemedicine.Hackathon

While telemedicine is well established in Northern Canada, it seemed that the benefits in parts of Canada closer to the US border where most of the population lives were not as well established, and a surprising number of telemedicine initiatives were still in pilot mode. Similarly there seemed to be a great disparity in electronic records management with some health authorities still entirely on paper.

Kicking off the Canadian Telehealth Forum, which was a pre-conference session and also an annual event, Joseph Cafazzo of the Center for Global E-Health Innovation showed examples of home monitoring technology that did not take into account the users, who are primarily seniors, and called on the audience to consider empathy in the design of products. One of the key reasons for this is that the only person capable of managing a chronic illness is the patient themselves, and yet many don’t want to identify with their illness or be reminded that they have it. Empathy to the patients experience can help in designing products that make it less intrusive for patients to manage their health. The Juvenile Diabetes Foundation has been putting pressure on manufacturers for this as teens in particular don’t want to take their blood sugar readings although it’s crucial to their health. The Center for E-Health developed an application that identified the times that teens really don’t want to take readings (at lunch when they are at school for example), and offered rewards like iTunes giftcards for doing so, a great example of a carrot that is attuned to the patient’s preferences.

Mobile health seemed in the same place as in the US: a lot of very interesting, patient-centered applications like the 30-day stroke assessment from the Center for E-Health and the Heart & Stroke Foundation of Canada, which used AirMiles rewards to entice a high-risk group of men to download and complete the assessment. Engagement was 12% across all groups, including seniors. One of they keys to the app was that it focused on a short-timeframe, although this does bring up the question of how to keep patients engaged over the long-run.

Not surprisingly a number of solutions were based on lowering costs of population health management. Because healthcare is government funded, unlike the US there are real incentives for decreasing costs as well as keeping the population out of long-term care. While many solutions addressing issues such as CHF and COPD are in early stages, we heard lofty goals of increasing the number of outpatients managed by one nurse to over 200, and also using wellness coaches to scale further.

Considering that unlike the US, all the economic and patient incentives are aligned for e-health, it was a bit surprising that so many of the solutions and presentations were about pilots rather than completely implemented systems. However, that might be a tradeoff of having government run programs. Regardless, the conference featured many passionate speakers who are using innovative solutions to both improve patient outcomes and experience while being cost-effective.

Posted in: Behavior Change, Health Regulations, Healthcare Disruption, Healthcare motivation, Healthcare Technology, M-health, Telemedicine, Uncategorized

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IT Can Make a Big Difference in Healthcare, Why Hasn’t It?

The final in the excellent collaborative healthcare series from the University of Washington and the Washington Biotechnology and Biomedical association did not necessarily end the series on a high note: speaker Peter Neupert presented a view of the near-term realities of healthcare evolution that was sobering for technology vendors. Basically Neupert’s thesis (and investing thesis) is that technology alone cannot have an impact on healthcare process and outcome improvement, and that pure technical solutions are doomed in the current situation where there is a lack of symmetry between the recipient of service and the payer of the service.Determinants of Health

The benefit of technology historically has been to create efficiencies and economies of scale by reducing manual efforts and waste. In the current system, the payers are incented to decrease costs, however, the way many providers are paid (fee for service) result in no incentives for them to reduce cost. Also, we currently have a disjointed system where payers and employers are responsible for the health of people until age 65 and the government is responsible afterwards, which is not conducive to preventative medicine or efforts to help the long-term health of the population.  Changes in healthcare models as part of the Affordable Care Act will drive the need for providers to be concerned about both population and long-term health but right now, we are in transition, which is why Neupert is betting (at least in the mid-term) on services that are delivered with technology rather than technology on its own unlike other industries. Neupert believes the winners will be those who can deliver a healthcare service more efficiently with technology, for example, home care systems that are able to do remote monitoring with telehealth and sensors and find problems before they become major issues.

Another reason Neupert cited as a reason that Health IT has not made the impact it could have is that in the US in particular, 5% of the people represent 50% of the cost. The reasons for poor health in this 5% are heterogeneous, which also makes it hard for a pure technology solution to address and do what technology does best which is scale. Neupert gave the example of an outpatient care company that produced better outcomes by simply making sure that patients had a ride to their follow-up care, a decidedly low-tech solution. As we think about preventative health solutions, it’s not enough to consider the person in treatment, we also have to consider the environment, for example, if you want to change a person’s diet you also have to change the diet of their family. Technology could help here, for example visual food journals have proven to be effective, but step one is often making sure the family has access to fresh food and knows how to prepare it.

