M-health

Archive for M-health

Wellpepper’s Top Healthcare Blog Posts of 2014

We had quite an amazing year at Wellpepper and are really looking forward to great things in 2015. We’re looking forward to more changes and disruption in mobile health and telehealth, as well as new business models, billing codes, and proof of the efficacy and effectiveness of mobile health.

As we look forward, we thought we’d spend a few minutes to recap our most popular blog posts of 2014. In order of popularity they are:

Misfit Shine

Jewelry? Hmm.

A Tale of Two Sensors: Misfit Shine vs FitBit Zip

Not surprisingly given the hype around sensors in 2014, our post comparing how the two stacked up was our most popular blog post.

The Future of Mobile Health is Like a Warm Marshmallow

We read somewhere that your favorite tweet is not destined to be your most popular. This blog post has a warm space in our heart as it was a surprise to see mobile health as mainstream as a heartwarming Disney film.

Forging Ahead With Telehealth: A Roadmap for Physical Therapists

Our conference recaps are always popular, and this one was especially popular as all healthcare professionals are champing at the bit for billing codes that reflect the innovative new ways they want to practice.

Healthcare Is Part Of Our Supply Chain: The Boeing Company

Boeing is really pushing the payers and providers to deliver cost-effective outcome-driven care, so we are chuffed to see this one at the top of the list. Which other employers are going to take the mantle for 2015?

Post or Perish: Disseminating Scientific Research and the Kardashian Index

This recap of a talk on social media and popularity as important to scientific research made our top 5, and while the advice was great, and the debate on popularity vs credibility is important, we suspect it may have something to do with the mention of the “K” word.

Posted in: Behavior Change, Healthcare transformation, Lean Healthcare, M-health, Rehabilitation Business, Telemedicine

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The Future of Mobile Healthcare is Like a Warm Marshmallow

As we look towards a new year, we thought it was time for a few predictions:

  • Patient satisfaction will be the most important focus of the Triple Aim
  • Patient reported outcomes will be combined with full-body scanning for key signs
  • Emotional health will be as important as physical health, and mobile health companions will focus on both
  • The standard 10-point pain measurement scale will still be in active use
  • Mobile healthcare will move on its own, and even fly

Big Hero 6 logoHow do we know this? Big Hero 6: Disney’s treatise on the future of healthcare delivered by robots. Okay, maybe it’s about the bond between brothers and how ordinary brilliant scientists can become superheroes but given that one of the main characters, Baymax is a personal health companion, we believe Disney is also trying to tell us something about the future of healthcare.

Baymax is a huggable robot and personal health companion who can scan, diagnose, and treat humans and cannot be ‘turned off” until his patient is “fully satisfied with his or her care.” Baymax takes the patient satisfaction pillar of Triple Aim to the extreme. He can also do kung-fu, packs a mean punch, and can fly.

Baymax: I fail to see how flying makes me a better healthcare companion.

Hiro Hamada: I fail to see, how you fail to see that it’s awesome!

Baymax is activated when he hears someone say “ow” and uses a standard 10-point pain scale to first identify problems. Given his ability to review vital signs by scanning, we have to assume he’s asking this question for the emotional benefit of patient rather than a real data point.

Baymax: Hello. I am Baymax, your personal healthcare companion. I heard the sound of distress, what is the problem? On a scale of 1 to 10, how would you rate your pain?

Baymax Big Hero 6

Like a futuristic country doctor, Baymax understands that a patient’s health and well-being is affected by his or her emotions. At one point he tells his young charge:

Baymax: “It is all right to cry, crying is a natural response to pain.”

While he is only activated in response to injury, once Baymax is caring for a patient, he anticipates future issues, and is aware of what’s happening before the patient.

Baymax: “You have sustained no injuries. However, your hormone and neurotransmitter levels indicate that you are experiencing mood swings, common in adolescence. Diagnosis: puberty.”

He is also prepared for health emergencies.

Baymax: “My hands are equipped with defibrillators. Clear!”

Unfortunately, in this situation, the patient was using a figure of speech about having a heart attack, and this is one central problem with this future mobile health: Baymax is naïve and doesn’t understand human emotion. As well, in his desire to help he asks his young patient if certain activities will make him feel better even though they are potentially ill-advised. Baymax 2.0 will need to have some situational learning skills and not confuse patient satisfaction with the “customer is always right” motto.

