Entries in self- management health tools (6)
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.
Geisinger has been investing in mobile technologies to engage patients and their families in their care since 2011. In my blog post last year, I shared Geisinger’s texting programs, mobile data capture and experiences with their first mobile app to support Cardiac Rehab.
Geisinger continues to explore new technologies to involve patients and to improve the patient and physician interaction. “Mobile apps are just another way to drive patient engagement. We think we will have better adoption by patients if we use technology that they have already adopted in their lives”, explains Chanin Wendling, Director, eHealth, Geisinger Health System. “Our goals are to improve patient outcomes and reduce costs. We pursue patient engagement because of studies from folks like Hibbard & Greene 2013 and Veroff & Wennberg 2013 that show that engaged patients have better outcomes at lower costs. We want to provide patients with tools that help them understand their condition and follow their care plans so they can stay as healthy as possible.”
Piloting Mobile App Supporting Bariatric Surgery
Geisinger began piloting their second mobile app Get~2~Goal in September, 2012 to help manage patients’ surgical weight loss expectation and provide a journal for tracking weight loss after the surgery. The Get~2~Goal app presents the patient with personalized weight management goals using her own entered data (e.g. age, weight, height). She can monitor her weight loss towards that goal and see how she is doing compared with other patients like her.
The app was developed by Geisinger’s Obesity Institute in collaboration with Bucknell University’s computer science staff and students.
Patients have shared positive comments including:
“Great App! Surgery on Tuesday, so this will be a great motivator”
“I like it. It's very helpful and lets you know whether you're on the right track or not weight wise. So far I'm doing above average. Woo hoo to us!”
The clinical sponsor for the Get~2~Goal project was Dr. Christopher Still, Director of Geisinger Obesity Institute and Medical Director for the Center for Nutrition & Weight Management. He uses the app when discussing bariatric surgery with his patients and, recommends that they download it to their mobile devices. Dr. Still has observed an improved patient/physician interaction when a patient sets realistic weight loss expectations with the guidance of the clinician. “This app allows patients and their physicians to discuss patient specific outcomes regarding gastric bypass surgery. It is important for both the patient and their physician to have real expectations and assess the risk/ benefit of the procedure.”
Building Mobile Apps Ourselves
In addition to experimenting with Cardiac Rehab and Get~2~Goal apps, Geisinger wants to expand into apps for different chronic conditions and set out to research the market. “We were disappointed with what we found. Most vendors had apps focused only on one chronic condition. Although vendors had plans to expand into other chronic conditions, we had a hard time picking a reasonable partner based on their stated direction”, Wendling explains.
Wendling feels the mobile health app market is still in the early stages. She explains that vendors are approaching her organization with a business model that just doesn’t scale. “If a vendor charges us a rate of $10+ per member per month, how do we make that work for patients with multiple conditions? We have over 75,000 patients with hypertension and 30,000+ with asthma. Although the app will not be appropriate for all of these patients, the costs add up rather quickly.”
After evaluating many mobile apps, Wendling points out that the patient experience is not thought through. She has asked vendors about how patients can personalize their app. “I may be a patient who works night hours so why shouldn’t I be able to set the time of the reminders to fit my schedule? Also, why can’t I select the method of receiving the reminders, through email or text messages”, adds Wendling.
The final reason that Geisinger has decided to build mobile apps internally is because integration is important. “We’ve found that many solutions do not integrate with our EMR which is essential since we need to incorporate the patient information into our clinical workflow” Wendling explains. “Although it is not unusual that the early innovated apps do not integrate with the EMR, vendors do recognize that they need to get there. So any app we purchase, we would most likely have to do the integration ourselves anyway. We haven’t made any decisions that we will always develop our own apps. If we see something out in the marketplace that works and we have the budget, we will go for it. We just may need to wait a little longer until the marketplace matures.”
Mobile App Development Journey
As their first venture into internal mobile app development, Geisinger selected a simple procedure and defined key capabilities which are replicable across more complex procedures. With the new Colonoscopy mobile app scheduled to be launched next month, patients can prepare for their procedure through:
- Education: explains what will happen during the procedure
- Shopping: lists can be created and transferred as a note to the mobile phone
- Reminders: for days before the procedure directing the patients to steps that need to be done
- Pictures: visual guides of their bowel movement during the preparation process
“Geisinger’s colonoscopy mobile app is unique among health care related apps in that it provides a personalized experience for the patient. From prep instructions based on scheduled appointment time, interactive ’am I ready for my procedure’ section to the ability to easily set reminders/alerts; this app takes advantage of a lot that mobile technology has to offer. As a gastroenterologist, my hope is that this app will allow patients to feel more empowered and in control of their bowel preparation; typically the most difficult part of the colonoscopy experience. We know that with improved prep comes better outcomes and thereby, over time, lives saved. I feel that modern health care needs to embrace mobile technology as a rapidly growing and exciting tool to improve patient care”, explains Dr. Amitpal S Johal, Director of Endoscopy, Geisinger Medical Center.
