Readers Write: The Importance of Technology in Ambulatory Care for Chronic Disease Management

The Importance of Technology in Ambulatory Care for Chronic Disease Management
By Allison Hart

Approximately 100 million people are affected by chronic pain in the United States, and, according to the CDC, nearly half of all adults in this country are suffering from one or more chronic health conditions. Not only are healthcare providers faced with the daunting task of caring for such a large population, but care for such conditions often require multifaceted treatment protocols to address a wide range of disorders. Due to this, care management for chronic patients can be costly – demanding additional healthcare resources and extensive treatment measures beyond the clinical setting.

Financial pressures and performance demands to keep chronic patients healthy have sparked efforts to find new ways of supporting patients during ambulatory care in order to maximize revenue, reduce readmission penalties, and improve outcomes for less. Due to the complexity of most chronic cases and the sheer number of patients, it is difficult for any organization to effectively manage and engage every patient outside of a clinical setting without the right tools.

According to a recent West survey, more than half of patients struggling with chronic disease are only somewhat confident, at best, when it comes to managing their condition. And, another 35 percent of these patients were not sure what their target numbers should be for key health indicators like blood pressure, cholesterol, and weight. In order to effectively manage chronic conditions, not only does each patient need to feel confident in their understanding of treatment adherence, but both patient and provider need to have a firm grasp on the patient’s daily health status in order to avoid declining health and costly hospitalizations.

Successful chronic disease management requires continuity of care. A patient’s checkup is only a small portion of managing a chronic disease, especially when dealing with complex conditions like diabetes that require frequent monitoring and balancing of insulin levels, weight, and blood pressure. Research has shown that patients have a strong desire to improve their quality of life, but in many cases, they are unsure how to make decisions or changes that will create real improvement. Healthcare providers can support chronic patients with engaging outreach and resources that give patients the knowledge they need to better manage their condition.

The Role of Remote Technology During Ambulatory Care

The rise in value-based payment models has prompted healthcare organizations to invest in more efficient methods of patient management – including technology-enabled communications – to help improve the quality of life for patients in a cost-effective way. The rise of biometric monitoring devices, such as pulse oximeters, blood glucose meters, and heart rate monitors is making it easier for physicians to closely monitor a patient’s health status remotely. But while tracking daily analytics is key to ensuring chronic patients are maintaining good health, it is only one aspect of treatment.

In addition to collecting data on a patient’s physical health, clinicians can also leverage existing automated reminder technology to create and schedule a series of communications to support the patient’s long-term health management plan. For example, a diabetic patient might receive notifications via email or text to remind them to take medications, schedule routine eye and extremity exams, or schedule an appointment for an A1C draw. Automated communications can also be used to lend preventive support to low-risk patients to provide educational materials such as recent research on how to manage their specific ailment, videos on diet or exercises, or links to support services. Pairing biometric device data with automated support during ambulatory care can help providers establish critical touch points for intervention, or better predict negative outcomes that might escalate into a readmission.

Automated Surveys Streamline Treatment Efforts

The use of surveys in chronic care management have traditionally been reserved for recently discharged patients and offer great insight into how a patient is coping outside of the clinical setting. In fact, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys found that patients often expressed feeling disconnected from their medical team after discharge and even confused or uncertain about how to comply with care instructions after leaving the hospital. This type of information is paramount for case managers dealing with newly released patients, but could also prove invaluable for physicians caring for the long-term health of chronic patients in the ambulatory setting.

Surveys are currently underutilized by most providers as a chronic disease management tool. The same survey found that many providers monitoring the health of their chronic patients depend on in-person visits to ask questions, while only five percent stated they use survey check-ins that ask questions specifically about treatment plans. Not only is this a costly approach for both healthcare organizations and patients, but it lends itself to poor results in terms of accurately monitoring each patient’s progress on a consistent basis.