Big data is another lauded savior of healthcare. But if data is not used it is not accurate. Again, there needs to be incentive to use it and that will drive data accuracy and results. Neupert gave the example of New York Presbyterian who have over 100 hospital applications and consequently very good data and contrasted that with the statistic that cause of death is cited incorrectly 25% of the time. Applying analytics to that data would be futile as we’d be trying to prevent the wrong cause of death.

Healthcare IT is grappling with problems that other industries faced years ago, for example, moving to the cloud, bring your own devices, or single-sign on. The key is for both healthcare organizations and technology companies not to see IT or the implementation of an EMR as the savior of improved healthcare, but as a tool that can enhance human-based processes. At Wellpepper we know that a key driver of patient adherence to outpatient treatment plans is the connection and relationship patients feel with their healthcare provider and think that technology is a great tool to enhance and extend that relationship.

We’d like to thank the Health Innovator’s Collaborative, the University of Washington, and the WBBA for this series. It provided inspiration, innovation, and an important dose of reality to big thorny problems. We hope to see this continue.

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

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Dispatches from the 2014 American Telemedicine Association Conference

BaltimoreWe just returned from the 19th annual American Telemedicine Conference in Baltimore, MD. It was an amazing opportunity to network, meet telemedicine pioneers, and get energized about the opportunities to improve patient care. While there are still some major barriers to care, first in the way of billing codes and second in the way of cross-state licensing, speakers were confident that these legislative issues will be solved for a number of reasons: telemedicine is effective, it’s what patients want, and it can improve access to care and decrease costs.

Telehealth in Practice: Chronic Disease Management

Similar to what we’re seeing in all healthcare, a one-size fits all approach does not work when it comes to telehealth either. For some patients it works extremely well, and for some even the most rudimentary telehealth (i.e. phone calls) doesn’t work. We heard many discussions about green, yellow, and red patients. Green are those that are able to take care of themselves and their recovery. Yellow are those that have some risk, particularly of hospital readmissions. Red are those who are a definite readmissions risk. While Red patients often cost the most money, they may not be the best candidates for the cost savings of telehealth. One speaker pointed out that the most challenging of “red” patients often move without notice or have their phones cut off which makes even the simplest intervention, either a phone call or a house call impossible. This speaker suggested that while the healthcare system needs to figure out a solution for these patients, they are often used as examples of why telemedicine doesn’t work. Using this as the standard will definitely set us up for failure as the benefits for those green and yellow patients are real.

Congestive Heart Failure is the number 1 reason for hospital readmissions, and not-surprisingly a number of sessions dealt with follow-up care for this population. As well, repeated CHF readmissions also lead to long-term mortality. In practice ensuring follow-up visits reduced readmissions, however, in-person follow up visits are both expensive and inconvenient for patients. Carolinas Healthcare Systems started a telehealth follow-up program for CHF in June of last year, and are already seeing results for their Heart Success Virtual Clinic. First, patients have been saved over 3,900 miles and 380 hours of travel. Second, the follow-up rate for virtual visits is >95% compared to 70% at the in-person clinic, and the no-show rate is 3% compared to 10%. Telehealth visits are more convenient and as one speaker pointed out “it’s hard to miss a visit that’s in your house” so no-shows decreased as well. While the study hasn’t been completed yet, they are expecting a 50% decrease in readmissions for the patients that are participating in telehealth visits.photo 2

The University of Arkansas Center for Distance Health also saw positive results for CHF by using a call center to manage 30-day post-discharge follow-up coupled with an EMR. While on the phone with the patient, an RN verifies whether the patient has been seen by a nutritionist, is on a special diet, is managing fluid intake, has been in touch with a patient educator, and has scheduled a 1-week follow up appointment. Patients were instructed to call the hotline with any questions, concerns, or worsening symptoms. During the pilot from May-July of 2013 the program saw a 31% decline in readmissions resulting in $60,000 in cost savings to the organization (this did not include the costs of any Medicare fines). When the program was rolled-out to the entire patient population in Q1 of 2014, 34 readmissions were prevented with a total cost savings of $418,000.