However, like a real healthcare provider, Baxmax has taken an oath not to hurt humans and he fuBaymax hug Big Hero 6lfils this to the best of his ability, even when the humans try to get him to do otherwise.

So what is Disney trying to tell us about the future of mobile health? Based on the example of Baymax, we’d say in the future it needs to be:

  • With you when you need it
  • Focused on the needs of the patient
  • Summoned by the patient
  • Comprehensive
  • Focused on patient satisfaction
  • Huggable

The last one can’t be underestimated. One of the great appeals of Baymax besides his childlike naivety, is that he looks like a giant marshmallow. Mobile health needs to be patient-friendly and approachable. People don’t like to be reminded that they are sick and medical apps with medical names too often do this. For us at Wellpepper, we have a dog as our logo for this reason. We want to be approachable, friendly, and supportive to patients. We’re going to be with them on their mobile devices so they’d better want to have us there with them, just as Hiro has Baymax.

Happy Holidays from all of us at Wellpepper! All the best for 2015.

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

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Texting to Better Health

This post is guest authored by freelance journalist Fiona Hughes.

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

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

Wellpepper's Secure Text Messaging

Wellpepper’s Secure Text Messaging

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

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

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

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

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

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

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

***

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

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

***

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

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

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

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

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

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

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

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

 

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

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Choosing the Right M-Health Tools for the Job

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

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

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

Validating Clinical Data To Reinvent Medicine

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

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

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

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

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

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

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

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

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

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

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

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The Connected Patient Is Here

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

Confronting Mental Illness Online

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

Serving the New Connected Patient

Source: MHealth Summit

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

 Email Is Our Killer Application

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

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

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

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

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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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Helping Patients Protect Their Own Personal Health Information

Last week I was leaving a meeting at a large hospital when I saw a patient record sitting on top of the payment machine in the parking garage. Incredibly this is the second time that I’ve seen documents left here. People put them down when they pull out their wallets to pay for parking and then walk away.

Patient Record on ParkingThe information the patients left behind included treatment plan instructions – so you can be pretty sure they are not doing their follow up home care – but worse than that it contained a schedule of future appointments with the patient’s name, date of birth, and social security number. Yes, you read that right: a perfect package for anyone practicing identity theft. This was all on a page that was printed directly from the EMR. The DOB and SSN were probably included on the record to verify that the information was for the correct patient, but this could be verified by asking the patient without printing it on a schedule of appointments.

So – first things first – I took the paper records back into the hospital. But afterwards it got me thinking about information protection and privacy, and in particular about the many people who still think that a paper print out is more secure than the cloud.

Although concerns about information protection and privacy are valid, many of the major HIPAA breaches of the last few years have had nothing to do with the cloud and usually are related to human error and not great security practices.

A few examples:

Good protection of patient information is important whether that information is in the cloud, on an internal computer or system, or on paper. HIPAA regulations encourage building good encrypted software, however we also need to have safeguards to protect against human error.

If patient information were in the cloud, the patient would either access the information through a secure portal, email, or application on their mobile device. He or she would then authenticate themselves to receive the information, and would not need to worry about accidentally forgetting their treatment plans sitting on a parking payment machine.

While patients expect to be able to interact with their healthcare providers through portals and mobile applications in the same way they interact with their banks, many healthcare CIOs we’ve encountered are still extremely wary of cloud-based systems. Financial services is another heavily regulated industry that has been able to successfully move to the cloud to better serve its customers.

Wellpepper is a cloud-based application, which in the healthcare world, makes us a business associate and on the hook for any breaches of patient health information. On the hook means that we need to sign a HIPAA agreement with any organization and we have liability for breaches of information. This is a job we take very seriously and we do our utmost to protect all information that flows through Wellpepper. This includes encrypting information at rest and in transit, ensuring strong passwords, and conducting audits of our system as well as making sure we are well-insured.

With Wellpepper, we provide the same level of encryption and safeguards to the patient’s own device as we do on the clinical devices. Information is not stored locally so if a device is lost or stolen there is much lower risk than in the laptop examples. Patient can do whatever they like with their own data. If I want to post my x-rays on the lamppost in-front of my house I can do that. However, that doesn’t mean that a healthcare organization should facilitate me in sharing my personal health information, which is actually significantly easier with paper-based systems than cloud based.

