As promised in the Viewpoint section of the March 2014 issue of HealthManagement Technology, I plan to follow the progress of the newly launched Mississippi Diabetes Telehealth Network. Below are transcriptions of two interviews I conducted to establish the purpose and the thoughts that went behind the initial planning of the project.
The first interview is with Dr. Kristie Henderson, Director of Telehealth at University of Mississippi
Medical Center (UMMC). The second interview is with Sean Slovenski, CEO, Care Innovations, and Ray Solone, Executive Director of Marketing, Care Innovations.
In May, I will post another update outlining the program in action.
Jason Free: How did you get this off the ground? How did you get these different people working together?
I kept seeing all these press releases where companies were testing telemedicine in large cities and metropolitan areas, or even in other countries, hoping to develop and test a different delivery model using this emerging technology. I felt most of these projects were interesting, but they also seemed to occur in places that did not possesses the level of acuteness we have in our state.
I am very active in the American Telemedicine Association, so I had a series of conversations with different vendors about this point. Every time I would talk to a vendor, I would say that Mississippi is where you need to test your clinical delivery models. If you can overcome the challenges Mississippi has with the worst outcomes, poverty, challenges with work force, then you can do it everywhere. This is about as bad as it gets in the Mississippi delta.
It was also a challenge to aligning the public/private partnership needed to execute a program. Our governor [Governor Phil Bryant] has been a huge supporter of telehealth, and he is from Sunflower County in the Mississippi Delta. On a side note, last year, he helped sign into law the legislation for parody telehealth reimbursement We were the sixteenth state to do that, not the last as we too often see.
I have, on a routine basis, been communicating our vision and strategy to as many people as possible. It’s not just about specialty care, but it’s really about trying to reach better health outcomes and to illicit the behavioral changes in our patients we want to see. Which we do, and we are really proud of, but we thought there needs to be more done in the delta.
Fast forward ahead many months, and General Electric was meeting with the governor, and then subsequently with us. This partnership started aligning, and we began to make plans to go to Sunflower County Medical Center. They’re very innovative in how they run their hospital, and they are trying hard to turn that community around. They have done other telehealth projects with us, and oftentimes when I have pilot projects, I go there. It’s a great place for me to test because of the challenging circumstances you see there. So we went to them and, of course, they were on board. Over a series of many months, we created many committees, trying to decide what the program would look like and how the telehealth technology would fit in. In the end, we created our current model.
JF: Your plan is to begin in the delta to address diabetes, but you aim to go beyond the region, as well as address other diseases, correct?
KH: Yes. That plan was part of our initial discussions, and we hope to find the results we need to ramp up our efforts.
Everyone is so committed to the program, but we know if we are going to be able to scale this up and make a difference nationally, we are going to have to study it as a real research project and analyze the outcomes. All of us jumped in, threw our dollars in and threw our time and resources in. This decision to work together transpired along with a telecommunications company, C Spire Wireless, which said it will make sure that the connectivity to the homes and to the patients and to the clinic is there.
What I love about this project is that it truly shows you how, if you have the right strategic partners and alignment of all the governmental officials, public health, as well as the private and public academic medical center, you really can come up with a phenomenal project. We have always sought out new partnerships to confront diseases like diabetes, and now not only do we have a unique opportunity to do just that, but we are also in the perfect place for us to really test innovative models that can go beyond Mississippi. This project should deliver outcomes where patients are going to show improved health, and healthcare is going to come to them. We are going to be able to scale it to other diseases and other areas.
JF: Who are the primary private companies that are involved with this and what are the holes that they are filling?
KH: Care Innovations is a 50/50 partnership between General Electric and Intel. The tablet that we are going to utilize is called the Care Innovations Guide Platform. It actually has a diabetes management program built into it. Patients will be given these tablets that are from Intel GE Care Innovations and they will answer questions on a daily basis, upload glucose levels, vitals, etc. Then C Spire is going to provide the connectivity, meaning either cellular or broadband connectivity needed to connect everyone. They have a wireless division, as well as a broadband side of their company.
JF: This is all going through a cloud, correct? Is it part of your organization? Is it part of the Mississippi government? Whose infrastructure is this all taking place on?
KH: This is going on at our servers at the University’s Telehealth Call Center. We’re going to run our whole population management program out of that series of servers and we will manage those and make sure they’re secure and meet all the standards that are required. We’re the only ones with the capacity to do that, and that’s why it’s very important for us to take the lead of that. The University of Mississippi is the only state academic center for the entire state. We’re not here for just the Jackson metropolitan area, and we take that seriously.
