Entries in mobile health and wellness texting (12)
Dartmouth- Hitchcock’s ImagineCare Platform Leverages Wearables, Connected Health & Analytics for Personalized Patient Care
Dartmouth-Hitchcock (D-H), an innovative New England healthcare system with 1,000+ providers is committed to creating a “sustainable health system”, which proactively engages patients through new care models to achieve the triple aim.
Over the years, D-H has invested in technologies that empower patients to collaborate with providers through shared decision tools and Telehealth, treating “patients and their families as partners in care”.
D-H has been a pioneer in innovative payment models with both the government and commercial payers.
In early 2015, D-H’s leadership team committed to create a truly patient-centric healthcare organization, which delivers high quality proactive personalized care to the patient beyond the hospital walls.
“Dartmouth-Hitchcock purposefully set out to assemble a team of employees with backgrounds from other consumer industries like hospitality and retail that would augment the world-class capabilities of our clinical staff, to improve the health care delivery experience”, explains Vin Fusca, COO, ImagineCare.
With their consumer- centric “healthcare without boundaries” vision, D-H management has designed a truly “care- driven” solution. ImagineCare, a cloud- based platform, enables providers to closely collaborate with each patient to meet her care goals at any time and from anywhere.
ImagineCare treats the patient holistically through the active and passive collection of a comprehensive set of patient data. In addition to condition specific evidence-based care pathways (i.e. ImagineCare Hypertension Pathway, COPD Pathway, CHF Pathway, Diabetes Pathway), D-H incorporates a “Core Health Pathway” to capture steps, heart-rate activity, sleep, and stress (Behavioral Health), providing contextual insight into the patient’s health.
With ImagineCare, the Provider and patient have a window into the latest health status for insight and action. In the background, ImagineCare collects information from the patient (i.e. sensor- based devices, apps), combines it with EMR data (i.e. patient visits, labs, meds) and processes it through complex clinical care algorithms with machine intelligence to pinpoint when the patient is at risk. High tech meets high touch when ImagineCare notifies the RN or Health Navigator to reach out to the patient for real-time support and intervention.
“ImagineCare leverages the best available technologies to assist with care, but does not replace the importance of the human touch to drive behavior change. ImagineCare seamlessly combines these components to help patients achieve their health goals”, shares Dr. Ethan Berke, Chief Medical Officer, ImagineCare.
During her recent doctor’s visit, (patient) Pam decides to participate in D-H’s new ImagineCare Program to help her lose weight and proactively manage her hypertension.
Within 48 hours, Pam receives an email to quickly enroll in ImagineCare and a welcome call to discuss her personal health goals. Two days later a personalized ImagineCare Kit (box) is delivered to her door containing a program overview, a wireless blood pressure cuff and an activity band, devices which fit her selected health goals. Pam follows the instructions to connect her devices to the ImagineCare app.
During enrollment, Pam’s shares her profile information such as personal health goals, challenges, communication preferences, family support, and defines her “medical neighborhood” (i.e. Providers, pharmacy, caregivers). She adds more information when responding to daily questions to create a rich picture about her health needs and resources required to tackle care plan activities.
Anxious about her attempts to lose weight, Pam indicates in the mobile app that she only wants to receive texts to help her stay on track with her weight-management goal.
Through the ImagineCare mobile app, Pam answers daily questions about how she is really doing, while her wireless blood pressure cuff and activity band retrieve and send real-time measures. Pam receives nudges, encouraging messages and digital check-ins to ensure she stays on track with her care plan. Yesterday’s text asked Pam if she was okay since she hadn’t provided her blood pressure as expected.
D-H’s RNs and Health Navigators continuously monitor Pam’s health status, review her trends, and respond to risk warnings by reaching out via text which is her communication preference. Since Pam designates her daughter as a personal health representative within the mobile app, ImagineCare’s RNs are permitted to speak with her about Pam’s health.
ImagineCare Success Measurement
ImagineCare is designed to empower a health care organization to right-size provider visits, lower ED utilization and decrease admission and re-admissions. ImagineCare provides a more engaging solution to help health care delivery systems increase quality of care, decrease cost and improve patient experience.
