Healthcare transformation

Archive for Healthcare transformation

Something old, something new, something borrowed, something blue

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

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

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

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

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

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

Finding Outlier Physicians

Finding Outlier Physicians

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

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

The Impact of Blood Sugar on Parole Hearings

The Impact of Blood Sugar on Parole Hearings

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

 

 

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

Leave a Comment (0) →

Reducing Avoidable Readmissions: Measuring and Influencing Change

To wrap up the 2-day “Reducing Avoidable Readmissions Course” from the Institute for Healthcare Improvement, was a session on measuring results. The session, while helping to provide measures and objects was as focused on how to manage change in an organization, with the understanding that within healthcare organizations this can often be akin to turning a cruise ship.

One presenter, describing a successful partnership between a hospital and skilled nursing facility to improve transitions in care mentioned that it took over 3 years to implement the program. She expressed frustration that often people’s roles changed in this period but seemed to accept that this length of time was pretty typical, and considering it was an inter-organizational transformation that is probably true, and possibly fast.

When planning to make changes within your organization, here are some great ideas for influencing change and getting it to stick.

  • Set realistic goals. For example, when trying “Teach Back” ask physicians and nurses to try teach back with their last patient every day. This will give them the experience without unrealistic expectations and if the new method takes a bit longer at first doing it with the last patient will not disrupt the schedule.
  • Use the lean principles of the 5 Whys to get to the root of why something is broken.
  • Make sure that new processes do not increase workload and have perceived value, using the “highly adoptable” formula from Chris Hayes.
Source: Christ Hayes, www.highlyadoptableQI.com

Source: Christ Hayes, www.highlyadoptableQI.com

  • Involve frontline staff in process design. They will be the ones who need to implement it so make them part of the solution.
  • Determine what you will measure before implementing so you can gage success.
  • Test changes under a variety of conditions before trying to replicate across an organization. That way, you will be prepared for any potential adoption blockers.
  • Prepare for and manage relapses. People may revert to older processes if the new ones fail. Plan for this, and see it as a learning opportunity rather than a failure.
  • Make the change about improving patient care. Even though the goal may also include reducing readmissions, lowering costs, and increasing predictability, these are topics that are hard to rally people around. Remember why you and your colleagues entered healthcare: to help people. Appeal to the highest goal of improving patient’s experience and health.

Posted in: Behavior Change, Healthcare transformation, Outcomes

Leave a Comment (0) →

Using “Teach Back” To Decrease Patient Readmissions

Marshall McLuhan, the late Canadian philosopher, famously said both “the medium is the message” and “the medium is the massage” meaning that the delivery mechanism of information provides insight into the meaning and can also shape the meaning.

In a recent course I attended from the Institute for Healthcare Improvement on “Preventing Avoidable Readmissions” there was a lot of focus on missed messages whether between healthcare professionals or from healthcare professionals and patients. Some of these messages were missed because of the delivery mechanism, and one session in particular focused on a concept called “teach back” which was designed to ensure that the message of discharge instructions actually landed with patients.

Source: IHI.org

Source: IHI.org

Throughout the course, the same refrain was heard that improving communications between healthcare providers and to patients were key to improving health outcomes. Examples of poor or rushed communications were provided across the course and included:

  • Patients in the emergency department not knowing why they were actually admitted
  • Conflicting discharge instructions from different hospital departments
  • Rushed conversations with patients

As well, patients often interpret information differently than intended. For example, when patients are discharged they hear “better” rather than “recovering.” As well the messages often don’t land because patients are thinking ahead to the implications of the information, for example, when told of impending necessity for surgery they are thinking about needing to take time of work, or who will walk the dog.

In our work at Wellpepper, we have interviewed many patients about why they don’t adhere to treatment plan instructions, and what most of them tell us is that when hearing the instructions in the first place they felt like they understood but when they got home they realized that they didn’t. Think about this with respect to how these messages are often delivered: patient have limited time with healthcare professionals, they are often intimidated and don’t want to ask questions, and then frequently the handouts they are sent home with don’t correspond to what they thought they heard.