JF: Have you ventured out and spoken to the potential patients yet? Have you gotten their input or their feedback on how they feel about this program coming into their life?
KH: North Sunflower Medical Center has owned the rural health clinic there, which is going to be one of our primary locations for enrollment in this project. When we came up with the 200 patient target, it was based on research we did through their existing diabetic patients. We started reaching out to them to see where their gaps were, and a lot of the patients couldn’t come in for their appointments, or they couldn’t get to Jackson for a specialty appointment, or they faced other challenges like that. We knew having the specialized tablet from Care Innovations and having internet access in their home would address these types of transportation issues. We also knew our portal in the tablet would be able to bring all the services of telehealth to the clinics and to the homes of our patients. We are going to bring endocrinologists, diabetic educators, pharmacists, entomologists, all those people that are needed for a real diabetes team approach. We also knew we were giving our patients the piece they needed to enter their daily information and we would be able to monitor vital signs, lab work results and everything else.
The first of April is when we start enrollment. We have some of the grass roots efforts in place. We are planning a big community fair. We are going to make it into a big deal. We cannot wait to announce it and educate the community when we start open enrollment.
JF: In terms of the patients and their custom tablets working with the healthcare clinicians, how do you plan for the project to operate on a day to day basis?
KH: The entire process will be individualized. We will customize the information and what they need based on reevaluation as we move forward. It’s not a cookie cutter approach. I think that’s very important to note. Education levels are very different, disease states are different, needs, the whole bit.
Each patient will have their initial visit at that clinic locally, where we will have the physician or nurse-practitioner there, pharmacist, dietitian, all those people to help set a care management plan for that patient.
The tablet is customized to that specific patient, so they’ll have daily questions where they’ll answer “Yes” or “No” and their glucose levels will be uploaded and that goes into a portal. That portal is what our telehealth nurses are monitoring, so that we can look for early trends and then push targeted information to address issues that we see occurring. It’s pushing education, but it’s also, if we see a trend that every afternoon this glucose level is up, we’re going to call them, talk to them, report back symptoms and the whole scenario to the provider there locally. Then we’re going to adjust things in real time, instead of them having to come back into the clinic. It may be “Oh, we need to adjust your afternoon.” Or whatever it may be.
There will be a constant, daily monitoring from our Telehealth Call Center here in at UMMC. We will communicate back to that clinic and its specialists involved in the team. There’s going to be weekly team calls with each case. It may vary in the time that it takes. (I don’t want to make it sound like I’m going over 200 patients every Monday.) We’re going to evaluate the trends and triggers and problems and issues and adjust people’s care plans on real time and have the whole team, that would normally only be offered to somebody in a metropolitan or academic center, in rural Mississippi, and adjust what information is pushed to them, how their treatment plan works, bring them dietitians, whatever it may be.
That will be on an ongoing basis and the communication and facilitation of all that is through the Telehealth Call Center here at UMMC.
JF: Given that you’re trying to build upon small successes and scale this up to not only incorporate more diabetic patients, but also patients with other diseases, what are you seeing as potential pain points or potential obstacles?
KH: Any time you’re trying to change a behavior, or to create lifestyle changes to be able to help control these diseases, you are going to encounter resistance. It’s not just taking a pill, or giving yourself an insulin shot. We feel very strongly that it’s a relationship, an accountability on our part, and motivating patients to be engaged enough to assist in their health. That’s not going to happen overnight, and we know that. We’re also assuming that these people want to be healthy, and so there’s some assumptions going into this. I think we’re going to have challenges in that this isn’t an easy task even under the most ideal conditions. It isn’t easy to change your diet. It isn’t easy to check your glucose three or four times a day, if that needs to be happening. It’s going to be us working with them and getting into the environment, understanding the social determinants that also impact health, that are so important in improving a patient’s health.
There’s a lot that we’re going to study in this research program. It’s not just about how many times they went to the ER. It’s going to be about their compliance. It’s going to be about weight management, and all kinds of things that impact their diabetes. It’s not easy to change a behavior and have it stick, but we’re going to work with these people, pooling our resources and doing anything else we can do to make those changes occur.
