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Falls Challenge

How might we enable older adults to live their best possible life by preventing falls? We have entered a challenge with AARP and IDEO to bring our proven falls solutions to the masses. Along side our partners at Harvard and Boston University, we believe that using mobile technology to enhance and scale a proven falls prevention program will lead to better life by increasing access to care and decreasing costs.

The challenge started with over 220 submissions and recently weeded down to the top 40. We’re thrilled to have made the first cut. Our method is proven and we invite you to participate in the next round to refine our idea and help achieve greater impact.

Click here to check out our entry!

 

 

Posted in: Aging, Clinical Research, Healthcare Technology, Outcomes, Physical Therapy, Research, Uncategorized

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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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T2 Telehealth aka ATA 2017 aka ATA 23: Part 1, The Eye of the Hurricane

While there is a focus on transformation, value, and outcomes going on, if the keynotes are any indication it may be a rough road ahead for telemedicine.

“It’s the 23rd year for the American Telemedicine Association conference, why are we still talking about how to get paid?”, admonished Pamela Peele, PhD economist and Chief Analytics Officer of UPMC during the opening keynote of the annual conference of the American Telemedicine Association.

Pamela Peele at ATA2017

Pamela Peele at ATA2017

“Especially since, as this audience knows, telemedicine is the best thing since sliced bread?

Why indeed? Well, it’s complicated. The problem is that each person in the value chain, the payer, the physician, the healthcare organization, the patient, and the patient’s closest adult daughter (aka primary caregiver), only see the value of one slice of that loaf of bread, and we collectively as purveyors of telemedicine have to sell the entire loaf. There’s no clear solution to this problem. However, with unsustainable costs of healthcare, and increasing consumerization we have got to figure it out. The taxpayer is bearing the brunt of the costs right now, and Peele characterized the shift of baby boomers to skilled nursing facilities as a hurricane we are unprepared for. One way out is to keep people at home, and for that we need Medicare to fund a cross-state multi-facility study to determine efficacy, value, and best practices. Fragmentation of trials is keeping us from wide scale adoption.

The Adaptation Curve

The Adaptation Curve

“We have got to figure it out” was also the theme of best-selling author and New York Times columnist Tom Friedman’s keynote promoting his new book “Thank-You For Being Late.” Friedman claimed to be more right than the rightest Republican and suggested abolishing corporate taxes and at the same time more left than the leftist Bernie Sander’s supporter suggesting we need an adaptable safety net. His major thesis is that we are undergoing 3 climate changes right now: globalization, climate, and technological. To survive and thrive in this new world, we need to adapt and evolve, and take our cues from Mother Nature, not from some sort of top-down regulation. Like Peele on the previous day, Friedman also sees a hurricane coming and suggests that the only way to survive is to find the eye of the storm not by building a wall.

Adapting and evolving will come in handy with the harder times for healthcare investment ahead predicted by the venture investing panel in the day 3 keynote. Tom Rodgers of McKesson Ventures, and Rob Coppedge of the newly formed Echo Health Ventures pulled no punches, as they tossed of tweet worthy statements like “Don’t tell me you’re the SnapChat of healthcare” and “it seems like there are only 3 business models for telemedicine.” The later was Coppedge’s comment on walking the tradeshow floor. (The models are direct to consumer, platform, and as a combined technology and service.) Rodgers had no love for direct to consumer models or anything that targeted millennials who he deemed low and inconsistent users of services. Platform vendors were advised to surround themselves with services: video was seen as a commodity.

So where does that leave us? Value, value, value. The challenge is that the value is different depending on the intervention, the patient, the payer, and the provider. Preventing readmissions, aging at home, decreasing travel costs, all provide benefits to one or more of the key stake holders. Can we figure out how to reimburse based on slices of value? How do we get together to realize that value? And how do we do it before the hurricane hits?

Posted in: Behavior Change, Healthcare Disruption, Healthcare Policy, Healthcare Research, Healthcare transformation, Telemedicine

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HIMSS17 Sessions of Interest

We are thrilled to attend a number of sessions at HIMSS17 with topics pertaining to Wellpepper’s Vision and Goals!

