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Attitudes Toward Patient Generated Data

February 11, 2016

Patient Generated Data: Insights or Nuisance?

Attitudes1For about 10 years now, we’ve been collecting data from patients, mostly from sensors in their environment (activity trackers, blood pressure cuffs, weight scales, etc.), trying to break free from less-than-reliable selfreported data.

We’ve shown that, properly used, patient-generated data is:

  • Central to improved quality of care for chronically ill patients (i.e., patients with heart failure in a telemonitoring program had significant improvement in mortality compared to controls).
  • Useful in engaging patients around lifestyle choices to improve the care of both diabetes and hypertension.
  • Useful in engaging patients in interventions that encourage them to improve their own care.

Despite these studies and a bevy of evidence from other investigators in the field, I still get routinely reminded, when I am out presenting on connected health, that “physicians don’t want this data.”  This is a resounding theme that ranks right up there with concerns about liability and reimbursement.

On the one hand this response is predictable.  Physicians’ time is squeezed more than ever these days. The thought of having to pour over reams of normal values seems daunting.  I take this objection as evidence that we aren’t clear in communicating our vision — or the true benefits of having real-time, real-world patient data available.  In so many other industries, software has been designed to troll through complex data sets and cull out the meaningful relationships or events, and then presenting them succinctly as actionable information or valuable insight rather than just raw data.  We can do this for patient generated data too.

Then there is the objection that it is complex and costly to collect such data.  Things are getting better on this front.  We’ve shown that for diseases such as congestive heart failure, remote monitoring programs that use patient generated data lead to a significant drop in hospital readmissions and, more importantly, a decrease in total medical expenses. These major cost savings quickly add up, while improving the quality of care delivered. It is hard to object to that combination.

Validic, a forward-thinking company, is one example of an organization providing software that enables easy collection and normalization of all sorts of patient-generated data. The company just came up with an exciting innovation that allows a patient to take a picture of any data-collecting device (imagine the screen on a home blood pressure monitoring device) with her mobile phone camera and have that data flow into the electronic record.  This is analogous to taking a picture of your check and having it deposited in your checking account.  This will lower costs significantly.

 

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The objection that irks me the most, though, is the one that basically admits to striking out before even getting up to bat: “I don’t know what I’d do with all of those readings anyway.”  This approach disappoints me in many ways. First as physicians, we’re trained in the scientific method.  We’re supposed to be curious, to think about novel ways of providing care and above all, ways to improve care.  Yet, some health care providers feel completely at ease that a disease as significant as hypertension can be adequately assessed by taking a few readings in the doctor’s office once or twice a year.  Maybe that made sense when the sphygmomanometer (aka blood pressure cuff) was first invented. But now that these devices are ubiquitous and can be purchased in every drug store, why would we not want to take advantage of the extra data points from home readings?  We made the leap for glucometers decades ago.

 

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Chapter 5 in my new book, The Internet of Healthy Things, outlines what I call ‘the new white coat anxiety’ — the myriad concerns and changes taking place in health care today that is causing providers angst. Chief among them is apprehension to change. Change is coming from all sides:  shifting payment models, changing from face-to-face interactions to virtual care, a lack of awareness about personal connected health trackers and real anxiety over what to do with all of this data.

My friend Dr. Steve Ommen, Associate Dean at the Center for Connected Care at the Mayo Clinic in Rochester, MN, told me when I interviewed him for my book: “Providers will come to see that incorporating connected care into clinical practice will be of benefit to both their practice and their patients, but it’s not the way we’ve all been trained to practice medicine for 150 years.”

Many don’t realize that when Laennec introduced the stethoscope it was ridiculed.  In fact, it took 20 years for it to be accepted as a standard tool for clinical practice.  The analogy may be apt, but we don’t have 20 years to wait for health care providers to embrace patient generated data.  As we embrace the world of value-based provider compensation, it is imperative that we look at collecting information from and about our patients differently.

 

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How do you think we will be able to help providers embrace patient generated data and accelerate the adoption of connected health?

The Connected Health Design Paradox

January 25, 2016

In what seems like the blink of an eye, all of the data inputs feeding the connected health ecosystem are wirelessly enabled and pretty easy to set up.  It is this realization that stimulated me and my coauthors to write The Internet of Healthy Things.

But it wasn’t always that way.

