Free EMR Newsletter Want to receive the latest news on EMR, Meaningful Use, ARRA and Healthcare IT sent straight to your email? Join thousands of healthcare pros who subscribe to EMR and HIPAA for FREE!!

What Would A Community Care Plan Look Like?

Posted on November 16, 2016 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

Recently, I wrote an article about the benefits of a longitudinal patient record and community care plan to patient care. I picked up the idea from a piece by an Orion Health exec touting the benefits of these models. Interestingly, I couldn’t find a specific definition for a community care plan in the article — nor could I dig anything up after doing a Google search — but I think the idea is worth exploring nonetheless.

Presumably, if we had a community care plan in place for each patient, it would have interlocking patient-specific and population health-level elements to it. (To my knowledge, current population health models don’t do this.) Rather than simply handing patients off from one provider to another, in the hope that the rare patient-centered medical home could manage their care effectively on its own, it might set care goals for each patient as part of the larger community strategy.

With such a community care strategy, groups of providers would have a better idea where to allocate resources. It would simultaneously meet the goals of traditional medical referral patterns, in which clinicians consult with one another on strategy, and help them decide who to hire (such as a nurse-practitioner to serve patient clusters with higher levels of need).

As I envision it, a community care plan would raise the stakes for everyone involved in the care process. Right now, for example, if a primary care doctor refers a patient to a podiatrist, on a practical level the issue of whether the patient can walk pain-free is not the PCP’s problem. But in a community-based care plan, which help all of the individual actors be accountable, that podiatrist couldn’t just examine the patient, do whatever they did and punt. They might even be held to quantitative goals, if the they were appropriate to the situation.

I also envision a community care plan as involving a higher level of direct collaboration between providers. Sure, providers and specialists coordinate care across the community, minimally, but they rarely talk to each other, and unless they work for the same practice or health system virtually never collaborate beyond sharing care documentation. And to be fair, why should they? As the system exists today, they have little practical or even clinical incentive to get in the weeds with complex individual patients and look at their future. But if they had the right kind of community care plan in place for the population, this would become more necessary.

Of course, I’ve left the trickiest part of this for last. This system I’ve outlined, basically a slight twist on existing population health models, won’t work unless we develop new methods for sharing data collaboratively — and for reasons I be glad to go into elsewhere, I’m not bullish about anything I’ve seen. But as our understanding of what we need to get done evolves, perhaps the technology will follow. A girl can hope.

A New Meaning for Connected Health at 2016 Symposium (Part 4 of 4)

Posted on November 8, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this article continued our exploration of the integration of health care into daily life. This section wraps up the article with related insights, including some thoughts about the future.

Memorable moments
I had the chance to meet with Casper de Clercq, who has set up a venture capital plan devoted to health as a General Partner at Norwest Venture Partners. He recommends that manufacturers and clinicians give patients a device that collects data while doing something else they find useful, so that they are motivated to keep wearing it. As an example, he cited the Beddit sleep tracker, which works through sensors embedded (no pun intended) in the user’s bed.

He has found that successful companies pursue gradual, incremental steps toward automated programs. It is important to start with a manual process that works (such as phoning or texting patients from the provider), then move to semi-automation and finally, if feasible, full automation. The product must also be field-tested; one cannot depend on a pilot. This advice matches what Glen Tullman, CEO of Livongo Health, said in his keynote: instead of doing a pilot, try something out in the field and change quickly if it doesn’t work.

Despite his call for gradual change, de Clercq advises that companies show an ROI within one year–otherwise, the field of health care may have evolved and the solution may be irrelevant.

He also recommends a human component in any health program. The chief barrier to success is getting the individual to go along with both the initial activation and continuing motivation. Gamification, behavioral economics, and social connections can all enhance this participation.

A dazzling keynote on videogames for health was delivered by Adam Gazzaley, who runs Neuroscience labs at the University of California at San Francisco. He pointed out that conventional treatments get feedback on patient reactions far too slowly–sometimes months after the reaction has occurred. In the field of mental health, His goal is to supplement (not replace) medications with videogames, and to provide instant feedback to game players and their treatment staff alike. Videogames not only provide a closed-loop system (meaning that feedback is instantaneous), but also engage patients by being fun and offering real-time rewards. Attention spans, anxiety, and memory are among the issues he expects games to improve. Education and wellness are also on his game plan. This is certainly one talk where I did not multitask (which is correlated with reduced performance)!

A future, hopefully bigger symposium
The Connected Health symposium has always been a production of the Boston Partners Health Care conglomerate, a part of their Connected Health division. The leader of the division, Dr. Joseph Kvedar, introduced the symposium by expressing satisfaction that so many companies and organizations are taking various steps to make connected health a reality, then labeled three areas where leadership is still required:

  • Reassuring patients that the technologies and practices work for them. Most people will be willing to adopt these practices when urged by their doctors. But their privacy must be protected. This requires low-cost solutions to the well-known security problems in EHRs and devices–the latter being part of the Internet of Things, whose vulnerability was exposed by the recent attack on Dyn and other major Internet sites.

