In-Depth: Provider adoption of digital patient engagement tools

By Brian Dolan
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You can't avoid the term "patient engagement" in healthcare today, and for good reason.

Health Affairs explains that "'patient activation' refers to a patient's knowledge, skills, ability, and willingness to manage his or her own health and care," while "'patient engagement' is a broader concept that combines patient activation with interventions designed to increase activation and promote positive patient behavior, such as obtaining preventive care or exercising regularly. Patient engagement is one strategy to achieve the 'triple aim' of improved health outcomes, better patient care, and lower costs."

Providers recognize that patients actively involved in their own care tend to have better health outcomes while also costing the system less. That's why providers are increasingly turning to digital channels to engage their patient population.

And when it comes to patient engagement, the best digital channel to reach patients and consumers is still the smartphone. 

Digital patient engagement by the numbers

“We’ve shown again and again that patients are not only digitally engaged for health, but they are so throughout the patient journey and mobile is really driving that,” Manhattan Research's Monique Levy said earlier this year. “We used to have the sense that people would go online when they had symptoms, and then go to the doctor and then through the traditional medical funnel. With mobile they’re online at multiple decision points in the journey.”

Levy said that 86 percent of the general population is online for health. Half are mobile health users of some kind, two thirds use social media to seek health information, and one third communicate digitally with doctors. About 20 percent of patients say that mobile is essential for managing their care. That goes up to 32 percent for people with diabetes and 39 percent for people with MS.

“What people mostly do on their smartphone is look for information,” Levy explained. “They’re not tracking their blood pressure or video conferencing their doctor; We’re not at that point yet. They’re using it to look up lots of different things: Where is my doctor, what do I need to talk about, how do I prepare for the conversation? What is this drug, what are my choices? Why should I take an oral versus an injectable?”

“In general my clients are wary about [building their own] apps at the moment,” she said. “There’s still people who are trying to pioneer niche apps, and it’s a great opportunity to do interesting work, especially around gaming and health development, but you have to be really careful about how you’re going to get users onto the app.”

A recent survey from Salesforce of 1,700 American adults showed that while for the most part their physicians have been  slow to adopt online tools to communicate with them, they're still mostly satisfied with their care experience.

Less than 10 percent of those surveyed said they set up their doctor appointments using the web, email or text, while 76 percent that still do so over the phone and 25 percent that schedule their appointments in person. When it comes to looking at their own health data, only 21 percent said they used the web (likely via a patient portal). Eleven percent use the phone, 10 percent use email, and 40 percent said they review their health data in person. Only six percent of respondents got any kind of text message reminder from their doctor, while 48 percent got reminder phone calls and 22 percent got reminders via email for things like appointments and prescription refills.

While 92 percent of respondents professed satisfaction with their primary care physician and 86 percent reported being generally satisfied with their care, respondents didn’t love the amount of attention they got from physicians outside the doctor’s office. Forty percent said they receive no ongoing care recommendations from their physician and the lowest area of satisfaction was with education on preventative care (70 percent satisfaction).

Millenials in particular are looking for a more personal connection with their doctor and hoping technology will support it. Forty percent of millennials said they didn’t think their primary care physician would recognize them if they passed each other on the street. Sixty percent of millennials support the use of telehealth options to eliminate in-person health visits, the survey showed, and 71 percent would like to have their provider use an app to book appointments, share health data and manage preventive care.

As Manhattan Research's Levy pointed out, most of the digital health tools with significant adoption are providing patients with education and information. True patient engagement tools are available but very few of them have significant adoption yet. Some 144 healthcare executives working in pharma, medtech, and biotech who were recently polled by The Economist mostly agreed with that assessment.

Seventy-nine respondents over all said the main role of mobile health right now is providing education and information, a big jump from the next most popular answer. Thirty-six percent saw improving the quality of communication between doctors and patients as the main role, and just 19 percent said it was “improving personal awareness through self-monitoring”.

