In hospitals and physician practices across the country, the implementation of electronic health records (EHRs), computerized physician order entry (CPOE), and other technology has brought on hope of increasing quality of care and decreasing cost. And to date, approximately 80 percent of the nation’s doctors are now using EHRs, a sure sign of progress when it comes to the adoption of health IT in the U.S.
Now, a new information source has begun to emerge in healthcare: patient-generated health data (PGHD), which is any medical data that a patient inputs electronically. During Health Datapalooza in Washington, D.C. earlier this month, Jay Nagy, associate principal of corporate strategy for The Advisory Board Company, headquartered in D.C., discussed how providers can take advantage of data coming from patients in between their encounters with clinicians, and what they can do with that data to improve care processes and outcomes.
Certainly, as healthcare moves from a fee-for-service world to a value-based world, opportunities will arise for PGHD to be worked into clinicians’ workflows. Nagy recently dug deeper into this issue with HCI Associate Editor Rajiv Leventhal, discussing the aforementioned points as well as how providers can build a successful partnership with patients on this data, the industry’s readiness for PGHD, what the future holds, and more. Below are excerpts of the Q&A interview between Nagy and Leventhal.
How “real” is PGHD at this point?
It’s still the early days. If you think about data getting collected through wearables, you can see that the market is very immature right now. Rock Health [recently reported] that Fitbit, Jawbone and Nike’s bands account for 97 percent of sales. In terms of being able to collect and share the data, which is the key, it’s really early, but the potential is enormous, especially if you think about the 5,000 hours between periodic encounters with patients. This amount of time refers to when sickness and health happen, which is outside the clinical setting, for the most part. If you’re able to quantify that somehow, it will lead to not only better treatment and diagnosis, but ultimately better outcomes where you don’t have to be in the doctor’s office and hospital because you got the right interventions. And there are case studies of having dedicated apps to get information back on specific conditions.
Regarding the number of hours between encounters with patients, what can providers do with the PGHD they receive in that time?
One of the basic elements would be to understand symptoms and what is actually happening. Zero in on the diagnosis and things that are tracked repeatedly, For a congestive heart failure (CHF) patient, for example, weight is a huge indicator. Another example could be with diabetics tracking their glucose.
A second area of benefit is adherence to the treatment plan. One of the big open questions that is more and more concerning to providers as they bear more risk for outcomes of the patient is, Are they following the treatment advice? To the extent that they’re not, what can we do to improve the chances that they will? What can providers do to communicate more effectively? And how can we better partner together to make sure they get the best help possible? If you track these metrics for CHF patients, for example, you can develop filters. So you won’t have a provider looking through day- by-day weight, but rather you can set up filtering mechanisms so you can get alerts when they matter as opposed to randomly sharing data. Providers are not sitting around waiting for more data to come in—they’re busy folks. So you need to make it valuable.
So how can the provider-patient partnership improve to ensure value on both sides?
From a patient perspective, if providers give better advice to get them on a better treatment plan and know when the patient’s health status is declining, patients will benefit directly. The missing link is how do providers directly benefit? That has been asked a lot. Of course, they benefit knowing that patients are in good health and adhering to the treatment plan, but in terms of a financial incentive, it’s not really there yet. In a fee-for-service system, so much of the financial benefit comes from patients being in the office. Going forward, with healthcare reform, from a practical perspective, it will be beneficial for providers not to have those patients in the office. You can’t ignore that missing financial link, though. There is a phrase in healthcare: no margin, no mission. So that is a big missing piece; there is no way through the normal reimbursement channel, whether Medicare or private insurance, to get providers compensated for what is going on outside of the clinic. There are lots of initiatives that are moving us in that direction, but there isn’t a clear incentive today to work with patients in this way.
It’s clear that PGHD makes more sense in value-based healthcare world. So what do providers think about all this?
Providers are frustrated with the uncertainly to what is happening outside of their clinical interactions with patients. That definitely comes across the more you talk to them. And talking about PGHD, there is the element of fear and uncertainty about the volume of data. Providers don’t want to be inundated with the minute recountings of the daily lives of their 2,000-3,000 patients (in the case of a primary care provider). There are some security concerns as well, as of course, once the data comes in providers’ possession, it is subject to Health Insurance Portability and Accountability Act (HIPAA) regulations. It needs to be right-sized, getting it at the right time when they can make the most of it. If it’s valuable to them, it will ultimately have a better impact for the patient.
Do you think the industry is ready for this new source of data?
Well, it is going to require a monumental shift. How much can you push away from the clinical encounters (one or two hours per year that you might see the patient), to manage things wherever the patients are, which is primarily where health and sickness happens? The hospital industry has been used to investing in very large facilities to attract volume and growth, so it does take time to accept the change in tactics. The mission is still to keep the population healthy, but there is a change in tactics. And patients are becoming more aware that you can actually measure these health indicators, so with them being on the hook for more of their healthcare costs, they are getting this extra incentive themselves. The demand needs to develop on the patient side, and I think you will start to see that to make it more achievable and realistic for providers to accept PGHD and new ways of managing care.
What needs to happen next to get past the “early days” of PGHD?
For fee-for-service providers, having another patient in the office is what you’re incentivized to do instead of answering emails or reviewing PGHD that one of your patients has shared with you. There are exceptions to that in certain employee physician models and certain at-risk models. Kaiser Permanente, for example, employs its physicians on a salary model, and the organization is very progressive in terms of physicians answering emails and getting data from patients. So again, it’s about right-sizing things and getting the most value from the PGHD.
How will PGHD eventually contribute towards the financial bottom line?
You need to think about it in broader terms. The vital signs and data that is collected, whether in a hospital or practice setting is a huge slice in time. There is a significant evidence base for monitoring blood pressure in home, as there is something called “white coat syndrome,” where patients are misdiagnosed with hypertension because for whatever reason their blood pressure goes up in the doctor’s office. So maybe that patient is misdiagnosed because of white coat syndrome, and the medication he or she is taking leads to other issues. It’s pretty easy to see that as opposed to making a diagnosis with a patient once a year at your practice, if you have a continuous measure of blood pressure throughout the day for a week and you don’t prescribe those blood pressure medications unnecessarily—thus avoiding other side effects—pretty soon, all of these quantities will have a financial value. And you can imagine how that would be quite substantial, as ultimately there will be more efficient and better care taking place.