  • Relieving the pressures on clinicians. Kvedar reported that 45 percent of providers would like to adopt connected health practices, but only 12 percent do so. One of the major concerns holding them back is the possibility of data overload, along with liability for some indicator of ill health that they miss in the flood of updates. Partners Connected Health will soon launch a provider adoption initiative that deals with their concerns.

  • Scaling. Pilot projects in connected health invest a lot of researcher time and offers a lot of incentives to develop engagement among their subjects. Because engagement is the whole goal of connected health, the pilot may succeed but prove hard to turn into a widespread practice. Another barrier to scaling is consumers’ lack of tolerance for the smallest glitches or barriers to adoption. Providers, also, insist that new practices fit their established workflows.

Dr. Kvedar announced at this symposium that they would be doing future symposia in conjunction with the Personal Connected Health Alliance (Formerly the mHealth Summit owned by HIMSS), a collaboration that makes sense. Large as Partners Health Care is, the symposium reaches much farther into the health care industry. The collaboration should bring more resources and more attendees, establishing the ideals of connected health as a national and even international movement.

A New Meaning for Connected Health at 2016 Symposium (Part 3 of 4)

Posted on November 7, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this article paused during a discussion of the accuracy and uses of devices. At a panel on patient generated data, a speaker said that one factor holding back the use of patient data was the lack of sophistication in EHRs. They must be enhanced to preserve the provenance of data: whether it came from a device or from a manual record by the patient, and whether the device was consumer-grade or a well-tested medical device. Doctors invest different levels of trust in different methods of collecting data: devices can provide more objective information than other ways of asking patients for data. A participant in the panel also pointed out that devices are more reliable in the lab than under real-world conditions. Consumers must be educated about the proper use of devices, such as whether to sit down and how to hold their arms when taking their blood pressure.

Costantini decried the continuing silos in both data sharing and health care delivery. She said only half of doctors share patient data with other doctors or caretakers. She also praised the recent collaboration between Philips and Qualcomm to make it easier for device data to get into medical records. Other organizations that have been addressing that issue for some time include Open mHealth, which I reviewed in an earlier article, and Validic.

Oozing into workflow
The biggest complaint I hear from clinicians about EHRs–aside from the time wasted in their use, which may be a symptom of the bigger problem-is that the EHRs disrupt workflow. Just as connected health must integrate with patient lives as seamlessly as possible, it should recognize how teams work and provide them with reasonable workflows. This includes not only entering existing workflows as naturally as capillary action, but helping providers adopt better ones.

The Veterans Administration is forging into this area with a new interface called the Enterprise Health Management Platform (eHMP). I mentioned it in a recent article on the future of the VA’s EHR. A data integration and display tool, eHMP is agnostic as to data source. It can be used to extend the VistA EHR (or potentially replace it) with other offerings. Although eHMP currently displays a modern dashboard format, as described in a video demo by Shane Mcnamee, the tool aims to be much more than that. It incorporates Business Process Modeling Notation (BPMN) and the WS-Human Task Specification to provide workflow support. The Activity Management Service in eHMP puts Clinical Best Practices directly into the workflow of health care providers.

Clinicians can use eHMP to determine where a consultation request goes; currently, the system is based on Red Hat’s BPMN engine. If one physician asks another to examine the patient, that task turns up on the receiving physician’s dashboard. Teams as well as individuals can be alerted to a patient need, and alerts can be marked as routine or urgent. The alerts can also be associated with time-outs, so that their importance is elevated if no one acts on them in the chosen amount of time.

eHMP is just in the beginning stages of workflow support. Developers are figuring out how to increase the sophistication of alerts, so that they offer a higher signal-to-noise ratio than most hospital CDS systems, and add intelligence to choose the best person to whom an alert should be directed. These improvements will hopefully free up time in the doctor’s session to discuss care in depth–what both patients and providers have long said they most want from the health care field.

At the Connected Health symposium, I found companies working on workflow as well. Dataiku (whose name is derived from “haiku”) has been offering data integration and analytics in several industries for the past three years. Workflows, including conditional branches and loops, can be defined through a graphical interface. Thus, a record may trigger a conditional inquiry: does a lab value exceed normal limits? if not, it is merely recorded, but if so, someone can be alerted to follow up.

Dataiku illustrates an all-in-one, comprehensive approach to analytics that remains open to extensions and integration with other systems. On the one hand, it covers the steps of receiving and processing data pretty well.

