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Alexa Voice Challenge for Type 2 Diabetes: Evolving An Idea

For the past couple of months some of our Wellpepper team, with some additional help from a couple of post-docs from University of Washington, have been working hard on a novel integrated device, mobile, and voice care plan to help people newly diagnosed with type 2 diabetes as part of our entry in the Alexa Diabetes Challenge.

Team Sugarpod

This challenge offered a great opportunity to evolve our thinking in the power of integrating experiences directly into a person’s day using the right technology for the setting. It also provided the opportunity to go from idea to prototype in a rapid timeframe.

Our solution featured an integrated mobile and voice care plan, and a unique device: a voice powered scale that scans for diabetic foot ulcers, a leading cause of amputation, hospitalization, and increased mortality, and is estimated to cost the health system up to $9B per year.

During the challenge, we had access to amazing resources, including a 2-day bootcamp held at Amazon headquarters during which we heard from experts in voice, behavior change, caring for people with type 2 diabetes, and a focus group with people who have type 2 diabetes. We also had 1:1 sessions with various experts who had seen our entry and helped us think through the challenges of developing it. After the bootcamp, we were assigned a mentor, an experienced pharmacist and diabetes educator, who was available for any questions. Experts from the bootcamp also held office hours where we explored topics like

Early Prototype Voice Powered Scale & Scanner

how to help coach people in what they can do with an Alexa skill, and how to build trust with a device that takes pictures in your bathroom.

As we evolved our solution, we were fortunate to have support from Dr Wellesley Chapman, medical director of Kaiser Permanente Washington’s Innovation Group. We were able to install the device in a Diabetes and Wound Clinic. We used this to train our image classifier to look for foot ulcers, and compare results to human detection, and also to test the voice service. We used an anonymous voice service as Alexa and the Lex services are not currently HIPAA-eligible.

We gathered feedback from diabetes educators, clinicians at KP Washington, and across the country, and from people with Type 2 diabetes. While not everyone wanted to use all aspects of the solution, they all felt that the various components: voice, mobile, and device offered a lot of support and value. As well, we determined that there is an opportunity for a voice-powered scale and scanner in the clinic which could aid in early detection and streamline productivity. Voice interactions in the clinic are a natural fit.

Judges and Competitors: Alexa Diabetes Challenge

The great thing about a challenge is the constraints provided to do something really great in a short period of time. We’re so proud of the Sugarpod team, and also incredibly impressed with the other entries in this competition ranging from a focus on supporting the mental health challenges faced by people newly diagnosed with Type 2 diabetes to a specific protocol for diet and nutrition, to solutions that helped manage all aspects of care. We enjoyed meeting our fellow competitors at the bootcamp and the final, and wish we had met in a situation where we could collaborate with them. We also appreciated the thoughtful feedback and questions from the judges, and would definitely have a lot to gain from deeper discussions with them on the topic.

Stay tuned for more on our learnings through this challenge and our experiences with voice.

Posted in: Healthcare Disruption, Healthcare Technology, Healthcare transformation, M-health, Managing Chronic Disease, Outcomes, patient engagement, patient-generated data

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Who Defines Value?

Pharma companies have recently jumped on the value bandwagon with proposals for value-based drug pricing based on outcomes and effectiveness. They have started to enter contracts with payers for specific drugs based on the impact the drug has on the condition the drug is treating.

This is a step in the right direction, and much better than pricing based on maximizing shareholder value, but value is in the eye of the beholder, and the patient is a key stakeholder. Shared decision making does a good job defining what’s important to a patient. The goal of shared decision making is to choose courses of care that offer the best outcome to the patient, and can consider some of the following:

  • Is this procedure my only option? What are alternative types of treatment?
  • What are the possible outcomes and side effects of each option, including the option of doing nothing?
  • What is the estimated cost of the procedure and any related follow-up care or medication?

Source: Center for American Progress

Simply, value can be defined by the following.

The challenge of the equation is in the definitions of acceptable outcomes and costs. Here are a few things that people might consider when evaluating a drug or a course of care.

  • Inconvenience or effort: How much does this disrupt their life? Does it prevent the person from doing other things?
  • Cost: How much does it cost? This could be in monetary terms, time, side effects, or quality of life.
  • Outcome: What is the expected outcome and how closely does it align with the outcome that’s important to me?