Just a few years back, we toiled to get information out of what were then ‘dumb’ sensors – blood pressure cuffs, weight scales, glucometers and the like.  Both the engineering required and the patient involvement needed to make these early systems work were burdensome.  The first phase of this journey was enabled by now nearly-obsolete home hub devices which typically used analog phone line connections and modem technology.  The patient had to connect wires to set it up and then push a button to upload any data, hoping the transmission would go through. Sometimes the patient thought she was transmitting when, in fact, no data was flowing.  Often, connections would work one day and break the next.

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In order to minimize patient frustration and all of the effort required, we asked our patients to ‘batch upload’ readings once a week or so. They would capture whatever data we asked for (blood pressures, glucose readings, etc.) as prescribed, but only upload that data periodically.  When it worked, this system actually worked well.  We studied this program and made several observations that became guiding principles for designing future interventions.

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One key principle that we have applied several times is the understanding that these tools allow for a very fine measurement of patient engagement.  Patients who participated in these early programs and put up with of the cumbersome set up — button pushing, uploading, etc. — were a bit like the earliest settlers moving across the US in the 1800s.  These patient pioneers cared enough about their disease to make all of this extra effort in order to share their health data with their doctor.  When we looked at the correlation between frequency of upload and clinical outcomes, we found a positive relationship for both diabetes and hypertension.  The more engaged patients were, as measured by uploads, the better their clinical outcomes.  In retrospect, our sample was probably enriched not for tech savvy users (doctors prescribed these tools based on disease severity) but for those who were motivated to improve their health.

We also learned that provider engagement mattered.  For a given sample, the more a nurse, diabetic educator or other front-line clinician logged in to the clinician portal, the better the outcomes of the group.

Another important, early finding was that patients dropped out of the program or gave up for a couple of reasons.  One was difficulty in using the technology.  This became glaringly obvious once we had passive data collection devices in the field.  With passive data collection, the patient took their blood pressure as they normally would and the data flowed from device to hub to Internet with no extra work on the patient’s part.  Set up for these systems was much easier too – no phone lines to mess with.  We were, for the most part, able to achieve what is known in the industry as ‘plug and play.’

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When we compared these passive data upload systems with the aforementioned push-button systems, we found patients uploaded 3X more often with the passive systems.  The tricky set up and the pushing of a button was too much to ask for many of our chronically ill patients.  These observations led to a design battle cry for ‘wear and forget’ sensors, passive data upload and frictionless technology (e.g., no set up).

The second reason we found patients dropped out was if they perceived that their doctor was not paying attention to their data.  You can see the logic – my doctor recommended this to me, it is a lot of extra work and if she is not acknowledging that work, I’m going to drop out.  This logic ignores the notion that we should be intrinsically motivated to improve our own health, but we’ll leave that for a future post.

The flip side of this phenomenon is that when patients perceive the doctor cares about their data, they try even harder to meet their health goals.  This led to our employing the design principle of the sentinel effect (we behave differently when we know we’re being watched, especially by someone whose opinion we care about).

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So, what’s the paradox?  As the Internet of Things has become a reality, increasingly sensors are designed to easily offload their data to the cloud.  Set up is easy, always through your smartphone, connections are much more robust and data flows effortlessly.  Wear and forget is becoming a reality and new products from companies like Proteus Digital Health and MC 10 take disposable/wearable/ingestible to a new level.  But as we perfect systems to capture health data and make it easy, people tend to forget about the data feedback loops that allow for improvements in health.

Yes, we’ve done a great job of frictionless data capture, but we’ve lagged on engagement.  Designers of consumer mobile apps are constantly studying how to employ mobile technology to keep users engaged with their content.  News apps get your attention through banners, notifications, etc. when there is fresh content. But I can’t think of a health app that does a good job at this.  For example, my favorite activity tracker app sends me the same three messages every day, “You’re almost there,” “You reached your goal” and “You’ve outdone yourself.”  It’s no wonder that the new industry phrase for measuring device success is “time to drawer.”  Or, stated another way, how long did you wear the thing before you got bored with it and threw it in the drawer?

