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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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Flipping the Clinic Visit

Doesn’t it seem like there’s never enough time? Nowhere is this more prevalent than with our healthcare system. We don’t have enough time to do things that keep us well, and increasingly doctors don’t have time to spend with us to thoroughly understand our issues. A spate of recent articles tries to blame the implementation of technology and the EMR as taking even more time away from the patient/doctor relationship.

Doctor and scribe, source New York Times

Doctor and scribe, source New York Times

Electronic health records have become a disease in need of a cure, as physicians do their best to diagnose and treat patients while continuously feeding the data-hungry computer. “A Busy Doctor’s Right Hand, Ever Ready to Type

This isn’t necessarily the fault of the EMR. It really stems back to money. One of the primary purposes of the EMR is to document for billing purposes and federal rebates. They weren’t designed to improve face-to-face care.

This New York Times article describes how scribes are helping to increase doctor face time with patients, but hiring another person to record what the patient is saying seems more like a band-aid solution.

Without much fanfare or planning, scribes have entered the scene in hundreds of clinics and emergency rooms. Physicians who use them say they feel liberated from the constant note-taking that modern electronic health records systems demand. Indeed, many of those doctors say that scribes have helped restore joy in the practice of medicine, which has been transformed — for good and for bad — by digital record-keeping.

What we really need is something like the “flipped doctor’s visit” being explored by the Robert Wood Johnson Foundation and inspired by Sal Khan, of the Khan Academy, an organization that has already made headway into education innovation by suggesting that classrooms are for homework and viewing lectures can be done at home. The idea of the flipped classroom is to maximize the interaction between teacher and pupil. The RWJF project suggests we need to do the same thing for the doctor’s visit.

The project is looking at ways that can turn the doctor’s visit on its head to get better results for patients and healthcare providers. While the example of EMR scribes seems like it might fit, to us it seems like a bit of a placebo. From personal experience, I had a doctor’s visit where an intern recorded my information and then read it back to the doctor and me. She had gotten some major facts wrong, for example, somehow she understood I worked in construction, not software. Open Notes and Blue Button, where patients see their own notes are two examples of trying to take this a step further. Who better than the patient to review what was written about them? We also need to return to documentation to improve patient care, not documentation for billing. The point of good documentation should be to accurately describe the situation and for continuity of care. Sadly, again technology is being blamed for an underlying issue of time, in this example the ability to copy and paste is being used for false records and billing. Again, it’s not the technology, it’s that people are pressed for time and again that time is money.

I recently had a few doctor visits that gave me time to pause and consider the flipped visit. The main thing that struck me is how different the doctor’s visit is from any other type of business interaction. As I was thinking about preparing for the visits with my list of things to make sure we cover, I thought about comparing this to a business meeting. The doctor had no agenda in advance, no idea why I was coming in, or even who she was meeting with until I walked in the room, and spent the first few minutes of a 10 minute visit looking at notes to try to remember who I was and what had happened before. Imagine you’d hired a consultant for a project (ie manage your health) who approached the project in this manner. You’d want your money back. You’d expect them to come to a meeting prepared. As the client you’d send them any pertinent information or updates for the project before the meeting. I was also trying to imagine the day of a doctor: every 10-15 minutes changing context with a new patient and no prep time while trying to care for patients and sometimes facing life-threatening decisions. Hairdressers have more insight into how their day is going to go: cut, color, cut, blow-out. We talk about moving to a preventative model for healthcare. First step would be to enable doctors to prepare to see patients and decrease the documentation burden after they see them.

We need better and more cost effective ways of communicating in healthcare. Ones that focus on patient care and are seamless for both patients and healthcare providers. We have applied technology for better communication and collaboration in business and in our personal lives, how can we extend this to healthcare? How can we flip the doctor’s visit and how can technology help?

If you’re interested, the Robert Wood Johnson Foundation is hosting a Google Hangout on the flipped clinic January 16 at 11:00 am PST.

Posted in: Healthcare Disruption, Healthcare motivation, Healthcare Technology

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Wellpepper’s Top Health Tech Stories of 2013

It’s the time of year to reflect and make lists! It’s been a great year for Wellpepper: our first full year in business. We’ve enjoyed bringing new features to our users and learning more about the needs of both patients and healthcare providers. We’re committed to building useful tools that patients and providers love to use. We’ve been inspired at conferences meeting with end-users, hospital administrators, and other startups who share the same mission of changing how patients and providers engage around their health. We’ve experienced the power of social media, met new friends through Twitter, and learned so much from Tweetchats. As a young company, it’s been a year of firsts for us that, while monumental for us, pale in comparison with the changes going on in health IT, so rather than telling you more about us, let’s talk about the year in Health Tech.

There is no scientific basis to this list, just what we think stands out from the year in Health Tech.

Healthcare.gov

The beleaguered website was definitely the top Health IT story of the year. At Wellpepper we were unable to make it through the registration process ourselves, and ended up going to a broker to find out our healthcare options. As the news came out on why the site was so bad, it was pretty obvious there was a lack of accountability and no project management. It’s really unfortunate that the Affordable Care Act was mired in this mess of an implementation, but we’re very excited that former Microsoft exec Kurt DelBene is taking the reins. Ship It!

