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One Industry Leader Urges a Shift from “Patient-Centered” Care to “Collaborative Health”

August 4, 2017
by Mark Hagland
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Michael Millenson explains why “collaborative health” is a better frame than “patient-centered care”

The world—including the healthcare system, but also including technology, consumer demographics and preferences, and the broader society—is changing rapidly, says Michael L. Millenson, president of the Highland Park, Ill.-based Health Quality Advisors consulting firm; and patient care leaders need to understand where things are really going. That’s why Millenson authored an essay published on July 5 in The British Medical Journal (BMJ), entitled “When ‘patient centered’ is no longer enough: the challenge of collaborative health.”

As Millenson notes in that BMJ analytical article, “A quarter of a century ago, researchers proposed ‘patient-centered care’ as a conceptual framework that ‘consciously adopts the patient’s perspective’ about what’s important in interactions with providers and institutions.” But, he says, “Today, technological, economic, and social changes are moving healthcare in directions unanticipated by the patient centeredness pioneers. It’s not that patient centeredness no longer pertains; rather,” he says, “it’s being subsumed under these larger forces reshaping 21st-century medicine.” As a result, he says, “I suggest ‘collaborative health’ as an umbrella term framing how clinicians should respond.”

Importantly, Millenson notes in his BMJ article, “The digital health domain provides some of the most visible evidence of this shift. Increasingly, people can find, create, control, and act on an unprecedented breadth and depth of information. For example, according to its website the for-profit patient network and research platform PatientsLikeMe has amassed more than 520 000 patient profiles for more than 2700 conditions, filtering data reported by patients through analytical tools in an independent online collaboration. Although most PatientsLikeMe users are American, participation in this and similar platforms will grow as the digital divide continues to diminish. In 2015, more than half of adults in 21 emerging and developing countries reported using the internet or owning a smartphone (rising to 87% in 11 advanced economies). In 2017, an estimated 8.4 billion objects were part of the “internet of things” (sensors and web connectivity in everyday objects).” And he quotes Tim Berners-Lee, PatientsLikeMe’s creator, as stating that people can increasingly “integrate data from diverse aspects of life—financial, medical, home automation—and control what to share with whom.”

The implications of all these different changes are enormous, Millenson argues; and they change the landscape of what “health” means, in some very practical ways. On the one hand, the whole “patient-centered care” concept remains deeply provider-centric, despite its name, as the centering still takes place within the context of the traditional healthcare system: hospitals and physician practices can strive for “patient-centeredness,” but the system remains the locus. In reality, he asserts, we are gradually moving towards a new world in which people—who are sometimes healthcare consumers and sometimes patients, but who have identity and agency outside those definitions—are going to be interacting with the healthcare system in new and different ways.

The fact that a large plurality of Americans are living with chronic disease, at a time of greater personal agency than ever before, and the availability of broader technological supports for healthy living, is changing the landscape in some fundamental ways, Millenson argues. For example, he notes, “Chronic disease is implicated in 60 percent of all deaths globally, prompting more intense attention to the socioeconomic conditions that affect health. The result has been an upsurge in interventions by organizations that bear financial risk for medical costs. Their purview has expanded both to areas once thought to be reserved for clinicians, such as drug adherence, and to the work of social service organizations. In the U.S., for example, some health plans have been helping members with food, shelter, and even finding a job.” In other words, health and not just healthcare, will be the playing field on which interventions increasingly take place; and that will lead to greater empowerment of healthcare consumers, and their interactions with a broader range of individuals and organizations around their health. In short, people themselves will be directing how they interact with the system more and more, he argues; and it’s time for the leaders of patient care organizations to wake up and smell the coffee on all of this.

In that context, Millenson spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding his BMJ article and the concept of collaborative health, as he has articulated it. Below are excerpts from that interview.

Fundamentally, in your BMJ op-ed article, you are urging healthcare leaders to rethink how they interact with consumers, and to end their healthcare system-centric perspective on those interactions, correct?

Yes, that’s right. The key here—people want to look at e-health, and at the social determinants. But collaborative health looks at both. Economics and technology—the old boundaries between them are dissolving. And it’s not that the old healthcare system is being completely disintermediated—when you’re sick, you need professional care. But the old healthcare system is being disintermediated not only by technology, but by other actors. You had an article where you referenced the NEJM’s article where the author talked about wearables. And the reality is that you’ll need to be able to accept and ingest data from self-management.