In addition to these quantitative measures, D-H actively gathers qualitative patient feedback to understand the patient experience. Comments from patients about engaging in the ImagineCare program include:
“I monitor my blood pressure every day, and after a particularly stressful day at the office I went home, took my blood pressure, and five minutes later one of the nurses called and talked me through an immediate care protocol.”
“It has improved my ability to manage my health…The ability to connect with people for support and also send information to my healthcare providers, makes it easier.”
"I am extremely impressed with the ImagineCare phone app. It is very easy to use and seems very intuitive”.
ImagineCare is constantly updating its services and products based on patience engagement data, clinical data, and new technological capabilities coming to market. In a digital health landscape that is becoming more fragmented, ImagineCare will continually create holistic, customer-centered health services to better care for patient populations.
D-H’s team has packaged up the ImagineCare platform for other providers, payers and (self- insured) employers to deliver personalized patient care for better outcomes.
During 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.”
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.
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.
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”.
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.”
“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”.
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.
Health Plans are finding new ways to bring value to consumers by empowering them with tools and guidance to manage their health while on the go.
At many conferences, health plans present their newest mobile application or texting campaign to engage consumers.
UnitedHealth Group announced their latest move at the recent Consumer Electronics Show to integrate several mobile health applications into their OptumizeMe solution, through partnerships with CareSpeak Communications, FitNow and FitBit. UnitedHealth is integrating content and tools to bring new capabilities to both consumers and caregivers.
Through the CareSpeak Communications’ partnership, consumers sign up to receive two-way texts to help them manage their medication and condition. UnitedHealth delivers CareSpeak’s personalized messaging to provide relevant content to each consumer segment ( e.g. asthma, diabetes, cancer, etc). A patient with diabetes opts in to receive customized education and reminder messages and can give a caregiver permission to monitor her health. The patient’s clinician is also kept in the loop with medication and condition management data to discuss during patient interactions. Patients are further engaged by receiving text based educational quizzes and viewing online reporting showing their effectiveness in managing their medication and condition over time.
With the integration of FitNow’s Lose It! mobile app, consumers can better manage their weight through fitness and food tracking tools, educational nutrition information, motivational reminders and social peer support.
From the FitBit integration, consumers automatically track their physical activity instead of having to key it in. Since this activity data is no longer self reported, UnitedHealth Group can use validated information to drive their rewards program. The FitBit app also tracks the consumer’s sleeping behavior for a more complete view of their health.
Integration Delivers Insight
UnitedHealth Group has invested in this set of mobile technologies to capture and connect multiple sources of data for a holistic view covering the consumer’s physical activity, dietary behavior, medication adherence, biometric and mood information.
“With these partnerships in place, we are connecting all the pieces of data across our platform for a common view for the consumer to self manage and share with their coach while creating a personalized experience”, explains Nick Martin, VP Innovation and R&D, UnitedHealth Group.
This supports the trend for “integrated end to end health to care solutions” where technology connects with care management platforms and programs, as noted by IDC Health Insights’ analyst Janice Young.
Coach/CareGiver & Consumer Collaboration
Nick Martin describes how the OptumizeMe application is being used by the consumer with their coach. “Let’s say you are trying to lose weight. Your coach can push messages to your mobile which are educational and supportive. And if you give your coach permission, she can see your tracked physical activity”. Think about how much more motivated and accountable the consumer will feel when her coach is monitoring and responding to her daily progress. On the health side, the asthma patient can give access to her caregiver to monitor and address medication compliance issues. Her caregiver can also send encouraging and educational messages between visits.
UnitedHealth’s partnerships deliver new capabilities to their OptumizeMe mobile app giving consumers a new way to remain in close contact with their coach and to self manage with the social support from caregivers. With the power of the personalized information pushed and pulled from the consumer’s mobile phone, UnitedHealth Group can successfully generate both stronger consumer engagement and better health outcomes.