The Personalized Healthcare Ecosystem of the Future: Welcome to the Year 2030

Against your better judgment, you've just checked your contact lens-enabled news feed. You're annoyed, because President Meghan McCain has just used the Trump Doctrine to "fire" Medicare's lead administrator over the botched roll-out of the Agency's block-chain claims payment system.  The mild spike in sweat stress chemicals detected by your clothing sensors prompts a boost in the transcutaneous dosing of the blood pressure pharmaceuticals from the networked skin patch on your thigh. 

 

It's the year 2030, and personalized "eDxTx" (ecosystems of Diagnosis and Treatment) has arrived for a lucky few who are able to afford it. That has created political headaches for the President and her campaign promise to bring Medicare out of the 20th century. Your decision to opt out of "Medicare for All" (a.k.a "TrumpCare") has been expensive, but worth it because your Geico insurance plan includes eHealth as a covered benefit.  Geico's ability to automate all underwriting and claims handling means high service standards and keeping costs down. Plus, those video ads are still cool.

Thanks to ubiquitous wireless connectivity, cloud-based machine intelligence and mass-personalized medicine, you and your private doctor's team were able to configure a suite of customizable off-the-shelf apps that meet your goals for living well as well as long.  The first step was your $2 psychometric, biomic and genetic testing (the expense of a mitochondrial analysis was offset with an agreement with the laboratory, Theranos, to pool your data with other customers) that spotlighted the optimum mix of nutrition and pharmaceuticals to blunt your risk of Type 15 Hypertension and GAB15a-linked gastrointestinal cancer. 

As you sit down and use the heads up display in your lens to ponder the short-list of candidates to replace the fired administrator (a well-placed leak suggests it reportedly includes Elizabeth Holmes), the patch modulates your drug dosing to account for the change in body position.

You're hungry and looking forward to your specially tailored evening meal that is being drone-delivered to your patio in.... your contact lens again... 28 minutes. 

This is one of the five days out of the week that you adhere to a configured meal of calories, carbs, proteins, fats, nutraceuticals, probiotics and prebiotics that's adjusted to meet your taste preferences. It will also achieve an optimal body fat percentage, and reduce your risk of cancer and a host of other chronic conditions. The other two days use competitive gamification that is linked to your online preferences to reward you with a real burger for meeting your nutrition goals.  Not for everyone, but your behavioral reward profile suggested that that would help motivate you to stick to the diet. Who knew?

You ponder getting a burger tonight, but fight the temptation by triggering a mindfulness app through your lens.  The lights in your living space also dim and a riff made up of an pleasing artificial jazz-indie chord progression offers a well-placed distraction.

Diet and risk reduction are not the only an ingredients you use to achieve your goal of living 105 years, but also participating in next month's Goggle Spartan Race.  Come to think of it, time to tailor a set of 3D printed sneakers. You look forward to you and your personal life-drone (your spouse suggests it's more evidence of your narcissism; you've named it "Donald" to confirm her suspicions and annoy her) competing in a mix of virtual and real obstacles in a course of that includes real rope climbing and a virtual 3-D avatar obstacle course. The drone and wearables will network, monitor and heads-up display your neuro and cardiovascular dashboard for optimal performance. It will also use the same technology that they used in hospitals to anticipate any medical emergencies that could happen to you.

Naturally, your drone will use artificial intelligence to image, edit and securely post the race video for friends and family to view.

That's what you did last year, when the video also showed you twisting your ankle.  You had to go to a treatment center and be evaluated the old fashioned way, where a doctor treated you.  Some things never change, but avoiding those opaque bills and paying your deductible using virtual currency was so convenient.

As your pour yourself your recommended 1.2 ounces of bourbon (personalized by the distillery with a proprietary combination of esters and lactones to create your preferred finish), you reflect on how healthcare has changed since the days of in-home monitoring and physician teleconferencing. It worked well while it lasted, but was soon eclipsed by the cloud-based technology that combined physician intelligence ("physint") with Watson (artificial intelligence) that "scaled" in an era of fully automated care. 

Sort of like the driverless car that will take you to next month's race.

Speaking of old fashioned cars, that eDxTx medical alert last year reminded you of that old fashioned "check engine" light.  It seems a biochemical marker profile was consistent with the presence of an early stage tumor.  Based on your past medical data, the calculated Bayesian risk that the tumor was real approached 1%.  Watchful waiting using Medicare's IPAB guideline recommendations was raised as an option by your doctor, but you decided to undergo the additional testing to rule it out.  Naturally, your insurance covered most of that cost.

You finish your bourbon after you get an alert that the pizza has arrived.  You silently wish President McCain good luck. Some things never change.

Image from Wikipedia

2016 is the Breakout Year for mHealth: Savings vs. Value

In this post, the Population Health Blog predicts how and why mHealth will be covered by more commercial health insurers in 2016, and why the retail "over the counter" mHealth market outside of insurance coverage will also continue to grow. 

 

While you're reading, consider this simple question: What are the revolutions per minute (RPMs) of your automobile's engine as you ascend from stationary idling to freeway speed?

