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Simple Patient-Centered Design

At Wellpepper, we work hard to make sure our software is intuitive, including working with external academic researchers on randomized control trials for people who may have cognitive or other disabilities. This is both to make sure our software is easy-to-use for all abilities, and to overcome a frequent bias we hear about older people not being able to use applications, and also to provide valuable feedback. We’ve found from these studies, the results of which will be published shortly in peer-reviewed journals, that software can be designed for long-term adherence, and this adherence to programs can lead to clinically-meaningful patient outcome improvements.

User-centered design relies on three principles, all of which can be practiced easily, but require continual discipline to practice. It’s easy to assume you know how your users or patients will react either based on your own experiences, or based on prior knowledge. There’s really no substitute for direct experience though. When we practice user-centered design, we think about things from three aspects:

Immersion

Place ourselves in the full experience through the eyes of the user. This is possibly the most powerful way to impact user-centered design, but sometimes the most difficult. Virtual reality is proving to be a great way to experience immersion. At the Kaiser Permanente Center For Total Health in Washington, DC, participants experience a virtual reality tour by a homeless man showing where he sleeps and spends his days. It’s very powerful to be right there with him. While this is definitely a deep-dive immersion experience, there are other ways like these physical therapy students who learned what it was like to age through simple simulations like braces, and crutches. Changing the font size on your screens can be a really easy way to see whether your solution is useable by those with less than 20/20 vision. With many technology solutions being built by young teams, immersion can be a very powerful tool for usable and accessible software.

Observation

Carefully watch and examine what people are actually doing. It can be really difficult to do this without jumping in and explaining how to use your solution. An interesting way to get started with observation is to start before you start building a solution: go and visit your end-user’s environment and take notes, video, and pictures.

Understanding what is around them when they are using your solution may give you much greater insight. When possible we try to visit the clinic before a deployment of Wellpepper. Simple things like whether wifi is available, how busy the waiting room is, and who is initiating conversations with patients can help us understand how to better build administrative tools that fit into the clinician’s workflow. Once you’ve started with observing your users where they will use your solution, the next step is to have them test what you’ve built. Again, it doesn’t have to be complicated. Starting with asking them how they think they would use paper wireframes or voice interface testing with Wizard of Oz scenarios can get you early feedback before you become too attached to your creations.

Conversation

Accurately capture conversations and personal stories. The personal stories will give you insight into what’s important to your users, and also uncover things that you can’t possibly know just by looking at usage data. Conversations can help you with this. The great thing about conversations is that they are an easy way to share feedback with team members who can’t be there, and personal stories help your team converge around personas. We’ve found personal stories to be really helpful in thinking about software design, in particular understanding how to capture those personal stories from patients right in the software by letting them set and track progress against their own personal goals.

Doctor’s often talk about how becoming a patient or becoming a care-giver for a loved one changes their experiences of healthcare and makes them better doctors. This is truly user-centered design, but deeply personal experience is not the only way to learn.

To learn more:

Check out the work Bon Ku, MD is doing at Jefferson University Hospital teaching design to physicians.

Visit the Kaiser Permanente Innovation Center.

Learn about our research with Boston University and Harvard to show patient adherence and outcome improvements.

Read these books from physicians who became patients.
In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope, Rana Adwish, MD
When Breath Becomes Air Paul Kalanithi, MD

Posted in: Adherence, Aging, Behavior Change, Clinical Research, Healthcare Technology, Healthcare transformation, patient engagement, Patient Satisfaction, Research

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Our Picks for HIMSS17

himss17-exhibitor-ad-design-300x250-copyHIMSS17 is right around the corner and we at Wellpepper have a lot to be excited about! By empowering and engaging patients, deriving insight from the data we collect, and delivering new value to clinical users without major disruption to existing clinical workflows, we can continue to improve outcomes and lower costs of care. At HIMSS17, we look forward to connecting with friends, partners, colleagues and industry leaders to continue the journey towards an amazing patient experience.