So, the paradox results from two observable facts.  First, because it was such an engineering challenge to get data flowing in a frictionless manner, most of the current devices and systems were designed by engineers (quantitative people) and adopted early by other quantitative people (e.g., quantified selfers).  Early adopters were engaged by their own data and probably needed less in the way of software engagement.  Second, creating sustained engagement via software is hard, especially in health-related interventions.  The most engaging apps are still in the communication/social realm – WeChat, SnapChat, Instagram, etc.  They harness the natural human need to share and interact with others.  Who wants to be reminded they are overweight? Or have high blood pressure? Or have to stick their finger twice a day to check their blood sugar?  The engagement challenge here is orders of magnitude more difficult.

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Achieving passive data upload (we’re not 100% done but the end is in sight) is a feat we can all be proud of.  If we’re going to make connected health a widespread reality in the lives of consumers and patients, we have to double down on engagement.  We need to bring together first class designers, motivational psychologists, marketing scientists, behavioral economists and all others who understand how to build sticky apps and services.  We owe it to our patients to create well-designed, engaging apps. If we don’t, they’ll be paying attention to Instagram and our connected health devices will lie fallow in a corner somewhere.

We’re building such a team at Partners Connected Health and I find their early work inspiring.

Reflections from CES 2016

January 12, 2016

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I just returned from the Consumer Electronics Show (CES) in Las Vegas.  If you have any familiarity with the tech world (or even read/watch the daily news) you’ll have heard of it. CES is one of the biggest gatherings on the planet, with somewhere around 175,000 attendees.  Companies large and small, from a wide range of industries, come to show off their wares with the hopes of capturing the market for gadgets and gizmos that consumers will use in the coming year.

There are always a few big themes each year. For instance, the last time I attended CES two years ago, 4K television was all the rage.  A year before that, it was 3D TV.  These two examples point to another interesting quality of this trade show — some of the products featured there never see the light of day.  Some companies spend large sums of money on fancy booths and demos in hopes of creating the right buzz, but haven’t even gotten their first round of funding.  So it is a bit of a circus, literally. Throw in the fact that it is always in Las Vegas (the only town, apparently, that can accommodate this large an influx of conventioneers) and the experience can take on the feeling of being in an old-fashioned Fellini movie.

The most interesting thing about CES over the past 4 to 5 years has been the growing attention to connected health.  I was not able to attend last year, but when I was there in 2014, there was noise made about the number of connected health offerings and the expansion of the Digital Health Summit from even a year later.

Having taken even a brief hiatus made me feel like we’d fast forwarded decades.  The exhibit space devoted to connected health this year took up most of one large hall at the Sands Hotel, at least quadruple the exhibit space  I saw in 2014.  In addition, as was detailed in a blog post by my friend, Jane Sarasohn-Kahn, CES president Gary Shapiro’s opening keynote was dominated by health-related examples.

It is also worth noting that CES selected my new book, The Internet of Healthy ThingsSM, to be featured as one of only ten books presented in “Gary’s Book Club,” hosted by Barnes & Noble.  Once again, when you consider the breadth of what this event covers, this is a feather in the cap of connected health.

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I could leave well enough alone and celebrate how far we’ve come to have connected health so prominently featured at this mammoth conference. But as Paul Harvey would have said, that would leave the rest of the story untold.

The other analogies I could use would be a good news/bad news joke or the hit song from the 1970s “57 Channels but Nothing’s On.”

There was so much featured, but not much of it was inspiring.  Most of the digital health technologies presented could fit under the broad heading of Internet of Things and wearables (which, of course are related). Here are a few themes:

Pet trackers:  I guess I shouldn’t be surprised, but really? Two areas of healthcare delivery that are always open to early innovation are veterinary medicine and dentistry, because they are based largely on a cash economy.  That said, I don’t know why we need a half dozen vendors peddling tags to track Fido.

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Jewelry:  This is not new, per se, but the sophistication, beauty and breadth of offerings was stunning.  It wasn’t that long ago that I witnessed an MIT Media Lab graduate student demonstrating ‘wearable computing’ and it looked as goofy and geeky as you could imagine.  But now, for those who want to spend lots of money on their health tracking devices and make a true fashion statement, the choices are many.