And collaborative health says that, for maintenance of well-being, and for sickness care, there’s a new paradigm. Sometimes, individuals will be collaborating with the healthcare system; sometimes, they’ll be doing self-care. Sometimes, they’ll be collaborating with others. If a care manager puts in remote sensors into someone’s apartment, that’s technology, but it’s blended. And value-based payment is incentivizing changes. But it’s also technology, where people have the ability to self-manage. Or you’re illiterate, and someone gives you the tools to self-manage. It’s not just for rich people or yuppies, it’s going to be everywhere. And that’s key: it’s actors outside the traditional healthcare system being involved. And individuals being involved. It changes the relationships, and you now have a multi-polar system.

One fascinating area, in that regard, is how some health plans, particularly those working in Medicaid managed care and with Medicare/Medicaid dual-eligibles, are verging into the area of paying for items that aren’t clinical at all, but whose use might be able to positively influence health. Years ago, I spoke with a medical director of a health plan who talked about how she had authorized the purchase of handrails for the house of a dual-eligible member, because she had been determined to be at considerable risk for a fall. As that medical director noted, the health plan could spend $85 on handrails for Mrs. Smith, or hundreds of thousands of dollars on care for her should she suffer a devastating fall and break a hip. So it’s about the bigger picture, isn’t it?

Yes, it is about that bigger picture. And when Mrs. Smith sees her doctor, she’ll get patient-centered care. That’s exactly right. And the people putting in those sensors and other items may not be from the traditional healthcare system. And that’s a new phenomenon, we’ve never seen that before. And no matter how person-centric you are at the hospital near Mrs. Smith, she may or may not come to your hospital. There’s now a different paradigm around this. Let’s extend that idea of Mrs. Smith a bit. Let’s say she’s retired from a bank.

And we the bank might put in the handrails and the remote monitoring for her, under the aegis of her employer-sponsored health insurance plan?

It might be the employer, true. But what is happening is that some of the interactions and relationships going forward are going to be completely untethered from the traditional provider-centric healthcare system. You know, people are fixated on the 25-year-old Asian-American fitness buff from Palo Alto, who demonstrates the new app and says, of course, you want to share your running times with your friends and neighbors and post it on Instagram. And yes, those people are great, but that’s not what we’re talking about. And if the employer enables it and the health plan enables it, and maybe also the health system enables it, yes—but it might be untethered. And maybe Mrs. Smiths’ kids enable it. I talk about shared information, shared engagement, and shared accountability. And for physicians to retain trust and their unique relationship, they’re going to have to send different signals to their patients. Be willing to engage not only with your patient, but with the health plan, the employer, etc. And shared accountability will become very complicated. And the thing is, mistakes will be made, problems will occur, and people will want to blame somebody. So who’s accountable? Especially when money is involved, who’s accountable for it all?

So we’re moving away from the physician-patient interaction in the clinic as the central nexus, right? Things are going to become diffuse.

Things are becoming more diffuse now. And people will say, you’re the CEO of your life. But maybe, maybe not. When you’re in Stage 4 cancer, and can barely get out of bed, then you’re not exactly the CEO of your life. And people’s situations, preferences, and abilities, change. And it’s going to be much more fluid and diffuse, and we’ll need an adjustment period. Who owns your data, what are they going to do about it? Recently, there was an app called Sugar.IQ, and they gave it to patients. So alright, when you get large technology companies involved, how does your family doctor engage with Microsoft, or IBM? When you take away some of these barriers to direct-to-consumer, we’re in uncharted waters.

So many physicians and patient care organizations are still so focused on retaining their power and centrality, correct? And that is what you’re trying to alert them to?

Yes, that’s right. The medical profession is losing power. It doesn’t mean that it’s not important or not needed; it just means you’re losing control. Here’s an analogy: when women got the vote and Women’s Liberation came along, there’s no question that men lost control. But some would say that marriage got better. And, analogously, physicians, clinicians, patient care organizations, need to get on board with this. You’ll need much more trust. I think the doctor-patient relationship is incredibly important, particularly with large corporations getting involved in this. But if the doctor-patient relationship is going to be your ethical refuge in this, its ethical foundations are going to have to change.

