Healthcare Talent Transformation

Remote Patient Monitoring: The Ideal RPM System

David Scher, MD, DLS Healthcare Consulting

Remote patient monitoring may serve patients who are in the post-acute care phase of recovery from a hospitalization as well as those with chronic diseases.  Monitoring may consist of communication tools or measurements of medication adherence, glucose measurements for diabetics, oxygen saturation measurements for those recovering from pneumonia or who have chronic lung or heart disease, symptom reporting, and vital sign measurements, and other potential parameters. Most important to consider is that these tools must be used in a context of a comprehensive approach to monitoring. A strategy regarding workflow and dedicated human resource support needs to be designed prior to implementation. Once implemented on a small-scale initially, it needs to be reexamined with an eye on identifying pain points in logistics, communication, and outcomes.  The following consist of what I consider five characteristics of an ideal RPM system, however individual needs might vary.

1. Single vendor for all technologies.  There are currently vendors which can furnish multiple technologies and even some with more than an organization or healthcare system might want. Be careful about a one size fits all proposal. Consider whether it would be of benefit to have the technology provided by a wireless carrier or not.
2. Easily implemented and unobtrusive to the user.  Anyone who has experienced difficulties with setting up a new TV or smartphone understands frustrations with technology implementation. Considerations for assisting the healthcare system, Senior living facility, and the individual user are an important point of an RPM business plan.  If the tool is difficult to set up or significantly gets in the way of daily activities of living, it will not be utilized. Involving a caregiver with instructions is crucial in this regard as well.
3. Must have optimized population alerts and superimposed personalized alerts.  Optimized alerts are those determined from evidenced based medicine, professional societies, or physicians associated with the customer.  In addition, these alerts should be customizable for the individual patient whose baseline measurements or variations might be atypical.  Both of the above should result in alerts to non-physician healthcare providers which are actionable only. What this means is that measurements which do not prompt a provider to recommend a change in course of treatment or other action should be stored but not transmitted. There might even be different levels of alerts which, after verified, are conveyed to the physician or other provider which ideally via an algorithm, would prompt different actions.  The aim is to minimize false positive alerts while maintaining a high degree of specificity.
4. It needs to be a closed loop system.  This refers to every alert being addressed with an interaction. This might be a human interaction (phone call) or algorithmically determined digital message with instructions. It also refers to a follow-up afterwards to determine adherence to the instructions.  This system must be bidirectional to work. There also needs to be a human component to discuss symptoms and interact with patients with limited capabilities.
5. There must be seamless integration with PHR and EHR.  The incorporation of data into the PHR and EHR is imperative. This is a logical progression of collection of data. It must be filtered so as not to clutter an electronic file with endless unimportant data points. It must be in an easily identifiable part of the electronic record.  It must be able to be shared with the caregiver and all designated providers in an interoperable fashion.

Hopefully the Telehealth Promotions Act of 2012 will be approved in this Congressional session and pave the way for widespread adoption of these technologies which are sorely needed.  It is up to both industry and adopters to optimize implementation and utilization and to create outcomes measures which might translate to health and financial ROIs.

David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLC advising digital health companies and their partnering institutions, companies, and providers.He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs. . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps. dlschermd@digitalhealthconsultants.com

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Five Fallacies of Remote Patient Monitoring

Five Ways of Achieving Patient Engagement: Part 2: WITH Technology

Remote Patient Monitoring: Operational Models

Remote Patient Monitoring: Operational Models

David Scher, MD, DLS Healthcare Consulting

In my previous post, I discussed some generalities of remote patient monitoring (RPM).  The current value of the RPM market is estimated at $10.6B. There are diverse clinical and non-clinical environments in which RPM might be utilized.  The healthcare ecosystem is becoming a continuum of care more than discrete silos of acute care and various post-acute care settings which must interact with each other in order to result in better outcomes and prevent hospital re-admissions.  These are the motives for the institution of RPM along this continuum. There are different models of deployment of RPM which affect investment by providers, ROI of the process, and logistics and workflows which I will discuss.