You can see that based on these factors, that healthcare can be a market of one. My idea of value and acceptable outcomes could be very different from yours. And, unfortunately, the patient is not a consumer in a free and transparent market. That said, it is possible to make consumer-like decisions in healthcare.

Let’s look at the value decision I tried to make this past weekend. I fractured and dislocated a finger while playing Ultimate Frisbee. I was pretty sure the finger was dislocated, which shouldn’t be a big deal, so tried to go to urgent care where I expected value based on time, outcome, and cost. Well guess what? Urgent care is not open on a Saturday night. I had a feeling that emergency care would not meet my value criteria of effort, since I expected a long wait, and I got it. On the cost, I did know that the provider I went to was in-network so that wasn’t a big issue, but I still don’t know the total cost if I’d had to pay out of pocket.

Waiting in ED

Waiting

Outcome was great, and the level of care was great. What was not great is that it took 4 hours to get x-rays, pop my finger back in, and splint it. If I had been choosing as a consumer, I’d never have chosen this. With higher deductibles and co-pays, people are making decisions as consumers which is why hospitals advertise wait times, and some are looking at how to completely overhaul the ER, both of which would get us closer to value.

Let’s look at an example on value-based drug pricing. Back when I had the Cadillac of US healthcare plans when I was working at Microsoft, I was prescribed a topical psoriasis drug. The expected outcome was no psoriasis lesions. The cost was $800 for a 60g tube. Since I didn’t have to pay anything out of pocket, I got the prescription. Did it work? Yes. Was it worth it to me? No. I had other creams that cost much less, and worked almost as well. I didn’t end up getting it again—I wouldn’t have paid $800 for it myself, so why should my employer? If cost is not part of the equation, people are making decisions with only partial information, and can’t possibly judge value. Co-pays and transparency can help guide people to consumer-like behavior in healthcare, even in an imperfect market.

What’s the upside? The upside is that we’re having these discussions, and that we can see a shift to value and consumer focus, even without legislation, which is really how it needs to happen. The other thing to remember is that people want to deliver excellent and quality care. Everyone I met during my finger ordeal, from the admitting staff to the x-ray tech, to the resident who was excited to see a dislocation he’d never seen before was excellent, and that defines quality in my mind. Maybe we have less far to go than we thought.

Posted in: Healthcare Disruption, Healthcare Legislation, Healthcare motivation, Healthcare Policy, Outcomes

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Meeting Consumer Expectations in Healthcare

We could talk about this all day, and we do! We’re glad to see healthcare executives start to take ownership of the digital experience, and understand that consumer and patient engagement is key to outcome success.

Consumer expectations are indeed hitting healthcare – hard. Patients are no longer shy about telling physicians and payers what they want and how much they’re willing to pay for it. While these expectations can seem overwhelming to those insiders who have long become accustomed to healthcare’s glacial pace, we shouldn’t be discouraged. These greater expectations can indeed be met, provided we take the time to develop and offer physicians and patients tools that meet their needs and fit their workflows.

Here’s the latest take on this topic from HISTalk

 

Posted in: Healthcare transformation, patient engagement, Patient Satisfaction

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Patient Experience Versus Patient Engagement

As a volunteer session reviewer for the Patient and Consumer Engagement track for HIMSS 2018, I’ve been thinking a lot about the difference between engagement and experience, and also what it means to deliver connected health. While Wellpepper is a platform for patient engagement, a session based on Boston University’s study using Wellpepper with people with Parkinson disease actually suited the definition of Connected Health better and was submitted in that track.

As I’ve been reviewing sessions submissions for the track, I noticed that quite a few focus on patient experience rather than engagement. The difference really is about commitment and action. Patient experience is what happens when someone engages with a health system or physician office. Patient engagement is what happens when someone actively participates in their own care as a patient. You could argue that patients can’t help but be engaged because whatever is happening is happening to them, but it’s a bit more than that. (Also that argument gets a bit existential.)

Both engagement and experience are important. With a crappy experience then people may not engage with you, your system, or their own health. This can be as simple as not being able to find parking. Good experience is the pre-requisite for engagement, but it is not engagement on its own. Engagement happens when you empower the patient and treat them as an active participant in their care.

