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Patient engagement and design in the art of medicine

Patient engagement is controversial for many physicians because it interferes with the traditional values that arise from the several hundred-year old guild of medicine. Per the NEJM Catalyst Insights Council, patient engagement is characterized as patients interested in participating in choices about their health care, taking ownership of those choices, and having an active role in improving their outcomes. Given the current epidemiology of chronic diseases, it is not surprising that many patients have low levels of engagement as well as health literacy. As someone who is preoccupied with the diagnosis and treatment of diseases, it is difficult for me to view any problem solving from the patient’s lens; yet, I know through the literature and intuitively that how patients feel impacts their outcomes. The following are a few of the things I have learned and will work on as I improve my ability to deliver care:

  • Time = effectiveness Opinions of clinicians and leaders in patient care have determined that increased patient time with a health care team lends to increased engagement. A basic concept in human dynamics is that the mere exposure to someone over time is enough to start an unlikely relationship. Tack onto that high quality communication and understanding nuances of healthcare literacy, and you have a more engaged patient. In modern medicine, this would be accomplished through a multidisciplinary team effort. This task is challenging given the constraints of our current healthcare system. Could I increase time with patients through mobile technology? If there was an automated way for me or another care team provider to connect with patients via text or a quick phone call at specific intervals, I would be able to increase exposure and augment time.
  • Shared decision making is key Another finding of the NEJM Catalyst is that shared decision making is one of the most effective strategies in improving engagement. We learn about this academically through the interpretative model (as opposed to paternalistic, etc.) of provider-patient relations; but this is also just common sense. I like to think this gives patients a sense of control, a sense of choice in a matter, where frankly, a lot make be out of your control. We are also better able to accept the consequences of the decisions we make, rather than the ones that are placed upon us. One of the reasons that UNICEF has been effective in helping children around the world is from the core guiding principle that children inherently have rights. American political views are reflected in the current model of access, but I would like to practice medicine with the belief that patients have inherent rights. It is a slippery slope because patients’ actions can be counterproductive to their health – but my preference is still to protect patient autonomy.
  • Technology alone cannot solve the problem The concept of remote monitoring with wireless devices doesn’t appear to improve chronic disease management or outcomes. Technology alone cannot solve a dilemma in a people’s “business”. I would opt to use adaptive technologies that improve my relationship and sense of connectedness to the patient over technology that would offer mostly education or content to the patient. The idea of people taking ownership for a difficult problem is non-trivial. It requires motivation at a level that is primarily internal. How do you access that in people? In the self-help world, the most effective motivational coaches tend to elicit a hyper-emotional state in people along with placing a high premium on discipline. I think it’s logical to work on building a relationship, connecting, allowing a safe space for vulnerability, and witnessing the struggle to achieve begin from that foundation. While patient engagement is primarily a patient responsibility, I think providers have a responsibility to elicit patient activation as this directly affects outcomes.
  • Design-thinking can help When Indra Nooyi became the CEO of Pepsi, one of her top priorities was to explore her staff’s beliefs on the concept of design. She asked business executives to take photographs of anything that they believed constituted design. After such an abstract request, she noticed that not only did people not care to complete the assignment, that some had even hired professional photographers to complete the task. My interpretation of this story is that she believes that there is an artistic aspect in the most unsuspecting of transactions. According to IDEO, human-centered-design is about building a deep empathy with the people you are designing for. In the process of being inspired, ideating, and implementing, a design researcher explores the texture and what matters most to a person before execution of a solution. How is this any different from delivering empathetic, tailored care to a patient? What we do well in medicine, some of the time, is already done at a higher level of sophistication in the real world outside of our clinics and hospitals. While design-centric thinking may lead to innovations in healthcare, for the provider I think the greatest advantage is that you amplify the relationship you have with the patient and increase overall engagement.

Whether it’s the creation of something that didn’t exist before or making decisions that are influenced by intuition, everyone is at one level involved in artwork. Improving patient engagement particularly with design-centric thinking would bring more value and meaning to the art of medicine, a skill I look forward to building throughout my career.