Thus, we’re talking about shared information, shared engagement, and shared accountability. It’s a three-legged stool. Those will be the pillars of the new relationship. And it’s difficult, right? Because expert information is what makes a profession. And I didn’t want this to be only about technology. But in the technology realm, this is the Martin Luther moment. With the information of the printing press, you could spread the Bible for everyone to see. That’s what’s happening here, in terms of information being spread. So when your FDA-approved wearable is monitoring you, the information could be as reliable as what your physician does. And so when that kind of expert information is now available without the priest-doctor being involved, that’s going to change the relationship.

One thing that’s clear is that younger healthcare consumers have a vastly different conception of the provider-patient relationship than do their parents, and certainly than do their grandparents. They’re really looking to physician to be expert consultants, but with the consumers themselves directing their care overall.

And there are times when you absolutely can’t understand the complexities of something and you have to trust your doctor—even if you’re another doctor. But to go to your point, in order for you to be able to trust in this new environment, you have to know that the clinician trusts you, in terms engagement and accountability.

And 80 percent of the time, we’re talking about people with well-known chronic diseases.

Yes, and also, the expected diseases of aging. And when you’re dealing with the diseases of aging and with chronic disease, the technology and the economics are both changing. And physicians often underestimate what Web 2.0 is doing—it’s not just web-searching, it’s interactive, personalized, algorithmically driven information that’s not perfect, not infallible, but really pretty good, and much better than you might think. And BTW, the American College of Surgeons has, out on the web, a tool for figuring out the risks of morbidity and mortality for certain conditions. And so we have a multi-polar world. And providers are used to thinking of insurers as insurers, but they’re managing risk by managing medical care in ways they never would have done before. Meanwhile, patient care organizations are taking on financial risk as never before. And so knowledge and technology and everything, they’re all crossing boundaries. And a lot of this can be disguised by simplistic talk about patient-centeredness, etc. And beyond the hype, it’s a true paradigm shift.

And the purpose of the article is really to tell clinicians, you really need to be participatory in this. I did after all write a book called Demanding Accountability. And finally, due to federal incentives, things are moving forward in these areas.

Do you have any specific advice for CIOs and CMIOs of patient care organizations, with regard to strategy around all of this?

I’m a big fan of CIOs and CMIOs. I think the really difficult and important task they face is to look at what I’ve written here and say, how do I prepare my institution for a cultural change being driven by information? And a CMIO or CIO can look at this—they need to ask, how can I look outside my own little insulated world of healthcare, where everything reinforces that I’m at the center of the world, in the healthcare system? How can I understand what’s going on in the world and help my organization to understand some things that are culturally uncomfortable, but are ultimately vital to the success of our mission? And CMIOs especially, as physician informaticists, are unique positioned to break out of the patterns of the past, and adjust, and thrive in the future.


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Health2047 Spin-Off Focuses on Prediabetes Coaching

October 9, 2018
by David Raths, Contributing Editor
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First Mile Care seeks to scale up CDC’s proven National Diabetes Prevention Program
First Mile Care CEO Karl Ronn

Health2047 Inc., a Silicon Valley-based innovation company founded by the American Medical Association (AMA), has spun out its second startup, First Mile Care, a preventive chronic care company focused on prediabetes.

Health2047 previously launched Akiri, a San Francisco-based company developing a blockchain-based network-as-a-service platform for the healthcare industry.

There are an estimated 84 million people living with pre-diabetes (higher-than-normal blood sugar level), according to the company. With $2 million in seed funding, First Mile Care is building a platform that will offer people coaching to make lifestyle decisions that can reverse prediabetes and reduce the risk that their condition will develop into type 2 diabetes.

The First Mile Care platform is based on the proven National Diabetes Prevention Program (DPP) method developed by the Centers for Disease Control and Prevention (CDC). The coaching program has been shown to reduce the incidence of type 2 diabetes by 58 percent compared to placebo.

In an interview with Healthcare Informatics, First Mile Care Founder and CEO Karl P. Ronn described First Mile’s approach. “The CDC developed an approved diabetes prevention coaching program that works, but it just hasn’t scaled,” he said. “Approximately 200,000 people have taken the program in the seven years it has been available. That leaves 84 million who haven’t. The question is: can we scale it?”

First Mile has set an ambitious goal of getting half of prediabetic population into a coaching program in the next 10 years. “That scale of intervention would change the chronic disease landscape in the United States, said Ronn, a former Procter & Gamble executive.