There’s a continuum from experience to engagement, and often the same digital tools represent both, although both also include the physical experience, and both will help you attract and retain patients but more importantly engagement will also help improve outcomes.

If you’re interested in this topic, this article in NEJM Catalyst from Adrienne Boissy, MD of Cleveland Clinic does much better job than I do of explaining it.

Posted in: Healthcare Technology, Healthcare transformation, M-health, patient engagement, Patient Satisfaction

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Making Patient-Generated Health Data Count

We’re strong advocates for the power and benefits of patient-generated data. In analyzing results from patients using Wellpepper, we’ve been able to derive insights that wouldn’t be possible if patients weren’t tracking and self-managing. In addition to improving care, using patient-generated data can impact quality, which is why we’re happy to see patient-generated data being included as a valid feedback source for Medicare quality measures. This measure in particular, which is a result of a collaboration between Healthloop, Livongo, and Wellpepper, is a first step in this.

We believe that collaboration and open data is going to be much more powerful if we work together, rather than against each other. This is the new spirit of openness, interoperability, and collaboration that will help move healthcare IT forward. If your vendors aren’t interested in working together, you might want to ask yourself why not.

Here’s the text of the proposed measure on Patient-Generated Data.

 

 

You can find it on page 181 of this document in CY 2018 Updates to the Quality Payment Program, which is open for public comment until August 21st.

There are other measures that would also benefit from including patient-generated data as a validation source. In particular, measures for tracking patient-reported outcomes, care coordination, and discharge and follow-up instructions, use and reconciliation of medications, blood pressure, and blood sugar tracking. As home sensors and connectivity to those are clinically validated and improve, there is even greater opportunity to streamline the process of quality reporting and reduce the burden for physicians and health systems.

Posted in: Health Regulations, Outcomes

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But Will It Fly? What Airlines and Healthcare Organizations Have In Common

What do airlines and healthcare systems have in common? Quite a lot it turns out, from a recent power breakfast featuring Rod Hochman, CEO of Providence St. Joseph Hoag Health system, and Brad Tilden, CEO of Alaska Airlines. In addition to the Pacific Northwest roots of both organizations, both have also undertaken mergers to gain market share and increase physical territory. Both serve a large cross-section of the population, and both are in highly-regulated industries that are not necessarily known for customer service that are grappling with new always connected user experiences and expectations.

The wide-ranging discussion included early inspiration for Hochman and Tilden’s early careers, how to motivate and engage a wide range of employees, and how to deal with competition and lead change. Both leaders had early influences on their career direction. Hochman knew he wanted to be a doctor at 16 when assisting on surgeries (!), and Tilden grew up beside Seatac airport watching planes while his peers were watching girls. Tilden grew his career at Alaska, while Hochman is a practicing rheumatologist, who has worked his way from small clinic to major system. Hochman joked that a rheumatology specialty is much more suited to success in administration than say surgery, equating running a hospital to the patient required in managing chronic diseases.

Airlines and health systems have similar challenges with employee experience. Both types of organizations have highly skilled staff, pilots and physicians, who demand a lot of autonomy. Mistakes in both professions can cause loss of life. The difference is that aviation has moved a lot faster in instituting standard procedures and checklists to improve safety and outcomes. Tilden frequently referenced an Alaska Air crash 17 years ago that impacted their approach to safety, and talked about the ways pilots and co-pilots double check settings. Hochman talked about his hope for quality improvements and better collaboration from the younger generation of physicians who have grown up in a world of checklists and standardization, and said that the ones who only care about being left alone to make decisions will retire.

They also have large teams of people who “get stuff done.” Hochman has banned the term ‘middle management’ since he sees those people as the ones who are making things happen, instead he calls them “core team”, a term that Tilden quipped he’d also start using.Rod Hochman & Brad Tilden

Customer experience was also top of mind for both execs. Tilden talked about Alaska adopting Virgin’s mission of being the airline people love. While he seemed to find some of Virgin’s approach to be a bit edgy compared to Alaska, he said you couldn’t find a better mission. Both grappled with the ease of sharing bad experiences on social media, and indicated that social media monitoring has become a key tool in managing consumer expectations. Hochman, also noted that it all comes back to the individual experience when he described that his staff hate when he has his own annual physical, because his expectations as a patient are much higher than what he experiences, especially with respect to convenience and information flow.

