Telehealth updates

Telehealth Updates – Are You Doing Enough?

A couple of great articles discuss examples of Telehealth programs being run by large medical centers, as well as where the state of policy is today and what might be coming from Medicare.

The Sept/Oct edition of  Health Data Management has a fairly in-depth story on specialty related telehealth programs already operating at UPMC, and an interesting section on the “bricks and clicks” primary care options at Stanford.   You may be surprised to learn that UPMC has 62 telemedicine related services!  They have taken the plunge, even in advance of fully monetizing the services, because they recognize it extends their reach, patients love it, and the evolving value-based payment landscape is building an ever-stronger business case.

Health Affairs in August published a terrific summary of the state of affairs in laws and regulations Health Policy Brief Telehealth.

Some key points:

Medicare is the laggard here.  There is some hope that they will modernize – Congress is considering the Medicare Telehealth Parity Act, but we all know how the wheels of change move (or don’t) in that body.

Currently, Medicare only reimburses for synchronous communications for the 20% of patients in rural areas, and the patient has to show up and receive the telehealth visit at an “originating site” – which is basically a healthcare provider of some sort. Neither remote monitoring, such as for CHF patients, or asynchronous communication – like email or store and forward photo and video services, are covered under Medicare today.

Strangely, Medicaid in many states is leading the way.  Levels of payment and types of services covered vary by state and both articles note that 49 states now cover at least some area of telehealth in their Medicaid programs.

A lot of advancement is being driven by consumer demand for convenience care, and employers are increasingly offering options, many times through free standing telehealth companies.

If you are a healthcare provider system – what are you doing to launch telehealth options in your organization?  As the system continues to evolve to value-based payment, the financial incentives are going to move in favor of telehealth, and groups that have taken the plunge in advance of payment reform will be better situated to benefit, and keep their patients.  Successful efforts require clinical leadership and workflow changes that must be thought through. Do you have a clinical leader who is a champion of this work?

Changing Clinician Behavior – Climbing the Mountain of Adoption

Changing Clinician Behavior – Climbing the Mountain of Adoption

Physicians and other clinicians are just as prone to challenges in changing behavior as the rest of the human race.  A recent study Applied Clinical Informatics Article  from Kaiser demonstrated that clinician behavior in adoption of a new clinical decision support tool (CDS) was much more likely when a couple of things were present:

  • A clinical champion at the site who provided active onsite promotion of the tool, talking it up and answering questions and challenges
  • Incentive gift cards for the first 3 uses of the CDS tool (they measured use far beyond these first 3 times)

The challenges in knowledge transfer in healthcare are well-known.  This is a complex issue, and goes beyond the idea that if healthcare technology is as easy to use as an iPhone, then adoption will just happen.  I agree with this to a certain extent, but:

I also think changing well-worn clinical care behavior and habits is very similar to the overall problem of changing our most difficult behavior patterns, like eating sugary snacks when we’re stressed.     

Charles Duhigg in The Power of Habit describes that we need 3 components of the habit circle:

Cue – what trips the behavior – in this case, uncertainty in patient treatment decision

Routine – what is the behavior we want to engage in – use of the CDS tool

Reward – could be several things – reassurance on the right clinical path with patient, resolution of uncertainty, gift card…

You also need to understand this loop for existing habits, and determine how you will insert the new behavior when the old cue happens.   This takes thought and discovery, and is a critical part of understanding clinical workflows, just as much as destructive habits.

If you are designing a pilot for your product, or leading an internal initiative to change clinician practice and adopt new tools, these are useful and important concepts to consider as you design your work.  I believe pilots and projects will be more successful if we account for the power of clinician habit, and built in component to address the 3 parts of habit formation.

State of Telehealth – Key Trends and Challenges

State of Telehealth – Key Trends and Challenges

Telehealth adoption is accelerating rapidly, but much controversy remains over the best ways to do this, with clinicians often divided in their feelings about this trend.  A recent article in the New England Journal of Medicine describes where the US is in the adoption and utilization of telehealth, and identifies 3 trends we (whether physician, administrator or patient) should take note of in this rapidly developing area.

