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At the Health IT Summit in Denver, a Look at What Can Be Accomplished Under the Banner of Patient Engagement

July 12, 2018
by Mark Hagland
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Debe Gash of Saint Luke’s Health System shared her organization’s story of patient engagement progress

Even as the term “patient engagement” has become hotter than ever, the reality is that the leaders of most U.S. patient care organizations haven’t yet figured out how to execute on the concept. But Debe Gash, senior vice president and chief digital officer at the Kansas City, Mo.-based Saint Luke’s Health System, offered attendees a lot to consider, as she shared the innovations taking place in her organization, on Thursday morning, at the Health IT Summit in Denver, sponsored by Healthcare Informatics.

Speaking on the topic “Using Mobile Apps to Increase Patient Engagement,” Gash told the audience gathered at the Grand Hyatt in downtown Denver that patient engagement has to be a strategy, not just a wish. That’s especially true at any large integrated health system such as St. Luke’s she noted. St. Luke’s encompasses 10 hospitals with a total of 1,100 beds, with 1,500 providers, 750 of them employed, and 1.5 million clinic visits. It also encompasses 17 retail clinics, and four micro hospitals, with eight beds each.

Indeed, Gash told her audience, St. Luke’s Health Systems’ overall strategy encompasses mobile apps, patient engagement, and various strategies around patient/consumer convenience and service, all of them interrelated.

Debe Gash speaks at the HIT Summit-Denver

“Our growth has primarily been in the ambulatory space; we heard from our customers that they wanted more access to care in their neighborhood.,” Gash said. “So we’ve been deploying our clinics, our big boxes, and have embarked on this initiative to build micro-hospitals in our area. A micro-hospital,” she explained, is a small facility of eight beds, anchored by an ED. And if we need to perform a procedure or they need more complicated care, we transfer them to larger facilities. We’ve opened four of seven so far. In fact, our fourth micro-hospital opened just this week. These are exciting times for us.” Further, she reported, “We’ve gotten into the retail space. So far, we’ve created 17 clinics, and they’ve served us well.”

Among the guiding principles in this journey has been the articulation on the part of patients of what they want in terms of service, convenience, and interactions with providers.

Gash cited a recent survey that found that millennials’ demands for digitally facilitated healthcare are accelerating. Among other survey results: 71 percent of millennials want to book appointments with mobile apps; 74 percent would prefer to see a doctor virtually; and 75 percent look at online reviews before selecting a physician. What’s more, one-third downloaded a health app in the last 30 days; and 42 percent have used synchronous video telemedicine.

But the idea that interest in the digital facilitation of healthcare delivery and service is limited to younger people is deeply mistaken, Gash told her audience. “It’s a myth that older people don’t use technology,” she said. “My mother is 76, and she had problems using a flip phone; but I got her a smart phone, and she uses her smart phone more than I do. I see that with the elderly community; it’s an interesting dynamic. But even more interestingly, the millennial generation really want to use digital features in their use of healthcare.”

A new world—of consumer demands

The reality, Gash told her audience, is that the old, provider-centric world is falling away quickly now, and is rapidly being replaced by a world in which provider organizations will have to compete strongly with one another for patient loyalty and engagement. Indeed, she said, “For a growing number of people we serve as providers, companies that fail to offer a friction-free digital connection are just not going to be acceptable anymore. And when consumers have a choice, and more do now, it’s going to be critical that we provide friction-free digital services. Kaufman Hall found in a recent report,” she said, “that only 14 percent of hospitals offer digital tools for consumer engagement, and only 23 percent offer some form of telemedicine—and that is primarily inpatient consults, but not direct-to-consumer-type solutions. Only 20 percent of healthcare consumers have digital access to pricing. It’s not something that you can go out and search on your own. And only 43 percent provide messaging between patients and providers. And I personally believe that that figure is that high only because of the meaningful use program.”

