In January 2015, Stanford Medicine launched ClickWell Care, a new type of Primary Care clinic which leverages technology to allow patients to virtually connect with their own Stanford primary care clinicians and wellness coaches via video or phone visits.  Patients use the MyHealth mobile app to schedule and conduct a video visit and share home health device data with the care team. Through this model, patients can choose to receive all of their primary care including integrated wellness coaching virtually, unless the physician indicates the need to come into the clinic for vaccinations, pap smears, procedures, or other physical exam needs.

“Initially we created this virtual model for our ACO. We knew that 18-30 year olds were not interacting with primary care and were choosing to go to the Emergency Department or urgent care for their needs. During focus groups with this patient population, we learned they were so busy and didn’t have time to come into the office but really valued the relationship with their doctor. They wanted to receive care from their doctor but it wasn’t available in a way that was convenient to them.  We knew that we needed to use technology to help support this relationship and not replace it”, explains Sumbul Desai, Medical Director ClickWell Care and Vice Chair of Strategy and Innovation in the Department of Medicine at Stanford University School of Medicine.

ClickWell clinicians and coaches support healthy patients and the ‘rising risk’ (e.g. up to 2 conditions), who are employees of Stanford University, Stanford Adult and Children’s Hospitals. With this highly educated, tech savvy patient population, there is a tremendous opportunity to leverage mobile tools to enhance the patient experience.

Patients see a doctor for primary care visits and engage with a wellness coach on health goals (i.e. weight loss, stress, activity, and nutrition) and to receive support for chronic conditions (i.e. diabetes, hypertension and hyperlipidemia).  “The average age of a ClickWell patient is 36 years old.  However, we have a growing group of 40-65 year olds, part of the ‘rising risk’ population, who prefer to do the majority of their visits virtually. These patients feel comfortable interacting by phone or video because they have a better understanding of the healthcare system and their health goals than our younger patients”, Desai shares.

The ClickWell Care program is designed to give patients complete control over how they want to access and interact with their doctor/coach and convenience of extended hours. Although patients have the option of scheduling a face to face appointment, they are incentivized to participate in a “no fee” virtual phone or video visit. Patients simply log into the MyHealth portal for their virtual appointment. 

To date in the ClickWell program, there have been 2,142 visits; 43% conducted in-person, 32% through phone visits and 25% via video visits. ClickWell staff have seen 1,223 patients. Although 30% of new patients start off with a virtual visit, most prefer to meet their doctor first in-person. After an initial face to face visit, 60% opt to see their doctor virtually for their return visits via phone or video.

MyHealth Mobile AppAll patient information from the virtual visit is transmitted to the Epic EMR and is accessible through the MyHealth portal. Patients can ask follow up questions through the portal.  When patients need to have blood work done, they are directed to the lab without having to come into the doctor’s office, and lab results are incorporated into the EMR with portal access. “Stanford was the first to use Epic’s integrated telemedicine service because we wanted this visit information available to patients in the portal and clinicians in their daily workflow”, confirms Lauren Cheung, Physician, ClickWell Care, and Medical Director, Strategic Innovations at Stanford University School of Medicine.

“One myth about telemedicine is that many patients choose to do video visits over phone visits. The truth is that it is an extra effort for the patient to participate in a video visit since the patient needs to be in front of a computer or mobile screen versus the phone visit which can be done while walking around”,  Cheung adds.

“Back in 2013, we rolled out video visits as part of our primary care practice but we didn’t see a strong uptake. When we conceived the ClickWell Care program, we knew that we needed to introduce wellness coaching to provide a complete overall healthcare experience and deliver a higher level of healthcare service to our patients”, describes Desai.

Strong collaboration with IT and Operations have been pivotal in implementing this new care model. Through this collaboration, ClickWell has been able to leverage the new MyHealth app developed internally and has worked closely with IT to improve the platform and video visit capabilities to provide an excellent patient experience.

As part of the ClickWell Care program, the MyHealth mobile app helps strengthen care collaboration. The doctor/coach prescribes the health tracking app to the patient as a way to monitor key measures which may include steps, weight and blood pressure. The patient uses the MyHealth app to upload tracking data from Withings, Fitbit and Apple HealthKit to the EMR, sharing health status between visits. “When I see a patient with blood pressure trending higher, I ask the patient to schedule an online visit so that we can discuss how to address this through diet or medication changes”, Cheung explains.