To accomplish that goal, Ronn said First Mile will have to make the coaching intervention as convenient as possible. “If I want you to do something weekly for 16 weeks and monthly or bimonthly for six months after that, it better be easy to do or you are going to drop out,” he said. “It has to be within 10 minutes of your home. The reason we are called First Mile Care is that rather than trying to figure out how we are going to get the last mile from our hospital or doctor’s office to your home, we are more interested in that first mile, and we need to be able to make it possible for you to get that coaching in that first mile from your home.”

An easy way to model that is ZIP codes, he said. There are 42,000 U.S. ZIP codes. “It has to be as convenient as regular weekly shopping trips and that means showing up in all those ZIP codes,” he said. “I could need 40,000 to 100,000 coaches to handle 84 million people.”

First Mile is building a technology platform to build a matching system between individuals and coaches much like Uber does between drivers and riders. The platform will also track progress and provide feedback to users and use analytics to discover best coaching practices. “The tech platform tis important in matching people and tracking progress,” Ronn said, “but really I am trying to build a relationship between you and your coach so you can get done what you need to do. I don’t want the technology to get in the way of that; I want it to support it.”

Another reason the timing is right for the company’s launch, he said, is that Medicare has recently started to pay for this type of coaching program and other insurers are starting to follow suit.

So what is next for First Mile? “Our seed funding will enable us to prove we can do what we said we could do in terms of develop this coaching process in the wild,” Ronn said, “and create the on-demand system. In the process of doing it, we want it to be effortless and delightful for the coach and for the person. We are in a learning model to prove we can do it. Within 18 months, we will be scaling it up. “



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Top Ten Tech Trends 2018: A Patient-Generated Health Data Future is Becoming a Reality

September 5, 2018
by Rajiv Leventhal, Managing Editor
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Providers are becoming more open to integrating patient-generated health data into clinical processes, but core challenges still remain

Editor’s Note: Throughout the next week, in our annual Top Ten Tech Trends package, we will share with you, our readers, stories on how we gauge the U.S. healthcare system’s forward evolution into the future.

Last fall, the Boston-based Partners HealthCare system launched a project with the aim to provide its clinicians and researchers with access to patient-generated health data (PGHD) from more than 420 consumer and clinical health devices. Working with Durham, N.C.-based vendor Validic, Partners Connected Health announced its plan to integrate PGHD into care plans and the electronic health record (EHR) throughout the Partners HealthCare network this year.

Of course, Partners HealthCare is far from the only organization working on PGHD projects across the U.S., but the initiative, along with many others, proves that patient care systems are turning more toward collecting and integrating key data from consumers that is accumulated outside of a facility’s four walls. Indeed, during the second quarter of 2018, wearables were one of the top-funded categories for digital health VC funding, according to a Mercom Capital Group report.

That said, plenty of fundamental challenges remain, even as the motivation to integrate PGHD into clinical processes increases. For one, patients must be willing to use the devices and be engaged in collecting their own data. In the Partners HealthCare/Validic project, the devices used were either ones that patients already owned and were comfortable with, or were purchased from Amazon or someplace similar. In previous PGHD initiatives, Partners HealthCare tried to get most patients to use a single device, but the results were less than ideal, recalls Kelly Santomas, R.N., senior director, Partners Connected Health, an arm of Partners HealthCare.

For this initiative, Santomas’ team particularly wanted to collect data on patients’ blood pressure and glucose levels, activity and weight. She notes that the data is being integrated into providers’ EHRs, and that incorporation has not been difficult. The challenge with this project, so far, she says, has been fighting the perception that the patient data is not valid.

For instance, Santomas offers, if a patient is taking his or her blood pressure at home, and then that recordation is sent to the EHR, some providers might see that number as invalid. “But that’s a misconception,” she asserts. “It’s interesting, because we send patients home right now, tell them to buy a blood pressure cuff, write down their levels, and email it to us. So how do we know that is valid? You are assuming patients will do the right thing and give the right information, and working within [providers’] perceptions [on that] is the biggest challenge,” she contends.

Kelly Santomas, R.N.

