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At the Seattle HIT Summit, UW Medicine’s Grosser Asks Leaders to Rethink Patient Engagement

October 22, 2018
by Mark Hagland, Editor-in-Chief
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UW Medicine CIO Joy Grosser shared her perspectives on patient engagement and the patient experience

Are patient care leaders failing to make a conceptual distinction that might really make a difference? That question was pondered by Joy Grosser, CIO at UW Medicine, the four-hospital University of Washington health system, in her opening keynote address on Monday morning at the Health IT Summit in Seattle, being held at the Grand Hyatt Hotel in downtown Seattle, and sponsored by Healthcare Informatics.

Speaking to an audience of healthcare leaders, Grosser, who joined UW Medicine as CIO just under a year ago, said that one key thing that patient care organization leaders need to ponder is the crucial difference between patient engagement and the patient experience, as an understanding of that distinction can really make a difference in how organizational leaders strategize forward to meet the needs of patients and communities.

Beginning her presentation, entitled “Patient Engagement: Can Digital Health Help Our Patients Become a Member of the Healthcare Team?” Grosser noted that she finds the terms “patient” and “provider” somewhat limiting and problematic, but also that terms like “consumer” can also be problematic, Grosser outlined some of the challenges and opportunities in enhancing both patient engagement and the patient experience







Joy Grosser

“When it comes to patient engagement, how are providers and patients—how are we working together to improve health?” Grosser asked her audience. “We all know that medication adherence is an issue. People do what physicians tell them to do, but how to we create greater engagement, which contributes to improved health outcomes? And how does information technology contribute? Even though my father was a physician, my parents were somewhat of the era in which you did what your doctor told you to do, without asking. Some years later, people began to research medical issues on their own. Now, my children’s generation has a completely different attitude. There is always the question of ‘why’ patients should do something in particular.”

Meanwhile, Grosser said, “I use the broader umbrella term ‘digital health’ to describe how we bring things to our patients.” Indeed, she said, “Oftentimes, ‘patient engagement’ and ‘the patient experience’ are described as interchangeable, but I find they’re very different things. The patient doesn’t have to be engaged to have an experience.” That said, “There is overlap, though. In fact, if you’ve had a bad patient experience, it’s going to be harder to engage as a patient.”

Meanwhile, Grosser told her audience that, while hosting a patient portal is just a beginning when it comes to engaging patients, website development is a necessary start. In fact, Grosser said, in a road trip the past weekend in which she went through several different large communities, she web-searched the websites of several different hospital organizations, and found that, among several of them, one could only scheduled appointments in a couple of or a few medical specialties, and that most appointment scheduling still had to be accomplished via telephone call.

So some of the limitations of patient portals include that, since the development of a patient portal was a requirement of the meaningful use program under the HITECH (Health Information Technology for Economic and Clinical Health) Act, simply having one really is no longer a differentiator in the market; second, portals tend to be not strongly customized versions of EHR (electronic health record) brand templates; and the portals that have been created tend to be difficult to customize as “containers” for a variety of patient-facing tools.

Still, Grosser noted, “There’s that opportunity to be a container of patient information, rather than just one place that the EHR sits. We recognized that there were limitations, as we moved into an app world and wanted to link those apps,” she said, of the hospital industry’s movement forward in this area.

Meanwhile, as a practical matter, telehealth inevitably started small, Grosser said. “It started with physicians saying, ‘OK, put my picture online’” to create an initial presence. “We didn’t move there as an industry, we moved as individuals; so much so that all our EHR vendors have pulled in virtual care elements into their EHR solutions. Our physicians were often slow to respond, though.” In relation to that, she recalled,  I worked in an organization in Southern California in which they began training physicians just out of residency” to specialize in telehealth, and “to learn how to interact from a screen. We actually worked with film industry people to train” those physicians how to interact more effectively through a screen. “There are literally physicians coming out of residency who are working online. People are calling them Uber doctors. They’re working for third-party vendors. We might want those physicians in our healthcare systems as well,” she noted.

More broadly, in terms of creating and expanding on a digital health presence, Grosser said that there really is a market growth opportunity there, but that so often, internal opposition will be a limiting factor. “Oftentimes,” she said, “your physician billing organization will say, ‘We can’t see a person virtually for the first time, because we can’t verify them as a real person. But there’s a real differentiator when teledoc companies said, I don’t care if I’ve seen you in person before or not.” So, she asked, “Are your physicians looking at this as an annoyance, an add-on, or a growth opportunity? I was at a conference about a year ago, and people were touting an online experience, except you got an appointment by calling first. They had linked the medical records, and visits, but not the scheduling for the visits. And are these visits recorded in your medical record as a visit? Or deemed as being an urgent clinic, where the documentation will have to be redone?” Numerous practical challenges remain.