The good part is that constant engagement is more likely to occur through using the Care Innovation platform. We will more effectively determine the problems our patients are having. Maybe they’re not taking their medicine because they’ve got a side-effect. You wouldn’t know that in a seven minute visit that happens once a year. We’re going to know that information in real time, and we’re going to be able to help adjust things from our pharmacy perspective, all the way through all the clinicians on the team.
I think our biggest challenge is just going to be adoption, utilization and making people comfortable with the program. That’s part of our analysis. Did they adopt it? Did they use it? Does it make a difference? Is this the best platform?
We’ve been doing telehealth now for ten years. We’ve learned a lot about how to utilize the equipment and what makes sense, and how people have responded to it. We’ve incorporated that into our education and roll-out plan. While we say it’s an individualized program, we know from national studies all across the country what the challenges are when trying to manage diabetes. There are already some very solid education programs that we will utilize and we’re not going to recreate the wheel. We’re just pooling all these resources and trying to perfect the model to be able to tap into all of this for the Mississippi delta.
Jason Free: This project is very ambitious and it presents some very unique opportunities for innovation. Can give some background information relative to your participation with this project?
To your comment before about unique opportunities and that intersection where innovation actually occurs, I have a very fundamental belief around that. In my past experience, a lot of times in healthcare, and in any industry, but in particular in healthcare, people get stuck staying in their silos. Therefore, you get linear incremental improvement. You don’t actually get breakthrough innovation. A lot of times, solutions to your problems can be found in different industries. They have been applied to different situations, but the concepts still work. I think that was the fundamental impetus for our participation with this project. The State of Mississippi was really looking for something different and unique. They knew the answer didn’t exist today in the traditional, current configuration of products and services. So the state, and the university, really had to put together something unique and different to kind of shake the tree. We get to try for different results. We get to truly experiment.
This project really is a proof of concept pilot. If it goes well, there will be expansion. Going well means lots of things. Going well means you get a desired outcome. Going well also means you learn why you got the outcome. Also, what didn’t work so that you can make corrections? Having success and understanding the failures that might occur, and how you can make the next generation of whatever it is better, is a big part of this. We’re all trying to get to the right answers to care for these people and not just retreading old ideas.
JF: Let’s discuss some of the technical elements of the project.
SS: Speaking at a very high level, our cloud-based platform allows us to aggregate and integrate mounds and mounds of data collected from a whole source of devices; literally any device that someone may be using to monitor an aspect of their health in the home. We recognized early on that the pace of innovation in technologies is every five to ten years, it doubles or triples. It’s substantial.
There is such a rush to the home, so to speak, to figure out how to care for people in their homes. That pace of innovation is exponentially so. We knew being out there, trying to build devices, and trying to keep up with all the entrepreneurs in the garage who probably have better ideas than anybody, just didn’t make sense. So the real play is to understand the human being themselves. What actually engages them? What makes them want to do the things that make them better when they didn’t want to do those before? Then to be able to give them and their care professionals the ability to choose the right devices, the right educational materials, the right interventions and integrate all of those. A pieces- parts menu so to speak, but pull all the right parts together so you can build a custom cocktail for each individual that works right for them. Do that in a very time and cost effective way. Versus one device and one approach and trying to have a one glove fits all mentality, and that’s just not how human beings work. You’ve got to have a very tailored approach. That is what our platform allows you to create; this custom cocktail for each individual based on their individual needs. You can get very personal and very engaging.
Then, as for the interface itself, a lot of people don’t have access to the Internet, or, especially in certain age groups, they’re uncomfortable using computers and mobile phones and technology. So over the last seven years, Care Innovations has been working with senior citizens, and people of all ages, to figure out what’s the best way and the right types of devices to use when someone doesn’t have their own computer or doesn’t have something they’re used to interacting with. Can we give them something in their home they can interact with and that they will like to use? Is it unobtrusive and does it connect to all the peripheral devices we would need to use on a project like this?
Due to this work, our tablet integrates with all the different peripheral devices that will be measuring the different aspects of an individual’s health. It gives them the opportunity to have two-way communication with their care professional via video and other means. We tie that into any interfaces that we can use to help support the family caregivers as well.
JF: This tablet has to be used by many people, to be easily used more specifically.