 

The Definition of mHealth: "the delivery of healthcare services via mobile communication devices." Other definitions can be found here.  Elements include handhelds, wireless communications, software, hardware, networking, social media, sensor technology, apps and cloud-based services. The World Health Organization says it's global and much is still in its infancy.

 

Three Population Health Blog predictions for mHealth in the United States:

 

1) 2016 will be a breakout year, because both the savings and value propositions will be clarified.

 

What does the PHB mean by this? 

 

The ultimate question for health services buyers, payers, providers and patients is whether mHealth technology is: 

 

Substitutive: achieving savings from displacing present or future high cost services,

 

or

 

Additive: co-existing with present, or increasing future utilization.

 

The same is true for many pharmaceuticals, population health programs and the medical home.   

 

2) Faced with the reemergence of unsustainable health care cost inflation, commercial health insurers will deploy today's premium to sponsor tomorrow's substitutive mHealth cost reductions.

 

Commercial insurers will look for mHealth that is "S³" or Smart, Synergistic and Scalable.

 

1. Smart: addresses the tailored needs of selected population segments; instead of being all things to all patients, think focusing mHealth on high risk patients with special needs. 

 

2. Synergistic: enhances, not replaces other incumbent resources, such as one-on-one care management or outreach telephony.  

 

3) Scalable: uses the economies of scale to provide a lower-cost service to larger numbers of consumers.  As more patients in a select population use mHealth, the cheaper it becomes. 

 

3) But.....Value-driven mHealth will also flourish in the direct-to-consumer, over-the-counter or retail market for three reasons:

 

1) Consumer notions of value: 

 

Interest in personal wellness, a cultural belief in the pervading merits of technology and the allure of every more innovative gadgetry will continue to outpace the underlying mHealth abandonment rate.

 

2) As Obamacare acquaints consumers with real healthcare costs, #mHealth will be viewed as a relative bargain.

 

Comparatively pricey physician encounters, emergency room visits or a hospital stays - especially for Bronze Plan enrollees - will only increase consumer appreciation for  mHealth's "over the counter" benefit-to-cost ratio: for a few extra bucks, why not have that weight-loss, blood-pressure, medication-management app or wearable, especially when you already have a handheld smart device and the bandwidth?

 

3) Some commercial insurers will "cover" wellness #mHealth, not because their actuaries support it, but because their customers (purchasers, brokers and consumers) demand it. 

 

"Coverage" will be in the form of a volume-based discount pricing borne by the consumer, not a value-based benefit covered by the insurer. If it increases customer loyalty/"stickiness," all the better.

 

Plus there's the mHealth "X-Factor." mHealth sponsors and their allies will collect, sell and use consumer data for marketing and surveillance.   The PHB calls it mining and monetizing. 

 

Back to the tachometer: Even though its dashboard displays it, the PHB doesn't know the vehicle's RPMs either. Aside from  the use of the tachometer by some car enthusiasts  to optimize manual gear shifting, it adds little to car performance or safety. 

 

Yet, it's standard and in the dashboard of just about every automobile being sold in the U.S.A.  Could gadgets, wearables, apps and mHealth physiologic monitoring become the healthcare tachometer?  Useful to a critical few and standard for everyone else?

 

So, What is the the Basis of the PHB's Predictions?

 

Growth potential:

 

None other than Eric Topol says "Until now, most of the effect of the digital era in the practice of medicine has been confined to electronic health records. But that is about to undergo a radical transformation in the next 5 years." As in $50 billion by 2020.

 

If you think it's all about "Fitbit" or managing diabetes, think again. How about promoting mindfulness, monitoring medication compliance, home-based high-risk pregnancy monitoring, in-home safety for the frail elderly, heart rhythm management, and home-based "pervasive" monitoring. Plus, mHealth style technology is being used outside of healthcare, such as in the automobile, for elite athletes and to promote safety in high-risk worksites

 

S³  = Savings

 

Smart: Here's a just-published JAMA study of a randomized clinical trial (RCT) that showed text-prompts had an clinically relevant impact on blood pressure in a group of select persons with coronary heart disease. Here's an rigorously conducted RCT that showed persons with Type 1 diabetes mellitus achieved better blood glucose control.  How about socioeconomically vulnerable patients with diabetes? Or patients with heart failure being discharged from a hospital?  The list of special populations with special needs goes on and on.

 

Synergy - This exhaustive peer-reviewed publication examining the merits of wellness mHealth for weight management, physical activity promotion, tobacco cessation, and cholesterol control shows that there's little evidence that it's better than existing therapies over the long-term.  Rather, the greatest promise appears to be in complementing existing interventions.  By the way, synergy does not mean overwhelming the system with data, but assisting the system with insight.

 

Scalable: While economists, policymakers and pundits legitimately worry whether bigger is better for healthcare in general, health system C-suites and boards of directors and their consultants are counting on information technology to drive economies of scale.  Papers like this and this suggest mHealth can be a part of that, especially if it can mitigate manpower constraints.

 

And an easy way to assess whether the insurer  really believes that it's sponsoring an S³ initiative is asking whether it pays for a handheld device for consumers that don't have one

 

Value:

 

Consumerism? Call it "the quantified patient." Here's a telling survey that shows the abiding faith in health information technology and a lack of privacy concerns.

