In the new healthcare, one which emphasizes comprehensive, team-based and accessible care, provider organizations will need to make concerted efforts to become more patient-centered. For many providers, patient engagement is no easy task, but it’s certainly at the top of mind for healthcare CIOs.
Indeed, according to findings of the 26th Annual HIMSS Leadership Survey, sponsored by the Chicago-based Healthcare Information and Management Systems Society (HIMSS) and released at the annual HIMSS conference this past April, patient satisfaction, patient engagement, and quality of care improvement have raced to the top of healthcare CIOs’ and senior IT executives’ agendas in the past year, a stark change from previous years which found that health IT leaders were more focused on business and financial goals. Nonetheless, it’s been a struggle for physicians to truly engage their patients, especially the 45 percent of U.S. adults with at least one chronic condition.
Enter the world of mobile health (mHealth) to help with care management and patient engagement, a growing trend in healthcare. In fact, another recent survey from HIMSS found that more than 90 percent of survey respondents are utilizing mobile devices within their organizations to engage patients in their care. The fourth annual HIMSS mobile survey, which included more than 200 healthcare provider employees, revealed that 73 percent of respondents believe the use of app-enabled patient portals has been the most effective tool in patient engagement to date.
Further, when asked about patient-generated health data (PGHD), 14 percent reported that all or most data generated by mobile devices is integrated into the electronic health record (EHR), while 52 percent reported that some data has been integrated into the medical record. “mHealth continues to evolve as a tool to drive healthcare efficiencies. The proposed meaningful use Stage 3 rule realizes this with the concept of application program interfaces (APIs) and patient-generated health data, and this year’s survey showed that the wide spread availability of mobile technology has had a positive impact on the coordination of patient care,” said David Collins, senior director of the HIMSS mHealth community.
Analysts do predict that the wearables market will grow tenfold to $50 billion over the next three to five years. So undoubtedly, putting personal devices in the hands of patients has begun to change the way patients and physicians communicate with each other. And for each of the major smartphone operating systems, there is now an app for almost every conceivable healthcare need.
What’s more, there are policy implications to consider as well. As HIMSS’ Collins mentioned, the recent meaningful use Stage 3 proposal that calls for more that 15 percent of patients to contribute PGHD or data from a non-clinical setting into the certified EHR technology during the EHR reporting period, will put the onus on providers to collect information from patients, often captured from exercise or fitness devices or recorded on mobile apps.
What does all this mean? For forward-thinking providers, it’s about getting patients to use mHealth tools for more effective care management. Mobile health tools have the potential to create a low-cost stream of highly actionable clinical data, using readily available cloud-connected sensors, ranging from glucose meters to heart monitors to asthma tools. To this end, all sorts of vendors in the market place are working on using mobile devices to get first get patients to track their own data, with the eventual goal to get said data into the EHR. For most vendors and provider organizations though, as noted in the HIMSS mHealth survey, this concept is a novel one.
USING THE DATA
According to Ken Kleinberg, director of health IT membership service at the Washington, D.C.-based The Advisory Board Company, mHealth vendors are now making it easier on patients to track and share their data than ever before. “These apps are now designed for a small device. You’re no longer trying to open a browser on a tiny screen, but instead you’re looking at an app designed just for that platform, so the data entry and reminders are pretty straight forward,” Kleinberg says. “You may get text message reminders, for example, and these are simple mechanisms that don’t require complex hardware,” he says. Kleinberg adds that there is also a trend involving smartphones with medical devices, where asthma patients, for instance, can have their inhaler with an attachment to it that keeps track of every time the inhaler is used. “This way you can sit down with your provider or look at the data yourself, and sit down and figure out trends,” he says.
To this end, at this year’s HIMSS conference, the Durham, N.C.-based Duke Medicine shared the experience it has had thus far with Apple’s HealthKit, a framework designed to house healthcare and fitness apps, allowing them to work together and gather their data under the Health app. Since HealthKit’s launch, many notable healthcare organizations, including Stanford Medicine, Cleveland Clinic, and EHR vendors like Epic, have all partnered with Apple to work in their own patient-generated data applications.
At Duke, Ricky Bloomfield, M.D., director, mobile technology strategy, has led the effort to integrate Apple’s HealthKit. For providers at Duke, the first step to getting the data integrated with their medical records involved asking patients if they want to share their information, says Bloomfield. Such data, which goes into the EHR via the patient portal, can be from activity trackers, blood pressure devices, glucose monitoring, and many other devices. But then there are limits, he adds. “Patients cannot unilaterally enter their data into the EHR, and that’s by design. There simply is no way for providers to handle that mass intake of data right now,” he says. As such, the provider enables Apple’s HealthKit for patients right now, and the provider has a flow sheet that keeps the patient-generated data separate from other data in the system, Bloomfield says. This way, you can still do analytics on it, but it’s separate from other clinical data, he says.