Thinking about how instructions are delivered to patients can help tremendously with patient understanding and follow up. The IHI course presented some practical strategies both for delivering the information and for testing patient comprehension wrapped in some specific strategies referred to as “Teach Back.”

Healthcare professionals learn many things in their studies, but information design, learning styles, and comprehension are not necessarily part of that. Understanding that people learn in different ways, that patients are often distracted by bigger life issues when you are trying to teach them, and that a patient’s ability to demonstrate what you taught them better indicates they can go home and replicate are all tools to improve patient comprehension and adherence. As well, often it is not just the patient who needs this information but also the patient’s caregiver.

The basic principles of Teach Back include:

  • Making sure that information is easy to understand. For example avoiding medical jargon, written for a 5th grade reading level, and including only the most important information.
  • Delivering the information in a way that shows the patient you care, and that the information is important. For example, taking the time to walk through the information, sitting down and looking at the patient, and using a warm and caring tone of voice.
  • Testing for understanding. Ask the patient to explain what you taught them in their own word and if appropriate to demonstrate what you taught them.

We loved this particular session as it’s in keeping with our findings that patients want to adhere to programs provided you provide them with the right tools. As well, we have been recommending a teach-back style when recording video tasks with Wellpepper. First explain the task to the patient, whether that’s physical therapy, wound care, or using an inhaler. Next have the patient demonstrate to you that they can do it. When the patient is able to show you they can do it without extra help or prompting, record the patient and make this part of the patient instructions that you send home with them.

Teach back and informational design concepts may seem like they are taking healthcare outside of a traditional realm. They may also seem like they take more time. In the short term that might be true, but in the long run you will need to spend less time with these patients as they will be self-activated, which needs to be the goal of any readmissions prevention program.

Posted in: Behavior Change, Healthcare motivation, Healthcare Policy, Healthcare transformation, Outcomes

Leave a Comment (0) →

Reducing Avoidable Readmissions: Transfer to Home

While studies show that discharge to home can be best for patient recovery from surgery, this is an area where communications and continuity of care often break-down, risking readmissions. The idea of a patient-centered medical home where the patient is at the center receiving consistent care from a group that can bring in specialists is intended to solve some of this problem, but better communications between healthcare organization, primary care physician, and patient and the patient’s care team can go a long way to improve discharge to home without requiring an entirely new model.

This post is part of a series recapping a recent training from the Institute for Healthcare Improvement’s course on Reducing Avoidable Readmissions.

Primary care physicians while often the most trusted person in the care team, and besides the patient the person with the best insight into the patient’s overall wellbeing are often out of the loop when it comes to hospitalization. Once a patient is referred to a specialist for surgery the hospital team takes over, and the primary care physician has little insight into what happens, even though when the patient is discharged they are back in the care of the primary care physician. Often the primary care physician has no idea when the patient has been hospitalized or re-hospitalized.

Primary care physicians who were participating in the course expressed both their desire to participate in this post-acute care follow up and frustration at both the lack of insight they had and felt powerless to influence the hospitals.

While the evidence on post-hospitalization follow up visits is mixed, common sense does point to following up with patients as being a good thing to prevent readmissions. However, depending on the model of care, this is either with a primary care physician or a hospitalist. Considering the PCP is responsible for the general health of the patient, moving to reimbursement models where this is possible also seems to make more sense.

 

Source: IHI.org

Source: IHI.org

One example cited was from Capitol District Physicians Health Plan, where physicians were paid to do post acute care follow-ups. The program plus a phone call from a case manager decreased readmissions from 14% to 6%. (Although it would be interesting to know whether the in-person visit or the phone call had the biggest impact.)

As with other sessions in this course, the keys to improving discharge to home were in communication with the patient and patient caregivers around expectations and communication back to the hospitalist or family physician about medication usage at home, and any concerning symptoms. Too often patients understand “You’re discharged” as “You’re better” and miss their responsibilities for doing follow-up care whether that is physical therapy, wound care, or just easing back into activities they participated in prior to surgery. Ensuring patients and their care givers understand that discharge to home still requires follow-up is a key to decreasing readmissions from this setting.

