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T2 Telehealth aka ATA 2017 aka ATA 23: Part 2, How Did We Get Here and Where Are We Going?

This was my second trip to Orange County Convention Center this year, so it was hard not to compare and contrast the annual American Telemedicine conference to HIMSS, the biggest health IT conference. As well, it was my third time at the ATA conference, back after skipping in 2016, and the gap made it easier to reflect on previous years as well.

The ATA annual is almost 10 times smaller than HIMSS, which makes it a lot less exhausting and easier to focus. There’s not a feeling that for every second you’re talking to someone you’re missing out on talking to someone else equally as interesting and valuable. (There is no shortage of interesting people, just a more manageable group.) The size also makes it a bit easier to talk to people as they’re not rushing off to walk a few miles across the convention center to the next session.

The first year I attended, 2014, the tradeshow floor was full of integrated hardware and software solutions, and Rubbermaid was even a vendor selling telemedicine carts. It was almost as though the iPad hadn’t been invented.  It was the year that Mercy Virtual launched their services as a provider of telestroke and telemonitoring for other health systems. A provider as a vendor caused a bit of a stir on the tradeshow floor.

By the next year, the integrated hardware and software vendors were dwindling, but talks were largely still given by academics and were focused on pilot projects that while showed success, talks often ended with a plea for thoughts on how to scale the program.

ATA evolved out of an academic conference and that’s still quite prevalent in the presenters who are often from academic medical centers, and reporting on studies rather than implementation. Data was important in all sessions, but measurement of value was inconsistent. In addition to academic medical centers, most leaders in telehealth seemed to be faith-based not-for-profits, like Mercy and Dignity, and as well as rural organizations where the value was clear.

That said, a welcome addition to this year’s content was two new tracks on Transformation and Value. I spoke in the Value track at ATA, along with Reflexion Health and Hartford Healthcare about the value of telerehab in total joint replacement, and we were able to share data points from real patient implementations, in addition to clinical studies. (If you’re interested, in the Wellpepper segment, get in touch.)

Although, harkening back to the day 1 keynote, the definition of value depended on the business model of the telemedicine platform being implemented. There’s no question that telestroke and neurology programs, and telebehavior programs deliver value especially in rural areas without direct access. At Wellpepper, we’ve seen definite results in post-acute care, both in recovery speed and readmissions.

In other sessions the value was not as clear and no one was able to fully refute the study that when offered the choice, patients used telemedicine in addition to in-person visits, thus driving up costs. In fact, the director of telemedicine for a prominent healthcare organization confirmed that patients were using televisits for surgical prep when they could have just read the instructions given to them. (Or interacted with a digital care plan like Wellpepper.)

As with every technology conference the voice of the patient was absent, with the exception of head of Mercy Virtual Randall Moore, MD who started all his presentations by introducing us to patient Naomi who was able to live out her life at home, attend bingo, and enjoy herself due to the benefits of the wrap-around telemedicine program that Mercy put In place. Oh, and it cost a lot less than the path of hospital admissions she’d been on previously. Sounds like triple aim, and what we all need to aspire to.

So, based on the keynotes, the sessions, and the show floor, I’d characterize this year’s conference as a world in flux, like what’s going on elsewhere. There was a sense of relief that the ACA had not been repealed. HIMSS took place before the proposed repeal and replace plan died, and there was a lot more fear and uncertainty. Vendors and providers alike are looking to strengthen the value chain. Unlike HIMSS, there was a lot less hype. Machine learning and AI were barely mentioned except in keynotes possibly because telemedicine is still largely a world of real-time visits, and extracting meaning from video is a lot harder than from records. We see promise, people want to do the right thing, but it’s not clear which direction will help us ride out the storm.

 

Still trying to figure out what this has to do with Telemedicine. Look better on realtime visits?

Posted in: Healthcare Disruption, Healthcare Legislation, Healthcare motivation, Healthcare Policy, Healthcare Technology, M-health, Prehabilitation, Rehabilitation Business, Telemedicine

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Cardiac rehab is effective, but patient-centered care needs to actually be patient-centered

With CMS’s new Cardiac Bundle, cardiac care (especially post-acute care), is the next service line to go under the microscope. As with total joint, variations in outcomes and costs are often seen in post-acute care so looking at how that care is delivered is key. For any bundle to be successful, engaging patients and ensuring their participation in follow up is a driver of success.