Fitness:  Once again, not new, but the complexity and number of offerings was impressive.  Among my favorites were two companies promoting cyclist sun glasses that have built in headphones for music/phone, as well as a Google-glass-style heads up display to feed you all manner of stats about your ride: calories expended, speed, etc.  Too bad these glasses are only for folks with 20/20 vision.  Likewise, I was taken by a cyclist’s jacket that has lots of built in flashing lights to enhance visibility.  The arms automatically blink like automobile signals if you raise your arm in anticipation of making a turn and then turn off when you’ve lowered your arm.  I took the card on that one and may place an order!

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Apart from that, there was a bevy of trackers, trackers and more trackers: Things you can stick onto items to turn them from dumb to smart; shoes that will tell you when you’ve worn them out and prompt you to reorder from the manufacturer; and all of the usual myriad of activity monitors, heart rate monitors, baby monitors and smart scales.  The volume of offerings was breathtaking, but so was the lack of innovation. Wearable computing seems to have entered the ‘me too’ phase.  With Fitbit now a public company and doing well, it seems everyone wants to reproduce their success without doing anything different than they’ve already done.

To quote a colleague, Rachel Kalmar, the data from all of these wearables is like flour coming from mills. The next phase has to be products that, by analogy, are the cakes, breads and cookies.  I saw none of that at this year’s meeting.

To wit, for our 2016 Connected Health Symposium, we’ve chosen the theme, “Wearables and Digital Therapeutics:  New Frontiers in Patient Engagement.”  We plan to feature companies and innovations that are creating some of these proverbial cookies and cakes.  The ones that easily come to mind (e.g., Spire, Muse, Empatica) were not at CES, or at least I did not find them. One honorable mention that had a presence at CES was Quell, a Boston-based firm with a wearable device for pain control.  They fit the category of digital therapeutic perfectly.

This is not meant as a knock on CES or on any of the technology featured there.  It is more of an observation on the state of the connected health ecosystem — and a call to action to companies, researchers, entrepreneurs and healthcare providers to continue to advance, inspire and implement truly innovative personal health technologies.

To reiterate, it is amazing how far connected health has come based on the sheer volume of activities, exhibits and interest at CES. I look forward to experiencing CES in years to come when companies are offering not just connected device data, but insight and inspiration!

Four Trends that Will Shape Connected Health in 2016

December 15, 2015

Can’t help but reflect at this time of year on what was, was not and what’s ahead. 2015 was an amazing year in the land of connected health. The most impactful trend I saw was the change of view from administrators on the delivery side of health care. Their perspective went from “Show me the evidence” to “If we don’t get involved, we’ll be left behind.” This has an enormous impact on our sales strategy for promoting the widespread adoption of connected health. Selling to a ‘fear of missing out’ mentality is easier than the healthy skepticism that preceded.

As we round out the year, I find my vocabulary changing as I describe connected health, particularly the activities at Partners Connected Health, because of the mainstreaming of concepts like wearables and apps. Even in healthcare, it seems that people are now assuming that services will be delivered via these platforms.

Speaking of Partners Connected Health, we had a banner year as well, starting with my designation as Vice President, Connected Health. This is an important symbol of Partners’ commitment to virtual care as a strategy moving forward. In fact, in 2016, there will be a concerted effort to bring thought leaders and experts from across our system together to map out a system-wide strategy for telehealth. And, with the help of two outstanding co-authors, Gina Cella and Carol Colman, I published The Internet of Healthy Things in October at our Connected Health Symposium.

 

 

In 2015, we also rebranded from “Center for Connected Health” to “Partners Connected Health” as a way to further demonstrate that connected health is becoming embedded in our care delivery processes across the network, which serves more than 1.5 million patients each year. We witnessed expansion in all aspects of our work, including more deployments of Blood Pressure Connect, as well as new pilots in medication adherence, all of these in tight collaboration with Partners Population Health Management. On the innovation side of our team, we’re now organized in three units: User Centered Design, Research and Data Science. Our relationships with corporate clients are both fruitful (progress with Daiichi Sankyo and Samsung) and growing with new partnerships to build more exciting engagement tools. The work funded by the Robert Wood Johnson Foundation to build new functionality under our site, Wellocracy, is also progressing nicely.

Symposium 2015 was a success by all measures, with increases in attendees, exhibitors, sponsors and near universal enthusiasm for our program offerings.

 

 

As we look forward to 2016, what will be the headliners?