New models of transitional care and intensive care where patients receive personalized follow-up care and regular check-ins with a healthcare professional after hospital discharge were shown to improve overall function in patients, decrease readmissions, and decrease costs. These types of new models become more practical with the carrot of value-based payments coupled the stick of penalties for readmissions. While the overarching goal of decreasing readmissions is about improving patient care, having financial incentives aligned will provide an extra boost.

Continuing with the theme of the course, there is no one silver bullet. There is no one reason that patients readmit. That’s the bad news. The good news is that some basic common sense improvements, like better communication with patients and their care teams can decrease readmissions. We’ll go into more detail on how to improve communications in the next post on this topic.

Posted in: Adherence, Aging, Health Regulations, Healthcare Policy, Healthcare transformation

Leave a Comment (0) →

Reducing Avoidable Readmissions: Care Transitions

This is the second in our series, recapping the lessons learned from the Institute for Healthcare Improvement’s Reducing Avoidable Readmissions course.

Care transitions are seen as key to improving readmission rates, and understanding that readmissions are not just the hospital’s responsibility but involve a care team that includes the patient, the patient’s caregiver, homecare, and skilled nursing depending on where the patient is discharged.

Both ensuring good care transitions to decrease readmissions, but also discharging to the right facility are crucial for lowering costs and improving care. Post-acute care shows the greatest discrepancy in costs per patient and is growing at 6% annually for Medicare patients. Today, 40% of Medicare patients discharge to a post-acute care facility, and 33% of patients in these facilities experience a care-related adverse event. By 2017, skilled nursing facilities could face penalties of up to 3% of Medicare payments for readmissions, thus there are real incentives to improve transitions, if patient safety isn’t enough to effect change.

The first step in improving care transitions is to ensure that the patient is going to the right setting, and this requires a decision by the care team that includes the patient and the patent’s caregivers. If money is not an object, many hospitals discharge to skilled nursing as a way of insuring that the patient doesn’t readmit. However, if care transitions are not handled properly, this adds costs without improving quality.

One of the biggest challenges in care transitions, is that there are no universally agreed upon assessment tools for determining the best next step for patients on hospital discharge, hence the over prescribing of skilled nursing. Beginning to track readmissions and outcomes should help organizations stratify risk and begin to be able to predict the best setting based on data. In addition to data, interview patients. Often missed care transitions are only identified by the patient him or herself as they are more aware of what was lost in transition.

Possibly because of the make-up of the attendees in the course, the transition from hospital to skilled nursing was a hot topic. Hospital attendees admitted to have little insight into how skilled nursing facilities worked. Skilled nursing attendees expressed frustration with the amount of patient information they received when admitting a patient. One attendee begged “just let me see the patient’s medical record.”

In order to facilitate better transitions, cross-functional teams need to be developed and these need to include members of the receiving facility. One skilled nursing facility reported significantly better transitions by simply placing one of their nurses in the hospital part-time to meet with patients before they were transferred.

These teams must have support at two levels: the executive level must provide resources and be open to changes recommended by the functional team that handles the care transitions. Functional teams must feel empowered to change and improve processes for care. Organizations that are pursing ACO models and bundled payments were seen as great opportunities for these types of cross-organizational and cross-discipline care teams.

The INTERACT tool is a way to ensure that the receiving organization gets the right patient care information during this transition. Unfortunately, given the lack of interoperability of medical systems, this approach requires additional paper work. There is no easy way to share patient records between EMRs or organizations, or sometimes within the same organization.

Other best practices in patient transfer include:

  • “warm handovers” that is, no patient is transferred with out a real-time conversation between physicians
  • Sending the patient with a 3-day supply of medication so there is no interruption and include pharmacy in the transfer team
  • Following up with the skilled nursing facility by phone within 24-48 hours post transfer
  • Sending information about patient preferences. One example was given of a patient who preferred to take her medication with Coke. She was greeted at the skilled nursing facility with a Coke and her medication.
  • Regular meetings between skilled nursing and hospital
  • Relationship building and storytelling for all parties to understand constraints that other side is facing
  • Creating a standard follow up and communication protocol based on patient risk of readmission

Post Acute Care Follow Up Communications

In keeping with the opening statement of the course, there is no silver bullet, just a lot of practical common sense advice, and clear and timely communication.

