Barefoot at HIMSS? Just Trying to Follow Dr. Google’s Orders

DrGoogle

If you see me in flip flop sandals, Vibram Five Fingers (VFF), or a barefoot-style shoe at HIMSS14 — please withhold fashion judgment. Since Jan 1, 2014, I have been performing a little “care management” on myself — as ordered by Dr. Google — and have been treating my sports injury by going about barefoot or minimally-shod.

Trusting Dr. Google over my Kaiser podiatrist (recommendation: prescription orthotics), and my Kaiser Sports Medicine Doctor (recommendation: wear a medical boot), was not easy. I was driven by: 1) pure desperation to get back to running, 2) A feeling that the KP system had nothing left to offer me, and 3) a high deductible health plan.

When my healthcare was paid for, and the doctor was all-knowing

I began running as a teenager and within a few years had developed posterior tibial tendinitis (pain and swelling along the inside of the ankle/foot). The podiatrist told me I had flat feet/over-pronated, and that I needed custom orthotics. I blindly trusted him, accepted his diagnosis as fact and was soon running again — pain-free and happy. Pre-Internet, I had no easy way (and no inclination) to really understand the biomechanics of running gait and why the orthotics fixed my symptoms.

A few decades later, I found myself again in a podiatrist’s office. I was suffering from some intermittent pain in my left ankle/foot, and assumed I needed the latest and greatest orthotics.

However, this time around I was no longer that oblivious teenager. I had read the book Born to Run and had also witnessed my husband suffer through various running injuries over the years — injuries that immediately disappeared after he started running in a VFF toe shoe.

I distinctly remember asking the podiatrist if there were any exercises I could do to strengthen my foot, negating the need for orthotics. He told me no, my problem was genetic, and that I would need new $300 prescription orthotics.

Turning to Dr. Google Instead of Dr. Kaiser

After running for several months in the new orthotics the pain came back ten fold. In order to simply walk, I began wearing an ankle brace in addition to the crippling orthotic. After 6 months of not running, I was in as much pain as ever, and was desperate.

During this time period (late last year), a perfect storm of events pushed me towards Dr. Google and healthcare consumerism.

I read The Story of the Human Body, by the “barefoot professor”, Daniel Lieberman of Harvard. Lieberman discusses how the habitual wearing of shoes since childhood deforms and atrophies the human foot — causing a host of problems including flat feet/overpronation. Lieberman also rails against the orthotics industry, describing how orthotics cause the foot to progressively weaken over time until wearers lose the ability to walk barefoot.

Feet

At the same time as I was learning about the deleterious effects of shoes on the human foot, I was transitioning into a high deductible Kaiser plan via Covered California. This meant that I would pay dearly for each office visit, and, at that point in time I didn’t feel like spending a dime on KP with regards to this injury. I very much felt (and still do) that I had been duped by both the orthotics maker, and the orthotics-salesman podiatrist.

In short, I had nowhere else to go except to Dr. Google, who was available for free, 24/7, instantly. Over a week I obsessively googled various keyword combinations. I found communities of barefoot runners, flat-foot sufferers, and numerous YouTube videos. Most helpful were the videos and blogs that described in detail, exercises to strengthen arches in flat feet. I also learned the important role of the big-toe in supporting the arch (in nearly all womens’ shoes, the big toe is pushed and squeezed to the side, causing the arch to oftentimes fall).

I formed a hypothesis that this barefoot stuff might cure my foot injury, and so on Jan 1, 2014 started slowly going barefoot as much as I could around the house and doing various foot and lower leg strengthening exercises. I wore VFFs and flip flops outside, and got rid of the ankle brace.

Testing My Barefoot Hypothesis, On a Sample Size of One

Wearing orthotics for so long, I hadn’t realized how weak my feet actually were. In going barefoot, I felt could feel just how feeble each tendon, ligament, and muscle was. At the same time (and despite the ongoing soreness), the post tib pain was subsiding. After 2 days barefoot I could walk without much pain.  7 days barefoot and the pain was gone completely. This was after 6 months of suffering.

Some other outcomes: My foot became noticeably wider, more muscular, and lo and behold I developed an arch in my foot. I have tried to prove these outcomes to myself by trying on a narrow shoe that used to fit but now does not, and by observing my footprint coming out of the pool — before it was a blob, now it looks like a normal footprint.

Disclaimer: yes, I am a sample size of one, this was a non-controlled study. I acknowledge that I too suffer from Optimism bias and Confirmation bias.  Also, I don’t yet have enough runs under my belt to know whether or not this barefoot transition will really enable me to run injury-free for a long time. (To date I have been able to run 4 miles at a stretch in the VFFs.)  I may get injured tomorrow but for now I am declaring victory.