But, when asked to look five years into the future, most respondents saw that primary role shifting. Fifty percent said it would be “enabling patients to participate proactively in their care,” 50 percent said it would be to cut down the cost of healthcare delivery, and 29 percent said improving awareness through self-monitoring. Only 11 percent thought education and information would continue to be mobile health’s primary role.

Sixty-two percent of public sector and 65 percent of private sector leaders said a top benefit of mobile health would be improved health outcomes, stemming from improved patient access to medical information.

While these recently published survey data help sketch out out the current perception of adoption of digital health engagement tools, there is some hard data too.

The integrated delivery network Kaiser Permanente has long been one of the trailblazers in patient engagement, including in the development and deployment of digital health tools. Late last year Christine Paige, senior vice president of marketing and digital services at Kaiser Foundation Health Plan, shared some of her organization's adoption stats for these tools.

Kaiser now has 70 percent of its 9 million members as active users of its online and mobile offerings. Paige said that the number of Kaiser members who are engaged and online pays dividends. In matched pair studies, she said, users who were online were more adherent to treatments, more satisfied with their care, and more loyal: they were two to three times more likely to stay with Kaiser Permanente than their non-connected cohorts.

Kaiser has found success focusing its digital efforts on the patient-doctor relationship. In fact, Paige said, Kaiser’s “killer app” is secure email.

“Probably about 1 in 4 times people do that they don’t have to have an office visit,” she said. “And in a world where there’s more and more cost sharing that’s a really great thing. I don’t have to drive, I don’t have to park, and I don’t have to pay whatever that office visit might have cost me.” 

Kaiser's focus on the patient-doctor relationship means it's not trying to have a digital presence in every area of consumer health and wellness.

“One thing we’ve learned is that we’re not going to be in the health and wellness app business,” Paige said. “There’s a lot of people who do great work there, some who don’t do great work, but many who do, doing fitness apps and monitoring etc. And that’s really important and for some people it’s very, very powerful, it helps them get motivated to get done what they need to get done with their health. But for us, our sweet spot is in making access to the clinical part, the medical part much, much easier. And that’s a complement to what people do in their own life.”

As the body of evidence for what works in digital health engagement grows, Kaiser has made an effort not to let their patients' personal preferences for how they want to interact with their care team to get pushed aside.

"We have both a generic evidence basis for what works better for getting people to comply with a specific behavior that is aligned with their personal goal, but in addition, people have their own preferences for how they want to communicate -- what modality, what kind of communication -- and we need to accommodate those," Dr. John Mattison, the assistant medical director, and Chief Medical Information Officer in the Southern California Region for Kaiser Permanente, explained to MobiHealthNews in a recent interview.

"There is this venn diagram, that I see, that is the personal preferences in one circle and the evidence-based communication, activation, and engagement science in the other circle. There is overlap," he said. "The art of the future is finding that sweet intersection... We need to develop that art -- the intersection of personal preferences and evidence-based science -- into a science of those two."

'You can't teach an old dog new tricks'

“It is a natural tendency of healthcare professionals to not want to be disrupted and not want to change the way that they work,” Dr. David Shulkin, president, Morristown Medical Center, a part of the Atlantic Health System in New Jersey, told MobiHealthNews. “It’s human nature to say, ‘Look, I’ve been seeing patients without this technology, without having them bring their phones into the exam room, I think that’s not a bad way to continue to practice.’ But this disruption, the issue of technology, the issue of consumerism, is an external force being imposed upon healthcare. What I’m trying to do... is to [show that we] shouldn’t fight this external force. We should embrace it and be a part of it, because this is not going away. And, actually, this will improve healthcare outcomes and value in healthcare."

Shulkin said that, like any healthcare provider developing an innovative new service that will change the way care is delivered at his facility, there are those on his team who embrace early adoption, those that have an open mind to it, and those who are resistors.

Dr. Eric Isselbacher, a cardiologist at Massachusetts General Hospital and the director of its Healthcare Transformation Lab, doesn't think it's realistic to expect all physicians to embrace patient engagement tools. He thinks it largely breaks down into a generational divide.