3 keys trends in healthcare and in telehealth that we intellectually know are occurring, but may forget about in the day to day: 

  1.  Moving from focus on access to care, to improving the convenience and lowering cost, if not for the health care system, at least for consumers (in reduced time away from work, parking, childcare…).
  2. Increase in use for chronic conditions and monitoring, not just acute issues.  This will be a huge boon to patients, and I expect research will soon show that systems adding this option to their repertoire have better outcomes
  3. Moving care from the hospital into the home, a good idea all the way around

You could get bogged down in this article in the sections on all the limitations facing adoption of telehealth – legal, reimbursement, clinical quality questions, workflow, the digital divide for rural, poor and elderly, but I urge you to read past that.  The upshot of the article is that we are on the cusp of solving a lot of these limitations, and we should NOT forget that there are large limitations and downside of our current state of healthcare.  By 2020 it looks like 90% of the world’s population will own a smartphone – that’s a little more than 3 years from now.  The digital divide is closing fast.

It comes down to pragmatic approaches to solving these problems and making them work for both patients and providers in a high – quality way.

Understanding Analytics with Go Healthcare Strategy

Workflow is key in use of analytics

I have been in multiple situations this week where teams have had Ah-ha! realizations.   That realization is – you can have a terrific set of information from an analytics package, but the key step to a good outcome is using that information in an effective workflow.

Key questions for refining your workflow to use analytics:

  • Is there an existing workflow that will use the information created? Or does something new need to be created?
  • Will that workflow need to change because you’ve learned something new in the analysis?
  • Can the team use the information in a timely fashion, or will delays end up making it a wasted effort because the data will be outdated?
  • How will you measure whether the workflow is having the intended impact?
  • Are there still data gaps that you need to fill so those doing the work have what they need?

Here’s an example: 

An ACO wants to increase adherence to diabetes and cardiac medications to improve clinical outcomes and decrease costs. There are a number of great packages out there that allow you to target patients for contact around their compliance.  The effectiveness of these packages ultimately depends largely on how the information from the analytics implemented.  Your workflow must be effective and timely.

So – everyone involved in this medication compliance process needs to think through the above questions.  Lots of challenges can be prevented up front through clear communication, asking lots of questions and thinking through the steps required to get to your end goals.

Precision Medicine, Big Data, and Rare Diseases

Precision Medicine, Big Data, and Rare Diseases

I just read a transcript of President Obama’s remarks last Friday about the Precision Medicine Initiative.

I think it’s important that the clinical community pay attention to this, regardless of your political persuasion, understanding or awareness of precision medicine, or feelings about big data in healthcare.

Here’s what spoke to me:

  1. The hope is that for those people with rare, incurable and fatal diseases, we now have techniques that will allow discovery and research for those issues where a randomized trial is never going to be possible.  One of the guests at this news conference was a woman named Sonia Vallabh – who has the gene for Familial Familial Insomnia – a fatal prion disease from which her mother passed away.  She now devotes her life to research in this area and is hopeful that through genomic studies, big data and patient willingness to share their data, a cure can be found before she feels the effects of this disease.   Read her story here: Sonia’s story 
  2. Open Data – as people, we can help by understanding and being willing to contribute our health data to research efforts, with appropriate protections and safeguards.  We need better systems to enable this to happen.  This is part of what the Precision Medicine Initiative is working to enable.
  3. Precision medicine does NOT replace the need for access to basic healthcare – let’s be clear about that.  We CAN do both.

Is your institution thinking about how to be part of this, or at least studying how this will affect your role in healthcare in the future?  We don’t know how this will all turn out, but things are guaranteed to be different.  Proactive healthcare providers, health IT firms and others will only be better prepared for the future by paying attention to these efforts, rather than thinking this is still far off in the future.

The importance of Online Appointing with Go Healthcare Strategy

Mobile Apps: Why It’s Hard To Launch Online Appointing

In a recent post I referenced the Accenture report showing that healthcare systems mobile apps do a very poor job of meeting patients top three requirements. One of those top three requirements is the ability to book cancel or change appointments online. Their statistics show that only 8% of provider apps allow existing patients to book online, and only 2% of them allow new patients to book online.

As a patient, I totally endorse the need for this capability. I can do it with my hair stylist, with my vet and other providers, but I can’t to do it with my current doctors.

That said, this is a loaded issue for doctors. One thing that many on the technology side of the industry often aren’t aware of are the operational details that go into making it possible to effectively book online. The requirements for this are a huge change management project within large practices.