1. Monitoring performed primarily by the individual. This would include glucometers, blood pressure recordings, weight scales, and other accessories to smartphones or computers which via wireless communication transmit and store measured data points. The patient can then present the data to a healthcare provider or have it sent electronically. This allows for the direct flow of data from the patient to the provider. There is little investment from a financial perspective in this model.
2. Monitoring  by the vendor.  In this model, the technology vendor itself provides technical data support and acts as an intermediary between the patient and provider. This was the original model adopted for RPM of implantable cardiac rhythm devices. This type of model might involve partnering of the monitoring company and a wireless provider such as seen between Intuitive Health Inc. and ATT&T. The cost of monitoring in this model is built into the cost of the technology if used with Medicare reimbursement because of safe harbor law restrictions.
3. Monitoring by a local healthcare system.  A local healthcare system might perform its own monitoring.  In this model, non-healthcare providers might take directives from physicians who set alerts and algorithms to treat patients based on data received if necessary. This logistical model also facilitates integration with the patient’s EHR. Patients can also call in and discuss related symptoms with the providers and appropriate follow-up appointments made if necessary.
4. Centralized healthcare system monitoring.  Countries in Europe have large academic institutions performing RPM regionally for smaller hospitals and unaffiliated healthcare providers. They are equipped to handle the 24/7 coverage as well as possibly the clinical expertise (as seen with implantable cardiac devices for example) not otherwise available.
5. Other third party commercial monitoring centers.  There are a growing number of companies performing RPM.  Some offer physician expertise (professional component) as well as the technical component of monitoring.  These companies might have an advantage of 24/7 coverage over small hospital-based monitoring centers.

There are advantages and drawbacks of all the above-mentioned models, and there might be others not discussed.  The lack of reimbursement for RPM might slow adoption, however the most significant impetus for the recent uptake in use has been the hospital readmission penalty policy. It remains to be seen which operational and business models fair economically better than others and more importantly, which ones produce better short and long-term patient outcomes.

David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLC advising digital health companies and their partnering institutions, companies, and providers.He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs. . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps. dlschermd@digitalhealthconsultants.com

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Five Fallacies of Remote Patient Monitoring

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Five Fallacies of Remote Patient Monitoring

David Scher, MD, DLS Healthcare Consulting

As defined in Wikipedia, remote patient monitoring (RPM) is: “a technology to enable monitoring of patients outside of conventional clinical settings (e.g., in the home), which may increase access to care and decrease healthcare delivery costs.”  I was a pioneer adopter of RPM as a BETA site for Medtronic’s Carelink wireless system which monitors implantable cardiac rhythm devices (defibrillators and pacemakers). RPM has gained significant attention because of recently mandated penalties for hospital readmissions for certain diagnoses (myocardial infarction, congestive heart failure, stroke, and chronic obstructive lung disease).  RPM is seen as a way of remaining in physiologic contact with these patients who might be managed at home via care systems. There are conflicting study results regarding the utility of remote monitoring preventing hospital readmissions. Some studies show no decrease in hospitalizations, and others with significant benefit.

1.    All remote monitoring is the same. There is no standard definition for RPM.  Some studies utilizing only telephone interviews have been called RPM. Other RPM technologies use body sensors which deliver data from the person’s body in an automated fashion into a server and/or a smartphone via an app, and/or an EHR.

2.     All remote monitoring is reimbursed.  RPM of implantable cardiac rhythm devices has been directly reimbursed for many years in the USA.  In fact, when it was first approved for reimbursement by CMS, it was approved at a higher level than in-office follow-up.  Many years following USA approval of reimbursement, European countries are still variable with regards to reimbursement models.  Besides RPM of implantable cardiac rhythm devices, – Not directly reimbursed but is an approved adjunct under the Home Health Resource Groups of the Prospective Payment System (HHRG PPS).

3.    Patients and physicians will welcome and embrace remote monitoring. My first foray into remote patient monitoring introduced me into the psychological aspects of the technology as much as the bells, whistles, and clicks entailed in performing it. The first pushback from patients is that the technology is replacing the physician, and eliminating the patient-physician relationship. If the technology conveys true benefit to patient care (implantable cardiac device monitoring leads to early discovery of arrhythmias and even led to detection of an eventually recalled defibrillator system wire).  What patients should know is that with any type of well-designed and thought out RPM system they will be more connected both literally and figuratively with their provider.  Interestingly according to the 2012 Study of mHealth by Ruder Finn, 33% patients would like their physician to use a mobile platform for RPM to alert them of serious medical problems.  The first reaction from physicians is that they will be deluged with useless generated data, and that the data will remain in cyberspace without them knowing about it. The first reaction is addressed with good design, with actionable (and customizable) alerts and a workflow system employing non-physician providers.  The second concern is addressed below.

