There’s an App for that !

Virtual Care, Live Decision Support, Handhelds and the Implications for Health Information Technology and Population-Based Care Management

 

Introduction

With a few exceptions, increasing the number and intensity of health care services to more U.S. consumers has not been accompanied by any commensurate improvement in quality or costs (1,2). This has fuelled a growing national consensus over the need to reward providers for greater “value” instead of “volume” (2). In response, government, commercial insurers, employers and other stakeholders are seeking higher value by linking improvements in quality to a variety of non-fee-for-service payment methodologies. These include case management fees, varieties of capitation, episode of care based payments and shared savings arrangements that, in turn, are partially dependent on measurable increases in clinical and consumer based outcomes (4, 5)

Health Information Technology for Providers

As value based reforms spread, providers are responding to the demand for value by leveraging health information technology (HIT) solutions. The most visible of these has been the electronic health record (EHR). While early versions served primarily as documentation and billing tools, EHRs have grown in sophistication and often provide other innovations, such as patient “portals,” care coordination resources, provider clinical decision support tools and data warehouses (6-9).

Health Information Technology for Individual Consumers

HIT’s value proposition has also grown thanks to its ability to enhance patient decision support. To date, the most obvious expression of this is at the individual level through the provision of evidence-based reminders that identify health screening needs, reduce the risks from chronic disease and optimize medication dosing. There is a considerable body of published scientific literature that has demonstrated that enabling patients to be active participants in their own medical decision making leads to commensurate increases in quality and lower health care costs(10-12). These opportunities to increase quality and reduce avoidable complications has undoubtedly been an important factor in the promotion of patient participation in the U.S. government’s EHR “meaningful use” criteria (13).

 


A Patient’s Story

Mrs. Smith* is an elderly woman with severe rheumatoid arthritis with mobility challenges who finds it difficult to leave her house for any reason, including doctor appointments.

During cold and flu season, she is prone to getting upper respiratory tract infections, which, thanks to her weakened immune system from her multiple medications, can turn into a life-threatening infection at any time. Frightened by the prospect of coming down with pneumonia, otherwise mild symptoms have prompted her telephone her physicians to seek out reassurance and medical advice. When her physicians have been unable to ascertain her status and the patient has been overwhelmed by her symptoms, she has traditionally sought out emergency room care.

By providing Mrs. Smith the ability to assist in her assessment in the home setting using a messaging system coupled with monitors for pulse oximetry, temperature, heart rate and blood pressure, Mrs. Smith’s physicians were better able to assess her illness. Shifting toward a value-based reimbursement system and the recent implementation of EHR-based decision aided the physicians in considering care options in addition to a referral to the emergency room.

Reassured by normal physiologic readings during her next cold, Mrs. Smith collaborated with her providers and decided to stay home that afternoon. The next morning, transportation was arranged to her primary care physician’s office. She was able to return home later that day.  (*Name changed)


 

Population Health

While the United States recoups the dividends of HIT at the individual level, there has been increased interest in also leveraging its advantages at the population level. Population health management can be defined as “an approach that aims to improve the health status of the entire population through coordination of care across the continuum of health in order to improve behavioral/ lifestyle, clinical and financial outcomes” (14). When coupled with the ability to assess aggregated outcomes, inform clinical programming and support “mass customization,” there is a tangible prospect that HIT will play an important role of achieving health care “Triple Aim” of lowered costs, increased quality and patient experience at a regional or societal level (15-18).

Health insurers and providers readily recognize the value of information technology to better serve their patient populations and achieve success with the rise of payment reforms. According to a recent HIMSS survey of HIT leadership, two thirds of participants predicted a significant budget increase in the IT operations to demonstrate improvement in the Triple Aim goals of improved costs, quality and consumer-patient experience (19).

Necessary, but not Sufficient

While advances such as the EHR, data warehouses, decision support, patient portals are exciting advances, medSolis believes that in order for HIT to achieve its fullest potential, two largely unmentioned ingredients are also necessary. Until they are included, the clinical and economic potential of population health will never be achieved:

1) Virtual Care: this is defined as offering services and support outside of the traditional on-site confines of the health care delivery system. In other words, by extending the information “ecosystem” beyond the four walls of the hospital or the clinic, consumers will be able to substitute or supplement their in-person one-on-one encounters with providers. Growing consumerist service expectations, the ubiquity of high-speed wireless networks and increasing reliance on handheld devices in other sectors of the economy are destined to catalyze the provision of care services in the home and workplace. At this time, the majority of this consists of electronically enabled and asynchronous interactions such as messaging and the transmission of stored data. medSolis believes this will grow in sophistication and scope. Examples include individually timed patient prompts, information-sharing outside the provider-patient dyad to include family and other caretakers, image sharing, “live” teleconferencing and the “real-time” capture and analysis of clinical patient data.