Brian Modena, a clinical researcher at the Scripps Translational Science Institute who has researched the effectiveness of mobile health data gathered outside the doctor’s office, also believes that integrating this information into EHRs “is easily doable.” But Modena doesn’t see this being done industry-wide and he says that’s because “healthcare is always so slow to adapt, and people are used to the old way.” The “old way,” he says, involves a nurse taking a patient’s blood pressure and handing that off to the doctor, who then gives the patient advice. “The question becomes, are doctors going to look at PGHD? And if so, how often will they use it? What type of format should you put it into so doctors can easily process it?”

To this end, Santomas believes that physicians genuinely do want to incorporate patient-generated data, but it needs to be presented in a way that makes sense and is actionable to them. “They don’t have the time to sift through [non-valuable] information. So we need to make sure we are providing the data in a format that makes sense, is actionable, and benefits the patient in the long run,” she says.

UPMC Innovating Toward a Patient-Centered Future

In 2017, the University of Pittsburgh Medical Center (UPMC) said it would be investing in Xealth, a digital health startup that offers a digital prescribing platform, allowing clinicians to prescribe patients digital educational content, disease management apps and monitoring devices.

Rasu Shrestha, M.D., chief innovation officer and executive vice president at UPMC Enterprises—the health system’s innovation hub that funds promising health tech ventures—says that one of the primary reasons for the investment was to solve what he believes is a major barrier in advancing forward with patient-generated health data: an EHR divide that exists between providers and patients.

As Shrestha sees it, on one end, clinicians spend a great deal of time in their EHRs, as that’s where they document and how they bill. “Essentially, it’s how they provide care, and these care pathways and decisions they make are all documented and contained in the EHR,” he says. But at the other end, patients don’t live in the EHR. “At best, they maybe live on their phones, and they might use apps that might be connected to mobile devices. But these apps and devices are separate and are different from the EHR, and they don’t communicate well with each other. So you have these two divides, these two worlds, that are coexisting in these two different spheres,” Shrestha says.

Rasu Shrestha, M.D.

What’s more, if patients do download a health data app, it’s likely they won’t use it very frequently, and even if they do, they might also be fitness fanatics and own Fitbits and Apple Watches, meaning there is a lot of data that is remaining in the confines of the patients, apps, and devices, and in no meaningful way is being made back to the physician’s eyeballs, explains Shrestha. “Patients might make mention of this [data] during an annual visit and maybe they even take printouts. But that’s the extent of the interaction we see today,” he adds.

Bridging that divide was a big factor in the work UPMC is doing with Xealth. Shrestha says that the two organizations are co-creating a set of capabilities that will allow for clinicians who live in their EHRs to directly prescribe apps to their patients, much like how they are prescribing medications in the EHR today.

The prescribed apps then appear on patients’ phones, and with patients’ permission, a bi-directional interface can be created between apps and devices—through the patients’ phones, to the EHR. “Data would then be consumed in a matter that the EHR could understand,” Shrestha says.  “All of the readings and the data elements would then be available to the clinical decision support systems within the EHR, or through various means into the database of the EHR itself. That is something that is noble and unique, and this needs to be a standard of care and best practice across the board,” Shrestha asserts.

And UPMC physicians are embracing the validity and quality of the data, too, he adds.  Up until as recently as a year ago, he notes, physicians were resistant to engaging patients and consumers. But what were once disconnected experiences and data that simply was overbearing for clinicians in the little amount of time they had has now become data that is easily consumable and digestible for them, Shrestha says. “I am seeing that change happen in front of my very eyes.”

What Could Apple’s Role Be?

In June, Apple introduced a Health Records API (application programming interface) for developers and researchers with the goal “to create an ecosystem of apps that use health record data to better manage medications, nutrition plans, diagnosed diseases and more.”

The Health Records feature allows patients of hundreds of hospitals and clinics to access medical information from various institutions organized into one view on their iPhone. “For the first time, consumers will be able to share medical records from multiple hospitals with their favorite trusted apps, helping them improve their overall health,” Apple officials stated at the time. And starting this fall, Apple officials say that developers building health apps can individualize experiences based on the user’s unique health history.

Shrestha, for one, says he’s excited about the way Apple is approaching things. “It’s a really good thing that there is now one place on patients’ iPhones where they can collect information that belongs to them from any health institution that they have their data in, and that they can also send data back to the hospital. That’s a big deal for patients,” he says.

But, he adds that it shouldn’t be just about the Apple ecosystem and iPhones, because “There is also a whole ecosystem of patients and consumers on Android devices and others.” So, Shrestha asks, “How do we make sure we enable a much broader view to apps that may reside across other ecosystems and allow for that bi-directional interface to happen?”