  1. We’re noticing an exciting trend in the wearables space. Whether you call it wearables 2.0, beyond wearables or some other name, this trend involves innovators creating technologies that offer insights — rather than just numbers — from wearable technology. Companies such as Spire, Interaxon, Empatica and others exemplify this trend. They don’t so much offer users things like step counts or hours slept, but stress maps, feedback around mindfulness and prediction of untoward health events.

 

 

  1. The pharmaceutical industry will have bought in to the concept of digital therapeutics. One of our current partners, Daiichi Sankyo, was early into this space and, in 2016, we’ll be ready to surface the exciting work we’re doing with them in atrial fibrillation. Others are coming on board as well.

We define digital therapeutics as an intervention delivered by digital means that, independently of any medications changes, has a positive effect on clinical outcomes. We became intrigued by this notion when conducting a study of teenagers with asthma. The intervention was a simple one: a private Facebook group. Giving these teens a private place to share with each other was correlated with improved outcomes, independent of any medication changes – which led us to the idea of digital therapeutics. We’ve seen the same phenomenon in the study and deployment of a variety of our mobile apps for increasing activity levels and cancer pain management, for instance. Companies like Omada and Welldoc have had great success with digital interventions.

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We’ve decided to feature these two trends as content pillars for next year’s Connected Health Symposium, with the working title of: Wearables and Digital Therapeutics: New Frontiers for Patient Engagement. We are eager to hear what you think of this. Help us shape the content for Symposium 2016 by commenting on this post.

  1. 2015 was the year that virtual visits went from an “up-and-coming-trend” to a “stay in business application” for payers and pharmacy chains. It will be exciting to watch how this evolves further in the year ahead. Consumer interest is just starting to emerge, but I picture the tired mom with frayed nerves and a crying, sick kid at 1 AM trying to figure out whether to leverage Walgreens, CVS, her insurer via American Well or Teledoc OR her own doctor’s practice for her virtual visit. Of course, this is not the time when you want to sort this out.

 

 

More payers will be reimbursing for virtual visits in 2016, so volume is sure to grow. Depending on how providers respond, we could see this category of care delivery as a disrupter too, in the same way we did with retail clinics 10 years ago. Also emerging in this category are specialized direct-to-consumer offerings such as Spruce, others in dermatology and Maven in women’s health.

  1. Also on the reimbursement front, the Centers for Medicare & Medicaid Services (CMS) released the chronic care management code in January of 2015, allowing providers to bill for 20 minutes/month of non-face-to-face time devoted to care management. CMS did not see a lot of claims in 2015, as expected, but organizations are building systems to bill for this code at scale in 2016. MD Revolution (where I am an advisor) is one company building such systems.

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The market for connected health is booming so there will be curve balls, new entrants and lots of other exciting developments. We’ve hit the rapidly growing part of the inflection point for adoption and I’m looking forward to it as our team continues to contribute both to real-world implementations and to creating the future.

Twenty Years in the Making

December 1, 2015

Recently, when I Googled the term “connected health,” I was astonished to yield over 158,000,000 search results. What’s remarkable is that when we launched what was originally called Partners Telemedicine in 1995, the terms connected health, mHealth or digital health simply didn’t exist. In 2007, we created the term connected health and renamed our Center to better reflect not only our work, but the trajectory of the industry.

CCH068_book_cover-1 0 1Today, connected health is mainstreaming in a rapid way. But as I talk to investors, entrepreneurs and business leaders, they are at a loss for what to do with this exploding opportunity. The space feels chaotic and they worry about healthcare—the complex, long sales cycles, liability concerns, overregulation and the like. My new book, The Internet of Healthy Things, takes the lessons we’ve learned over the past 20 years and brings them all into focus, providing guidance on what investments, business strategies and technology considerations are necessary to improve health and wellness, and achieve order (and profit) from the chaos.

Having been fortunate enough to enter this field from the ground floor, I’m proud to be among some of the earliest pioneers who helped invent it. When I embarked on this journey, it was well before the Internet, cloud computing, ubiquitous sensors, social networks, tablets, e-readers, mobile phones and apps became part of the fabric of our everyday lives. I didn’t know with what, with whom or how we would be connecting to our patients. I did, however, recognize the need for technologies that could deliver health in a manner independent of time and place. And I knew that healthcare should be available to people in the context of their everyday lives, and that implementing care in this manner would improve both quality and efficiency.

