Minders keepers

Kevin Fickenscher, M.D., Chief Medical Officer and President, Healthcare Division, AMC Health

Fickenscher: Personal care extends from the traditions of medicine whereby one individual serves another as part of a professional obligation to the use of genomics to more personally define the interventions which should be employed with a particular individual based on their genetic make-up. Personal care represents the individual intervention, with population health representing the community or population intervention in the care matrix. The two, when coordinated, can be very powerful in altering the course of disease, modifying behaviors, enhancing service and generally improving the care process. One without the other leaves an incomplete solution. The core problem with healthcare in America is the clear disconnect between personal care and population health. The incentives of American healthcare are focused almost exclusively on the personal care front. If we want to alter the cost structure to reduce waste, enhance service and increase quality through better outcomes, we need to focus on the misaligned incentives of the current system.

David Muntz, CIO, GetWellNetwork

Muntz: The definition of these terms can change depending upon the circumstance or role of the perceiver. From my perspective, I would hope that most participants in care would agree upon one definition: A course of treatment or lifestyle, whether the patient, consumer or member is in a state of wellness or illness, that has taken into account all pertinent data (regardless of source) combined with evidence from trusted sources based on the judgment of a fully informed care team. Personal care often involves handoffs or coordinated efforts from one caregiver to another. In the ideal situation, those handoffs and coordinated activities should enhance, not jeopardize, the quality of care.

Population management is the capability and desire to manage a group of individuals who are organized based on a set of criteria relevant to those members of the population. The range of criteria can vary significantly and may include, but is not limited to: geographies, medical conditions, interests (e.g., friends and families of patients), membership in a group and anything else that meets the needs of the members of that population. It is common for a patient, consumer or member to exist simultaneously in multiple populations.

Riskin: All of the above, but additionally:

Bradley: Personal care is healthcare at the single patient scale. Population health is the application of our knowledge of each patient to the entire patient population, with the goal of leveraging the aggregate data to see patterns more efficiently that allow us to improve the delivery of care.

Hobson: In addition to “all of the above,” population health adds a new dimension by looking at the health of an entire population and targeting those individual patients that are at highest risk for adverse outcomes and/or excessive costs. Health organizations and providers need the capability to reach out to all patients using a modality of the patient’s choice targeted at the individual patient’s specific needs.

Beard: I think the key word we rally around is alignment. From this list above, I might select “Adhering to clinical treatments,” but I believe it is more about alignment and what the economic driver wants to drive. We ask: What are the payers doing? What is the organization doing? There, I am thinking about quality measures. What is the physician engagement? What is the physician adherence to what the payer and its own organization wants? And it is important to align that vision with what the patient is engaged in.

There is power in your personal care and patient engagement if it is tethered to a physician, the physician is tethered to the organization and the organization is tethered to the payer. If you do not have that alignment all the way back to the payment source, it will not be as effective.

Lipton: All of the [suggestions] are great ideas, however, I do have an issue with the belief that patients paying for more of their health and taking on more financial responsibility will necessarily help improve personal health or improve motivation. I personally had a health (dental) plan that had an increased financial responsibility once, and it deterred me from regular visits at the time because I was already balancing a tight financial situation with my student loans. Think of it this way: Patients are trying to balance costs the same way that a health system is. I’ve heard more than a few health systems say, “No” to a minor increased financial cost in return for higher quality care, even when the ROI is amazing. Don’t underestimate a patient’s capability to evaluate their options and choose to risk their health when facing a choice between quality of life and a proactive health service. “Better pay now, or it might possibly cost you later” is an approach that the majority of a population that is struggling financially will likely ignore.

Why do you believe making IT more flexible, interoperative and intuitive for patients will motivate them to change their behaviors and habits, participate more actively and take more responsibility for their care?