Next we’ll look at some best practices for discharging to home and the role of the primary care physician.

Posted in: Health Regulations, Healthcare motivation, Healthcare Policy, Healthcare Technology, Healthcare transformation

Leave a Comment (0) →

There’s No Silver Bullet: Reducing Avoidable Readmissions

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

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

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

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

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

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

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

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

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

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

Leave a Comment (0) →

Bundled payments: a holistic approach to patient care

Institute for Health Care Improvement
Bundles and Buy-Ins for Value-Based care
March 12, 2p ET

Guest speakers:
Mark Jarrett
Susan Browning
Alice Ehresman
Mark Hiller
Kathy Luther

Last week CMS announced a new innovative payment and care deliver model for Accountable Care Organizations (ACOs), called the Next Generation ACO Model. This model requires participating providers to ‘shoulder more financial risk’. This new value based reimbursement was no doubt created due to the success that bundled payments and the Pioneer ACO program have had. In this bi-weekly Institute of Healthcare Improvement (IHI) audio broadcast the focus was on bundled payments for Care Improvement. For those of us new to the various innovations being implemented to improve patient care, bundled payments have the additional potential to save healthcare systems big bucks.

Healthcare Delivery Systems involved in Bundled Care.

Healthcare Delivery Systems involved in Bundled Care.

A thorough, but brief introduction from IHI’s own Kathy Luther was given on the roles of teams and leadership in value driven care redesign. Considering Kathy’s role with the IHI to “help hospital leaders and staff achieve bold aims” her presentation outlined structure strongholds that are vital for tackling value based payment reform. Baystate Medical Center, North Shore LIJ and Premier discuss their experiences and thoughts on these roles.

At Baystate Medical Center, Alice Ehresman has the role of ‘Nurse Bundled Navigator’ (later mentioned as a imperative role for ACOs). She provides real time data metric dashboards to physician groups that are currently involved in Phase II, Model II of total joint replacement and coronary heart bypass surgery bundles. Their success relies heavily upon heavy buyins from the team, strong management of post-acute care resources and a ‘champion’ physician role that is engaged/educated in bundled improvement work. Baystate ‘transparent’ monthly meetings on bundled care has also been vital towards their success which is exemplified in the increase of attendees.

North Shore LIJ had two speakers, Mark Jarrett, MD & Susan Browning, MPH. Mark was very straightforward with how it has been difficult to get physicians, especially procedure orientated physicians like surgeons, to look at the whole continuum of care- from focusing on discrete data points and processes to looking at the big picture of patient outcomes. Physicians have concerns that they are put at risk for part of their compensation because they are not able to fully impact the outcomes of the patients throughout the continuum of care after they leave the surgeons table. Another issue that physicians are bringing to attention is the lack of evidence based metrics. North Shore has also had issue with patients not being discharged to a post-acute environment ; it’s difficult to keep communication clear on negative impacts on one site vs. positive on another.

Mark Hiller also spoke about bundled payment influence on Premier. Mark has a background in financial analysis and developing practical tools to assist hospitals in reducing their costs, so naturally he is involved in bundled payment reform. Mark mentioned the shock some physicians displayed upon learning what their patient went through 90 days post discharge, and in some cases this was the first time they had learned as much. I think this is an extremely interesting comment because it exemplifies how broken the fee for system is in providing holistic care to a patient. He focused a lot on the importance of communication with physicians about bundled payments and that understanding post-acute utilization will be imperative.

One thing that struck home with me was the ‘Culture of transparency and working together’ theme that was mentioned throughout the one hour broadcast. Does value-based care success rely solely on this statement alone? What do you think? Please post any comments you may have below.

Up next with IHI is Managers and Management: We need to improve care on March 26, 2015.

Links to the audio, slides and chat can be found here.

Posted in: Healthcare transformation

Leave a Comment (0) →

BIG-BIG-BIG. Company, heart and checkbook.