“Some of the older physicians have been practicing in a very traditional environment for a long time,” he said at an event last year. “And an EHR is difficult to grapple with, having everything typed, not handwritten is difficult to grapple with, having people monitor your performance as a physician is difficult, and certainly the digital age communicating with patients in ways other than sitting in the office face-to-face is difficult. I think that for some people that may be too big of a transition, it’s too late in their careers and I don’t think it’s realistic to expect that they are going to embrace it.”

The way to fix this, Isselbacher said, may be to just let this generation of doctors practice medicine the way they always have and then retire out of the system. On the other hand, Isselbacher said that the younger generation of doctors is much more comfortable with electronic devices and social media, and therefore they see patient engagement tools as an opportunity.

“I think they realize that the traditional system of interacting with the patients face-to-face in the office is very limiting,” he said. “And to be able to engage face-to-face with patients at home in real time rather than scheduled visits in the office is a real paradigm shift for them. They think it’s exciting.”

Late last year Boston Children's Hospital's recently departed CIO Naomi Fried also described the rise of digital patient engagement as a paradigm shift.

“We have always been a brick and mortar industry, we have always been a physician-centered industry. The idea that we’re going to have a paradigm shift, we’re going to think differently, provide care differently, is uncomfortable to people,” Fried said. “Even though there are many benefits we can imagine to getting there, it’s not easy to make that shift.”

Under Fried's leadership Boston Children's has identified three factors that can help create a culture of innovation: securing resources, accepting failure, and encouraging innovators.

“It’s really hard to innovate in the absence of getting time, getting money, getting space, and getting support,” Fried said. “So I think putting some energy into resourcing innovators can help get the culture moving.”

As for accepting failure, Fried explains that it’s really important to create an environment where risk is welcome and accepted.

“Innovation is fundamentally a risky process,” she said. “A lot of what you do doesn’t work out. Failure is a common part of the innovation process. So creating an environment where risk is welcome, failure is acceptable — where failure is really seen as a learning opportunity — [that] opens up the environment, opens up the culture, makes people feel comfortable to innovate.”

The third factor, Fried said, is recognizing that innovation is hard and that it’s important to encourage innovators to create new products. The way to do that, she explains, is by recognizing them, acknowledging their work, and appreciating that they are innovators. At Boston Children’s, Fried said, the hospital makes a concerted to recognize and appreciate innovators.

Of course, it helps when a provider organization has leaders who champion innovation in the first place.

Ochsner Health System in New Orleans has made headlines in the past few months for more than one forward-looking patient engagement initiative.

“We were anxious to start and I guess our sense of urgency came from both physicians and patients,” Ochsner’s Chief Clinical Transformation Officer Richard Milani said at an event late last year. “We had a lot of patients that were clamoring. They’re tired of entering blood pressure data with a pen and pencil. They’d like to see it in the medical record. And certainly on the physician side, much the same thing. Physicians asked and we listened.” 

Sometimes patient engagement projects get started at the board level. In a recent interview with MobiHealthNews, Larry Barnes, VP and CIO, of the Salina Regional Health Center in Kansas, said the genesis of his system's new patient engagement app came from a question posed to him from his board of trustees.

"We are fortunate that we have a board of trustees that is engaged," Barnes said. "They are people who have their own businesses and who regularly use apps in them. They're not just familiar with them, they use them. We also have [board members] from outside of the healthcare industry -- from banking -- and they've seen some advanced applications being used. That's what prompted the question to us."

Morristown Medical Center's Shulkin found that the vast majority of his physician leaders were not familiar with the types of digital health technologies in the market. Getting them familiar was an important first step.

"I went to my clinical leaders and said to them, I want you to go on iTunes and look at the most popular apps in your area. When I did that -- and this was 24 clinical leaders -- only one of them had ever been on the AppStore to look at apps before. The reaction of the doctors after they had looked at the store was pretty consistent and pretty incredible. They were amazed at the information that was out there and of the quality of the information that was out there. Many of them, not all of them, then became believers and started talking to their own patients and the faculty in their departments about the quality of the apps that they saw."