Yes this information would have been transferred over the Internet which could leave it open for hacking but a secure cloud system is no less, and sometimes more secure than internal IT systems which are also vulnerable. The key is to ensure that everyone in the chain, from internal IT to external partners, and finally to the providers and the patients understands the importance of protecting health data, and has the tools they need to do so, whether that’s on paper, online, or in the cloud.

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

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A Tale of Two Sensors: Misfit Shine vs. FitBit Zip

On a 5-day back-packing trip in British Columbia, I put two sensors to the test. While neither were designed specifically for this purpose, my impressions are definitely relevant to the usability of the sensors in everyday life.

I’ve been using the FitBit Zip for over a year, and here at Wellpepper, we’ve blogged about experiences with sensors before. We integrated Wellpepper with FitBit for a Boston University study on engaging Parkinson’s patients and so the Wellpepper team all got FitBits to test the product and integration. BU chose the FitBit Zip because it had a long battery life and was easy to sync. They didn’t want study participants to have to worry about constantly charging the device.

For my trip, I decided to also try the Misfit Shine that I received as gift at the XX in Health Conference. I started on the trail with the Shine on my wrist and the FitBit clipped to my shorts. I had two main goals for the devices, which may be different than their intention but I thought they should work for the purpose: to tell time and to know how far I’d gone and how far I had to go until the next campsite.

I have to say, that sadly, I actually needed both devices to accomplish the task and there were problems with each.  The following is my review of how the devices stacked up for telling time, judging distance, ease of use, and form factor.

Misfit Shine

Telling time: The Shine shows you the time by flashing a light at 12, and then flashing the hour location and minute location using lights on a radius, because the time doesn’t advance the “hour” hand stays on the previous time until it hits the next full hour making 6:45 for example, look like 5:45. This made telling time an intellectual exercise. Maybe this was the point, but not being able to glance at the thing on my wrist to find out the time was pretty frustrating. It was also extremely hard to see the flashing lights in bright sunlight. So, for telling time, I’d have the Shine a C.

Misfit Shine

Jewelry? Hmm.

Distance: The Shine uses goals that are awarded according to points. This is so that you can track multiple activities. The problem is that by default it only tracks steps or distance but the reporting on the device is only how complete you are on your goal. This makes it actually impossible to use the Shine for distance tracking without syncing to a cellphone. (I did not bring a cellphone on the trip due to battery life and complete lack of wifi signal.) Tracking Distance: I’d have to give the Shine an F.

Ease of Use: To get information from the Shine, you double-tap it. This in theory is easy but sometimes it didn’t respond or because of the bright sunlight I’d miss what it was trying to tell me. However, syncing with the app was very easy and the app is reasonably usable (although I still haven’t figured out which night sleep tracking is showing). I didn’t find out until after the trip that in order to record other activities like swimming, I was supposed to tell the Shine that an activity other than walking had started. Ease of Use: B+

Form Factor: The Shine is an attractive metal disk. However, it’s on a rubber wrist band so to call it jewelry is a bit of stretch unless you live in Silicon Valley or maybe Seattle. The metal is smooth and pleasing to the touch but I really wish it told you some information when you look at it. Form Factor: A-

Other: The Shine tracks sleep, which is quite interesting. However, I didn’t have this information until after the trip when I synced it with the app. And, as mentioned previously, it’s hard to tell what night it’s showing. For example, it’s Thursday. The sleep tracking I see shows “Today” which I’d assume is “Wednesday night”, “Yesterday” which I’d assume is “Tuesday night” but then “Tuesday” is that “Monday night”? Again, the Misfit Shine feels like it makes me work too hard for the information.

Misfit Shine Sleep

What is restful sleep?

FitBit Zip

I’ve been using the FitBit for about a year, so I know the issues with it a bit better and have many friends that have the FitBit Flex or Zip. I bought I FitBit Zip for my mother specifically because it gives you information without needing to sync to an app. However, since I’ve been using the FitBit for a year, I’ve started running into some issues: I think it’s on its last legs.

