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Behind Providence St. Joseph’s Daring Push Into Digital Consumer Engagement

November 5, 2018
by Mark Hagland, Editor-in-Chief
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Providence St. Joseph’s Aaron Martin shared insights on the success of his organization’s digital consumer engagement strategy

On October 23 at the Health IT Summit in Seattle, sponsored by Healthcare Informatics, Aaron Martin of the Renton, Washington-based Providence St. Joseph Health, shared with attendees his organization’s vision of a digitally connected consumer population—and what he and his colleagues have done to achieve that vision.

Martin joined Providence St. Joseph Health—which encompasses 51 hospital facilities across seven western states—Washington, Oregon, Alaska, Montana, California, New Mexico, and Texas—as chief digital officer in January 2014, and has been helping to lead a team of 200-plus Seattle-based software engineers and programmers and marketing professionals, in the health system’s push to engage patients, families, and communities.

Speaking to the audience gathered at the Grand Hyatt Seattle, Martin, who spent several years at the Seattle-based Amazon, spoke to attendees on the subject “Disruption from the Inside: Why Digital Matters: Lessons I Learned from My Time at Amazon.”

“I get asked, what lessons did you learn at Amazon over ten years that you can apply to healthcare?” Martin said. “First, healthcare has got many, many, many, many, many, many problems—so you have to decide where to start. There’s limited bandwidth to solve all the problems. It sounds a little weird to say that we have to go top-down, but that’s what we’ve been doing at Providence. U.S. healthcare is so big, that it’s the fifth largest economy on the planet,” he noted, pointing to a slide that showed the size of the U.S. economy at $19 trillion annually, the economy of China at $12 trillion, the economy of Japan at $4.3 trillion, the economy of Germany at $3.1 trillion—and the size of the U.S. healthcare system larger than that of the German economy, at $3.2 trillion per year.

Aaron Martin

As a result, Martin said, “You have to pick and choose” which issues to tackle. What’s more, he told his audience, “You’ve got to innovate at the end of the value chain. Amazon started with books.” Historically, the value chain around book publishing involved the following stakeholder groups: authors, publishers, distributors, bookstores, and readers. “And we learned that only two members of that value chain matter; everybody else is expendable,” Martin said. “And if someone can figure out how to disrupt that value chain, you can reduce friction and create value. People think that Amazon disrupted bookstores; they didn’t; they disrupted the value chain.”

As a result, he noted, “Amazon literally carries tens of millions of titles now, because of Kindle. Distributors quickly went away because Amazon became its own distributor. The second thing that happened was self-publishing, and then, e-commerce. The value proposition in the past was that you’d work hard on a book and submit your manuscript to a publisher. And if you were lucky enough to get published, you’d get 5 to 10 percent of the net. And the publisher really couldn’t provide a worse marketing experience,” he noted. “So at Amazon, we created a situation where you could publish a book in print and digitally, on demand, globally. And we only charge you if you sell a book? And guess what? You get 30 percent of net. So Amazon totally disrupted that. And Kindle got rid of the last-mile problem. I can be sitting on a tarmac and get a book on my Kindle in 30 seconds. Amazon methodically went through the value chain and got rid of the middlemen.”

Importantly, Martin told his audience, “We’re in the same situation in healthcare. Physicians and nurses are necessary, and patients are necessary. Everyone else is expendable. How do we collapse and create a frictionless environment, at scale, to allow physicians and nurses to give care to patients?” That, he said, is the key question for the healthcare delivery system going forward—the transformation of the delivery system towards a truly customer-centric model.

“So how are we going to that at Providence St. Joe’s?” Martin asked. “Most of the healthcare system is beginning to move past the hospital-centric mindset. We realize that patients are at the center, and that we have to push care closer to the patient. Health 2.0—specifically, we’ve eliminated the word ‘care’—it’s about health. So at Providence St. Joe’s, we’ve got to eliminate the healthcare system and be a health system. If you look at any e-commerce company like Google, Apple, they created a daily habit of connecting with consumers. My job is to take an offline consumer experience and make it an online experience. And we’ve got a huge lift on my team, because we see patients an average of two-and-a-half times a year. Look at Starbucks: they’ve got an ongoing engaged experience online” that often involves daily interactions between consumers and Starbucks. “So we’ve got two big lifts: we have to both get patients online, and engage them.”