“Delivering Innovation Across the Healthcare Continuum”
Christopher Hall, Ph.D.
Senior Director, Radiology Solutions, Philips Healthcare
March 2, 2015

The last time I was in the Turner Auditorium at UW Health Sciences, I was a Clinical Informatics student learning about telehealth as more or less a theory. That was five years ago, now sitting in the same seat the numbers are flying in with results of how telehealth is saving big bucks for hospitals. For example, according to the presenter Mr. Hall, Banner Health saved 20-40% utilizing more or less the same platform that Wellpepper uses. Sending patients’ home with a tablet and/or connection devices (scales, heart monitors, etc.) and having patient compliance mechanisms in place, i.e. emails, chats between providers and patients. 20-40%, honestly? Wow.

A common thread through his presentation was the importance of streamlining care from the “waiting/hospital room to the living room” and to empower patients through careful, thoughtful and collaborative innovation. To me this is the ultimate goal to accomplish in telehealth, that and the obvious, for patients to get better. Philips currently has 190 million patients with 1 million being monitored in their homes everyday under their charge, this is a large population to be accountable for, so much so next year there will be ‘Philips Lighting’ and ‘Royal Philips’, the latter being in charge of just healthcare.

Telehealth Project from my UW SON Clinical Informatics class. Circa 2011

Telehealth Project from my UW SON Clinical Informatics class. Circa 2011

Philips’ focus now and in the coming years as Royal Philips, is on the Chronic disease patient population, since they make up about 75% of healthcare spending and home health care can help reduce costs without compromising quality. Home healthcare can also prevent readmission to the hospital by 20% and their electronic ICU platform helps significantly with early detection through the ‘over the shoulder care’. Patients are 26% more likely to survive and 15% are discharged faster. Those percentages are not easy to ignore, and the stronghold that telehealth has on a patient’s life, quite literally, and family is remarkable. Ironically I couldn’t help but giggle, during my graduate degree our team designed an ‘electronic ICU’ of sorts as a project, and it was nice to see those numbers while sitting in the same seat. Kudos Philips, who knows maybe someday you will save my life or someone I love.

Please view previous blogs from the Health Innovators Collaborative series.

For more information on these seminars please visit UW Dept. of Bioengineering website.

Posted in: Healthcare Technology, Healthcare transformation, Outcomes, Seattle, Telemedicine

Leave a Comment (0) →

Healthcare Reform and the Affordable Care Act: One Year Later

APTA CSM 2015 Recap: Healthcare Reform and the Affordable Care Act: One Year Later

Speaker(s):

Edward Dobrzykowski, PT, DPT, ATC, MHS

Janice Kuperstein, PhD

Karen Ogle, PT, DPT

Charles Workman, PT, MPT, MBA

CSM StepsThe consensus from the speakers in this session was that the changes are real, they require work on the part of healthcare providers, and that physical therapists have a great opportunity to participate. There was definitely a greater sense of urgency on this topic than in previous years at CSM, and speakers made sure the audience knew that:

“While we’re all worried about G-codes, new players like Walmart, Walgreen’s, and Google are creating entirely new models of care.”

“Patient satisfaction is not enough, we need to look at outcomes”

“Reducing length of stay is not going to be the only way to reduce costs.”

Some of the major themes of the Affordable Care Act that speakers believed impact physical therapy include:

  • Realignment of care models from management of chronic disease to preventative medicine
  • Conservative interventions preferred over surgery due to costs and outcomes
  • New payment models and reduction in visits
  • Direct access to physical therapy
  • Standardization of service
  • Accountability for services delivered
  • Outcomes measurement

All of these were seen to provide both challenges and opportunities to the profession. Similar to other sessions, opportunities in improving outcomes and decreasing costs of post acute care, and in improving discharge, and care transitions to reduce readmissions were seen as key areas where physical therapy could have a big impact, however, physical therapists needed to participate more in the process.

Presenters pointed out that homecare workers and occupational therapists are already working in health coaching positions for population health management, but physical therapists were not really serving in these roles. Given that many studies show that discharge to home is best for the patient, and also lowers costs, this is seen as a missed opportunity for physical therapists.