Sessions that we look forward to:

Our CEO and co-founder, Anne Weiler, will be speaking at 2 sessions:

  • Anne will be a featured speaker at the Venture+ Forum, where former competition winners will be sharing how their business has grown, lessons learned and plans for the future. Since being named a winner of the 2015 Venture+ Forum Pitch competition, Wellpepper has continued to bridge the gap between the patient and care team and we are excited to share our progress and vision.
  • Anne will also be presenting a session titled, Designing Empathetic Care Through Telehealth for Seniors, which will explore the role of design-thinking in design empathetic applications to deliver remote care for seniors based on studies completed by Boston University and researchers from Harvard Medical School.

Patient engagement expert Jan Oldenburg, who was featured in our August 2016 webinar, will be speaking at 2 sessions:

  • Jan will be presenting a session titled, The “P” is for Participation, Partnering and Empowerment. This session will highlight what it takes to create a truly participatory healthcare system that incorporates patients and caregivers, using digital health technology to reinforce and support participatory frameworks.
  • Jan will also be presenting a session titled, Importance of Narrative: Open Notes, Patient Stories, Human Connections. This session will focus on how Open Notes enhance the patient’s narrative of their journey through their condition and how this both strengthens the patient-physician relationship and empowers patients to take charge of their illness and wellness.

Christopher Ross, Chief Information Officer at Mayo Clinic will be leading a session on Emerging Impacts of Artificial Intelligence on Healthcare IT. This session will discuss how the advancement of Artificial Intelligence (AI) and Machine Learning (ML) are having a profound impact on how insights are generated from healthcare data.

Posted in: big data, M-health, patient engagement

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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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Every Patient Has a Story

I have just returned from my first Beryl Institute Patient Experience Conference 2016 (PX2016), and I’m inspired. At Wellpepper, we are focused on empowering the patient to feel ownership and accountability to participate in their healthcare journey. The Beryl Institute and their members are doing the same and it was great to connect with so many like-minded people. The PX2016 conference is just one way they bring together this community.

PX2016 is 6 years young and attended by mostly caregivers, nurses, doctors, regular people who were touched by a personal health experience and now are in the field, and patients. With only 1000 attendees, it’s possible to form relationships. There was lots of hugging, sharing, pictures and overall excitement to be in Dallas. I met several newbies and like me, they were inspired too.

The conference opened up with a real life patient story. Les, a heart attack survivor, told his story of how he was participating in a sculling exercise and went into cardiac arrest in the middle of the water. The following chain of events happened that allowed him to be standing in front of us to tell his story. A retired nurse was on board and jumped into action to do CPR (she was filling in for her friend who couldn’t make it), the bowman had his cell phone to call 911 (typically he doesn’t bring it on the boat), another rower in his own boat happened to be near the dock gate and had a key to unlock the gate (usually locked because it was 5:30AM) which allowed the paramedics to get to Les. If there was one break in that chain, Les would not be with us. He went on to share his experience about his care at UCLA Medical Center and how every touch point from the people on the boat, to paramedics, to the care team made a difference in his recovery. By this time, there was not a dry eye in the place. It was all about why we in this profession of healthcare really do want to make a difference in the patient experience.

This lead to the theme that every patient has a story. From the other keynotes to the sessions I attended, this theme was pervasive. The focus of PX 2016 is to share stories, best practices and ideas on how to bring together interactions, culture and perceptions across the continuum of care.

In the session, Removing Complexity from the Post-Acute Care Patient (one of our passions at Wellpepper), it became clear that the long term care model needs to be reinvented for simplicity. True simplicity comes from matching the patient’s experience with the patient’s expectations. As an example, The New Jewish Home is renaming its post-acute rehabilitation to The Rapid Recovering Center which supports setting a different tone for the patient and ultimately in their experience. When a patient is sent to a post-acute rehabilitation center it can suggest a long and difficult recovery. But, naming it the Rapid Recovery Center aligns with the patient’s expectation of wanting to get better as soon as possible.

Another session that hit close to Wellpepper’s core values was how University of Chicago puts family and patients first in their patient experience strategy. Enhancing Patient Experience and Engagement through Technology Innovation by Sue Murphy, RN, Executive Director- Patient Experience and Engagement Program and Dr. Alison Tothy, Associate CMO – Patient Experience and Engagement Program at University of Chicago suggest the ability to capture real-time opportunities for engaging patients in their care and in their service expectations with innovative technology and techniques can lead to overall happier patients. Such technologies like rounding, discharge call centers and interactive patient care have led to substantial outcome improvements. However, just implementing technology did not solve the patient experience challenge. A culture shift in the staff was required which inspired them focus on individualized care for each patient. Combining a culture shift with innovative technology has allowed the University of Chicago to increase patient satisfaction scores, reduce readmission rates and improve outcomes. Furthermore, leadership is engaged and excited about the power of technology to improve the patient experience.