4.    Remote monitoring should be totally automated. The most effective RPM systems have some sort of human interaction involved in closing the monitoring loop. This is advisable for a number of reasons. There needs to be individualization of programmed parameters and alerts. This will allow for actionable alerts that are both meaningful from the provider’s standpoint and beneficial to the patient. Data cannot e managed in a vacuum. There will be false positive and negative readings which must be correlated to the clinical condition of the patient in order to result in optimal management.  Caregivers should be involved in the loop as well.

5.    Remote monitoring is only for recently discharged patients. It is no secret that RPM has both garnered and generated extraordinary attention because of Medicare penalties for hospital readmissions.  Regulatory requirements have driven much of digital technology adoption in the past decade. This includes EHRs, tools to determine and improve patient satisfaction, and patient portals. This is sad insomuch as one would hope that providers would invest in improved patient outcomes independent of mandates, following the tech adoption leads of the retail and finance sectors, focused on customer satisfaction and transaction outcomes. That being said, one would hope that the theoretical improvements brought to patients vis a vis decreased rehospitalizations (though 30 days is hardly a measure of long-term success) could extend to all relevant patients (those not hospitalized with chronic illness as well as those beyond the 30 day discharge period).

I have witnessed firsthand the dawn and benefits of RPM over time.  I look forward to the partnerships of RPM, mobile health, health IT, and non-tech patient-centric care. 

David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLC advising digital health companies and their partnering institutions, companies, and providers.He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs. . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps. dlschermd@digitalhealthconsultants.com

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DigitalHealth: Patient Engagement Does Not Imply Patient Empowerment

Five Ways of Achieving Patient Engagement: Part 2: WITH Technology

DigitalHealth: Patient Engagement Does Not Imply Patient Empowerment

David Scher, MD, DLS Healthcare Consulting

Patient engagement is a phrase that is everywhere now. It is part of the vernacular in advocacy circles, government, health technology companies, and payers. It used to signal a new healthcare ecosystem in which the patient is more of a spotlighted consumer; where reimbursement hinges on patient satisfaction, where the shortage of physicians dictates new care paradigms, and where the cost of healthcare must decrease as well as be redirected to wellness and home care from the more expensive treatments of preventable chronic diseases and institutional care. The Center for Advancing Health defines patient engagement as “actions individuals must take to obtain the greatest benefit from the health care services available to them.”  It is defined by an active role that patients play in their own care.

According to the National eHealth Collaborative, the Five Phases of the Patient Engagement Framework consists of:

1. INFORM ME
2. ENGAGE ME
3. EMPOWER ME
4. PARTNER WITH ME
5. SUPPORT MY E-COMMUNITY

Each of these phases has a process corresponding to a stage of Meaningful Use.  They are also provider-facing, in much the same way the Patient Centered Medical Home is.  I agree fully with the framework of ‘INFORM ME’ preceding ‘EMPOWER ME’.  But the accompanying narrative (“A healthcare provider in this phase demonstrates basic levels of patient engagement with an emphasis on the use of simple tools that make healthcare more convenient and accessible. This also includes providing patients with standard forms, both printable and electronic, and information about advance directives, privacy and specific conditions.”) implies that a patient will become informed if they can use simple technology tools. I would say that the technology is a tool, not a solution to informing patients. The technology itself must be put into a framework which involves human interactions and ‘EMPOWER ME’ refers to “advanced patient engagement activities through substantive use of health IT.”  If the MU directive only requires 5% of patients to have patient portals, how substantive is it?  Do patients need to wait for this third phase to be empowered?  Should Stage 3 of Meaningful Use be a surrogate for true patient engagement?