Shulkin said that "by getting people to stop what they are doing and engage in exploring what [is available in the market], it changes people. It really is part of the process because now they are personally involved, and it makes it much more likely that they are willing to have the conversation with others since they've taken the time to look at this stuff."

Kaiser Permanente's Mattison agrees that many providers just haven't had time to learn about newer technologies like those used for patient engagement.

"You would think providers would want to optimize health for their members in anyway they could, but what's happening right now is all these regulatory 'clusterbombs' ... have burdened the physician so much," he said. "This debate over the un-usability of health records is absolutely true, too. The un-usability of health records on top of regulatory clusterbombs has caused most docs to be just exhausted with getting through their day and worrying about doing something wrong."

Mattison says to appeal to physicians right now, patient engagement programs need to demonstrate improved outcomes to physicians without requiring more of the time, especially when it comes to training.

"What they are looking for is something that shows them how to get better outcomes with less time invested," he said. "'Show me how I can do it without requiring training.' The way to captivate the clinician today is to show them how with just a few minutes of training, they can actually improve outcomes and save time."

Mattison also said these programs need to be very easy to adopt and the value proposition has to be apparent -- "mind-numbingly apparent". According to Mattison, a good place to start is OpenNotes, an initiative first piloted at Beth Israel Deaconess Medical Center in Boston that gives patients access to their doctors' notes from their visits.

A starting point: OpenNotes and OurNotes

"Cross the Rubicon of OpenNotes -- it's really easy," Mattison said. "It's really powerful and you begin to see that providing more transparency is an extremely efficient method of communication and better compliance. Once they've had that experience, I think it opens up peoples' minds to the fact that sharing more data and being more collaborative is a good thing, not more work."

The first reaction many provider groups have to the prospect of sharing their physicians' notes with patients is a worry that the patient would then be calling them ten times as much to better understand what the notes mean, Mattison said. But the pilot programs for OpenNotes showed that not to be the case.

"The proof is in the pudding. In all the places it has been tested, in no place has the volume of the work gone up," he said. "And the quality of the notes has gotten better as a collateral benefit."

Kaiser has made its physicians' notes available to its members via its mobile app, which has proven especially helpful to patients who receive unexpected news during a visit.

“You go to the doctor, you think it’s going to be a routine visit, and then you learn something, you’re told something you don’t want to hear, or your loved one is,” Kaiser Foundation Plan's Paige said. “You have a lot of attention at that point in time, but you have no retention. You will not remember a thing the doctor said in there because it’s all emotion. So what’s very powerful, I can go back online and I can see the essence of what I was told in that really important interaction.”

Earlier this year Beth Israel announced new funding from The Commonwealth Fund to launch an off-shoot of the OpenNotes program, called OurNotes. This pilot takes the patient-provider relationship one step further by enabling patients to not only review notes but to also contribute to them.

“This is really building for the future,” BIDMC Principal Investigator Jan Walker said. “We envision the potential capability of OurNotes to range from allowing patients to, for example, add a list of topics or questions they’d like to cover during an upcoming visit, creating efficiency in that visit, to inviting patients to review and sign off on notes after a visit as way to ensure that patients and clinicians are on the same page.”

BIDMC’s grant from The Commonwealth Fund will support work at four other sites as well. Two of the sites, Geisinger Health System in Danville, PA and Harborview Medical Center in Seattle, WA were in the original OpenNotes study. Group Health Cooperative in Seattle and Mosaic Life Care in Missouri will also participate in OurNotes. 

Apps from providers, through partners or home-built

While note-sharing might be the best first step for providers, according to Mattison, one way some providers dip their toes into the digital waters of patient engagement is with a branded smartphone app. Typically, these are apps not developed in-house but by an app development shop that has healthcare as an area of focus. Last year MobiHealthNews found more than 200 hospital-branded apps in the Apple and Android app stores, and while a handful are creative takes on patient engagement the vast majority offer a standard set of features not too different from those found in patient portal app offered to providers by EHR vendors. That said, almost none of these non-EHR vendor-developed apps grant users access to their patient portals.