I have to admit, I haven’t read the bundle specs yet, just the news on the bundle. According to Becker’s Hospital Review’s “10 things to know about CMS’ new mandatory cardiac bundle”, the bundle includes provisions to test cardiac rehabilitation services, with 36 sessions available over 36 weeks. However, according to this article from NPR, although cardiac rehabilitation is proven to be effective, most people don’t participate. If you read through the comments on the NPR article (ignoring the trolls of course), you’ll start to see the reasons: cardiac rehabilitation care is built around the needs of the people providing the rehabilitation, not the patients.

From our experiences delivering post-acute care plans, as well as talking to payers and providers we’ve learned a few reasons why patients don’t follow up with their outpatient care:

  • Distance: In cardiac cases, patients are taken to the closest hospital, but this may not be the closest to their home or work. In other post-acute scenarios, they may have gone to a center of excellence that is also at distance.
  • Time commitment: These programs often require multiple days of treatment a week. Not everyone has the flexibility to take off work.
  • Timing: Programs are usually offered during 9 to 5, to accommodate the needs of the providers. Patients might prefer evening or weekend programs. We talked to one provider that focuses on lower income patients. People in hourly wage jobs don’t get to choose when they take breaks and their breaks are usually 15 minutes, and maybe 30 minutes for lunch. It’s next to impossible for them to attend in-person sessions.
Francis Ying/Kaiser Health News

Francis Ying/Kaiser Health News

The NPR article keyed in on these within the one example of Kathryn Shiflett (a healthcare worker herself!) whose distance and work hours (4:30 AM – 3:00 PM) pose a significant barrier: “She lives an hour away and is about to start a new job. Cardiac rehab classes happen Mondays, Wednesdays and Fridays, with sessions at 8 a.m., 10 a.m. and 3 p.m.”

While the bundles are definitely driving the right behavior in focusing on patient outcomes rather than procedures, they need to go further to promote patient-centered care. In this case, that should be testing new models like mobile health or community-based rehab programs that are adaptable to the unique needs of different patient groups.

Posted in: Adherence, Healthcare Disruption, Healthcare Legislation, Healthcare motivation, Healthcare transformation, Occupational Therapy, patient engagement, Patient Satisfaction, Rehabilitation Business, Uncategorized

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Our Picks for APTA CSM 2016

APTA CSM 2016Wellpepper CTO Mike Van Snellenberg will be at APTA CSM in Anaheim this year, and here are a few of the sessions you might see him at. If you want to be sure to see him, book a meeting.

As usual we’re following sessions about healthcare transformation, patient experience and patient centered care, patient reported outcomes, and interventions that include technology. With the conservative care and physical therapy being an important part of new bundles like CMS’s Comprehensive Care for Total Joint Replacement, these are hot topics as well.

Here are a few session picks from Wellpepper.

Patient-Centered Care

Exercise and Diabetes: Tools for Integrating Patient-Directed Practice

The Customer Experience in Health Care: The Game Changer, Part 1

Words Mean Things: How Language Impacts Clinical Results

Acute Care Productivity Measurement, “What about the Patient?” The Time has Come to Shift to a Value Based Measurement System

Technology

Wearable Technology Meets Physical Therapy

Virtual Reality and Serious Game-Based Rehabilitation for Injured Service Members

Tracking Outcomes

Changing Behavior Through Physical Therapy: Improving Patient Outcomes

Functional Reconciliation: Implementing Outcomes Across the Continuum

Using Outcomes Data to Improve Provider, Patient and Payer Engagement and Demonstrate the Value of Your Services

Healthcare Transformation and New Models of Care

Exceptional Care and Profitability in Light of Health Care Reform for Patients with Chronic Musculoskeletal Pain

The Complicated Hip: A New Debate

Emerging Issues in Medicare and Health Care Reform, Part 2

Bundled Payment Implementation for Primary Total Joint Patients

Managing Patient-Centered Care in a Changing Reimbursement World

Health System PT’s Leading the Transition to Value-Based Health Care

Posted in: Adherence, Health Regulations, Healthcare Disruption, Healthcare motivation, Healthcare Policy, Healthcare Research, Physical Therapy, Prehabilitation, Rehabilitation Business