Quantified-Self Hits the Mainstream

tec-gift-guide-fitness-trackers.jpeg-1280x960Or, “everyone is tracking.” The mainstream press started writing about fitness gadgets and our Facebook feeds were full of friends who got new FitBits for Christmas. Not sure what this means about the trend though. We have found the FitBit to be really interesting to calibrate activities, for example, a game of Ultimate Frisbee but after you know how inactive or active you are do you really need to track? And do you become okay with your activity or lack thereof?

Meaningful Use Phase Delayed

The Centers for Medicare and Medicaid have delayed the deadlines for implementing Meaningful Use Stage 2. Stage 2 will be extended through 2016 and Stage 3 won’t begin until at least fiscal year 2017 for hospitals. Meaningful Use Stage 2 focuses on patient engagement, which is very minimally defined as patients interacting with healthcare information electronically. We’ve always said that electronic medical records vendors are not the best equipped to deliver tools that patients (ie consumers) want to use, so it’s not surprising that healthcare providers are struggling with this phase. That said, m-health is poised to deliver on these requirements.Wellpepper2-1195a

M-Health Comes of Age

While we can definitely debate where we are in the m-health hype cycle, there is no question that M-Health is a formidable category. The FDA is now monitoring and releasing guidelines, albeit with little clarification. Eric Topol made headlines by using an iPhone EKG on a plane to diagnose a heart attack and and advise the captain to make an emergency landing. Most positively, we’re hearing less talk of ‘apps’, and more talk of integrating mobile health into the overall patient experience and the official hospital records.

23andMe Ignores FDA

Source: Wikipedia commons

You might consider this one to be a bit specific, but it’s representative of a number of key stories in 2013: big data, the explosion of healthcare investing, and the dramatic gulf between current Health IT and other technologies, and between Silicon Valley and the FDA. 23andMe, which does cheap DNA testing, direct to consumer, was forced to stop providing genetic results and only include ancestry after effectively ignoring FDA warnings for over a year. Speculation is that they were trying to get to a million tests (they are at about 500K) so that they could prove their tests were valid and thereby circumvent long FDA approval processes. Those on the side of the FDA saw this as Silicon Valley thumbing their nose at patient safety and regulations. Those on the side of 23andMe saw this as tech disruption at its purest. As recipients of some of the last full genetic and ancestry tests before the shut-down, expect more from us on this topic. 😉

This one is not healthtech, but we’d be remiss if we didn’t mention the focus on costs of care. Time Magazine, and the New York Times both published rather scathing interactive features on the costs of healthcare in the US. One of Reddit’s top threads right now is about a $50,000 appendectomy. It’s great to see these issues called to light. Let’s hope we see progress in solving them in 2014.


NewYearWP

We’re pretty excited to see what 2014 brings Wellpepper and what new innovations, disruptions, and improvements are brought to the healthcare industry as a whole. Best to you and yours from all of us at Wellpepper!

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

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My Life with Trackers

My Facebook and Twitter feeds are full of people talking about the new gadgets they got for Christmas. Tracking has gone mainstream as many of those gadgets are fitness and activity tracker devices. I thought I’d share a bit about what I’ve learned as an avid tracker for some of these newbies.

I have been using apps and devices to track my activities for over 7 years. When Nike in-shoe sensors came on the market in 2006, I was an early adopter and since then have upgraded to various GPS watches and apps like RunKeeper on my phone. I love tracking my runs and hikes. It adds an extra sense of accomplishment seeing exactly how far you’ve gone, elevation climbed and how fast you’ve traveled. Seeing my progress overtime was especially motivating and helpful when training for upcoming races.  It led me to want to track more. I definitely felt myself getting caught up in the quantified self movement.

flex

Fitbit Flex

So when we decided to get Fitbit trackers at Wellpepper, I was all over it. I was very excited to start tracking activities outside of runs.  I chose the wristband format while Mike and Anne chose the Fitibt Zips that clip onto your pocket or waistband. I liked the idea wearing the Fitbit at all times tracking all activities (including sleep) and thought I would have a better chance of not losing it. We found this to be true right away as Mike lost his first two Fitbits.  (Protip: Clip your Fitbit with your Fitbit inside your pocket.) Anne wasn’t too keen on the look of the sporty black wristband so chose the smaller out of sight zip and also appreciated that the Zip didn’t need to be charged. (However, both Anne and Mike had over a week of no activity recorded when their batteries actually died.)

Fitbit Zip

Fitbit Zip

Initial findings were very fun and intriguing: an Ultimate Frisbee game is about 8,000 steps and a good round of golf about 18,000 steps with up to 20,000 steps if that happened to be a bad round of golf. The most lucrative activity turned out to be dancing, it’s surprising how many steps you can take while dancing at a wedding! (23k)  Step counts varied between the different Fitbit types. As my steps were tracked by the movement of my arm, I definitely got credit for additional steps including a few 1000 from petting an upset dog during a thunderstorm. This caused some debates over the accuracy and fairness of the Wellpepper Fitbit leaderboard, which is definitely a fun and motivating feature of the Fitbit app. 