ClickWell Lessons Learned

The Stanford Medicine team has gained insight into ClickWell Care program usage, the telehealth platform and mobile app to bring the most value to primary care patients and providers. They understand that it is not about the technology but instead about how the technology is put into the care model through a program.

Patients have shared many positive comments about the ClickWell Care program:

“Video visits allowed me to continue with pressing work concerns, instead of taking time off work to travel to a clinic. Video visits allowed me to chat with a Doctor late in the evening, and appointments were very easy to get.  I felt that my virtual care was more personalized and provided a better experience.”

“I have not had many medical issues until recently. It is such a relief being able to ask questions and get answers quickly. My wellness appointments have me watching my diet and exercise regimen. Everything is done efficiently. I cannot say enough about the whole team that has been watching over me.”

“My experience with the ClickWell Clinic has been extremely informative and remarkably efficient. The flexibility they offer works perfect for people with busy schedules, without sacrificing the quality of care. The model of the Clinic makes other forms of healthcare communication feel outdated.”  

“I have never had better communication and quicker responses than I have since becoming part of this program. I travel a lot and therefore keeping up via phone calls is not that practical. Being able to send messages electronically and to have an appointment via video chat is ideal.”

Doctors and wellness coaches have provided mostly positive feedback as well:

“Overall my experience with virtual visits in the clinic has been very positive. Compared to my previous experience with only in-person visits, it seems like the virtual option may make wellness patients more likely to continue with follow-ups. The integration with the doctors is also helpful in learning more about the patients and providing well-rounded care. It is a unique experience to be able to discuss treatments so closely with the patient’s doctors and in such a timely manner.”

“The integration of clinical care with wellness coaching has been phenomenal. I couldn’t imagine going back to health coaching without it. I am able to provide more targeted, individualized, and thorough care to my patients since I have full access to their medical records, provider notes, and work directly with their primary care physicians. Working directly alongside physicians has helped me to expand my knowledge on chronic disease management, stay up to date on clinical guidelines and recommendations.”

“As a provider, the technologies we use in this clinic allow us to quickly connect with our patients and address concerns for our patients proactively. The extended hours also allow for expanded patient access, as well as a flexible schedule for providers who staff the clinic who may desire alternative hours outside of the usual 9-5 business day.” 

“Through our discussions with patients, we have also heard some suggestions for change. In the beginning, we were contacting patients to convince them to switch from in person to virtual visits. This frustrated some patients and most wanted to stay with the modality that they had initially chosen”, Desai shares. 

Future ClickWell Care

As with other healthcare systems across the country, Stanford Medicine sees what is happening with the retail pharmacies increasing care access to patients. However, they believe this only fragments care because the visits are outside of the patient/doctor relationship. ClickWell Care is designed to be “longitudinal” and not episodic.

In 2016, Stanford Medicine is looking to extend into specialty care. “We are interested in integrating preventative cardiology for our patients since care entails discussing and improving risk factors for cardiovascular disease, which can be done virtually. Preventative cardiology patients would also benefit from wellness coaching to improve their risk factors for disease.

We also want to expand the use of connected health devices. Currently, very few patients upload and share their data with our care team. We are planning to incorporate this health tracking into a program for a  patient population (e.g. specific chronic conditions) and integrate this information into clinical workflow to ensure that these patients receive excellent care. With our Precision Health initiative, we are not just interested in treating illness but rather finding tools to deliver a personalized health and wellness experience to ensure the best outcomes”, Desai concludes.

Dr. Milani with longtime patient Andres Rubiano, pilots Apple WatchDuring the last eighteen months, the Ochsner Health System has moved into new territory, meeting consumers where they are, from their OBar, a retail genius format to patient hypertension pilots with the Apple Watch to drive behavior change. 

As an innovative healthcare organization, Ochsner, a large Louisiana- based health network with 12 hospitals, 40 clinicians and an a 1,000+ Physician Group Practice, is committed to helping consumers use mobile and wearable connected health tools for self- management and care collaboration

It all started back in late 2013 when Dr. Richard Milani, now Chief Clinical Transformation Officer and Vice Chair of Cardiology at Ochsner, observed what was going on nationally, a tremendous growth of mobile phone and smart apps. “At the time, I noticed that a lot of people didn’t know much about the health apps and wearables or were fearful about how to use them. My background is in preventive medicine”, explains Dr. Milani. “I saw a powerful opportunity for Ochsner to empower consumers to use mobile technology to enhance their health, opening the door to favorable behavior change.”