Martin cited six key “digital journeys” involved in moving to “health 2.0”:

> Caregiver-facing interactions: “How do I turn technology from a buy into a feature for caregivers?
> “How do I simply care for consumers
> “How do I enable revenue streams?”
> “How do I grow commercial share?”
> “How do I better serve Medicaid patients?”
>“How do I better enable behavioral health?”

When it comes to developing a digital innovation model, Martin told his audience, “We take those six journeys and we mine them for opportunities. Our digital team works with our customers, the owners of our businesses, and we define problems. It sounds easy, but is hard to do. Here’s where you know you’re not defining a problem—when you call a project by the vendor’s name,” he said. “Then,” he said, “we size and prioritize these problems—again, that’s something easy to say, hard to do.”

The next step? It’s “what we call the tech cascade,” Martin said. If an existing vendor solution already in place can be used, it is simply used. If the organization doesn’t own a solution, “We’ll go out and search for a solution. That’s where we use a company called Avia, that helps us solve problems. And then what happens is, Providence Ventures, the venture team I run, gets involved. So they’ll determine whether we want to invest in a company, because we’ll add a ton of value b being an early investor. That’s where we’ve ended up with a portfolio of ten companies we’ve invested in.”

Next step in the “tech cascade”? “If we don’t already have something in place, and can’t find it in the market, we’ll build it,” Martin told his audience. “I’ve got about 120 people, 85 of whom are software engineers, down the street in downtown Seattle, some from Amazon and Microsoft, and we build solutions. We’re going to scale something up and prove value; get it in front of as many customers as possible. Secondly, we’ll actually sell that solution to another health system, and once we’ve done that, we’ll spin it out to another company. The first was Xealth, we spun them out a year ago June. That allows you to prescribe anything not a pharmaceutical, from the EMR. I can prescribe a lift ride, a digital app, content such as a knee brace, anything that can be sold retail. We also spun out a company called Circle.”

Putting it all together

“We’re a mission-based non-profit,” Martin emphasized to his audience. “And why do we care about our commercial business so much? When I say ‘commercial business,’ I mean private insurers and employers, everything that’s not Medicare or Medicaid. In the U.S. healthcare system, we make money off commercial contracts, and subsidize Medicare and Medicaid. So the commercial insurance business is oxygen to our system.” One key element there, he said, is thinking strategically about how to use technology to connect with patients as healthcare consumers. Disruptors like the new CVS-Aetna organization that is merging a nationwide retail pharmacy company and a nationwide health insurer, promise to challenge traditional patient care organizations, he insisted. Speaking of those organizations and others, he said, “All these disruptors are going after the best part of your business; it’s called cream-skimming. Jeff Bezos used to say, ‘Your margin is my opportunity.’” Meanwhile, he noted, “There are technology companies with literally millions of existing, strong relationships” with consumers—consumers who are using their smartphones on average about three-and-a-half hours a day.

Per that, Martin said, “When we’re talking about digital, we’re really talking about changing the business model. The issue with new technologies like telehealth, artificial intelligence, etc., is that version 1 is taking new technology and applying it to existing models, and it doesn’t work well. So for us, it’s not just the technology, it’s how you acquire patients, how you engage with them, how you make the platform efficient on the back end, and how you engage them in the continuum.”