Across the country, providers are handling patient-generated data in the same manner. In Palo Alto Calif., Stanford Health Care recently released its MyHealth mobile app that will allow patients to review test results and medical bills, manage prescriptions, schedule appointments, and conduct video visits with a Stanford physician. The app also connects directly with Epic’s EHR system and with Apple’s HealthKit. The idea behind this integration, according to Aditya Bhasin, executive director of software at Stanford Health Care and part of the team that built the app, was to get both doctors patients to be looking at exactly the same sources of truth.
Similar to the process at Duke, providers at Stanford also wanted to keep patient-entered data separate from other data in the EHR. “There has been a lot of discussions with the physician community, and they preferred a model in which you have to have an interaction with the physician before you start [entering data],” Bhasin says. “Physicians can also set boundaries for the duration they want to get that data, for a certain amount of time rather than just pump in anything and everything.”
Plenty of other challenges exist as well when it comes to getting patient data from mobile devices. Regarding privacy/security, a huge issue with PGHD, Duke’s Bloomfield said that the design puts control of the data in the hands of patients directly. “They can turn it off at any time in Epic’s MyChart. Our goal is to make it clear that they have that control. They can share it with other vendors, apps, healthcare systems that integrate with HealthKit, or with us,” he said.
Also at Duke, a modified consent for the MyChart app was created, but points were added so that patients were sure to understand it all, Bloomfield notes. “Will they read all the fine print? That’s an open question for sure. When we get data from them, we cannot guarantee that we will view and act on it in real time. This is evolving technology, and we might find that it is so reliable that we can act on a measure of 180/120 blood pressure levels and intervene immediately. Now is not that time though, as we can’t be sure of the reliability of the data,” Bloomfield says, adding that if providers do see concerning values, they will alert the patient to seek medical attention. “We don’t want to give patients a false of security,” he says.
Ricky Bloomfield, M.D.
According to The Advisory Board’s Kleinberg, providers are not always the most willing to accept data that they didn’t ask for “They will say ‘I didn’t ask for this,’ ‘I don’t know what you expect me to do with this,’ and ‘I don’t know the circumstances,’” Kleinberg says. “That’s the way it’s been, which is a challenge, but the organizations that gave deployed this stuff at an expense have been careful about which patients they have chosen and educate them about how to exactly collect the data,” he says. In the example of a wireless scale for example, it is given to patients who are asked to weigh themselves every day, Kleinberg explains. “If instructions are given to weigh yourself when you wake up and before you got to bed each day, now the provider has more confidence about what that weight means. If a consumer comes in with data, they don’t know how it was captured.”
A BURGEONING FUTURE
Challenges aside, the potential for mHealth tools to help with care management is certainly there—a sentiment shared by many in the industry. Recent research published in the Journal of the American Medical Informatics Association suggested that patient-generated information could be used to fill gaps in EHR data. The researchers noted that letting individuals contribute to their medical files would increase engagement and build stronger relationships between medical professionals and their patients, while also improving the efficiency of EHRs, according to a blog post from medical product vendor NueMd, which reviewed the research. “Using electronically collected patient-reported outcomes to capture the review of system outside of the clinic visit may not only improve the efficiency, completeness, and accuracy of data collection for the review of system, but also provide the opportunity to operationalize incorporating the patient’s voice into the electronic health record,” wrote authors Arlene Chung, M.D., and Ethan Basch, M.D., both from the University of North Carolina’s School of Medicine.
Another study recently published in the Journal of Medical Internet Research further suggests that patients’ interest in mHealth for chronic care management has paid off. The research compiles data from more than 100 separate studies on mHealth’s effect on diseases such as diabetes, cardiovascular disease and chronic lung disease. Researchers used four main categories to organize mHealth tools: SMS/texting; mobile phone software/applications; phone plus connected instrument; and phone plus wireless/bluetooth-compatible device. Generally, texting tools were the most commonly utilized, followed by mobile apps. Researchers found strong correlations to suggest that the mobile technology did have a noticeably positive effect in helping patients stick to chronic care management regiments.
Undoubtedly, says Kleinberg, the trend is significantly evolving. “Almost every major vendor has something big there to capture that data, but how it works its way for use into clinical decision support will vary. It has to get staged in some way. But a billion smartphones have been bought over the last year, and that provides a whole new platform,” he says. “People are sleeping with them! The fact that these smartphone platforms have become so ubiquitous has changed the game.”