Similar to the HCAHPS, clinicians can leverage their automated reminder technology to more proactively and regularly send their chronic patients a series of questions regarding things like pain levels, medication compliance, and sleep patterns to determine if the patient is on track with treatment or if they need to intervene. Leveraging their EHR systems, care teams can also target efforts based on risk stratification – sending more in-depth questions to those more likely to develop complications. This method provides clinicians with a cost-effective method of collecting continual feedback on how each individual patient is coping during daily life. It also addresses the issue of patients feeling disconnected with their providers and makes them feel that their care team is engaged in their treatment journey.

Chronic disease management is complex and requires a multifaceted approach by providers and patients. The office visit is just the beginning of care – effective care management requires that providers and healthcare organizations incorporate the right tools and strategies in the ambulatory setting to reduce readmissions, engage patients, and prevent long-term cost deficits. Leveraging cost-effective technologies that allow patients and providers to stay connected on a day-to-day basis is changing the way doctors and patients approach chronic disease treatment.

Allison Hart is vice president of marketing for TeleVox Solutions at West in Omaha, NE.

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Readers Write: The Promise (and Pitfalls) of Greater Consumer Expectations

The Promise (and Pitfalls) of Greater Consumer Expectations
By Anne Weiler

Consumer expectations are finally hitting healthcare. We’ve long become accustomed to having anything we want delivered to our homes at any time, in minutes. This level of 24/7 convenience is driving an expectation that all service delivery should be that good. And healthcare is no exception in the eyes of increasingly cost-conscious consumers. After all, rising deductibles, premiums, and copays are causing people to examine where they spend their healthcare dollars, leading them to evaluate care based on outcomes, convenience, and overall experience. We first saw indications of this on highway billboards advertising emergency room wait-times. It’s now spilling over into other areas of healthcare, like concierge medicine and direct primary care, both business models that give patients almost unlimited access to their care team. Healthcare technology is certainly aiding and abetting these expectations, with telemedicine perhaps offering the most promise in meeting expectations around convenience and up-front costs.

Virtual assistants and interactive mobile treatment plans also show huge promise. But for these burgeoning healthcare concepts to take off, their popularity with patients and physicians alike hinges on some basic tenets. First, patients need to feel supported and confident. Once they do, they can start to self-manage outside the clinic. The old way of delivering care instruction – be it verbally or on paper – is seriously lacking in providing this support and confidence. Patients forget between 40 and 80 percent of what is said to them in a face-to-face visit, while paper instructions are often lost. Virtual assistants and apps are always available, and can deliver tailored information when and how patients need it. They can alert both the patient and care team when something requires greater attention. This ability to provide actionable, personalized, and real-time care shows great promise in improving patient experience and outcomes.

However, the challenge in creating this always-connected world of healthcare – whether that’s through consumer health apps, wearables, or even those apps prescribed by healthcare organizations – is that they generate more data than physicians know what to do with. Though this data can provide extremely valuable insights to manage populations, there’s often no place for it in the medical record, which is not designed for patient-generated data.

Data without context is meaningless, which is why physicians initially balked about having device data in the EHR. While understanding how much a healthy person is active is interesting, you don’t need Fitbit data for that when there are other clinical indicators like BMI and resting heart rate. Understanding how much someone recovering from knee surgery is walking is interesting, but only if you understand other things about that person’s situation and care, such as how much they walked before surgery, pain levels, and side effects.

However, if you ignore the patient experience outside the clinic, decisions are being made with only some of the data. In Kleiner-Perkin’s State of the Internet Report, Mary Meeker estimates that the EHR 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 from aggregated information.

How do you marry this patient-generated data with current healthcare IT systems? The value of patient engagement and self-management through virtual assistants and applications is real. Current systems, however, aren’t designed for this data. To the patient, every single one of those Fitbit steps or recorded symptoms is interesting. To the physician, it’s noise. To make sense of these two worlds, we need a few things. First, we need to leverage machine-learning and big data tools to make sense of the terabytes being collected directly from patients. Next, we need to identify indicators of adverse events or negative trends. Then, we need to be able to react to and act on those indicators for patients, either with alerts and instructions delivered by an app, or by direct outreach from a clinician.