Patient Engagement

Sessions that impact our ability to deliver an engaging patient experience that helps people manage their care to improve outcomes and lower cost:

Insight from Data

Sessions that impact our ability to derive insight from data to improve outcomes and lower cost:

Clinical Experience

Sessions that impact our ability to deliver more efficient experience for existing workflows and are non-disruptive for new workflows:

 

Posted in: big data, Healthcare Technology, Interoperability, M-health, patient engagement

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MACRA: A Rule Worth Learning

Introduction to MACRA

Those of us who that work closely with clinicians or simply work in healthcare have no doubt heard of the total revamping of Medicare (Part B) clinician payments from a fee-for-service to a value-based system; this sort of change hasn’t occurred in over a generation. If that isn’t incredible enough for you, how about the fact that this 892 page document was passed by Congress with a bi-partisan ‘supermajority’; that alone speaks volumes on the importance of this change. The culprit of my angst and information overload is called the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) that will go into effect 1/1/17. This rule is so complicated with so many layers, it does not even have a Wikipedia page (nobody as been so bold); so keeping that in mind this blog post is my attempt to sum up my own understanding of this proposed rule.

Courtesy of CMS.gov

Two pathways to payment. MACRA is built upon two value based pathways that eligible clinicians (physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists) must chose from: Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Model (Advanced APM). Which path a clinician takes depends on their patient threshold and if they are new to the Medicare. It also depends if the clinician is part of an Accountable Care Organization that is established as an APM entity. The advantage of one over the other is a 5 percent annual payment increase from CMS over 6 years if a physician decides to be grouped with their ACO APM entity. The risk is if clinicians do not meet metrics chosen and set by their ACO they will not be rewarded with their shared savings. The good news is Physicians can elect to switch between the two payment models from on year to another. This flexibility is the foundation to the MACRA proposed rule. Additional choices given to eligible clinicians are: they can report on measures that are important to them and decide if they want to report as an individual or in a group.

Courtesy of HIMMS MACRA information Webinar

Fundamental basics to the MIPS. The MIPS replaces the Physician Quality Reporting System (PQRS), Value-Based Modifier (VBM) and Meaningful Use (MU) programs with the categories: Quality, Resource Use, Clinical Practice Improvement Activities and Advancing Care Information. Quality metrics are mainly derived from PQRS, Advancing Care Information is a simplified version of MU, and Resource Use is similar to VBM. The biggest change, as far as I can tell, is clinicians can choose six quality reporting measures that are important to them. Each year HHS will publish a list of quality measures to be used in the forthcoming MIPS performance period (which is 365 days) for clinicians to choose from. Out of these measures, one must be an outcome measure of high priority measure, one must be cross-cutting (hit on several quality measures), and clinicians can choose to report a specialty measure set. Clinicians composed quality score is measured against clinicians similar to themselves; this is another significant change. If you recall previously the sustainable growth rate (SGR) “set an arbitrary aggregate spending target” not based upon individual performance or clinician peers.

Introduction to Advance APM. There is a reason why I explained in more detail the MIPS path- because I understand it better; as with many things in my life I relate it to food. MIPS takes the wholesome ingredients from MU, PQRS and VBM programs and makes it a much better appeasing entrée. Whereas the Advanced APM program doesn’t focuses so much on the recipe but on the consumer. From what I understand so far, you have to be an eligible clinician determined by CMS, and work in an organization that participates already as an APM through an agreement with CMS. Also, so far, CMS has only identified six APMs that qualify as Advanced APMs. These include Comprehensive End Stage Renal Disease care, Comprehensive Primary Care Plus, Medicare Shared Savings Program (Track 2 and 3), Next Generation ACO Model, and Oncology Care Model. The three criterion’s in order to become an Advance APM clinicians are: 50% of physicians must use Certified EHR technology; payments are based on quality measures; financial risk and nominal amount standards. I hope to dive deeper into Advanced APMs in a later blog post. For now please check out the HIMSS information deck here.

MACRA professional I am not… is anyone? Whereas I love to always learn, MACRA was difficult for me to grasp, HOWEVER I spent about 2 years in Graduate school studying Meaningful Use, so that says a lot. I am sad to say that a lot of what I learned about MU no longer applicable, but good riddance! The beginning of this year the Acting Administrator of CMS said “The Meaningful Use program as it has existed, will now be effectively over and replaced with something better.” I hope we you are right Mr. Slavitt.

Posted in: Healthcare Legislation, Healthcare Policy, Healthcare transformation, Outcomes

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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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Decreasing the Patient Survey Burden for Total Joint PROs

At Wellpepper we believe strongly about the value of patient-reported outcomes, especially when they are delivered as part of the patient care plan. However, the recent trend towards collecting PROs for reimbursement, plus HCAHPS and other surveys can result in some over-surveying of patients. We were pleased to hear at AAHKS that there is a movement to decrease the number of questions for total joint replacement with a proposal of using a HoosJr and a KoosJr. Outcomes-mobile.screen3

