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