OBar, Retail Genuis Bar with Apps & Devices  

After more than nine months of planning, Ochsner launched their OBar in early 2014 at the new Ochsner Center for Primary Care and Wellness. The OBar is located in the lobby to attract people walking by as well as patients. The retail store is welcoming with digital tablets loaded with vetted mobile apps to support consumer health, “non-clinical” genius types to answer questions, provide guidance and sell discounted devices (i.e. Activity Tracker, wireless scale, blood pressure cuff and glucometer). “We created this retail setting to show people how to make themselves healthier on their own, independent of their health system. We also felt that as a health system, we could show you which health apps were good and can help you get the app loaded on your phone to begin using it.”

Doctor gives patient RX for App, directs to OBar Ochsner wanted to go further, tying the OBar into their primary care services. Dr. Milani and his team created a prescription pad for their PCP offices, which lists the types of available apps and devices. The doctor simply checks off, hands the patient a prescription pad sheet and directs him downstairs to the OBar. Since this extension into primary care, clinicians have heard back from their patients about how the apps and devices have helped them make better health choices around activity, diet and their disease. Patient feedback has motivated these clinicians to tell others about the OBar.

Dr. Milani went on to explain that the OBar initiative is not designed to be a profit center. As a non-profit, Ochsner is most interested in helping people stay healthy and has invested in a retail format as a way to be sticky to attract and keep consumers coming back. As with any retail store, visitors walk in and out which makes it challenging to capture and measure the value that consumers have gained from using these apps and devices. Through anecdotes, however, Ochsner has heard about the weight loss, the knowledge about “buying the right foods” and the ability to better “understand my disease”, which has helped many consumers visiting the OBar.

Apple HealthKit & Epic Integration for Connected Health

Ochsner was the first hospital to integrate the Apple HealthKit with their Epic system. This integration powers their Connected Health programs. While the patient is still in the hospital, she is given a tablet to answer a detailed questionnaire. Hypertensive patients, for example, are asked sodium consumption, medication adherence and affordability, social situations, depression, physical activity, BMI, sleep, Health literacy, Patient activation and more. Ochsner believes that patients respond more truthfully to the tablet.

“We are phenotyping patients based on their specific disease and psycho- social measures that are fed into algorithms to personalize the care plan and decision support tools”, Dr. Milani explains. “Ochsner started with Heart Failure in early 2014, with a program for CHF patients to avoid readmissions through weight monitoring. In February 2015, we launched our Hypertension Digital Medicine Program, monitoring blood pressure and heart rate. “With the HealthKit/Epic integration, we are able to use the patient’s unique responses to the survey combined with the monitoring data to tailor the intervention to the individual”, adds Dr. Milani. Ochsner care providers monitor the dashboard to determine which patients are the priority today and to see the task check list for action.

The national data reflects that currently, only 50% of individuals diagnosed with hypertension (high blood pressure) have their blood pressure under control, or at goal.  Lack of achieving goal blood pressure means that these individuals have significantly higher rates of stroke, heart disease and kidney failure. Ochsner has enrolled only patients that have failed to meet control blood pressure goals, and using this integrative approach, has achieved more than 60% control rates within 2 months.

Dr. Milani and his team wanted the patient to see his progress in the program and designed an insightful report, which visually displays results and progress, quantifies risk and describes how the patient can reduce that risk. This program report is available in the patient portal and is also mailed monthly to the patient. “We decided to mail the report because we wanted the patient to have the opportunity to share the report with their family and to have the discussion about how they are doing in controlling their blood pressure in order to strengthen every day support”, admits Dr. Milani.

In addition to the program report, program participants receive ongoing mobile texts for motivation and encouragement.

Ochsner closely tracks, monitors and has presented very positive patient outcomes of their Integrated & Connected Health programs. One interesting insight that Dr. Milani has shared is that these participants are more successful in the beginning when they have the OBar support. “A Hypertensive patient can go to our OBar, get the program app downloaded on her phone and a demonstration about how to use the devices. This is especially important with older patients who may not feel comfortable getting set up over the phone. We realize the importance of providing this face to face technology support for our Connected Health program and are adding OBars to our other regions”, confirms Dr. Milani. Ochsner is planning to launch three more retail OBars by the end of the year.