 

 Bargain? The title of this peer-reviewed paper says it all" "It's like having a physician in your pocket!"

 

 Insurer discounts? The same thing happened to health club memberships.

 

The X-Factor: CIOs everywhere agree that they're not only apps, but software "vacuuming up data."

 

Image from Wikipedia

 

 

Three Health App Lessons from the James Bond Movie "Spectre" - Shaking and Stirring Health Care

The Population Health Blog took time out of its busy schedule to check out the latest James Bond movie. While posting anything that refers to a months-old movie is inconsistent with standards of modern social media, Spectre has some important lessons. 

 

The PHB begs its readers' forgiveness as it is filters out the improbable car chases, dubious gadgetry and staged fisticuffs and examines the underlying health app technology insights. 

 

Without revealing too much of the plot, Mr. Bond continues to recklessly expose himself and others to STDs while battling a global conspiracy that is led by a cryptic master criminal.  The bad guys want to exploit the weaknesses that come with combining the intelligence data of the world's democracies. 

 

And what are three cinematic health app teaching moments?

 

Health Information Technology vs. People is a Classic False Choice: In Spectre, British Intelligence seems ready to invest in a global big-data initiative and jettison the "Double O" programme; Whitehall apparently fails to realize combining both would be greater than either alone.  Think Deep Blue "versus" Kasparov, or Dr. Watson "versus" Dr. House. Yet, Bond prevails precisely because Ms. Moneypenny is his 24-7 data muse.  Smart health app designers understand that the best apps are the ones that synergistically enhance, not replace, what doctors and patients bring to their care planning.

 

For example: Asynchronous two-way HIPAA-compliant communication that allows consumer concerns to be mutually addressed in partnership with a nurse-provider before the emergency room becomes the best option.

 

Health Information Technology Needs Good People: No Bond movie is complete without legions of pistol-wielding bad guys who can't hit the side of data warehouse, which is why Bond prevails. Think putting an Acela locomotive on decades-old train tracks under AMTRAK's ossified management. The health technology insight here is that any health app that perpetuates health workers' can't-shoot-straight business-as-usual will enable incremental, not transformative change.

 

For example: During a recent health plan launch involving the medSolis app, the PHB had the pleasure of working with expert professionals who knew the purpose of the program (er, programme) initiative was to enable informed patient decision-making.  In response, we also began to alter long-standing health plan policy and procedure.  

 

All Things Equals No Outcomes: Other than pooling the intelligence data, none of spy-administrators seem to be able to articulate the purpose of their joint data initiative. While cleverly branded and all-purpose apps strive to "be" the intended outcome, truly successful health apps will be those that can be purposed for a defined population and prospectively aimed at a limited set of clinical, financial and patient-centered outcomes.

 

For example: Once the generic coding/architecture is set, a winning app's content, channel and outcomes can be tailored for, say, a precisely defined group of high risk persons with diabetes.  And, to borrow from the concept of "parallel processing," the app should also be able to be altered to simultaneously serve a parallel population that is prone to rehospitalization (outcome: reduce avoidable readmits), or who would benefit from weight loss (outcome: reduce BMI).

 

Conclusion: Health concerns aside, perhaps nothing signals Bond's adaptability better than his willingness to forego his long-standing "shaken, not stirred" workflow in favor of quaffing a "dirty" martini with the sultry Dr. Madeleine Swann.  Even the Bond franchise is not immune from the adage that "change happens."

 

The same should be true for traditional health care as it continues to import an emerging ecosystem of health apps.  Delivery systems, hospitals, clinics, ACOs and networks that understand that will win.

 

And "Cheers!" to that, Dr. Swann.

 

Image from Wikipedia

Smartphone Apps: Architecture Trumps Content

According to this The Wall Street Journal article, the prospect that "your doctor may soon prescribe you a smartphone app," has put us on the cusp of a new age of m-healthiness. 

 

Regular Population Health Blog readers are not surprised. They have an "over-the-horizon" awareness of health information technology and know that the health app ecosystem has been flourishing for quite some time. 

 

What is surprising, however, is how the news article from a prestigious news organization conflated architecture and content. 

 

The PHB explains.

 

The WSJ article describes how intrepid e-researchers from marquee academic institutions are documenting the impact of apps on medication compliance, symptom management, risk reduction and provider-patient communication. Once users open these apps, there's not only an eHealth technology platform but an accompanying library of tailored e-prompts, e-reminders, e-pop-ups, e-recommendations, e-messaging, e-images and e-videos.  Mix one app with one patient and quality goes up and costs go down.

 

Unfortunately, what the article failed to mention is that much of that content made up of information that is freely available in the public domain, and that these app developers have reconfigured and adapted it according to the interests, expertise and culture of their sponsoring institutions.

 

While policymakers and researchers would like to believe that on-line and public domain health information is a commodity, the fact is that buyer, purchaser and provider organizations have been accessing and downloading it for years.  They've take special pride of ownership in the wording, editing, formatting, presentation of that content.  That's what makes it "theirs" for both their providers and their patients.  After all, all healthcare is local.

 

This has important implications for the smartphone app indsutry.  While the academic e-researchers and business e-developers dream of having their apps adopted by delivery systems everywhere, the problem is that their apps are often tethered to their own organizations' content. 