One of the only ways that providers can feel a sense of autonomy and control of their professional lives is to have control of their schedule. This has led to the majority of clinicians wanting to set up their schedule in a way that meets their needs, which often doesn’t align with goals for standard schedules. The discussion in practice groups about implementing this technology often gets testy, and a root cause of that is the fear of a loss of autonomy.

I’ve had an experience with ZocDoc for my dermatologist – which allowed booking of a new patient appointment online. It was fast and easy to find an appointment time which worked for my schedule, without having to spend time waiting on the phone. It all seemed quite easy, but then I very quickly got a call back from the office saying that that appointment that I’ve selected wasn’t actually available, and we had to reschedule. An example of the operational details being just as important as the usability of the app!

Embarking on this aspect of launching mobile apps in your system will require sensitivity and understanding of these issues.

Mobile Apps with Go Healthcare Strategy

Mobile Apps: Bringing Providers and Marketing Together

A study was published last week by Accenture where they collected some good solid data showing that hospitals and providers are not meeting patient needs with their current mobile apps. A lot of hospitals have created mobile apps, but a stunning percentage of them don’t meet the needs of patients. The three top features that patients want are the ability to work with their providers and have access to their medical record, book or cancel appointments, and pay their bills. Overall, they calculate hospitals have engaged less than 2% of their patients with mobile apps.

I think one of the root causes of this is the disconnect that often exist between the marketing department and clinical leadership in healthcare organizations. All too often they function in separate silos.  I experienced this first hand a few years ago in when my earlier organization was pushing to go mobile. We had significant effort to work through to join what marketing felt were big requirements for mobile, and our clinical informatics goals to provide patients access to their medical records and expand on the extremely popular web presence for clinical care. As CMIO at the time, I was frustrated by what I felt was the lack of understanding of what patients had clearly stated that they wanted.

However, I learned a lot about marketing in the process, and developed a great respect for the techniques used in marketing to nudge people and cause them to take action. These are techniques that can work equally well in moving people forward to make the right health decisions. Now I believe that it is also clinical leaders responsibility to learn and understand and incorporate some marketing techniques into how we work with patients.

There’s a lot to be gained from incorporating marketing principals in clinical approaches and a great place to start is in beefing up or launching mobile applications that will combine marketing and clinical goals. The entire system will benefit if you can create something that is both useful to help patients with the clinical and financial aspects of their care, and creates an awesome customer experience to bind them more closely to your system. Starting the dialogue is the first step.

HIE improves patient care- Go Healthcare Strategy

HIE – Traveling the last mile into operations

The world of ACOs and value based care for populations requires sharing of information across systems. It is not common that patients get all their care in one clinical system, even with models such as Kaiser’s. This is exactly what has given rise to Health Information Exchanges, or HIE’s, both public and private. Lots of good technical progress has been made in this arena over the past 20 years, but my experience has shown that the real last mile, even with great technology, is getting use of HIE tools into the real day to day of clinical practice and operations.

It continues to surprise me how many times clinicians or staff say things like: “It’s really no problem, I can have my medical assistant call and get a fax of the discharge summary.” I think part of the challenge in driving adoption is changing the expectation of the status quo. We forget about this at the leadership level sometimes. We cannot underestimate the challenge of changing deeply ingrained behavior.

Clinical leaders must take the time to work with the IT staff who are tasked with learning about and implementing HIE capabilities. Clinical leaders are the only ones who can state what the clinical benefits will be, both on individual patient basis, and to the organization as a whole.

Front-line clinical staff need to be engaged to determine what needs to happen within clinical workflow to adopt and use new HIE functionality. Only then can an adequate training and communication plan really be put forth for the organization.

Often I have seen that implementing HIE is viewed by clinical teams as a purely technical problem, and then the project becomes a failure when it is “connected” but not “used”.

We WILL get to a place in the future where new functions appear as easily as they do on our Iphones, and I am optimistic that I will see this during my career, but it is not the case today. So, we have to step up as clinicians and clinical informaticists to drive adoption of functions that clearly improve patient care.

If you or your teams don’t have the time or expertise, bring in knowledge from outside. Folks experienced in this area can help you understand, communicate and use new HIE functionality. This will save lots of time, and potential lives, in the long run.