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EvergreenHealth Selects Wellpepper as Mobile Patient Engagement Solution for Total Joint Replacement

SEATTLEJan. 20, 2016 /PRNewswire/ — Wellpepper, Inc., a clinically validated platform for patient engagement, today announced that EvergreenHealth, an integrated health care system that serves nearly 850,000 residents in northern King and southern Snohomishcounties in Washington State, has selected Wellpepper as the mobile engagement solution for all total joint replacement and musculoskeletal care plans. The project was made possible at EvergreenHealth with a generous donation from The Schultz Family Foundation, a private not-for-profit foundation founded by Howard Schultz, CEO of Starbucks Corporation, and his wife Sheri.

Patients with musculoskeletal issues that require surgery or rehabilitation will use Wellpepper on their mobile devices to track their outcomes and adhere to their care plans. This information will enable patients, physicians, and other healthcare providers to track progress and patient-reported outcomes in real-time to improve care. Wellpepper enables health systems to implement their own care instructions on its task-based platform and makes it easy for patients to understand and adhere to their care instructions.

“Across our organization, we strive to be a trusted source for innovative care solutions for our patients and families, and our partnership with Wellpepper helps us deliver on that commitment,” said EvergreenHealth CEO Bob Malte. “Since we began using Wellpepper in 2014, we’ve seen how the solution enhances the interaction between patients and providers and ultimately leads to optimal recovery and the best possible outcomes for our patients.”

The Wellpepper remote care management solution is designed to be easy-to-use and highly engaging for patients while being flexible and easily customizable for use in clinical practice. It is clinically-proven to improve patient adherence and outcomes with over 70 percent patient engagement.

Health systems are increasingly looking for solutions to enhance patient care while reducing costs, and this is particularly true in total joint and musculoskeletal scenarios. The new Comprehensive Care Model for Total Joint replacement announced by the Centers for Medicare and Medicaid aims to reduce the cost and quality variability of procedures.

“We are seeing a lot of interest in using the Wellpepper platform in orthopedic and total joint replacement scenarios,” said Anne Weiler, co-founder and CEO of Wellpepper. “Interest and adoption are largely being driven by our ability to customize the care plans based on the health system’s own protocols, personalize the plans for each patient and collect the standardized outcomes required as part of the new Center for Medicare and Medicaid requirements.”

The Wellpepper platform doesn’t dictate care plans; instead it provides a set of task-based building blocks that health systems and providers can customize to reflect their own methodologies and practices. The patient interface is simple and straightforward, so patients get only the tasks and questions they need on a given day.

For more information about Wellpepper or to find out how the Wellpepper patient engagement solution can support value-based payment models, please visit wellpepper.wpengine.com or email info@wellpepper.com.

About EvergreenHealth
EvergreenHealth is an integrated health care system that serves nearly 850,000 residents in King and Snohomish counties and offers a breadth of services and programs that is among the most comprehensive in the region. More than 950 physicians provide clinical excellence in over 80 specialties, including heart and vascular care, oncology, surgical care, orthopedics, neurosciences, women’s and children’s services, pulmonary care and home care and hospice services. Formed as a public hospital district in 1972, EvergreenHealth includes a 318-bed acute care medical center in Kirkland, a network of 10 primary care practices, two urgent care centers, over two dozen specialty care practices and 24/7 emergency care at its Kirkland campus, Monroe campus and at a freestanding center in Redmond. In 2015, the system expanded to include EvergreenHealth Monroe – an accredited, full-service 72-bed public hospital district, established in 1960 in Monroe, Washington. EvergreenHealth has clinical and strategic partnerships with several health care entities, including Virginia Mason, Seattle Cancer Care Alliance and dozens of independent practices that are part of the clinically integrated EvergreenHealth Partners network. In addition to clinical care, EvergreenHealth offers extensive community health outreach and education programs, anchored by the 24/7 EvergreenHealth Nurse Navigator & Healthline. For more information, visit www.evergreenhealth.com.