These hospital-branded apps' features include facility locators, physician directories, educational content, and emergency contact information. A few offer more advanced features like appointment booking, secure messaging with providers, health or fitness tracking, bill pay, or prescription refill requests.

Salina Regional Health Center recently launched its first patient-facing app and because it connects patients to their patient portal, Salina's CIO Larry Barnes believes it will help the provider increase its patient portal usage numbers. Salina, which uses Meditech's EHR, is already at meaningful use stage 2 and it has met requirements for patient portal use, but not by a wide margin. Barnes thinks the new app can help with that.

"I don't think patient portals are going to be used very much if you have to have a degree in IT to be able to use them," he said. "Accessing the patient portal with this app has to be simple enough that non-IT people, who are not familiar with computers at all, can still find their information. I think this app is a very good solution for us. We'll start to see once we get more people downloading it. We're less than 50,000 people in this community, but we are already seeing people downloading and using our app."

Other providers have created apps that patients or their family use once admitted. Boston Children's MyPassport app is preloaded onto loaner iPads that are given to patients' families upon arrival.

“MyPassport is actually a mobile app for patients admitted to the hospital and once they’re in the hospital allows them, or their parents in our case, to see what the lab results are as we make them available,” Former CIO Naomi Fried said last year. “It also shows the family everyone who is taking care of the child — pictures of the care team along with their role and their names so [parents] can track who’s who. It shows what the care plan is because patients and families want information. They want to understand what’s going to happen.”

The creation of Boston Children's MyPassport app is unusual too. It was conceived of by the facility's urologist Dr. Hiep Nguyen, who entered the idea for it into the hospital's innovation awards contest and won.

George Washington University's associate professor of emergency medicine Dr. Neal Sikka is piloting a tool he helped develop for patients before they are admitted to GW's hospital: a virtual mobile health coach that preps a patient for a colonoscopy. Sikka is curious if the program can help better prepare patients for the procedure and whether that leads to improved detection of potentially cancerous polyps.

Most healthcare providers aren't developing these tools in-house, however. That's true for smaller providers like Salina Regional but also large ones like CHE Trinity Health.

"If you look at the position that a lot of the not-for-profit healthcare providers are in, it's just very difficult for us to keep up in this digital health world," Scott Nordlund, Executive Vice President for Growth, Strategy and Innovation Development at CHE Trinity Health told MobiHealthNews during an interview last year.

Nordlund said that because the technology changes so fast and some of the investments required to build these tools are so large, it makes more sense to partner with health technology companies rather than building these tools themselves.

Letting the EHR vendor drive

While CHE Trinity Health and others have sought out partners to build patient engagement tools with, most providers today are still relying on their existing health IT vendors, especially their EHR vendors, to build these tools for them.

"The default is, as one vendor said, you go with the radio that comes with the car," Chilmark Research Analyst Naveen Rao told MobiHealthNews in an interview. "You use the patient portal that came with your EHR. It’s free, you paid for it, it checks off meaningful use, you move on."

Rao's most optimistic estimate for when patient engagement technologies -- like telemedicine, chronic disease management tools, patient generated data, and mobile apps -- will be widely deployed is 18 to 24 months. The delay is a result of providers waiting for vendors to step up, while vendors are still finding that the most reliable money is in basic, meaningful use-driven tools like patient portals.

"I wouldn’t call it a standoff, but it’s kind of like both sides are waiting for the other one to move," he told MobiHealthNews. "You have these healthcare systems who are basically sticking to a portal and they’re kind of looking to their health IT vendors -- who they’re already paying lots of money --  to roll out mobile apps, telemonitoring solutions, and things like that. And the vendors are like, 'The doctors and the hospitals they tend to want things to get them the meaningful use dollars.' So it’s like, who’s going to move first to these newer technologies?"