2) Continuous Decision Support: this can be defined as enabling consumers to meaningfully participate in their own care on a live or as-needed basis. Until now, decision support has been largely validated in the context of a face-to-face provider visit and used to inform more long-term decision making, such as elective invasive surgery, cancer screening or use of medications (20, 21). While this a critically valuable advance in patient care, its true value will be unlocked by contemporaneous access to information as patients flow through their episode of care (22).

medSolis also suggests that virtual care and “live” decision support are mutually supportive, making the product greater than the sum of its parts.

The Twofold Standard of e-Care: Ease of Use and Hand helds

Despite the best intentions, virtual care and patient decision support will be of little use unless patients and providers find that the supporting technology is easy to use and portable.

For Patients

Health providers have known for decades that complex and jargon filled educational materials are unlikely to be have any impact on patient care. Fortunately, there are guidelines that have been developed to increase understandability and actionability of patient information (23).

However, in addition to these longstanding issues around content, virtual care and live decision support will never be adopted by consumers unless they are conducive. Having an overcomplicated interface, poor legibility, slow connectivity, loading delays, electronic dead-ends and crashes are as certain as opaque medical jargon to frustrate the user experience and diminish its effectiveness.

Fortunately, the advent of consumer-friendly “smart” devices, such as touch-screen smart phones and tablets has transcended the traditional reliance on keyboards, mice and the other residue of complex PC-based operating systems. “Two touch” innovative programming (24), high speed networks, off-the-shelf technology, touch screens, interchangeable components and cross-platform interoperability have finally put a highly functional and affordable consumer-patient experience within reach.

medSolis believes this emerging standard of easy to use and portable e-care are the critical ingredients that will deliver the right assistance at the right time for the right patient.

 


A Doctor’s Story

After receiving demographic, clinical and utilization data about of a highly vulnerable group of patients, Dr. Jones* quickly concluded that her current electronic health record (EHR ) was ill-suited to coordinating care at a population level. As a result, she worked with like-minded colleagues to convince her leadership that the price-point of hand-held tablets was not only extremely attractive, but that they could be used to facilitate shared decision making. By tapping a specially-designed “app”, patients had access to a variety of resources, including the ability to communicate directly with members of the health care team.

Dr. Jones was also interested in being able to link the tablets to her EHR, as well as create a browser-based interface that she could use to gauge the well-being of her patients. While there were operational details to be worked out on adapting the app to her team’s work flows, the outcome was far more preferable than the status quo. What’s more, she was able to collaborate with co-workers in the hospital as well as within the care management department of a local health insurer. The cost of the intervention was far less than the savings that were ultimately achieved.  (*Name changed)


 

For Providers: Whither Workflows?

medSolis believes that in order for population-based HIT to succeed, it is vital that any technology solution seamlessly integrates into day-to-day provider workflows. The resource-expensive work-arounds necessary to adapt the EHR into busy clinics remains an important lesson about the need to develop solutions that help, not hinder, efficient patient care (25-27). Important options to ease the integration of HIT into this workspace includes adaptability to both PC and tablet-based browsers, providing summary dashboards, making updates automated, making documentation easy and facilitating ready access by members of the health care team without regard to setting or level of care.

HIT and local health care

Thanks to falling infrastructure costs and innovation, HIT is no longer the exclusive province of large or well-capitalized providers. Cloud-based technology, modular platforms and increasing data fluidity have not only led to unprecedented drops in cost and jumps in usability, but in availability. As a result, HIT and all it offers is now accessible to small provider-owned practices that still provide the majority of health care in the United States (28).

Yet, even large health systems are interested in low cost solutions that can be offered to their individual work-units. Thus, while a flagship hospital may have to invest in a large EHR, a downstream subsidiary or an aligned independent clinic may benefit from locally tailored solutions.

Yet, whether they are a large health system or a small independent primary care practice, users of HIT are increasingly wary of its indirect and hidden costs. These include unwieldy updates, training costs and the effort involved in integrating it with other information systems and databases. This not only adds complexity, but is a source of income for incumbent legacy systems that traded transitioned from providing value to protecting market share.

medSolis believes this hidden side of HIT is also an emerging differentiator among competing HIT systems.

Summary: The medSolis Aspiration

medSolis believes the excitement behind the saying “there’s an app for that” is based on meeting patient and provider expectations for an intuitive interface that offers a manageable and affordable set of meaningful options that are easy to navigate, provide feedback and generate immediate results. The virtual care combined with decision support must 1) ultimately assist the patient to participate in medical decision-making, and 2) facilitate care by providers in a manner that enhances, doesn’t hinder, the Triple Aim of higher quality, lower cost and with a patient experience.

