Senior leaders at the University of California Davis Health System (UC Davis Health), a Sacramento-based patient care organization serving 33 counties covering a 65,000-square-mile area north to the Oregon border and east to Nevada, have long been focused on using technology to keep patients healthy while lowering costs. One example of this is its Center for Health and Technology Telehealth Program, which was established in 1996 to improve access to specialty neonatal care for expectant mothers living in a small community 60 miles from the UC Davis Medical Center in Sacramento. Today, that telehealth program, which when it started was one of the pioneering projects in the field, is one of the largest telehealth programs in the country.
UC Davis Health’s latest health IT endeavor is one that earned the organization semifinalist status in the 2017 Healthcare Informatics Innovator Awards program. The technology aim of the project, called “Integrating Patient-Generated Health Data to Improve Health,” included diabetes and better blood pressure initiatives that would leverage patient-connected devices and integrate the patient-generated data points into the electronic health record (EHR), thus enabling clinicians to utilize coaching for behavior change when necessary.
More specifically, the clinical aim of the diabetes initiative was to improve the health of diabetic patients through the strategic use of technology and health coaching. From a technology standpoint, the aim was to leverage patient-connected devices (i.e. fitness trackers) and integrate the patient-generated data points (i.e. steps, active calories, resting calories, etc.) into the EHR via a vendor-neutral platform. Similarly, the clinical aim of the better blood pressure initiative was to improve the health of patients diagnosed with hypertension. By incorporating patient-reported blood pressure readings via connected devices into the EHR, clinicians could utilize coaching for behavior change when necessary, officials of UC Davis Health said.
For the diabetic patient initiative, the aim of the health coaches and clinical care providers was to recruit 300 patients over a 12-month period. And for the better blood pressure initiative, the aim of the health management and education team was to recruit 300 patients over a six-month period. The recruited patients were provided an iHealth wireless blood pressure and on-boarded on how to “connect” their device to Apple HealthKit to the patient portal, which would feed into the clinicians view of the patients’ EHR.
Madan Dharmar, Ph.D., an associate professor in residence at the Betty Irene School of Nursing at UC Davis and the Department of Pediatrics at the UC Davis School of Medicine, and dubbed as the “mastermind” of this project, notes that the diabetic initiative was the organization’s first foray into patient-generated health data, and thus it focused on non-actionable data. “So this means metrics around physical activity, nutrition, sleep, how much energy is taken in and being spent, and calories spent and taken in. This is all non-actionable data,” Dharmar says. “The uniqueness of this project is that we wanted for providers to be able to take a four-week period, for instance, so they have a complete understanding and flexibility for how to look at that data and how it’s being presented to them. We needed to capture all of that data and have it within the EHR so they could pick a specific time period, drill into it, and understand the data from that time period,” he explains.
Dharmar notes that UC Davis Health also wanted to give physicians the ability overlay that data with other clinical metrics which are routinely collected, such as lipid profiles and HbA1c levels so they can have a conversation with the patient. “This way, they can tie that patient-generated health data with the clinical data and help them understand how a behavior change in their lifestyle can have an impact in how they manage that disease. So that’s why we wanted to collect all the data points and have it all within our EHR,” he says.
How Accurate and How Valuable?
An Accenture survey from March 2016 found that the number of U.S. consumers who use wearables and mobile apps for managing their health has doubled in the past two years. What’s more, the research that included a survey of more than 8,000 worldwide consumers revealed that of the one in five consumers were asked by a doctor to use wearables to track their health, such as fitness or vital signs, three-quarters (76 percent) followed their physician’s recommendation.
Despite this uptick in wearables and mHealth app usage, many providers find that issues around data quality and integration into EHRs are still major pain points. Dharmar says that data integrity was a big concern of UC Davis Health’s, as it’s commonly known that if physicians don’t trust the data they’re getting, they won’t use it. “A lot of patient-generated health data integration is focused on the patient entering the data, but there are questions around patient errors and also about the honesty of the patients who are the entering data when they are told they need to meet a certain criteria to meet goals,” Dharmar says. “We automated a lot of that process so that once the data is acquired by a certain device, it gets into our EHR. So there were really no issues around data quality at that point in time,” he says.
Dharmar does point out, however, that the data is coming from consumer devices, and there is inherently an imperfection or accuracy of consumer devices, as they are not meant to be accurate at a “medical grade level or a clinical decision level.” He says that the accuracy of the devices in use “was debated a lot,” and after discussions with physician stakeholders, it was concluded that “since we are focused on a population-level metric, we understand the imperfection of that data, and are looking at shifts in data.” Dharmar continues, “That was one of the reasons we were comfortable in leaning towards consumer devices. As we look more at collecting actionable data to improve care, we are looking at FDA-approved devices which can better accurately capture that information. Like everyone else, we struggle with this problem.”
On the integration front, care management portals have mostly existed outside of the main EHR system, but the secondary portals are difficult for clinicians to manage because each portal/system requires a username and password. Additionally, providers often can’t find the information for patients in one location, and must go to multiple systems and locations to get a full view of the patients’ overall health, officials note. As such, UC Davis Health has developed the platform not just for local population health disease management, but has made it scalable for all patients to use (it just requires turning on the functionality). Through the new integration, patients can provide vital stats to the clinician from one location without having to move all around the EHR and log into and out of additional systems. “Integrating it into the providers’ workflow was a new and innovative way to share data between patients and the clinicians without the clinician having to probe for important health-related data points,” officials say.
In all, for the diabetes initiative, more than 1.4 million patient-generated health data points have been integrated into the EHR for clinical review and patient health management to-date (based on the count of patients recruited for this initiative). For the better blood pressure initiative, more than 2,700 data points have been made available to clinicians for review and patient health management (based on the count of patients recruited for this initiative). Patients participating in the initiatives have provided clinicians with improved visibility into patient health via ongoing data collection; clinicians now have the ability to collaborate with patients using real-time personalized data points, officials say.
Moving forward, Dharmar says that UC Davis Health is strongly moving towards rolling this project out to the rest of their patient population. “We have a network of primary care clinics, but we used three [for this program]. So we are expanding this program to [everyone else].” He says that the idea is also to expand this to managing the community at a population health level—so beyond diabetes and blood pressure.
Laura Martinez, communications and measurements, UC Davis Health System IT, agrees, noting that executive leadership here is “pushing for these types of initiatives because they see the value of population health management.” She adds, “Most projects like this start in one clinic; this started in three with multiple providers on board. It’s the first time we took health-related mobile devices and integrated it into the EHR. It’s just a first step, but it’s an exciting first step.”