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Today, everything and everyone is connected. Experts predict that by 2020, 26 billion everyday objects will be able to capture, receive and share data via a vast, interconnected global network linked together by inexpensive sensors, GPS and the cloud. Just around the corner, real-time biometric data will be automatically captured and used to learn more about the impact of lifestyle on disease and wellness, and ultimately change behavior for the better. Hence the term and title for my book, The Internet of Healthy Things, or IoHT. In the new world of the IoHT, virtually any object—a watch, a shirt, the steering wheel of your car or the mattress you sleep on—can be transformed into a data-collecting object that can be used to improve your health.   

But selling devices and apps is just a small piece of the connected health market. Personal tracking data contains a treasure trove of information about how people live, work, play and even think, which sheds a great deal of light on their lifestyle, including their habits and preferences. It is also an incredible resource for businesses, insurers, healthcare providers and entrepreneurs—even government health ministries—who need to better understand what motivates the health consumer.

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The business of healthcare is also changing dramatically, with providers taking on risk for population-level care and consumers buying insurance on exchanges and paying a much larger part of their bills. And all of this medical information is available to patients on the Internet, creating a more aware and demanding healthcare consumer. The disease burden is changing, too, with the ever-growing specter of lifestyle-related, chronic conditions such as diabetes, hypertension, high cholesterol and obesity. These growing healthcare challenges are well-suited for connected health solutions, and create a huge opportunity for businesses that produce the goods and services that can move health and wellness into the everyday lives of consumers and improve clinical outcomes.

But where, specifically are those opportunities? How is the IoHT opening up healthcare to companies that have never before ventured into this space? Who will be the winners–and who will be the losers–in the new connected health ecosystem? In my book, I explore these and other topics, including:

  • Consumer behavior and the strategies and programs that can apply to the coming IoHT, while anticipating future trends
  • ‘Frictionless’ design for personal health devices and platforms that make the health consumer experience more compelling, engaging and addictive
  • New and potential applications of the many different (and novel) form factors that can be used for connecting health information to consumers
  • Strategic advice for startups and entrepreneurs to the connected health market
  • Unavoidable trends and important opportunities for the future

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Healthcare delivery needs to change, becoming more efficient and more patient-centric. We need all of you to work furiously at the challenge at hand. My wish is that each of you takes something from this book that will enable you to take a risk, but do so with greater confidence.

I would also be interested in your feedback on the book, and the concepts and ideas put forth to help disrupt and advance care delivery.

What is Your Competition?

October 19, 2015

This post marks a bit of a renaissance for the cHealth Blog. I took a record sabbatical from blogging from mid June to early October because I was focusing my energies on writing a new book, due out at the time of our Connected Health Symposium, October 28-30. I hope to see you at the event and please stay tuned for more details about the book in the coming weeks.

I was privileged to be invited to an interesting meeting earlier this week, participating in an advisory board for some work done by a prominent policy institute. The topic of the project and the meeting was focused on bundling of care model innovations. The room was filled with notable, experienced individuals, all who have had experience disseminating care delivery innovations.

iStock_000005340466_MediumWe met for a full day and I am sorry to say the amount of time allocated to connected health was only about five minutes. We discussed innovations that send care providers to the home, innovations that moved the hospital into the home, innovations in palliative care in the home and innovations involving the restructuring of the medical practice. All were chosen because there was high quality scientific literature demonstrating that these strategies could lower costs. I can’t say the innovations we discussed didn’t involve connected health, but my favorite type of care model innovation was, at best, a footnote in the discussion.

I meet with a lot of early stage entrepreneurs. Among the questions I always ask is, “Who is your competition?” How they answer tells me a lot about how they are viewing the market. Some say, “We really don’t have any competition.” That tells me that they either have an innovation that the market really doesn’t appreciate the need for yet (like the original iPad) or more likely, they are focused on what they perceive to be different about their product or technology, not the problem they are trying to solve. One rule of thumb I always remind entrepreneurs is that, when disseminating a new innovation, if people perceive a problem and pay for products to solve it, that is what forms a market. So, rather than focus on what makes an innovation unique, it is more productive to focus on what problem the innovation is solving and how others are solving it presently. This can be very helpful in crafting a communications and marketing strategy.