In the end, Partners Connected Health’s Santomas believes that it’s realistic to think PGHD can soon be used to improve clinical outcomes. “Ideally, I’d love to see a world where the patient can access the healthcare system virtually, on their phones and computers, and as a provider I can sit there and talk to patients, pull up their record, and pull up their PGHD so I can have a sense of what’s going on while they’re at home,” she says. “All of that works together and gives us a much more holistic view of what’s going on with the patient versus just these small episodes of when I see them only in the office. That’s my vision.”

Related Insights For: Patient Engagement


Connecting Expectant Moms and Others with Trusted Content—and Gaining Patient Engagement

August 31, 2018
by Mark Hagland
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Leaders at South Shore Health System in Massachusetts invest in mobile app infrastructure to increase patient engagement

Can the implementation of mobile health applications improve patient outcomes and enhance patient engagement? The leaders at South Shore Health System (SSHS) have invested in the proposition that it can. That three-hospital integrated health system, located in South Weymouth, Massachusetts, had been facing the same types of challenges that other integrated health systems have long faced, in terms of consumer health content that was not optimally presented or shared with patients and families.

So, partnering with the Raleigh, N.C.-based MobileSmith, an “app-as-a-Service” company, South Shore leaders have been able to achieve more targeted, consistent messaging and care to all obstetrical patients, regardless of practice.

Now, instead of frustrating users with irrelevant notifications or pages of unnecessary content, expectant mothers can use the app to quickly connect to everything they need to know at each stage throughout their pregnancy.

Among the results SSHS leaders have documented include the following:

  • OB-Maternity HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey scores have risen by 68 percent -- jumping SSHS from the 53rd percentile to 89th
  • The hospital’s Care Transitions ranking also improved by 40 percent (from 43rd percentile to 60th)
  • Nearly 50 percent of new moms have opted for the app over printed handouts
  • Beyond new referrals, SSHS saved $10,000-15,000 in printing costs alone last year, reducing wasted paper-based booklets still used by many OB/GYN practices
  • SSHS is about to roll out a new bariatrics app that will be used as part of their certification program

Recently, three leaders from South Shore Health System spoke with Healthcare Informatics Editor-in-Chief Mark Hagland about their initiative, and its results. Kim Dever, M.D. is the health system’s chair of obstetrics and gynecology, and president of its medical staff; Luke Poppish is executive director of obstetrical and gynecological services; and Faye Weir, Ph.D., is director of parent/child services for the organization. Below are excerpts from that interview.

Tell me about the origins of this initiative?

Kim Dever, M.D.: At South Shore Health System, patients were getting the bulk of their information through smartphones, and we thought, what better place for our information to go to them, than through the tool they use every day? So, Luke Poppish said, let’s develop an app for our pregnant patients. We wanted to get them information. So we created the South Shore Hospital Babies app… Paper information wasn’t being used or saved. And we also could save money on printing all those brochures, etc. They can time their contractions, they can register for classes. It’s really been a nice way to reach our target audience.

Luke Poppish: We also had a lot of moms coming from a variety of different private practices—five at that time—whose doctors delivered at South Shore. So, we were faced with five different ways of communicating, and sharing feedback. We were getting a lot of input that there was a lot of fragmented communication at the practices, about processes and procedures at the hospital when they would check in. So we wanted to achieve standardization of messages, of focused content, of referrals, etc.

Faye Weir, Ph.D.: It wasn’t a one-and-done. Given the vast amount of work that nurses do in terms of preparation for childbirth and delivery, breastfeeding, post-partum, etc., as Luke partnered to develop the app, we linked him into the shared governance professional practice model here at South Shore, which means that nurses are actively involved in decision-making; so Luke was able to partner with a number of the nurses doing the patient care, and collaborate. It’s been a very iterative process; the staff has been able to identify even other areas to work on, including first-year, second-year areas. So it’s been a very collaborative process.

What has the timeline been like around this initiative?