About The Schultz Family Foundation
The Schultz Family Foundation, established in 1996 by Howard and Sheri Schultz, creates pathways of opportunity for populations facing barriers to success. The Foundation invests in innovative solutions and partnerships that unlock people’s potential, and strengthen our businesses, our communities, and our nation. For more information about the Foundation and its work: schultzfamilyfoundation.org.

About Wellpepper
Wellpepper is a healthcare technology company that provides a clinically validated platform for digital treatment plans delivered via mobile devices. The Wellpepper patient engagement solution improves patient adherence and outcomes with its patent-pending adaptive notification system and just-in-time, task-based instructions and by fostering communication between healthcare providers and patients. Wellpepper is used by major health systems that are moving to an accountable care organization model and need to track and improve patient outcomes while lowering costs. Wellpepper was founded in 2012 to help healthcare organizations lower costs, improve outcomes and improve patient satisfaction. The company is headquartered in Seattle, Washington.

Media Contact:
Jennifer Allen Newton
Bluehouse Consulting Group, Inc.
503-805-7540
jennifer (at) bluehousecg (dot) com

SOURCE Wellpepper

RELATED LINKS
http://wellpepper.wpengine.com


Posted in: Healthcare Technology, Healthcare transformation, Interoperability, M-health, Outcomes, Physical Therapy, Prehabilitation, Press Release, Rehabilitation Business

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This Month [August] in Telemedicine

This Month [August] in Telemedicine

Moderated by:
Jonathan Linkous
Chief Executive Officer,
American Telemedicine Association

Gary Capistrant
Chief Policy Officer,
American Telemedicine Association

This month in Telemedicine webcast was interesting because more than once was the ATA sentiment geared towards realizing the big picture of telemedicine: To help patients. Unless you are lucky enough to work directly with patients that utilized telemedicine on a daily basis, I think sometimes, including myself, we get caught up in the bureaucracy/methodological side of things. Sometimes it takes talking with patient or clinician in order to make me grasp how HIT is improving lives, my life too! So I appreciate the reminder John! At the end of the webcast he asked if you have a personal story of how telemedicine helped you or a loved one ATA needs to hear it, please email John Linkous -jlinkous@americantelemed.org

The main highlight of the first 20 minutes of this webcast focused on the positive trend of telemedicine utilization. Not surprising the younger crowd just beginning their careers in medicine strongly support the use of telemedicine; Medscape conducted a survey and found out that 70% residents had no problem consulting via telemedicine. And maybe because I am of the ‘younger’ crowd (bahaha) I think this is ingenious: the Colorado medicine board is doing away with the rule that patients need to see doctors face to face before utilizing telemedicine; ok so how many times have you gone all the way to the doctor’s office only to get a referral or need blood work done before they can give you a diagnosis/treatment?! Genius! Other interesting facts: 20% of American adults use some technology to track health care (counting steps, migraine triggers & heart rate, etc.) and 57% of households with children access one health portal per a month. Finally big employers are seeing the benefit of telemedicine to cut back on insurance costs; 75% of large employers will be using telehealth as a benefit next year.

Licensure compacts. Ok guys really? Every “This month in telemedicine” webcast talks about this. What is the hold up?! It is so frustrating to me that if I get ill on vacation in Hawaii (ok dreaming, who gets sick in Hawaii?) I cannot get a consult from my doctor over the phone or the internet. This is silly people and it was clear to me that John thinks so as well. He underscored the importance that ATA supports the federation’s compacts in principal, but has some concerns… it is estimated that it will cost 300 million for the 21% of physicians that have more than one state license. Oh money, yea ok that’s the same old hold up every time. Next time they talk about state licensure compacts I am just going to put a dollar sign in my post… you’ll understand.

Circa 1934. Broadcast to Webcast; Radio Technology to Wireless Telegraphy… and now just ‘wireless’. http://www.cio.noaa.gov/rfm/index.html

Frustration was also heard in John’s voice about the FCC Telecommunications Act of 1996. The last Telecommunications act was in 1934, 62 years it took to write a revision, and it looks like it will take another 62 years at the rate they are going! ATA continues to be disappointed in the Act; the FCC estimated there would be a 400 million a year in spending on broadband linking rural healthcare, last year they approved for 200 million. They have only deployed 100 million; only spending a quarter on what the program was supposed to spend- “they need to step up.” Why John? They have 62 years to spend that!