Telling Time: Normally, the FitBit would have gotten an A+ in this category. However, after changing the battery and syncing with the phone, as soon as we got on the trail the time somehow changed to 3.5 hours later than the current time. Telling time: D

Distance: This is where the FitBit is awesome. It counts steps and distance. We relied on the distance tracking constantly to track progress on the trip. Distance: A+

Ouch. :(

Ouch. 🙁

Ease of Use: The FitBit wins here too. The display on the actual device shows you everything you need to know, and cycles through steps, time, distance, and an emoticon representing your daily activity by simply tapping the face. You don’t need to sync to the phone to get crucial information. I bought at FitBit Zip for my mother for this reason: simple and easy to use. Ease of Use: A+

Form Factor: The FitBit Zip is light and can easily clip to your clothes. On a backpacking trip it doesn’t matter if you’ve got a funny plastic thing clipped to your pants. In the city, it’s hard not to look like a bit of a dork. Recently, my FitBit lost its protective cover and now has some exposed prongs that have the potential to snag clothes. Also, it’s pretty easy to lose, either from it falling out of the case or putting it through the was on a pair of pants. Form Factor: B (until I get a Tory Burch FitBit.)

Other: The FitBit provides really great weekly summaries of your activity via email. It also enables you to challenge or track your friends activities. Downsides seem to be in durability. Both the Flex and the Zip only seem to last a year (based on anecdotal evidence from friends).

The reason so many friends on this list are “unranked” is that their FitBits have died.

FitBit Friends

The fallen

Neither of these devices were designed specifically with back-packing in mind and the Misfit Shine definitely was built with the assumption you would always have access to a phone to sync, however, it seems that each of them could have worked a bit better ‘off the grid.’ On the other hand, if my FitBit wasn’t approaching the end of its life, it probably would have performed very well.

Regardless even reviewing some of these glitches in the light of daily usage, it still seems we have a long way to go. We’re really just at the beginning of what’s going to be possible with self-tracking. Let’s hope devices get more durable, smaller, and easier to use.

 

Posted in: Behavior Change, Healthcare Technology, M-health

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Just Because You Can, Does That Mean You Should?

Facebook’s recent experiments in social media mood contagion got us thinking about user-based testing in general and especially how that applies in healthcare technology that is intended to influence behavior.

The Experiment

happyFor one week in January 2012, Facebook manipulated the feeds of users to show content that was either positive or negative and then looked at whether this had an influence on users. The main point of contention or dissention is that this was human subject research without consent from the subjects and without the oversight of a review board as would be expected for university research. If the research hadn’t been published in a scientific journal then there might not have been so much controversy. What is the difference between A/B testing and what Facebook did? In A/B testing, marketers test different landing pages or campaigns and see which one works the best for their desired goal. Consumers don’t know that they are part of an experiment to test messages. However, consumers did freely follow a link that brought them to the content. The difference with Facebook is probably first, that they have significant power due to the volume of users and more importantly what they know about those users, and second although Facebook lawyers will tell you their terms of use covered it, Facebook users probably did not sign up with the expectation that Facebook itself would actively attempt to make them happy or sad.

How Do You Test Behavior Change?

It’s an interesting question for those involved in healthcare, and in particular trying to help people modify their behavior. In our case, at Wellpepper we are helping people be more adherent to home treatment programs. To do that we use a number of motivating factors including personalization and notifications. As part of building our application we test which features are effective in motivating people. We continually improve and change the application based on what we learn. Is this testing on human subjects? Yes. Did we get permission? Yes. This is part of our terms of use and it is also an essential part of how the industry builds software that people will use: by testing that software with real users. When people start using our software they use it to help them with a specific problem and they are happy when we make improvements to make it more effective to solve that problem. We encourage user feedback and implement new features based on it. So while, we may test new features, it is part of the implicit agreement of delivering software to users. (If you’ve ever used software that was not tested with real end-users, you’ll know the difference.)

When we test and add features that help improve user experience and become more adherent to their treatment program users are happy because we have helped them with their goals for using our software and the implicit contract with them. If we started testing and adding features that made them less adherent or changed some other type of behavior that they weren’t trying to change using our application we would have broken that contract and they might vote with their feet or in this case fingers and stop using the application.

What’s Your Implied User Contract?

The same thing could happen with Facebook, and it stems back to what their intention is with this research. The unfortunate thing is that they probably have enough data to have figured out that positive newfeeds make you happy and negative newsfeeds make you unhappy without actually manipulating the feeds. The fact that they did this, and did this without consent, brings up a bigger question of what their intention is, and what exactly is the implicit contract you have with Facebook. What exactly is their motive in trying to manipulate your emotions? For marketing experiments of this type the motive is pretty clear: consume more of their product. For Facebook it might be the same, but the fact that they tested negative messages does cause some alarm. Let’s hope they use their power for good.