Posted in: Behavior Change, Healthcare transformation, patient engagement

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Comprehensiveness + Comprehension: effect of technology on discharge instructions

Whether patients are leaving the emergency department or being released from an extensive hospitalization, they need discharge instructions in order to solve their initial problem, better self-manage, and coordinate the appropriate follow-up. These instructions are typically written and are also articulated to the patient. We know that due to varying levels of health literacy, or the degree to which individuals have the capacity to process and understand basic health information needed to make appropriate health decisions [1], a patient is especially vulnerable during the process of discharge in terms of overall understanding and appropriate follow through. Can technology empower patients operating from a position of weakness in this transition?

  • According to the 2013 study entitled Information Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality Measure, researchers were able to show that electronic discharge instructions were more complete than paper-based information. The electronic discharge instructions had 97.3% compliance to a CMS quality measure while the paper-based discharge instructions were at 46.7%. This compliance is more than doubled with electronic discharge documentation (relative risk 2.09, 95%CI 1.75-2.48) [2]; however, there were no statistically significant differences in documentation of patient care instructions nor diagnosis between paper-based and electronic formats.
  • In a 2015 study entitled Readability of patient discharge instructions with and without the use of electronically available disease-specific templates, patient readability of a web based discharge module, which has diagnosis-specific templated discharge instructions, was assessed. Patients had better readability with electronic templated discharge instructions than those that were clinician-generated (p< .001). Furthermore, the primary reason doctors created discharge instructions by themselves was due to lack of disease specific template availability.

The most exciting time in medicine is now, where the application of information technology during vulnerable transitions can provide a patient more complete information that he/she can actually act upon. Taken together, these studies suggest enhancement of both comprehensiveness and comprehension; the former very important for the primary care physician who will assume care of this patient status post hospitalization and the latter important for the patient’s overall health literacy necessary for improvement. The next logical extension is to have web based applications assist a patient in the transition from the hospital to the outpatient setting, something that innovative companies like Wellpepper are doing.

References

  1. Nielsen-Bohlman, L.; Panzer, AM.; Kindig, DA. Health literacy: A prescription to end confusion. National Academies Press; Washington, DC: 2004.
  2. Bell EJ et al. Information Technology Improves Emergency Department Patient Discharge Instructions Completeness and Performance on a National Quality Measure: A Quasi-Experimental Study. Appl Clin Inform. 2013; 4(4): 499–514.
  3. Mueller SK et al. Readability of patient discharge instructions with and without the use of electronically available disease-specific templates. J Am Med Inform Assoc. 2015; 22(4): 857-63.

Posted in: Healthcare Technology, Patient Satisfaction

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Wellpepper attends Episodes of Care Summit at Cambia Grove

Last week, Wellpepper CEO, Anne Weiler and I attended a half-day Episodes of Care Summit put on by Cambia Grove. It was great to see payers, providers and technologists come together to focus on initiatives that directly impact the patient experience. Here are some of our takeaways:

Horizon BCBS of New Jersey is an episodes of care pioneer

Focus on retroactive bundles before proactive. Episodes of care and bundled payments are often used interchangeably. An episode of care typically refers to a payment made retrospectively while a bundled payment typically refers to a payment made prospectively. Horizon BCBS of New Jersey first launched retrospective pilots in 2010 (total hip and total knee replacements). In this model, savings are shared with the physician or practice once quality benchmarks and patient experience thresholds are met and costs come in below budget. After 7 years of scale and success, Horizon is now launching more immediate, risk-based, prospective initiatives in 2017.

Drive success through quality. Horizon piloted with over 200 quality metrics with member-specific, risk-adjusted financial targets. Metrics are key in driving success. Identify 3-5 standard quality metrics and 2-4 episode-specific metrics.

Community involvement is imperative

It’s great to see continued focus on community involvement in innovation and healthcare. The Bree Collaborative is an excellent example of bringing together community and industry leaders to identify and promote strategies that directly impact patient outcomes, quality and affordability. Wellpepper firmly believes in the work that the Bree Collaborative is doing. In fact, our total joint and lumbar fusion care plans follow Bree recommendations.

