Digital health tools and data have the potential to propel America’s beleaguered healthcare system into a value-based care environment.
The challenge comes in aligning incentives with workflow.
That’s not an easy road to travel.
New technology that promises but doesn’t deliver, data that can’t be verified as accurate, a reluctance at the federal level to approve or reimburse digital health platforms, and a general wariness among the healthcare community to accept new ways of doing things have combined to slow the pace of mHealth and telehealth adoption.
But advocates say the benefits outweigh the challenges.
"We in healthcare know that there are always drawbacks to technology,” Susan Peiffer, chair of the American Society for Quality’s healthcare division, said in remarks accompanying the ASQ’s September 2016 release of a healthcare quality improvement survey. “While not a panacea, technology can help engage patients, increase access to care, help improve safety, and make data collection easier.”
The survey of more than 170 quality improvement professionals in healthcare found that 80 percent see improved workflow efficiency as the key to new technology implementations, and more than 70 percent see digital health tools as having the most impact.
The top hindrance, according to the survey, is resistance to change from staff and physicians unwilling to learn new skills or fearing that the technology will impede their workflow; some 70 percent of those surveyed said that would be “very difficult” to overcome. Some 64 percent expressed concerns with the cost of new technology, and 61 percent cited complexity, poor integration and the fear of patient errors caused by “haphazard introduction of new devices.”
Peiffer, a performance improvement specialist at the Wisconsin-based Hospital Sisters Health System, said those barriers will fall as providers become more comfortable with digital health.
"Just as technology continues to evolve, we will continue to improve how we use technology and how we integrate it into our interactions with patients," she said.
QUALITY OUTSIDE THE HOSPITAL SETTING
Healthcare providers are finding great value in connecting with patients outside the brick-and-mortar confines of the doctor’s office, clinic or hospital. And in this fast-paced, mobile environment, it’s all about the quality of the data.
Physicians are looking for data that enables them to keep track of their patients at home. They might want to know what a patient is doing in the days or hours leading up to surgery, or they’re keeping track of someone following discharge. Perhaps they want to monitor someone with a chronic condition, or they want to know how the environment – physical and social – plays into a patient’s ongoing health and care management.
In years past, a doctor would depend on the patient relaying that information. But with the advent of mHealth devices, that data can be captured electronically and sent to the care provider, who can then review that data, determine whether a care plan is working and make adjustments to improve that plan and keep the patient from suffering an adverse health issue.
The examples are endless. A doctor can monitor a diabetic patient’s blood sugar, insulin intake, diet, exercise, sleep patterns, even moods through connected devices. The same goes for patients with heart and breathing issues, those recovering from medical procedures, those undergoing treatment for disease like cancer and Parkinson’s, even those dealing with mental illnesses or addictions.
“Obviously you want information that is legally valid – you don’t want to be making some major medical evaluation on something that is flimsy,” says, Dr. Richard Milani, MD, chief clinical transformation officer at New Orleans-based Ochsner Health, one of the first health systems in the country to integrate mHealth devices into care management. “In the healthcare space, you have to have a higher level of reliability.”
“But that doesn’t mean the Fitbits and other (devices) don’t have value,” he added in a 2015 interview. “You can look for trends, and you can learn from these devices” in ways that promote and improve patient engagement. “They are a platform, and they’re being used by individuals who are thirsty for the ability to manage themselves.”
The challenge lies in making sure the provider gets the right data, and data that is accurate. Providers have been slow to accept consumer-facing products like fitness bands, smartwatches and sensor-embedded clothing because they don’t trust the data coming from those sensors, and inaccurate data could lead to ineffective or even dangerous treatment. Likewise, those devices require the user to collect and decide to send that data to a provider.
Instead of consumer-grade data, providers are looking for medical-grade data. That information is taken directly from devices and transmitted through the cloud to the clinician. The patient plays no part in that transfer of data, so the clinician knows the data is reliable. The challenge, again, is in finding devices that can capture and transmit accurate and reliable data.
“(I)f you're going to make life-and-death decisions, you're going to want to use a medical grade solution,” James Mault, Qualcomm Life’s chief medical officer, pointed out in a 2015 interview.
That said, providers are also interested in what the patient has to say, and patient-reported outcomes often give them valuable insight into how a patient perceives his or her treatment.
Patient-reported outcomes “have become more important than ever before,” says Jason C. Goldwater. MPA, MA, senior director of the National Quality Forum. He sees information collected from wearables, home devices and even social media as “a huge repository of data” that can help providers shape how they care for their patients.
And that data has value. Goldwater says an engaged patient is ten times more likely to comply with a doctor’s care plan, including adhering to medication protocols and following a more healthy lifestyle.
Once that data is collected, it has to be filtered through the patient’s medical record, so that the clinician receiving it knows it has value and can apply it to the patient’s care plan. Here lies another common roadblock – too much data coming in, not enough filtering taking place, leaving the doctor overwhelmed with information he or she doesn’t need.
“EMRs capture everything that happens within the hospital,” says Roy Schoenberg, MD, CEO of telehealth vendor American Well, whose latest efforts have been in integrating remote monitoring solutions at home with electronic health record platforms in the health system, “while telehealth has been designed to capture everything that happens outside the hospital. There is a recognition now that these two sides have to integrate.”
Remote monitoring, then, requires a set of checks and balances to achieve value for the clinician. The devices in the home have to be accurate and reliable, the data has to be reliable and directly related to the patient’s care plan, and that data has to be presented to the clinician in such a way that he or she can quickly interpret and apply it to the care plan.