What is medSolis?

medSolis pairs a simple, smart and scalable care management record with an easy-to-use hand-held patient “app.” Both relies on the latest and most cost-efficient cloud-based technology. Preliminary piloting has shown that it can be integrated into practically any care setting, including the post-acute care setting for readmission reduction, medical homes, ACOs and health plans.

1) Simple intuitive interface. This takes advantage of the “tipping point” in hand-helds and monitoring devices; in fact, if a patient doesn’t already own one, medSolis will work with your organization to provide it.

2) Zero risk start. No training. No infrastructure. Start small and scale up.

3) Faster, better and cheaper turnkey solution to run specific program that addresses your population’s needs. Minimal staff workload or additional IT resources that appeals to the largest health care system as well as a local clinic.

4) Deep expertise in risk stratification and care management systems.

Care Management

Defining Care Management

Care Management is the art and science of monitoring and maintaining a person’s health between hospital or physician interactions. It involves encouraging right actions by or on behalf of the person, at the right time, and identifying the need of appropriate interventions. A well-executed care management program can go a long way in achieving the triple aim of: improved outcome, lower cost, and increased (patient) satisfaction.

Care Management 1.0 – how is it done today?

Care Management in the healthcare industry has traditionally been driven by Health Plans, who have had the economic interest in reducing the cost of care. The delivery has been led by Care Managers, who are nurses or other healthcare workers, relying primarily on telephonic interaction with individuals receiving the care. These Care Managers have relied on the claims data or self-reported data by members, which has the perils of some combination of being delayed, incomplete and inaccurate. Reliance on telephonic interaction also poses the problem of reaching a member at a time suitable for and preferred by him or her. As a consequence, care managers typically spend more time chasing a member than enabling management of care for them. In the midst of all of these problems, providers have remained only loosely connected with care management programs due to very distinct non-overlapping distribution of responsibilities between Health Plans and Providers.


Care managers typically spend more time chasing
a member than enabling management of care


As a result most care management programs suffer low participation and poor compliance. No wonder, traditional care management programs have not been able to deliver the promised value despite the best efforts by care managers and Health Plans.

Care Management 2.0 – how is it evolving?

With the emergence of new payment models including but not limited to bundled payments and ACOs, the industry is decidedly shifting from fee-for-service to value-based healthcare reimburse-ment. This has catalyzed significant changes in the need for care management, which is now emerging as a priority for Providers along with Health Plans.

With Providers taking on more risk-share payment arrangements, there is a greater incentive for them to work with Health Plans to implement effective care management strategies. Hence there is an increased willingness by Providers to invest in care management programs. At the same time, Health Plans are increasingly exploring ways to work with Providers to synchronize care management activities.

Simultaneously, technological innovation and resulting penetration of mobile devices have led to vast new opportunities to reach members, which didn’t exist even a few years ago. This opens up exciting new avenues of synchronous and asynchronous communication that can be personalized down to the population of one.


Synchronous and asynchronous communication
that can be personalized down to the population of one.


The combination of these two factors has a transformative impact on the discipline of care management as we know it. While this potential transformation does not change the fundamental strategies or invalidate decades of learning of the discipline, it does present new opportunities to implement, and sometimes modify, them.

Coordination of the care team

With providers launching their own care management initiatives, the industry is at a crossroads – what is the right structure and ownership of care management programs?

Multiple entities running care management programs has the potential of creating confusion and irritation for members who are the target beneficiaries. Instead of increasing participation and compliance such overlap and confusion may make it even worse.


An integrated continuum of care will deliver a single Care Plan to members, and will be driven by a single “quarterback” managing that delivery with the rest of the care team blocking, tackling or catching based on their roles.


Successful approaches in care management will see increasing coordination between Health Plans and Providers. An integrated continuum of care will deliver a single Care Plan to members, and will be driven by a single “quarterback” managing that delivery with the rest of the care team blocking, tackling or catching based on their roles.

The same continuum will also hold over for the life of a member, as a member transitions from one care setting to another, and one type of care need to another. Moving from post-acute to long term chronic care, for instance, will not mean hand off across organizations and programs, but will mean evolution of care plan with morphing roles of stakeholders and frequency of touch.

Who needs care management programs?