Physicians and other providers need more than this framework to begin to engage patients. There needs to be a change in the mentality and culture of healthcare on the part of all stakeholders to empower patients before they become engaged. When my practice hired a nurse practitioner 13 years ago, referring physicians were livid that patients were seen (for routine follow-up, not consultations) by a non-physician. That culture has since changed dramatically, but took many years to do so.  Empowerment or enabling will come simply with the realization of how much one can do with lifestyle changes to improve health and maintain wellness.  This need not take years and should be independent of MU schedules and technology. Patient engagement is more  conceptually restrictive and technology-oriented than patient empowerment.  I submit that patient empowerment can come to those even unwilling or unable to use digital technologies. Without empowerment there can be no engagement. Engagement cannot be passively bestowed upon a patient because technology is available.  Patient empowerment should start in schools. Children are always seeking to become enabled in all aspects of life, and I believe that teaching them how much they can do to keep themselves well will, if done appropriately, yield huge benefits.  I applaud the efforts of the e-Health Collaborative. But we need not wait for MU to mature nor depend upon technology to have patients obtain the respect or responsibilities from others to become empowered, which only takes knowledge and a change of culture.  Patient engagement will require technology including mobile health and other tools.  there is no debate about that. Demographics and economics dictate this. I am a champion of technology.  But for technology to succeed as an integral part of patient engagement, empowerment must occur first.  Critics of engagement and empowerment will say that there are many patients and consumers who do not desire to participate in their care. I realize this and that topic is for another discussion.  The above implies to those who wish to.

David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLC advising digital health companies and their partnering institutions, companies, and providers.He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs. . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps. dlschermd@digitalhealthconsultants.com

Five Ways of Achieving Patient Engagement: Part 2: WITH Technology

David Scher, MD, DLS Healthcare Consulting

Read Part 1: Five Ways of Achieving Patient Engagement: WITHOUT Technology

In my previous post I discussed what I believe to be the most important paths to patient engagement without technology. I would like to now follow-up and discuss how technology can promote patient engagement.  This technology might be in the form of a health/medical app, a patient portal, information derived and transmitted via a sensor, or other type of digital health technology.

1.    Technology is always to be utilized as an adjunct tool, not the sole solution.  This is probably the most fundamental consideration.  I chuckle when I hear of a technology presented as a ‘solution.’   Solutions do not occur in a vacuum. Technology must always be incorporated into some process, whether it is limited to the user or spans a network of individuals. Much data might be generated, but if it resides in a magic silo without it being filtered and translated into a meaningful actionable message, it is useless. It is also useless if the following four issues are not addressed.

2.    It must be used with consideration of health literacy, ethnicity, and language.  The patient experience is a phrase getting much attention these days. While there is little in the way of data correlation between quality and patient satisfaction,  one cannot argue that intuitively if cultural, ethnic and language barriers are addressed with technology tools, the potential for reduced medical errors, better patient satisfaction and perhaps even better outcomes might result.  In searching for such a tool, I found a unique and interesting technology called SpeechMed which incorporates language translation into connected platforms. Improving language literacy will undoubtably improve health literacy. Platforms should also take into account ethnic and cultural differences which might imply utilizing a different user interface for selected populations (as well as ages).

3.  It must include the caregiver. Any technology aimed at self-management needs to take into consideration the caregiver. The importance of technology in assisting caregivers is discussed in a review entitled Family Caregiving and Transitional Care by the Family Caregiver Alliance. The role of technology and the caregiver has also been discussed in aprevious post by me.

4.    It must be connected.  I believe that the patient portal is the single most important key to patient self-management. It can serve as a repository for medical records including videos, pdf files, medical apps, and other content. For this piece of the puzzle to be most effective, it must permit connectivity from diverse technological sources. Barriers to this are economic and political, not technological. As the patient portal market and health information exchanges mature (Stage 2 of Meaningful Use which dictates the use of patient portals only requires that 5% of patients have them), I see connectivity becoming less of an issue. The development of open sourced platforms will also help in this regard. The patient portal can thus become the source of convergence of many different digital health technologies.   

5.  It must be endorsed, not despised by healthcare providers.  Technological advances in therapies are expected and even anticipated by many healthcare providers. They are seen as symbols of progressive and modern medicine. Yet due in large part by experiences with EHRs, many providers to push back other types of digital technologies. If technologies are easy to use, are accepted by the patient and caregiver, provide demonstrated benefit, and deal with data in a filtered and algorithmic manner, attitudes would change. As a former practicing clinician who speaks with former colleagues daily, this is not a small barrier.