Fickenscher: The current system presents the consumer, the provider, the system, the payers and any other party to the care delivery system with an inordinately complex, redundant, disconnected model for sharing information. Imagine the airlines having siloed information technology functions so that as I travel my air travel ticket, the management of my accumulated points, the use of my credit card for paying the ticket’s cost, the transfer of my baggage from one plane to another let alone from one airline to another, were all different systems. Any airline that approached travel in that manner would very soon feel the rage of consumers who would no doubt decline to use their services. In many respects, healthcare epitomizes such a disparate, disconnected system. The key for driving efficiency and effectiveness in healthcare resides in the demand for interoperability, which represents the cornerstone for solving these problems. Once the cornerstone is in place, user interfaces, ease of use and cross-system integration will be a natural outflow.

Rohde:Data in every other industry shows that when consumers can work with companies through easy-to-use information technology, the customer/company relationship and loyalty improves. In industries such as retail and banking, personalization helps both the consumer and company make more informed decisions. The issue in healthcare is, that type of technology has not yet reached the doctors’, nurses’ or patients’ hands.

Our data shows that patients who use our patient engagement applications for self-care have an 85 percent retention rate. That is because we are giving the patient and the provider information that brings the patient into sharp focus and makes understanding their health much more clear.

Muntz: IT is a critical element of motivating patients to change, but it is only one part. The advantage of IT is the ability to remain objective, consistent and unaffected by distractions that impact a person’s ability to avoid unnecessary variation, to consider all alternatives, to collect and understand all pertinent data and to provide simultaneous access to resources impacting behaviors. What it cannot do effectively is combine this objective data with the judgment of trained care delivery personnel who must interpolate what cannot be effectively represented in digital form.

The tools we put into patients’ hands must be intuitive and available to the family or community who is caring for them. Any tool that requires a patient manual or that cannot be learned by watching a very short video simply won’t be utilized. All providers, patients, consumers and members will expect their devices – whether phones, computers or televisions – to have interoperability, that is, access to data that is usable and relevant to their situation.

To be truly effective, it makes sense to study and use a change management framework that utilizes IT as an enabler to deliver personalized care and encouragement to those who are seeking to change. Critical to enabling change is understanding where a patient, consumer or member is psychologically and culturally. There are many people who have a desire to change but simply don’t have the resources – such as literacy, health literacy, technology or a support system. Activation requires all of these elements.

Riskin: As a doctor, I find there is little that is certain. But it is clear that IT alone will not change people’s health behavior. IT can help people understand their health, get engaged, communicate with their physician or access information. But people need to make their own decision to be healthy. A healthcare IT revolution is only as good as the parallel revolution in which individuals come to understand and care about their health.

Bradley: The most important step is to eliminate the barrier of inaccessibility and enable patients to leverage health technology in their daily lives in the pursuit of their personal health goals. As with other consumer-facing industries, healthcare ultimately relies on the actions of patients for its success. If a patient doesn’t follow through with a physician’s recommendation or treatment regimen, or does not maintain a healthy lifestyle, the entire healthcare delivery process will break down.

The essential first step to motivate the typical patient to action is by making technology more flexible, interoperable and intuitive. In doing so, we remove one potential barrier to its regular and pervasive use. After removing factors that make taking action more difficult, it is then about rewarding the patient through unique insights and a positive usage experience. An intuitive user experience and empowering content and insights are crucial in encouraging patients to take command of their own health in a massive way.

Cogan: We’ve seen it in other technologies and industries. In the past few years, there has been a slew of fitness and weight control-related apps. Runkeeper is a popular example. For motivated individuals – and, yes, the key is “motivated” – they have become an essential tool to track fitness. Similarly, several years earlier, the accessibility to online stock trading tools put stock trading in the hands of the masses. As long as the technology is easy to use, convenient, trusted and contains useful content/tools, a motivated population will use it.

In healthcare, “motivated” may well not mean a healthy individual – it often takes becoming ill or caring for an ill relative or even a newborn to get motivated enough to interact more proactively with your healthcare. One approach that we know didn’t work so well was the personal health records (PHRs) of a few years ago. They required manual data entry and did not interoperate with providers or their systems, making them labor-intensive to maintain and not action- or task-oriented. An interactive system that allows for provider communication, assignment of tasks/reminders to patients and automatic uploading of medical records is much more likely to be adopted.