Wellpepper2-1216aFor software developers that aim at healthcare behavior change there is an additional challenge as we think about testing features with real users. In order to help someone change behavior you need to test what works and that does need to be with real users. In general software development there are industry best-practices, for example, where you test different designs to find out which is most effective. This may be considered “experimentation” as users will not see the same features and some of the features they do see may not make it into the final version of the product. When you are doing this type of testing, you are looking for what is most effective in helping users achieve their goals. However, this testing must be done while protecting personal health information and not providing any harmful impact to the patient. Software developers can partner with research organizations whose internal review board will ensure that research on human subjects is conducted in the right way. To prove out efficacy of an entire application, this is often the best way to go but not practical for feature testing.

Guidelines for User Testing in Consumer Healthcare Applications

While looking at specific feature testing, these guidelines can help make sure you respect your end-user testers:

  • Unless you have explicit consent, all user testing must be anonymous. This is because if you are dealing with PHI and have signed a HIPAA BAA you have agreed to only access PHI when absolutely necessary. If you need to know demographics of your users for user testing, then you should err on the side of getting their explicit consent. This could be either via a form, or simply a non-anonymous feedback form on your application or website. By providing you with direct feedback the user has agreed to not be anonymous. (The good thing here is that patients can do whatever they want with their own data, so if they give you consent, to look at it, you have it.) That said, if you are working with healthcare organizations you will also have an agreement with them about contacting their patients: you need to make sure they have agreed to this as well. When possible err on the side of making data anonymous before analyzing it.
  • Think about the implicit contract you have with the user. If you are providing them with an application that does one thing, but you discover it may have applications for something else, don’t test features for that something else without getting consent. That is breaking the contract you have with them. Let’s look purely hypothetical example: at Wellpepper we have an application that increases patient adherence to home treatment programs for those undergoing physical rehabilitation. Let’s say we found out that people in physical rehabilitation are also often fighting with their spouses and started adding features or asking questions about the user’s relationship with his or her spouse, users would find this both unnerving and intrusive because that was not their expectation that we would help them with marital issues when they signed up for the application. Obviously this is a bit far-fetched, but you get the point.
  • Don’t get in the middle of human-to-human communication. This is essentially where Facebook broke the implicit contract with users by dis-intermediating the newsfeed. Your expectation with Facebook is that it’s a way for you to communicate with people (and sometimes organizations) you like. By changing what showed up in your feed, Facebook got in the middle of this. In healthcare this is even more important: don’t get between healthcare professionals and their patients. Make sure it’s clear when it’s you (the application, the company) talking and when it’s the caregiver and patient.
  • Consider where you’d get more value by partnering with a research organization. Sure it will take longer and may require more effort, but you will be able learn a lot more about why or how people are using your features by getting explicit research consent. I am not sure if it’s a coincidence or not but about a month ago I noticed that my Facebook newsfeed was full of extremely depressing stories. I remember wondering what was going on both with Facebook and the world in general and I remember wanting to post something depressing but then thought, “No I don’t want to add to this. I will only post positive things.” It’s possible that I was part of another study by Facebook and if so, they didn’t get the full picture that they would have if they’d been upfront about it, got my consent, and were able to ask me questions later about my thought process.

There is no doubt that we will see more discussions of ethics and consent in the space of user testing, especially as it relates to consumer-facing health applications. Having no regulation or guidelines is not good for consumer. However, only doing research with IRB and third party researchers is also not good for the consumer as innovation that could really help them can be slowed dramatically. Most people, whether healthcare practitioners or entrepreneurs got into the space because they wanted to help people. If we remember this, and we consider the ethical implications of our actions, we should be able to balance the two worlds.