I look forward to hearing thoughts from readers about these points. Patient engagement is going to be a cornerstone of healthcare in the future.  We must find the best ways in which to achieve it, with both humanistic and technological factors considered.

David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLC advising digital health companies and their partnering institutions, companies, and providers. He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs. . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps.dlschermd@digitalhealthconsultants.com

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Five Ways of Achieving Patient Engagement: Part 1: WITHOUT Technology

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Five Ways of Achieving Patient Engagement: Part 1: WITHOUT Technology

David Scher, MD, DLS Healthcare Consulting

If one looks at communications revolving around healthcare these days, whether emanating from political, healthcare economics, clinical, or technology spaces, the term patient engagement is invariably found as one of the cornerstones of the conversation.  This is no more evident than in the digital health technology space. One would think that patient engagement is only possible by hitching a wagon to the technology horse.  I would like to explore the issue with two posts, the first devoted to non-technical considerations and the second examining best practices of technology utilization in this regard.

1.     Listen to the patient.  Patient-physician communication is the basis for much of what transpires during the tenure of the professional relationship.  Lack of good communication has been cited for medication nonadherence.  William Osler, the father of modern American medicine famously stated that the patient will tell you the diagnosis with the narration of the history. Given the fact that most office encounters today last 15-20 minutes and that patients have comorbidities requiring attention, it is no wonder why many times they are not heard.  The physician is looking at the computer screen clicking off checks. The system is no longer geared towards human interaction and this creates a recipe for poor care, even if unintended.  This is why direct care or concierge medicine is becoming popular.  Both physicians and patients are returning to communicating in this setting. Other solutions need to arise to promote communication. Providing patients with pre-visit guidance in order to organize their thoughts and concerns might help.

2.    Motivate your staff to be as patient-focused as you are. Office and hospital staff should reflect the provider’s patient-focused approach to care. Many times they are too task-oriented and forget there is a patient who is the reason behind those tasks.  If the staff takes on the mindset of a stakeholder in the patient’s care and not just performing a job, the result will be a happier patient. Patient satisfaction surveys (an important part o the future healthcare landscape) will reflect this aspect of the care.  Patient-centered professionalism should be the goal of all ancillary staff.

3.    Demonstrate to the patient that you are an advocate.  Going to bat in front of an insurer for a patient who really needs a specific drug or procedure is something I always felt good about. Spending time on such matters is something physicians years ago (dating myself) went into the field thinking they would have to do.   However onerous, it is what patients need docs to do in critical moments. And patients do very much appreciate this. It is what made me feel good going to sleep at night.

4.    Show them your personal side.  Social media is a great way for providers to show their personal side.  This is not to say that personal interactions with patients should take place one on one, but a way in which patients see the personal (and hopefully appropriate) side of their healthcare professional.  I believe Twitter is a better forum for this than ‘friending’ between a provider and patient on Facebook.

5.    Individualized self-management.  Patients will partner with providers in their treatment plans with different levels of enthusiasm.  Some patients will require more support than others (motivational and material) and this should be discussed. Discussing patient engagement early on in the relationship is important.  It should also involve a caregiver who might be the one participating in the engagement on a larger scale. A provider who embraces co-management and is seen as both a partner and supporter of the patient will be appreciated.

The above might seem obvious to most people, but in today’s discussions surrounding patient engagement, the humanistic aspects of achieving this are lost in the vision of technology magically transforming how patients react to their medical conditions and to their healthcare providers.

David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLC advising digital health companies and their partnering institutions, companies, and providers.He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs. . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps.dlschermd@digitalhealthconsultants.com