Finally, this data needs to make its way back into the patient’s medical record – but not all of it. Scores from patient-reported outcome surveys, important recorded symptoms, and trend data should be attached to the EHR. The rest should be available directly to the patient, and to clinicians and analysts to work with in BI and other tools. To make this new world a reality, patient engagement systems must be interoperable and open, and sit side-by-side with the EHR. There’s a whole world of data and learning out there to improve patient experiences and outcomes, but to capitalize on it, we need openness and interoperability.

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.

Anne Weiler is co-founder and CEO of Wellpepper in Seattle.

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Readers Write: Guiding Principles for Designing a Useful Healthcare Mobile App

Guiding Principles for Designing a Useful Healthcare Mobile App
By Calvin Chock

Healthcare mobile apps can provide many benefits to busy physicians. Roughly 80 percent of healthcare providers use smartphones and medical apps, and more than 25 percent rely on mobile apps to provide patient care. In discussing mobile app usage, physicians strongly voice the need for quicker and easier access to patient data. If a mobile app is well designed, enables efficient access to patient data, and is easy to use, it can serve as a powerful companion to an EHR. By following some basic guidelines during the concept and development process, a robust, user-friendly mobile app can be built that meets a physician’s need for quick and easy data access.

The methodology outlined here is specifically targeted towards large applications with hundreds of features, complex workflows, and a vast number of users interacting in different ways. For these complex applications, the challenge is to design a solution that is useful but that will also fit into a much smaller form factor. Often, the trade-off involves realizing the full application cannot be fully converted into a mobile app, and instead making a version that is less complex, sequestering a subset of valuable features that are not meant to replace the full application but instead complement it.

Guidelines for Developing Critical Elements Help Ensure Success

There are several basic elements that require much thought and consideration when building a mobile app from a complicated application such as an EHR. This includes the overall design and layout, the types of user interfaces, and user experience.

Follow Design Principles and Build a Strong Foundation

First and foremost, realize that it is unlikely that all the information in the application can be crammed into a tiny screen. Distil the information down by breaking it into smaller subsets using a few logical steps:

Build an inventory of workflows.

Physicians, nurses, pharmacists, and other key staff all have different screen sets. Take an inventory of the workflows for various users to find out what they do during the day. Watch, observe, study, and write down each user’s role and their distinct user pattern.

Determine which items on the list are a good fit for a mobile app.

Look at the subset list closely and decide which workflows make sense to put in a mobile app and which will be challenging or cumbersome due to the limited size. Also, review each one and ask yourself, “Was the user able to fully complete a useful task?” If the answer is yes, keep it on the list. If not, then consider whether that specific workflow is a good candidate for a mobile app.

For example, during office visits, physicians document a wide range of a patient’s medical details. This function is probably not the best candidate for an app due to the large number of data entry fields and content. Phones are not great data entry vehicles, so trying to type a lot of information in can be cumbersome and frustrating. In contrast, physicians spend a tremendous amount of time reviewing patient data and acknowledging this review was done.

An example of a typical day would include a review of hundreds of lab results, dozens of notes, and several new orders. Lists of data that require limited data entry lends itself well to a mobile app. This tedious and time consuming work can now be done outside of the office, which now gives physicians the flexibility to do this work on the go.

Rank each item’s value.

Of those workflows that you determine will work well on a phone, rank the value of each subset based on potential user utilization of the app or other factors.

Once the subsets have been ranked, establish one theme for the app’s purpose. Too many different themes are confusing. For example, if the main goal is to empower the user to perform tedious work on the go, then define that as the primary goal and rank the features based on achieving that goal.

Utilize the Minimum Loveable Product (MLP) concept. In many applications, there is a choice between speed of delivery versus quality. If the mobile app is meant to be a compliment to the main application versus a full replacement, then designing an MLP will allow you do deliver a solution quickly and with high quality. Start the design work of just the most valuable workflows first, building one highly usable feature at a time. As users rally around that one feature, they get eager for the next one. You won’t sacrifice quality, and will still deliver new features at a good pace.

Lastly, use smart phone features to your advantage. Incorporating Location Based Services can save the user time in filling out location-related data entry fields, notifications can provide important alerts to users while the app is not in focus, and the camera phone can be used to take photos of documents or patients for immediate upload.