To clean incoming data (the biggest task on most data projects), their DSS system can use filters and even cluster data to find patterns. For instance, if 100 items list “Ohio” for their location, and one lists “Oiho”, the system can determine that the outlier is a probably misspelling. The system can also assign data to belonging to broad categories (string or integer) as well as more narrowly defined categories (such as social security number or ZIP code).

For analysis, Dataiku offers generic algorithms that are in wide use, such as linear regressions, and a variety of advanced machine learning (artificial intelligence) algorithms in the visual backend of the program–so the users don’t need to write a single line of code. Advanced users can also add their own algorithms coded in a variety of popular languages such as Python, R, and SQL. The software platform offers options for less technically knowledgeable users, pre-packaged solutions for various industries such as health care, security features such as audits, and artificial intelligence to propose an algorithm that works on the particular input data.

Orbita Health handles workflows between patients and providers to help with such issues as pain management and medication adherence. The company addresses ease of use by supporting voice-activated devices such as Amazon Echo, as well as some 250 other devices. Thus, a patient can send a message to a provider through a single statement to a voice-activated device or over another Internet-connected device. For workflow management, the provider can load a care plan into the system, and use Orbita’s orchestration engine (similar to the Business Process Modeling Notation mentioned earlier) to set up activities, such as sending a response to a patient’s device or comparing a measurement to the patient’s other measurements over time. Orbita’s system supports conditional actions, nests, and trees.

CitiusTech, founded in 2005, integrates data from patient devices and apps into provider’s data, allowing enterprise tools and data to be used in designing communications and behavioral management in the patient’s everyday life. The company’s Integrated Analytix platform offer more than 100,000 apps and devices from third-party developers. Industry studies have shown effective use of devices, with one study showing a 40% reduction in emergency room admissions among congestive heart failure patients through the use of scales, engaging the patients in following health protocols at home.

In a panel on behavior change and the psychology of motivation, participants pointed out that long-range change requires multiple, complex incentives. At the start, the patient may be motivated by a zeal to regain lost functioning, or even by extrinsic rewards such as lower insurance premiums. But eventually the patient needs to enfold the exercise program or other practice into his life as a natural activity. Rewards can include things like having a beer at the end of a run, or sharing daily activities with friends on social media.

In his keynote on behavioral medicine, the Co-founder & CEO of Omada Health, Sean Duffy, put up a stunningly complex chart showing the incentives, social connections, and other factors that go into the public’s adoption of health practices. At a panel called “Preserving the Human Touch in the Expanding World of Digital Therapies”, a speaker also gave the plausible advice that we tell patients what we can give back to them when collecting data.

The next section of this article offers some memorable statements at the conference, and a look toward the symposium’s future.

A New Meaning for Connected Health at 2016 Symposium (Part 2 of 4)

Posted on November 4, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this article talked about making health a routine part of everyday life, particularly where consumer devices are concerned. We’ll continue in this section with other considerations aired at the symposium.

Tullman’s principles of simplicity, cited in the previous section, can be applied to a wide range of health IT. For instance, AdhereTech pill bottles can notify the patient with a phone call or text message if she misses a dose. Another example of a technology that is easily integrated into everyday life is a thermometer built into a vaginal ring that a woman can insert and use without special activation. This device was mentioned by Costantini during her keynote. The device can alert a woman–and, if she wants, her partner–to when she is most fertile.

Super-compact devices and fancy interfaces are not always necessary for a useful intervention. In a keynote, John Dwyer, Jr., President of the Global Alzheimer’s Platform Foundation, discussed a simple survey that his organization got large numbers of people to take. They uncovered a lot of undiagnosed cases of mental decline. I imagine that the people who chose to take the survey were experiencing possible symptoms and therefore were concerned about their mental abilities. Yet they apparently had not expressed concerns to their doctors; instead they responded to the online suggestion to take a survey.

Most of us spend a large chunk of our day at work, so wellness programs there are theoretically promising. A panel on workplace-connected health solutions talked about some of the barriers:

  • Inadequate communications. Employees need to be informed regularly that a program is available, and its benefits

  • Privacy guarantees. Employees must feel assured of a firewall between their employer and the organization handling their sensitive data.

  • Clear goals. A wellness program is not just a check-off box. Employers must know what they want to achieve and design programs around these goals.

I would add that employers should examine their own environment honestly before setting up a wellness program. It’s pretty hypocritical to offer a wellness program on the one hand while subjecting employees to stress, overwork, and bad ergonomics on the other.

Telehealth is also likely to grow, and in fact, 200 bills to improve regulation of telehealth are pending in Congress. A speaker at a panel on preserving the human touch said that the Centers for Medicare & Medicaid Services are held back by uncertainty about how to measure telehealth’s value. Another speaker pointed out that we have a severe shortage of mental health professionals, and that many areas lack access to them. Telehealth may improve access.