Apple Watch for Patient Pilot

Dr. Milani views the Apple Watch as a behavioral change tool. As a foundation, this is a wearable, with many non-health features which captures the consumer’s attention and motivates consumer engagement. It takes the consumer’s focus off the phone and onto the wrist to communicate time as well as personal and professional messages.

Ochsner is designing a study to understand the potential for changing the consumer’s behavior around health. They will be enrolling hundreds of hypertensive patients with the goal of increasing physician activity and improving medication adherence.

Dr. Milani mentioned two of the health related Apple Watch apps which he plans to incorporate to help patients achieve the pilot goals. “There is a WebMD app which is a great medication reminder. It taps you on your wrist and shows you the picture of the pill that you need to take at that time. This is important because 50% of patients with chronic disease do not take their medications as prescribed. The second built-in app is for physical activity which can be used to set goals. It will tap me and remind me to stand up every 50 minutes. I can also see how I am doing against my activity goals”, shares Dr. Milani.

For the Apple Watch pilot, Ochsner will compare the outcomes and behavior change for patients in their Hypertension Digital Medicine Program with a subset of patients who also have the Apple Watch medication and activity reminders and tracking. Throughout the pilot, Dr. Milani and his team will be closely monitoring whether and how these apps impact positive patient behavior change. 

Carolinas Healthcare System, the second largest public, not-for-profit healthcare system in the U.S. (39 hospitals, 900 care locations) based in the Southeast, is committed to using technology to engage patients for better care. Last Fall, Carolinas HealthCare launched their Virtual Visit initiative to bring convenience to patients. Like other innovative healthcare systems, Carolinas HealthCare also launched a mobile app for patients to access their portal (MyCarolinas), inform about the closest urgent care location with wait times as well as offer a provider search.

 “This was just the beginning,” explains  Pamela Landis, AVP Information Services at Carolinas HealthCare System. “We wanted to go beyond supporting patients when they needed care to becoming part of our patients’ every day health.” 

 Based on the market trends showing consumer’s increasing use of both mobile and social media, Carolinas HealthCare System decided to invest in technology to provide ongoing information and support. While conducting marketing research, Carolinas HealthCare learned about consumers use of different wearables and tools to track activity, fitness, nutrition, sleep and health issues and heard about their frustrations having  information housed into various apps. For instance, a person could be tracking their activity in Runkeeper and using a Bluetooth-enabled scale and blood pressure cuff. All that data is being stored in separate apps.

 “We wanted to address their needs, giving them a holistic view of their health by bringing together information from all of their trackers. We leverage the health kits from the major smartphone platforms for the information aggregation,” shares Landis.

 “The first app, Carolinas Tracker, available in both the Apple and Android stores, enables consumers in the community to aggregate their health data from apps and devices into one place and view a dashboard to see where they need to focus their attention (i.e. be more active and manage their health conditions).” Carolinas Tracker gives people an easy way to track their health and provides clinical context around how they are doing. Consumers can not only see how many steps they have done through their Fitbit data but also whether that is enough to reach their goals through their Carolinas Tracker dashboard.

The second app, MyCarolinas Tracker for Carolinas patients, will enable patients to bring together the same tracking information as the consumer app but will also integrate with their lab data in their patient portal. This patient app will also have goal setting capabilities and enable some patients to collaborate with their health coaches.

New Tool for Diabetes Patient & Coach Care Collaboration

Carolinas HealthCare System is planning a program to provide this new mobile app to diabetes patients, given the size of the diabetes patient population at Carolinas (90k patients), significant rise in Type 2 diabetics, the impact on other diseases and long term impact on a patient’s health.  

“We are envisioning an ongoing program (i.e. not a pilot) and want to learn from the early adopters. We plan to invite patients through their physician practice and through our coaching program,” Landis adds. 

Success Measures for Diabetes Coaching App Program

After launching the Diabetes program, Carolinas HealthCare System will look at “adoption metrics” since this type of technology is still in the early stage of use in the market. With many health apps today downloaded and not used, Carolinas HealthCare is interested in seeing app usage such as when and how the app is being used.

“We want to see if patients will integrate the app into their life to live better by taking ownership of their health,” explains Landis.