The HOOS and KOOS surveys are standard, validated survey instruments that are commonly used for measuring hip and knee function. We’ve heard that CMS is moving towards requiring these measures for evaluating outcomes of TJAs and other surgical procedures. A group of surgeons representing the major American orthopedic associations (American Association of Hip and Knee Surgeons, the American Association of Orthopedic Surgeons, The Hip Society and The Knee Society) has recently proposed shortened version of these surveys to lower the patient data collection burden. Details were presented at the 2015 AAOS and AAHKS conferences. These shortened versions are being called HOOS Jr. and KOOS Jr. Note that these are different than the lesser-used HOOS-PS and KOOS-PS physical short form surveys. The updated surveys are designed to be used standalone or in combination with a general health survey like VR-12, or PROMIS 10 Global. The number of questions is reduced from 40 to 6 (for HOOS) and from 42 to 7 (for KOOS), while retaining reliable, responsive output scores. With a patient completion time of under 3 minutes, these shortened surveys should dramatically aid in increasing survey response rates. Wellpepper supports HOOS and KOOS today, and looks forward to supporting HOOS Jr. and KOOS Jr. as soon as scoring rules are released.

Posted in: Health Regulations, Healthcare Technology, Outcomes, 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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Accountable Care and HealthIT Strategies Summit 2015: Still early days

Patients and providers both need to be empowered to deliver on the promises of the Affordable Care Act. That was the major theme and takeaway of the recent “Accountable Care and Health IT Strategies Summit” that I attended a few weeks ago in Chicago. I would add to this sentiment that IT needs help to implement technologies that empower these end-users. While not underestimating the importance of making sure technology is secure, and scalable, with too much focus on the back-end, IT can miss an opportunity to help deliver real value and change by putting tools in the hands of end-users.

Since value-based payments require health systems to be able to impact patient behavior outside their four walls, technology (and therefore IT departments) have the ability to play a greater role in helping to monitor and manage patients, and scale healthcare providers. Access to real-time data can also help identify issues and impact patient behavior before small problems turn into big ones.

While some of the stories and sessions at the conference were promising, I came away with the impression that we are still in really early days, and the leaders in this care transformation are willing to take leaps without having all the data. Considering that even with data, it still takes 17 years from innovation to transfer from research to clinical best practice, it seems that some amount of faith is required for this healthcare transformation.

In no particular order, here are a few of my notes from the 2-day conference.

Theme: Population Health 2.0: Accountable Care, Big Data and Healthcare Analytics

Population Health seems the furthest along in this transformation both in the way care is delivered and how technology supports care. Participants on this panel from Partners, Geisinger, and Hackensack University Medical Center, along with population health vendor Wellcentive debated the differences between Population Health 1.0 and 2.0. They even tried to see the future with Population Health 3.0.

Population Health 1.0 was seen as identifying risk and gaps in care, and attempting to plug those gaps. Although many organizations are still in this stage, some haven’t even gotten there yet. The panel saw themselves moving to a more evolved state of Population Health where data is used to drive better care, while responsibility for population health moves to the individual primary care physician rather than being managed in aggregate by remote care teams. However, this type of shift requires engagement by both the patients and the physicians which is still a work-in –progress.

The representative from Geisinger stressed for an effective implementation of population health, a multi-disciplinary team needs to be assembled that includes both clinical and IT. Wellcentive agreed and added that analytics need to be in the hands of end-users so they can make informed decisions.

The panel was also asked to speculate on Population Health 3.0: historical data, data driven decisions, and patient empowerment through data from sensors and surveys were all seen as key.

Honestly, my biggest takeaway from this session is that while some organizations may be claiming it’s time for Population Health 2.0, many haven’t gotten to 1.0, and no one seems to be in agreement on the definitions of each stage. Given today we already have the ability to collect survey and sensor data in the context of care, it seems like we are already have the tools for Population Health 3.0. But, we haven’t implemented the technology to address Pop Health 1.0 & 2.0 to achieve value…..so how can we even look to addressing the road to 3.0?

Theme: EMRs and Enabling Technology for ACOs

Another major theme that arose across many sessions at the conference is the limitations of current technology to support the infrastructure of new models of care. While organizations are looking for the EMR to be the Holy Grail, it’s a challenge as most EMRs are built to support older models of care, specifically around billing and reimbursement. Renown Health’s Accountable Care Organization, in Northern Nevada, will look to EPIC to solve some of their technology care needs, but realizes the need for M-health and other care coordination technologies to move up the stack, and exist separately from the EMR will be required.

Many of the participants are either trying to collect and track ACO data in the EMR or build their own systems to engage patients that fed data back into the EMR. Others acknowledged that new systems to directly engage patients need to be built on new technology stacks, although surprisingly one panelist on the Connected Care – How Trends in mHealth, Wearables and Connected Medical Home are Shaping Healthcare keynote boasted about 20-30% engagement rates with paper surveys. Yes, paper.