Rao said that the smaller EHR vendors are the biggest laggards as larger firms have more funds to build and iterate their apps. In recent weeks Epic Systems announced plans for making APIs available to developers who are interested in creating apps that sit on top of their EHR platform. The move has been widely compared to an app store.

"I have been urging Epic for five years to open up their APIs so that they can exploit a platform model and rely on third party creativity, innovation, and development to do that so providers don't have to rely on a purely out of the box solution," Kaiser CMIO Mattison told MobiHealthNews. "As you know, Epic has announced plans to do just that, just recently."

Mattison is very bullish on what this move could mean for providers and patients on Epic's platform. Mattison characterized open APIs as a "necessity to liberate innovation across the health records community and the mobile health community."

Epic's plans are still in their early stages, but considering the company was the very first EHR vendor to work with Apple to integrate patient generated data from that company's HealthKit data exchange, the work developers do thanks to the forthcoming Epic app store will certainly help shape the future of digital patient engagement. 

Providers try embracing data from wearables, health-tracking apps

“Earlier this spring, I had a couple of clinicians approach me — one from cardiology, one from oncology — and they both had pilot studies they wanted to conduct using remote patient monitoring and patient generated data,” Dr. Ricky Bloomfield, Director, Mobile Technology Strategy for Duke Health Technology Solutions said last December. “My answer at the time, as director of mobile technology, was one that was very unsatisfying to me: That there wasn’t an easy way to get that data into our Epic EHR, which we just went online with in the last two years. There was technology coming in a future version of Epic that would give us access to Fitbit and Withings data but that wasn’t available yet. So when Apple announced HealthKit at their Worldwide Developer Conference in June, I knew that it would solve the problem we had. So we were very excited to work with both Apple and Epic to make it happen.”

Last year Apple's unveiling of HealthKit, which makes it easier for health apps to push and pull data from each other, it announced that it was working with Epic to push data to that company's EHR product, too. Apple flashed a slide with a dozen or so healthcare facilities around the country who would be in position to take advantage of that integration since they were Epic shops.

Duke, Stanford, and New Orleans' Ochsner were among the earliest providers to test out the new patient generated data opportunity. For now the data pipe is just one-way:

“It doesn’t come in as an unintended flood of information I didn’t ask for,” Dr. Richard Milani, Chief Clinical Transformation Officer at Ochsner Health System said. “So if I’m seeing a patient and we’re having a discussion and I want to monitor their blood pressure, I can put an order in and I can determine the frequency with which I want to be notified or my staff to be notified, and off we go.”

Additionally, Milani said, the data stays stamped with the app it originated from, so if the hospital determines that a particular app or device has an accuracy problem, they can flag it and disregard that data in the future, or recommend that patients switch to a different app.

Providers recognize, of course, that fewer patients use iPhone than Androids, so the need for a way to receive this kind of health data from Android users is top of mind for those running these HealthKit pilots at facilities today. Google has a data aggregation platform called Google Fit, but it hasn't yet announced integrations (or plans for them) with EHRs.

“I think Google needs to do a little bit more to get it into the place where HealthKit currently functions, but I can’t wait until we can use Android devices as well as iOS devices, one to the other,” Duke's Bloomfield said. “For me the most important thing is we give this ability to our patients. And I don’t care which device they have, I just want them to be able to give us the data so we can make good clinical decisions to help them out.”

Moving from data feeds to digital interventions

Integrating patient generated data into EHRs is no small feat, but it's also just one step toward true patient engagement. Many of the most promising companies working in digital health today have created digital interventions that are enabled by mobile devices, sensors and apps, but actually use that data in a clinically-proven program that produces better patient outcomes than the status quo.

Chilmark Research's analyst Naveen Rao believes that because these innovative approaches to patient engagement get more press coverage than the more common legacy approaches, patients and providers might believe these tools are more widely deployed than they actually are.

"A lot of the progress does tend to come from the smaller companies, the startups and the people who aren’t held back by the baggage of having so many customers they have to be servicing and keeping happy all the time," he said. "What that means is they’re usually backed by venture firms that have an interest in them getting good press and being bumped up. So it’s sort of the nature of the game."