Both are optimistic and passionate leaders who genuinely care about the consumer and employee experience, and had as good a time interviewing each other as the audience did listening to them. This event was sold out, so if an opportunity like this comes up again, sign up early.

Posted in: Healthcare Disruption, Healthcare Technology, Healthcare transformation, M-health

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Introducing Sugarpod by Wellpepper, a comprehensive diabetes care plan

We’re both honored and excited to be one of five finalists in the Alexa Diabetes Challenge. We’re honored to be in such great company, and excited about the novel device our team is building. You may wonder how a team of software folks ends up with an entry with a hardware component. We did too, until we thought more about the convergence happening in technology.

We were early fans of the power of voice, and we previewed a prototype of Alexa integration with Wellpepper digital treatment plans for total joint replacement at HIMSS in February 2017. Voice is a great interface for people who are mobility or vision challenged, and the design of Amazon Echo makes it an unobtrusive home device. While a mobile treatment plan is always with you, the Amazon Echo is central in the home. At one point, we thought television would be the next logical screen to support patients with their home treatment plans, but it seems like the Echo Show is going to be more powerful and still quite accessible to a large number of people.

Since our platform supports all types of patient interventions, including diabetes, this challenge was a natural fit for our team, which is made up of Wellpepper staff and Dr Soma Mandal, who joined us this spring for a rotation from the University of Georgia. However, when we brainstormed 20 possible ideas for the challenge (admittedly over beer at Fremont Brewing), the two that rose to the top involved hardware solutions in addition to voice interactions with a treatment plan. And that’s how we found ourselves with Sugarpod by Wellpepper which includes a comprehensive diabetes care plan for someone newly diagnosed, and a novel Alexa-enabled device to check for foot problems, a common complication of diabetes mellitus.

Currently in healthcare, there are some big efforts to connect device data to the EMR. While we think device data is extremely interesting, connecting it directly to the EMR is missing a key component: what’s actually happening with the patient. Having real-time device data without real-time patient experience as well, is only solving one piece of the puzzle. Patients don’t think about the devices to manage their health – whether glucometer, blood pressure monitor, or foot scanner – separately from their entire care plan. In fact, looking at both together, and understanding the interplay between their actions, and the readings from these devices, is key for patient self-management.

And that’s how we found ourselves, a mostly SaaS company, entering a challenge with a device. It’s not the first time we’ve thought about how to better integrate devices with our care plans, but is the first time we’ve gone as far as prototyping one ourselves, which got us wondering which way the market will go. It doesn’t make sense for every device to have their own corresponding app. That app is not integrated with the physician’s instructions or the rest of the patient’s care plan. It may not be feasible for every interactive treatment plan to integrate with every device, so are vertically integrated solutions the future? If you look at the bets that Google and Apple are making in this space, you might say yes. It will be fascinating to see where this Alexa challenge takes Amazon, and us too.

We’ve got a lot of work cut out for us before the final pitch on September 25th in New York. If you’re interested in our progress, subscribe to our Wellpepper newsletter, and we’ll have a few updates. If you’re interested in this overall hardware and software solution for Type 2 diabetes care, either for deploying in your organization or bringing a new device to market, please get in touch.

Read more about the process, the pitch, and how we developed the solution:

Ready When You Are: Voice Interfaces for Patient Engagement

Alexa Voice Challenge for Type 2 Diabetes: Evolving a Solution

 

Posted in: Behavior Change, chronic disease, Healthcare Disruption, Healthcare Technology, Healthcare transformation, M-health, Managing Chronic Disease, patient-generated data

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In Defense of Patient-Generated Data

There’s a lot of activity going on with large technology companies and others trying to get access to EMR data to mine it for insights. They’re using machine learning and artificial intelligence to crawl notes and diagnosis to try to find patterns that may predict disease. At the same time, equal amounts of energy are being spent figuring out how to get data from the myriad of medical and consumer devices into the EMR, considered the system of record.