Theme: Engaging Patients and Providers

For ACOs and the ACA in general to be effective, the consensus at the conference was the need to enable both patients and providers. Adding individual providers into the mix seems to be a bit of a shift in thinking, and one that we’re supportive of at Wellpepper. We know that a key driver of patient adherence is the relationship between patients and providers. With our system, a good provider can influence patients to be over 85% adherent to their treatment plans. Some key ideas at the conference were providers may still need to be convinced of the need to influence patients directly, and that showing them data is the way to do that. However, the method of communication to that patient needs to connect in a way that is of their everyday life routine.

Overall, the conference presented some early wins in the shift to ACOs and value-based payments, but showed that we still have a long way to go and a lot of opportunity to improve care based on data. That said, this was the first conference I’ve been to where IT was front-and-center at the table and able to drive change if they wanted to. We have an opportunity to leapfrog old ways of doing things and implement new systems that have focus on the patient and provider, and are based on data to drive better outcomes. I for one am excited about this new opportunity and how it will change the way we deliver care in the future.

Posted in: Behavior Change, Health Regulations, Healthcare Disruption, Healthcare motivation, Healthcare Technology, Outcomes

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Measure What You Manage, With Caveats: Thoughts on Surgeon Ratings

When I worked at Microsoft, we managed by the scorecard. The scorecard was meant to provide key indicators of the business health. If something wasn’t on the scorecard, it didn’t get focus from the worldwide sales and marketing groups, and if a product or initiative didn’t get this focus it would die. The scorecard had tremendous power and was a rallying and focal point for a sometimes unwieldy global organization. So powerful was the scorecard that if any errors were made in how something was tracked, it could drive exactly the wrong behavior.

One year, a metric was introduced to measure sales of a new product, in relation to an existing product. The thought was that the new product was a good “upsell” from the existing product so tracking one in relation to the other was a logical measurement. The intention of the metric was to show the new product growing as it “attached” to the existing product. The metric was calculated as:

Product target calculation

 

The sales teams behaved rationally and stopped selling the existing product, because if they sold the existing product, they had to sell even more of the new product to meet their target since the denominator of the equation kept increasing. They met their targets and got their bonuses, but their behavior was exactly the opposite of what the product teams and the company wanted which was for both businesses to grow or at least for the existing product to stay steady while the new one grew.

Last week, ProPublica caused a flurry by releasing a report of complication data for US surgeons. Using their database you can look up any surgeon and find how their patients fared on average for complications after surgery.

As with any measure, it is fraught with controversy about both the accuracy of the data or whether we are measuring the right things. On the surface complication data seems like it’s a good way to track surgeons, and it is if the complications are caused by surgeon error. The problem is that complications are caused by lots of things including patient behavior (for example not caring for a wound properly or taking too many narcotics and falling down after surgery) or by the patient situation, for example, age or co-morbidities. Looking at complication data alone, as Dr. Jennifer Gunter points out eloquently in her blog post, does not give the whole picture. Dr. Gunter’s mother had two surgeries, one that would be recorded as “no complications” and one full of complications. From the raw data, the first surgery looks like a success with a 7-day hospital stay, and the 2nd a failure with a 90-day hospital stay and many complications. (Note that the 2nd surgery could be counted as a “readmission” which would be counted against the hospital.) Regardless, in this situation data alone does not tell the whole story.

In addition to not telling the whole story, looking at complication data alone can drive the wrong behavior, which is surgeons only taking on the “easy” cases, those who are younger, in perfect health, and have no other diseases, for example diabetes. There are many things that patients can do before surgery to ensure successful outcomes like quitting smoking or losing weight, there are things they can’t do, like get rid of a chronic disease or suddenly shed 10 years. Judging surgeons on only complications can encourage them to “cherry-pick” patients so that they have low complications and high scores. In turn these surgeons will be sought out by the “best” patients, and we could end up with a bifurcated system where the “worst” surgeons (looking only at complications) operate on the hardest cases.

There’s a saying that you can’t manage what you can’t measure. It’s important as well to consider what you are measuring, the behavior that you intend to drive, and the long-term implications of it . Healthcare is making small steps to become more data and outcome-driven and we need to encourage and commend that. At the same time, let’s make sure we are looking at the right metrics.