Fitbit 3Definitely the most surprising findings were how many steps could add up with regular day to day activities.   I found that I generally took around 1000 steps just walking around the house and getting ready in the morning.  A walk to the store to grab a few groceries could garner up to 2000 steps. Turn that trip into a walk to the farmer’s market and you could easily generate 4k steps! It was surprising how a few small decisions could turn a relatively normal day into highly productive and active day.  I found this infographic: The Exercise Experiment: A Tale of Two Days does a great job of showing the difference small choices can make.

Even more surprising, or even shocking, was how many steps I didn’t take on an inactive day.  I work from home and it’s not uncommon for me to grab a cup of coffee in the morning, jump on my laptop and get to work. Some days, the time can slip by and before you know it, the day is gone.  I never used to worry about it because when I am not working, I am highly active. However, after I came across The Truth about Sitting, I decided I needed to be more aware of my overall activity. I think this has been the greatest impact of the Fitbit. I thought that I might dive deeper into analyzing my runs or hikes, but it has actually created this awareness to keep me moving all the time. It reminded me of something John Mattison (CIMO of Kaiser Permanente) said at FutureMed:

It’s not about wearing a million sensors, we don’t need digital nannies, it’s about becoming more mindful.

Posted in: Healthcare Technology, M-health

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Health 2.0 Europe “Tools for the Elderly”

Filming a patientPrior to the Health 2.0 Europe Conference there was a deep-dive 3 hour session called “Tools for the Elderly.” I was particularly interested in this session for two reasons, first we are doing some work with Boston University on a study using Wellpepper to manage the health of Parkinson’s patients the eldest of whom is 75 and second, a common criticism we hear from healthcare providers and investors is “old people can’t use technology.” We disagree wholeheartedly, but acknowledge that those who may have less than 20/20 vision or arthritic hands may require different types of interfaces and engagement than the stereotypical 20 year old developer is building for. Based on this, I was very interested to see what types of innovations and challenges this session presented.

Two of the most interesting were Many Happy Returns and Intelesant. Many Happy Returns is a memory, engagement, and conversation aid for people with dementia. It was developed originally as a not-for-profit by Sarah Reed who was introduced to the world of dementia when her mother was diagnosed over 10 years ago. Originally a card game, and now being developed into a mobile application, Many Happy Returns presents pictures from different decades to jog the memory of dementia sufferers and encourage inter-generational communication. People who have dementia have increasingly clear long-term memory with deteriorating short term memory and the cards provide the ability to have meaningful conversations with those with dementia and also learn family stories before they are lost. The app interface was simple and highly usable, and the benefit of using an iPad app over printed cards is huge: sound can be added, and sounds have proven to be very evocative for memory jogging, new card sets can be created by scanning and adding the person’s own photos, and finally, tracking can be done related to which photos, or sounds are most interesting to people.

Tools for the Elderly

Intelesant could have also been in the “unmentionables” session in the full conference. They provided an advance “end-of-life” care plan that was accessible by patients, their care givers, and could be shared with healthcare providers, especially in a care home setting. Too often this information is lost or not communicated clearly until it’s too late, and Intellesant aims to change this. What was compelling about the Intellesant presentation is that the interface, while capable of reporting clinical results, was designed for the patient and the caregiver who are really the most important constituents in this scenario.

There were also three startups that were focusing on building interfaces for the elderly, one to make it extremely simple to use a phone,  one to make it extremely simple to use a tablet, and one to make it extremely simple to have a conference call or telehealth chat through your TV. The first two were solving the problem that Android interfaces are generally a lot less usable than other interfaces, which really seems like 1. A short term problem and 2 something that should be addressed by Android OS developers. (Are you listening Samsung?). The third, SpeakSet was solving a problem that of course affects the elderly, but also everyone else. According to some former colleagues of mine at Microsoft (Skype), it takes 10 minutes on average for any conference call to get started. While there are definitely tools that can help the elderly manage their health and wellbeing, good usable design should be available to everyone. I’d love to use a big button that says “start conference call” and have it work immediately.

The AARP has gone on record asking Silicon Valley to start building tools for the aging population. Based on this session at Health 2.0 Europe, they may want to look further afield.

Posted in: Aging, Healthcare Disruption, Healthcare Technology, M-health

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Health 2.0 Europe “Improving and Enriching the Patient-Provider Relationship”

Last week, I had the opportunity to demonstrate Wellpepper and participate on a panel on “Improving and Enriching the Patient-Provider Relationship” at the Health 2.0 Europe Conference in London.  I’m grateful to the Washington Trade Association who funded a trade delegation to the conference and helped facilitate other meetings in London as well.

Health 2.0 Europe Panel

Health 2.0 Europe Panel

The panel format was that the moderator, in this case Health 2.0 CEO Indu Subaiya, and invited guests framed the conversation, and then invited companies to demonstrate their products related to the topic. After the demo, the panelists asked questions and discussed the implications and relevance of the product to the topic. The “Provider” view was represented by Dr Simon Brownlee, a primary care physician and Chief Medical Officer of Healthloop UK. The “Patient” view was represented by Susan Jones, a person living with ME also known as “chronic fatigue syndrome.” I spoke with Susan a bit backstage and learned that she was frustrated by the lack of knowledge about her condition, she took it upon herself to look for specialists and treatments outside of the UK, the epitome of an engaged patient.

Other startups on the panel were:

Mark Friess from WelVU, focused on patient education and engagement.

Nishant Bagadia from Nuehealth, helping patients find and connect to surgeons.