There are a few flaws in this plan:

  • A significant amount of data in the EMR is copied and pasted. While it may be true that physicians and especially specialists see the same problems repeatedly, it’s also true that lack of specificity and even mistakes are introduced by this practice.
  • As well, the same ICD-10 codes are reused. Doctors admit to reusing codes that they know will be reimbursed. While they are not mis-diagnosing patients, this is another area where there is a lack of specificity. Search for “frequently used ICD-10 codes”, you’ll find a myriad of cheat sheets listing the most common codes for primary care and specialties.
  • Historically clinical research, on which recommendations and standard ranges are created, has been lacking in ethnic and sometimes gender diversity, which means that a patient whose tests are within standard range may have a different experience because that patient is different than the archetype on which the standard is based.
  • Data without context is meaningless, which is physicians initially balked about having device data in the EMR. Understanding how much a healthy person is active is interesting but you don’t need FitBit data for that, there are other indicators like BMI and resting heart rate. Understanding how much someone recovering from knee surgery is interesting, but only if you understand other things about that person’s situation and care.

There’s a pretty simple and often overlooked solution to this problem: get data and information directly from the patient. This data, of a patient’s own experience, will often answer the questions of why a patient is or isn’t getting better. It’s one thing to look at data points and see whether a patient is in or out of accepted ranges. It’s another to consider how the patient feels and what he or she is doing that may improve or exacerbate a condition. In ignoring the patient experience, decisions are being made with only some of the data. In Kleiner-Perkin’s State of the Internet Report, Mary Meeker estimates that the EMR collects a mere 26 data points per year on each patient. That’s not enough to make decisions about a single patient, let alone expect that AI will auto-magically find insights.

We’ve seen the value of patient engagement in our own research and data collected, for example in identifying side effects that are predictors of post-surgical readmission. If you’re interested, in these insights, we publish them through our newsletter.  In interviewing patients and providers, we’ve heard so many examples where physicians were puzzled between the patient’s experience in-clinic or in-patient versus at home. One pulmonary specialist we met told us he had a COPD patient who was not responding to medication. The obvious solution was to change the medication. The not-so-obvious solution was to ask the patient to demonstrate how he was using his inhaler. He was spraying it in the air and walking through the mist, which was how a discharge nurse had shown him how to use the inhaler.

By providing patients with useable and personalized instructions and then tracking the patient experience in following instructions and managing their health, you can close the loop. Combining this information with device data and physician observations and diagnosis, will provide the insight that we can use to scale and personalize care.

Posted in: Adherence, big data, Clinical Research, Healthcare Disruption, Healthcare Research, Healthcare Technology, Healthcare transformation, Interoperability, M-health, patient engagement, patient-generated data

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Consumerization Is Not A Bad Word

When you say consumerization, especially with respect to healthcare, people often jump to conclusions about valuing service over substance. There’s a lot of confusion over the meaning of consumerization, whether it’s possible in healthcare, and whether it’s happening. I recently had the privilege of speaking at the Washington State Health Exchange’s Annual Board Retreat on this topic. (Perhaps you saw it, the event was live-streamed to the public. 😉 ). The Health Exchange is pondering questions of how to attract new users, how to better serve their needs, and how to make the experience more useful and engaging. And, this my friends is consumerism, or at least one facet of it: user focus, better service, understanding needs. Doesn’t sound bad at all, does it? In fact, it sounds like something any good service or organization should be doing for its customers.

Consumer-centered pain scale. Baymax from Disney's Big Hero Six

Consumer-centered pain scale. Baymax from Disney’s Big Hero Six

And there’s that word, customers. That’s the debate. Are patients really customers? Not really, often they don’t have a choice, either because of their insurance coverage or from the necessity of an emergency where decisions are often made for patients. However, patients, and everyone else for that matter (except people in North Korea), are consumers, and they judge healthcare experiences both service delivery and technology as consumers. Think of it like this, your patients will judge your experiences through the lens of any other service they’ve interacted with. Fair or not, they will do that. Why do they do this? It’s human nature to remember positive experiences and try to seek them out. Although there’s another reason: high-deductibles are also driving people to examine where they are spending their healthcare dollars, and they evaluate based on outcomes, convenience, and the overall experience.

