Are we there yet?
It’s become challenging to understand where things are in terms of the adoption and impact of clinical patient engagement technology. As healthcare’s quest for population health management (PHM) finally starts turning its eye towards patient engagement, we should expect to see more growing interest from data/analytics firms, payers, telecom and device makers, and non-healthcare tech giants in issueing consumer-friendly, clinical-grade tools.
It will become important for these new entrants and the healthcare organizations they sell into to understand where we need to strive for more progress in patient engagement technology. This applies equally with regards to the gizmos and software applications themselves, as well as the way we deploy these new tools into increasingly consumer-centric marketplaces.
An engagement strategy for the post-portal era
According to a New England Journal of Medicine study, a majority (59 percent) of clinical staff feels that the most effective patient engagement strategy is simply spending more time with patients. Other common responses included better communication through shared decision-making and better education.
Neither patients nor doctors were thrilled about EHRs’ patient portals, which never made it from the tactics to the strategy phase of Meaningful Use’s bold vision. We’re now in the post-MU use phase of market maturation, a phase that will see a lot more provider-driven activity. A CTO of a national trade group on patient data rights explained via e-mail:
“Providers are not happy with what they can do using their EHRs. I think we will see more and more hospital systems move to a stand-alone consumer applications that interacts with their EHR rather than an EHR-based portal. As patient engagement gets more and more important to providers – and it is – they are less and less confident that the EHR vendors will give them what they want as long as MU is driving what the EHR vendors produce. I think we will also see more and more HIOs providing consumer applications for those hospitals or provider groups not large enough to make the investment in time or licensing or development.”
For an example of what this looks like in practice, look at New York Presbyterian Hospital, whose innovation program includes a suite of digital health tools for patients and providers. These include a fusion of home-grown use cases and partnered technologies for things like urgent care visits, wait times, appointment bookings, and in-network telehealth visits.
mHealth apps for engagement remain a work in progress
We’ve seen that tools for better engagement won’t come from incumbent vendors. It’s no coincidence that we keep on seeing platforms emerge to help clinicians find and recommend apps to their patients. Researchers from Brigham and Women’s Hospital in Boston recently published a paper in Health Affairs where they evaluated 137 patient-facing apps for usability, functionality, safety and security, among other criteria. Their main goal was to assess how well patient-facing mobile health tools address the needs of the people using them.
The research reveals an industry that is growing quickly, but remains immature when it comes to deployment strategy. One prominent example is the low level of alignment between apps’ functions and the levels of engagement of its end users. This simply means that people are different; we have different receptivity and responsiveness to tools for, say, education, versus tools for behavior change, or communication, or social support.
This seems like an obvious premise, but it’s one that bears consideration as it reveals a shortcoming of today’s digital patient engagement marketplace: health tech vendors and customers are still at a phase where they are pushing apps onto broad segments of people – employees, Medicare beneficiaries, self-insured individuals, patients with a certain disease, and so on – rather than mapping certain features to the right level of health literacy, financial status, or patient activation. Think a one-size-fits-all radio station versus curated playlists on Spotify.
The truth is, we remain very early in this journey towards doctor-partnered, personalized digital health engagement. The majority of health systems today have only a primitive ability to understand their patients beyond the clinical dimension. There are plenty of vendors in the so-called “patient relationship management” (PRM) space that are working on addressing this challenge through scraping together social, geographic, financial, and other data (a.k.a. SMAC) to drive more sophisticated understanding of a patient population. But at this stage, most of those vendors are (rightfully) focused on demonstrating financial ROI, looking at either specific cost-savings goals (e.g., how to impact readmissions or how get patients to appointments), or profit-center upsells (childbirth, back surgeries, etc.).
How might this space evolve? One could imagine a health system-vendor partnership that involves channeling these PRM-derived insights into a usable workflow to guide clinicians in their routine, everyday engagement. This might entail mapping patients demographics and social to a customized menu of engagement features that is uniquely suited to guide them into healthier behaviors.
We’re seeing the beginnings of this responsive, user-driven onboarding and engagement process from digital health companies like Omada. CEO Sean Duffy warns of the “Single Instrument Fallacy,” wherein the end game is simply to get X patients to use Y tools. We’ve seen too much of this approach over the last few years, driven by the MU quota for View, Download, Transmit, rather than any patient-specific, contextual goals. Can health systems take a similar approach to Omada, but across different diseases, departments, insurance reimbursements, ages, and so on? This represents the next frontier of population-level digital health engagement.