“We are looking into other surgical procedures which can use this same set of capabilities. One area that we are considering is Vascular surgeries since we work closely with our Vascular department at Geisinger”, shares Wendling.
Future Mobile Health Roadmap
As they look to the future, Geisinger is working on enhancing current mobile apps and is exploring the use of mobile to support patient care before, during and after a hospital visit.
The next version of the Get~2~Goal app is under development. Geisinger is improving the patient experience through a better user navigation, the capability for patients to enter their own weight loss goals, and the addition of recently developed calculations for other bariatric surgery outcomes (i.e. likelihood for remission of diabetes).
Geisinger is also looking into ways that mobile devices and apps can help patients pre, during and post hospital stay. They are starting with their Janet Weis Children’s Hospital which treats kids with complex conditions such as cancer, heart or neurological issues. Geisinger understands that being in the hospital is scary for the child and their family. “With mobile apps, children and their parents will be able to prepare for the surgery, use an iPad during their hospital visit to capture pain levels and then track their recovery at home”, describes Wendling.
In the future, Geisinger is planning for a personalized patient experience. “Our dream is to be tailored in our patient care. Given the patient’s profile, s/he will have technology options and tools to gather preferences and schedules to guide the care plan. We want to use this information to also match the appropriate intervention”, Wendling concludes.
Patients Engage with Data & Tools for Better Health Decisions and Health Management @ Partners' Connected Health Symposium
During the 9th Annual Partners’ Connected Health Symposium, several speakers shared examples about how consumers are taking responsibility for their health by using online and mobile tools. Given the changes in health reform, Providers and Payers welcome patients taking on a more active role in both monitoring and managing their health.
1. Trackers for Self Management:
Susannah Fox presented findings from the latest research by the Pew Internet Project and the California HealthCare Foundation which focused on self-tracking. One interesting insight is the segment of adults who track a “health indicator or symptom”; “62% of adults living with two or more chronic conditions is self- tracking”.
The research also revealed that only one third of all self trackers shared this information with someone and half of those shared with a clinician and the other half with a member of the family, group or a friend.
2. PHR with Mobile Capture of Observations of Daily Living (ODL):
Patricia Flatley Brennan, Professor, School of Nursing, University of Wisconsin, discussed the insights that can be gained by “listening in the moment”. Patricia provided an overview of the Project HealthDesign’s five projects for this second round. I was particularly interested as she described how these projects capture the “words of the patient” about their observations of daily living.
Imagine the tremendous value in sharing the patient’s words not only to help the clinician communicate in a way that resonates with the patient but also to discuss the observation data patterns and their impact on the patient’s live.
After the conference, I reviewed the projects on the Project HealthDesign website to get a better understanding about the tools that were being used by patients. Several projects entail having the person enter the observations into their mobile phone; symptoms for Asthma, pain and energy levels for Crohn’s disease, caregiver stress for high risk babies and moods for Obesity. For the project focused on elders, I was interested to see sensors being used to collect information to monitor their cognitive decline.
3. Online Patient Communities
Right from the beginning, I knew this panel was designed to be provocative- “Online Patient Communities are an effective way to Deliver Care”. Alex Drane, moderator and CVO at Eliza explained the panel's focus on peer to peer patient communities without clinicians.
Shouldn’t this panel really have been titled “Online Patient Communities are an effective way to ‘support’ care”? So much has been written about the strong value that patients receive sharing their experiences.
Taking patient communities to the next level, it would be interesting to consider how one type of patient community differs from another. Is there the same intensity of involvement for different types of conditions? Do patients participant in them mostly when they are diagnosed or do they stay on to give back? Are patients using the tracking tools and sharing with others in the community? Are there examples where clinicians are successfully participating in these patient communities?
Opportunities to Empower Patients with Data & Tools
Healthcare organizations have any opportunity to provide data and tools as resources to support consumer health management. Here are some areas that I am closely watching.
Connecting the Data Dots on Health: As a patient gathers information from the various tracking tools, how can this information be combined with other data about him to provide a more comprehensive picture to guide their collaborative care decisions? As Joseph Coughlin, Director MIT Age Lab asked during his Symposium keynote “Data, data everywhere but where are the drops of actionable knowledge?”