And those deficiencies are a problem. “The lack of contemporary digital experience, I believe, is a major vulnerability for hospitals and health systems today,” Gash told her audience. “And that’s because we’re seeing [disruptive new] entrants into the healthcare industry that can pose a threat to our not-for-profit systems. Look at the merger of United Healthcare and Optum, and of CVS and Aetna,” she said. “What are they doing? They’re employing physicians and practices, acquiring practices, employing health management programs; and their goal is to basically do that primary care service. So they’re pulling assets out of the healthcare system, and they’re highly capitalized companies. So that’s the threat. And what are Apple and Amazon doing? Apple says, we can go directly to the consumer; they’re good at that. And what could Amazon do? They’re investigating healthcare, and they, too, are highly capitalized companies.”

So what should provider leaders do? “We need to think about that threat, and how we can continue to compete and differentiate ourselves and work with that potential down the road,” Gash told her audience. “So those are things that could disrupt our industry, and the real reasons why St. Luke’s is trying to deliver a better experience, so that we’ll be the choice of our consumers, and create that friction-free service, and make sure that we’re better at delivering that last mile of care. We’re known in the market as being the least convenient type of service provider. So we need to change that paradigm, and that’s critical.”

Among other actions, Gash and her colleagues “have been pursuing digital solutions for a while,” she noted. “We’ve deployed MyChart”—the personal health record embedded in the electronic health record product from the Verona, Wis.-based Epic Systems Corporation—“and we’ve mobile-enabled our website, Still,” she said, “there was a lot of friction in our service delivery model, which still relied on traditional forms of communication, including phone, letters, and face to face encounters. And yet we still had really good customer satisfaction scores. Our HCAHPS [Hospital Consumer Assessment of Providers and Systems] scores are great,” she noted.

“So our thought is that we need to continue pursuing the removal of friction in that last mile of delivery of care. How many of you have trouble scheduling an appointment with your doctor? I do. It takes two or three interactions to get one scheduled. That’s friction. Or I get discharged from my provider, and he says, I want you to go get a diagnostic test, and I have to call, and it can only be done between 7 and 4 on weekdays or whatever, and I have to take off work or whatever, and that’s friction. And we want to remove it.”

Pacing those efforts has been one strategic element involved. After deploying MyChart, Gash and her colleagues enabled “Saint Luke’s 24/7 Virtual Health visits, through our app. You can schedule an appointment, you can do it via video,” she explained. “That was deployed, and people were very excited about it. We pushed it with our employee health plan. But we were only getting about three visits a week. We partnered with ZocDoc to offer online scheduling. It was hard to convince doctors to allow us to do this,” she reported. “So I went back and did a lot of research, wanted to know if we were doing what our consumers wanted. Through focus groups and reading research papers,” she said, “I found that it’s really generational, what people want.”

Research shows that millennials—18 to 29—are “very digitally fluent, are the most socially connected, and are the most likely to read reviews, find prices, and seek for value,” Gash noted. “They are the most likely to shop for providers and write reviews online.” Meanwhile, “The 30-49-year-olds are often directing not only their care but their family members’. And they want care to fit into their busy lives, through non-traditional hours, etc., and virtual care delivery. The 50-64-year-olds are active, managing personal wellness, and managing multiple chronic illnesses, and they want timely access to care. Over 65s are traditionals. They don’t mind seeing the doctor, but traveling is hard for them. And they’re probably the most resistant to virtual care options.”

Doing that research was eye-opening for herself and her colleagues, Gash told her audience. “It helped us to understand what consumers were looking for, including access to after-hours care, weekend availability, etc. Value was a key factor; and what we heard was that convenience and service trump what is free. In other words, people are willing to pay for extra service. People are looking for cutting-edge technology and convenience of service,” she said. “We wanted something we could brand our own and could leverage that brand in our market, the perception of St. Luke’s, as a way to publish some of these capabilities. And we wanted to bring those digital features together as part of that brand, and simplify that access. So we started looking for features our customers asked for. They thought wayfinding would be great in these big facilities. Also, food service, and e-check-in. Those were all things we heard from our population. So we changed our approach, and expected we’d see increased utilization of e-services.”