The Episodes of Care Summit held breakout sessions that mapped out the ideal episode of care/bundle experience through the lens of people, process and technology. Think of people, process and technology as a three-legged table. Remove one leg and the table falls. If the three legs are not the same size, the table does not function properly. Effort needs to be allocated equally across people, processes and technology to drive behavior change. Reimbursement seemed to take a precedence in every conversation rather than the patient’s needs or the provider’s care. Until this mindset is fixed, it’s hard to focus on what healthcare is really about. Dr. Hugh Stanley, from the Bree Collaborative did an excellent job bringing the focus of the conversation back to the patient.

Memorable quotes from breakout sessions:

  • “Patients need to be at the center of episodes of care.”
  • “We need to capture patient satisfaction in real time.”
  • “I’m blown away I can get more info on a dog bed than a provider.”
  • “We need to rebuild the patient deductible and copay mindset.”
  • “The payer community has a responsibility to share information to publicize data that drives provider readiness.”
  • “Creating episodes vs bundles benefits providers and ultimately patients.”

Posted in: Healthcare Policy, Healthcare Technology, Healthcare transformation, patient engagement, Patient Satisfaction, Uncategorized

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Patients As Designers Of Their Own Health

Seattle’s grassroots healthcare community continues to gain traction with a new meetup for patient-centered design. Last week’s meeting was generously sponsored by MCG a subsidiary of Hearst Publications who are quite active in the healthcare world with content and education. The panel discussion featured Dana Lewis, a patient-maker who is active in the open source movement for diabetes care and built her own artificial pancreas, Christina Berry-White from the digital health group at Seattle Children’s, and Amy London, Innovation Specialist at Virginia Mason. The group talked about how to effectively get feedback from patients, and how patient hackers like Dana can take poor design into their own hands build tools they need, and ultimately influence large healthcare companies, in this case device manufacturers.

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Dana, Christina, and Amy, photo credit Alina Serebryany

The panel had great advice for understanding and developing products and improving processes for patients, as well as for soliciting feedback from patients. Here are a few of my takeaways.

Tips for developing products and process

  • Understand patient’s goals and desires. Often the goals of the hospital or health system are not the same as the patient’s. After meeting with a group of patient advocates one Virginia Mason surgeon realized that the only outcome that really mattered was whether the patient had a positive experience.
  • Let patients customize their views and experiences. Amy talked about a particular chart where she wanted to see the graph rising to show increasing blood sugar and another user she talked to wanted to see the graph lowering to show insulin lowering and a need for intervention. Amy was confused by this view but created her open source artificial pancreas interface to enables people to choose their own view, and the result was that people who had diabetes looked at it the same way Amy did and parent-caregivers of diabetic children wanted the second view. Which brings us to the next point–
  • Differentiate between users. Patients often have different requirements than their caregivers, whether that’s parents caring for a child or teen, or adult children caring for a parent. As well, the clinical workflow shouldn’t dictate the patient experience.
  • Get feedback early. Amy mentioned meeting with a device manufacturer who showed her an almost ready for release glucometer that was intended to fit in the pocket. She quipped “you obviously didn’t test this with women’s pockets.”

Tips for collecting feedback

  • Build it into the product. Christina from Children’s mentioned that when they switched from reams of paper to an iPad-based tool for patient on-boarding forms the physicians wanted to stop using it because it did not immediately integrate with the EMR. Luckily the tool had a feature to survey users on whether they preferred using it to paper, and the answer from parents was overwhelmingly yes. The digital health team showed these results to the physicians, and the tool stayed in place.
  • Be creative when soliciting feedback. Children’s knew from experience that parents and patients were reluctant to give them negative feedback after a lifesaving experience like an organ transplant, so they used techniques that are often used in brand market research: analogies. For example, they asked teens to describe a digital tool as a car, and found out that their tool was like a pick-up truck to them: useful but utilitarian.
  • Use patients to collect feedback. Patients are also often intimidated to provide direct feedback to healthcare professionals as they see them as authority figures. At Virginia Mason patients who have already had a successful joint replacement visit post-surgical patients to find out how they are doing, and talk about their own experiences. Patients are a lot more candid with each other, and Virginia Mason was able to benefit from understanding the questions they asked the peer ambassadors and incorporate that information into formal programs.
  • Ask the questions at the right time. If you want to understand post-operative experiences ask within a few weeks of the actual experience, not 6 months later.
  • Be aware of selection bias. Patients who volunteer for focus groups are often those who have the time and money to be able to do so. Your feedback may be skewed towards retired patients, and those who are not hourly workers. Consider how you will cast a wide net.