For more reading on this topic as it applies to the software industry, see:

http://en.wikipedia.org/wiki/A/B_testing

http://ai.stanford.edu/~ronnyk/2009controlledExperimentsOnTheWebSurvey.pdf

http://www.exp-platform.com/Pages/expMicrosoft.aspx

Posted in: Behavior Change, Data Protection, Health Regulations, Healthcare motivation, Healthcare Social Media, Healthcare Technology, M-health

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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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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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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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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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Seattle Health Meetup: Focus on Consumer Health and Wellness Technology Sector

Less than a year ago, I was at an event sponsored by the Washington Biotechnology and Biomedical Association, where a room full of health IT and consumer health startup CEOs bemoaned the lack of a healthtech community in Seattle. We have all the elements here: talent, world-class healthcare facilities, and b2b or enterprise IT pedigree. Events like Seattle’s Health Innovators Forum Meetup and Health 2.0 are trying to change that by bringing together startups, investors, and general health enthusiasts for learning and sharing. This month’s Health Meetup, organized by Edmund Butler, was focused on Consumer Health and Wellness, and featured local startups in this space. Speakers were:

54824v1-max-250x250Marcelo Calbucci (@calbucci) is Co-Founder and CTO of Everymove, a company that automatically integrates data from various fitness trackers and provides consumer rewards from its partners.

 

 

 

Julie Kientz (@juliekientz) is the director of the Computing for Healthy Living and Learning Lab (CHiLL), a group of UW researchers interested in designing, developing, and evaluating apps that aim to promote healthy lifestyles and education.

 

 

Rebecca Norlander (@rebatwork) is the Co-Founder and CEO of Health123,  a consumer health company that helps people make decisions and track the small changes in their lives that can make a big difference in their health.

The three speakers shared a passion for designing person friendly applications for consumers to manage and improve their health. The three talks provided different perspectives on the topics of how to engage users and overcome their barriers or burdens to both application use and improving their health.

Marcelo kicked it off with his “8 Pet Peeves of Health Apps.” (I’m sensing an Everymove love of numbers as I also attended another talk by CEO Russell Benaroya called 25 Reasons You Suck At Sales. They also like to have provocative titles. 😉 )

Here they are in order:

    1. Calling people patients. Marcello pointed out that for all other applications they are users. He prefers people or member. (Later Rebecca noted that some industry conventions need to stay in order to communicate with your target customer. Patients is a tough one. People don’t like to be called patients, but the entire healthcare industry refers to them this way.)
    2. Trying to be all things to all people. This was a criticism of apps that try to track too many things. Figure out what behavior you’re trying to affect and do a great job of that.
    3. Putting the organization rather than the person at the center. This would be designing for the healthcare organization rather than the patient or worse yet for the insurance company rather than the patient.
    4. Misaligned or misguided incentives. Marcelo used the example of paying people to track something for example finding out their BMI rather than trying to incent them to change something, like become more active (and then lose weight). Historically there has been an idea in the health and wellness area that if you have information you will change. Information is really only one component (as Julie elaborated on in her session).
    5. Health Risk Assessments. Marcelo thought that these were particularly dangerous as people tend to associate these types of assessments with tests and then inflate their answers and then assume they are healthier than they thought.
    6. Bad UX and bad visual design. Marcelo showed an EMR screenshot saying “the 90s called, they want their interface back”.
EMR Screenshot

Source, Microwize.com.

  1. Treating a person as a condition. The person’s condition is not who they are and is only one component of the information a healthcare provider or application needs to understand to care for or help support that person.
  2. Making you change to fit the application or service. Wearables still fall into this category. You need to remember them, you need to wear them, and in the case of the new FitBit force, you need to get medical attention after wearing them.

Julie Kientz was up next, and her human-centered design approach provided practical advice to solve many of the pet peeves that Marcelo mentioned. The goal of Julie’s research is to understand and reduce the burdens in healthcare design. She described 8 key burdens that can impact adoption of healthcare technology.

Physical: Is the technology comfortable to use or to wear? Does it fit in with my surroundings or what I am doing? With wearables, physical is obvious, but physical could also be how you access the application, for example which tasks are better for a mobile device versus a PC?

Privacy: Where does the data go? Who is able to see it? For applications that have social sharing, are others able to track you? (Did you call in sick and then go for a 15K run?)

Mental: How do you feel about the technology? Julie said she feels sad when she forgets to put her FitBit on, and often goes back home to get it. As well, she is on her 6th FitBit in 3.5 years due to losing them, so is also feeling some guilt about the loss.

Access: Is the technology designed for diversity? For example, many nutrition trackers do not include foods that are popular with different ethnic groups.

Time: How much effort is required to enter or review data? Julie personally doesn’t look at her FitBit data online, just at the step count on the display. The online reporting is too much effort for her.