Together with Analytics and Go Healthcare Strategy

Building New Analytics Programs – Getting the Buy-In to Succeed

One of the biggest challenges in building an analytics organization within your business is framing it so that both leaders and front line teams understand what the goals are, and buy in to help bring it to life. You may be doing this because, as with many businesses, you realized that although there is information at hand, it often is conflicting and causes the organization to dissolve into arguments about who is “right”. Or, it is really hard to get answers to “urgent” questions to make a good decision.

These are all laudable reasons to move into a more robust analytics approach, but you have to think about the change management that will go into making this successful. You will be “moving the cheese”, and some people will naturally feel threatened by this new way of doing things.

Most organizations have built up data “silos” over time, in the natural desire for speedy answers. It’s important as an executive to understand that the people who have built these databases, reports, etc. take a great deal of pride in their work and have met a need over the years, and often been publicly rewarded for doing that work. When suddenly there is an organizational change that says this hasn’t been enough, it is disconcerting. If not handled correctly, the hurt and anger produced by this process can manifest itself in harmful ways that will derail your best efforts. You need to engage them so you don’t lose critical business knowledge or specific data knowledge. Also – the challenge of finding talent – given the immense competition for qualified folks in analytics these days, your best option may be to train from within, so you don’t want to burn bridges with your talented people.

While you, as the executive, want to move fast and make things happen, this desire can put you at greater risk of failure in the long run. The smarter course is to take the time up front to clearly define the why, what, when and who of your analytics initiative, and then spend even more time on socializing and communicating about it. Only then will you get a majority of people on board to make it happen.

Doing this work can involve painful conversations. It can often be helpful to bring in a neutral party to facilitate this work who also brings experience and guidance to the table, and can help you avoid the mistakes of others.

Most importantly, remember that everyone is there to do good work – when the definition of what “good” work is changes, it’s time for lots and lots of communication!

What if our medication profile followed us, like our credit score?

Over the years I have experienced the pain of poor access to healthcare data both as a physician, and as a patient. This was brought into stark relief for me over the past couple of weeks, as I dealt with the process of getting approved for a specialty drug for treatment of rheumatoid arthritis. The process actually reminded me of applying for a mortgage, so I am going to contrast them here.

I’ve had RA for 15 years. Over that time, I have been on numerous medications, some good, some not so good. When I started on this journey, it never occurred to me that I would have to provide information on my reactions and response to a medication at a time that would be more than 10 years in the future, to get my future insurance plan to be willing to cover some fraction of an as yet undiscovered medication. Yet, for people who have longstanding chronic diseases, this is what we ask of them, without giving them adequate tools to track this over years.

The process of questions and consideration from the health plan or pharmacy benefit manager, which often asks about treatment information from years ago, is called prior or pre- authorization. It is one of the most painful aspects of practicing medicine in the US, as it requires navigating a health plan process that is not set up for customer friendliness, and often requires the physicians have information that is never spelled out up front, and frequently changes. Usually there are back and forth phone calls by their staff to the insurer, then to the patient, then back.

It is even more painful for patients, as they wait to determine if their doctor’s recommendation will be covered, and then, for just how much.

Fortunately, I did have the presence of mind to get printed copies of my records each time I moved and changed rheumatologists. I am able to produce a list of medications I have taken over the years, when I took then, when I stopped them, and what happened with each. This is not well represented in structured data anywhere in my multiple medical records. All of my rheumatologists have been diligent in getting this information, but it is buried in text, and only recent prescriptions since the advent of e-prescribing are in electronic form. BUT, even in the EMR, it is not possible to adequately represent what happened with each. An adverse reaction or side effect is not the same as an allergy – the blunt instrument of how EMRs allow one to document this information.

Contrast this with the student loans I took out in the early 1990s. My bank has that info, (I paid them off on time, happily) and I do not have to produce that information each time I apply for a mortgage. (Mind you, I am NOT saying the mortgage process is painless!). I have had to correct some information in the past, for sure, but the bulk of my lifetime of financial history follows me wherever I go, without effort, for better or worse.

We need to automate this process! We need the technical capability to create good longitudinal profiles of our medication use, more nuanced history of how we react (bring on personalized medicine!) and use this to make all the administrative hassle much easier and automated for all involved. I look forward to seeing how healthcare technology vendors, insurers and providers can work together to make this happen. Patients (we will be patients someday) need it.