A big note: telemedicine care for post discharge (knee and hip replacements) isn’t expanded out to Physical and Occupational Therapy for Medicare patients. CMS has waived two of Medicare restrictions: allow any Medicare beneficiary to provide services regardless of where they reside but somehow does not include health innovation- “we will be commenting to CMS” and so they did in a letter dated 9/8 strongly urging CMS “…to allow for PT and OT to provide rehabilitation by telehealth means, otherwise covered by Medicare…”

The ATA Fall Forum is next week (9/16-18) in Washington D.C. (and yes I put in D.C. being from Washington state!) with the highest registration rate ever and the exhibits have sold out. They actually have a ATA meeting mobile app for those of us that cannot make it. With a conference that has “Tele” in the name, I see this as the most logical and sensible way to attend.

Posted in: Healthcare Technology, Healthcare transformation, Occupational Therapy, Physical Therapy, Rehabilitation Business, Telemedicine

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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

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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

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

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

Presenters:

Mary Altpeter, PhD

Tiffany Shubert, PhD

Clinical Support for Otago

Clinical Support for Otago

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

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

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

Delivering Otago: Calendar view

Delivering Otago: Calendar view

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

Clinical Barriers to Implementation

Clinical Barriers to Implementing Otago

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

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

6-Stage Behavior Change Model

6-Stage Behavior Change Model

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

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

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

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

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

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

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

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

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

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Get Your Engines Ready for CSM 2015 Indianapolis

CSM2015Marquee_960x222I’m not a physical therapist, healthcare professional, nor do I play one on TV, but I can’t wait for my third American Physical Therapy Association conference. While I’ll be spending most of my time at our booth (2114 if you’re looking) on the exhibition floor, I’ve managed to find a shortlist of 46 sessions I’d like to attend, and this is from someone who is not looking for clinical practice sessions.

Screen Shot 2015-01-27 at 11.10.50 AMNext week over 10,000 physical therapists, doctors of physical therapy, PhD researchers, and students will converge on Indianapolis (yes, in winter) for the annual American Physical Therapy Association Combined Sections Meeting. The Combined Sections Meeting or CSM as it’s often referred to (we do love our acronyms in healthcare) combines all the interest groups and professional associations within the association including private practice, oncology, neurology, homecare, acute care, orthopedics, sports medicine, and students and academic researchers. The result is a diversity of topics that represent the major trends in healthcare today including: concussions in youth sports; the impact of the Affordable Care Act on practice; high-intensity interval training; caring for an aging population; managing chronic disease; preventative medicine, health and wellness; healthcare technology; and the psychology of pain.

See for yourself in a selection of some of the 46 sessions we’ve flagged:

Sports Concussions in Youth: The Role of PT for a Surging Population

Transforming Physical Therapy Practice for Healthcare Reform

Exercise Prescription for the Older Adult With Multiple Chronic Conditions

Getting Patients Into Cardiac Rehab and Other Wellness Programs and Keeping Them Exercising After Rehab

Google Glass in Physical Therapy Education and Clinical Practice

High-Intensity Interval Training: Rehab Considerations for Health and Cardiovascular Risk

Practice Issues Forum: Does Medicare Really Cover Maintenance Therapy?

I Have Arthritis. Is My Running Career Over? Evidence-Based Management of the Runner With Osteoarthritis

Called to Care: Integration of Positive Psychology

Integrating Physical Therapy in Emerging Health Care Models

Virtual Reality and Serious Game-Based Rehabilitation for Injured Service Members

Of course, our most anticipated session will be “Use of Mobile Health Technology to Facilitate Long-Term Engagement in Exercise in Persons with Chronic Neurological Conditions” where Dr. Terry Ellis Director of the Center for Neurorehabilitation and a Associate Professor at Boston University will be presenting the results of a study where they used Wellpepper and Fitbit to improve adherence to home exercise programs for people with Parkinson’s disease. For a sneak preview of what she will present, see this article from Inside Sargent Magazine.