But getting back to the care model innovations meeting, I was struck by how ingrained the use of human interaction is in solving healthcare challenges. To whit, at Partners Connected Health, we recently queried a group of hospital presidents about increasing their use of telemonitoring for congestive heart failure (CHF). We knew each hospital’s CMS readmission penalty and devised our sales pitch around how telemonitoring is an efficient tool enabling a one-to-many care model, leveraging each nurse across 100 patients (or thereabouts) and predictably lowering readmissions, as well as achieving an overall decrease in total medical expenses. These audience members had a significant interest in efficient care, as their payment is at risk depending on outcomes and efficiency for this CHF patient pool. We perceived our logic to be air tight and expected everyone to sign on to adopt more telemonitoring.

Perhaps you won’t be as surprised as I was about the relative lack of enthusiasm. We heard a number of different reasons why to not invest in telemedicine further. Among the most salient (from the perspective of this post) was the comment by one executive that her hospital has a robust cardiac management program that bringing patients into the clinic for follow up. Another cited the use of care managers visiting the home to do medication reconciliation.

I expect the picture I’m trying to paint is coming into focus for you now. In healthcare, our biggest sunken costs are in facilities and labor, so we build financial models around making use of those resources. For instance, if you’re a bit overstaffed in nursing, it may make sense to deploy nurses to patients’ homes. Likewise, bringing patients in to your facility helps offset the cost of depreciation on that asset.

We started the journey of connected heath adoption 20 years ago. The first barrier we had to overcome was skepticism about quality. Then came the cry of “How do we get paid?” (This is why there has been an uptick of interest directly proportional to the adoption of value-based reimbursement and overutilization penalties.) Then providers implored, “But it needs to be part of my workflow.” Today, almost all EMR vendors have integrated telehealth or a roadmap to offer those integrations.

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So, the next phase of our journey will be integrating connected health into the deconstruction of facility-based care as we know it. Consumers now have many options for receiving their care, including at the local pharmacy or via a virtual video visit. Providers will come on board with these new care delivery models. And, it is imperative that those of us who advocate for connected health be at all of the meetings and involved in the key decisions so that connected health is presented as a viable option to solving today’s healthcare challenges.

Our competition, at this point, is the business-as-usual approach: “the way we’ve always done it, by one-to-one human interaction.” Overcoming inertia is harder that presenting an airtight sales pitch.

This explains the lineup of care bundle innovations from the advisory board meeting I referred to above. They are innovative in that they move the locus of care, in most cases, to the home. Perhaps that’s the state of progress at this time. We take the one-to-one interaction and move it out of the facility and into the home. That only disrupts one of our major fixed costs.

I expect you can tell I’m puzzled. I’d love your thoughts on the matter.

Telemedicine Is Vital to Reforming Health Care Delivery

October 9, 2015

Telemedicine Is Vital to Reforming Health Care Delivery

By Joseph C. Kvedar, MD

October 7, 2015

Harvard Business Review

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Health care remains one of the few services that require people to have a face-to-face interaction to obtain access. But more and more consumers are questioning that reality, and change is on the way. In January 2015, the Centers for Medicare and Medicaid Services (CMS) issued a new provider reimbursement code for non–face-to-face health care services for patients who have chronic medical conditions. A new CMS code may seem like a tiny matter, but this one emblemizes a larger shift toward delivering health services independently of time and place, enabled by technologies such as smartphones, sensors, and wireless health-monitoring devices — what we in the field call telemedicine.

The concept of telemedicine is not new (its roots go back to the late 1950s). In the 21st century, the widely held goal of improving health care outcomes while lowering costs is accelerating the shift from a one-to-one to a one-to-many model of care delivery, which telemedicine makes possible. Understanding telemedicine has now become crucial for decision makers in the health care industry, and I aim to help in that effort. Let me start by exploring some industry fundamentals.

The rising prevalence of chronic illnesses in an aging population puts pressure on the supply side of health care. Clinicians are not being trained fast enough to keep pace with the rate of service demand. In addition, given the rising cost of care, new models for reimbursing hospitals and other providers have begun to emphasize quality and efficiency rather than units of delivered services. And consumers are increasingly shopping on open markets for health insurance policies that require significant deductibles and out-of-pocket expenses. These trends underpin the need for a one-to-many model of care delivery that offers flexibility and transparency.