It all comes down to the environment
Health care has to fully acknowledge the role of environmental factors in creating sickness. These include the marketing of fatty and sugary foods, the trapping of poor and minority people in areas with air and water pollution, the barriers to getting health care (sick leave, geography, insurance gaps, ignorance of gender issues, and so forth), the government subsidization of gambling, and much more. Similar issues came up during a keynote by David Torchiana, President & CEO and Partners HealthCare.

In her keynote, Jo Ann Jenkins, the CEO of AARP, quoted Atul Gawande as saying that we have medicalized aging and are failing to support the elderly. We have to see them as functioning individuals and help to support their health instead of focusing on when things go wrong. This includes focusing on prevention and ensuring that they have access to professional health care while they are still well. It also means restructuring our living spaces and lifestyles so the elderly can remain safely in their homes, get regular exercise, and eat well.

These problems call for a massive legislative and regulatory effort. But as a participant said on the panel of disruptive women in health care, plenty of money goes into promoting the interests of large hospitals, insurers, and device manufacturers, but nobody knows how to actually lobby for health care. Look at the barriers reached by Michelle Obama’s Let’s Move campaign, which fell short of ambitious goals in improving American’s nutrition.

Grounding devices on a firm foundation
A repeated theme at this symposium was making data collection by patients easier–so easy in fact that they can just launch data collection and not think about it. To be sure, some people are comfortable with health technology: according to Costantini, 60 percent of US smartphone users manage their health in some way through those devices. Nevertheless, if people have to consciously choose when to send data–even a click of a button–many will drop out of the program.

At a break-out session during the 2015 Health Datapalooza, I heard prospective device makers express anxiety over the gargantuan task of getting their products accepted by the industry. The gold standard for health care adoption, of course, is FDA approval based on rigorous clinical trials. One participant in the Datapalooza workshop assured the others that he had gotten his device through the FDA process, and that they could to.

Attitudes seem to have shifted over the past year, and many more manufacturers are treating FDA approval as a natural step in their development process, keeping their eyes on the prize of clinical adoption. Keith Carlton, CEO of HUINNO, in a panel on wearables, said that accuracy is critical to stand out in the marketplace and to counter the confusion caused by manufacturers that substitute hype for good performance.

Clinical trials for devices don’t have to be the billion-dollar, drawn-out ordeals suffered by pharma companies. Devices are rarely responsible for side effects (except for implantables) and therefore can be approved after a few months of testing.

A representative of BewellConnect told me that their road to approval took 9-12 months, and involved comparing the results of their devices to those of robust medical devices that had been previously approved. Typical BewellConnect devices include blood pressure cuffs and an infrared thermometer that quickly shows the patient’s temperature after being held near his temple. This thermometer has been used around the world in situations where it’s important to avoid contact with patients, such as in Ebola-plagued regions.

What’s new over the past three years is Bluetooth-enabled devices that can transmit their results over the network. BewellConnect includes this networking capability in 17 current devices. The company tries to provide a supremely easy path for the patient to transmit the device over a phone app to the cloud. The patient can register multiple family members on the app, and is prompted twice to indicate who was using the device so as to prevent errors. BewellConnect is working on an alert system for providers, a simple use case for data collection.

Many products from BewellConnect are in widespread use in France, where the company is based, and they have launched a major entry into the US market. I asked BewellConnect’s CEO, Olivier Hua, whether the US market presents greater problems than France. He said that the two markets are more similar than we think.

Health care in the US has historically been fragmented, whereas in France it was unified under government control. But the Affordable Care Act in the US has brought more regulation to the market here, whereas private health care providers (combining insurance and treatment) have been growing in France. As of January 1 of this year, France has required all employers to include a private option in their health care offerings. For the first time, French individuals are being hit with the copays and deductibles familiar to Americans, and are weighing how often to go to the doctor. Although the US market is still more diverse, and burdened by continuing fee-for-service plans, it is comparable to the French market for a vendor such as BewellConnect.

The next section of this article will continue with a discussion of barriers in the use of patient data, and other insights from the Connected Health symposium.

A New Meaning for Connected Health at 2016 Symposium (Part 1 of 4)

Posted on November 3, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Those of us engaged in health care think constantly about health. But at the Connected Health symposium, one is reminded that the vast majority of people don’t think much about health at all. They’re thinking about child care, about jobs, about bills, about leisure time. Health comes into the picture only through its impacts on those things.

Certainly, some people who have suffered catastrophic traumas–severe accidents, cancer, or the plethora of unfortunate genetic conditions–become obsessed about health to the same extent as health professionals. These people become e-patients and do all the things they need to do regain the precious state of being they enjoyed before their illness, often clashing with the traditional medical establishment in pursuit of health.

But for most people with chronic conditions, the opposite holds true. A whimsical posting points out that we willingly pay more to go to a masseur or hairdresser than to a doctor. I appreciate this observation more than the remedies offered by the author, which fall into the usual “patient engagment” activities that I have denigrated in an earlier article.