Create a Great User Experience with a Simple Layout and User Interfaces

Once the main theme is selected and an initial set of features has been identified, the last step is to take the time to think about how the app will look and how the user will interact with it. Going from a wide screen to a tiny one is challenging, so screen element choices are critical to maintaining a high level of usability. Only essential information can be shown, and creative ways must be utilized to display information. For instance, instead of showing the full directory of a file system, a hierarchy can be represented by descending shades of a color, saving time and real estate.

Be consistent with elements used throughout the app. If a field is accepted by clicking a button or swiping left to right, the same method should be used on every single page. Having a consistent user interface is key to the learnability of an application.

Employ user-friendly interface elements, such as big toggle switches, buttons, swipes, or gestures. Entering a lot of data using a phone is frustrating, so limiting free text entry when possible is important.

Make the app look simple and easy to use so practice staff can absorb the view quickly. Avoid too many user interfaces, text, and other details, or the screen will look cluttered and confusing.

Finally, verify that the user interface design will work on the majority of phones users have. While phones today are standardizing, it is still important to check. Time and expense can be saved by building the app to support only the top two or three phones potential users have.

Calvin Chock is VP of product management and engineering at McKesson Specialty Health in The Woodlands, Texas.

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Readers Write: Will Blockchain Survive Healthcare?

Will Blockchain Survive Healthcare?
By Daniel Kivatinos

Blockchain technology is here and thriving, with bitcoin as its primary use case. I expect it will be applied to many industries in the coming years; but the question is, will it work for healthcare? Generally, healthcare has lagged in adopting newer technologies. We have seen the medical industry struggle to move fully off paper, slowly digitizing medical records over the last several decades. The digitalization of healthcare is still happening. Ten years from now, everyone will have easy access to their medical information from around the world via their smartphone. But will blockchain survive the healthcare hype and end up the game-changer some are predicting it will become?

Blockchain Basics

Blockchain’s initial HIT use case began in cryptocurrency along with bitcoin. At the simplest level, blockchain is a distributed ledger. The power of a distributed ledger is that there are many copies, and it creates a new system of checks and balances. As we’ve seen from the headlines, the concept of an encrypted distributed ledger via blockchain is now spreading to other areas like healthcare.

Today, organizations typically have one central administrator that holds the key(s) to the kingdom, one canonical source of truth, one ledger, and one log of transactions. The ledger isn’t spread across a network of different parties. The concept of having multiple digital ledgers from different parties offers a number of security benefits:

• It would be very hard to simultaneously hack all digital ledgers.
• Errors in one ledger can be checked against other ledgers from other parties.

Healthcare Use Cases

Here are several use cases that illustrate how blockchain could work in the healthcare industry:

● Use Case 1: If a physician specialist needs access to a patient’s health history, blockchain would duplicate the medical record and log transactions. One transaction would happen at a physician encounter where a checkup might happen, maybe a radiology image is taken and a prescription refill occurs. After the encounter, a trusted party would validate the transaction with an access key. The blockchain app would timestamp the verified block and add it to the chain of older blocks in sequential order, hence adding a block to the chain. Then the transaction would be distributed to other ledgers, giving other parties copies of the medical record. This would be a great way to keep up to date on a patient’s health if, for example, two providers from different organizations needed to keep track of a patient.

● Use Case 2: Blockchain technology could also be used for medical billing, logging with blocks on a chain and showing all payments from claims from multiple payers. With the United States GDP Health expenditure growing from 13.1 percent in 1995 to 17.1 percent in 2014, according to worldbank.org, having a bit more logging around medical transactions might help identify billing discrepancies and potentially reduce costs.

● Use Case 3: Organizations are also thinking about how they can apply blockchain internally to boost their infrastructure while having multiple parties that, under lock and key, have copies of the ledger. This has the potential to stop hospital ransomware attackers in their tracks.

In summary, healthcare organizations of all sizes are contemplating the ways in which blockchain may benefit their business models. But as we’ve seen with healthcare, its adoption will occur only after its obstacles have been overcome and its value-adds fully realized. Time – and lots of it – will be the barometer of blockchain’s survival in healthcare.

