Industry-First Exclusive: Cleveland Clinic Medical Informaticists and Authors Discuss the Global mHealth Journey

Nov. 19, 2013
On Nov. 18, Colin Konschak of Divurgent, a healthcare management consulting firm, and David Levin, M.D., CMIO of Cleveland Clinic, and William H. Morris, M.D., director of clinical informatics at Cleveland Clinic, announced the publication of their new book, mHealth: Global Opportunities and Challenges. Drs. Levin and Morris spoke exclusively to HCI's Mark Hagland prior to the book's release, to share their perspectives on the global mHealth journey. Part one of a two-part series.

On Nov. 18, Colin Konschak of Divurgent, a healthcare management consulting firm, and David Levin, M.D., CMIO of Cleveland Clinic, and William H. Morris, M.D., director of clinical informatics at Cleveland Clinic, announced the publication of their new book, mHealth: Global Opportunities and Challenges, published by Convurgent Publishers.

As articulated in a summary online, the authors explain that mHealth: Global Opportunities and Challenges provides the ultimate coverage of all aspects of the burgeoning mobile health arena. It integrates issues around the clinical, policy, and technical aspects of mHealth to highlight the potential this transformative technology holds for healthcare systems throughout the world.”

As the authors further note, readers will “read about what works and what doesn’t’; the barriers to full integration; and the strategies that companies like Aetna, AT&T and Intermountain healthcare employ, as well as organizations like USAID and countries like Zimbabwe, are utilizing.”

Shortly before publication, Drs. Dave Levin and Will Morris spoke exclusively with HCI Editor-in-Chief Mark Hagland regarding their objectives for the book, and their perspectives on where the mHealth phenomenon is headed. Below are excerpts from that interview. This will be the first in a two-part interview. The second part of the interview will be published soon.

Gentlemen, you’ve produced a very important new book in this very important arena. Was part of your purpose to produce a textbook-like resource for healthcare leaders, as they lead their organizations forward in this area?

David Levin, M.D.: Part of the vision of the book was that we wanted to create a guide that people could go to and begin to see the whole landscape. At the same time, we wanted it to be accessible, so we had to balance putting in enough detail to be credible, but engaging for people.

How far along are we on the mobility journey, as a global healthcare system? Is it a bit like the human journey around the discovery of fire, then tools, then machines?

William H. Morris, M.D.: My perception is, we have fire—we have the core elements. So we’re well on our way on two things, in healthcare, towards pervasive health IT. And you need two things: the first is a purely electronic infrastructure; you can’t be paper-based, obviously. And we’re well on our way on that one. Where we’re not quite as far is in making the data liquid and easily transferable. And we have to work through the issues of security and privacy and data standards. The challenge is making it liquid now.

The other key piece on the clinical side is in terms of the culture. And though clinicians would like data to be liquid, that’s not how healthcare is organized right now. So something as seemingly obvious as an open medical record, that’s not a technological issue, but a cultural issue: making the record accessible to patients—there’s a cultural barrier there. So it’s one of culture, and I think we’re about 50 percent over the hump. Once the data is out there and you can personally view your data at home or on a mobile—I think we’re about 50 percent there. So we’re not in our infancy, we’re well underway, and I see parallel efforts in both those areas daily, and things are moving at a very rapid pace. Six months ago, we were barely talking about an open record, for example, but that’s changing quickly.

Levin: I agree with everything that Will has said; we have fire now. But you can get burned with fire, too. We’re seeing all kinds of really crappy apps; we’re seeing stuff that is not secure; we’re seeing stuff being pushed into the workflow that’s not going to work. I was doing a presentation recently to people from another health system, and I asked them, are the guys trying to sell you apps showing up? And they all raised their hands. There are a lots of well-meaning technologies, but poorly executed. The core infrastructure is being put in place, and culture, we’ve got to work on that; but what actually what works, what will stick, that remains a very open question.

And part of the theory of this book is that there are these three things driving this perfect storm of things. One is mobility, which goes far beyond smartphones, towards a vast array of streaming data. The other two drivers—one is rising consumerism. And the third driver is the coming transformation of how we get paid to do what we do. Classically, it’s defined as the conversion from a volume-based to a value-based system.