To bring it to a close, we were inspired by another personal patient story from Kelly Corrigan. She is a New York Times best-selling author who shares her most personal stories, including her health challenges. She has had more than her share of health encounters between herself and her family. She read an excerpt from her book, The Middle Place, where her and her Dad where both diagnosed with cancer in the same year. It was a compassionate and funny rendition of when she just starting her chemotherapy sessions and her Dad came across country for support. She talked about how in the middle of crisis, magnificent can happen. She was amazed to witness how all the people around her, including herself, able to conform into the new reality – cancer. Although a happy ending for her, not so much for her father. He passed away last year. She emphasized how at the end of her father’s journey, she made a point to thank all the caregivers for they really did make a difference in a very difficult time. Then looking out at all of us in the audience at that moment, almost with a tone of authority, she challenged us to hold on to the feelings of why we went into healthcare.

For some of us, it was a personal experience. For others, it was the opportunity to make a difference. Regardless, as Kelly so eloquently put it, people want to feel as if they have been felt and be a good listener because every patient has a story.

Posted in: Behavior Change, chronic disease, Healthcare transformation, Managing Chronic Disease, patient engagement, Patient Satisfaction

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Disruptive Innovation to Improve Mental Health Care

Health Innovators Collaborative, University of WA Bioengineering
Dr. Jurgen Unützer, Chair of UW Psychiatry and Behavioral Sciences

The Health Innovators Collaborative seminar that I attend last week by Dr. Unutzer gave me an emotional whirlwind, which is ironic because the subject was mental health. That afternoon I innocently put my boots on and galloped down to the university in my VW Beetle and waited for the seminar to begin by eating an apple in the front row. I had no idea what was in store for me in the next 60 minutes or so. I would have cowardly slumped down into my chair if this was a talk taking place outside of Washington… because I am so ashamed about how we brush our mental illness folks under the rug. My jaw almost dropped in shock; we are ranked 48 out of 51 to have the correct resources available for our mentally ill with only 20 psychiatrists in Rural Washington. Dr. Unutzer argued that we spend more money on preventing auto accidents and homicide, when the rate of suicide is much higher- there is a suicide every 15 minutes in our country and 2-3 a day in Washington.

IMPACT- Collaborative Care Model

After giving us such somber news he talked at great lengths about ‘working smarter’ in order to close the gap of inadequate mental health professionals. One of the largest treatment trials for depression, Improving Mood–Promoting Access to Collaborative Treatment (IMPACT) was spearheaded by Dr. Unutzer and his colleagues. They designed IMPACT to function in two ways; “The patient’s primary care physician works with a mental health care manager (can be a mental health nurse, social worker etc.) to develop and implement a treatment and the mental health care manager and primary care provider consult with psychiatrist to change treatment plans if patients do not improve.” The IMPACT study was started over 15 years ago when the use of EMRs and video conferencing were just starting to become ‘mainstream’. Therefore in a way this study was the forerunner in utilizing a multi-based ‘high tech’ mental health patient care platform; population registry/database (tracking tool of patients PHI, treatments, etc.) psychiatric consultation (video), treatment protocols and outcome measures (I feel I am writing about Wellpepper!). The video consultation takes place between the patient and a remote psychiatrist typically after treatments protocols are administered in the primary cares office with little or no patient improvement. This is imperative especially in Washington where half of the counties don’t have a single psychiatrist or psychologist.

There is a great JAMA article written on the outcomes of the IMPACT program (I am proud to say I did my homework on the positive slides presented and not the slippery slides) that really nails out the particulars in the normal scientific journal fashion. As always I shot to the bottom of such article for the ‘results and conclusions’ because I knew this one was going to be great, I had a sneak peak last Wednesday. After a year 45% of the 1801 patients studied had a 50% or greater reduction in depressive symptoms from baseline compared with 19% of usual care participants! Furthermore this study reduced healthcare costs; $6.50 saved for every $1 invested, with the most being saved in inpatient medical and pharmacy costs. In conclusion having a system that provides population based care, that is patient centered, has target treatment solutions, and is evidence based leads to more efficient modes of getting a patient in and out the door with positive results.