Weir: In the spring of 2016, we started investigating apps, evaluated them through the early summer, by mid-summer of 2016, we decided to go with MobileSmith—the longest period of time actually was developing and signing the contract—it was a new process for us. That was a two- or three-month process. By late October of 2016, we had a skeleton developed—with feedback from nurses, midwives, and obstetricians. And by the beginning of December, we had our first test app. We launched into the app stores by the end of December of 2016, started marketing it in February 2017. That’s when we started measuring our metrics. We circulated it once it got to the stores, to make sure we didn’t miss anything. Since March of 2017, we’ve probably gone through seven or eight iterations of the app. We’ve added content around transitions of care, breastfeeding and support for breastfeeding, modified some elements. And we’re planning to continue to produce a quarterly to biennial revision of the content, over time.

What have been the biggest challenges and learnings so far in this initiative?

Devers: The biggest has been getting the information to the providers so they could share it with their patients; that’s always a challenge. Next challenge, to get patients to sign up for it. And helping providers help get patients signed up. And then there’s the sustainability needs, once you get the initial group going.

Poppish: And I would say, feedback from the private practices. It was a little bit weird for some of the nurses who had been in practice for a long time not to have lots of pieces of paper—15 to 20 leaflets—to hand out to patients. At first, the practice managers were a little bit reticent. We haven’t yet gone 100-percent app yet. Patients who need any paper can be offered that.

Weir: It was communication, making sure the patients were aware at every contact point in the organization and in the offices, so that we could maximize communication. Having the nurses value this instead of handing out paper. And from time to time, we have to invigorate this. That involves shifting the culture from paper, to a new concept of mobile health.

Poppish: Because it’s free and there’s no protected health information—you simply enter a due date—family members would join in, extended family members would follow the pregnancy, after putting in the due date. And, around the process of taking the education out of the EHR [electronic health record] paperwork and putting it into the app, getting used to that shift—we’ve seen really good progress in that, too.

Weir: I underestimated the involvement that my entire division would want to have—pre-natal, post-natal, and then NICU, and then child development. I underestimated the scope that this particular app would take, well beyond the pregnancy period. That’s part of that ongoing adjustment that we’re making.

Devers: It is dynamic. In the past, if you printed something, you would have to change it entirely. And we found that mental health issues, substance abuse, in the post-delivery phase, those were areas we could add more information into.

And the informational content is private and it’s reliable, because it’s coming from your health system.

Weir: Yes. And as the app’s been built, these places in the app have direct links into it, and we can link them to ACOG [the American College of Obstetrics and Gynecology], or do evidence-based breastfeeding information, and so on and so forth—so the patients are landing in the right place and accessing the right sources.

Devers: And we’re tracking we’re they’re going.

Poppish: Yes, with every internal page they hit on the app, we get a monthly report from MobileSmith. And we have a lot of… And we can determine how much and what type of information to add to pages. We get monthly usage data, page viewing data, MobileSmith does the development, and we agreed we would track metrics, for improvement on a quarterly basis. We’ve been tracking HCAHPS around transitions of care and post-partum, and likelihood to recommend. We thought this would have positive impact on.

Has it had a positive impact?

Poppish: Yes.

Devers: We definitely can attribute a drop in printing to this.

What would you say to health IT leaders, to clinicians, and to other hospital and health system leaders, about all of this?

Kim: You have to look at your patient and consider them your consiumer and consider where they get their information. I love that the information they’re accessing is information that we know is evidence-based. From the clinical side, the discussion is easy; we just need IT support for this, because there are costs.

Poppish: From an IT standpoint, we’ve learned to keep it as simple as possible. Having a dynamic development platform is important; we’ve changed it many times. It’s important for it to be easy to work with. We also were getting ready to implement Epic at the same time as we were launching this. IT asked whether we needed additional resources, and we said no, we can do this. And it doesn’t have any PHI or HIPAA in it; that would have added a year or longer to its development and implement. So I think IT leaders need to balance how much information they want from patients, what they need, and what is their true goal, and then figure out how many resources you need to support your goal. It helped a lot that we were pretty hands off with them, and that was very helpful.

Is there anything you’d like to add?

Poppish: We’ve had such a great success with SSH Babies that this April, we launched an SSH Bariatrics app with a few surgeons—it helps to prep people ot qualify for bariatric surgery. And we’ve had good results with that as well. Possibly soon a post-partum depression and mental health app. Possibly a NICU app. Everybody wants to get their information in; so when do we launch a new app?

Weir: It does provide dynamic and interactive connection to content and to providers.

Devers: And people like to see the doctors, and they like to interact, too, via video tools.



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