Understanding health as a facet and determinant of everyday life becomes even more important as we try to reverse the rise of costs, which in many nations are threatening economic progress and even the social contract. (Witness the popular anger in the current US election over rising insurance premiums and restrictions on choice.) We have to provide health solutions to people who are currently asymptomatic. The conventional focus on diagnosed conditions won’t serve us.

It’s thus commendable that the Connected Health symposium for 2016 has evolved to the point where participants can think not only of reaching out to patients, but to embedding their interventions so deeply into patient life that the patient no longer has to think about her health to benefit. This gives a new meaning to the word “connected”. Whereas, up to now, it referred to connecting a patient more closely with their clinicians and care-takers (through data collection, messaging, and online consultations), “connected” can also mean connecting our healthful interventions to the patient’s quotidian concerns about work, family, and leisure.

We can do this by such means as choosing data collection that the patient can enable and then stop thinking about, and integrating care with the social media they use regularly. In her keynote, Nancy Brown, CEO of the American Heart Association, pointed out that social connections are critical to health and are increasingly taking place online, instead of someone dropping by her neighbor for coffee. The AHA’s Go Red For Women program successfully exploited social connections to improve heart health.

If you want an overview of what people mean by the term “connected health,” you would do well to get The Internet of Healthy Things, by Dr. Joseph Kvedar, leader of Partners Connected Health and chief organizer of this symposium. For a shorter overview, you can read my review of the book, and my report from an earlier symposium. Now in its 13th year, the annual symposium signed up 1200 registered attendees–the biggest number yet. This article looks over the people and companies I heard from there.

Exhausting the possibilities of passive data collection
Glen Tullman, CEO of Livongo Health, offered basic principles for consumer health in a keynote: it must be personal, simple, context-aware, and actionable. As an example, he cited Livongo’s own program for sending text messages to diabetes patients: they are tailored to the individual and offer actionable advice such as, “Drink a glass of water”.

A panel on consumer technology extolled the value of what analysts like to call data exhaust: the use of data that can be collected from people’s everyday behavior. After all, this exhaust is what marketers used all the time to figure out what we want to buy, and what governments use to decide whether we’re dangerous actors. It can have value in health too.

As pointed out by Jim Harper, Co-Founder and COO of Sonde Health, providers and researchers can learn a lot from everyday interactions with devices–diagnosing activity levels from accelerometers, for instance, or depression from a drop in calls or text messages. Similarly, a symposium attendee suggested to me that colleges could examine social connections among students to determine which ones are at risk of abusing alcohol.

Lauren Costantini, President and CEO of Prima-Temp, said in a keynote that we can predict all kinds of things from your circadian rhythm–as measured by a sensor–such as an oncoming infection, or the best way to deliver chemotherapy.

Spire offers a device that claims to help people suffering from anxiety, with a low barrier to adoption and instant feedback. It’s a device worn on the body that can alert the user in various ways (buzzes, text messages) when the user’s anxiety level is rising.

Does the Spire device work? They got a partial answer to this in a study by Partners Health Care, where people had an option of using the device on its own or in conjunction with a headband from Muse that helps train people to meditate. (There was no control group.) Unlike the Spire device, which one can put on and forget about, the Muse purchaser is expected to make a conscious decision to meditate using the device regularly.

The Partners study showed modest benefits to these devices, but had mixed results. For instance, fewer than half the subjects continued use of the devices after the study finished. Those who did continue showed a strong positive effect on stress, and those who discontinued use showed a very small positive effect. Strangely there was a small overall increase in tension for all participants, even though they also demonstrated increases in “calm” periods. There is no correlation between the length of time that individuals used their devices and their outcomes.

Jonathan Palley, CEO & Co-founder of Spire, said participants often liked their devices, but stopped using them because they have learned from the devices how to identify stress and felt they could self-regulate and no longer needed the devices. I believe this finding may apply to other consumer devices as well. The huge rate at which devices are abandoned after six months, the subject of frequent reports and agonized commentaries, may simply indicate that users have reached their goal and can continue their fitness programs on their own. Graeme Moffat, VP of Scientific & Regulatory Affairs at Muse, reported that many purchasers use their headband for only three months, but come back to it over time to refresh their training.

We’ll look at some more aspects of integrating devices into patient lives in the next section of this article.

Health Plans Need Big Data Smarts To Prove Their Value

Posted on November 2, 2016 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

Recently, Aetna cut a deal which suggests a new role for health insurers in big data analytics and population health management. In partnership with Merck, the health insurer is launching a new program using predictive analytics to identify target populations and provide them with health and wellness services. AetnaCare will start by targeting patients with diabetes and hypertension in the mid-Atlantic U.S., but it seems likely to go national soon.