Analysis: Why Didn’t Kaiser Care if I healed or Not?

Of all healthcare providers, KP as a capitated system should have cared about healing my foot and preventing the need for surgery. However, in this case KP acted completely episodically.

What about population health management outreach? I didn’t receive a single outreach from KP, checking in as to whether the orthotics worked or not. Not even a simple email. (Actually, I am naïve to expect this. KP is a smart actuarial organization and has made the calculation that this type of outreach is more likely to increase utilization for a generally healthy member. Not so for the sickest, most complex patients.)

What about care coordination? I visited a primary care doctor after the fact for a routine checkup. Why didn’t she ask me how my foot was doing? Maybe going through my (very short) medical record was too much to ask? Why then install Epic at $6B?  If this kind of basic care coordination isn’t being achieved within a closed, integrated system who has been on Epic for years and touted by many as the “gold standard” then how do we expect loosely integrated clinical networks to share data?

Note: In Kaiser’s defense, before I visited Dr. Google I did make one last attempt and had a phone conversation with a sports medicine doctor (no deductible charge) who wasn’t interested in talking about orthotics and told me the next step was a medical boot. I asked him about barefoot running and he didn’t disregard it as possibly helpful.

In Summary: Healthcare Consumerism Driven by Complex Factors

With this post, what I want to do is shed some light on the complex conditions driving healthcare consumerism today. In this case, my ACA high-deductible plan offered me some tough love and forced me to take control of my own health — though there are many use cases where these plans might backfire.

There is also the role of tech/IT therein. Aside from the obvious benefits and pitfalls of going to Dr. Google, this use case made me think deeply about just how far providers are from truly harnessing user-generated data. For example, KP in the far future might want to exploit my smartphone’s GPS data to predict if I am trending towards a sports injury in the first place.

I have also written this post as a small way of adding my voice to Dr. Google — I hope it can be useful to anyone who has suffered from similar injuries. You don’t always need to mindlessly believe a podiatrist who tells you that your feet are genetically defective and need to be propped up by an expensive orthotic.

I am now preparing to walk ~8 miles daily through those long hallways at HIMSS, and looking forward to it, though be forewarned, I may be not be wearing the most stylish shoe.

Share

Benchmarking Payers Adoption of Consumer Tech

Awhile back, a large health insurer (payer) commissioned Chilmark Research to do a market scan on how payers across the country were using emerging consumer technologies to engage their members. We found this project to be quite interesting and rather than have much of that research sit on the shelves forevermore, we decided to build upon it.

Today we are releasing the results of that effort.

Our latest report: Benchmark Report: Payer Adoption of Emerging Consumer Technologies takes a close look at over 40 payer (health insurers) initiatives that are using a wide variety of consumer technologies (apps, social media, games, etc.) for member engagement. Here’s the PR announcing the report’s release.

Now it is well-known that payers have had a very mixed record in engaging their members. Part of the problem has been trust as members are justified in taking a cautious approach when sharing their health information with payers for fear of future denials. Secondly, many payer initiatives have been half-baked wherein payers have not been fully engaged themselves in the concept of member engagement.

But as we pointed out in a post earlier this summer, this is all beginning to change. Numerous market forces are now pressing down upon payers and payers are increasingly coming to the realization that they need to deploy member engagement solutions that work. Payers are now going to where consumers already are seeking to engage their members via a variety of consumer-based technologies. This report is our initial effort to gain a greater understanding of what payers are doing today and provide some guidance as to how their efforts will evolve overtime.

One thing we have learned in the course of our research is that despite all the talk, the majority of these efforts are in their infancy and that the vast majority of payers have not even begun to venture down this path. Therefore, we intend to update this report on a periodic basis to benchmark payer adoption of consumer tech in support of member engagement and gain an even deeper understanding of what works and just as importantly, what does not.

Thanks to the many that we have interviewed over the course of the last several months to compile this report as your inputs have been invaluable.

Share

Payers Take Another Stab at Engagement with Consumer-based Tools

It is now nail-biting time, as we here at Chilmark Research brace ourselves for the upcoming Supreme Court decision on the legitimacy of the Affordable Care Act.  We as a nation are indeed living in very interesting times and I am again reminded why I find healthcare markets endlessly fascinating (and perplexing). (Editor’s note: This post was written by senior analyst Cora Sharma and highlights some of her latest research that looks at payer strategies for patient/member engagement.)