One area of real opportunity, Grosser said, involves live chat with patients. “I’ve looked through many surveys” of healthcare consumers, to determine what it is that consumers say they want. Fundamentally, she said, patients want three things: access, communication, and knowledge. “But maybe how they want those will evolve, as the IT side evolves as well. They want mobile, including chat. And honestly,” she said, creating “chat is so easy. It’s an incredibly important part of that mobile industry as well.” And, she said, patients want a voice experience—in some cases, via technology like Alexa. That opportunity will be particularly strong on the mental health side of the industry.

In fact, Grosser said, healthcare consumers “want the same experience they get when booking airfares. They want to do that here in Seattle with hospitals and clinics,” to find out which patient care organizations will offer what types of physician visit availability, and eventually, even to compare specific moment-to-moment comparative availability. “And how do they get a Kayak-type experience, where they describe the kind of physician they want, and a mechanism can help them?”

Beyond scheduling ease, Grosser noted, “Patients want communication with their healthcare team. And they want knowledge,” including trusted, customized knowledge. That is where some type of Alexa experience, involving artificial intelligence, could prove quite appealing to patients in the near future.

Meanwhile, engagement could also apply along another dimension, Grosser told her audience. And that would be in the area of wearables and other consumer-facing devices that could appropriately communicate specific types of patient data to clinicians, as needed. For example, she said, “If I’m in orthopedics, I might not want to know how much you walk every day, but I might want to know you walked after your hip or knee replacement, or that you went for your physical therapy. AI [artificial intelligence] can help me filter the information I need as a health system.”

Ultimately, Grosser said, when it comes to innovation, “We are moving towards a mobile health maturity model. We’re looking for patient-generated data, generated in a meaningful way. We have to understand that that kind of information is meaningful.”

Meanwhile, Grosser asked, “How do we get to those empathetic health and healthcare tools? This is where I think the market for engagement will take us a long way. Patients will want to connect with non-threatening people to help them take the next steps. How do we make sure that they’re taking the right steps? That we want them to go off particular medication? How do we classify the right apps for them? Work together with their clinicians on the best apps for them?”

There are vast opportunities to create new forms and channels for the engagement of healthcare consumers, Grosser emphasized. But patient care organization leaders need to be very aware of the emergence of a broad range of disruptors, from technology and retail companies like Microsoft and Amazon, but also from such business combinations as CVS as Aetna, as any of those entities might easily rush in to fill voids that patient care organizations have not yet figured out how to fill.

“I think disruptors are good things to the industry,” Grosser told her audience. “If we look at Amazon-related headlines—at Amazon, they’re looking for data scientists, and have been talking about tackling healthcare for some time. My adult children were born before Amazon was created,” she noted. “I asked my children this weekend what they thought about doctors being on Amazon. They said, oh, that’s a great idea! And ended up being engaged in a great conversation. They don’t look at healthcare as a continuum of care. They look at it as offering options” to consumers. And in that context, she said, it's important to note that “The book industry was a test for where else Amazon wanted to go.” And after several years focused primarily on selling books, the executives at Amazon figured out how to succeed in selling a vast range of consumer goods via the same model. Could Amazon disrupt the retail pharmacy industry? Could the CVS-Aetna merger end up strongly disrupting the patient care delivered in medical clinics? What about the announcement last week on the part of Walgreens, which will be partnering with the 14-hospital, Grand Blanc, Michigan-based McLaren Health Care, to expand pharmacy and healthcare services across that state?

Meanwhile, employers represent another potential disruptor in this area. And auto manufacturers, who face the reality that one-quarter of the cost of producing a car, is eaten up by employee and family healthcare costs, are contracting directly with organizations like Cleveland Clinic, in order to cost-effectively manage their employees’ and employees’ family members’ costs for high-volume procedures like total joint replacement. Patient care organization leaders also need to look at the venture capital funders in healthcare to see where VC companies are investing their money into the future.

In the end, Grosser told her audience, the potential for patient care organization leaders to move proactively to engage their patients and improve their experiences, is great; but the potential for outside organizations to come into healthcare as disruptors, is also significant.

Patton concluded her presentation by sharing a quote from General George S. Patton: “Never tell people how to do things. Tell them what to do and they will surprise you with their ingenuity.”


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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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