These companies are developing the technology, piloting it, and building out their teams to get ready for scale. Most of the startups are focused on just one or two chronic conditions today, but their approach -- once validated -- should enable them to make lateral moves into other conditions. Rao believes a natural shift in the market will pave the way for them to finally scale.

"So as we see this develop over the next couple of years, what we see [coming is] two waves of adoption of infrastructure and IT and technologies. And patient engagement, for better or for worse, is not really a part of that first wave," he said.  "The first wave is infrastructural stuff -- building out analytics, building out registries, figuring out how to basically take on the management of populations of people. This is new territory for a lot of the providers. ... So once they get the first level built, the foundation, then patient engagement, connected health, telemonitoring, smarter care planning tools, and mobile apps [can follow.] Those pilots that are out there today are going to spread from one-office practices to five-office practices, and from one department to three or four departments in an organization, and we’re really going to see a lot growth." 

Hospitals carve out a physical space for engagement

A few forward-looking healthcare facilities have even begun setting up physical stores, what they call "Genius Bars" because they were inspired by Apple Stores, where hospital staff meet face-to-face with patients, their familiar, and sometimes providers to help them figure out how to use various patient engagement technologies.

Toward the end of last year, Morristown Medical Center, a part of the Atlantic Health System in New Jersey, opened up HealtheConnect, an on-site, physical store located just off the hospital’s main lobby where patients, family members, and medical professionals can learn about health apps and wearable devices. While the store is currently backed by the hospitals foundation, the longterm plan is to transition it into a business and revenue stream in its own right — in about a year’s time.

“Even though I am the CEO of the hospital, I am still a physician with an active practice in internal medicine. One of the things I was seeing with my patients was they were coming to me and asking me what apps would I recommend they use,” Shulkin explained.

Patients have asked Shulkin for his take on the recent spate of wearable health device launches and how he might be able to integrate some of the data from these health apps into his practice, too.

“Whenever I think patients are coming in with questions or information about their health that I can’t answer, or my doctors can’t answer, I think we have an obligation to be part of that dialogue, to learn along with them, and to be there as a resource for them,” he said. “Throughout my career, whenever I’ve seen the healthcare industry act paternalistically and like they know better than patients, the healthcare professional has been left behind. The example that I use is integrated medicine where patients, many years ago, were coming to us and asking us how to use herbs and different types of supplements and how to deal with some of their chronic problems with some of these non-Western or non-traditional therapies. By and large the medical profession ignored it — and that didn’t stop it.”

Shulkin said that like integrated medicine, digital health and the rise of health consumerism will be fundamental change agents for the practice of healthcare.

Last summer Ochsner Health System in New Orleans launched its O Bar, which was the first “Genius Bar-type” in-person center for learning about health and wellness apps. The facility recommends apps and devices to patients from a bank of 200 to 300 vetted health apps. The apps run the gamut from food and nutrition tracking, to fitness and activity, to apps that help manage chronic conditions like diabetes. Some help users quit smoking while others offer support and education to expectant mothers.

A room in the Ochsner Center for Primary Care and Wellness has a fleet of five iPads locked to a bar, each one loaded with all the apps the health system has vetted and approved. The O Bar is staffed by a technology specialist that can help patients find out what’s available and help teach them to download and use the available apps.

“The apps are out there and people are going to get them,” Ochsner’s Chief Clinical Transformation Officer Richard Milani said. “The smart thing for us to do is get our hands around what we think are pretty good apps and make them more helpful to patients.” 

Accountable care is driving patient engagement

There are any number of trends driving the growing important of patient engagement in healthcare, but arguably the most forceful one has been the rise of accountable care models.

“We have to earn patient engagement,” Steward Health Care System’s President Dr. Mark Girard said recently. “We have to drive good outcomes, we have to drive quality. [Patients] don’t really care about the overall [total medical expenses]. They might care about some of their deductibles and copays, but what they want is convenience. They want access, they want quality, they want good outcomes, they want integration. They want to know that when they’ve seen one doc and then they get an appointment for another doc, that the information is arriving there at the same time.”