Five Reasons Why Self-Insured Companies Need Mobile Health

David Scher, MD, DLS Healthcare Consulting

According to 2011 research by the Employee Benefit Research Institute, workers for companies with self-insured health plans make up 58.5% of workers with health coverage compared to 40.9% in 1998. The increase has been consistent over time. This percentage varied by state, from 30.5% (Hawaii) to 73.8% (Minnesota). This number was 10.8% for companies with ten or fewer employees to 86.3% of companies with 1000 or greater employees. It is very interesting to note that in Massachusetts, a theoretical model for predicting the full effects of the ACA, the percentage of self-insured company workers has risen dramatically in small (50-99 workers) companies from 54.4% in 2006 to 67.2% in 2011 and in large (1000 or more) companies from 74.1 to 86.4%. Therefore, it is likely that the percentage of self-insured company workers will rise even more in the coming few years ahead. Regardless of the size of the company, the cost of healthcare is critical to the bottom line. In a previous post, I discussed why payers are critical to mHealth adoption. However, mHealth is critical to payers as well. And as seen above, self-insured payers are a big piece of the puzzle. I’d like to discuss reasons why mHealth is good for self-insured companies.

1. mHealth tools encouraged by a company show the worker is valued. The potential benefits of mHealth tools in the form of apps and portals remains to be demonstrated in this setting. However, the offering of tools which promote health, fitness, and self-management conveys a tie stronger than just an employer-employee relationship. It is for this reason that health insurance companies have embraced patient portals and health coaches.

2. mHealth tool utilization in employee health plans sets examples for customers and clients. Demonstrating the company’s progressive (in the non-political sense) approach to healthcare might make for good marketing to clients and customers, whether they be other companies or individual consumers. One imaginative approach would be for the company to offer some of these tools to its clients or customers.

3. mHealth tools will result in more productivity. According to the Met Life Caregiving Cost Study (often quoted today though it dates to 2006), the total estimated cost to employers for all full-time, employed caregivers is $33.6 billion annually and the average cost per employee/caregiver annually is $2110. If these employees had apps which allowed them to communicate with healthcare providers, allowed them to get test results of the patient, afforded them the opportunity for a short video smartphone or other telehealth consultation at the place of work, or for them to receive actionable alert alarms from sensors their loved ones wear, the price of lost productivity could plummet dramatically. In addition, employees themselves would benefit physically from mHealth tools which improve their own lifestyles thereby decreasing the impact of or even potentially preventing chronic diseases.

4. mHealth tools can integrate with other mobile platforms. If a company already has mobile tools for work itself, integrating mHealth apps is not a big leap. It will fit in with work flows or at least the adoption of mobile tools for other purposes. What about a reminder timed to pop up at break time to take a walk instead of chatting at the cooler, or to take the stairs prompted by a meeting reminder?

5. mHealth apps will create happier employees. Healthier employees are happier. Employees are happier if their family members are benefitting from the tools. Some of these tools have associated social communities and employees can increase bonding if they take part in them. Utilization of these types of tools or creating employee health social groups based on them might improve employee satisfaction and teamwork.

While the adoption of mHealth technologies has obvious potential benefits to all, the self-insured company offers unique challenges which are great opportunities for worthwhile products. The workplace also affords an interesting research environment for mHealth apps. They can be evaluated from many outcomes perspectives. Health coaches employed by traditional insurance companies are too costly for smaller self-insured companies. Apps offer convenience and more options. Different sectors will require apps more specific to workers with unique health challenges based on occupation. The marketplace is there. I challenge companies with quality solutions to step up to the plate.

David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLC advising digital health companies and their partnering institutions, companies, and providers.He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs. . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps.dlschermd@digitalhealthconsultants.com

The Healthcare Cliff

David Scher, MD, DLS Healthcare Consulting

The term ‘fiscal cliff’ is one familiar to most Americans and many outside observers of this periodic political posturing around the need to address hardcore financial issues facing the country.  If both political parties hashed out their differences and came to a (very) hypothetical agreement of significantly higher taxes, markedly reduced spending (including modest cuts to Medicare providers and Social Security), with a plan that would be estimated to decrease the deficit to almost zero, there would still be a large elephant in the room: rising healthcare costs. We have a healthcare cliff which has contributed significantly to the fiscal cliff.  US healthcare spending  was estimated to be 17.9% of the GDP in 2011 and costs are estimated to rise 7.4% in 2014 when a significant portion of health care reform legislation takes effect.