Emotional: What is the emotional impact of not meeting the goals the technology is tracking? Do you feel like a failure?

Financial: How much does it cost? Does it require expensive equipment like a smartphone? Are there added costs like a data plan?

Social: Does others use of tracking make you feel better or worse? Do you feel guilty when someone posts their runs online?

Because these burdens compete with each other it’s impossible to design to eliminate all of them at once, and so you have to understand which are the most important or provide the biggest barriers for the audience you’re designing for. Julie and her lab published a paper on this if you want to know more “Understanding the emotional burden of health technologies”. She also provided some practical examples of how her team has developed technologies and studies to accommodate these burdens.

ShutEye

One example is the ShutEye sleep tracker that’s designed for people who have some trouble sleeping but are not motivated enough to seek professional help. ShutEye is an Android app that displays on the homescreen with recommendations based on the time of day. For example, it will tell you whether it is too late to have caffeine if you want to get a good night’s sleep.

Another application, BabySteps deals with the emotional component of child development, by displaying development stages as trees in different stages of growth. This removes the stigma of clinical terms like delayed. BabySteps is designed to be used over the first 5 years of a child’s life so the team is also experimenting with different interactions to keep parents engaged for example, a Twitter feed that asks questions about child development. You can find links to all of Julie’s research here.

Julie then summarized with these words of advice:

  • Embed actions in activities people are already doing
  • Provide multiple options for tracking/achieving goals
  • Balance between manual and automated tracking
  • Priortize which burdens you will resolve based on your user’s desire and what your application is intended to accomplish
  • Match the burden to the motivation level of your user

Rebecca took the stage next and tied the two previous talks together with examples from how they built Health 1-2-3 to overcome barriers to engagement in health. While 85% of people say they want to feel better, a number of factors prevent them from reaching that goal. The absence of the following can be barriers to wellness:

Awareness: Not knowing what the actual situation is. (See Marcelo’s Pet Peeve # 5 on Health Risk Assessments.)

Knowledge: Once you have awareness, what can you actually do? Health information is often not delivered in a way that is actionable.

Self-efficacy: People cannot make big changes all at once. How do you make small and incremental changes towards health?

Personalized Solutions: Generic solutions don’t speak to the person or help them take personal responsibility for their health. Personalized solutions are customized based on information about that patient and provide options appropriate for that person’s health.

Time: Solutions need to integrate with people’s lives. Behavior change cannot take so much time as to be prohibitive. What small steps can be integrated?

Support: What types of social support does a person need to make a change? For example, there are many great fitness and health communities, like Strava for cyclists, where people support each other’s goals. On the other hand, social support needs to be in the control of the person. Applications shouldn’t be posting updates on the person’s behalf.

Rebecca walked through all of the above in the context of a Health 123 demo that showed how they simply address the issues. For example, awareness takes the form of a series of simple health questions. Knowledge is tailored health information based on the questions the patients answered. Self-efficacy is addressed by making health challenges reasonable to fit into a person’s day and week.

If you’re interested in or working in health technology in Seattle, I highly recommend these meetups. The content and discussions are packed with inspiration and information, and the burgeoning Seattle Health IT community needs your support.

You can find out about the next meetup here.

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

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APTA 2014 Recap: Forging Ahead With Telehealth: A Roadmap for Physical Therapists

Presenters

Justin Elliott, NA

Matthew Elrod, PT, DPT, MEd, NCS

Alan Lee, PT, PhD, DPT, CWS, GCS

Christopher Peterson, DPT

Telehealth, which originated as a way to provide care to rural settings, has become an accepted way although not widely adopted method of delivering healthcare. Benefits include convenience for patients, the ability to access specialists in other locations, and being able to monitor chronic conditions at lower costs. Advances in technology, that have put powerful microcomputers in everyone’s pocket, have made telehealth significantly more in demand and more feasible than ever before and as a result the telehealth market is forecasted to grow to a 4.5B market by 2018.

The good news is that telerehabilitation is part of this growing market, and people are already practicing today. The bad news is there’s still a lot of confusion about reimbursement and regulation. A show of hands at the beginning of this session revealed that while 5 out of approximately 50 attendees were practicing telehealth, no one put their hand up when asked if they felt confident about the rules and regulations, and most people seemed to not be getting reimbursed.