Other examples from the conference involved care team and peer support for patients. A bariatric program run by DPS Health included patient discussion groups that were moderated by healthcare professionals. Moderators were present to guide the discussion and ensure that patient questions were answered, but they did this by prompting patients to answer each other’s questions rather than having the moderator jump in. This peer support helped participants achieve an average weight loss of 4-5%.

Sensors and Information Overload

It seems that the greatest promise for telemedicine though comes at the convergence of patient self-care, collaborative team care, and access to information, and patient provider communication. Patients can take more responsibility for their care outside the clinic using monitoring, apps, and sensors. However, the best results were seen when those patients were able to communicate remotely with healthcare professionals, and when those healthcare professionals also had access to information. However, none of this should come at the expense of care. While sensors were a hot topic, tools must be developed to help healthcare professionals deal with the influx of data. They need to be able to triage the information and get to the relevant and actionable information. One physician said that we don’t have a primary care physician shortage, but due to the extraordinary demands of documentation, we do have a shortage of physician time. Trackers and sensors should not increase this burden if they want to have an impact on care.

At the conference we saw sensors for just about everything, including a few questionable brain scanners. The sizes of scanners ranged from ankle bracelets to band-aids, and from flashy consumer designs to highly clinical. One speaker was adamant that disposable sensors are the future, citing the “razor/razor blade” model. While disposable are appealing in that they are usually designed to be worn under clothes and are small, we’re not sure about the analogy as the software that comes with sensors is usually free. However, given the number of FitBits we’ve had to replace at Wellpepper due to loss, the idea of a cheap disposable sensor is highly appealing.

What Patients Want

We’ve know since we founded Wellpepper that patients want information, convenience, and access to support from healthcare providers everywhere. It was heartening to see this echoed throughout the conference. Perhaps the most interesting was the data presented by Carena on what happened when a major employer in Seattle moved to a high deductible plan: the total number of PCP visits decreased 52% and the remaining shifted to telehealth. If this doesn’t prove without a doubt that patients are cost-conscious consumers, we’re not sure what does, especially since we happen to know that major employer pays pretty well. It also probably shows that if services are unlimited, people will overuse them.

This was really just a small glimpse of an extremely busy conference. On the one hand, it’s heartening to see all the passion about change, however, it’s also sobering to realize that this was the 19th year for this conference, and yet we still are debating the merits of telehealth, and some states do not allow telehealth. Hopefully though between patient demand, increased access to technology, and the need to reevaluate both the costs of care and how to support population health, this will change.

We will definitely see you next year at ATA 2015, and are looking forward to see how small the sensors have become and how much more ubiquitous telemedicine has become.

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

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Good, Fast, and Cheap: Demonstrating Value in Health Innovation

The goal of Triple Aim is to say that, despite what any project manager will tell you, you can have all three.

Good, Fast, Cheap

Source: http://ollmann.cc/

This provocative statement, set the tone for this third installment in Seattle’s  Health Innovator’s Collaborative, a talk called “Demonstrating Value in Health Innovation: Lessons from Comparative Effectiveness Research” by Larry Kessler, Professor and Chair, Department of Health Services, UW School of Public Health and formerly of the FDA, NIH, and NIMH. Dr. Kessler believes that the new accountable care organizations are mandated to deliver on all three and used the example of the Institute for Healthcare Improvement which was founded in 1991 on this principle and brings together leading hospitals, policy people, and researchers who are finding the best ways to deliver triple aim across many specialties.

Changes in how healthcare systems deliver care will drive innovation; however, innovation for its own sake will not win. Innovation must show evidence, cost savings, and revenue drivers. At the same time, it must satisfy a much wider group of stakeholders than previously including patients, physicians and clinicians, payers and providers. Innovative approaches and technology will take the leap past simply showing evidence of clinical outcomes to delivering value. This is a dramatically different approach from how typical NIH or FDA studies are done today. Those studies are done with a small slice of the population that is homogeneous, for example, they only have one issue and no co-morbidities. This type of study may prove outcomes with this particular population, but it doesn’t show cost or revenue based value and is no indicator of how something would work in the population at large, where the sickest patients are usually struggling with more than one issue.

Quality needs to be redefined as the best service AND the best health outcomes AND the best cost outcomes. Dr. Kessler went on to show some clear examples where solutions needed to go to the next level to be adopted and show results.

The first example provided a model that showed over a 5 year period, gastric bypass surgery proved cost effective. However, insurance plans do not include this surgery and require copious paperwork to justify it. This may make sense though, as the determinates of whether surgery is actually cost effective include a number of additional factors like the population and especially whether they will be part of your problem in 5 years. This is where the new accountable care organizations that are charged with population health will have an easier time with the cost benefit analysis as they be responsible for these patients in 5 years.