At Steward, Girard said that about 4 to 5 percent of the company’s covered lives generate about 50 percent of the total medical expenditure, while 20 percent of the patients account for about 80 percent of the spend and the remaining 80 percent of patients account for about 20 percent. Girard said that this means the entire economic viability of his program right now is managing and engaging that 4 percent of the patients.

Where patient engagement goes next

As CHE Trinity Health and other providers have recognized technology moves quickly, and what some believe to be the form factor that eventually supplants the smartphone is already making its way to the market: the smartwatch. Apple's take on it, the Apple Watch, is set to commercially launch in April, but at least one healthcare provider has already announced plans to pilot it with patients.

Springfield, Illinois-based Hospital Sisters Health System (HSHS) has begun work on a pilot program to examine how nurses and physicians can integrate the Apple Watch into the medical group’s Advanced Medical Home program.

HSHS’ Advanced Medical Home program, which has a total of 1,100 patients, uses nurse navigators to offer specialized care to high-risk patients with chronic diseases. While the patients in this program are also participating in face-to-face visits, the program plans to expand their health monitoring efforts by using the Apple Watch potentially in conjunction with other healthcare tools. When the pilot starts, the team will recruit between 25 and 50 patients from the Advanced Medical Home program to participate.

The Apple Watch, which was unveiled in early September, will track movement through a built-in accelerometer and heart rate through optical sensors in the back of the device. It will extrapolate further data from the GPS and WiFi on the user’s iPhone.

“Our plan is to give [the Apple Watches] to our nurse navigators to take a look at, to use, to test, and to find out what information is there and compare it to ensure that it’s reliable so we know where the shortcomings are,” HSHS Medical Group Chief Quality Officer Andrew Bland told MobiHealthNews.

As a healthcare provider that has been out in front of the digital health trend for years, Kaiser Permanente's current projects probably best serve as an indication as to where patient engagement is headed.

Dr. John Mattison, the Assistant Medical Director and CMIO of Kaiser Permanente in Southern California Region, told MobiHealthNews in a recent interview that one of his ongoing programs has been focused on maximizing his group's ability to inform patients through capturing passively acquired data. Once patients agree to participate in a program like this, they aren't required to manually enter health data or fill out questionnaires, but an analytics engine can determine various things about their health status based on how they use their phone, the tone of their voice, how much they move around, and so on.

Mattison said his team is also working on a similar program specifically for people with diabetes that enables their glucose readings to be automatically uploaded in a closed loop that returns some decision support tools that help them self-manage better. The provider oversight only gets triggered by outlying values, red flags, that might be a particular high or low value or a troubling trend in the data.

Kaiser Permanente is also fine-tuning is ability to figure out exactly how its members want to communicate with providers and their health plan. Mattison recently began testing a platform that uses psychometric profiling of individuals to figure out how to personalize communications to them.

"Do they respond to humor? Do they respond to very directive 'you should do this'? Or do they respond to an option analysis where they make their own decision? Or an option analysis that includes some shared decision making?" Mattison asked. "We have tons of data showing what kind of interaction is generally more effective through text, through email, an embedded app, or various incentives models... Again, we have lots of information there. But the population-based evidence should not override personal preferences. Personal preferences should not override the evidence either. It's a blending of the two that is critical."

This year is set to be an important one for many providers working on patient engagement initiatives.

In January at CES, one of the largest technology events in the US, Dr. Glen Stream, the chairman of Family Medicine for America's Health, a group that represents primary care doctors, took to the podium to offer his organization's help to those working on digital patient engagement programs:

“We are here as part of a broader effort to improve our health care system and the health of all Americans,” he said. “We believe consumer health technologies — apps, wearables, self-diagnosis tools — have the potential to strengthen the patient-physician connection and improve health outcomes. We are here to talk about where we see opportunity and need, and how we, working together with technology companies, can overcome the barriers that are keeping us from fully leveraging the power of consumer technology in primary care.”

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