Lacking in breadth as well as depth
The study highlighted another emerging issue – there’s an uneven distribution of apps across different healthcare conditions. As one might expect, apps for chronic diseases like diabetes, hypertension, obesity, and mood disorders topped the list in terms of frequency and availability. On the other hand, apps for people with arthritis, people with any type of pain, and the elderly lagged behind considerably. While chronic disease management plays tend to dominate the digital health industry, the opportunity for pain and aging-related care is only going to grow. For those interested, Dr. Bonnie Feldman recently put together a great resource.
It’s not just the lack of variety in apps that poses a challenge to achieving a broad scope of population engagement. (Over a third of the apps lacked an Android version – a red flag for health systems or startups basing their engagement strategies on Apple Healthkit alone.) If not addressed proactively by vendors, startups, and other stakeholders (e.g., Aetna as part of their new partnership with Apple), we may witness the rise of a new lack of interoperability based on hardware/software territorial disputes.
In terms of improving apps themselves, safety is one area that still needs work. Specifically, clinical apps should be able to respond when patients enter information that indicates danger, such as a suicidal mood. In the Health Affairs study, only 23 percent of the apps that let patients enter information offered an appropriate response. Industry stakeholders, policymakers, and especially technology vendors have a tendency to simply expect patients to start using new technology. It will be important to involve real-world testing – that means incorporating feedback from patient end users – early and often.
A related finding – most healthcare apps didn’t perform any better than generalized conversational agents, like Apple’s Siri or Amazon’s Alexa. As we witness the birth of the hype cycle for voice UI’s, we’ll need to make sure that our new bots don’t replace clinical rigor with cuteness:
— Maneesh Juneja (@ManeeshJuneja) December 30, 2016
Policy: regulation versus leadership
What roles can the government play in the domains of regulation, leadership, strategy, and reimbursement to ensure health care apps are used appropriately and to their potential?
Several agencies share the responsibility of regulating mobile health applications:
- The Office of Civil Rights (OCR), of the Department of Health and Human Services (HHS), enforces HIPAA regulations for health care organizations and business associates
- The Food and Drug Administration (FDA) oversees regulation of apps whose functionality interfaces with or replaces medical devices
- The Federal Trade Commission regulates misleading claims by businesses, as well as ensures that organizations who have suffered security breaches must notify consumers that their health information has been compromised.
Most industry folks will be quick to point out there is a fourth major agency that might also appear on this list: The Office of the National Coordinator for Health IT (ONC). The ONC prominently displayed their goal of ensuring that care is “patient-centered, accessible, and safe” as the very first part of their 2015-2020 Strategic Plan.
Yet, the ONC always seemed too far behind the puck when it came to mobile health and patient engagement. We shouldn’t expect that to change at this point, even if the Meaningful Use program survives the chopping block. The agency’s latest report on patient-generated health data (PGHD), for example, is little more than a re-hashing of the same findings we’ve known about for three or four years.
What about the Center for Medicare and Medicaid (CMS)? CMS released their Person and Family Engagement Strategy in December, and includes four goals that aim to expand principles and strategies of engagement throughout CMS programs.
CMS’ Person and Family Engagement Strategy – December 2016
- Goal 1: Actively encourage person and family engagement along the continuum of care within the broader context of health and well-being in the communities in which people live.
- Goal 2: Promote tools and strategies that reflect person and/or family values and preferences and enable them to actively engage in directing and self-managing their care.
- Goal 3: Create an environment where persons and their families work in partnership with their health care providers to develop their health and wellness goals informed by sound evidence and aligned with their values and preferences.
- Goal 4: Develop meaningful measures and tools aimed at improving the experience and outcomes of care for persons, caregivers, and families. Also, identify person and family engagement best practices and techniques in the field that are ready for widespread scaling and national integration.
It’s clear that these goals include more tailor-made engagement campaigns that go beyond matching apps to diagnosis codes and begin matching features to the needs of the people we are trying to take better care of.
Obviously CMS officials may be focusing their attention elsewhere than the minutiae of patient engagement strategy at the present moment. Despite the ACA’s fate, we can expect to see CMS incorporate the above principles into bundled payments, accountable care organizations, MACRA-driven pay for performance measure sets, and other federal initiatives. Other associations have been quick to endorse this direction, whether explicitly through press releases (the AAFP) or implicitly through partnerships (AMA, Intermountain and Omada).
In closing: quick to grow, slow to mature
It’s often been said that patient engagement represents the last mile in healthcare. In the original context, this meant that it is the most challenging part of the PHM journey. In practice, it has often meant that engagement is the last item executives pay attention to. Entering 2017, we’ve made laudable progress to deploy specific engagement tools as they relate to broader business opportunities, whether those are driven by incentives or penalties, or even simply good press.
To truly realize the potential of digitally enabled population health management, we have to develop an advanced, contextual engagement strategy for every patient, as part of his or her routine and ordinary healthcare experience.