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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.”


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N.Y. Hospital Conducts Digital Assessments of Patient Interactions

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

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

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

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

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

Among other things, they assess:

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

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

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

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

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

 

 


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GetWellNetwork Acquires HealthLoop

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

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

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

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

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

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

 

 

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

 

 

 

 

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