As in 2013 and 2014, we will do our best to blog about as many sessions as we can so that if you can’t make it to the conference this year, you can still experience some of the flavor.

If you’re going to CSM, what sessions are you looking forward to most?

Posted in: Adherence, Aging, Exercise Physiology, Health Regulations, Physical Therapy, Prehabilitation, Rehabilitation Business, Sports Medicine

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Wellpepper’s Top Healthcare Blog Posts of 2014

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

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

Misfit Shine

Jewelry? Hmm.

A Tale of Two Sensors: Misfit Shine vs FitBit Zip

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

The Future of Mobile Health is Like a Warm Marshmallow

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

Forging Ahead With Telehealth: A Roadmap for Physical Therapists

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

Healthcare Is Part Of Our Supply Chain: The Boeing Company

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

Post or Perish: Disseminating Scientific Research and the Kardashian Index

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

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

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Support for Telemedicine in Rehabilitation

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

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

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

Instead what they showed was:

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

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

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

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

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

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

Patient benefits

Telemed costs

 

 

 

 

 

 

 

 

Benefits that the team saw were:

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

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

 

Tele-rehabilitation: A New Frontier In Geriatric Rehabilitation”

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

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

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

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

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

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Cautious Optimism In Spinal Cord Research: The Model T Stage

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

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

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

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

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

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

Man walking in exoskeleton

Man walking in exoskeleton

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

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

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

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

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

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

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

Posted in: Healthcare Disruption, Healthcare Technology, Rehabilitation Business

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Should Patients set SMART or MEANING(ful) Goals?

Goal setting provides incentive, improves adherence, and helps measure progress. Right? Maybe. Presenters in the session “Goal Setting in Rehabilitation: Theory, Practice, Evidence” at the annual American Congress of Rehabilitation Medicine conference in Toronto were consistent in their believe that goal setting is important for rehabilitation but also pointed out a lack of evidence and a distinct lack of consistency in application. It seems that goal setting theory in healthcare has been largely borrowed from business and sports, and while it makes sense that goal setting should help patients, there is not a lot of decisive evidence and there is a lot of debate on how goals should be set.

Does goal setting work?

A survey of the clinical research on goal-setting in rehabilitation showed that goal setting didn’t improve physical function, however it did improve patient self-efficacy. Evidence was inconclusive on whether goal setting affected motivation, adherence, or engagement. However, the overall analysis showed a statistically significant difference in favor of goal setting. The issue is how goals are set and could setting them differently improve care.

How are goals set?

Currently the usual care condition for setting goals is having healthcare professionals set them instead of patients. The problem with this is that the goals may be SMART, but they are not meaningful for the patients. There is often a mismatch between patient and physician goals: physician goals are often functional goals and patient goals are quality of life or aspirational goals. Since goal seems to have a bigger impact on intrinsic factors, like efficacy and possibly also satisfaction, it seems that patient-directed goals would be more effective.

The following are “SMART goals” adapted to apply in rehabilitation. However, the speakers adapted them slightly to apply more directly to rehabilitation. (Assignable rather than achievable.)

Specific, measurable, assignable, realistic, time bound
 
 

How should goals be set?

Goals that help a patient connect with their care plan are preferred, for example, goals that fit the following criteria.

MEANING goal setting

 

While presenter Kath McPherson from the Auckland Institute of Technology argued that patient goals could be vague and also asked why goals had to be realistic: wasn’t it better that the patient continued to hope and work towards something, William M. M. Levack the concept of helping patients set “fiduciary” goals. That is, guide the patients goals based on the situation more initially and less as the patient gained autonomy. To illustrate this he used the example of Mr Roberts a blind diabetic amputee who had a goal of going home to live. If Mr. Roberts’ goal were the only thing taken into consideration, it would ignore the realistic factors that might not make this possible, for example, his wife’s ability to care for him. As such, a better approach for goal setting for Mr. Roberts was to consider a number of factors including:

  • The values and preferences of the patient
  • Clinical judgment of the healthcare professional
  • Time and resources required for the goal
  • Likely consequences of pursuing the goal

For Mr. Roberts, this approach would look like this:

value pluralism in goal setting

The takeaway from these sessions was the necessity to link the clinicians small functional goals with the patients big aspirational goals. Functional goals are necessary and will measure progress but aspirational goals are what drives patient self efficacy which is so important for recovery.