Full moon over Indianapolis

Full moon over Indianapolis

In order to effect change, moving to more accountability and measurement is important, for example predictor tools to score patient on risk of readmit and standardized outcome tools. By moving to these measures and recording outcomes, physical therapists will be better able to participate as part of new payment models, like bundled payments.

Considering that for the patient, function is usually the most important outcome, and physical therapists are experts in delivering a return to function, the core value equation could be applied directly to physical therapy to deliver better outcomes at lower costs.

Value = Quality x Patient satisfaction

Attendees were encouraged to ask questions during the session and feedback ranged from a hospital-based physical therapist participating in a bundled total joint replacement scenario, where the hospital was receiving 3% back from CMS due to delivering positive outcomes at a lower cost than stipulated to those in smaller or private practice wondering whether there was room for them to participate in these types of payments with hospitals, or whether they would be shut-out. This was a common theme at the conference as private practice owners questioned whether controlling costs and outcomes would mean that hospitals would bring outpatient physical therapy in-house.

Similar to other sessions, suggested that the two keys to delivering on new value-based payment models required better care collaboration among multi-disciplinary teams and standardized outcome reporting.

“Merely aligning financial incentives between providers of acute and post-acute care will not improve quality and reduce costs for episodes of care. True coordination of care is required to ensure the best possible outcomes.” Ackerly DC and Grabowski DC. Post-Acute Reform- Beyond The ACA. NEJM 2014;370(8):689-691

For outcome reporting, the question was asked if patient-reported outcomes were the new gold standard. If patient satisfaction and functional outcomes are key in the value equation, then they are.

To conclude presenters reminded participants what they can do to participate in this new world, which reflects the larger clinical, demographic, and social trends.

  • Develop strategies and tactics around population health management
  • Optimize efficiency in each practice segment
  • Build collaboration “upstream” and “downstream”
  • Position for more integration

The session did a great job of showing that the change is real, the opportunities are there, but also making attendees understand that the time is now. Our overall impression of the conference this year is that physical therapists have a great opportunity to be on the front-lines of some of this change but that they may need to move faster than in the past. Exciting times to be in patient-centered care!

Posted in: Behavior Change, Health Regulations, Healthcare transformation, Outcomes, Physical Therapy, Rehabilitation Business

Leave a Comment (0) →

The Power of Data: Achieving Consistent Health Outcomes

Recap from APTA CSM 2015: The Power of Data: Achieving Consistent Health Outcomes

Speakers:

Dianne Jewell, DPT, PhD

Heather Smith, PT, MPH

Mary Stilphen, DPT

Outcomes were a hot topic at APTA CSM 2015, and not surprisingly as CMS just announced that by 2018 50% of Medicaid payments would be through new value-based payment outcomes with value defined as the relationship between outcomes and costs.

This session presented a basic primer on outcomes, how to evaluate them, and the differences between functional and patient-reported outcomes before jumping into the meat of the topic, presented as a case study of some interesting new work done at The Cleveland Clinic to drive better decision making in post-acute care.

Embarking on a new model is not for the faint of heart and the case study outlined in this session is still under-development and refinement even though the journey was started in 2010 with a definition of which outcomes they wanted to collect.

To explain this, presenters quoted Eleanor Roosevelt:

“Each time you learn something new you have to adjust the whole framework of your knowledge”

For The Cleveland Clinic, Step 1 back in 2010 was to implement an EMR so that consistent data could be tracked for every patient visit, and then start to use this data to effect care, with the main goal to make better decisions about appropriate discharge from acute care.

In order to collect data consistently however, they had to define a tool, and wanted to ensure that it was not cumbersome. They modified Boston University’s 24 question “Activity Measure for Post Acute Care” or “AMPAC” to a shorter survey they named“6 Clicks” to represent the number of mouse clicks to complete the survey. While acronyms are often all the rage in research studies, a catchy and evocative name is better if you want someone to actually use something, and “6 Clicks” definitely fit the bill.

The goal of completing the “6 Clicks” survey was to measure longitudinally across patient care and eventually be able to predict the best discharge setting based on this information. The ultimate goal was to improve outcomes without increasing costs and the flip-side decrease costs without impacting outcomes.