Tim Williams from myClinicalOutcomes, helping patients track and get information about long term conditions.

Interestingly, while we all focused on the patient-provider relationship, each took a different approach and the technologies ended up being complementary rather than competitive.

We discussed how patients are often confused by treatment plans and how care outside the clinic was becoming increasingly necessary as patient volumes increased. A recent study by Deloitte showed that elderly patients will increase the demand for in-person consultations by 33%. Given the expected shortage of healthcare providers, this isn’t going to be possible so we need new ways to engage. We also discussed the need to align outcomes between patients and providers. Oftentimes the patient has a very different view of a successful outcome as the provider, as outlined in this Harvard Business Review Infographic.

The conference was inspiring as healthcare providers, industry professionals, and startups acknowledged that we need to start doing things differently if we want to see better health outcomes. While there were similarities between the solutions presented across all the panels, there was actually very little duplication, which points to the vast challenges in healthcare today. Solutions came from all over the US, UK, and Europe and were tackling both local and international markets. The best solutions were on par with what you see coming out of Silicon Valley, and in particular we liked UMotif for it’s extremely usable approach to patient tracking and engagement and the as yet unreleased  “You app” from Health Puzzle of Finland, that enables collaborative health challenges with friends.

My favorite session was the “Unmentionables” where startups tackled problems that often weren’t discussed like sexually transmitted diseases and alcohol abuse. My panel featured 3 US based startup and one UK, this session was a representation of European innovation, and organizers were pleased so showcase so many more local talents than in previous years. Presenters represented their countries well, and moderator Matthew Holt, pointed out that true to form and stereotypes, a Norwegian presented a light-based solution for depression, an Italian for sex information, and a Brit for drinking.

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

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Data-Driven Exercise for the Disabled

Machines can be used by able-bodied and disabled athletes

Machines can be used by able-bodied and disabled athletes

A few weeks ago, I had the opportunity to visit the PARC facility at the ICORD Spinal Cord Research Centre in Vancouver, BC with our guest blogger Lynda Bennett. Lynda is participating in an exercise study for people with spinal cord injuries and she wanted to show me around. The study is in pilot stage right now and has less than 50 participants all of whom have spinal cord injuries. Lynda doesn’t actually have an injury, she was born with Spina Bifida. However, she has recently started using an electric chair and is concerned about keeping up her core and upper body strength, especially for transfers from the chair. The pilot study is looking for positive outcomes associated with regular and increasing levels of exercise in people with spinal cord injury.

All machines track workouts using a SmartCard system

All machines track workouts using a SmartCard system

The equipment at the facility looks like that at any gym, however there are two key differences. Each machine is adapted so that a person can access it from a wheelchair. Actually the machines are designed both for able-bodied and disabled users and ICORD employees are allowed to use the gym if the study isn’t actively using it. If a machine has a seat, which an able-bodied person might use, it swings away to enable someone to wheel up to it. The other difference is that each machine is fitted with a smart card reader. Study participants enter their cards to start the weight program. The machines use air-pressure to provide resistance, and the resistance is increased automatically based on previous day’s activities. All the data is collected and can be reviewed by researchers. You can think of it as ‘quantified-self’ but with extremely expensive quantification.

Super Mario on Weight Machine

Playing Super Mario provides motivation

While Lynda enjoyed her workouts and meeting with others at the facility, she would have liked to have seen active rather than passive goal setting. She wanted the goals to be translated into something that she needed to do in everyday life.  “to be able to transfer from your chair to a truck, you’ll need X amount of core body strength.” As the study is designed, she is increasing the amount of weight but doesn’t know what outcomes this will provide in her daily life.

“I’d like to see how I am progressing towards a goal rather than try to correlate the increased weights to some improvement myself.”

Since this is just a pilot, and they are trying to keep the research relatively open to start, this might be able to be designed into future research.

Unfortunately, the pilot study isn’t guaranteed to go to a large scale study. The initial funding was used to set up the facility, and additional funding will be required to expand beyond the pilot. However, pilot organizers are hoping once they get enough data and can start to form hypotheses, they will attract the interest of the many researchers in the labs upstairs at ICORD, who are working with cells and microscopes but not as often with real human subjects like the people who volunteered for this study. Facilities like PARC and the data they collect can go a long way to bridge the gap between research and human outcomes.

Posted in: Exercise Physiology, Healthcare motivation, Healthcare Technology

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How much for that appendix? In Russia?

The recent news about the cost of healthcare in the United States has gotten me thinking. While critics say that transparency will not lower costs, it’s hard to imagine how hospitals will be able to continue to justify dramatic differences in costs for procedures between organizations or between countries. With numbers like this, is it any wonder that medical tourism is on the increase?

According to the Atlantic magazine, “getting your appendix out can cost between $2,000 and $180,000Hip replacements run from $10,000 to more than $100,000″.

The New York Times shows comparative pricing between the US and other countries, in the article “The 2.7 Trillion Dollar Medical Bill

Comparative Procedure Costs

Comparative Procedure Costs from the NY Times

“In the U.S., we like to consider health care a free market,” said Dr. David Blumenthal, president of the Commonwealth Fund and a former adviser to President Obama. “But it is a very weird market, riddled with market failures.”