And so much of success, Martin told his audience, will depend on engagement. “How do you engage patients on Google?” he asked. “We built a platform that’s optimized for web search. The key takeaway? We’ve achieved a nine-times increase in appointments and starts, just by applying this platform, attuned to how Google works. The other thing we’ve done,” he added, “is that we’ve stepped this up as if it were an Expedia experience. We don’t make you fill out a huge form, we delay the acquisition of data until the last minute, until you’re ready to book. You go into the physician detail page after search (SEO/SEM, primary care/specialist), we take you through that process, land you on a detail page, have you book online, schedule a visit, and then have you download the IOS/android app.”

And, Martin added, “We’ve also started to experiment with AI, to launch an express care assistant virtual assistant, we call Grace. We’re looking to make her smarter and smarter and smarter.” And the results have been quite noteworthy. “Thirty percent of our consumers are new in-clinic, and 40 percent are new virtual customers, he noted. Meanwhile, with regard to customer retention, he said, “With regard to returning consumers, 20 percent of our in-clinic consumers are returning customers, and 17 percent are new virtual consumers.” What’s more, 55 percent of clinic patients booked online, a 10-fold growth in online engagement since the program began, while 80 percent of those patients coming through digital channels are commercial insureds.

Wildflower: A Focus On Women Consumers

One of the key areas of success at Providence St. Joseph has been with it Wildflower program. “Wildflower focuses on the female head of household,” Martin explained. “She controls 90 percent of household healthcare spend. She is basically our customer. We need to understand how she thinks, and to engage her.” Wildflower was initially designed to engage women from preconception through fertility, through the first 100 days after childbirth; and has since been expanded to engage women across their adult lifetimes. That program, he noted, has been wildly successful.

A week after his presentation at the Health IT Summit in Seattle, Martin spoke on the phone with Healthcare Informatics Editor-in-Chief Mark Hagland, to share additional information and insights. Below are excerpts from that interview.

Can you tell me more about the Wildflower program?

So Wildflower, what they do—this is the second spin-out I mentioned. We go through rank lists, where we prioritize six different digital or technology journeys where we could move the needle. And we work with the business owners to prioritize what they want to accomplish. And we do problem definition, and get a team focus on the problem we’re solving, and we walk it through a tech cascade. Do we already have a license with Microsoft or some other company, for example? If not, we’ll go out and look for best-of-breed, and if we can find a best-of-breed existing solution, we’ll use that. And then if we don’t have it and can’t find it, we’ll actually build it. My team is based in Seattle, and we’ve built a fairly large team of 200 people, software engineers, marketers, etc. And we build these as businesses. And the reason why is because we want to spin them out to finance their own road maps. So it’s sort of like an incubator, but we tend to “cook” them a little bit longer. We’ll implement and scale, and to test the market, we’ll test them with one or two health system.

So the first spinout was Xealth, a year ago in June. And then the second spinout was Circle, which we merged with Wildflower. What it is is, we had built a women’s health platform that basically curates content, products and services that an expectant mother might need from the health system, and allows her to book prenatal visits, then well-baby visits, and then it follows her throughout her life. The Wildflower thing does the same thing for payers and employers. We had three customers: ourselves, Sutter, and OSF (in the Midwest). So we merged these two businesses together. And it made total sense. And Leah (Sparks), the CEO of Wildflower, and I got very excited about the idea that an expectant mother and the female head of household is by far the most powerful person in a household. She controls her own spending, as well as that of her kids, her partner, her adult parents. So we built the platform to build a relationship with her, and that’s why we started Wildflower. But what we got really excited about was the intersection of those worlds, to help Mom get things done for her family. She could get curated content from our experts; she could be getting information about her charges and benefits from the health plan; and about what programs the employer was providing to support her. It’s a three-way intersection. So that’s exciting.

We’ve been working on this for five years. I always like to tell people, this is not magical.

For CIOs, CMIOs, marketing, web development, patient engagement leaders, what have been key lessons learned?

I think the first thing is that I would tell them, use the fact that healthcare is very regional, to your advantage. So a lot of the progress we made was simply by collaborating with a ton of other health systems, and learning from their learnings. We’ve met with 80 health systems in Seattle over the past several months (out of about 400). And we’ve really leveraged the fact that we’re a big health system that covers seven states, but that we don’t compete with the 80 we’ve been meeting with. And that’s different from a consumer-facing company in the outside world. I worked with Amazon, and would have been fired instantly had I reached out to Google, right? So that’s an advantage in healthcare.