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

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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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Pre-habilitation: Effective Preventative Medicine for Rehabilitation

If an apple a day keeps the doctor away, what can a knee bend do? The American Academy of Orthopedic Surgeons recently answered this question with the results of a new study of the impact of physical therapy on surgical outcomes for hip replacement. The answer: “Prehabilitation reduces the need for perioperative care by 30%.” Amazing results, especially considering that total joint replacements will increase by 400% by 2030 according to the academy. Considering that post-acute care costs are the fastest rising and most variable, an investment in pre-habilitation can pay off huge dividends. Based on data from the AMA and CDC we’ve estimated that a 10% decrease in post-acute care costs could help realize $4.3B in savings over this same period. The AAOS study showed that patients who received pre-habilitation saw a decline in up to $1,215 per patient in perioperative care, due to a decrease in costs for skilled nursing and home care. Given that total joint replacement costs vary from a low of $6000 to a high of $30,000, providing pre-habilitation and a means for patients to be adherent is a very easy way to get to this 10% decrease. If you’d like more information on how we calculated these costs contact us.

The theme of pre-habilitation was also prevalent at the recent ACRM annual congress in Toronto, consider it the preventative health of rehabilitation, which literally means the act of restoring something to it’s original state. If you can decrease the amount of damage done in the first place, restoring it to the original state becomes easier or at least if you don’t see complete recovery, you see better outcomes. Two sessions at the conference explored this concept where there was known risk of damage: one focused on pre-habilitation for cancer patients that would need to undergo surgery, and the other a focused study on adults with lower back pain who were at risk of declining.

Effect of Diet on Outcomes for Cancer Surgery PatientsOne session focused on pre-habilitation for patients undergoing cancer surgery, and was striking both for the outcomes and for the collaborative and interdisciplinary team. The session, “Improving Outcomes With Multimodal Prehabilitation in Surgical Cancer Patients” was notable both for the outcomes presented and for the strength of the collaborative and inter-disciplinary team that included led by Dr. Carli from McGill University that included physicians, dieticians, and physical therapists. The team presented the results of their randomized clinical study that showed that a prehab program including strength training, exercise, diet, and nutrition counseling could decrease hospital stays by ½ a day and that the strength training helped patients compensate for surgery-related weakness perioperatively.

Patients were given either just nutrition counseling or nutrition counseling plus a whey supplement or a placebo. Patients with nutrition counseling sustained their levels in the 6 minute walk test before and after surgery. Patients with both nutrition counseling and the whey supplement improved their distances in the 6-minute walk test after surgery.

Together the strength training, nutritional counseling, and protein supplements improved patient surgical outcomes. Ideally, nutrition counseling was recommended to begin at cancer diagnosis, but at the very least pre-surgery. This study proved that there are modifiable patient risk factors before surgery that can improve outcomes.

Exercise for Lower Back Pain in SeniorsA second study outlined by Dr. Gregory Hicks from the University of Delaware  in the session “Novel Ways to Improve Mobility and Physical Function in Older Adults: A Targeted Intervention Approach”, looked at whether stabilizing trunk exercises could prevent decline in high-risk seniors. Interestingly, the presenter X pointed out, any studies involving trunk muscle stabilization had purposely excluded adults over 65 so there was no evidence of the impact. In this study, the control group was given the usual care condition of heat, ultrasound, massage, and stretching. The second group was given trunk muscle training and Neuromuscular Electromagnetic Stimulation. Unfortunately, the second group had low adherence to their programs, and were not happy to miss out on heat and massage. This probably says more about the need for patient education and engagement than anything. In many studies strengthening exercises have proven helpful, but not if you can’t get patients to do them. Regardless, patients in the trunk muscle group had a 17% higher rating on the top 3 functional limitations that they had reported as being most important to them at the outset of the study and their exercise self-efficacy was expected to continue to improve over time.

While the results were positive, Hicks outlined some of the limitations of the study, including the exercise adherence but also pointed out that patients had different outcomes based on the physical therapist delivering the treatment and based on how closely they identified with the pre-defined outcome measures that were used in the standard tools (OSWESTRY). This brings up an interesting point about how to deliver care.

While research has proven that proactive activities, like improving diet or exercise, can improve outcomes, patients, and by that I mean humans, are subject to human nature, which is not always doing what’s in our own best interest.

There are ways to change this within the care delivery system to help patients adhere to their treatment plans:

  • Making sure patients understand what they are being asked to do
  • Making it easy to follow instructions
  • Fostering a positive relationship between patient and healthcare provider

Adapted from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624/pdf/tcrm0103-189.pdf

These principles are fundamental to our Wellpepper patient engagement solutions and help us get over 70% patient engagement. We’re pretty excited to see the opportunities for these types of solutions to be used in pre-habilitation scenarios that are proven to improve outcomes.

Posted in: Prehabilitation

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