Carolinas HealthCare is planning to collect qualitative feedback from consumers and patients  through surveys and focus groups to see if/how the app has helped the patient better understand their health and whether it has made the patient feel more in charge of their health.

“We are very interested to hear about the patient’s motivation to use the app and understand triggers, actions and rewards. We want to explore social influence. For example, do the social capabilities with family/friends/care circle help the patient stay more engaged and does this make her more motivated to use the app?  Carolinas Healthcare will also look at hard core usage stats – usage/how often,” Landis explains.  

"When thoughtfully designed and deployed, technology can enhance the relationship of patients with their health and their healthcare team. The solutions we are building will promote empowered patients and collaborative care delivery," explains Dr. Gregory Weidner, an internist at Carolinas Healthcare System in Charlotte, N.C. . Dr. Weidner is also the medical director for Primary Care Innovation and Proactive Health and brings vision and leadership to ambulatory care redesign and digital patient engagement initiatives.

Twine Health Mobile App Engages Patients with Chronic ConditionsThe story about the health decline of our citizens is being told everywhere. According to the CDC website, “as of 2012, about half of all adults—117 million people—have one or more chronic health conditions. One of four adults has two or more chronic health conditions”.

This negative trend is driving up healthcare costs and putting an ongoing strain on our healthcare system. A 2010 Robert Wood Johnson Foundation Report on Chronic Care: Making the Case for Ongoing Care states that eighty-five percent of all health care spending was on people with chronic conditions.

The positive part of the story is where the industry is heading. In the December 2014 PwC Health Research Institute (HRI) Report, two relevant health directions are described. The first is the “Do –It Yourself Healthcare movement” with implications for healthcare organizations to offer new patient engagement tools. The second is that “physician extenders see an expanded role in patient care”, where “doctor delegates” play an increasing role on the care team, which helps address physician shortages.

The real opportunity is at the intersection of the two, where patients use Do- It Yourself (i.e. self- management) tools which collect and communicate patient data (e.g. chronic condition vitals, medication adherence, lifestyle choices) to “doctor delegates”, who deliver guidance and support during the 99% of the time that the patient is living with his chronic condition.  

Innovative healthcare organizations are experimenting with new technology tools and care delivery models to bring better care to their patient populations. 

Care Collaboration for Hypertensive Patients  

Through Twine, patient collaborates with her nurse coach“We were looking for a way to help our Hypertensive patients get their blood pressure under control more quickly”, explains Dr. Katherine Rose, Brigham and Women’s Advanced Primary Care Associates, South Huntington. “When a patient is having trouble managing his blood pressure, we ask him to schedule a follow -up visit. We have found that some patients choose not to come in for another visit. When our nurses call patients to check- in on their blood pressure numbers, many patients don’t have them which limits the support that our nurses can provide”.

The CDC confirms that hypertension is a growing problem in the U.S; “67 million adults (31%) have high blood pressure” and only about “half (47%) have their condition under control”.

Dr. Rose and her colleagues were determined to find a better way to support hypertensive patients through continuous communication and collaboration with their care team. “After evaluating different ways to leverage technology with a strong patient experience, we decided to use the Twine Health platform. In October 2014, we started a 6- month pilot and plan to recruit one hundred patients to participate”.

Twine Health is a spin- off from MIT Media Lab’s New Media Medicine Group. John O. Moore, MD, CEO and his team have designed the Twine solution with the goal of empowering patients to be an “apprentice”, learning to be “active participants in their care, par­ticularly care of chronic disease”.

The Twine Collaborative Care Platform allows people to co-create a personalized care plan that serve as common ground for continuous collaboration with their care team; their own clinicians, family and friends, and a health coach (sometimes staffed by the clinic and sometimes provided on-demand by Twine).

Twine Health was awarded an opportunity to pilot as a winner of the Brigham and Women’s Hospital 2014 Pilot Shark Tank competition. “We are very excited about the Twine pilot,” shares Lesley Solomon, MBA, Executive Director of the Brigham Innovation Hub. “The Brigham is dedicated to providing outstanding patient care and we believe that innovative health IT solutions like Twine will help us to improve patient experience and engagement and better enable our clinicians to address complex clinical challenges. We look forward to seeing the results of this pilot."