And all of that was based on building a mobile application first. In that regard, Gash reported, “I did a lot of research in the market to see what’s out there and available. We do not have mobile application developers in our shop. We wanted something that we could purchase as a service. There really wasn’t anything in the HIT space that could meet our needs. So I have a friend, Andrew Burns, who works in our space and he said, ‘Hey, Debbie, I have a product.’ They primarily work in the entertainment industry, but what he explained was exactly what I needed—a mobile platform that would enable me to bring all these products together and drive engagement. So we partnered with them to develop the SaintLukesKC mobile app. It provides access to the medical record, and to online scheduling. It also facilitates virtual visits; and it provides directories of locations, as well as wayfinding information within facilities.”

In terms of results, Gash reported, “We have been promoting our app. We started with a soft launch, using it primarily without our own employee population, to get feedback, then… Our adoption is growing rapidly… 97,188 visits… we’re retaining our users. We have about 7,500 users using our mobile app right now, and that is growing exponentially. Our MyChart utilization is increasing as a result of the mobile app. We’re seeing many users leveraging the product, doing more messaging; and we’re seeing more patients participating in online payments.”

Lessons learned

In terms of lessons learned, Gash said, “You really need to find out what your customers want, because what you think may not be right. I really encourage you to do focus groups and talk to your customers and discover what they’re looking for. And our demographic is very different from children’s hospitals, ambulatory spaces, etc. You do need to check with the consumer. I think you need to define a strategy and execute it. And also talk to your business units about what would work for them. Also, don’t be afraid to try something new. Just because another system hasn’t done it, doesn’t mean you shouldn’t. Look outside our industry—we are way behind! Look outside the healthcare space for solutions. We are so far behind in digital—look outside healthcare and figure out how to apply what they’re doing, to healthcare.”

Two other key pieces of advice: “Make sure that people know what you have to offer. And that means, when it comes to patient engagement solutions, that you’ve got to include your marketing team” in the development process. The other key piece of advice: “Measure results. It’s so important to go back to the organization and say, here’s the success, here’s what we’re seeing. I encourage you to figure out what those measures of success might be. When I meet with the board, I’m sharing those kinds of results.”





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Consumer Health Tech Startup Ciitizen Raises $17M

January 16, 2019
by David Raths, Contributing Editor
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Building a platform to help patients collect, organize and share their medical records digitally

Ciitizen, a California-based company working to build a platform to help patients collect, organize and share their medical records digitally, has closed $17 million in new funding in a round led by Andreessen Horowitz and that included Section 32 and Verily.

The Redwood City, Calif.-based company said it would use the proceeds to accelerate platform development and expand commercial operations. The company received a Series A financing round of $3 million led by Andreessen Horowitz in July 2018. As part of the new financing, Vijay Pande, general partner of Andreessen Horowitz's Bio fund, will join the Ciitizen board of directors. Michael Pellini, managing partner at Section 32, and Andy Harrison, head of business and corporate development at Verily, will join the board as observers.

Ciitizen’s co-founders are Anil Sethi, Premal Shah, and Brian Carlsen. CEO Anil Sethi’s last company, Gliimpse, was acquired by Apple. Carlsen was formerly special projects lead at Apple, and serves as director of clinical informatics at Ciitizen. Deven McGraw, who has deep experience in HIPAA and medical data sharing, and was formerly the head of privacy at the U.S. Department of Health and Human Services, also works for Ciitizen.

"We are aggressively hiring to support release of products in partnership with select healthcare stakeholders that will immediately benefit patients—all driven by obtaining and organizing a patient's health data," said Premal Shah, COO, in a prepared statement. "Contrary to what is happening today, we want to facilitate patients gaining maximum direct benefit from what is rightfully theirs: their personal healthcare data."