Since healthcare technology is my area of expertise, let’s stick to that rather than critiquing hospital parking, food, or beds. (Although these are often things that impact HCAHPS scores.) Consumerization when applied to health IT means that patients have an expectation that any technology you ask them to engage with, and especially technology you ask them to install on their own devices, will be as usable as any other app they’ve installed.

Consumerization also impacts internal health IT. Doctors were the first wave, when they pushed using their own devices to text with other providers within the hospital setting. (In IT this is often referred to as “bring your own device.”) The pager became obsolete and replaced with our own always on, always connected mobile devices. (Sadly, the fax machine, like a cockroach, keeps hanging in there.)

Patients are also bringing their own devices, and using them in waiting rooms and hospital beds. We’ve had patients reporting their own symptoms using Wellpepper interactive care plans from their hospital beds. This presents an opportunity to engage, and at a low cost: they are supplying the hardware. The final wave of consumerism will happen when clinicians and other hospital staff also demand convenient, usable, and well-designed tools for clinical care.

Consumerization is late to arrive in healthcare IT. Other industries have already reached tail end of this wave, and have already realized that technology needs to be easy to use, accessible, interoperable, and designed with the end-user foremost. However, consumerization is coming, both from internal staff demands and patients. Technology, healthcare IT, and the people that build and support it are facing scrutiny, being held to higher standards, and becoming part of the strategic decision-making healthcare organizations. This is a great thing, as it will result in better clinician and patient experiences overall, because at its core consumerism is about expecting value, and ease and getting it, and who doesn’t want that?

Posted in: Healthcare Disruption, Healthcare Technology, Healthcare transformation, Interoperability, M-health, Outcomes, Patient Satisfaction

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Realizing Value In Patient Engagement

Patient engagement has moved from a theory to a reality, which means that evaluation criteria as evolved as well. It also means that instead of the early pilots where innovative organizations intuitively took the leap because helping patients self-manage just made sense, for enterprise-wide deployments questions of return-on-investment, and where and how to realize value are crucial.

Our customers are realizing value in 3 key areas:

Improving patient outcomes and satisfaction. This is practically a table stakes issue. If a solution doesn’t improve outcomes and patient satisfaction, don’t deploy it. We work closely with researchers, and analyze our own data, and in a randomized clinical study conducted by Boston University’s Center for Neurorehabiltation, people with Parkinson Disease showed positive physical outcomes and 9/10 patient satisfaction. We see these high levels of patient satisfaction in studies, and in real-world patient scenarios.

“This program has empowered me, lifted my morale, renewed my hope, and given me tools. Thank you for helping me regain my life!”

Parkinson’s patient, Boston University Center for Neurorehabilitation

Increasing access to care. Time is money, especially for specialists. We’ve been able to decrease follow-up visits by 10% because patients were able to self-manage. This means that the specialists had more appointments available for new patients, and were able to decrease wait times for referrals.

Decreasing and avoiding costs.  Through our automated message classifier, we’ve determined that 70% of patient messages in the system do not require a follow up. This decreases the need for unnecessary outreach to patients, while patients still stay on track. Other hard cost reductions are in the administration of patient reported outcome surveys—automating these processes deliver better completion rates, and frees your staff for more important tasks.

Possibly the most important way to decrease costs is to decrease readmissions. By analyzing patient-reported symptoms post-surgery, we are able to determine patterns that indicate a higher risk of readmission. Catching these issues early can prevent readmissions and deliver better outcomes.

You should see value in each of these three areas when deploying an enterprise-wide patient engagement solution. However, where you see the most value depends on a number of factors: 1. Your practice and reimbursement model. 2. The patient population. 3 The service line. We’ve found however, that one area of value will be the tipping point for either your organization or your patients.

For a consultation on return on investment and value of patient engagement, contact sales@wellpepper.com.

Posted in: patient engagement, Patient Satisfaction

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Evaluating A Patient Engagement Solution

In the past year, patient engagement has evolved past pilots to enterprise-wide deployments, and standards are emerging to evaluate patient engagement platforms. We definite patient engagement platform as a comprehensive system to enable patients to participate in their care, follow treatment plans, and get support from their care team. These patient interactions may occur outside the clinic or inside the hospital setting or clinic. What’s key is that they occur on the patient terms, and the patient device.