Hypertensive Patient Pilot

Dr. Rose explains that initially patients in her practice were recruited during an office visit. After hearing about Twine Health from her doctor, an interested patient worked closely with the Nurse to download the mobile app to her phone, set up her care plan, goals and select daily activities to support self- management.

Patient recruitment efforts are being accelerated through an email campaign with a link to the Twine mobile app and through television promotional messages in the waiting room. These communications show patients how to use the Twine Health mobile app to receive ongoing support and guidance from their nurse at the practice. Patients learn that they do not need to come in for all of their visits and can communicate their blood pressure readings and health behaviors digitally for continuous care.

Once enrolled in the Twine Health program, patient Patricia can view her daily care plan and check off activities which include completing certain activities (e.g. taking medications, walking, relaxing) and avoiding others (e.g. not eating salty foods, reducing alcohol consumption). Patricia can elect to receive reminders to take her medications, log her blood pressure readings and walk at lunch. She can monitor progress towards her goal and send a secure message to her nurse.

Nurse monitors chronic patients needing motivation and supportNurse Nancy monitors the Twine Health dashboard to see her patient’s care plan progress and identify patients that need support (e.g. missed medications, failed to measure blood pressure, blood pressure measure out of range). Nancy sees patient’s blood pressure readings, number of days adherent and days remaining on the patient’s care plan and quickly answers patient’s questions or concerns (e.g. running out of medication, experiencing medication side effects). She sends congratulatory messages to Patricia and other patients reaching goals and encouraging messages to less engaged patients to come back onto Twine to share information and issues. Nurse Nancy creates new and modifies existing care plans working closely with her patients. She also uses the platform to check in with the patient’s doctor about care plan and medication changes.

Pilot Considerations

Dr. Rose and her colleagues worked closely with the Twine team to plan their pilot.

Participant Selection:

“Not all of our patients have a smart phone which is required to access the Twine Health platform. We also needed to choose patients who would feel comfortable using a smart phone to support and extend their care. Since Twine is currently available in English, we are only offering it to selected patients”, Dr Rose explains.

Nurse Selection:

“As we thought about the role of coaching and motivating our patients to better manage their hypertension, we decided to use our LPNs to support the Twine Health program. Our LPNs interface with our patients all the time and are often on their computers doing triage. At our practice, we also like to have our professional team members operating at their top of license.”

EMR Inclusion:

Dr. Rose wanted to incorporate summarized patient data information into their EMR and appreciated that Twine Health created a note template to capture changes in the care plan, goals and medications. The nurse copies and pastes this information into the EMR so that everyone can access the latest patient care information. 

Pilot Evaluation

At the end of the 6- month pilot, Dr. Rose and her team will review qualitative and quantitative feedback from patients and clinicians. “We will also look at measures to see how often the patient’s blood pressure was controlled, how many blood pressure check visits were avoided, how engaged the patients were (e.g. use the platform, make better lifestyle decisions) and how satisfied patients felt (i.e. their team took better care of them).

Patient Feedback

Patients appreciate encouraging feedback from their nurse, find it motivating and feel a sense of achievement when reaching their goal.  They also like being able to ask the nurse questions through the app that they may not have otherwise asked.

“Our patients are helping us enhance Twine. For example, a patient suggested that we expand the capability to add blood pressure measurements more than once a day” describes Dr. Rose.

Clinician Feedback

The clinicians using Twine value understanding what is happening to the patient outside of the office visit to provide ongoing support. From a clinical perspective, Dr. Rose shares “I am excited that the app gives the patient ownership of their health.  While working with one patient on his care plan, he suggested increasing the time on his stationary bike to avoid adding a medication.  Since extending his exercising will help more than just his blood pressure, I was all for it”.

The Twine platform gives clinicians at the Brigham and Women's practice valuable visibility into the barriers that impact the patient’s adherence. With this insight, nurses are able to better understand and provide more relevant guidance to support the patient holistically for better outcomes.

Dr. Rose explains “there are many reasons why patients are unable to take their medications.  Some are simple—the pharmacy didn’t get the prescription, and others are more complex—the patient has concerns about a possible side effect.  As providers, we sometimes don’t hear about the problem for a couple of months which is lost time. With improved communication tools, we can address problems immediately, hopefully improving compliance and health outcomes”.

With only two months into the Twine Health Pilot, Dr. Rose admits that they are just beginning.