In its press release on the matter, Aetna says the goal of the program is to “proactively curate various health and wellness services… to support treatment adherence, ensure that critical social support needs are met, and reinforce healthy lifestyle behaviors.” That in and of itself isn’t a big deal. We all know that these are goals shared by providers, employers and health plans, and that most of the efforts health plans make on this front are pie in the sky, half-baked initiatives featuring cutesy graphics and little substance.

But then, Aetna’s chief medical officer gives away the real goal here — to power this effort by analyzing patient data being spun out by patients in varied care settings.  In the release, Dr. Harold Paz notes that patients are getting care in a wide variety of settings, including retail clinics, healthcare devices, pharmaceutical services, behavioral health, and social services, and that these services are seldom coordinated well, and implies that this is the real problem Aetna must solve.

If you listen to this with the ears of a health IT chick like myself, you hear Aetna (and Merck, actually) admitting that they must engage in predictive analytics across all of these encounters – and eventually, use these insights to help patients make good healthcare choices. In other words, they have to think like providers and even offer provider-like services fulfill their mission. And that means competing with or even beating providers at the big data game.

The truth is, health plans are in the same boat as providers, in that they’re at the center of a hailstorm of data and struggling with how to make use of it. Also, like providers they’re facing pressure from health purchasers to slow healthcare cost growth and boost patient wellness. But I’d argue that they’re even less prepared, technically and culturally, to improve health or coordinate care. So jumping in now is critically important.

In fact, I’d argue that health insurers are under greater pressure to improve population health than even sophisticated health systems or ACOs. Why? Because while health systems and ACOs can point to what they do – they make people better, for heaven’s sake — insurance companies are the eternal middleman who must continue to prove that they add value to the healthcare equation.

It remains to be seen whether programs like AetnaCare succeed at helping patients find the resources they need to improve and maintain their health. But even if this concept doesn’t work out, others will follow. Health plans need to leverage their unique data set to boost quality and reduce costs. Otherwise, as providers learn to work under value-based payments and accept risk, employers will have increasingly good reasons to contract directly — and leave the insurance industry out of the game entirely.

The Pain of Recording Patient Risk Factors as Illuminated by Apixio (Part 2 of 2)

Posted on October 28, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this article introduced Apixio’s analytics for payers in the Medicare Advantage program. Now we’ll step through how Apixio extracts relevant diagnostic data.

The technology of PDF scraping
Providers usually submit SOAP notes to the Apixio web site in the form of PDFs. This comes to me as a surprise, after hearing about the extravagant efforts that have gone into new CCDs and other formats such as the Blue Button project launched by the VA. Normally provided in an XML format, these documents claim to adhere to standards and offer a relatively gentle face to a computer program. In contrast, a PDF is one of the most challenging formats to parse: words and other characters are reduced to graphical symbols, while layout bears little relation to the human meaning of the data.

Structured documents such as CCDs contain only about 20% of what CMS requires, and often are formatted in idiosyncratic ways so that even the best CCDs would be no more informative than a Word document or PDF. But the main barrier to getting information, according to Schneider, is that Medicare Advantage works through the payers, and providers can be reluctant to give payers direct access to their EHR data. This reluctance springs from a variety of reasons, including worries about security, the feeling of being deluged by requests from payers, and a belief that the providers’ IT infrastructure cannot handle the burden of data extraction. Their stance has nothing to do with protecting patient privacy, because HIPAA explicitly allows providers to share patient data for treatment, payment, and operations, and that is what they are doing giving sensitive data to Apixio in PDF form. Thus, Apixio had to master OCR and text processing to serve that market.

Processing a PDF requires several steps, integrated within Apixio’s platform:

  1. Optical character recognition to re-create the text from a photo of the PDF.

  2. Further structuring to recognize, for instance, when the PDF contains a table that needs to be broken up horizontally into columns, or constructs such the field name “Diagnosis” followed by the desired data.

  3. Natural language processing to find the grammatical patterns in the text. This processing naturally must understand medical terminology, common abbreviations such as CHF, and codings.

  4. Analytics that pull out the data relevant to risk and presents it in a usable format to a human coder.

Apixio can accept dozens of notes covering the patient’s history. It often turns up diagnoses that “fell through the cracks,” as Schneider puts it. The diagnostic information Apixio returns can be used by medical professionals to generate reports for Medicare, but it has other uses as well. Apixio tells providers when they are treating a patient for an illness that does not appear in their master database. Providers can use that information to deduce when patients are left out of key care programs that can help them. In this way, the information can improve patient care. One coder they followed could triple her rate of reviewing patient charts with Apixio’s service.

Caught between past and future
If the Apixio approach to culling risk factors appears round-about and overwrought, like bringing in a bulldozer to plant a rosebush, think back to the role of historical factors in health care. Given the ways doctors have been taught to record medical conditions, and available tools, Apixio does a small part in promoting the progressive role of accountable care.