Another similar example is the new drug Solvaldi for the treatment of Hepititis C. It’s recently been in the news for its staggering price tag: $84,000 for a 12-week course. However, the drug has proved to be extremely effective, and University of Washington health economist Sean Sullivan points out “the drug is far cheaper than the alternative, which is a liver transplant and a lifetime of immunosuppressant drugs.” Again, though, whether this is a bargain or not depends on how long the payer thinks they will be responsible for the patient.

Successful business outcomes based on cost savings were shown in the example of two diagnostic tests for whether breast cancer would reoccur. The FDA-approved test MammaPrint could predict the recurrence of breast cancer. The non-FDA approved test Oncotype DX could predict the recurrence of breast cancer AND whether chemotherapy would work for the patient. This test, while not FDA-approved became far more popular as it showed very clear cost savings and quality of life for patients who did not undertake unnecessary chemotherapy.

Another study, Back Pain Outcomes Using Longitudinal Data-Extension of Research (BOLDER) was able to consider the patient experience as part of treatment. This study looked at 5,239 patients over 65 with new primary care visits for back pain across 3 integrated systems: Kaiser Permanente of Northern California, Henry Ford Health System, Harvard Vanguard/Harvard Pilgrim. The study goal was to determine the impact of early imaging as an intervention. The results are not yet published, but a couple of observations were already apparent. First, patients sent for MRIs, delay getting physical therapy and if the MRI shows they need physical therapy rather than surgery they have delayed their recovery by the time they waited for the MRI. In this case, the intervention of imaging if it was not needed produced less positive results for patients.

This study used the Roland-Morris Disability Questionnaire and it was also noted that many of the standardized testing tools do not account for what the patient actually considers a good outcome, like whether they can sleep soundly or have sex. Again, this shows that studies need to go a step further into the real world application of the patient’s situation.

These examples showed that it’s not enough to show that an intervention or new technology worked in a study, they also need to work in the real world. For payers that means lowering costs, for providers that means lowering costs or generating revenue while improving outcomes, and for patients that means delivering outcomes that are important to them, not just clinically validated.

The final lecture in this series will be June 3rd with Peter Neupert of Health Innovation Partners. See you there!
“IT can make a big difference in health:  Why hasn’t it?”

Health Innovators Collaborative
4:30 PM, W.H. Foege Building, UW Campus
Seminar: Foege Auditorium (S060)
Reception: Foege North 1st Floor Lobby

 

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

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Transforming Healthcare Through IT in Washington State

It seems every week there’s another health IT event in Seattle these days and we’re pretty excited about that. The grassroots efforts to build a health community really seem to be starting to take hold.  This week we had the pleasure of attending and presenting about Wellpepper at a Technology Alliance and WBBA event called “Transforming Healthcare Through IT: Investment Opportunities in an Emerging Sector”  held at K&L Gates beautiful offices. The WBBA officially launched their new Innovative Health initiative at the event: they are adding a third focus area to their current biomedical and biotechnology pillars and taking up the mantle of healthcare IT. Given that the lines are blurring between medical devices and mobile devices and software in particular, and that the WBBA are experts in healthcare regulations, this is a welcome move.

The view from K&L Gates Seattle, copyright K&L Gates

The view from K&L Gates Seattle, it was that beautiful this week. Source: K&L Gates

The event was kicked off by Rob Arnold of VantagePoint Investments, who outlined why health IT is so hot right now with a review of a number of trends including patient-centered care and the new requirements of the Affordable Care Act. However, he pointed out that Seattle really didn’t register as a center of healthcare IT investment. San Francisco, New York, Chicago, and even Atlanta and Nashville were far ahead. And yet, as we’ve heard many times we have some of the best healthcare systems in the country and some of the best software developers in the world. What we don’t have is investment, but this event, by bringing together investors, startups, and providers was aiming to change this.

Next up was a panel focused on the landscape of and future of IT moderated by John Koster, MD and former CEO of Providence Health & Services, with panelists Todd Cozzens from Sequoia Capital, Mark Gargett, VP of Digital Integration, Providence Health & Services, and Ralph Sabin from Fortis Advisors. The current state of health IT is not great: 80% of health records are running on a 45-year old technology called MUMPS (ie Epic), and 65% of providers continue to look for cost savings instead of at the $1T opportunity to fundamentally change how we do healthcare.  The current systems were characterized as a “big calcified hairball.”