“We will be looking at the financial impact of using the Twine platform. So far we know that our nurses are spending 20- 30 minutes to set up each patient and 25- 30 minutes daily responding to and motivating patients,” confides Dr. Rose.

She appreciates that Twine Health conducts conference calls with other healthcare organizations participating in pilot programs to learn ‘best practices’ together such as incorporating Twine into existing workflows, recruiting patients, engaging patients and trying an approach for a specific patient segment.

“Ultimately we think that patients who are more engaged in their care and mindful of their choices will be healthier. We are excited to use new technologies like Twine to encourage that”, Dr. Rose concludes.

Interested in seeing Twine Health results across all hypertensive patients? Twine displays this on an aggregate level through their online dashboard. 

Healthloop Virtual Patient Check in

Healthcare reform has placed increased demands on doctors who are already managing increased patient loads. As a result, doctors are spending less time with their patients.

Patients are being asked to take on more responsibility in managing their care. This is particularly challenging before and after a surgical procedure. A patient typically leaves the hospital with a stack of paper discharge instructions about medications, the follow- up visit and a list of symptoms to monitor with directions to contact the doctor if problems occur. Throughout recovery, the patient is often left to figure things out because she "doesn’t want to bother the doctor".  When the patient makes uninformed decisions about medications or readiness to begin an activity level, it can set her back on her recovery path or lead to costly hospital readmissions.

Other than checking in with patients during the follow- up visit, providers are in reactive mode; patients calling with complex problems or heading to the ER.

Since patient satisfaction, care quality and costs are impacted by the current process, providers are motivated to find a solution that virtually supports the patient's needs for guidance, education and shared decision making.

Virtual Patient Support

It all started in 2007 when Dr. Jordan Shlain was treating a patient who wasn’t feeling well. After discussing her symptoms, he gave the patient his cell number and asked to please call him if she felt worse by morning. He discovered a few days later that she had developed pneumonia. From this experience, Dr. Shlain learned that although he wanted to be proactive with his care, he couldn’t depend on the patient to call with an update. His began texting patients asking “do you feel the same, better or worse?” Dr. Shlain did not take any chances and assumed that a non- response from the patient indicated there may be a problem.

After speaking with providers about not really knowing how a patient is doing post discharge, they expressed interest in daily virtual interactions with the patient as a way to increase patient engagement and prevent readmissions. Patients loved the idea of interacting electronically with their doctor on a daily basis since it would give them unprecedented access to communicate concerns and address problems in a quick and convenient way. This was the backdrop that led to the development of Healthloop.

“Since late June, we have been using Healthloop for patients who have hip and knee replacement surgery”, shares Dr. Mohan, Surgeon for a large Integrated Delivery Network. “Our team was looking for a solution that would enable us to share the experience together with our patient. We also wanted to put the patient in the driver’s seat and give them control, while we were in the passenger seat as an observer and navigator.” Dr. Mohan’s orthopedic patients are on Healthloop before surgery and throughout recovery which tends to be 1-3 months.

Dr. Andrew Goldstone, ENT Surgeon at Greater Baltimore Medical Center started using Healthloop in February with his adult and pediatric patients throughout recovery which typically lasts 2-4 weeks. Healthloop electronic communications are delivered to the parents of his young patients for ongoing support. "HealthLoop, in a technologically modern way, tries to mimic the old days when we admitted patients a day or so before and kept them as many days as we or they wanted to stay after surgery. This gave patients and their families a comfort level that most current M.D.s have never witnessed. The same goes with patients who, after ambulatory surgery, pay at the next window and go home. They have no clue how patient friendly it used to be having an extended ’hand holding‘  before returning home. I view HealthLoop as an attempt to recreate that extended comfort,” explains Dr. Goldstone.

Patient Experience

HealthLoop enables the physician to support the patient before surgery and monitor him post discharge and between visits, engaging each patient “as if he is the most important person”. With the goal of delivering guidance when the patient needs it, Healthloop works closely with the provider organization to define the questions that patients ask at each step of the recovery process. Together, they review typical calls at day 1, 2, etc., determine the appropriate response and set up the schedule to deliver the information to the patient right when they need it.

Taking a closer look at the patient experience, Gary is referred by his primary care physician to a specialist about knee surgery. After deciding together to move forward with the operation, the surgeon quickly enrolls Gary in Healthloop to guide him before and after the surgery. Gary receives an email to complete his enrollment including his preferences for receiving Healthloop communications (i.e. email, text). 