SS: That’ correct. One of the things that we recognize is that the family caregiver, the spouse of the patient, maybe the adult child of the patient, maybe the neighbor of the patient, they have as much influence, if not more, on that individual getting better. They have to follow through on what that patient does, and, quite frankly, as the care professional does as well. So our guide product, our tablet, is a simple, easy to use all in one, open the box, press go and it just does it for you. It gives the nurse professional the ability to make adaptations on the fly, to push educational content, to rout, to monitor, to switch out devices if they need to. It gives a lot of on-the-fly customization and personalization. We think that is going to be the key to the success of this project.
The data is going to show which kind of adaptation and customizations are more typical and universal than others. So we can start saying 50% of what we learned is similar for everybody, so we can standardize that to bring down cost of care and increase effectiveness. The rest still needs to be highly personalized, so let’s go to the next level of learning.
That’s the general gist.
JF: What sort of training or education do the patients get in terms of using the device? What sort of oversight is there in making sure that patients are using it on a regular basis?
SS: The high level answer is we have our own clinicians here that are primarily focused on training. So what they do is consumer testing. What they do is train the care professionals of the organization who are working with the patient on how to use the device, how to customize the experience and how to support and train the patient that’s going to use it. The reality though is it doesn’t take a whole lot of training to use the device because we built it to be as simple as possible. As long as you can find the “on” button, you’re pretty much in business. In terms of setting a routine, because it’s a two way communication tool, so were not waiting on the patient to do stuff, the practitioner behind the scenes is monitoring what’s happening or not happening. They are actually kind of pushing into the device notices like, “Hey, let’s chat.” It’s almost like a phone call. Or they can always just pick up the phone, or if their actually visiting in their home they can politely encourage the right sort of utilization. It’s really pretty simple.
Our plan is to say, “Turn the sucker on. We need to monitor mostly this one thing about you to get started. Let’s not overwhelm you with twenty-five things to do. Let’s just get in the routine of checking your glucose level three times a day, at these times, and let’s not worry about anything else right now. And because we’re new at this with you, we’re going to do a video chat with you at one of those times randomly, just to kind of see if you are really doing it or I’m going to call you.”
You really start to learn about the patient and you can start to customize the care plan from there. So we have a pretty intensive training program, but the reality is for the patient, it’s pretty simple. The training is more for the care professional.
It’s a very simple and easy-to-use interface. It was designed through ethnographic research. Let’s start with the blood sugar levels and get that under control. Then let’s step you into education that’s delivered just in time. If your blood sugar is high, we may deliver certain content too you. If it’s under control, we’re going to congratulate you and reinforce that behavior through the platform, and through a series of questions that we call “Daily Health Sessions.” Those daily health sessions evolve over time to move the patient from first, let’s get control of the physiological component, and then let’s move into being able to better manage your condition. That’s really the promise of the platform. We progress the patient through to self-management. That’s really when you begin to see patients really engaging with the platform. They feel somebody’s taking care of them, even though it’s remote. Their usage of the platform and their adherence to the care plan is very high, and that’s what we like to see as the patients engage through the process. The interface is super simple, so we don’t have those fears of “I can’t do it.” They get engaged with the platform.
JF: How much attention was given towards security, making sure the information is secure, especially in terms of HIPPA compliance issues?
RS: Our platform is an FDA class-2 medical device, and we’re fully HIPPA compliant in the delivery of our solution, and because clinicians are making decisions based on behaviors of their patient’s interaction with the platform, it’s critical and paramount for us that the privacy and security measures are handled correctly. The data that’s in the patient’s home—there’s really no data, it’s the application that’s there. The data goes back through the cloud and is encrypted on both ends, both at rest and in transit. The privacy and security components are rock solid around the platform, and the cloud-based delivery really is helping to enable that.
JF: The pilot has just started, correct?
SS: The pilot itself actually doesn’t launch until the end of March. It’s focused initially on recruiting in two hundred patients. Right now, we’re just in the gear up phase. We’re getting all the devices prepped and ready, which is starting the training for the professionals, starting the recruitment process, etc.
JF: What sorts of benchmarks do you use internally in terms of when are you going to really start looking at results?
SS: Speaking of a follow-up schedule, to be realistic, the first opportunity to do that will probably be the tail end of May. We get things launched in March, and then we plan to get about a month of data. You need about 60 days of data to work out the kinks. We want to ask, “Okay, how much of an impact are we having on AC1 levels? How much influence are we having on weight gain and reduction in weight, adherence to glucose monitoring, self-monitoring and etc.?” It takes a couple of months. Even though we’re doing all of that starting in March, for the data to come out and be analyzed.