EMRs need to transform and unlock the data in them to change this system, to be able to be prescriptive rather than reactive, for example, imagine identifying asthma patients and telling them about environmental changes that might impact their health.

All the panelists agreed that the transformation needs to come from within the healthcare system, and cited Microsoft, Google, and GE’s entrance and exit from personal and electronic health records as examples of why technology alone without a keen understanding of the process and system will not effect change.

On the other hand, there are lots of opportunities to fix small problems, for example, patient workflow or outpatient care. However, these incremental changes are harder to predict: it’s easier to see the large scale changes necessary than to fully understand the steps on the road to get there. This may be why the venture money shies away.

The panel also agreed that healthcare is becoming a retail model with patients as consumers driven by both high-deductibles and also expectations from conveniences in other industries. Providence recognized that consumers are increasingly in control of their health decisions and “want to be delighted.” Todd Cozzens from Sequoia predicted the winners would be those who could deliver on a retail experience, and close to or possibly even in a patient’s home.

Similar to discussion we’ve heard at other conferences about the future of healthcare, there was a belief that the fundamental skillset of individual healthcare providers needed to change: in the past remembering a number of facts and applying them in a particular situation was important. With technological advances like IBM’s Watson, computers can do a much better job of diagnosis and the role of the doctor changes to a social role of translating diagnosis into an effective care plan. Or as we’ve heard it characterized: “putting the care back in caregiving.”

Next up Mary Haggard and Joe Piper from Point B Managing Consultants and Capital, showed their “Health IT Landscape Matrix” which was an attempt to characterize Washington’s health IT companies according to the big buckets of Triple Aim categorized as “Creating Efficiency,” “Unlocking the Data,” and “Improving the Delivery of Care.” At the same time they attempted to categorize by the buyer (consumer, employer, provider, or payer), which wasn’t quite as easy and probably reflects the changing landscape of healthcare. What was amazing about the exercise was to see the diversity and number of players in Washington State. This is a great start to hopefully what will become a definitive reference source for the local industry.

Next up were the startup pitches from Corengi, Owl Outcomes, Health123, MedaNext, Spiral Genetics, 2Morrow, CadenceMD, TransformativeMed, and Wellpepper, which ranged from patient engagement to unlocking data genomics to unlocking data in the EMR (not sure which is harder ;)). We’ve been at events with most of these companies before and it was great to hear how they have gained traction and how their businesses and stories are evolving. As a presenting startup, we were happy to be in such great company both with our fellow audience and with attendees.

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

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UW Medicine’s Journey To Become An Accountable Care Organization

As part of the newly forming Health IT community in Seattle, the Unveristity of Washington and the Washington Biotechnology and Biomedical Association have partnered on the “Health Innovator’s Collaborative” which launched with a series of seminars on how the coming changes in US healthcare affect organizations and innovation.

Accountable Care OrganizationsThis past Tuesday, I attended a talk by Paul Ramsey, MD, and CEO of University of Washington Medicine entitled “The Transformation of Healthcare: Forces, Directions and Implications.” Despite this lofty title, Dr. Ramsey focused on the nuts and bolts of the new Affordable Care Act (ACA) with specific examples of how UW Medicine is becoming an Accountable Care Organization (ACO).

First off, Dr. Ramsey started with some definitions of the goals of the Affordable Care Act and Accountable Care Organizations. When asked if the ACA is having a profound effect, he stated that regardless of any other measures, the number of individuals who are now insured is significant. Harborview Medical Center, a member of the UW Medicine System that covers a diverse and often low-income population, has already seen a 2% decrease in patients without coverage.

What was striking about the session was Dr. Ramsey’s clear conviction that while the ACA is morally just (we need to stop pricing people out of healthcare) organizations becoming ACOs were currently doing it because it makes human sense, while not currently financial sense. The reason it doesn’t currently make financial sense is that the first ACO contracts between payers and providers are still in negotiation and in the switch between reimbursements for procedures to reimbursement for outcomes providers initially see lower revenues as they decrease the number of unnecessary procedures. In the long run, this is mitigated by getting the right care to patients and by managing population health in addition to individual health

The triple aim of the ACA is to improve experiences for individuals, improve overall population health, and reduce the cost of care: lofty but extremely important goals. While managed care and HMOs were supposed to do this in the 90s, their main failure was having the primary care physician as the gatekeeper to all other services. This did not guarantee that the patient received the best and most cost effective care. Dr. Ramsey contrasted this to the goals of an ACO, where a patient might call a nurse hotline and be referred to emergency, their primary care physician, or receives an e-care visit, depending on which was best for the patient and most cost effective in the long run.