Before surgery, Gary answers questions about risk factors and receives guidance and checklists to prepare for his operation. For example, he learns how to to prepare his house to easily navigate when he returns home following surgery.

After surgery, Gary receives a daily electronic communication with a set of questions to understand how he is feeling (i.e. pain level, specific symptoms, problems with meds, etc.), personalized education materials, activity and medication reminders and a checklist of To Dos. Based on Gary’s feedback and progress, his care plan is updated and his next day’s check-in is automatically prepared. 

Healthloop is designed for two way engagement. If Gary experiences any health problems, these are gathered through his check- in responses and trigger an SMS message to his care team for intervention and support.

With recent integration to Apple’s Healthkit, patient information is extended beyond daily check- in responses to include health tracking data. For example, Gary’s doctor has instructed him to take steps while healing from his knee operation. Gary’s tracker information is combined with his daily check-ins to give his care team more insight into his health status. Concerned about not enough movement, his clinician may call and learn that Gary is not moving enough because of his medication side effects which can be addressed through a prescription change. 

Pilot Feedback; Patients & Providers

Healthloop wants to deliver a truly patient- centric communication channel and uses patient feedback to enhance the solution. After hearing a patient comment that the messages felt “too robotic” and “do not sound like they are coming from my doctor”, the communications were refined to be more conversational.

Another patient commented that the messages were using doctor’s words which resulted in changes to incorporate more patient vocabulary and experience. For example, questions about a blood clot were replaced with “feels like a cramp in my calf”.

Patient Comments

Healthloop has delivered over 57,000 daily check-ins to patients and has received positive feedback about the experience:

Guidance: “I wanted to be able to say ‘I have this” and have someone come back and say that is normal and here is the process. Then all of my negative energy goes away”, “easy way for me to make sure that I was on the track with my recovery”. “The questions promoted me to be more aware of my situation”.

Convenience: “Without Healthloop. I would have called (doctor) 5- 7 times”, “This saved me a trip to my doctor”.

Access: “It was an extension of my doctor so instead of talking to a nurse and having her get back to me, I had a direct conduit to my doctor.”

Provider Comments

Healthloop Clinician Dashboard

“As our team developed our Healthloop, we charted out what a recovery really is. With this, I know what my patient is going through, can emphasize and say with confidence that over half of my patients have their pain under control after day 4”, explains Dr. Mohan. “We also participate in a Medical Destination Program with patients traveling to our hospital, often from out of state. After staying in a hotel for 10- 14 days, they come to see me for a follow-up visit before returning home. We are now thinking about how we can use Healthloop to manage their care from a distance to make sure that the patient has a successful recovery.”

Comments from other providers:

Patient Satisfaction: “My patients told me that they looked forward to their daily Healthloop check-ins because it felt like ‘someone was watching over me’ who really cared”.

Operational Efficiency: “For my practice, the volume of calls from patients has dropped tremendously. I notice it and my staff notices it too.”  “I am thinking about eliminating the 2 week follow-up visit and to just see the patient at the 6 week visit since I can check in on their pain management, incision and any other issues through Healthloop.”

Better Quality: “Helps us pick up complications much sooner. It reinforces a plan with what to do and reminders”, “We are raising the bar on care by ensuring that we are giving the patient the pre and post-surgery education and care that they need”.

Success Measures

Providers using Healthloop are evaluating a set of success factors based on their program goals. In addition to lower costs which is measured over time, providers are monitoring:

Patient Engagement; Patient Satisfaction using the net promoter score.

Better Quality; Benchmarking patient progress, measuring patient’s perceptions of care quality received

Operational Efficiency; Call reduction to the practice 

Regarding patient engagement, some providers are leveraging positive ratings through social media. Patients who give the highest scores (5 Star Ratings) are encouraged to share their ratings and experiences through the link provided to public review sites such as HealthGrades and Vitals. Patients who give average or below average score are asked to explain how the provider can improve. Patients have commented on everything from old waiting room magazines to being put on hold for too long when they call.

With Healthloop, “my patients tell me that they are happy with the surgery because I was right there with them. I also notice patients are much more relaxed during their follow-up appointments. That is so important to me”, Dr. Mohan concludes.