Value Creation for Healthcare Apps - or - Avoiding the Mistakes of "Meaningful Use"

Meaningful Use is debated

Any health care provider who hasn't been sealed in a Faraday cage for the last five years is likely aware of "Meaningful Use 3" or "MU3." Briefly, thanks to the American Recovery and Reinvestment Act (ARRA) of 2009, CMS can impose incentive payments to promote the adoption and "meaningful use" of electronic health records (EHRs).  Meaningful Use or MU has since become its own government program.  MU1 and MU2 are well underway, and CMS is preparing for the third phase, or MU3.
 
But a phunny thing happened on the way to this phase phorum. While insiders have saluted the good intentions behind the latest requirements, there's a lot of bad and even more ugly. It's telling when even the prestigious New England Journal publishes a highly critical perspective like this. It seems that skepticism over the fit of MU with the realities of clinical practices is being misinterpreted in some quarters as technophobic non-cooperation.

And so it goes.

Fortunately, for the Population Health Blog, its psychological EHR scars have long healed.  It, like a lot of other colleagues, has moved to a market of (for example) electronic care solutions that are not local and PC-based,  but are mobile and cloud-based.  And the good news is that - so far - there is no ARRA statute intended to enable a well-intentioned lawyer from uttering those Nine Most Terrifying Words just when the health app ecosystem is reaching critical mass.

But that doesn't mean that we can't learn from the EHR-MU Wars.  To wit:
 
1) Learn from mistakes; for example, better, not more, information technology begets more patient safety.

2) It's ultimately all about user value creation: for example, resist linking the technology to billings/revenue and link it to care/satisfaction.

3) Design with the end-user in mind: for example, release no product unless the intended user has shown that it can fit in their (provider) work flows or their (patient) home setting

4) Align the time frames: keep in mind that the short-term time technology horizon of 2-3 years to may not align with the 5 or more years it takes to "bend the curve" for a insurance risk-bearing organization

5) Resist the allure of government help: while incumbent companies may believe federal legislation may turbocharge their business models, the MU suggests that the downsides are considerable.

Curing the Healthcare Digital Divide: There's an App for That

Whither meaningful use?

For better or worse, policymakers, politicians and health leaders in the United States are committed to achieving paperless healthcare environment. Even if there is lack of high quality research and reasonable skepticism over the ultimate cost and quality merits of "e"care, there is no going back.

As a result, visitors to ehospitals and eclinics are increasingly surrounded by monitors that, in turn, are surrounded by providers. To gain their attention, patients need to have internet access to make appointments, update medications, obtain education and communicate with their doctor.

And what if they don't have that access? For the last decade, that worry has been characterized as "the healthcare digital divide. " As recently as 2014, it's been documented that the lack of computer hardware and access can have important healthcare implications for persons with low socioeconomic status.

For the doctors and nurses staring at screens all day, the millions of Americans who are living paycheck to paycheck risk being out sight and out of mind.

But it turns out that that it doesn't need to be that way.

The PHB explains.

Check out this telling report from the Federal Deposit Insurance Corporation on the "unbanked" and "underbanked."  Not having a bank account (unbanked) or using any financial services (underbanked) are linked to persons with low income, being of color, disability and being unemployed.

In other words, these are the very persons at risk of being on the losing end of the health care digital divide.

While there's interesting data on how close to 8% of U.S. households are unbanked and just over 20% were underbanked, there were also these stunning observations:

"Relative to fully banked households (86.8%), underbanked households were somewhat more likely to have had access to mobile phones (90.5%) and smartphones (64.5% of underbanked households compared with 59.0 percent of fully banked households)."

"Notably smaller, but still significant, proportions of unbanked households had access to mobile phones (68.1%) and smartphones (33.1%)" (bolding PHB).

In other words, persons of low socioeconomic status are more likely to have smart phones vs. the "banked" population. They may not have a checking account, but, compared to other segments of the population, they are also more able to use these devices to access and manage their "e"care.

The PHB's conclusions?

1. Not  explicitly fostering heandhelds as a part of the healthcare informatics "ecosystem" may be shutting out persons of low socioeconomic status from the health system. While the Washington DC's "meaningful use" (MU) criteria are not explicitly tilted toward desktop/tower computing, they seem to conspicuously silent on advocating for ease of smartphone use, for example, to manage appointments, medications, education and messaging. 

Compare MU that with Google's mobilegeddon and the unwillingness of innovative systems (like this and this) to wait for CMS to catch up.  They're loaning handhelds to patients.

What do you know: if you want to increase access to healthcare for the economically disenfranchised, there truly is an app for that.  It was there all along.

2. Yet, smartphones for the economically vulnerable and access to health information technology are not necessarily a slamdunk.  This report reminds us that smartphone contracts are vulnerable to non-payment and that it's not unusual for service to be turned off. 

Health systems that can navigate that reality that will win.

Image from Wikipedia

Electronic Health Record Portals: So What Is the Evidence That Supports Their Use?

Talk about a compelling story that went ignored.

In the November 19 issue of the Annals of Internal Medicine, Caroline Lubick Goldzweig and colleagues examined the published science on the purported advantages of electronic health record (EHR) portals.

Recall that portals are web-based entryways that on-line health consumers can reportedly use to access their records, request medications, correspond with their doctors, manage their health conditions, reduce health care costs, increase U.S. life expectancy, reduce our national dependency on jumbo-sized sugary drinks and fix everything else that ails the U.S. health system.

Unfortunately, facts have intruded.  After looking at fourteen randomized prospective trials, 21 observational, hypothesis-testing studies, five descriptive studies and six qualitative studies, the authors concluded...

 "...evidence that patient portals improve health outcomes, cost, or utilization is insufficient."

Ouch. 

In particular, any impact on diabetes care was short-lived or nonexistent, patients with heart failure had no meaningful improvement, blood pressure control did not improve and adherence to prevention recommendations were marginal.  One observational study found persons with heart failure were more likely to use the emergency room.  The only study that found any benefit involved a single randomized control trial that examined the impact of portals in the co-management of depression.

After looking at this review, depressed advocates of EHR portals may have to personally use their own portals to communicate with their docs health care medical neighborhood.

The only good news is that there were some data that suggested that a substantial number of consumers liked using the portals.  But the DMCB likes channel surfing too, but that doesn't mean that the spouse agrees that its television-watching quality has improved or that the cost of all those premium channels is moderating.

The authors pointed out that it was difficult to isolate the impact of a portal vs. a portal plus care management.  To the DMCB, that means that portals are at best a means-to-an-end of enabling care managers to better communicate with their enrollees. 

To the thousands of DMCB readers, that is not a surprise.

In the meantime, the Feds and the NCQA have one more reason to re-examine their many cherished assumptions about health information technology and the stand-alone electronic record. The last time the DMCB looked, the federal government continues to extoll portal's stand-alone virtues. The National Committee on Quality Assurance (NCQA) still includes two way communication for appointments, referrals and prescription referrals as a standard for the medical home.  Finally, the Fed's promotion of the electronic health record (EHR) approves of portals as an option in meeting meaningful use criteria.

Image from Wikipedia