Hopefully, changes to the health care field will permit more direct ways to deliver accountable care in the future. Medical schools will convey the requirements of accountable care to their students and teach them how to record data that satisfies these requirements. Technologies will make it easier to record risk factors the first time around. Quality measures and the data needed by policy-makers will be clarified. And most of all, the advantages of collaboration will lead providers and payers to form business agreements or even merge, at which point the EHR data will be opened to the payer. The contortions providers currently need to go through, in trying to achieve 21st-century quality, reminds us of where the field needs to go.

The Pain of Recording Patient Risk Factors as Illuminated by Apixio (Part 1 of 2)

Posted on October 27, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Many of us strain against the bonds of tradition in our workplace, harboring a secret dream that the industry could start afresh, streamlined and free of hampering traditions. But history weighs on nearly every field, including my own (publishing) and the one I cover in this blog (health care). Applying technology in such a field often involves the legerdemain of extracting new value from the imperfect records and processes with deep roots.

Along these lines, when Apixio aimed machine learning and data analytics at health care, they unveiled a business model based on measuring risk more accurately so that Medicare Advantage payments to health care payers and providers reflect their patient populations more appropriately. Apixio’s tools permit improvements to patient care, as we shall see. But the core of the platform they offer involves uploading SOAP notes, usually in PDF form, and extracting diagnostic codes that coders may have missed or that may not be supportable. Machine learning techniques extract the diagnostic codes for each patient over the entire history provided.

Many questions jostled in my mind as I talked to Apixio CTO John Schneider. Why are these particular notes so important to the Centers for Medicare & Medicaid Services (CMS)? Why don’t doctors keep track of relevant diagnoses as they go along in an easy-to-retrieve manner that could be pipelined straight to Medicare? Can’t modern EHRs, after seven years of Meaningful Use, provide better formats than PDFs? I asked him these things.

A mini-seminar ensued on the evolution of health care and its documentation. A combination of policy changes and persistent cultural habits have tangled up the various sources of information over many years. In the following sections, I’ll look at each aspect of the documentation bouillabaisse.

The financial role of diagnosis and risk
Accountable care, in varying degrees of sophistication, calculates the risk of patient populations in order to gradually replace fee-for-service with payments that reflect how adeptly the health care provider has treated the patient. Accountable care lay behind the Affordable Care Act and got an extra boost at the beginning of 2016 when CMS took on the “goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to alternative payment models, such as ACOs, by the end of 2016 — and 50 percent by the end of 2018.

Although many accountable care contracts–like those of the much-maligned 1970s Managed Care era–ignore differences between patients, more thoughtful programs recognize that accurate and fair payments require measurement of how much risk the health care provider is taking on–that is, how sick their patients are. Thus, providers benefit from scrupulously complete documentation (having learned that upcoding and sloppiness will no longer be tolerated and will lead to significant fines, according to Schneider). And this would seem to provide an incentive for the provider to capture every nuance of a patient’s condition in a clearly code, structured way.

But this is not how doctors operate, according to Schneider. They rebel when presented with dozens of boxes to check off, as crude EHRs tend to present things. They stick to the free-text SOAP note (fields for subjective observations, objective observations, assessment, and plan) that has been taught for decades. It’s often up to post-processing tools to code exactly what’s wrong with the patient. Sometimes the SOAP notes don’t even distinguish the four parts in electronic form, but exist as free-flowing Word documents.

A number of key diagnoses come from doctors who have privileges at the hospital but come in only sporadically to do consultations, and who therefore don’t understand the layout of the EHR or make attempts to use what little structure it provides. Another reason codes get missed or don’t easily surface is that doctors are overwhelmed, so that accurately recording diagnostic information in a structured way is a significant extra burden, an essentially clerical function loaded onto these highly skilled healthcare professionals. Thus, extracting diagnostic information many times involves “reading between the lines,” as Schneider puts it.

For Medicare Advantage payments, CMS wants a precise delineation of properly coded diagnoses in order to discern the risk presented by each patient. This is where Apixio come in: by mining the free-text SOAP notes for information that can enhance such coding. We’ll see what they do in the next section of this article.

Time To Treat Telemedicine as Just “Medicine”

Posted on October 25, 2016 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

Over the last year or two, hospitals and clinics have shown a steadily growing interest in offering telemedicine services. Certainly, this is in part due to the fact that health plans are beginning to pay for telehealth consults, offering a new revenue stream that providers want to capture, but there’s more to consider here.

Until recently, much of the discussion around telehealth centered on how to get health insurance companies to pay for it. But now, as value-based purchasing becomes more the norm, providers will need to look at telemedicine as a key tool for managing patient health more effectively.

