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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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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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What’s True Now?

 

Health systems and payers alike are scrambling to figure out what the incoming administration means by repealing Obamacare. The payers admitted to having no contingency plans if Trump won. Trump doesn’t have a clear model, and the Republican party has a number of proposals. Some involve changing the names of programs or offering them in a different way. Some involve scrapping large sections of the affordable care act.

Rather than second-guessing what’s to come, at Wellpepper, we are focusing on what’s true now and what will remain true going forward.

We believe these things will continue to hold true:

  • Innovation will continue. If anything we hope that new innovation in healthcare, and technology innovation in particular is driven by market forces rather than legislation which created winners out of what was not always the best technology.
  • Consumer-focus is good. 20M newly insured individuals and high-deductibles helped create a market for new care organizations like local urgent care and patient-focused primary care. This consumer evolution will continue as patients demand that their healthcare dollars deliver good service.
  • Value and outcome focused approaches will be rewarded. Whether it’s traditional payers or self-insured employers, the light has been shone on areas to improve care AND reduce costs. Healthcare organizations have seen investments in outcomes pay off as well.

It’s time for a new patient experience that is real-time, connected, and based on the individual. We need to take advantage of the ability of technology to scale, analyze, and deliver personal experiences to leapfrog the current technology implementations in healthcare and deliver better outcomes and greater value in healthcare.

Posted in: Health Regulations, Healthcare Legislation, Healthcare Policy, Outcomes

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