Many health systems are trying to figure out how to make it easier for their clinicians to prescribe digital health applications. Brad Crotty, M.D., chief digital engagement officer for the Froedtert & Medical College of Wisconsin Health System, is leading his organization’s efforts to build up a digital health formulary.
The Milwaukee-based network includes five hospitals, nearly 2,000 physicians and more than 40 health centers and clinics. Froedtert is both an investor in and customer of Xealth, the digital health platform that spun out of Providence Health. “That investment speaks to what we believe about this — that it's going to be hard to integrate all of these point solutions into the EHR,” Crotty said. There's still work that's required from the EHR teams — whether it's an interface team, or the interoperability team or even the orders team — but we can dramatically reduce it by having everything go through a third-party platform like Xealth.”
Crotty explained that Froedtert has extended the concept of a prescription formulary into the digital health space. One digital health tool it has experience with involves diabetes care. Glooko is prescribed to patients by their medical provider through Xealth, enabling providers to increase their visibility into how patients are managing their diabetes. Patients receive a better understanding of how their body is interacting with food, exercise and medication such as insulin as well as a deeper connection with their care team.
Froedtert has created decision support tools in Epic around recommending such a service. “If someone met the criteria and they were on insulin and had an A1c that was not well controlled, this would be identified as something that they may want to consider,” Crotty explained. “Similarly, for depression screening, we rolled out SilverCloud for digital behavioral health. When we went enterprise-wide with depression screening, if a person scored three or above, we would tell them they may want to consider SilverCloud. They could just click a button and get their order placed for that.”
I asked Crotty if data flowed from these digital health apps directly into the EHR. “We're being a little bit picky about what data actually get written back into electronic health record,” he said, “because some of it is likely to be noise. With Glooko, for instance, we're not writing back every single glucometer reading. We're writing back an element to the EHR that basically says: this is when this person started this program, and they're affiliated with this program. The clinician can see what the vendor provides in a summarized view, with the ability to drill down into that over time, but we're not recreating the summaries or the raw data in the EHR, in the form of flow sheet rows, which, honestly, is not super helpful.”
He said they will ask the app vendors for some documentation or snapshot of a program, particularly when someone completes a program, to be stored in an EHR or available as part of the legal health record. “But for the most part, I paint the analogy to what people are doing offline. If someone brings their glucometer book and readings, we flip through it, we make a clinical decision, we document the clinical decision, and we move on. We don't Xerox every single page of their log and scan it into the EHR.”
So far, the apps Froedtert is using are free to the patients. “We've tried to really not get too bogged down in payment issues,” Crotty said. “We don't expect any patient payment for these digital tools. We want to get people more digitally engaged; we want to get people more digitally connected to us. We believe that if digital health is successful at helping people manage and address their health needs better in the home on their own time, that will eventually set us up for value-based care. We're taking the friction out and really trying to get the cultural change and the buy-in from both patients and clinicians. We're not having to worry about the payment on the front end. We are considering where this fits in with particular parts of a pay-for-value approach that we're exploring, including concepts around remote patient monitoring.”
I also asked Crotty how they evaluate which digital to deploy. “We figure out what problems we have to solve, and then we look to see if there is a digital tool in that space,” he explained. “We'll look to see if it's one of the list of 40 already integrated with Xealth, which is a good start for us. We've made the business decision that because of the investment that we've made in the Xealth platform, any digital tool we are going to add really needs to be integrated into Xealth or have that on their roadmap. Because even if things say that they are in Epic’s App Orchard, there's still integration work to be done. So we just say please integrate into Xealth.”
Crotty said Froedtert has been adding to its portfolio. “We have Babyscripts as part of our digital health formulary. That's our program around maternity care. We have expanded our use of SilverCloud beyond depression and anxiety. There are several other use cases.”
They also have deployed GetWell Loop, a digital care management software that automates patient engagement follow-up care. It is used for different episodes of care such as joint replacement surgery. “We also rolled that out automatically for all COVID-19 patients last April,” Crotty said. “We’ve had a full year of doing this. If someone has a COVID-19 diagnosis, we automatically enroll them in GetWell Loop and we have a centralized nurse monitoring team that reviews all of those. They’ve used that to manage thousands of people. We've also been doing this around post-discharge. So if someone's discharged from the hospital, we follow up with questions like: Do you understand your discharge instructions? Did you have a follow-up appointment? Or did you talk to your primary care provider? Are you better than when you came into the hospital or are you worse.” That gets escalated to a care coordination program if necessary.
Going forward, Froedtert is working to make the process of signing up for some apps more self-service. “We are looking at automation as a way that we can have people get what they need without having it be behind the counter, if you will, for many of these educational, low-risk types of things,” Crotty said. “Xealth creates accounts for people automatically, so it takes all the friction out of signing up for an account and basically gives people an e-mail that enables them to activate.”
One goal, Crotty said, is to share lessons learned with other health systems also using Xealth. “We're going to try to move into a space where we can reap the rewards of the network effect and look at implementing other tools that others have used,” he said. “For instance, we're looking at physical therapy and we're rolling out MedBridge, which was already on Xealth.”