Interjecting Data into the Discussion: When can the patient discuss this information with their care team and get the needed guidance for behavior change? How can this information be incorporated in to a coaching session as the patient discusses the management of her chronic condition? During an intervention, how can this information support the decision discussion?
Measuring the Impact of the Tools: Each organization will need to think about measuring the elements that make the tool actionable. During her keynote on “e” is for Engagement, Susannah Fox shared a few key measures that they captured for the self trackers including the percent that said their data collection “affected a health decision”, led them to “ask a doctor new question or seek a second opinion” and “changed their overall approach to health”.
As organizations continue to evolve their business models and approaches, these data and tools become more important because they effectively engage patients in their own health. In recent discussions with leading organizations, I have heard about their increasing investments in connecting data and tools to bring more insight to the patient to better manage their health with the support of their care team. What is your organization doing to provide truly engaging online and mobile resources for your patients?
More than two years ago, Mass General launched their Ambulatory Practice of the Future, an innovative primary care clinic for employees and adult dependents. Developed as a Patient-Centered Medical home and ACO, today they support 3,000 enrolled patients with three doctors and two nurse practitioners.
This innovative practice was designed for and with patients for a better patient experience. Their experience begins with the initial greeting and extends through ongoing care interactions. There is a strong focus on patient education and empowerment. The care team collaborates to support each patient both in person and online. One of the goals of the practice is to reach patients where they are both physically and with their health.
Designed to Support Shared Decision Making
Once patients enter the welcoming and intimate care setting at The Ambulatory Practice of the Future (APF), they are ready to collaborate with their clinician. Sitting side by side, they review the medical record together and begin the discussion with health goals.
“We actually added a data field to the record called ‘Health and Life Balance Plan’ where we document mutually agreed upon goal(s) for the coming weeks and months and then it is easily reviewed by the patient via their portal after the visit and in preparation for upcoming follow- up encounters”, explains Dr David Judge, Medical Director, Ambulatory Practice of the Future, Massachusetts General Hospital.
This collaborative approach has helped patients who have not historically been able to get engaged around a goal. Dr Judge shares a story about a 54 year old woman with diabetes who was reluctant to discuss next steps in management due to her fear of taking insulin. After allowing her to shape the goals with a focus on other areas of lifestyle management initially, coaching to realize some success and encouraging patience with the process, she has recently decided to proceed with insulin therapy.
Patient Engagement Tools
APF uses shared decision making videos developed by the Foundation for Informed Medical Decision Making to educate patients about screening tests and in managing specific medical issues such as prostate cancer.
Between their visits, patients can access the portal to view their medical information and communicate securely with their clinician. Although the care team can access the EMR from their mobile devices, APF expects that patients will be able to access their portal and records via mobile devices in the near future.
Patients can currently participate in an online visit with their care team. Dr Judge describes one of the complex patients that they monitor closely with frequent virtual visits. “Mr. K is struggling with end stage renal failure, congestive heart failure and it has become difficult for him to come for office visits. Between scheduled virtual visits, emails from the patient and his wife and monitoring by visiting RNs, we are able to manage his needs fairly well with rare office visits. We are on the verge of implementing true remote monitoring technologies but currently the patient or RN need to report the measures (i.e. blood pressure, weight, blood sugar, PHQ 9 depression score, etc.).”
On the prevention side, several employees are using mobile apps to track their daily lifestyle choices regarding exercise and nutrition and sharing the information with their clinicians during their visits.
Future Path to Patient Engagement
During my panel at the recent Shared Decision Making Conference, Dr Judge spoke about some exciting new ways APF will be leveraging technology to engage their patients.
“We will be piloting the concept of 'apprenticeship' in which patients go through a more formal education process with coaching and demonstration of increased knowledge and skill to push the boundary on self management. We are developing programs tailored to specific medical conditions (i.e. HTN, DM and Depression). Goal setting for each patient helps the team to understand how to customize the program and to identify what specific barriers may be preventing success.”
“As we have done with diabetes, we expect that patients will learn not only to change their lifestyle and make healthier choices but also adjust medication in the management of multiple chronic diseases. The care team will be able to monitor and assist but patients will truly drive their own care more effectively from day to day”, adds Dr Judge.
APF is starting a pilot soon using a mobile tablet that “allows very easy synchronous communication to transmit monitored blood pressure and to enable the patient and team to collaborate around lifestyle management and medication adjustment”.
The term “apprenticeship” is being used by Dr. John Moore at MIT Media Lab. Dr Judge explains, “I think it appropriately describes the next step in the evolution of making shared decisions with patients. Beyond that is potentially a mastery of health and the potential for patient - to - patient support to grow. We are hoping to launch both face- to -face and virtual peer to peer interactions in the near future.”
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.