According to a report from The Commonwealth Fund published in May 2012, Australia’s per capita healthcare spending was one half ($3,445) that of the US ($7960).  Interestingly, according to the same study, Australians pay 51% and 60% less than Americans for all drugs and brand name drugs respectively.  Australia spends 8.7% of its GDP on healthcare compared to our 17+%.  When looking at tax rates, Australia has a 30% corporate income tax rate and an individual maximum income tax rate of 45% as well as a 10% VAT.  In the US, corporate rates are 0-39%, individual rates 0-35%, and no Federal VAT.  I am not an economist and don’t even play one on TV.  What I do know is that it doesn’t make sense to me or anyone to have this degree of healthcare disparity with the countries mentioned in the Commonwealth Report and at the same time have significantly inferior outcomes with regards to studied quality indicators [mortality from asthma in 5-39 year olds, myocardial infarction, diabetes lower extremity amputations, in-hospital fatality rates (w/in 30 days of admission) of heart attack and hemorrhagic stroke.] This brings to mind the comparison I’ve made in the past between healthcare and education systems and costs.  Throwing money at a problem is not the answer. Bigger newer technology isn’t the answer.  MRIs on every corner have not improved healthcare (and some might argue have harmed it) but have markedly driven up costs. mHealth technologies will become an important part of healthcare.  This needs to happen soon. They won’t be the complete answer to a healthcare cliff but will certainly do a lot to change thinking about the way in which care is delivered and paid for.

So what should legislators do? Sen. Mike Honda recently proposed legislation called the  Healthcare Innovation and Marketplace Technologies Act  The bill “establishes an Office of Wireless Health at the Food and Drug Administration (FDA) that will coordinate with other governmental agencies and private industry to provide recommendations to the FDA Commissioner on how to develop and maintain a consistent, reasonable, and predictable regulatory framework on wireless health issues. This office will not expand the mandate or responsibilities of the FDA, but rather it will seek to better clarify and simplify existing regulations.  Though well-meaning, it would seem that such a framework could increase the bureaucratic path rather than shorten it.  Consider if a technology is being looked at by multiple government agencies to determine if the FDA framework is relevant to it after it is submitted.  One could see this delaying the submission or approval process.

In addition, the Bill would establish an HHS program to support mobile health developers “build their devices in line with current privacy regulations.” Are mobile medical apps included in this program? Will this process involve only apps falling under the FDA mobile medical app scope? If so, how is privacy ensured with the other estimated 85% of mobile health apps? If it does not, then how is regulation enforced? Would Happtique’s App Certification Program (which will have publicly available standards soon addressing not only privacy, but safety, operability and content from which developers can blueprint) be more appealing in scope (By way of disclosure I am Sr Medical Advisor at Happtique)?

The bill would also create a low-interest small business loan program to encourage clinics and physician practices to purchase health IT technology and services.  Sound familiar? Have we not already seen the backlash in Congress with regards to Meaningful Use incentive payments? In addition, the bill would establish a tax incentive program to help health care providers deduct the cost of certain health IT systems, excluding electronic health record systems. This is possibly a good idea but is a tax break really a solution to mhealth adoption? Rep. Honda’s bill proposes to set up a grant program to provide support to health care providers who retrain employees for new health IT-related positions. The bill suggests new prize and grant programs like the Tricorder X prize. There are plenty of small and big prize competitions out there.  In my opinion,  the biggest prize should go to the technology that increases any X Prize type technology patient engagement to 100%. Exclusive of the last item, I believe all the previous proposals by Rep. Honda will create bureaucracies and add significant costs to government.  I understand that Rep. Honda is from Silicon Valley and represents technology businesses.  But the need is for legislation on the patient care side of things.  I would recommend reimbursement for proven mHealth technologies, Federal licensing for physicians to increase telehealth, FLEX spending account approval for mHealth, and incentives to payers and patients to adopt mHealth technologies where applicable.

The fiscal cliff will not be solved if the cost of healthcare is not tackled with the same intensity and at the same time.  It is my hope that mHealth technologies scaled to the needs of millions of patients are addressed soon by legislators and regulators in a meaningful way.  I understand the difficulties of mHealth start-ups.  But I believe if patients become the focus of these government bodies, development and adoption of mHealth happen faster and will be less costly. The healthcare cliff is here  now and 2014 will be a watershed. Let’s prepare earlier for it than we have for other cliffs by addressing patient concerns and needs, and realize that if we don’t, we will assuredly have many fiscal cliffs to come.