Here’s a checklist to get you started, and you’ll find in this check-list why your EMR will not deliver a compelling patient engagement experience.

  • Engagement: The first job of a patient engagement system, is of course, engaging patients. You should expect significantly better uptake in user interactions from a patient engagement system than from your patient portal. What percentage of patients login and use the platform? Do they show the ability to engage patients over time? Are there statistics for engagement for different patient demographics?
  • Usability: Patients are consumers, and their expectations for usability of your application are the same as for any other application on their devices. Can you deliver an experience on par with great consumer applications? Can patients of all ages and abilities use the application without help?
  • Multi-modal Interactions: This is a fancy way of saying that the system needs to support different ways of interacting with patients, for example, SMS, email, web, mobile application, and emerging technologies like voice. Can the system deliver patient interactions in ways that are appropriate for the patient and the content?

multimodal patient interactions

  • Interoperability: Your patient system will need to interface with other systems, like your EMR, scheduling, referral management, and possibly even billing systems. Interoperability needs to be built in from the initial design of the system. Does the patient engagement system have an API? Does it charge extra for application integration interfaces? If the answer to either of these is no, you don’t have an interoperable.
  • Scalability: Scalability takes two forms. Does the system help you to scale care? Can you see more patients, or see patients more efficiently because they can self-manage? Does it provide recommendations for providers and alerts that are at the right level for the interactions? The second form of scalability, is in interventions. Point solutions may address one type of intervention very well, but both patients and health systems need to manage multiple problems. Does the system scale to any type of intervention?

You’ll notice that this list does not include HIPAA compliance: that’s a given. Security and the protection of PHI are table stakes that any good system can show you before you start the rest of the evaluation.

In addition to the technical and usability criteria, your patient engagement solution needs to deliver on value. Determining value will be different for each organization, but we have some tips to help you make the case for yours.

Posted in: Adherence, patient engagement

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Trends That Survive Healthcare Reform

While many aspects of the Affordable Care Act drove significant new opportunities, innovation and change in healthcare, this recent article from Harvard Business Review points out that there are trends that are not dependent on the system. In particular they identify three trends that are not dependent on the act in its current form:

  1. Aging population
  2. Technology adoption
  3. Discoveries in life sciences

However, we think there are at least three more that will mean that the momentum in technology innovation and a patient-centered approach will continue.

  1. Consumer focus: High deductibles are driving two types of behavior. Patients are acting more like consumers and are shopping with their healthcare dollars. Healthcare organizations are trying to attract patients and better understand their experiences and pathways through the organization. The expectation of good and real-time service is high.
  2. People are getting less healthy: While we would like to see this change on its own, through diet and exercise, the fact is that people are not eating well or active enough, and the rates of diabetes and pre-diabetes are increasing. By 2030, it’s estimated that over 470M people world-wide will have pre-diabetes.
    Leading causes of death

    Leading Causes of Death from http://www.independent.co.uk/news/health/the-things-most-likely-to-kill-you-in-one-infographic-a7747386.html

  3. Value stays top of mind: Our healthcare costs cannot keep rising indefinitely, and experiments in value-based payments have shown to work. Payer/provider organizations are looking to deliver better outcomes at lower costs, and patient self-management and self activation can help with that.

While patient engagement is not the only solution, we believe activated people and patients are an under-utilized source of positive health outcomes. Regardless in of changes in the healthcare act, that will remain true.

Patient engagement has been a mantra for those seeking to reform health care, as it’s widely accepted that patients who are engaged in their own health care have better outcomes. Frank Baitman & Kenneth Karpay

 

Posted in: Healthcare Policy, Healthcare transformation, Outcomes, patient engagement, Uncategorized

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Mary Meeker’s 2017 Healthcare Trends Report Shows Opportunity

An annual highlight of Recode’s CodeConf is Mary Meeker’s internet trends report. Last year, I had the pleasure of hearing her in person, and I’m not sure I’ve ever heard a presentation with so much good data, presented so quickly. This year, I wasn’t able to attend, but she also ran out of time for some of the most important slides for a healthcare entrepreneur like me. Based on a quick run-through of the deck, these three slides struck me. (If you want to see the full section on healthcare, it starts at Slide 288.)