The goal of the session was to provide some clarity on the definition of telehealth, examples of how it is used in physical therapy, a survey of the current regulatory and reimbursement situation, and a toolkit for those who are interested in moving forward with a telehealth practice.

Telehealth communication is used in two settings, between a healthcare provider in an office and a patient at home, or between two clinical settings where one healthcare provider wants to consult with or have the patient consult with a specialist in another clinical location.

Telehealth Scenarios

There are two types of telehealth:

  • Synchronous, or real-time where the two parties communicate directly via video conference.
  • Asynchronous, or store and forward where video, text, or voice communication is transmitted between the two parties but they do not respond to it in real time. Email, texting, and even voicemail are all forms of asynchronous communication. (Wellpepper is an example of asynchronous telehealth.)

Synchronous communication more closely resembles a typical clinic visit, as it is a dedicated and scheduled visit, with the difference being that the two parties are not in the same location. Asynchronous is better for remote patient monitoring, check-ins, and chronic disease management were the parties do not require constant face-to-face communications. In fact, one of the areas that telehealth has shown real promise is in chronic disease management, first because most of the management of chronic diseases occurs outside the clinic, and second because these patients often need access to specialists who are not local.

Telehealth should be considered a way to augment in person treatment but not replace it, especially in the musculoskeletal world where treatment is often hands-on. Follow-up treatment, home treatment plans, questions and answers, and consultations with specialists are all areas where telehealth can add value in treatment. Telehealth also provides more convenient options for patients, not just rural ones. With busy lives many patients find it difficult to get to a clinic to an in-person appointment. It can also help lower costs of care.

While telehealth has many benefits, there currently many potential blockers. For example, before embarking on a telehealth program, make sure you fully understand privacy laws. All communication needs to be encrypted, and tools like Skype, while very convenient, do not deliver the level of security required by healthcare law.

The elephant(s) in the room in the whole discussion are regulations and reimbursement. This session provided hope that these will be resolved: both the APTA and the The Federation of State Boards of Physical Therapy are working to define and eventually change the legislation to enable more widespread adoption of telehealth. Unfortunately, it seems that the change may be slower than consumer demand and certainly than innovations in technology.

Currently 21 states have private coverage legislation for telehealth billing and 11 states have Medicare billing with 6 more in proposal stage. This legislation applies to intra-state practice, that is the patient and the physical therapist are within the same state. Inter-state practice where the physical therapist and the patient are in different states is only possible if the physical therapist is licensed in the state where the patient resides. Note that Medicare does not include telehealth for PT, OT, Audiology, or Speech Therapy. Since some of the real power of telemedicine is being able to practice across state boundaries (and possible across country boundaries in the future), we need to solve this inter-state issue.

It’s not really feasible for physical therapists to get licensed in each state so that they can practice telemedicine regardless of patient location. There are two possible solutions to this problem. One is a “telemedicine license” which is a license to practice telemedicine in a particular state even if you don’t reside in that state. Louisiana is a state that has this license type. The other, and more practical long-term solution is to create an interstate licensure compact. This would enable the portability of licenses from one state to another. The most common example of this is the driver’s license. Your driver’s license may be granted by the state of Washington but it is recognized and honored in all the other states (as well as Canada). The Federation of State Boards of Physical Therapy is leading a committee to put forward a proposal for an interstate licensure compact, and there is some discussion at the global level as well. (Nurses are much further ahead in this area, 24 states have joined a nursing licensure compact that enables nurses to be licensed in their home state and practice in any of these states, which is great for both telehealth and for portability of nursing careers.)

With respect to billing, there are billing codes for telehealth for physical therapy but they vary depending on state and by insurer. Two state practice acts, Washington and Alaska, recognize telehealth. In California, physical therapists are covered under a general assembly bill that allows for telehealth. Arizona, Kentucky, Minnesota, Nebraska, and New Mexico, list physical therapy and/or telerehabilitation services in their Medicaid policies. Perhaps the most promising change that will move telehealth forward is the new “accountable care organization” and bundled payments. With bundled payments, the organization is paid based on patient diagnosis and outcome not by the number of procedures that are provided, so there is built-in incentive to focus on the most effective and cost effective way to get a great outcome.

If you’re interested in moving telehealth forward for the physical therapy profession, the APTA has a lot of great resources in their telehealth toolkit. At Wellpepper, we’re very excited about the prospects and look forward to working with you on these new ways of treatment.

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

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