Hobson: Information is power. Seeing the numbers is a great motivator. With personalized medicine, the more that information is adjusted to individual patients needs the better from the perspective of getting patients motivated.

Bau: If we look at the use of IT in banking, airline and tax completion, such as TurboTax, in all these cases, interaction via IT led to far higher engagement levels. It’s the same with healthcare, and patients are looking for IT solutions that make their everyday lives easier. Today a patient encounters barriers to patient engagement at the early stages of the healthcare process. If healthcare can’t manage its waiting rooms, send out adequate appointment reminders, bill correctly and keep track of a patient’s information, then why should the patient part with their money and time to work with an institutional healthcare system?

If it is difficult, time-consuming and expensive to visit my doctor, then I will put it off until the problem has passed a critical state, thereby impeding preventive care. But if I can securely message my provider from the convenience of my own home and have confidence that the system will work, I will choose the technology to navigate the healthcare system.

Rose: Making IT flexible and interoperative allows for a more consistent message to come from providers and from automated systems across the community. The more intuitive they are for patients, the more likely that the patients will access the information. But I do not have confidence that this will move the needle on population health management alone. It allows for more convincing and uniformity across information shared, but it does not make a huge difference.

Beard: If you look across HIT in general, we are all being challenged to make more intuitive rules because we are trying to engage not only providers and care managers, but also patients. We are doing it in a time where everyone has “iPhone taste.” That is when a tool is very Apple-like, easy to use and intuitive. That culture is pushing all of the vendors in that direction. For us –TriZetto and Wellcentive – and our combined solution, it really is helping with that alignment. If it not intuitive and not in a consumable format, you are going to lose the audience. To achieve our goals and what we want to do with patient engagement, we have to get the physician engagement right. Physicians have so much going on that the IT must be intuitive.

Lipton: Already today, many people are using IT to better enable personal health. Many fitness apps, medication management applications, patient portals and other technologies are helping patients get better access to care and better manage their own personal health. The motivator for much of the population is the convenience of IT and the widely available devices that can provide access to this information and tools at low [or] no cost. The issue that lies in continued and strengthened motivation in my opinion is communication. While IT helps many people get better access to information, I still believe there is a strong disconnect between personal health and population health that needs to be solved through open communication. Some of the best motivators in my opinion involve the utility of social networks and expanding communication into the mediums that patients are already communicating with today. For example, at Agfa HealthCare we are striving to provide IT solutions that allow imaging data to be shared and communicated between patients and providers to better motivate patients to participate in health programs.

Will you identify, explain and debunk some of the myths about patient-centered, personal care?

Rohde: Myth: “Patients don’t care and won’t do what it takes to get better.” No one wants to be sick! But today’s patient-physician appointment tends to be a break-fix session of limited value to either the patient or provider.

Myth: “Patient engagement is a project managed by IT.” Patient engagement is not a tech project. While it is true that technology, particularly mobile devices, are the most effective means for keeping patients engaged between encounters, patient-centered care is a model of practicing medicine that departs from the norm of health system-centric care.

Myth: “Seniors won’t use mobile devices.” Patients over the age of 65 are in the fastest growing cohort of smartphone users and tablet purchasers. This is a red herring for keeping lagging health systems from getting connected to their patients.

Muntz: Providing resources and education to a patient, consumer, or member does not necessarily mean they will understand, much less be activated. Change is good, but the transition from current state to future state is very difficult. Many unmotivated people will not change until the pain of staying in their current state is less than that of moving to the future state. Waiting for motivation to happen is not a successful strategy. Caregivers must really understand patients, consumers, members and the family in order to effect real change.

Riskin: Patient-centered care is an idea that is growing in popularity. It is clear that healthcare consumers should be offered engagement in their own care and should have an opportunity to help shape care priorities. But patient-centered care does not mean patient-run care. The pendulum should not swing too far. A preferred course would be collaboration between the individual and the healthcare system, making decisions together and leveraging the expertise of all involved.