When asked if this model was a capitated model, Dr. Ramsey said yes, but at a population level, and that is why the current negotiations between payers and providers are so important. Providers are choosing which measures they will be held accountable for in their first year as an ACO. UW Medicine is choosing seven disease management measures, three health status and screening measures, and number of caesarian sections, which is apparently a hot button measure for CMS. Because all measures will not be implemented immediately UW Medicine will spend some time transitioning between models, however, this does not mean they won’t continue to improve care in all areas. He cited his own recent experience as a cataract patient at UW Medicine as of an example where high quality outcomes, patient care, and cost-effectiveness were combined.

As a guide for these types of measures, and as an example of the medical profession taking on best practices regardless of financial incentives, Dr. Ramsey cited http://www.choosingwisely.org where each medical specialty association provides their own guidelines for reducing unnecessary procedures and promoting best practices. This is a great resource for patients as well to review whether costly procedures are actually recommended and effective.

Accountable Care OrganizationsThere was some discussion that the US medical system as a whole could decrease costs by 25% without reducing the quality of care. UW Medicine has been able to reduce costs by $90M annually which is only a 2-3% of their operating budget and remain a top hospital. UW Medicine will continue to improve on both costs and their overall ratings.

Interestingly, the most important factor in patient satisfaction, a key health system rating, is the communication with their healthcare provider, rather than the outcomes. Improving patient/provider communication is an extremely cost effective way to ensure great care.

This was a great talk, realistic yet optimistic about the challenges and opportunities inherent in this transition to the new models of care we so desperately need.

The two remaining talks are:

May 13, 2014: “Demonstrating Value in Health Innovation: Lessons from Comparative Effectiveness Research”

Larry Kessler, ScD, Chair of UW Department of Health Services and former Director, Center for Devices and Radiological Health, FDA, will consider the coming necessity for innovations to demonstrably provide value and how the experience with comparative effectiveness can help innovators gather the needed evidence.

June 3, 2014: “IT can make a big difference in health: Why hasn’t it?”

Peter Neupert, Operating Partner of Health Evolution Partners and former VP of the Health Solutions Group at Microsoft will draw on his extensive experience with both institutional and consumer aspects of health IT to consider the enormous potential and serious pitfalls that make this area of innovation so challenging.

Editor’s Note: The primary care physician as gatekeeper is a failure in the single payer system as well. It denies patients access to the care they need and also adds waste into the system. In Canada for example, a referral to a specialist must be done by a primary care physician and expires every 6 months. So, if a patient has a chronic disease that they need to see a specialist for, the patient cannot keep seeing that specialist without getting another referral, even if all parties agree the patient should keep seeing that specialist.

Posted in: Health Regulations, Healthcare Disruption, Lean Healthcare

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23 and Who? The results

This post is the 2nd in a 2-part series on our experiences with 23andMe.

Wellpepper: What made you want to try 23andMe?

Anne Weiler: I wanted to see what the customer experience was like. It seemed so simple. $99 and they promise to tell you about your ancestry and DNA.

Jacquie Scarlett: I was really interested in getting back the results and seeing if the information I received from 23andMe was consistent with what I already knew about myself and my family history.

Wellpepper: What did you think you would learn?

Anne: I was curious about my ancestry. I had a theory that somewhere in my family someone was Jewish. They weren’t.

Jacquie: I figured that I would get confirmation that I was mostly European and that arthritis ran deep in my history and would be a high risk for me.

Wellpepper: Were you surprised by the results?

Anne: Originally, I was surprised at being 99.9% European. People are always asking where I’m from and they aren’t satisfied with “Canada” as an answer. When I was travelling in Nepal people thought I was half Nepalese. However, since I originally received results, they have been refined, and I’m now only 99.5.% European. I am not sure if that explains anything though.Anne Weiler Ancestry from 23andMe

Jacquie: I wasn’t overly surprised by the results, but found some items very interesting. I knew that I would be mostly European, and I was – 99.7% (mostly British and Irish) – but it was fun to find out that I was .1% Jewish and .1% Native American.  It was also pretty cool to see 479 DNA relatives pop up in my results from all over North America and the UK.