If all works out as planned, those mHealth devices give the clinician a more complete picture of the patient at home, and that data can be used to refine and improve not only the care plan by the patient’s overall health and wellness. Adverse medical issues are reduced or eliminated, expensive medical treatments are avoided, and the doctor is free to focus on timely and important treatments.
This, in a nutshell, is quality-based care.
QUALITY INSIDE THE HOSPITAL SETTING
Digital tools and data within the confines of the healthcare institution serve a slightly different purpose: they’re clinician-focused, rather than patient-focused. They target communications, collaboration and workflows, and are designed to make the clinician’s job run more smoothly.
Digital communication tools make up the lion’s share of the mHealth platform inside the health system. Where once a doctor or nurse might be equipped with a pager, a couple phones and a hard-earned knowledge of every available nurse’s station and PC within range, one smartphone or similar device can now accomplish all of those tasks – and more.
Today’s enterprise communications device enables clinicians to receive and automatically sort through urgent messages and pages, connect with other members of a specific patient’s care team, call up a patient’s medical records or other information, schedule tasks and appointments, look for or engage in consults, and – of course – make a phone call. Some devices can even allow nurses and other care team members to search for medical instruments or other inventory, check on the availability of a doctor, restock supplies or alert housekeeping.
“The strategies are evolving,” says Gregg Malkary, managing director of the Spyglass Consulting Group. “Hospitals and health systems are finding that you can do a lot more on a platform with a common workflow engine that just communication. Care coordination means a lot more these days.”
“While initial deployments are often limited to support clinical messaging between nurses and their support staff within targeted medical departments, many organizations quickly expand the scope and usage models to include all hospital workers and workflows across medical departments, standalone hospitals and ambulatory environments and clinics,” he adds.
The idea behind a digital communications platform is to improve the literal workflow of a doctor or nurse, so that every phone call or trip down the corridor is meaningful, rather than a search for someone or something that wastes time and effort. An improved, smoother workflow means doctors and nurses are more productive, less stressed and more satisfied, and that in turn means their patients are better off.
“Mobile technology is transforming the way medical providers access patient information, communicate and coordinate care, as well as the way that patients acquire medical information and manage their health,” said C. William Hanson, MD, chief medical information officer at Penn Medicine, who co-authored a two-hospital study in 2016 that found a 14 percent reduction in patient hospital stays when staff used an mHealth platform instead of pagers.
The challenges, of course, are many. Access to more people, more channels of communication and more information means that clinicians can just as easily become overwhelmed. Communications devices have to be configured so that each user has access to the right people and functions, not every person or task available to the health system at large.
Aside from communications, digital devices within the healthcare setting also – like their counterparts outside the hospital – serve as platforms for collecting, channeling and disseminating data.
The most popular example is a smartphone or tablet with decision support capabilities. A doctor on the run can pull up information rather than searching out the nearest PC. A doctor or nurse can also use that platform to call up information to present to a patient, adding pictures, graphs and lists to the typical doctor’s orders.
And while the home is evolving into the so-called Internet of Things, the hospital or clinics is seeing its own transformation to the Internet of Medical Things. Wireless devices and monitors within the hospital can now transmit information directly into the patient record, enabling clinicians to call up that data at a moment’s notice rather than waiting for it to be compiled.
In that sense, mHealth is working to make the electronic health record a dynamic tool for patient care, by streaming in vital data at or as close to real-time as possible. When clinicians have access to that data at the point of care, rather than waiting for it to be collected and doing the collecting themselves, they can make quicker, more informed decisions on care management.
TAGGING AND QUALITY
Digital technology is also giving new meaning to mobility. Resources in the hospital, ranging from wheelchairs to crash carts, are tagged so that staff will always know where they’re located and can position them where they’re most likely to be used, or find something in an emergency. Inventory can also be tracked and restocked more conveniently, while medications can be monitored to determine who’s using them and how often.
The same goes for people. Doctors and nurses can be easily located by their tags in case of emergency, as can patients, especially those in danger of wandering off. Pediatric units are now tagging their patients for safety and security, while staff can use their tags to quickly summon help when dealing with an unruly patient or one in distress. And mothers, fathers and their newborns are fitted with tags so that moms are matched with the right children and dads can point out the right crib in the nursery.
The value in tagging and tracking resources and people can be summed up in a simple concept: Traffic control. By studying traffic patterns, hospital administrators can learn how to improve processes by positioning supplies and people where needed and cutting out wasteful patterns and activity. Such studies are also useful when renovating or redesigning a hospital or clinic or building a new structure. Ease of access and comfort can go a long way toward making a healthcare setting more valuable for both the people working there and those visiting.
THE VALUE OF MOBILITY
When digital health tools first entered the healthcare space, advocates said they’d improve the healthcare process by removing geography as a roadblock. Gone are the days when a clinician would have to wander the halls of a hospital to look for a nurse, a colleague or information, or wait for the patient to come into the office to gather vital signs or learn what happened in between visits.
With value-based healthcare, mobile platforms are pushing the needle on quality. They’re giving clinicians access to information they didn’t have before, enabling them to make more informed decisions on care management and coordination inside and outside the hospital. And doctors and nurses are using these tools to improve their own workflows.
They’re also bringing the patient into the healthcare equation. Clinicians are using this new information to better inform and educate patients, and to collaborate with them on health and wellness plans that extend outside the doctor’s office and into the home.
“They will work with the patient, not just for the patient,” says Garth Graham, MD, MPH, president of the Aetna Foundation and a strong advocate of digital health and quality-based care. mHealth “empowers not only the patient, but the doctor."