While the industry is still in great flux, it is becoming clear that an increasingly varied type of entities need care management, and opportunities are emerging for greater alignment. Various industry participants that need to think about (or rethink) their care management strategy:

1. Hospitals and multi practice physician organizations

These organizations are taking on risk for some of their patients in the form of bundled payments or other risk share arrangements. They are also under a constant threat of penalties resulting from avoidable read-missions and often spend a lot of effort and money on preventing that penalty. They usually have a limited care coordination program in place that helps synchronize healthcare resources and schedule followup appointments. However, to accomplish their goals, they need a full blown care management program which requires operational as well as technological enhancements. While they would do best by coordinating their care management initiatives with Health Plans, they typically work with multiple Plans, complicating the ability to coordinate. They need their technology to be integrated with EMRs. Solution provided by most EMRs vendors are inadequate for various reasons, complicating their technology decisions.They do not have the benefit of much experience in managing care post-transition out of their facilities, and would need to integrate the care management efforts with any existing outpatient chronic disease management programs, and outpatient clinics.

2. Long term care facilities

Long term facilities are downstream participants of bundled payment arrangements adopted by hospitals. They do not have the budget to roll out an independent program and will be best served by coordinating their care management initiatives with those of hospitals’.

3. Accountable Care Organizations

These organizations are integrated systems taking on risk for their members in the form of risk share, gain share or full capitation arrangements. They have a health plan as a part of the organization and hence have established care management capabilities. Their capabilities, however, suffer the shortcomings of traditional Health Plan based care management programs. They can enhance these programs by promoting greater coordination between participating providers and using recent member engagement approaches. They need enhanced workflows and technology to accomplish their care management goals.

4. Health plans with increased exchange population

Health Plans participating in Health Insurance Exchanges are facing increasing commercial population that are all at risk. With the increase in risk pool, the need for effective care management is higher than ever before. They need to increase the effectiveness of their care management programs to manage the new risk, which means driving higher member engagement and compliance than their current programs are able to achieve. They have a very capable staff in place and have a significant investment in technology. They need to enhance their capability by complimenting their existing operational and technology infrastructure, not replacing it. Given the need to evolve a sizable existing care management programs, it is a difficult organizational change management problem, which is best spearheaded by bold and creative leadership at all levels of their organization.

5. Medicaid plans with increasing enrollment

Most Medicaid plans have seen increased enrollment. They have also seen an increase in coordination attempts like Patient Centered Medical Homes (PCMHs). While they would like to delegate care management initiatives to PCMHs, the distributed scale and lack of expertise makes such an approach unrealistic. Hence, the larger pool, and newer initiatives, necessitate increase in scope and function of their care management programs. Their task is even more challenging than that of Health Plans in that in involves significant expansion, change management, and oftentimes a severe financial limitation. Addition of MCOs by many states adds another dimension to their task of implementing an efficient and effective care management program.

6. Medicare plans with the highest risk population

Medicare plans have the highest risk population. They have typically run extensive care management programs, which include complex case management, case management and disease management. With new payment arrangements and new technology, they need to enhance their care management capabilities by modernizing their technology and workflows. Additionally, they need a more coordinated care management approach with providers. They also need the new technology to work along with their existing technology. They also face a daunting organizational change management challenge.

7. Employers facing higher medical costs

Self-insured employers are facing increasing medical cost, and are passing more of it to employees. Selective care management approaches can help them control the cost while offering better healthcare options to their employees. They are already providing incentives for change in health behavior. Layering a targeted care management program can make those initiatives more effective.

Challenges faced by Care Management 1.0

While each of the above organizations face their own unique challenges, a few obstacles are common across all of them. Adaptation of a program that fundamentally solves these obstacles is likely the most effective approach for them.

Common obstacles:

1. Inability to reach members/patients

Primary means for care managers to get in touch with members is through telephonic conversation, during work hours. The resource intensive nature of this approach forces only a small percentage (2-5%) of population to be included in any care management program. Even that population is contacted based on a pre-determined schedule, often not any more frequently than once a month. Furthermore, those infrequent contacts are rarely at the convenience of the member, and often need multiple attempts to even have a conversation. The result is unenthusiastic participation by members, leading to poor compliance.

2. Delayed information

The information based on which care managers operate comes from claims. That information is delayed and incomplete (for instance, it says that a test was done, but not what the result of the test was). Lacking current information, care managers have limited ability to recommend timely interventions stunting the value of the care management program.

3. One size fits all approach

Care managers hardly have any systemic ability to personalize their approach for each member. Current programs depend on care managers’ personal ability and initiative to connect with members, which obviously is uncertain and uneven. Lack of personal connection is another disincentive for members to value the program.