Wellpepper: What was the most surprising result?

Anne: Most surprising were results that contradict my actual experience. For example, 23andMe says I’m at reduced risk for Psoriasis, a hereditary disease that runs in my family and that I do in fact have. This does make me question other results.

Jacquie: There were a few illnesses in the Elevated Risk section that took me back for a moment, but then when I dove into the results I realized that I was merely a few % points above the average for all people and I relaxed. It is a bit surprising to see those illnesses listed in front of you.

Wellpepper: What was the least surprising?

Anne: That I’m at risk for glaucoma. It’s hereditary and I’m familiar with my family history.

Jacquie: High risk for arthritis – very prevalent in my family history and I already have the illness.

Wellpepper: What is your understanding of the accuracy of this test?

Anne: I don’t know the statistical accuracy, but I know that 23andMe was trying to get to 1M DNA records sampled so that they could claim accuracy. I also saw the NY Times article showing the discrepancies between tests. Based on some of my results that are wrong it’s hard to know. The brain is funny though: I definitely want to believe that the results showing low risk for Parkinson’s or MS are correct even though I have other results that are incorrect based on my personal experience.

Jacquie:  I do not know. I have the understanding that the more DNA they receive from the population, the more accurate the results will be and the more information they will be able to find out. I took this as an opportunity to learn more about DNA and the possibilities of what you could learn versus that this is the absolute truth.

Wellpepper: What was it like to receive your results?

Anne: Anne Weiler Norovirus ResistanceIt was addictive. We all want to know about ourselves, and here it was, in great detail. I really loved the random things I found out, like I’m resistant to Norovirus (stomach flu) or that I am likely to sneeze in bright sunlight. I intuitively sensed those things, but had no idea they were genetic.

Jacquie: It was pretty fun and interesting. I love learning more about myself and family history. Even though there was a lot of information, I found myself wanting more and wanting to dive deeper. Every time there was an unknown listed – I wanted the answer – this is what keeps me coming back to the site.

Wellpepper: Since you have received your results how have you engaged with 23andMe?

Anne: They are very good at pulling you back in, either through relatives who want to connect or by releasing new test results. That’s the really interesting (and scary) part. Once your DNA is analyzed it remains on file and they run new tests or more accurate versions of previous tests on it. I didn’t realize that it was going to be such a sticky experience.Anne Weiler DNA Relatives

Jacquie: I have checked in from time to time to see if any of my results have been updated. I also really enjoy doing the surveys – I am very interested in the research that 23andMe is doing and want to help in any way I can.

Wellpepper: Have you shared your information with anyone? Who and how?

Anne: I’ve connected with two 2nd or 3rd cousins on the 23andMe website. I’m interested in finding my maternal grandmother’s family. We don’t know as much about them.

Jacquie: I have shared my results with close friends and family, mostly with family to entice them to do the test as well.

Wellpepper: Would you share it with your doctor?

Anne: If I thought it was relevant to symptoms I was experiencing yes, but otherwise not unless my doctor asked. Doctors are being overloaded with data these days.

Jacquie: I would share the results with them if they would find it helpful.

Wellpepper: Do you think 23andMe will continue to engage you?

Anne: I don’t seem myself using it all the time, but as I mentioned before they do a good job of bringing you back in, and maybe I’ll become more interested in genealogy as I get older.

Jacquie: I will check in here and there. I imagine that if I have a health situation, it will be helpful to be able to pull these results when needed.Anne Weiler Asparagus 23andMe

Wellpepper: Do you think people should have access to this type of personal health information? Is it dangerous?

Anne: They should definitely have access. I thought 23andMe did a good job of presenting potentially disturbing results with the appropriate cautions. For results for chronic and debilitating diseases they make everyone read information about the disease before they tell you if you have the marker for it. I think it could be dangerous if someone started to make changes before talking to their doctor, except for some basic things like avoiding tobacco or caffeine, which are good for you regardless of the markers you have.

Jacquie: Absolutely! I think it’s very beneficial for people to have the most information possible so that they know more about themselves and feel empowered to take care of themselves and their health.

Wellpepper: Based on receiving your results, will you make any personal changes?

Anne:  I will be more helpful to people with stomach flu since I know I can’t catch it, and I’ll be even more strict on my caffeine in the morning only policy.