One of the things that makes this such a weird market is that healthcare can be one of the biggest household expenses and yet people have no idea of the costs. This is true in both socialized medicine and an insurance-based system like the US. A number of years ago, my friend Bob tore his Achilles and needed surgery. As Bob, our friend Henry, and I were chatting about the procedure, Henry asked how much it would cost. Bob had no idea: the thought had never crossed his mind. We all worked at Microsoft HQ in Washington state and at the time, Microsoft had bar-none the best healthcare plan in the United States. (Microsoft has since changed their plan from this all-you-can-eat service.) The surgery was probably in the $25K range but Bob had absolutely no idea because he knew his insurance would cover it.

Like me, Henry had been raised in Canada with socialized medicine and before anyone got smug about the problems in the US system, he pointed out that neither system held people accountable for costs or decisions. We had no idea how much the surgery would cost in Canada either. This was the first time I really thought about healthcare costs, the amount of money changing hands, and how the beneficiary of the service had no idea what was being paid.

A few years later, my friend Diana, held a wonderful party in Seattle to celebrate overcoming breast cancer. One of the activities at the party was a contest to guess how much her breast cancer had cost. Diana and her husband are teachers, and while their salaries may not be particularly high, they do have good insurance. Total bill: $250,000, or 5 times the average annual salary for a Washington state teacher.

As I mentioned, I grew up in Canada, where thanks to Tommy Douglas, there is universal healthcare. Canadians do not need to worry about going bankrupt if they get sick. Canadians also do not get the kind premium service that the best insurance plans in the United States offer, and if you look you’ll find plenty of skeletons in the closet about wait times for procedures and so on. Although the individual does not know the costs of treatments, the healthcare system as a whole does a good job of ingraining the need to “not overburden the system.”  What this means is that people often second guess whether they are sick enough to go to the doctor or hospital, often because there is guilt associated with using the system unnecessarily. My friend Harriet describes this perfectly this in her blog post about her son’s asthma.

“This really isn’t right;  I should take him to the hospital.” But I hushed my inner voice thinking that once daylight hit, things would improve. And besides, I didn’t want to waste the taxpayer’s money on an unnecessary ER visit.” http://seetheorun.com/2012/09/12/trust-your-gut/

Canadians are often smug about our healthcare, and I suppose considering that the entire country receives free healthcare at a cost lower than what the US spends, maybe there is some justification. However, in 2001 when I moved to the US and experienced the “Cadillac of healthcare programs” while working for Microsoft, I have to admit it was pretty amazing. Unexplained coughing? Let’s see a lung specialist for airway testing. Psoriasis? Here’s an appointment with an expert at University of Washington. Contrast that to Canada where specialist referrals need to be renewed every 6 months by your GP. When I finally saw a dermatologist, we talked about how ridiculous it was that he couldn’t continue to treat me for a chronic skin condition without a note from my GP. Now who’s wasting taxpayer dollars?

Like Harriet, I have also internalized the “you’re okay, don’t see a doctor” mentality, exemplified when I experienced severe abdominal pain while living in Russia in early 2010. I moved to Moscow in 2008 for a 3-year posting with Microsoft, and was still supported by the best healthcare a corporation can buy. At 3am, with 12 hours of severe abdominal pain, I was still second guessing whether there was really a problem. It took an instant messaging chat with a friend in San Francisco to convince me to go to the hospital.

Again, thinking it couldn’t be that bad, I didn’t call an ambulance, but drove myself to the European Medical Center, a private clinic catering to expats and wealthy Russians. To put things in perspective, the healthcare plan that my Russian Microsoft colleagues had did not enable them to go this clinic; it was out of reach for their coverage. Within half an hour, I had an EKG, blood tests, CT scan, and a differential diagnosis of appendicitis. By noon the next day, I was minus one appendix.

The author and her Russian team in Moscow

Now here’s where the story might start to seem a bit ridiculous to you. Once my appendix was out, the rest of my hospital stay was so pleasant I didn’t want to leave. It was quiet, clean, with attentive staff, and a extremely comfortable bed with a down duvet.  I had a shared room with a Swedish woman who said the food was some of the best she’d had. (I wasn’t allowed to eat sadly.)

The final bill? $3500 Euro ($4900 at that time). Seems pretty reasonable doesn’t it? For comparison, my follow up visit with the surgeon was $90 Euro which is not cheap for a 15-minute consultation. This was one of the best facilities in Moscow, out of reach for most of the population including my affluent colleagues, and yet the costs of my surgery were not outrageous. It wasn’t as cheap as the $2000 lowest price cited by the Atlantic article but nowhere near their high-end of $180,000 plus I had CT scan (which can start at $1200 in the US), general anesthesia, laparoscopic surgery,  time in the ICU, an overnight stay, and some pretty amazing pain drugs.

Where does this leave us? Socialized medicine isn’t perfect but the free market isn’t working either. Prices can’t vary so widely. People need to understand their options and the costs of those options. Price transparency will help stop the gouging that happens at the high-end. The Obamacare mandate to cover more people will require less expensive solutions. Prevention and less expensive ways to manage health are key. New ways of paying for outcomes rather than diagnosis and procedures could help too.