The 6-Clicks consists of 12 questions, 6 each for PT and OT accessment. For PT the questions are related to Mobility and for OT to Self-Care. The ultimate use of the data is to ensure the best care for the patient and the optimal use of resources within the hospital.

The 6-Clicks tool raised the visibility of the physical therapists within the hospital as they were able to make the best recommendations for patient discharge setting based on analyzing the data, and the data-driven approach gave all staff a way to talk about these decisions. Prior to using the tool, it wasn’t clear whether in-patient physical therapists were spending time with the right patients or whether the patient would thrive in the discharge setting.

6-Clicks Results. Source: The Cleveland Clinic

6-Clicks Results. Source: The Cleveland Clinic

Based on the patient’s 6-Clicks score they could determine whether to discharge to home with no services, with services, to skilled nursing facility, or to long-term care facility. 6-Clicks could also be used to determine the appropriate in-hospital care based on eventual discharge. For example, if a patient was predicted to be best discharged to home with no services, the in-patient physical therapists would focus on mobility and self-care to make sure the patient was self-sufficient on discharge.

As The Cleveland Clinic continues on this outcome journey, which has been rolled out across all of their hospital locations, the next step is to provide outcome analysis for the continuum of care: that is what happens when patients are discharged to these different settings. To do this they will repeat 6-Clicks on each care transition and continue to amass and analyze data. Other extensions will be adding additional outcome measures based on patient issues, and potentially beginning to communicate this data back to patients.

For those daunted by this impressive but long journey, presenter Mary Stilphen offered a few tips to get started on an outcomes journey:

  1. Rally stakeholders
  2. Determine what you want to measure
  3. Understand what change you want to effect
  4. Choose your instruments
  5. Collect data
  6. Share and socialize data

And we would add, keep it simple as evidenced by the thinking behind the 6-Clicks tool.

If you’d like to read more about the 6-Clicks Tool, there’s a great description in this publication.

Posted in: Health Regulations, Healthcare Technology, Healthcare transformation, Outcomes, Physical Therapy

Leave a Comment (0) →

Looking Outside Healthcare To Teach Physical Therapy Business Practice

Recap from APTA CSM 2015

Speakers:

Beth Davis, PT, DPT, MBA

Zoher Kapasi, PT, PhD, MBA

Physical therapists have many choices on what to do after graduating: research, private practice, join an existing business, hospital in-patient and outpatient, and home care to name a few. Some private practice owners we’ve met are evangelical about getting their peers to think in a more business oriented way, and have even hatched at Twitter hashtag #bizPT to focus on these issues. They would have loved this session from two PT/MBAs from Emory School of Medicine. The session was a brief review of an elite elective course in the physical therapy program at Emory called “Business Management for the Physical Therapist Entrepreneur.” The course teaches a broad understanding of business issues, not the nuts and bolts of running a practice rather skills for problem solving, thinking like an entrepreneur, and applying the same methodology students use for medical cases to solve business cases.

#BizPT Usual Suspects

#BizPT Experts

In the course, students are challenged to solve bigger issues in healthcare like rising costs, poor care coordination, and the increasing demands of an aging population. Instructors asked students to look beyond healthcare to other businesses and apply these solutions to healthcare. To warm up this comparative muscle, presenters shared some famous examples of innovation transfer including:

Students are trained to evaluate three types of business cases in what could be seen as a mini-business school education. They tackle decision cases, problem cases, and evaluation cases. Instructors try to help them translate their medical investigation and decision making skills to these cases, which have direct medical analogies. Students are shown how analysis of both medical and business cases have similar phases of:

  • Examination
  • Evaluation
  • Diagnosis
  • Prognosis
  • Intervention
  • Outcomes

The course also helps students talk with business lingo which can prepare them to work in larger practices and hospitals, as well as provides them with critical thinking and problem solving skills that will help them fully participate in both business and clinical work upon graduation.