Bradley: The biggest myth about patient-centered care is that healthcare can exist without it. More and more we’re seeing glaring evidence to support the fact that the current approach to healthcare delivery is not making people healthier and is generating a ton of waste. The industry is starting to understand that the practice of medicine is fundamentally about the individual, their unique biology and unique behavior.

We are no longer in a world where an impersonal, population-level recommendation is going to be sufficient. We now have the data and the technology to start focusing on each individual in a way that has never been possible. It is important for the entire industry to continue to come together; to make sure the policy and technology foundations are in place to keep making this vision a reality for all patients.

Cogan: That patients aren’t engaged or interested enough to take an active role in their own healthcare or to seek providers based on quality and cost. Changing market conditions, such as high-deductible plans and improved technologies, mean that we should not let the past be our guide on this topic.

Hobson: Being patient-centered takes too much time. Longer appointments and, therefore, longer work hours for busy professionals are two simple examples that are often raised by clinicians. Yet we know that allowing patients to speak and not be interrupted by their physician for, say two minutes into the consultation rather than the usual interruption by the provider within 30 seconds, actually results in shorter, more productive consultations. Properly done, access to technology gives patients further ways to express themselves. Another myth can be stated as “my patients are already satisfied, so why should they – the provider – have to do this?” The reality is that there’s always room for improvement, and technology that enables more meaningful engagement of patients is exactly the kind of initiative that offers the chance to improve patient satisfaction across the board.

There is also the thought that patient-centric care is not cost effective, that the time and effort involved doesn’t return extra revenue. This is certainly not the case, since having more satisfied patients engaging productively with their physician means consultations are shorter, involve less stress on the physician, better clinical outcomes and, ultimately, a more successful practice.

Bau: One major myth is that technology depersonalizes care. Studies show just the opposite. Allowing the provider to focus on the patient rather than manual data entry can increase patient satisfaction. The other benefit is obtaining accurate data. Studies are also suggesting patients answer difficult or personal questions more honestly via an electronic device, versus speaking with a person.

Another myth is that personal tracking is going to revolutionize care. Until personalized tracking reaches a state where it is second nature to the patient and the benefits accrue automatically, it will remain largely a hobbyist tool. Online banking had to come before mint.com. Likewise, in healthcare the basics of today’s interactions – scheduling, pre-registration, check-in, secure messaging, clinical questionnaires, PHR delivery – need to be automated by patient self-service before higher level personal care services have a massive impact. A third and final myth is that a clinical portal that simply allows the patient to view her data is the full HIT solution in patient-centered, personal care. Technology needs to provide a platform that gives the patient a seamless interface throughout the continuum of care. Allowing a patient access at home and on site helps providers to understand their patients as a whole.

An effective portal allows patients to view and update their information, and it must provide value. By value I mean elements such as providing access to pre-registration that actively engages the patient in preparing for their appointment. This is an instance where results contradict patient surveys where they prioritize seeing things like lab results. Moreover, adoption rates demonstrate that the most effective technology engagement solution is a unified approach that delivers patient-facing functionality that’s accessible via devices such as kiosks, mobile phones and in-facility tablets that all work together.

Rose: None with respect to “patient-centered.” Our medical records and our attention to healthcare must be centered on the patient or communities of patients.

For personal care, I have my doubts. I don’t think anyone has shown that in a lot of the efforts to date. I do not see personal health records or social sites or other things making a huge difference yet. The success of the personal health record is still dubious. I think outreach to consumers is important, but many people do not have access, especially those who are underserved. Many people who do have access do not have interest. Even with accuracy, follow up and action taken on the information by consumers at large, the value and effectiveness on a large scale is still unknown.

Beard: It conveys that a patient is really running things. It goes back to alignment and being tethered with the physicians. We can empower patients, but at the end of the day, the one who directs the care is the one in charge. It must be more of a collaborative relationship, but it is certainly not patient run.

There is a myth that access equals engagement. Giving someone access to information does not equate to the level of engagement a patient has. This goes back to the other question about being intuitive, but it also talks about the relationship between the patient and the physician, and rallying those patients around what they need to be focused on, and having information in a consumable format. Accessing records, if they are not intuitive and not consumable, does not increase engagement.