"We are aggressively hiring to support release of products in partnership with select healthcare stakeholders that will immediately benefit patients—all driven by obtaining and organizing a patient's health data," said Premal Shah, COO and Co-Founder of Ciitizen. "Contrary to what is happening today, we want to facilitate patients gaining maximum direct benefit from what is rightfully theirs: their personal healthcare data."

Ciitizen also has initiated a weekly blog, The Voice of Ciitizens, that offers opinions from healthcare thought leaders on ways to address some of healthcare's most pressing challenges, including patient empowerment with their data.



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Survey: Consumers Want to Manage Healthcare Benefits, Costs via Smartphone

January 15, 2019
by Heather Landi, Associate Editor
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There is a growing “mobile first” trend, as consumers increasingly want to preform everyday tasks and utilize services on their smartphones, and this trend is moving into healthcare. A recent consumer survey indicates that consumers want more transparency, convenience and control of their own healthcare, particularly through mobile access, and, this demand could be influencing their healthcare decisions.

A survey by Metova, a provider of mobile, connected care, connected home and Internet of Things (IoT) solutions, found that 80 percent of consumers would be more likely to visit a doctor or seek treatment if they could see the exact out-of-pocket cost on their smartphone. And, three-quarters of consumers are interested in viewing and managing their health care benefits using a smartphone.

Metova surveyed 1,000 consumers who have healthcare to gauge their understanding of their health benefits, and to find if technology can improve their experience.

Nearly half of consumers have avoided going to the doctor or seeking treatment due to uncertainty around their benefits, according to the survey. Looking at the role of technology, nine out of 10 consumers said they would like an app that provides notification when a doctor sends a prescription along with pharmacy location and pickup time. In addition, 60 percent would like to purchase eyeglasses or contact lenses using their smartphone.

“It’s impressive to see how having a clear understanding of out-of-pocket cost on a smartphone would have a powerful positive effect on consumers’ deciding to seek treatment or even visit a doctor,” Jonathan Sasse, CMO at Metova, said in a statement. “Our sentiment surveys overwhelmingly demonstrate that the new connected consumer is ready and wanting to manage a wide range of facets of everyday services all via their smartphone, and that a person will choose one business, or even a doctor or insurance providers over another based on this mobile experience.”

Ken Erickson, CEO at Bridge Purchasing Solutions, said in a statement, “The healthcare industry is overdue for disruption. Consumers want more transparency, convenience, and control of their own healthcare.”

Related Insights For: Patient Engagement


One Thought-Leader’s Look at the New Social Contract in Medicine and Healthcare

January 7, 2019
by Mark Hagland, Editor-in-Chief
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Healthcare thought-leader Michael Millenson shares his perspectives on the emerging new social contract around medical care and healthcare—in a time of accelerating technology disruption

Last week, Michael Millenson, president of Health Quality Advisors LLC, and an associate professor of medicine at Northwestern University’s Feinberg School of Medicine, authored a thought-piece in the online publication STAT, entitled, “Google is quietly infiltrating medicine—but what rules will it play by?” Millenson looked at the emerging landscape in healthcare around the accelerating participation of healthcare consumers in using web search, consumer-facing apps, and other tools, to help them educate themselves about personal health and healthcare delivery issues, as well as the emergence of a number of corporations, including Google, Amazon, and Apple, as disruptors in the healthcare world—both as innovators in technology, as well as, increasingly, players in the care management and care delivery arenas.

“If ‘data is the new oil,’ as the internet meme has it, Google and its Big Tech brethren could become the new OPEC,” Millenson wrote on January 3. “Search is only the start for Google and its parent company, Alphabet. Their involvement in health care can continue through a doctor’s diagnosis and even into monitoring a patient’s chronic condition for, essentially, forever.”