Second, don’t build anything when something already exists. If somebody else has figured something out, just use it.

And then the last thing is, follow from other industries. How we’re structured—the division of responsibility between me and the CEO, how marketing reports to me as chief digital officer, is kind of settled law in other industries. You’ve got tons of industries dealing with disruption for over a decade, and they’ve had plenty of time to think through the chief digital officer role, and the CDO reports to the chief marketing officer, or vice-versa. And there’s a very close interaction and relation between the two roles, and they’re all very customer-focused; whereas our CEO is very focused on the B2B relationships, and relationships with plans and enterprise systems. And if I can be judged by a single metric, and it would be the NPS score for the consumer, whereas the CEO might be judged on the metric the NPS score of the caregiver. Net promoter score, the degree to which somebody would recommend your service over somebody else’s. A typical score of whether you’re doing a good job for consumers. A standard outside healthcare for determining preference or satisfaction.

Should everyone do what you’re doing?

No. We’re in a “Goldilocks zone” for HIT innovation: we’re not in Silicon Valley, and we’re not in a place where there are no software engineers at all. So we’re in this great middle ground where it’s possible for us to get really, really great product and software engineering folks in Seattle, because we’ve got these two great software companies. And we say, code what matters. I think that summarizes what we’re trying to do, which is to be a place where your efforts are going to work for the greater good. And if you’re in Silicon Valley, you’re really trying to learn—that’s where I learned how to lead and manage at Amazon. And when you’re there, and you’re thinking, wow, do I want to do the next feature on a new product like Kindle at a big company, or do something more focused and meaningful to me personally? In Silicon Valley, the way that manifests is that you go create a startup. In our area in Seattle, we don’t have nearly as robust a startup community here, so we have a lot of people looking to do something meaningful in their lives. And Seattle’s a nice, reasonable place to live, and it’s relatively cheap compared to SV; or do I stay in Seattle and do something like this? So that’s our value proposition. And we have an unusual context here, and situational dynamics. Not everyone can do this.


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N.Y. Hospital Conducts Digital Assessments of Patient Interactions

November 13, 2018
by David Raths, Contributing Editor
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Upstate University Hospital uses Vocera Rounds mobile app to gather data, provide feedback
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Physicians at Upstate University Hospital in Syracuse, N.Y., are using a mobile app to collect data about hospitalists’ behaviors during patient interactions in order to provide real-time feedback.

Amit Dhamoon, M.D., Ph.D., internist at Upstate University Hospital and associate professor of medicine at SUNY Upstate Medical University, said he was looking for a way to improve physician-patient communications.

“It is still unclear why some physicians really connect with patients and some just are not able to,” he said. “It is unclear why certain patients trust certain doctors more than others. We want to look at some basic behaviors.”

His team decided to do the digital assessment using a customized version of Vocera Rounds, a mobile application that enables clinicians to collaborate in responding to patient feedback and closing care gaps. “We needed a way to collect the data, relay it, and analyze it,” he said.

Fourth-year medical students who are going into internal medicine join the team of hospitalists on their rounds and serve as “silent shoppers,” Dhamoon said. They focus on the communication aspects of each interaction, and enter their observations into an iPad.  Residents and physicians also use the app to conduct a brief patient survey after the encounter. 

Among other things, they assess:

• how much time the provider was in the room;
• whether the provider introduced themselves;
• whether they sat down at eye level with patient; and
• At the end of conversation, did they ask if there were any questions?

Dhamoon said patients may pick up on body language or other things that physicians are not even cognizant of. “We are focusing on how to treat gall bladder disease or make their pneumonia better. We are focusing on the medicine,” he said. “We have to do that, but we also have to communicate what we are thinking.”