 

In other words, you can have any breast cancer, heart failure or post-hospital discharge smartphone-based solution that you want, just so long as you also import their prompts, reminders, pop-ups, recommendations, messages, images and videos. 

 

The Population Health Blog believes the secret sauce for competitive success for app developers is accordingly three-fold:

 

1) Architecture Trumps Content: Smart app developers understand that the value proposition of the underlying technology architecture is separate from the value proposition of the content.  The app itself needs to be independently stable, secure and snappy with minimal branching logic, an easy-to-use interface and freedom from annoying bugs, whether it's heart failure in for a hundred patients in Halifax or a dozen persons with diabetes in Des Moines. 

 

2) Architecture Supports Content: Very smart app developers also understand that the architecture should be able to accommodate any content that is preferred by their customers. If ABC Regional Health System wants their in-house policies, procedures, pamphlets, web-pages, in-house guidelines and electronic record prompts to be reflected in a smartphone app, then the app's framework should be able to import it.  Think plug and play.

 

3) Architecture Has Content: That being said, not every buyer, purchaser or provider will have all the content needed to manage a target population. That means app developers will need to have generic content ready to go to fill in the gaps. 

 

The business case for apps may be similar to selling a house.  First off, make sure the foundation is solid and the roof is intact.  Be prepared to move walls and windows, if that's what the buyer wants.  And, if the house needs to be furnished with some furniture, do it; if the buyer wants some or all of their furniture to furnish the house, do it.

 

Image from Wikipedia

Apps Will Astonish

"Now this is meaningful use!"

In case you think the future for healthcare apps will be characterized by health information technology (HIT) "dead zones" of free downloads, fun gadgetry and vacuous consumerism with nothing to show for it, you should take a look at  this article appearing in the peer-reviewed journal Cell Systems. 

If authors Kenneth Mandl, Joshua Mandel and Isaac Kohane are even half right, "apps" could truly revolutionize HIT.  They argue that a superimposed "apps layer" ecosystem will demolish the "walled gardens" of EHRs and allow for true information sharing across clinics, systems and regions.

And that's just for starters.

As the Population Health Blog understands it, "Application Programming Interfaces" (or "APIs") will enable multiple third party apps to bridge to legacy EHRs.  That, in turn, will catalyze the creation of newer and better user experiences that reconcile doc and patient preferences with the current clunky one-size-fits-all EHRs. 

The result?

1. A "mash up" of "risks, trends and trajectories" with external data sources, telehealth and decision support systems. Why should a patient with cancer and his/her oncologist use the same computer operating environment as a patient and a dermatologist dealing with a rash?  Even better, apps can be easily substituted if a better one comes along.

2. Never mind ICD-9 or ICD-10, apps will be the "afferent limb" that links your unique genetic and phenotypic "diagnosis code" to the efferent limb of tailored treatment protocols.

3. Apps can collect and arrange the data from numerous devices at scale that not only allow for treatment compliance or disease management outside of the clinic, but the early identification of an emerging epidemic or medication side effects.

To achieve this, the authors recommend the EHR manufacturers not only retool, but adopt a uniform and open source approach to API development. Purchasers of EHRs consider should consider the future of APIs in their requests for proposals (RFPs).  They also recommend that research funding be directed toward apps that can operate across multiple information platforms. It would also help if there was a "seal of approval" process for app development that wasn't too closely tied to industry or too tied up in the regulatory miasma of government.

The Iron Triangle of mHealth Apps Due Diligence: What CEOs and Boards Need to Know

As the Population Health Blog's medSolis CMO expertise in mHealth expands, it can't help but admire the infectious "can-do" optimism of its "app" programmer-developer colleagues and competitors. Even if healthcare is a morass of dreary economics, regulatory meddling and dysfunctional politics, these entrepreneurs really do believe that "there is an app for that!"

And neither are leaders in hospitals, clinics, provider systems, insurance companies, medical device manufacturing and population health immune from the developers' enthusiasm. "Apps" are being built or bought with the belief that they'll lower costs, create profits, increase quality, promote satisfaction, build brand, secure customer loyalty and generate invitations to White House conferences.

The PHB agrees. Apps can certainly achieve many of these outcomes, and it is looking forward to seeing the Roosevelt Room for itself in the not-too-distant future.

But that doesn't mean that CEOs, Boards and investors shouldn't be wary of how the healthcare "Iron Triangle" should factor into their "app" due diligence.

Old fashioned management experts will recognize the concept. They know that any project involves trade-offs between cost, quality and access. Improve any single dimension and the other two will suffer.  Improving two means having to compromise on the third. 

In other words, there are inevitable trade-offs.

Population health service providers are well acquainted with this. For example, launching a diabetes initiative means balancing the costs of the program, the intensity with which the enrollees will be managed (quality) and outreach with a span of services as well as associated risks that will be addressed (access). Accepting a lower fee per patient may lead to compromises in quality. Insisting on a greater span of managed risks could lead to higher costs or cut-backs in the level of patient counseling.

Which brings the PHB to mHealth. To the PHB, the three iron sides to configuring an app are the same:

Cost: This is not only a function of the nuts and bolts of programming, hosting and updating the app, but includes the additional economic burden of maintaining up-to-date security for the users' personal health information. There's also the added cost of updates.