I exhaled what a clever man you are Dr. Unutzer to present your slides in such an order, from negative/scary to positive/uplifting, it’s almost like you are a psychiatrist and now how the mind works, oh wait you are!! Thank you for a wonderful talk, it was superb and always nice to learn something new!

Next seminar is “Bad Language, Worse Outcomes” with Jeremy Stone, MD MBA on November 3.

Posted in: Healthcare Disruption, Healthcare Research, Healthcare Technology, Healthcare transformation, Interoperability, Outcomes, Seattle, Telemedicine

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This month [May] in Telemedicine

American Telemedicine Association: This month [May] in Telemedicine
June 2, 2015

Presenters:
Gary Capistrant, Chief Policy Officer, American Telemedicine Association
Jonathan Linkous, CEO, American Telemedicine Association

John commenting on the heat in Washington, D.C.

John commenting on the heat in Washington, D.C.

The annual ATA conference in LA last month had the largest attendance rate that ATA has seen in 20 years. It featured over 500 presentations; the video recordings of every presentation is available for purchase. Our own Wellpepper CEO, Anne Weiler, went to the conference and you can read her blog here. Also in May there were some big changes at ATA; a new president, new officers and members of the board of directors were elected. Their backgrounds are all impressive, thank goodness because we need them!

Telehealth’s exceeding advantages in both entrepreneurial and patient health naturally have lead to several new organizations popping up every year (or every month it seems) that use clinical consultations over the internet/phone. And where there is money to be made and quite literally lives at stake, legality is involved. The Texas medical board ruling prohibiting use of telehealth without previous relationship with patient, or a healthcare professional being present with patient when telehealth is being utilized (Huh, how is that telehealth?) lead to Teladoc filing a lawsuit against TX. Consequentially last Friday the Federal court ‘temporarily’ stopped TX medical board ruling. With that said ATA provides accreditation for online consultation sites to make sure sites are open/transparent, adherence to all relevant laws and regulations and promotes patient safety; however Teladoc isn’t accredited by ATA.

For those of us waiting for a particular practice guideline from ATA, there are now 10-12 Telehealth practice guidelines available on the ATA website and six active workgroups are under development; Teleburns, teledermatology, child mental health, general pediatrics, remote health and data management and telestroke. Please contact ATA if you would like to be involved in a workgroup, it is practicing professionals like you that make these guidelines viable.

If your state has a Telemedicine Parity Law, kudos, but 23 still do not. To be positive, we are getting there, a new milestone was achieved in the laws; Minnesota, Nevada and Indiana this week alone have added their own parity laws. Also in state news ATA added the highly awaited and much needed resource, the ATA State Telemedicine toolkit titled “Working with Medical Boards: Ensuring Comparable Standards for the Practice of Medicine via Telemedicine”. Again this is a call for involvement!

Congress or digress? The three letter difference is slight! But hey three new bills were introduced to Congress since the last webcast that will be interesting to watch; Telehealth Enhancement Act 2015, Amendment to Social Security Act to expand access to telehealth stroke services under Medicaid, and the VETS Act of 2015. The VETS Act of 2015 would permit U.S. Department of Veterans Affairs health professionals to treat veterans nationwide with a single state license. I cannot help but speculate the motives of introducing this bill; are they using the VA as a pilot for licensure compacts for ‘civilian’ physicians, etc.? Let’s hope so and more importantly I hope it goes well and only reaps benefits.

The announcement of a new Distance Learning and Telemedicine Grant from the USDA was mentioned and I wanted to make note of it in case any of our readers qualify. Please check it out here.

The next ‘This month in Telemedicine’ will be announced shortly on the ATA website and as always is free to watch.

Posted in: Healthcare Policy, Healthcare Research, Healthcare Technology, Telemedicine

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The Connected Patient Is Here

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

Confronting Mental Illness Online

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

Serving the New Connected Patient

Source: MHealth Summit

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

 Email Is Our Killer Application

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

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

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

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

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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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