Telemedicine is well positioned in this environment, particularly given patients’ growing comfort with technology in their consumer endeavors. The core technologies of telemedicine include those that collect data (such as wearable and ingestible sensors, and vital-sign and health-status monitoring) and those that enable communication (videoconferencing, text-messaging, mobile apps, and voice calls). These types of virtualized services will become an integral part of care delivery. Indeed, several commercial payers are now reimbursing providers for video-based visits, not to mention the CMS’s new telemedicine-friendly reimbursement code.

How does telemedicine work in practice? Here are some common examples:

  1. When patients with congestive heart failure use a home-based weight scale and a blood pressure cuff, and then check in routinely by phone with a nurse, their survival rates improve, and costs decline. A nurse can care for hundreds of patients at a time in this way, keeping them healthy and happy in their homes and away from costly emergency rooms and hospital beds.
  2. For patients with mental illness, video follow-up visits with a mental health provider have been shown to improve quality and efficiency of care. The provider can more easily assess environmental influences on the patient’s condition, and patients more accurately reveal their daily state of being because they don’t always have to endure the stress of traveling to an office and the social anxiety of sitting in a waiting room with other patients.
  3. Text-messaging interventions can aid in smoking-cessation efforts. My institution is collaborating on a texting intervention for smokers who try “practice quits” (quitting for a short period, such as an hour or a week). Timed text messages help the smoker cope with cravings, encourage longer practice-quit commitments, and applaud successes. The smoker can also text in the word “crave” and receive text-based coaching on the spot. Relatively automated systems like this one have great potential for improving public health.
  4. Both Walgreens and CVS offer virtual video care as an extension of their retail clinics. Many health plans, led by UnitedHealth Group, are doing the same. These offerings will push hesitant providers to offer these services as well.

Despite those examples, most telemedicine efforts are still in early, small-scale phases of implementation. Countervailing forces, like these, stand in the way:

  • Although most young doctors are digitally savvy, they represent a much smaller group than the physicians who were trained in an era when a face-to-face interaction with a patient was the only option.
  • Fee-for service reimbursement, still the dominant payment model in the U.S., is fundamentally at odds with a one-to-many model of care delivery.
  • Some doctors worry that virtual care will mean greater liability, even though most malpractice insurance carriers are telemedicine-friendly and the case law on virtual care is almost nil.
  • State physician-licensure laws in the U.S. create false geographic barriers that have impeded some forms of telemedicine. For example, some laws require that a physician be licensed in the state where his or her patient is located.
  • Many health insurers fear that telemedicine will lead to overutilization — such as a doctor looking at an image of a patient’s mole, submitting a bill for the virtual service, and then saying he needs to see the patient in person to be sure.
  • Frequent users of health care services are typically disproportionately less tech-savvy and place great value on their social interactions with their clinicians.
  • Privacy concerns about remotely delivering care persist.

Even if all of these obstacles are overcome, face-to-face care visits will not become obsolete, given the complexity of some patients’ clinical profiles and illnesses, especially when a doctor needs to arrive at an initial diagnosis. And some highly sensitive communications (such as news of a newly diagnosed cancer) are obviously best conveyed in person. But for health care interactions that are algorithmic in nature (think: blood pressure checks and acne follow-up visits) or that have a low emotional impact, virtual encounters can be ideal for both parties.

Pressure to lower costs also bodes well for innovation in telemedicine’s one-to-many model of care delivery. Early results suggest that new payment models that reward providers for higher quality and efficiency (including virtual care) are working.

I am excited about the possibility of automating certain care-delivery processes and using technology to enable patients to obtain better care. The advertising industry now has a model for collecting and analyzing consumers’ digital fingerprints so that ads can be personalized. In a somewhat similar vein, people can now have their walking steps counted, purchasing behavior tracked, and mood and other health indicators monitored to create a highly personalized messaging program that motivates them to improve their health.

If we do telemedicine right — with the direct and enthusiastic consent of the patient — I believe that most people will make the privacy tradeoffs. Realizing the potential of telemedicine will indeed require those tradeoffs if we want to improve the current system of health care delivery.

Joseph C. Kvedar, MD, is the vice president of Connected Health at Partners HealthCare, which will publish his forthcoming book The Internet of Healthy Things.

Reposted with permission from Harvard Business Review (HBR.org)

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