Jacquie: The results weren’t surprising enough to cause any personal changes.

 

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

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Health 2.0 Seattle Meetup: How to Build Solutions in Healthcare

This was the second Seattle health meetup we attended in March, the previous was the Health Innovators Meetup. Health 2.0 is a global organization (we demoed at a Health 2.0 event in London back in November 2013) but the Seattle group is quite new. They are valiantly trying to help build a community of healthcare industry and startups, and those just interested in healthtech issues in Seattle.

The meetup was hosted and moderated by Tory Kelso of GenieMD, and formerly Microsoft HealthVault and Cerner, and panelists were:
Anand Gaddum, Director, Health & Life Sciences at iLink Systems.
Howard Mahran, CEO & Founder Deep Domain, Inc
Sailesh Chutan, CEO and co-Founder at Mobisante, Inc.

Each talked about the drivers for their participation in healthcare. For Howard Mahran, like many entrepreneurs we’ve met, ourselves included, it was frustration born from a personal experience. When Howard’s father was diagnosed with prostate cancer, he was amazed at the lack of information and data available about the diagnosis and prognosis. Sailesh Chutan was driven by a passion for accessibility to technology on a global basis. Anand Gadddum cited the opportunity for applying resources to the wealth of health data out there to make a difference.

When asked how to pinpoint the right problem to solve in healthcare, panelists discussed how to find the pain point by looking at something that doesn’t work today, and how to spot the disruption by seeing how a market or technology change could become amplified when applied to another industry. Sailesh used the example that the computing power in a smartphone today is more than enough to do complex image processing, and recalled his ‘aha’ moment when he realized to reduce cost and improve access, move access to services closest to the patient and find the lowest cost person to deliver the care. (We’ve written about this before. It’s often called “operating at the top of your license”, that is, making sure that if a lower licensed person can perform a task, enabling them to do it.)

Howard talked about the pain of trying to make sense of the “dumptruck” of data that the over 1100 non-standardized EMRs produce, an acute pain for smaller hospitals and clinics that do not have a large IT staff. Also related to the proliferation of non-standard EMRs, Anand talked about customers that are stuck with old technology that is siloed and not easily integrated. Services companies like iLink can help integrate and unlock this information.

Networking at Health 2.0 Seattle

Networking at Health 2.0 Seattle

At this point Tory pointed out that all three solutions had started with the technology, as technologists often do, and asked how to translate a technical solution to a customer focus. Howard readily agreed with the need to translate, saying that his customers don’t care about the technology at all, they care about the problem they have which is not being able to get information. He talked about how Deep Domain had completely changed their sales process to focus on customer pain rather than how great their technology is, and shared the enviable example of a sale that closed in 4 days after they took this approach.

Sailesh also talked about how they had adapted their sales strategy and focus based on what they’d learned in the field. In particular, they found that their mobile-phone based ultrasound offered new billing opportunities to small and particularly rural communities. Rather than providing a referral to a hospital for an ultrasound these clinics could perform ultrasounds themselves for a fraction of the cost resulting in a new revenue stream for the clinic and much higher convenience for the patient. He also realized in selling to these smaller customers, Mobisante had to provide a complete solution including training and image management.

The next topic was on healthcare’s slow embrace of platform, and perhaps the best quote of the night that the current crop of EMRs are why healthcare doesn’t understand platform. Certainly the lack of openness and data interoperability as well as the late adoption of many now standard enterprise IT practices pointed out by Anand are the key reasons behind this.
Some other reasons that healthcare has been slow to embrace platform and cloud technology is the very real fines for HIPAA breaches, although the panel pointed out that most breaches are not due to technology vendors but human error like losing laptops that have PHI on them.

Upcoming Health 2.0 Talks

Upcoming Health 2.0 Seattle Events

To conclude the session, Tory asked for some tips for anyone wanting to get into healthcare technology. Howard jokingly responded “don’t” but the underlying truth is that with long sales cycles, lack of standardization, and many regulations, health technology is not for the faint of heart. He also recommended to “look down not up”, that is don’t ignore the smaller hospitals that can implement more quickly or where your solution offers value they might not normally afford, like Deep Domain’s reporting or Mobisante’s ultrasound. Would-be entrepreneurs were also advised to seek out the early adopters in customers, those people who have passion, understand your value proposition, and are mission driven. These people will help you succeed.

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

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