And that’s so important because that begins to realign the economic incentives, so that all of a sudden, thinking about giving a patient a tablet to help them avert a readmission actually begins to make business sense.

Where are doctors  in practice, in all this? My own personal physician, Dr. X, simply feels oppressed by all the demands on him that are forcing him to use an electronic health record and other clinical information systems. If he were forced right now to engage directly with patients via mobility, he’d really be upset.

Levin: Let’s start with the Dr. X’s of the world. I have nothing but enormous respect and sympathy for the clinicians on the front line. It’s very tough to be a physician in practice right now, and the typical workday is totally overwhelming. And so for the most part, they are in survival mode; they’re facing dwindling reimbursement, increasing regulatory and compliance requirements, increasing patient expectations, and they’re not being given a whole lot of resources to deal with all those things. Now, you layer on top of that the typical EMR implementation, which is often being done to them rather with them. And at best, that feels net-neutral to them, and often, it feels that people are just taking away more of their time.

And so often, they’re reacting rationally to what’s happening to them. And often, when we engage them, they have very legitimate concerns. When we say, we’re going to now expose clinical notes and problem lists to the patients, and they say, well, wait a minute, that note is not all that great a note, and the patients are going to call us in a panic, and I can’t even answer the phones that are ringing now. But what we’re finding is that patients are being very responsible with this information. And if you design better methods for prescribing a refill, that will actually improve medication compliance. And if you plan this carefully, it actually becomes a win for everyone.

And this brings me to the docs who are out in front. They’re the path-leaders, and this is what they’re doing, and they are opening up their records and seeing the benefit of transparency, and seeing the benefit of e-enabling their practices. And I think if we can get the economic incentives to ultimately line up, then we can make true long-term progress in population health management and care management.

And the reality is that your patient, Mrs. Smith, who has two or three chronic illnesses, needs to be connected to the clinicians in the care delivery system in a far more effective, regularly present, way, correct?

Morris:  You’re one-hundred-percent correct. Chronic disease is where we have to go, and how do you manage that? Well, it’s the 364 days a year that Mrs. Smith spends outside engagement with the healthcare system that matters. It has to be a pervasive, ongoing, bidirectional experience, with healthcare that’s ongoing, engaged, and participative, with the resources and dollars spent to educate and engage her. And get the community to support free gym memberships or put in a bike path, things like that. And mobility will certainly be part of the way to do that, because you’ve got to be physically touching and engaging them, and that’s the beauty of mobile, it’s the doc in your pocket. And certainly operationally, mobile is the way to do it in terms of population health, because there aren’t going to be enough docs or physician-extenders; you’re going to have to manage cohorts of patients.

Levin: And that’s where you’re going to have to implement patient-facing clinical decision support systems. And so Mrs. Smith, who has CHF [congestive heart failure], steps on a connected scale every day, and gets a message saying, “Mrs. Smith, take another water pill today, please.” So we see this as an evolutionary thing that will over time help us to see thousands of patients at once to do health risk stratification, but ultimately, it will get us to automated processes.

Morris: The signs that are next to the elevators that say, hey, take the stairs, are actually very effective. And we can proactively prescribe exercise, and there are tools that can send you messages saying, hey, Will, you’ve only walked one mile today. Messages that say, exercise more, eat healthier. It’s engaging them at a place where you’re affecting their behavior. And if we can manage cohorts of patients in population health management, then you’re really on the road.

And what does the term “pervasive health IT,” as you use it in the book, mean?

Levin: It’s about removing time and space as barriers to effective healthcare. We want to remove bricks and mortar as barriers. Today, people have to come to the healthcare system. And that’s a barrier. The notion of pervasive computing is actually pretty old. I started by looking at some of the literature in the late 1990s, and it wasn’t a great leap to see how those concepts apply to healthcare. So it’s removing time and space as barriers, virtualizing healthcare, and it’s alive and dynamic, and everything is connected, communicating, and smart.

In part 2 of this two-part interview, Drs. Levin and Morris discuss the implications of the mHealth revolution for CIOs and CMIOs in their current work, and their perspectives on the future of mHealth.

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