At Wellpepper we’re passionate about improving the value of healthcare delivery while decreasing costs by extending the reach of the healthcare professional outside the clinic. We believe that technology, used by caring healthcare professionals can provide some solutions to these problems and we’re hoping to be part of the solution.

Author’s Note June 4th: Maybe Harriet and her family are stoic, or maybe we have some more problems in the system. Today after finally demanding x-rays her husband found out he’d been walking on a broken ankle for a month. The first doctor gave him painkillers and sent him on his way.

Posted in: Healthcare Disruption, Healthcare Technology

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The Case for M-Health

M-Health has been touted as the next-big thing in healthcare. We believe it’s more than a big thing, we believe that it’s where people want to interact, and mobile provides the opportunity to influence people much more than simply e-health. It makes sense right? Even if you sit at a computer all day, your mobile device travels with you and is always on. Some people are even sleeping with their devices.

Don’t take our word for it though, we’ve compiled some really interesting information and statistics on the growth of mobile and why it’s so important for healthcare.

Mobile Usage and Demographics

Starting from usage, The Harvard Business Review has an interesting take on the Rise of the Mobile User.

“55 percent of Americans said they’d used a mobile device to access the internet in 2012. A surprisingly large number — 31 percent — of these mobile internet users say that’s the primary way they access the web.”

What’s interesting about this, is that it crosses income lines. When we first started Wellpepper, one of the common objections we heard to our mobile focus was that “poor or old people don’t have smartphones” so we couldn’t reach enough of the population. That’s proving not to be true, in particularly because of the types of offers that the carriers provide. People who are accessing the Internet only through their cell phones may have never owned a personal computer.

Tablet technology has also opened up computing to a larger group of people. The ubiquitous iPad is used by babies and grandparents alike. Mobile Marketing Watch reports that 53% of seniors are online, 33% use social media and 70% have a cell phone. Over 50% of people in the US have a smartphone and we know that number is going to keep growing.

“78 Million baby boomers use technology to stay in touch with loved ones, connect online and improve health.” Not really surprising is it?

Mobile for Health

Patient preferences for e-health communications

Patient preferences for e-health communications

According to an Accenture study of 1,100 people, 90% want to use digital to manage their healthcare. However, they see this as a way to augment in-person visits. 85% of those surveyed also want to communicate in-person with their doctors.

Consumers already understand the value of electronic and mobile communications to improve their healthcare: 63% of respondents to the Accenture study want to receive reminders for preventative or follow-up care on their mobile devices.

Research2Guidance reports that 500M people will be using healthcare mobile apps by 2015. Ralf-Gordon Jahns, Head of Research at research2guidance, points out “Our findings indicate that the long-expected mobile revolution in healthcare is set to happen. Both healthcare providers and consumers are embracing smartphones as a means to improving healthcare.”

The Pew Internet Foundation’s recent study looked at people who track health indicators. Tracking indicators is a positive way to improve health outcomes. They found that while up to 60% of people track some health indicator, only 21% of those who do this are using some form of technology to do so. Most people are keeping track in their head or on paper. Given the benefits of recording the information, like seeing progress overtime and being able to share that information with a loved one or healthcare professional, again, we think this is a trend that will only increase.

References

Is Healthcare Self-Service Enough to Satisfy Patients? Accenture

The Rise of the Mobile Only User Harvard Business Review

Tracking for Health Pew Internet Research

500M People to Use Mobile Apps for Tracking Health FastCompany summary

Mobile Health Report Research2Guidance

 

 

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

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If you can’t measure it, you can’t manage it

If you can’t measure it, you can’t manage it.

For years we’ve heard this familiar business adage, attributed to either Peter Drucker or  W. Edward Deming. Reading today that 9 out of 10 Americans believe that they are in good health, made us think that perhaps not everyone is measuring and managing your health. Then we wondered whether measuring your health, in the kinds of  ‘quantified-self’ ways that guest-blogger Jacquie recently talked about, enables you to better manage your health?

9 out of 10 Americans say they are healthy

9 out of 10 Americans say they are healthy

First off, let’s start with the study. Americans were asked whether they thought they were healthy: 90% said yes. And yet, we know that people are moving less, eating more fat and sugar, and chronic diseases like diabetes are at an all time high. Perhaps the next question in the study should have been “how do you know you are healthy?” Let’s go back to the business analogy. Let’s say a CEO asked her CFO, are we profitable? If the CFO said yes, wouldn’t he be asked to provide some proof of that? In the same way, how can an individual actually know if they are healthy? What is their proof? And what are they measuring against?

To answer those questions, it does seem that you need to track something. As we’ve seen recently there are a myriad of new consumer devices measuring all kinds of things. One I’ve been using is Moves. If you’d asked me before I started using it whether I walked more than the average person, I would have said “yes, absolutely.” Now that Moves is tracking my every step (although it does get a bit confused when I’m snowboarding), I would have to say no, not really. So much for my subjective view of my habits.

Not enough steps

Not enough steps

Next, you have to compare your measurements to some sort of standard. FitBit and other activity trackers have popularized the idea that a healthy individual takes 10,000 steps. Taking that as a benchmark, I could feel good about all the days I took more than 10,000 steps. However, at the American Physical Therapy Conference in San Diego in January, we learned that 10,000 steps would put a person in the ‘active’ but not ‘highly active’ category. So, now you have a whole lot of people patting themselves on the back, but maybe they are not as active as they think.