Meanwhile, Millenson wrote, “Suppose you’re worried that you might have diabetes. Googling ‘diabetes’ brings up not just links but also a boxed summary of relevant information curated by the Mayo Clinic and other Google partners. Google recently deployed an app enabled with artificial intelligence for remote professionals to use that can all but confirm diabetes-related retinopathy, a leading cause of blindness. Diabetes is also a diagnosis your doctor might have predicted using more Google AI applied to the electronic health record. Meanwhile, a Google joint venture called Onduo recently announced a partnership to allow a major pharmacy chain to use its “virtual diabetes clinic” to coach patients on managing their disease. And, of course, at home you can get daily diabetes reminders from your Google Assistant.”

And, in some cases, he added, “[Y]our doctor could actually be Dr. Google. The brick-and-mortar Cityblock clinic, whose first site opened in Brooklyn, N.Y., earlier this year, is an Alphabet spinoff. It promises a ‘personalized health system’ experience for low-income patients.”

And with Google hiring the former chief executives of both the Geisinger Health system and the Cleveland Clinic, more and more interesting developments are certain to be at hand.

Michael Millenson

And all of this, Millenson noted, is prompting some in the industry to ask what the implications are of these developments for the social contracts that have long anchored physician-patient/clinician-patient, and patient care organization-patient relationships and interactions. In that context, he spoke with Healthcare Innovation Editor-in-Chief Mark Hagland, following the publication of his STAT commentary, to discuss the implications of some of those current trends, for the future of patient care delivery. Below are excerpts from that interview.

There are so many developments taking place right now involving what might be called “interspecies” business combinations—payers and providers, payers and retail pharmacy companies, employers and providers, and on and on. Do you see some potential dangers in the uncharted territory that’s emerging in healthcare, because of such combinations?

What I was trying to sound as a cautionary note, not an alarm, but a cautionary note, was that, when barriers are breached in terms of definitions, there are new challenges to long-established ways that we do things. We all like to talk about disruption, but there are downsides. And those downsides need to be confronted squarely. And what I was trying to propose in my commentary was a practical ethical framework for dealing with downsides—not a mission statement, or whatever, but practical thoughts. If you have a commitment to accountability and shared responsibility, it brings up issues. Just because you believe you’re committed to patient engagement or lowering healthcare costs, or whatever noble goals you espouse, particularly if you’re working for a not-for-profit entity, or even a for-profit, personal and corporate interests can conflict with noble goals.

And even as all these kinds of partnerships can be wonderful, we also realize we need new ways of dealing with potential negative side effects. No hospitals that merge ever say, thank God we can get rid of the price pressure from insurance companies! And it’s not that individuals making statements about mergers are deliberately telling untruths, but they sometimes make statements that may not be in the best interests of patients.

Healthcare informatics arose from people who were in the HC field, who wanted to apply the benefits of informatics knowledge to improving care, lowering costs, and other problems. That’s a different set of assumptions from when you take people whose expertise is in manipulating data and information, and put them into healthcare. There are cultural issues there. People from within HC tend to say, there are certain problems, and let’s look for solutions.

But people outside healthcare sometimes have the tendency to say, we have this wonderful tool; look at all the ways we can solve your problems.

Looking at the entry into the healthcare delivery process of disruptors like Google, simply because of the near-universality now of web search as a consumer activity in healthcare—will consumers simply start self-diagnosing off the web now?

It’s one thing to look at Google as a search engine. It’s another to look at the issue of Google as an element in care delivery. The issue of “Dr. Google” is a significant one. I wrote an article recently called, “Beyond Dr. Google.” What happens if you’re using the Babylon Symptom Checker with AI? What happens if you’re looking at a mole? Because they’ll have a legal disclaimer. But we’re looking at an entire paradigm shift around how we interact with doctors. Years ago, I said the Information Age is to medicine as the Protestant Reformation was to the Catholic Church. It changed the people’s relationships to the priests; the Church didn’t go out of business, but it had to change. Once the laity could read the Bible, the role of the priests had to change. And I think that the role of physicians as holders of knowledge, has to change. They still have specialized knowledge; but the conversation has to change, and the tone has to change.