 

We think a lot about goal setting and patient reported outcomes at Wellpepper. Patient reported outcomes are great tools to show progress and also validate clinical efficacy but they must be linked to patient’s goals for real impact. We’re working on some interesting ways to do this through our technology and are excited to be able to share this with the rehabilitation medicine community.

Posted in: Adherence, Behavior Change, Healthcare motivation, Healthcare transformation, Occupational Therapy, Rehabilitation Business

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

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

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

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

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

The Problem with Information Dissemination

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

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

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

Barriers to Implementing New Methods from Research

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

Barriers can include:

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

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

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

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

Organizational Barriers

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

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

So should we give up?

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

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

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

Methods that won’t effect change

  • Pamphlets
  • Total quality measures
  • Lectures

Methods that will effect some change

  • Patient driven or mediated
  • Conferences

Methods that will effect real change

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

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

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

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

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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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APTA 2014 Session Recap: The Success of the Profession Lies in the Consumer: Who Are They?

This post is part of our recap from attending the American Physical Therapy Association Combined Sections Meeting in Las Vegas Feb. 3-6.

Speakers:

Andy Lodato, MPT

Jerry Durham, PT

This session from Jerry Durham, cofounder of San Francisco Spine and Sport and Andy Lodato, cofounder of PhysioCarePT in the Private Practice section explored how the business of physical therapy needs to consider patients as consumers first, even in states where patients do not have direct access to physical therapy. The patient as consumer is a popular theme in healthcare these days, as high-deductible plans increase out-of-pocket costs and make patients more discerning about the cost-value relationship in their care, and many of the ideas in the session were appropriate to both private practice and hospital outpatient settings.

The session began with Andy talking about how he and his business partners transformed their business from the early days when they “said yes to everyone”, that is they accepted every patient even if the terms of that patients insurance caused them to operate at a loss. While this may seem like a great thing to do for patients, they also weren’t discerning in whether they accepted patients that appreciated the value that PhysioCarePT provided. This devalued their brand promise. Now Andy and team target the “conscious consumer”: the patient that connects with the value that Physiocare provides. Andy also talked about how the profession is so focused on measuring patient outcomes but does not measure business outcomes. His business turned around when he started applying this same rigor to the business.

After taking this approach, Andy and his partners started actively targeting patients that would appreciate the value that Physiocare provided. He works in an extremely competitive market, however, also a market that has a well-educated, athletic, and well-insured patient base.

Andy outlined some of the ways in which he and his staff cultivate relationships with patients as consumers. All of the physical therapists at the clinic are expected to network and market the value of the services they offer. Here are some of the ways they do that:

  • They share infrequently on Facebook: only when they have something important to say, for example, the most successful Facebook campaign included a pair of Nike running shoes designed  with the custom colors of PhysioCare’s branding. This attracted the most likes and shares of any campaign.
  • Similar to other best practices we’ve written about, PhysioCare created a “Solemate’s Running Group” that meets weekly. This serves two purposes, it shows patients that you care about their goals, and also keeps you top of mind when injuries occur, as they do for the majority of runners.
  • PhysioCare offers community lectures on topics like whether young ballerinas are ready to dance on point, corporate fitness programs, the right way to carry a baby to prevent back injuries. These events are a pure community service but also establish PhysioCare PTs as experts in topics “conscious consumers” care about.

Andy talked a bit about referrals from doctors, often a contentious topic: should you market to the doctors or their patients? First off, Andy said he never buys lunch, referring to the practice of sending gifts to doctor’s offices, he works on establishing a mutually beneficial relationship. He works with a group of 7 surgeons who refer patients to him, while his team refers patients to them if they think they require surgery. Surgeons would rather spend their time with patients who require surgery, so this provides them with well-qualified leads. Andy considered the relationship a success as his team had not even met some of the surgeons who had been referring patients back and forth.