In an academic medical center, it is not unusual for teams of eight to nine doctors, residents and students enter a patient’s room. “Sometimes they don’t know what to do with their hands, so they stand with their arms crossed in front of them,” Dhamoon said. “For the patient, who is lying down with an ailment, it can almost feel like an inquisition.”

Dhamoon says hospital rooms are sometimes cramped and there is not a chair available. “I can say that it should be the gold standard that we are at eye level, so it doesn’t send a message to the patient that we have one foot out the door. But if we don’t have the basic tools in place, like a chair, then it is not going to work.”

Dhamoon and his colleagues are studying the effectiveness of this training approach and its impact on patient satisfaction measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys.  “My colleagues are incredible people. I want our patients to see how incredible they are. We get in our own way sometimes.”



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GetWellNetwork Acquires HealthLoop

November 9, 2018
by David Raths, Contributing Editor
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Company seeks to provide comprehensive digital patient and family engagement platform

GetWellNetwork, a Bethesda, Md.-based company offering a platform for improving patient engagement, has acquired Silicon Valley startup HealthLoop.

The acquisition expands 280-employee GetWellNetwork’s reach into nearly 700 healthcare providers. Mountain View-Calif.-based HealthLoop’s platform enables care teams to engage patients before and after admission through automated, daily check-ins. Customers include Advocate Aurora Health, UCSF Health and LifeBridge

GetWellNetwork said it is combining its nearly two decades of experience implementing patient engagement solutions with 30-employee HealthLoop’s expertise in mobile technologies and digital care management. The move is designed to catalyze growth in the ambulatory space and signals its plans for more investment in cross-continuum tools to connect patients, families and providers.

GetWellNetwork was named one of Healthcare Informatics’ “Up and Comer” companies back in 2014. In an interview then, CEO Michael O’Neil described how the company uses the TV set in a hospital room to enhance patient engagement. To deal with pain management, GetWellNetwork has a workflow called the pain assessment pathway. If a patient is on a morphine pill, the system interrupts the TV show every hour to ask the patient to rate their pain on a scale. "If I report a certain threshold or below, it is simply going to document that in Epic, Cerner or Allscripts," O'Neil said. "If I report a five or above, it will document but also, through a Vocera badge, signal a nurse to go to the room. That is one pathway we help deploy, where pain management is a service or quality metric that a particular organization is trying to move the needle on. We are working with healthcare systems with the courage to take the 'patient-centered mission' off the poster in their office and bring it to the point of care."

In a prepared statement about the most recent acquisition, O’Neil said:  “Adding HealthLoop to our portfolio advances our strategy to provide the most comprehensive, end-to-end digital patient and family engagement platform. The changing nature of the how and where care is delivered requires dynamic solutions to meet modern engagement challenges. With HealthLoop as part of the GetWell portfolio, we’re excited to help health care organizations rethink and accelerate their digital strategies.”




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Dr. Mark Smith’s Five Tasks for the Healthcare Sector

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Founding CEO of California Health Care Foundation challenges industry to allow laypeople to do some tasks now done by professionals
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A good keynote address gets us to challenge our assumptions and consider some new possibilities in our field, often bringing in ideas from other disciplines or markets. That is what Mark Smith, M.D., M.B.A. founding president and CEO of the California Health Care Foundation, did last week at the annual meeting of the Patient Centered Outcomes Research Institute (PCORI) in Washington, D.C.

Dr. Smith is a professor of clinical medicine at the University of California, San Francisco, and a visiting professor at the University of California, Berkeley. As a clinician, served on the front line of the HIV/AIDS epidemic in San Francisco. From 1996 to 2013, he led the California Health Care Foundation, where he helped build the organization into a leader in delivery system innovation, public reporting of care quality, and applications of new technology in healthcare. In his PCORI talk he laid out five tasks for the field, which I will paraphrase here:

1. Continue to work with providers and patients to develop robust clinically specific measures of quality.

2. Accelerate the integration and automation of quality measures into the work flow of care delivery as opposed to separate flow of funds, personnel and work.