On to Care Management 2.0

In light of the challenges facing Care Management 1.0, a program that allows multi-channel, asynchronous, on demand communication with members can solve a big hurdle in interacting with them. Additionally, personalization of interaction with members can further enhance their willingness to actively participate. Finally, insight into the everyday condition of a member can empower care managers to prompt timely interventions, which may prevent the escalation of a problem while increasing members’ confidence and engagement in the program.


Note the emphasis on minimizing member efforts,
empowering care managers, and simplifying for all stakeholders.


While several approaches attempt to address these problems using mobile apps for members, over reliance on such apps puts a significant amount of demand on members and does little to empower care managers, who are a critical part of any care management program. The optimal approach to a modern care management program, therefore, is a mix of what has worked in the past (use of expert care managers providing a human touch and intelligence), approaches made possible by new payment models (alignment of provider and Health plan interests), and new technology (simpler and smarter technology offered to care managers supported by sleek biometric and mobile devices for members). This combination should create a sensible care team, empower the participating care managers, and enable members to plug in while asking for minimal effort on their part. Note the emphasis on minimizing member efforts, empowering care managers, and simplifying for all stakeholders.

KISS

The age old principle of “Keeping It Simple, Stupid” could not be more applicable while considering the implementation of Care Management 2.0. Simplification does not mean doing only simple things, but means prioritizing highly effective things, and making them intuitive and efficient. Striving for simplicity in an inherently complex endeavor, such as this, requires clarity of goals, expertise, and commitment. It also requires recognition that different approaches are needed for simplicity for members (non healthcare and technology experts) and that for care managers (health care experts).

For established care management programs, it starts with an across the organization “buy in” of the opportunity presented by this change. It involves inspiring and supporting the staff with easy to use, yet powerful, technology and workflows. It also includes recognition by the leadership to expect more from their care management program, and start measuring the success parameters that actually move the needle towards achieving the triple aim goals. The need for reporting for compliance complicates this effort and must be dealt with practically. For new care management programs, an appropriate emphasis on people, process and technology, coupled with an incremental roll out approach, can be most effective.

Can MEDSOLIS help?

MEDSOLIS suite of care management solution is designed from the ground up to address precisely the problems in the current approaches, and take advantage of new possibilities. Moreover, it does so without requiring any additional infrastructure investment, minimal training, and no additional human resources. Finally, it prioritizes adherence to the principle of simplification.

How it works

MEDSOLIS proposes a care management program – mPower – that is a combination of suggested workflows and a suite of applications. Both the workflows and the technology are amenable to incremental customization allowing care managers to make it their program. The suite has the following components:

• mCompanion: A smartphone and tablet app for members that is capable of connecting wirelessly with a wide range biometric devices such as glucometer, BP monitor, oximeter, and weight scale.

• CareConnect: A web based interface for care managers that is a smart and simple to use care management application

• mDoc: An optional smart app for physicians, if their involvement is a part of the workflow

The MEDSOLIS application delivers a personalized care plan for members/patients, and helps them comply with it. It sends to them timely notifications and simple actions to be performed by them. As they execute those simple actions, the care plan compliance is automatically achieved without them having to bother about learning it, or even knowing about it.

During this interaction, the application captures information about member’s day-to-day progress and summarizes it in real-time on their care manager’s dashboard, where the platform dynamically prioritizes which members need attention at any given time. Using these insights, care managers can communicate directly with members via the product’s secure communication command center. Communication options include offline messages and / or questions, thereby reducing the need of burdensome live communication.

The impact of MEDSOLIS

MEDSOLIS does not replace human care. It simplifies and amplifies it. By drastically reducing the burden of unproductive activities, it makes care managers more efficient and effective. Further, it empowers care managers to operate closer to the top of their license, connecting with members in a more continuous and better informed manner. It enables personalized care planning, communi-cation and education for each member. This helps members feel better supported and cared for. Finally, it enhances the strategic and financial value of the existing care management program by optimizing utilization, increasing revenue through value-based payment, and improving network retention.

Implementing MEDSOLIS

Adding MEDSOLIS to your care management program is easy, and getting started doesn’t require replacing current systems or additional IT investment. The MEDSOLIS platform integrates with existing systems and can be configured to meet the needs of diverse clinical programs. It can be personalized and adapted to members’ specific needs. It enables collaboration across a care team, and supports standard evidence based care guidelines. More importantly, it provides the necessary support to deliver the program goals beyond just offering the technology.

 

The bottom line

MEDSOLIS products are simple, effective and efficient. They can be implemented easily. They can substantially increase the return on your care management investment.


If you would like to explore how MEDSOLIS can help you, please ask for a demo!
http://www.medsolis.com | info@medsolis.com | 7460 Warren Parkway, Suite 100, Frisco TX 75034