Next up was the eminently tweetable Jerry Durham. The person beside me said that the whole profession would be moved forward if you could bottle Jerry. Jerry also has a “no lunches” policy. He wants to place his business in the center of a healthcare team, including doctors, nurses, nutritionists, and physical therapists. Sending over lunch devalues his organization as part of the team. (Disclosure, I once bought Jerry lunch: won’t be doing that again. 😉 )

While Jerry thinks constantly about the patient experience from the first contact with his office through billing, he does admit to marketing to the providers for referrals. However, similar to Andy, he also thinks about targeting the right type of “provider consumer” that is, a referring doctor who understands the value that a physical therapist can offer to the patient’s recovery or in preventing injuries. He focuses on what’s most important to these providers and to their patients, and makes sure his team delivers on it, and surprisingly, outcomes are often not the most important thing for patients.

He cited some basic things that make the difference to the patient:

None of these things have anything to do with outcomes or how knowledgable the physical therapist is. As Jerry puts it “outcomes are not a value proposition.” Patients expect outcomes, how they value the care they receive is comprised of a myriad of other factors. Do you know what your patients value?

Here’s a selection of our tweets from the session.

Tweets from the APTA Conference

Posted in: Healthcare Disruption, Rehabilitation Business

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You Too Can Be An Orthopedic Surgeon

This past weekend I performed arthroscopic surgery on a knee and extracted a sponge that was clogging up the joint. Sounds scary doesn’t it? It was great fun, part of the open house at UW Medicine’s new Sports Medicine Center at Husky Stadium in Seattle. The newly opened clinic has been operating for about a month, but this was an opportunity for the general public to see what it was all about.

The open house was framed around a “Passport to Health” and participants visited various stations staffed by doctors, physical therapists, and radiologists. At each stop, experts explained procedures and benefits, and answered questions from attendees. Volunteers from some of the UW sports teams acted as guinea pigs for some of the treatments.

Specialties in the clinic and stops along the tour included:

 

    • Anti-gravity treadmill

      Anti-gravity treadmill

      Dr. Ashwin Rao explaining platelet-rich plasma therapy

      Dr. Ashwin Rao explaining platelet-rich plasma therapy

      Running Medicine: Here we saw how the anti-gravity treadmill can help both running performance and rehabilitation.

    • Sports Performance and Rehabilitation: In the “gym” area of the center, physical therapists discussed how they help improve performance and restore function using exercise and equipment including a full Pilates set up.
    • Soft-tissue Injuries: The focus was on preventative measures and bringing people back to full performance.
    • MSK Ultrasound: Ultrasound technology has come a long way from fuzzy gray images. In this session we saw how ultrasound can be used to access and diagnose nerve damage using Doppler technology to show nerves and blood vessels.
Dr Elena Jelsing demonstrating MSK Ultrasound

Dr Elena Jelsing demonstrating MSK Ultrasound

  • Platelet Rich Plasma: This technique involves injecting a patient’s plasma back into a troubled area to help repair and regenerate cells. It’s particularly helpful for nagging tendon injuries, although physical therapy is recommended first if it’s an acute injury.
  • Minimally Invasive Surgery (Knee and Shoulder demonstrations): I don’t want to say this was the most fun, but it was, as participants were guided in performing arthroscopy surgery on a dummy knee or shoulder joint.
  • Sudden Cardiac Arrest: The focus of this stop was prevention. Young athletes are at the highest risk for sudden cardiac arrest and UW is leading the way by offering screenings to high school teams around Puget Sound.
Shoulder Surgery Dummy

Shoulder Surgery Dummy

Visitor performing shoulder surgery

Visitor performing shoulder surgery

In some cases, tour participants received minor consultations, like one woman who had an MSK ultrasound. In addition to providing education and showcasing the clinic’s staff and new technologies, the event generated new patients for the clinic. The tour conveniently ended at reception where many people were seen booking appointments.

The opening of a new clinic like UW Sports Medicine at Husky Stadium provides the perfect time to engage patients. However, maybe adding a new service or technology could provide you with the opportunity to invite the public in for a tour of your facilities. Or maybe it’s a patient appreciation thank-you event. Any opportunity to engage with patients is an opportunity to help educate them to take charge of their own health, and let them know that you’re there when they need help.

Posted in: Exercise Physiology, Rehabilitation Business, Sports Medicine

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