Evidence increasingly suggests that making providers available via telemedicine channels can help better manage chronic conditions and avert needless hospitalizations, both of which, under value-based payments, are more important than getting a few extra dollars for a consult.

Looked at another way, the days of telehealth being a boutique service for more-sophisticated consumers are ending. “It’s time to treat telemedicine as just ‘medicine,’” one physician consultant told me. “It’s no different than any other form of medicine.”

As reasons for treating telehealth as a core clinical service increase, barriers to sharing video and other telemedical records are falling, the consultant says. Telemedicine providers can already push the content of a video visit or other telehealth consult into an EMR using HL7, and soon information sharing should go both ways, he notes.

What’s more, breaking down another wall, major EMR vendors are offering providers the ability to conduct a telehealth visit using their platform. For example, Epic is offering telemedicine services to providers via its MyChart portal and Hyperspace platform, in collaboration with telehealth video provider Vidyo. Cerner, which operates some tele-ICUs, has gone even further, with senior exec John Glaser recently arguing that telehealth needs to be a central part of its population health strategy.

Admittedly, even if providers develop a high level of comfort delivering care through telehealth platforms, it’s probably too soon to rely on this medium as an agent of change. If nothing else, the industry must face up to the fact that telemedicine demand isn’t huge among their patients at present, though consumer plays like AmWell and DoctoronDemand are building awareness.

Also, while scheduling and conducting telemedicine consults need not be profoundly different than holding a face-to-face visit — other than offering both patient and doctor more flexibility — working in time to manage and document these cases can still pose a workflow challenge. Practical issues such as how, physically, a doctor documents a telehealth visit while staring at the screen must be resolved, issues of scheduling addressed and even questions of how to store and retrieve such visit records must be thought through.

However, I think it’s fair to say that we’re past wondering whether telemedicine should be part of the healthcare process, and whether it makes financial sense for hospitals and clinics to offer it. Now we just have to figure out where and when.

E-Patient Update:  Registration Can Add Value To Care 

Posted on August 15, 2016 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

For those of you who end up seeking care in hospital emergency departments now and again, the following will probably be familiar. You’re spending the precious few minutes you get with the ED doc discussing your situation, having a test done or asking a nurse some rather personal questions, and a hapless man or woman shows up and inserts themselves into the moment. Why? Because they want to collect registration information.

While these clerks are typically pleasant enough, and their errand relatively brief, their interruption has consequences. In my case, their entry into the room has sometimes caused a nurse or doctor to lose their train of thought, or an explanation in progress was never finished. As if that weren’t irritating enough, the registration clerk – at least at my local community hospital – typically asks questions I’ve already answered previously, or asks me to sign forms I could easily have reviewed at an earlier stage in the process.

Not only that, there have been at least a couple of situations in which a nurse or doctor was so distracted by the clerk’s arrival that some reasonably important issues didn’t get handled. Don’t get me wrong, the skilled team at this facility recovered and addressed these issues before they could escalate, but there’s no guarantee that this will always happen, particularly if the patient isn’t used to keeping track of their care process.

Also, given that alarm fatigue is already leading to patient care mistakes and near-misses, it seems odd that this hospital would squeeze yet another distraction into its ED routine. At least the alarms are intended to serve as clinical decision support and avoid needless errors. Collecting my street address a second time doesn’t rise to that level of importance.

Of course, hospitals need the information the clerk collects, for a variety of legal and operational reasons. I have no problem signing a form giving it permission to bill my insurer, affirming that I don’t need disability accommodations or agreeing to a facility’s “no smoking on campus” policy. And I certainly want any provider that treats me to have full and accurate insurance information, as I obviously don’t want to be billed for the care myself!  But is it really necessary to interrupt a vital care process to accomplish this?

As I see it, verifying registration information could be done much more effectively if it took place at a different point in the sequence of care – at the moment when physicians decide whether to discharge or admit that patient.  After all, if the patient is well enough to answer questions and sign forms while lying in an ED bed, they’re likely to remain so through the admissions process, and verify their financial and personal information once they’re settled (or even while they’re waiting to be transported to their bed). Meanwhile, if the patient is being discharged, they could just as easily provide signatures and personal data as they prepare to leave.

But the above would simply make registration less intrusive. What about adding real value to the process, for both the hospital and the patient? Instead of having a clerk gather this information, why not provide the patient with a tablet which presents the needed information, allowing patients to enter or edit their personal details at leisure.

Then, as they digitally sign off on registration, it would be a great time to ask the patient a few details which help the facility understand the patient’s need for support and care coordination. Why not find out, before the patient is discharged, whether they have a primary care doctor or relevant specialist, whether they can afford their medications, whether they can get to post-discharge visits and the like? This improves results for the patient and ties in with a value-based focus on continuity of care.

These days, it’s not enough just to eliminate pointless workflow disruptions. Let’s leverage the amazing consumer IT platforms we have to make things better!