3. Develop instruments to measure and improve self-care capability and work with industry on enabling technology that would allow laypeople to do tasks now done by professionals.

4. Think about non-creepy ways to use social media, search, shopping and other non-health data to inform care of patients.

5. Develop, promote and deploy nimble, adaptive research methodologies.

I want to touch on a few of these in detail because I think he made interesting points, some of which are counter-intuitive or go against the grain of current thinking. For instance, Task No. 1 involves quality measures, and Smith acknowledged that there are legitimate complaints from clinicians about the terrible burden in our current system of measurement. “But the answer to that is not a search for five magic measures” useful in all settings, he said. Smith added that the call for fewer measures is a false path.

The current measures are imprecise and often not compelling to patients and professionals, he stressed. The key is to develop measures that are relevant to patients and clinically significant. “We have all sorts of things important to hospitals, doctors and CFOs and CMOs,” he said. “We are just now learning how to create robust measures that are important to patients. I believe those will only be compelling to patients and their doctors if they are clinically specific. When I hear people say we need fewer, better measures, I say no, we need more better measures.”

Smith went into a few reasons why measurement is so challenging in healthcare. “Our IT systems are so primitive that the burden of collection, analysis, and reporting is substantial,” he said. “The answer is more clinically specific measures with greater integration into workflow.” In no other sector of the economy, he pointed out, are the systems for monitoring the quality of the process different from the established and funded system to do the process itself. “We have to Integrate the process of measuring quality and collecting information from patients with the view toward the ergonomic and economic integration into the work flow,” he said.

Smith turned to the concept of patient engagement, noting that everyone has a different definition. “In the early part of 21st century, patients should be engaged in the co-production of healthcare services. It is an extreme notion, but I have been known for being extreme sometimes,” he said.

In fact, Smith focused a good deal of his talk on the idea of co-production. He pointed to the fact that other industries have taken advantage of technology to allow customers to co-produce a service. For instance, people book their own travel now instead of using a travel agent; they use an ATM or bank online instead of getting money from a teller. “Those industries have economic incentive to involve us in the transaction that used to be one way from the professional to us,” he said.

Smith stressed healthcare could do more of that, citing examples such as patients in Great Britain taking their own blood pressure and managing hypertension with medications based on the results. Or patients being trained to test coagulation. Some patient cohorts are doing self-dialysis.

“We have a system that does not take advantage of modern IT,” he added, “because our payment system is based on early 20th century notion of healthcare and how it should be delivered. The only way the practitioner gets paid is if you go somewhere to get information.”

Health systems are starting to move toward involving patients in scheduling decision making, and reporting outcomes. The Open Notes movement is a big improvement in the co-production of information about patient health, but clearly Smith is envisioning more revolutionary changes.

Perhaps the most controversial topic he touched on was No. 4, finding non-creepy ways to use social media, search, shopping and other non-health data to inform care of patients. He asked the audience to imagine clinicians having access to what Google Amazon, and Facebook know about you. “I know that is creepy,” he stressed. “I get there are privacy concerns. We need to think of non-creepy ways to do it. Social media is like nuclear energy,” he added. “It can be used for good or ill. We need to try to integrate that profound deep knowledge about you into the management of your care.”

How you respond to that suggestion may reflect in part which generation you come from. Personally, I recoil from the idea of my primary care doctor reviewing my social media streams or my shopping bill from Whole Foods. But Smith said the search is for a non-creepy way to do that, so I will withhold judgement until I hear an idea that doesn’t sound creepy or Big Brother-ish to me.

But overall, Smith left the PCORI audience with a lot of ideas to consider, and he applauded PCORI researchers for “trying to figure out what is important to patients and get the right instruments to measure it.”

PCORI, he said, “is on the cutting edge of the most important thing we can do: spend time and effort and money on things that are important to patients rather than to professionals. We are just at the beginning of that process.”







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