Using cases from Harvard Business School, topics cover all facets of business including growth, customer service, human resources, operations management, marketing, and information technology. Presenters provided some strategies for applying these technique in private practice as well using staff training or lunch & learn discussions. For the folks tweeting on the #BizPT hashtag this course is a welcome addition to a physical therapy curriculum and it seems to have benefits far beyond private practice.

Posted in: Healthcare transformation, Lean Healthcare, Physical Therapy, Rehabilitation Business, Seattle

Leave a Comment (0) →

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

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

Speaker: Pamela Duncan, PhD

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

Source @mdaware on Twitter

Source @mdaware on Twitter

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

Translating Research to Evidence and the Humble Researcher

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

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

Best Practices for Stroke Recovery

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

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

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

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

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

Post stroke care costs:

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

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

She sees the benefits as:

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

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

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

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

Leave a Comment (0) →

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

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

Presenters:

Mary Altpeter, PhD

Tiffany Shubert, PhD

Clinical Support for Otago

Clinical Support for Otago

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

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

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

Delivering Otago: Calendar view

Delivering Otago: Calendar view

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

Clinical Barriers to Implementation

Clinical Barriers to Implementing Otago

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

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

6-Stage Behavior Change Model

6-Stage Behavior Change Model

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

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

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

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

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

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

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

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

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

Leave a Comment (0) →

What Can We Learn from the UK Health System?

There’s no perfect health system in the world, at least not that we’ve heard of. The US is plagued by high costs and uneven coverage across the country. Other systems like those in Canada and the UK have long wait times and can be glacially slow to adopt new technologies (aka pilotitis). However, taking a closer look into those systems can provide an interesting alternate viewpoint, and yet, so much is strangely familiar especially in the struggle to address the health problems of an unfit and aging population. We’ve recently been turned on to the Inside Health podcast from the BBC where topics range from those of national healthcare administration and benefits to specific health issues. Unlike many health publications, Inside Health frequently features patients talking about their experiences with the system.

Here’s a snapshot of questions posed on recent episodes:

  • Should medical screening with MRIs and CT scans be done proactively? This session talked about the risk of over-screening patients who are not visibly ill. While early detection is key to catch and treat many types of cancer, the screens often catch issues like tumors that would have gone away on their own, and therefore cause undue stress, cost, and discomfort to patients.
  • Should fruit juice be removed from food guidelines? Citing that calories that are drunk rather than eaten are not recognized by the body (aka empty calories) and that most fruit juice has all the fiber (aka the best part of the fruit) removed, the guest argued that fruit juice should not be part of the 5-6 services of fruit and vegetables recommended per day.
  • How should private hospitals be regulated? This story was particularly interesting, as it seems that the many private hospitals that are cropping up to take excess demand from the UK’s National Health Service, are not regulated in the same way as government-run hospitals. In this episode they examined some cases of knee and hip replacements gone wrong due to the lack of proper follow-on care. Since private often denotes more expensive and hopefully better quality it was curious to hear that they were not following standards.
  • Should healthcare professionals be fit? This controversial question was asked about whether healthcare professionals should be held to higher health standards, especially with respect to obesity, to set a good example for patients.
  • Should doctors be paid based on specific quality measures? This segment examined financial incentives for primary care physicians to complete certain tests and concluded that doctors will ignore financial incentives if they don’t believe the tests are in the best interests of the patients. However, in the example they cited, the incentive was $50 for doing a standard depression screening test which might be argued is not enough compensation for the hassle of the additional charting and follow up that the depression screen would have caused, not to mention the impact on patients who might not have actually been depressed.

You may notice a slightly paternalistic (or is that maternalistic?) bent to these topics, which is understandable as the UK has a national health system. However, all of them are topical and relevant to discussion occurring in the US right now. (Remember the uproar over soda sizes in New York?) Segments are short and conversational and feature real patients. Plus they are all delivered with the dulcet tones of the BBC broadcasters so you feel smarter just by listening. If you’re looking for insight, and inquiry in healthcare, this is a great podcast to add to your list.

Posted in: Healthcare motivation, Healthcare transformation

Leave a Comment (0) →

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

Leave a Comment (0) →

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

Leave a Comment (0) →

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

Leave a Comment (0) →
Page 6 of 7 «...34567
Google+