Quality: This includes dimensions such as symptom control, condition management, promoting patient safety, reducing identifiable risks and measuring outcomes for quality improvement as well as research.

Access: The interface has to be speedy and intuitive, meeting consumerist expectations for ease-of use. That includes connectivity, screen loading, minimal manual inputting and efficient asynchronous communication.

How should CEOs and Boards think about apps? 

They should think about cost, quality and access and understand the inevitable trade offs that underlie the sweet spot of a successful app.

Costs will never go away. But smart app developers are using off-the-shelf, open-source as well as modular programming with (secure and encrypted) web-based hosting. Shortchanging IT support or security risks not only crashes and hacking, but could limit the end-users' ability to manage the continuum of health risks (quality) in a user-friendly and speedy manner (access).

Quality is important but judgment is necessary in understanding the secret sauce that links quality, behavior change and risk. It's possible to "overdo" condition management with a glut of care options, unnecessary attention to every risk, over-engineered branching logic and over dependence on human inputs. 

Access will be what the end-user cares the most about, including ease of use in a pleasing interface. Streamlining this too much, however, could lead to shortcuts that compromise optimum condition management or require additional costly information technology.

Bottom line?

If a company's senior leadership or Board of Directors is grappling with an app-based product launch, they need to understand the inevitable cost-quality-access trade-offs that were made in the course of its design.  If the cost is low compared to benchmarks, ask about the compromises in quality or access that were made.  If the developers claim that the condition management is the highest quality, scrutinize development costs and how access could suffer. 

Accordingly, the best apps on the market will be those that strike the right balance between cost, quality and access.

mHealth Apps to Monitor Recently Discharged Patients

After knee surgery: how do you
monitor this patient at home?

The "this paper" link in the original post directed readers to the wrong web site.  It's been corrected and the PHB apologizes for the error)

While the Population Health Blog is tantalized by the prospect of healthcare consumers using mHealth apps to lower costs, increase quality and improve care, it wanted to better understand their real-world value propositions. 

Are app-empowered patients less likely to use the emergency room?

Do they have a higher survival rate? 

Do they have higher levels of satisfaction?

In other words, where's the beef?

That's when this paper caught the PHB's search engine eye. It's a report on using an app to monitor post-operative patients at home.

This was a "feasibility study" involving a Canadian cohort of home-based post-operative patients who had gone through either reconstructive breast or knee (anterior cruciate repair) surgery. In order to qualify, patients had to be between age 18 years and 75 years, not using tobacco and able to speak English.  Once the app was activated, patient were asked about pain, their recovery and satisfaction (using a 1 to 4 scale).  They also used the app to take pictures of the surgical site. 

To maintain confidentiality, there were no patient identifiers linked to any images and a "locked down" subscriber identify module (SIM) was used. Data was encrypted on the server and the device.

Three surgeons participated and were responsible for reviewing their patients' data on a daily basis.  The app flagged any measure that was unexpectedly out of range for expedited review.

Instruction on use of the app took between 30 and 45 minutes. Patients were loaned a smartphone or a tablet, along with an instructional booklet.  At the end of the 30 day period, the smartphone or tablet had to be returned.

38 breast patients were approached at 33 agreed to participate.  40 orthopedic patients were approached and 32 agreed to participate.

Results?

The mean number of log-ins over the 30 days ranged from 19 to 24, with greater use in the first half of the month. Over 2000 photos were generated. Based on the pain and recovery scales, two early infections were identified and one was treated over the phone with antibiotics with subsequent improvement. On a 1 to 4 scale, the overall level of satisfaction was 2.7 to 3.9.

The PHB's take?

It would appear that the science on using apps to address specific outcomes in narrowly defined populations is still in its infancy.  While the Triple-Aim potential of mHealth is high, we're just beginning to understand how an app would work in the real world, say.... monitoring the outpatient status of recently discharged surgery patients.

That's why this particular study was interesting. It would appear handhelds or tablets can be used in the post-operative setting, that patient satisfaction is high and that, with symptom monitoring and imaging, an early wound infection can be identified and managed early.

Naturally, it'll take a study involving a control group to better understand the true value of an app like this.  Based on this feasibility study, the PHB is looking forward to reading about it in the not too distant future.

Image from Wikipedia

CMS and Health Reform: More of the Same

Unmentioned.....

Whoa, with breathless media coverage like this (dramatically change! ambitious!) you'd think that the Feds had just announced something important about health reform. 

After reading the CMS press release, a CMS blog post and this article in the New England Journal, the Population Health Blog has concluded that it's more of the same. 

As the PHB understands it, Medicare's January 26 announcement is that it will build on three ongoing reforms:

1. Financial incentives to expand "alternative payment" methodologies to 30% of all reimbursement by 2016 and to 50% by 2018.  These include accountable care organization arrangements, monthly fees to Patient Centered Medical Homes and use of bundled payments.  In addition, 85% of fee-for-service payments that are still in place will be linked to quality by 2015, with an increase to 90% by 2018.