We recently discovered a new startup called WellnessFX that would appeal to the quantified self people, and also make sure they are measuring the right things. WellnessFX enables you to have your blood tested for a number of different criteria, see your results online, discuss the results with a healthcare professional, and then determine whether you need to make any adjustments to your health. Kind of brings it all together doesn’t it?

At Wellpepper, we’re not going to draw your blood, but we are going to try to connect you, your healthcare professional, and your positive health outcomes by tracking and measuring. We’ll remind you to do your exercise and ask you what you did. We’ll also let your physical therapist know if you reviewed your exercises. Yes, some of it is based on self-reporting like the study, but you wouldn’t lie to us or your healthcare professional would you?

Posted in: Healthcare motivation, Healthcare Technology, Uncategorized

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My Quantified Self

My nephew asked me the other day “How fast can a human run?” My first thought was of the Olympics and the 100 meter dash and I was quickly trying to make the conversion in my head to miles per hour. Then I thought, “Wait! I know my average speed.” I look at this information all the time.

Look Mom - I ran around a volcano!

Look Mom – I ran around a volcano!

I am training for my first half marathon and use NikePlus and RunKeeper to track my progress. I absolutely love these applications and have become addicted to tracking, analysing and sharing my personal running stats. Both of these applications do an excellent job of visualizing the data – distance travelled, calories burned, and average pace – which makes it fun and easy to share. I even received a “speeding ticket” the other day from Notch.me an integrated app with RunKeeper when I hit a new pace milestone.

This addiction to data has led me to start tracking other items in my life. I now track my sleep patterns with an app called Sleep Cycle. HeartMath checks my daily stress levels by using the camera on my iPhone to take my resting heart rate. This tracking isn’t limited to health data, I have used Klout to measure my influence in social media, InMaps by Linkedin to see a visual representation of my connections and Mint to recognize patterns in my spending. The awareness this tracking provides has led to personal growth and positive change in all of these areas.

And I am not alone. A recent survey by the Pew Research Center’s Internet & American Life Project states that

Seven in ten (69%) U.S. adults track a health indicator for themselves or a loved one and many say this activity has changed their overall approach to health.

Some people go much further in their health tracking: founded by Kevin Kelly and and Gary Wolf of Wired Magazine, the Quantified Self Movement has exploded over the last 5 years starting with the initial group of 15 in the Bay area to an organization of thousands that spans the US and Canada. Meet-ups, where members get together to discuss what they are tracking, how they are tracking and what they are learning, are popping up all over North America.  The Quantified Self Motto: “Self Knowledge Through Numbers.”

Moves Storyline

Moves Storyline

However, according to the Pew study, not everyone is taking advantage of the thousands of new apps and medical tracking devices available with only 1 in 5 people using some form of technology to track their health data.  A lot of this tracking remains informal with 49% saying they keep track of progress in their heads.

Passive data tracking applications,  like Moves which tracks your daily movement, can augment the ‘in your head’ tracking. There is absolutely no input required, the iPhone app just automatically records any walking, cycling, running that you do. It’s a diary of your daily movements, a summary of your everyday exercise to help you think about your life in a new way. Knowing how many steps it is to the office might encourage you to walk there more often. Even the smallest changes can make a huge difference and that is generally where people start when making choices that lead to long time healthy habits.

So how do we encourage people to use these tools and technology when we know the data has such a powerful impact on their motivation for positive change?

I think apps like Moves that allow users to ease into self tracking without a lot of effort are a great start. Beautiful interfaces and fluid navigation are critical.  For every app I have on my iPhone , I have downloaded and deleted 6 more.  If it’s not engaging, easy to use and provide a new and valuable service – it’s gone and usually within the first 10 minutes.  Stunning visualizations of relevant data are also important to enable users to see usually boring stats in a fun and creative way,  motivating them to improve those numbers and share with their supporters.

What self-tracking apps do you use? And what features have motivated you to continue using those apps?

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

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Best practices for Telemedicine

Telemedicine has great potential to deliver just-in-time physical therapy. While it’s not appropriate for all situations, where it is, it can be a cost effective way to stay connected to patients and deliver service.

Our previous recap from the American Physical Therapy Conference session featured Just-In-Time Management principles including telemedicine. There was so much good advice in the session we’d expand on some of the best practices for telemedicine outlined by Carol Jo Tichenor, Director Physical Therapy, at Kaiser Permanente.

Where to Implement Telemedicine

First consider where telemedicine can augment, improve, or streamline your practice. For Kaiser Permanente, telemedicine was very effective treating students who were part of Kaiser’s system in California but attending out-of-state colleges. A British study found that using telephone calls as an intial screening for back pain resulted in shorter wait times for patients, and fewer missed appointments.

As you consider where you might include telemedicine, ask yourself whether you have patients who:

  • Are remote or need to travel long distances for treatment.
  • Are ‘road warriors’ and travel frequently for their profession.
  • Have work schedules that make it difficult to schedule appointments.
  • Have physical difficulty getting to the clinic but are not candidates for home care.
  • Might need a short-check in rather than a full-scheduled visit.

How to Implement Telemedicine

Successfully implementing telemedicine, or any technology into your practice for that matter, requires not just a technical implementation plan but also a people and process plan. Technology projects fail if they are not integrated into the way people work.