David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLC advising digital health companies and their partnering institutions, companies, and providers.He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs. . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps. dlschermd@digitalhealthconsultants.com

Five Imperatives for Better Patient Outcomes: Implications for Digital Health Technology

David Scher, MD,
DLS Healthcare Consulting

As both patient outcome and satisfaction gains more attention because it is becoming a basis for scaling healthcare reimbursement, management struggles to determine what constitutes a good patient experience and how best to achieve it. According to a recent survey, 84% of healthcare leaders identify a good patient experience as one of their top three priorities.  However there is no consensus on how to achieve this.  As an active participant in healthcare as a cardiologist for 20 years, I have my own frame of reference, but would like to inject digital health tech as an important variable in my assessment.

1. The patient has a good comfort level with the provider, even it is a new one.  There are many reasons why patients feel uncomfortable with their healthcare.  The erosion of the patient-physician relationship is a fairly recent phenomenon which has as its basis patients changing insurers and subsequently primary care physicians, time pressures of providers, and mutual mistrust. Adding insult to injury, many times (especially at non-routine office visits and during hospitalizations), a patient will see providers never seen before.  This scenario creates anxiety and decreases confidence on the part of the patient.  An EHR which is shared between the provider’s office and the hospital which houses the entire patient’s information is seen as a security blanket by the patient.  My office had an electronic record system accessible in the hospital and on my Palm Pilot mobile device in the 1990s. If I was seeing the patient of one of my partners in the ER and let it be know that I knew everything medically about him from the EMR, the look and feeling of relief was palpable.  EHRs level the playing field if treated with respect and providers pay attention to detail entered and modified appropriately during treatment.
2. An educated patient is a better patient.  Patients who ask the right questions are better patients. Those who take the initiative in both evaluating their providers well and making sure that they participate in shared decision-making increase their chances of having a better outcome. Bedside mobile health patient education tools are here.  Few institutions are aware of their existence let alone utilize them.  They can be placed on a patient or caregiver’s phone or tablet as an app, or transmitted via wifi to a large monitor. Educational videos pertinent to a patient’s condition, test, or procedure in advance of discharge or surgery for example will increase knowledge retention as well as help in risk management and readmission rates.
3. An efficient hospital is a safer place.  Institutions which keep track of patients, tests, materials, and have policies in place to ensure patient safety (surgical ‘time outs’, ‘Did you wash your hands?’, 90 minute ‘door to balloon time’ for heart attacks, etc) demonstrate a general commitment to patients. In the same vein, utilization of unique device identifier technologies for materials might avoid not having the right equipment at the right time in an emergency.  Patients who see order and methodologies in place feel more comfortable than one in which chaos reigns.
4. Communication must be a priority.  Handing off a patient among nurses and physicians at change of shift is the classic time for the creation of medical errors.  I used to listen as a fly on the wall many times and correct errors in these conversations involving patients I knew.  It was a bone chilling experience.  A mistake at that time could easily lead to a wrong test ordered, a wrong diagnosis, and dangerous middle of the night questions to a third-party healthcare provider who knew nothing about the patient.  Patients must be encouraged to ask questions especially about tests and medications and keep diaries about who sees them in the hospital.  If they are incapable of such, they need to have a caregiver present to do this. Many times this is still might even be done via tape recorder when the sign out nurse has already left and questions cannot be answered.  Telemedicine would be an ideal tool for a face to face electronic exchange of critical information. Patients who have providers who are familiar with their cases well feel better and more secure about the care they are receiving.
5. Patient assessment is not just for ‘paperwork.’ Patient assessments are made on admission, every shift, and more frequently according to appropriate clinical protocols. Designing assessments to be incorporated into clinical decision support algorithms and other tools to help healthcare providers at all levels would raise the level of importance and relevance of these assessments. I look forward to this being the case.  This might revive the importance of the physical exam and increase provider-patient interaction because the information gleaned might need to be more detailed or relevant to the patient’s clinical problems, not a standard myriad of check off boxes which are attended to solely for the purpose of ‘paperwork’ requirements by JCAHO.

David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLC advising digital health companies and their partnering institutions, companies, and providers.He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs.  . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps. dlschermd@digitalhealthconsultants.com

 

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