2. Promoting "provider integration." That apparently means a new forum called the Transforming Clinical Practice Initiative, with a first yet-to-be-planned meeting in March of 2015.  In addition, CMS will continue to rely on its Partnership for Patients and the Patient Centered Outcomes Research Institute.

3. Information technology (IT) including more promotion of electronic records, meaningful use, interoperability and universal information technology standards.

[Yawn]

The cynical PHB is not impressed. The Obama Administration was using, is using and will continue to use faux announcements to advance its reforms.  What's more, when it reads the CMS pabulum, it's riddled with the same top-down mainframe rhetoric on realigning care, moving from volume to value, accountability, alternative payment models, serving populations, building a better system, increasing coordination, convening meetings, promoting information technology etc. There are no new details here.

The PHB will share three insights, however:

1. CMS, Ms. Burwell and their White House handlers lost an opportunity to reach out to the Republicans about the sustainable growth rate and leveraging that to build on multiple areas of agreement to jumpstart bipartisan reform.  Doing so could have accelerated the forward momentum of value-quality-cost-based reforms beyond the 2016 elections.

2. That being said, health care providers need to increase their familiarity with the opportunities as well as perils of payment reform as well as the very real barriers to fixed payment schemes.

3. The announcements are a reminder how CMS is still fixated on the EHR, while the real innovation is occurring in handhelds and their associated applications.  The PHB figures that its not about the providers and their desktop electronic records, but about patients and their smart phones. As these devices continue to grow in speed, power and sophistication, providers who figure out how to use the iPlatform to leverage self-care, communication and decision support will thrive.....

With or without Medicare's incentives, promotion or IT policies.

Image from Wikipedia

Either You Give Your Patients a mHealth App, or They'll Get One Themselves

That's what the Population Health Blog learned after reading this research paper by Bauer and colleagues that recently appeared in the Journal of the America Board of Family Medicine.

It also confirmed that chronic care management apps are a business opportunity.

What was the research and what did it show?

All adult patients receiving care at six clinics in a northwest U.S. primary care network during a two week window of time (June 2013) were anonymously surveyed about their use of mHealth.

Depending on the clinic, 22% to 62% of the patients were insured by Medicaid.  More demographic info can be found here.

1363 surveys were distributed and 918 (67%) were completed. 

91% had a mobile phone and more than half (55%) owned a smart phone.

Among the smart phone owners, 70% had used "mHealth." 57% had downloaded at least one app. Of these, 69% used it less than 3 times a month, while 11% used it on a daily basis.

There was no association of mHealth participation with health literacy, chronic conditions or depression. Use was more prevalent among persons less than age 45.

One third used "general" health apps, while one quarter used fitness, diet or weight-loss apps. Only 3% used it for chronic disease management.

The authors asked respondents to use a 1-5 scale to rate the desirability of various app features. Appointment reminders came in first, followed by medication reminders and general health information.

10% learned about this from their physicians and only 31% "prioritized" their physician's involvement.

The PHB's summary:

Smart phone and app use may be more prevalent in the northwest, which may make the findings of this survey less generalizable to the rest of the United States.  With that caveat, approximately 40% of the patients sitting in the average primary care clinic waiting room are mHealth users and about 20% are using health apps. And what do patients most prize in their apps?  Reminders about appointments and medications.

What's more, most of this is occurring without the benefit of their providers' participation.

Last but not least, apps have not penetrated the chronic disease population.

The PHB's take?

1) If all those patients with smart phones are going to download apps, they might as well download ones that - at a minimum - are endorsed by their providers. Optimally, they should complement their providers' services.  Used right, they might be able meet their patient's desires for coordinated appointments and increased medication compliance. 

Providers and patients would benefit from better quality and lower costs.

2) And patients with chronic conditions have yet to discover apps.  That may be a function of age, but it may also be a function of the conspicuous silence of their providers as well as the failure of the currently available apps to meet their potential customers' desires. 

That spells opportunity.  Recall the adage of the two shoe salespersons who were sent to Africa.  The more pessimistic of the two found that none of the natives were using shoes and decided to return home.  The optimist likewise found that no one was using shoes, but he called back to the home office and asked for help.

The market for chronic care apps needs help.

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Could mHealth Apps Be a Reprise of the EHR? The Need for Clinician Input

While the Population Health Blog continues to delight in the emerging science of "mHealth" as a newly minted start-up Chief Medical Officer, it ran across this interesting article on risk and patient safety.

Authors Thomas Lewis and Jeremy Wyatt worry that "apps" can lead to patient harm. 

They posit that the likelihood of harm is mainly a function of 1) the nature of the mistake itself (miscalculating a body mass index is far less problematic than miscalculating a drug dose) and 2) its severity (overdosing on a cupcake versus a narcotic).  When you include other "inherent and external variables," including the display, the user interface, network issues, information storage, informational complexity and the number of patients using it, the risks can grow from a simple case of developer embarrassment to catastrophic patient loss of life.

In response, they propose that app developers think about  this "two dimensional app space" that relies on a risk assessment coupled to a staggered regulation model.  That regulation can range from simple clinical self assessment to a more complex and formal approval process.

What's clear to the PHB is that hidebound mainframe entities like the Food and Drug Administration are no match for the app "ecosystem".  Rather than try to formulate a one-size-fits-all "not function as intended" model like this, maybe it should triage its oversight using the Lewis and Wyatt framework.