Not surprising that consumers expect digital health services, or that Millenials lead in most categories. It’s also not surprising that Boomers have sought the most remote care–they have probably sought the most care overall. It might be interesting to see this pro-rated by care usage. That Boomers are not looking at online reviews is very interesting given how much attention the surgeons we work with give to them.

 

 

 

 

 

 

 

 

 

 

 

 

Even with all their consumer device troubles, Samsung squeaks above Apple, and Facebook and Amazon both with a tremendous amount of data about you, are still reasonably well trusted. Both Microsoft and Google have tried and failed previously to own your personal health record, but they are well positioned to do so. What would also be interesting is to see these trust levels against traditional healthcare companies like GE or Johnson & Johnson.

 

 

 

 

 

 

 

 

 

 

 

 

EHR adoption is not surprising since it was mandated through meaningful use. It’s a bit depressing to look at the 2004 stats, and think back to which parts of your life weren’t digital in 2004, and compare that to your medical records. However, the biggest opportunity we see in this slide is dramatically expanding the data points available by tracking patients outside the clinic. Physicians are making decisions with only a few data points when there is so much richer information available through patient-entered and patient generated data.

Posted in: Healthcare Research, Healthcare Technology, Healthcare transformation

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Patient engagement and design in the art of medicine

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

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

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

Posted in: Behavior Change, Healthcare transformation, patient engagement

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Comprehensiveness + Comprehension: effect of technology on discharge instructions

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

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

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

References

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

Posted in: Healthcare Technology, Patient Satisfaction

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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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Exposure at a digital health startup

Physicians typically endure years of training by being put in a pressure cooker with no safety valve. They persist through sheer brute force and discipline within a highly regulated, high barrier to entry industry. The high stakes culture of medicine often lends to emotional immaturity and an inability to relate to most of the world around. Ironic and sad, given that one of the core principles in patient care is to demonstrate empathy towards the human condition. The information asymmetry that exists between patient and provider further puts more onus on the physician to have character and compassion. In addition to being out of touch with reality, physicians also grapple with the changing times. Technological advancements and accessibility of information through technology has influenced the way physicians learn and practice medicine. Physicians who are uncomfortable with technology tend to find it harder to keep up with the latest innovations and research that affects patient care.

I chose to do a rotation at a digital health startup because of the fear of being disconnected and clueless. Plus there are a few other beliefs of mine that I wanted to more fully explore during my time at Wellpepper:

  • Understanding patients in the aggregate is important. Understanding what patients want, feel, and expect is not just an interesting data set, but is essential for me in providing optimal care. While a physician still deals with a patient one on one and the experience is influenced by patient characteristics, knowing the context in where the patient is coming from provides the best chance for an optimal encounter.
  • Technology that enhances the patient-physician relationship is a top priority. The physicians I have respected the most have tier 1 communication skills and relationships with their patients. A good relationship can literally bend the physics of the situation (e.g. that’s why doctors who have good bedside manner don’t get sued).
  • Technology that promotes value based care is the current landscape. It is no longer around the corner. Every stakeholder in healthcare is interested in improvement of care from an outcomes and cost perspective. Current practices in medicine are rapidly adapting in order to keep up.
  • Betting against yourself is a great strategy for growth. Based on the culture of medicine, it has always been more important for me to implement care that is standardized and in service of saving a patient’s life rather than considering how he/she feels. Something as simple as a patient having to give five histories within the same hospital admission is normal to me and also has value due to the difficulties in eliciting accurate information. But what if I considered that a patient doesn’t want to hear the same question repeatedly and that ultimately effects his/her perception of care? What if their lives were saved but they didn’t believe that anyone truly cared for them in the hospitalization? Would this be a meaningful experience, or a shallow one sided win? Challenging the way I think, the way I was indoctrinated into thinking and behaving, is something I look forward to in this process.

In summary, I chose to do a rotation at Wellpepper because I have a growth mindset. I want to consciously be a part of the most exciting time in medicine, where the hard work of innovative and creative minds improve patient lives.

Posted in: Behavior Change, Healthcare motivation, patient engagement, Patient Satisfaction

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