What I’m concerned about is when an organization like Google, Amazon, or Apple, starts partnering with physicians, what happens? When Google, Amazon or Apple, starts being a partner to help you with your diabetes, are they helping you have a better conversation? Or are they starting to use gathered information to try to cause behavior change, to manipulate you? And there’s a fine line between doing this for your own good, or because I want you to change?

And then there’s the accountable care issue—when you have attributed patients, and it’s in your financial interest now to collect and use social-determinants-of-health data and other forms of data, as well as apps and tools, to try to motivate your patients towards participating in the enhancement of their health status.

Exactly—now, there’s also a profit motive. I wrote an article about the secret use of the social determinants of health, for care management—and for profit, on the part of vendors that are putting data into algorithms and selling those solutions. LexisNexis found a correlation between someone in the household having completed some kind of professional certification, anything from a plumber’s license to a PhD—with medication compliance and adherence. The point is, you get companies that use information about my life, as raw data for analytics, that are meant to influence my behavior. We need a different kind of safeguard doesn’t go awry. And I’m not saying that what they’re doing might not be wonderful and disruptive in a good way, but nothing turns out as promised, whether Brexit or Google.

The social contract in healthcare, particularly between providers and patients, especially that between physicians and patients—what might that look like, or need to look like, in the coming years?

I see collaborative health as the new social contract. I’m not sure that that patriarchal, hierarchical relationship has changed as much as we might be thinking. I remember writing things 30 years ago that everything would change, and the hierarchies would be totally gone. They haven’t disappeared, though. Your grandmother was probably just grateful to see a doctor. And there are still a lot of people in the country who are still grateful just to see a doctor.

So part of that issue involves socioeconomic class, of course?

Yes, absolutely. That said, I also absolutely agree that a new social contract is going to center around collaborative health. And an explicit one is needed. There’s a lot of talk about that, around Google, Facebook, Alexa. But the medical element is different. When organizations that have tremendous data analytics capabilities, are applying those to the problems of individual patients, that gives us both the potential for unprecedented breakthroughs in patient care, and for the unprecedented ability to manipulate people. The fact that I know everything about your Google searches, your purchasing and eating patterns, and I’m tracing your driving patterns—that can help me improve your health, but also control your life, and manipulate people. And even if the decisions are to your benefit, a social contract demands shared engagement and shared accountability, because that’s the social contract that medicine needs, to retain its soul—even if that doesn’t help increase the value of the IPO or the price-earnings ratio, or the amount of money you get back from meeting your obligations under an ACO contract.

How do you see physicians and other clinicians adapting to this new world?

I think the social contract is even more important, because the power of the individual doctor is often decreasing now. If more and more doctors will be employed, and operating under stricter rules of accountability, that’s good for patients, but the balance between accountability and autonomy is a balance we’ve got to find. And we should welcome Amazon, Apple, and Google—they have an incredible potential to disrupt HC for the better; but the individual doctor, just like the individual patient, is going to be powerless to set a new social contract on their own. That’s why we need a social contract that encompasses clinicians, patients, patient care organizations, payers, pharmaceuticals, and everyone. It may be to my benefit that my doctor is using an app to track population health issues, but with the blurring of lines between different types of organizations, things get complex. Information is power, and the information we’re gathering is extraordinarily powerful, and good things can go awry. So frankly, I see this new social contract as a protection for physicians, and as something that will ensure that the “therapeutic alliance” that doctors like to talk about, will remain strong, even as other boundaries dissolve. And whether my doctor is employed by an insurance company, a hospital, or is a solo practitioner, it should make no difference to certain kinds of relationships.



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