In addition, the PHB agrees with Lewis and Wyatt that safety is also a function of clinician input.  Docs and nurses can assess possible mistakes, their downside severity and the impact of all those variables.

The PHB couldn't have put it better:

".... many app developers have little or no formal medical training and do not involve clinicians in the development process and may therefore be unaware of patient safety issues raised by inappropriate app content or functioning."

Without the insights of seasoned real-world doctors and nurses, apps could end up with the same safety issues that are plaguing electronic health records, many of which were also developed with little regard to physician or nurse input. 

In other words, just because it's a "health" app doesn't mean its necessarily so.

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Two Additional Reasons Why Health App Adoption is Bound to Grow

The Population Health Blog is avidly learning about health apps for patients. 

As described here, half of U.S adults now own a smartphone, half of them use them to obtain health information and approximately a fifth have at least one health app loaded on their device. 

Regular PHB readers are well aware of the potential for health apps, including lay-person education, the promotion of consumer behavior change, increased consumer-provider connectivity with greater access to care, better medication compliance as well as medication reconciliation, increased self-care, greater quality and lower costs.

But as the PHB's e-health experience grows, it's encountered two under-recognized features of apps that - in its opinion -  are sure to also drive their adoption:

1. The Provider App Arms Race:  As  competition for loyal patients grows, health systems, care organizations, insurers, buyers and provider networks are going to expect their apps to create greater consumer "stickiness."  For example, offering a tablet with a pre-configured app may enable hospitals to not only reduce readmissions, but enhance their brand recognition.

2. The App Is the Outcome: It will take years for science to prove that apps cause better outcomes. While lingering skepticism will prove to be another bonanza for outfits like this, the luster of smart-device gadgetry will be too much to resist. As a result, it's only a matter of time until Boards and their CEOs pressure their management teams to launch their own app.  While the electronic record and big data are important advances, let's face it: they're in the background. There's nothing like a patient-facing app to remind customers, families and providers of the organization's health tech chops.

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Ten Things to Know About the mHealth App Ecosystem.

A mHealth app walled garden:
enter at your own risk?

If, like the Population Health Blog, you're interested in the hand-held mHealth app ecosystem, you may want to check out this just published JAMA review article "In Search of a Few Good Apps." 

Naturally, for time-pressed readers who'd rather not read it all, your PHB is happy to provide this ten point summary.

1) There are more than 40,000 of mHealth apps and the industry is still in its infancy.

2) Despite their faddish sexiness, there is very little hard evidence that many of the commercially available apps to lead to measurable improvements in clinical or economic outcomes. However, some of the underlying technology (such as pedometers) does provide a benefit.

3) The Food and Drug Administration (FDA) will assert its regulatory authority if the app "acts" like a "medical device" or as an accessory to a "medical device." Logging data, retrieving content or communicating won't be regulated, but medication dosing guides or the provision of diagnostic information will be.

4) 3) Little is known about the physician prescribing patterns for apps.  We also haven't figured out if or how a patient's access to an app should depend on a licensed professional's approval/prescription.

5) There is a possibility that many currently available apps are putting users' privacy at risk.

6) Little is known about apps' compatibility with electronic health records (EHRs).  This may be less of an "ecosystem" and more a bunch of isolated "walled gardens."

7) One vulnerability to any app's usefulness is data overload. Hundreds of food entries, for example, may do little to increase user insight about his or her diet.

8) Other than the FDA and its fussing over apps' medical "deviceness", there is no agency or entity that provides certification for apps. Consumers are on their own, based largely on on-line reviews and word of mouth.  One organization tried to do it and conspicuously failed.

9) The time is right to create "guidelines" for app developers, such as how to provide useful data summaries as well as visual displays, maximize patient safety, ensure information accuracy and protect consumer privacy.

10) The time is also right for funding agencies to support research on apps, especially for persons with chronic illness.

Naturally, the PHB offers commentary:

It remains to be seen if the FDA can keep up, especially with apps that are in the "grey zone" between offering advice/possibilities vs. diagnosis/treatment. That shortcoming is vulnerable to overlawyering and regulatory overreach. That means prolonged time to market, increased uncertainty, hampered innovation and the threat of retroactive and potentially capricious reviews.

As you are reading this, many apps are undoubtedly being developed by the population health service providers.  It may be time for entities like the Population Health Alliance or stakeholder organized medicine organizations to take the lead in establishing app benchmarks, best practices and guidelines.  If they don't lead on this, someone will do it to them. 

While vendors that offer apps along with their coaching may be inclined to regard them as proprietary and shield them from the scrutiny of peer review research, apps that are proven to improve outcomes will ultimately rise to the top.  It's not just the funding agencies but the companies that offer these apps that have a stake in "proving it," while also advancing medical knowledge for the betterment of all of us.

Finally, wouldn't it be neat if there was a generic mHealth app that could be used by medical homes to facilitate nurse-patient coaching, link the patient to the EHR and enhance communication with providers?  If there is one that the PHB isn't aware of, it wants to know about it.

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Five Novel Health Care Apps

The Disease Management Care Blog wonders if 2014 is the tipping point for "health care apps."