Some things to consider.

  • Will you offer virtual appointments to all patients or just some who meet a certain criteria?
  • Will you use virtual appointments for pre-screening or will you require a face-to-face visit first? There are pros and cons to either approach. Pre-screening might help get patients to treatment faster. Face-to-face allows a hands on assessment and the ability to establish a rapport with the customer.
  • Do you have space in your clinic to run the telemedicine sessions? You will need a quiet location with good lighting.
  • What technology will you use? Does it work on existing computers? This could be an entire blog post in itself. A few key points for you to consider:
    • Is it secure? Skype and FaceTime do not provide the security required for HIPAA or other personal data protection laws. These are consumer technologies that will not guarantee that data is passed securely.
    • Is it easy for the provider and the patient to use? Does the patient need to install plug-ins?
    • How many people will need to use it?
      Teleconferencing with Microsoft Lync

      Teleconferencing with Microsoft Lync

Thinking about the way people work, do you have some providers who are better than others at patient communication? Telemedicine removes some forms of communication, so only your best communicators should probably participate. When will you schedule appointments? During the day or before or after office hours? If the equipment is shared, how do you make sure it’s available for an appointment.

Also think about how you will make technology adoption as easy as possible for practitioners. What types of training programs will you offer for them to learn the technology? How will you make sure it’s available?

How to Run the Session

With the adoption of telehealth there are starting to be best practices on how to conduct a session. Here are a few things for you and your practitioners to consider.

  • If possible, start with an in-person visit to establish rapport.Consider how you can make the technology adoption as easy as possible for practitioners.
  • Plan what is possible for the visit. Telehealth is better for check-ins than to establish a new program with a patient.
  • Practice using the technology before the session, and if you don’t have a lot of personal experience with video calls with consumer technology like Skype or FaceTime, make sure to do some practice calls first.
  • Start the session with some small talk to make communication easier.
  • Look at the camera. Make eye contact.
  • White coats add too much glare and it’s hard for the other person to see you.
  • Try not to move around too much.
  • Keep the background clear of distracting clutter.
  • Keep the patient aware of what you’re doing. If you’re looking something up or thinking about a response, tell them. Video calls often miss these queues.

Telemedicine might not be for every practice, however, increasing costs coupled with increasing expectations of consumers and patients, it will most likely become a key service in healthcare delivery.

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Mobile health and the gap between professional and consumer tools

FitBit One Wireless Activity Tracker

FitBit One Wireless Activity Tracker

M-health, quantified-self, daily tracking, FitbitBodyMediaRunkeeperMyFitnessPalStrava, even Nike has gotten in the game. The ways in which consumers can keep track of their health seems to multiply each day. The average consumer device is about $200, often with a monthly subscription fee to track results. Some only charge a subscription if you want more detailed access to your results. At the same time, complex sensors and accelerometers used in medical research can cost thousands of dollars. Sure they are more accurate, but are they more effective in motivating behavior change?

These were some of the questions raised in the American Physical Therapy Conference Session “Mobile Health Technologies” presented by George D. Fulk, Edward Sazonov, and James Cavanaugh.

BodyMedia Tracker

BodyMedia Tracker announced at CES 2013

They reviewed popular consumer devices from a clinical research perspective and weighed them against professional healthcare devices, looking at accuracy, convenience, user preference, and price. While the professional devices are still more accurate, for all other factors it did seem like the consumer devices were winning. For example, many of the new devices, like FitBit can be easily hidden beneath your clothes, while ActivePal‘s anklet makes the wearer look like they are under house arrest. Female participants in one study using ActivePal removed the anklet when they wore skirts. At the Consumer Electronics Show this year, BodyMedia showed trackers that look like jewelry which would solve this problem, and provide some nice word of mouth marketing for them.  While professional devices may record more accurate results, is the overall study more accurate if the subject isn’t being consistently monitored?

Another criticism of the consumer devices was the inability to get raw data, and that if the data were shared, it wasn’t encrypted for HIPAA compliance. Given the price difference, market potential, and popularity of consumer devices, we can imagine these differences will fade in the long run. 

The New York Times reported this past week that more and more people are turning to electronic health monitoring. There are over 13,000 personal health tracking apps available. While some track automatically, self-tracking has shown promise in chronic disease management.

Nike+ Activity Tracker

Nike+ Activity Tracker

A study by Pew research referred to in the NY Times article found “most people with several chronic conditions said that tracking had led them to ask a doctor new questions, led them to seek a second opinion or influenced their treatment decisions.” As well, at Wellpepper we’ve noticed that FitBit has driven a new level of awareness around the number of steps a person should be taking each day, 10K according to Locke et al, with technology venture capitalists challenging each other on a virtual leaderboard.

What does all of this mean for physical therapists? The panelists in the session admitted that the profession is often behind the game in technology adoption, and as a result the technology isn’t developed in a way to be most useful to physical therapists. They encouraged researchers to collaborate with engineering to see better results. Here at Wellpepper, we are technologists building our products in close collaboration with professionals in rehab and research. We are hoping to help bridge this gap between consumer and professional healthcare technology. If you’re passionate about how mobile technology could improve your practice, we’d love to hear from you!

 

Posted in: M-health

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