Daniel Kivatinos is co-founder and COO of Drchrono in Mountain View, CA.

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Readers Write: America’s Doctors Need a Neutral Internet

America’s Doctors Need a Neutral Internet
By Matthew Douglass

In 1984, Stewart Brand, a close friend of the founders of the Internet, famously said, “Information wants to be free. Information also wants to be expensive.” Three years ago, I detailed why classifying the Internet under Title II of the Communications Act was so important to preventing Internet services and accompanying information from becoming expensive for Internet consumers and businesses. An active public debate occurred that year, with a record 3,700,000 public comments submitted to the FCC, including the views of hundreds of top investors, leading technology companies, churches, and civil society groups.

After much public debate and consideration, the FCC in 2015 voted to regulate broadband Internet service as a public utility in an effort to “protect innovators and consumers” and reassert the Internet’s “core of free expression and democratic principles.” Cable and telecommunications companies are now explicitly restricted from discriminating among website providers and content, or treating them in a different manner. Today, the Internet thrives as it has since its invention: There are no fast lanes or slow lanes, and no company’s Web traffic can receive preferential treatment or prioritization.

Just two years after that rulemaking by the FCC, Ajit Pai, the new head of the FCC, has now proposed repealing that critical decision. Changing these existing rules could allow Internet service providers to charge different prices to consumers and businesses based on the influence of the company transmitting data or the type of information being transmitted.

As was successfully argued a few years ago, differently priced lanes on the Internet would primarily benefit incumbent Internet applications and be particularly burdensome for Internet consumers and small businesses fighting to compete with larger, entrenched companies.

The Health IT Connection

Medical practices in the US are becoming increasingly reliant on EHRs to run their businesses and treat patients. The future of EHRs is in the cloud, especially for independent physicians who are particularly sensitive to technology costs for their lean, small businesses. The last thing that independent physicians need is to have to bear additional costs to their business on top of what they already spend on critical medical technology.

Imagine if there were more expensive lanes on the Internet that promised faster speeds. By definition, the less expensive lanes would be slower. Since healthcare applications are now mission-critical for doctors to be able to treat their patients, customers of ISPs that introduce tiered pricing would be forced to choose the faster, more expensive plans. Physicians operating their practices on a shoestring budget would be directly affected and would potentially face significant harm. At a time when the entire healthcare industry is shifting to value-based care, we should be looking at ways to ensure the financial viability of independent practices, rather than endangering their existence by imposing additional, unnecessary costs.

Another ramification of allowing ISPs to determine which traffic belongs in a fast lane is that they could preferentially speed up or slow down the services of specific companies. For instance, a digital health company owned by an ISP could be given preferential speed over the services of competitors. This situation would directly impede competition, discourage startup companies from entering the space, and reduce freedom of choice for physicians and patients. America’s doctors and patients should determine which Internet-enabled healthcare services will thrive based on better functionality, not because of delivery speeds decided by ISPs with potential conflicts of interest.

If it Ain’t Broke, Don’t Increase the Cost

The Internet Association and its member companies, including mine, has reasserted its support of the existing FCC regulation of the Internet: “The [I]nternet industry is uniform in its belief that net neutrality preserves the consumer experience, competition, and innovation online. In other words, existing net neutrality rules should be enforced and kept intact.”

Doctors need new, innovative technologies and freedom from the burden of new, unnecessary costs to be able to do their jobs well in our rapidly evolving, 21st century information economy. The last thing they need is the heavier burden of additional costs required to run technology that is essential for patient care. A neutral Internet without fast or slow lanes is crucial for the US to maintain the innovative and entrepreneurial engine that has driven our powerful information-driven economy for decades.

When medical students begin studying for careers as physicians, they pledge to “first, do no harm.” The FCC would be wise to take a similar approach to net neutrality as it stands today: “If it ain’t broke, don’t fix it.”

Matthew Douglass is co-founder and SVP of customer experience at Practice Fusion in San Francisco.

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