Lots of great advice at this event, much of which we already incorporate into our processes and products at Wellpepper, although I definitely got some new ideas and it’s great to see the community coming together to share best practices. My only disappointment with the event was that with a title of Patients as Designers, I expected to see more patients on the panel. While there was a last minute cancellation of a patient-maker, it would have been amazing to have Children’s and Virginia Mason bring one of their patient-designers to be on the panel. Maybe next time?

Posted in: Healthcare Disruption, Healthcare Research, Healthcare Technology, Healthcare transformation, Lean Healthcare, Research, 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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Resolve to Create Better Resolutions!

Tis the season to regret all the cookies, chocolate, and rich foods you ate over the last few weeks and start the New Year off right! Resolution time is here. Do you make them? Do you think they work? Do you incorporate behavioral change methods in your resolutions? Simply deciding to do something new or stop doing something old without making corresponding changes in your ability to do so will not have the impact you’re looking for.

There are three key factors that facilitate behavior change:

  1. You have to have the capability to change.
  2. You have to have the motivation or desire to change.
  3. You have to have the opportunity to change.

If these three conditions exist, you can change. So let’s say your goal for 2014 is to sit less. However, you have a job where you sit at a computer all day, and while you know that sitting is not good for you, you like your job and quite frankly your family and mortgage like your job too. You might be motivated to sit less but unless your employer supports you in this desire for example by helping you install a standing or treadmill desk, or removing all the chairs from the conference rooms, you might not have the capability to change. Or let’s say you want to walk to work but your office is 20 miles from your home in an industrial park off a freeway. Again you might have the motivation, but not the opportunity unless you are able to change jobs.

Picture of cocktail

Cocktail source: Steamykitchen.com

One year I decided that I had become old before my time (in my pajamas by 9 on a Friday, if you must know), and I made three resolutions:

  1. Drink more cocktails
  2. See more films
  3. Go to more art galleries.

Now, you’re thinking, these don’t sound like good New Year’s resolutions, but according to the factors that facilitate behavior change, I was on the right track. I had disposable income, single friends, and lived in a large metropolitan area with plenty of theatres and art galleries. Friends were more than happy to help me keep these resolutions, and I got out of my hermit-like funk and was inspired by connecting with people, the vibrancy of the city, and by art.

If you need some help designing your resolutions, first off use the simple framework. Are you capable? Are you motivated? Do you have the opportunity to make the change? If any of these is no, consider whether these factors can change. This video by behavior change expert, BJ Fogg can also help you break it down to something that is manageable.

Finally, get help! Studies show that even if friends of your friends are obese, you have a greater chance of being overweight. The same is true with positive behavior. As a long time “left-coast” dweller, I can attest to the positive transformation that happens when people move here and are surrounded by those with an active lifestyle. Get some friends together who are working towards the same goal. Start a walking group at work. Employee wellness was one of the hot topics of 2013, and while some of the promise of employer-organized wellness programs have not come to fruition, there are simple things that employees and employers can do to facilitate change. We loved these examples from the BUPA HQ in London. If any employee has the motivation, the company facilitates the opportunity.

Eat more fruit!

Eat more fruit!

Take the stairs!

Take the stairs!

Psst. Over here!

Psst. Over here!

Best in 2014 from all of us at Wellpepper for a healthy and happy year!

Posted in: Behavior Change, Healthcare motivation

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