I have seen the future of healthcare information technology and it is in Madison, WI. No, I’m not talking about Epic, the behemoth that bestrides the world of EMRs, although clearly they are part of that future. I am talking about a small, start up, Propeller Health.
On a recent bitterly cold and snowy day, this southerner ventured up to Madison to visit their offices in a funky renovated old Kroger Grocery building filled with small companies. Despite the weather, I am glad I made the trip. It was a reminder of both the opportunity and challenges that lie ahead in revolutionizing our healthcare system.
Sitting around a conference room table eating pizza with CEO David Van Sickle and his team made for a delightful and educational afternoon as we explored their product, it’s potential to improve patient care, and the conflicting market forces that HIT entrepreneurs face.
The team at Propeller has combined sensors, mobile apps, and services to create a mobile platform for respiratory health management. At the heart of this mHealth “triple-play” is an FDA approved device that sits like a cap on top of the inhalers that are commonly used by patients to self-administer medications to control respiratory diseases like Asthma and Chronic Obstructive Pulmonary Disease (COPD).
The medical literature is pretty clear that patients who use these medications appropriately can greatly reduce the number of exacerbations, improve their quality of life, and reduce overall costs of care. Frequency of use, in addition to being an obvious marker of compliance can also be an indicator of worsening clinical status. Patients who begin to use their inhalers more and more frequently are likely sliding into an exacerbation that may lead to an ED visit or hospital admission.
Historically, doctors have asked patients to keep diaries that can be reviewed to look for patterns of use. You can probably imagine how well that approach, though well intended, actually works in the busy, complex real world that patients live in. Not. Very. Well.
Part of the genius of Propeller is that it automatically and unobtrusively records inhaler use. The “cap” then transmits that data to a smartphone or small Bluetooth base station. The smartphone can also harness geo-location data and weather to give even more information about the patient’s situation. Patient friendly dashboards can be viewed on smartphones, tablets or via a web portal. There is even a feature that allows the “sandwich generation” to track their kid with Asthma and their parent with COPD at the same time.
This device also represents the leading edge of a new approach to population health and care coordination. A provider dashboard can be configured to follow large numbers of patients simultaneously. This dashboard helps providers find the “needles in the haystack” by highlighting the subset of patients who may be deteriorating or non-compliant. Care coordinators can utilize this information to intervene and help patients avoid or mitigate a full-blown exacerbation. One can also imagine a day when patient-facing clinical decision support, driven by protocols, could provide an automated layer of support between the patient and the care coordinator.
If you’ve read my book on mHealth you can see why I like this technology. It is elegant, unobtrusive, easy to use, patient-centric, leverages consumer technology, and can provide the basis for large-scale population health activities.
So what’s the problem? I see at least two. First, there are the complex and changing economic incentives. In a fee-for-service world, healthcare providers are generally not rewarded for investing in this kind of technology. In fact they have two strong economic disincentives: the devices represent additional costs and, when they work mean fewer office and ED visits and hospitalizations and therefore less revenue. To be clear I am not saying providers are not motivated to do the right thing for patients. Most are truly troubled by the lack of alignment between the case for quality and the business case. But, no margin, no mission.
Companies like Propeller have to navigate this world by appealing to payers like insurance companies, self-funded entities (typically large employers) and other organizations that have assumed financial risk and would reap the savings the devices may generate. They also need to be positioning themselves for the emerging world of value-based purchasing which will flip the economic incentives on their head and make these technologies much more appealing to providers. In the case of COPD, incentives to reduce hospital readmissions provide a test case today for what this new world may look like tomorrow.
The second problem is the challenge of integrating these devices into the existing HIT ecosystem. It’s pretty obvious that having these devices stream their data into an existing EMR or population health registry increases their utility dramatically. As I like to say, if it’s not “View and Do” then it probably won’t do.