Given the turmoil surrounding Mr. Obama's reform agenda, consumers will be seeking better self-care options, policymakers will want DIY punditry and providers will want marketshare.

Here are five timely DMCB ideas for apps that can help them.

Expert Health Policy Bingo: Compete with fellow policy weenies with an on-screen bingo card with cells that are randomly populated with catch-phrases like "26 year olds," "botched," "pre-existing condition," and "ovaries." Spell out BINGO during a speech, CMS conference call or Fox News broadcast and you get bragging rights!

HandHeld Insurance Exchange: Instead of a desktop browser, this app will help health insurance consumers use their smart phones to access Obamacare. Once launched, the screen will naturally announce the functionality is down. Price in the App Store to download: $91 million.

Random Anecdote Generator: Depending on your politics, this app will tap NSA heuristics to download Facebook data to spin a mostly-true story of a [insert number] year old with [insert condition] who [did/did not] get health insurance because of health reform. Great for talking heads and politicians alike on either side of the political spectrum!

Show Me the Money: This is for users who are unsure of just how to estimate the ultimate impact of health reform on the U.S. budget, and know that the words "billions" or "trillions" are insufficient. This app generates better numbers, like "quadrillion," "gazillion" and  "shabwillion." A bonus: can be used to describe savings or costs!

Best Care: When confronted by a new diagnosis, patients naturally want to know where they can find the "best" provider for that particular condition. This app will input the condition and use the internet to match the user to the clinic. Naturally, since every hospital has been on at least "Top 100" list for every condition, the app will use geo-mapping software to really guide the user to the closest hospital.

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More on Health Apps: Opportunities, Risks and the Implications for Population Health Management

It's called "mHealth" but others may call it "health apps." The FDA calls it a target rich regulatory opportunity. Others may call it hype.

The Disease Management Care Blog calls it inevitable.

Writing in JAMA, Drs. Steinhubl, Muse and Topol of Scripps agree and say that the future is bright for mHealth. Its adoption is being driven by the threefold convergence of:

1) the search for solutions that address otherwise unaffordable levels of healthcare spending,

2) the availability of broadband wireless connectivity, and

3) consumer demand for individualized care.

The DMCB suspects any one of the DMCB's 5000 regular readers could have written this article. Like Steinhubl et al, they already know that patients want self-diagnosis and condition monitoring. Health consumers want greater efficiencies and enhanced patient-physician collaboration.

Even tech-skeptics have to admit that it's possible that mHealth could lead to a utilization trifecta of fewer office visits, avoided emergency room visits and decreased hospitalizations. Imagine the handheld that can accurately catalog signs and symptoms that help the user discern between a simple self-limited cold vs. a more serious case of pneumonia, or benign skipped heart beats vs. a more worrisome arrythmia.

Handheld apps for chronic conditions are more available than realized. They are on the cusp of going mainstream with assisting hypertensives, diabetics and asthmatics monitor and act on their blood pressure, insulin dosing and inhalants.

If they work right, providers could review summary data and offer guidance via emails and texts in lieu of adding a patient on to the schedule at 5 PM. If done right, the background algorithms could liberate physicians to pay greater attention to the important stuff that requires their complex cognitive or procedural skills.

The authors point out that that doesn't mean it's going to be easy. Medicine is complex and getting paid for it is more so. There's also worry - warranted or not - about the decline of face-to-face doctor-patient relationship. mHealth can lead to overwhelming data gluts characterized by a lot of numbers with little actionable insight. Finally, there's the danger that an app can offer ineffective, inaccurate or dangerous guidance that leads to patient harm.

Bravo to the editors of JAMA for recognizing the importance of the topic and committing precious space to this manuscript.

That being said, however, this article fails to give a full accounting of all the opportunities as well as risks for "mHealth."

First off, as this Kaiser Health News article demonstrates, there are two additional opportunity dimensions that draw on the population health management business model:

1) Apps are not just for diagnosis and monitoring, but also for wellness, and

2) They're being principally sponsored by commercial health insurers who not only readily embrace innovation, but probably consider apps a "sticky" way to maintain customer loyalty. That is doubly true for engaged enrollees who ultimately represent a better insurance risk.  In fact, the DMCB suspects that value proposition is so compelling that insurers are willing to use apps as a "loss leader."

Oh, and while mHealth can be built, it's far more likely it's being bought. As in population health management vendors.

Risks?  You bet.....

1) The fit of mHealth with the electronic health record (EHR) remains an open question.  The DMCB is no coding geek, but it's safe to say that it's not automatic that two independently contrived technologies can automatically "speak" to each other or that the data from an app can by downloaded, summarized and coherently presented to a user at the point of care.

2)  As noted in this article on telemonitoring, it's also not necessarily true that mHealth can be equated with stand-alone technology. Depending on the condition and the need, mHealth will have to be often tethered to human support services.

3) As even casual observers are aware, allegations of "malpractice" are not unusual in health care.  Rather than comment on its friends who make a living off of contingency fees, the DMCB will only point out that mHealth may offer a target-rich rich environment for personal injury attorneys intent on using the legal theory of joint and several liability to maximum effect.  That threat may slow adoption of mHealth.

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