Of interest is just how many of the ~30 million uninsured US citizens will land on insurers’ doorsteps in 2014. Even if the Individual Mandate is upheld, it is still uncertain just how many of these uninsured individuals will opt to pay penalties rather than purchase health insurance.

For my patient engagement research, I have spent the past several months speaking with executives at large payers about their consumer-focused strategies.  Just how are payers planning on using relevant consumer technologies to keep new individual customers engaged and healthy?  After such a dismal track record over the years around health/wellness/DM initiatives, is it worth another go-around? (Cora’s research will culminate in a forthcoming report to be released within the next couple of weeks.)

Payer Initiatives in Consumer Technologies
Kaiser Permanente and Humana actually began experimenting in this area circa 2008, creating flash-based, online health games for children. In 2010, UHG released the first version of the OptumizeMe social game App, Anthem released its Grocery Guide App (now EOL), and Aetna partnered with OneRecovery.com to provide a social network for members in recovery.

Now all of the major payers have ongoing products, partnerships, and pilots around consumer-focused health and wellness and disease management — though with varying respective strategies (the upcoming report explores these 35 ongoing payer initiatives in detail).

The figure below shows an interesting slice of data around social games, in that the majority of these initiatives are becoming social and ‘gamified’:

Note: Data point positions do not represent degree of gamification/ social-ification. These are just meant to illustrate number of initiatives in each category

Another trend our research has found is the willingness of payers to look beyond health and wellness and towards the complex FDA-regulated space of chronic disease management solutions (partnering with Healthrageous and Welldoc), as well as seeking to improve member ‘Wellbeing’.  Aetna’s partnership with Mindbloom to offer members the premium version of the Life Game™ is one of the few efforts we found among payers that looks to engage the full spectrum of health of a member with a focus on Wellbeing.

Growing market in payers that can transition to a post-FFS world.
In the future, we predict that this market will continue growing along two distinct tracks:

  1. In payers that successfully transition their businesses to risk-sharing, care coordinating models (ACO/PCMH) looking to proactively engage members/patients in self-managing their health; and
  2. As pure marketing-plays, e.g. releasing cool mobile Apps that generate a nice press release, some market buzz, but little else.

As many readers may know, the health insurance industry is going through a period of rapid transformation.  Payers with the means and the wherewithal to innovate their business models are purchasing providers, as well as partnering with them for data-sharing agreements and ACO-like payment contracts.  Some large payers are also getting into the ACO-enablement business through acquisition of software companies.

Insurers who do not innovate their business models towards a post-FFS (fee for service) world (be they pure insurance providers or mostly claims processors) will find little incentive to experiment heavily with emerging consumer technologies.  The crux of the matter is that they will never have the long-term incentives (nor the culture) to shift gears away from their actuarial focus and will remain low margin businesses, if they manage to survive at all.

Affecting behavior change towards health and wellness has proven incredibly difficult over the long haul. There is scant evidence that these new payer initiatives that seek to adopt common consumer engagement technologies and strategies are meeting objectives. As the entire healthcare industry pivots towards new bundled care reimbursement models though, there may be a glimmer of hope. I remain cautiously optimistic to see payers experimenting with and adopting emerging consumer technologies, knowing that there is still a long road to travel.

Share

Much Ado About Patient Portals

From Chilmark Research’s perspective, patient portals are by and large Much Ado About Nothing. Sure, plenty of healthcare organizations (HCO) talk about patient access, engagement, and satisfaction and how they wish to empower their patients. They point to their glossy patient portal and say look at this wonderful tool we are providing for our patients. But if one digs a little deeper one finds that most patient portals suffer from numerous ills including:

  • Providing a patient only limited access to their records. There are no clear and consistent policies in place today as to what a healthcare organization is obligated to provide a patient access to.
  • Do not support portability that allows the patient to export personal health information (PHI) to another site/repository that they can then control (e.g., Google Health, HealthVault or other PHR).
  • Do not allow for patient entered data nor the ability for a patient to annotate records.
  • Rarely support transactional processes such as online appointment scheduling, Rx refill requests, eVisits.
  • Are just about as user friendly as a clinician’s EHR.

The problem with patient portals is that they are not seen as an integral part of the care process. In fact, we would argue that the use of the terms PHR and EHR create an artificial division – let’s just call it a CHR (Collaborative Health Record) and be done with it. But alas, such is not the case. Ask your local HCO where funding for their patient portal comes from – 9 times out of 10 they’ll say the marketing budget. As we reported from this year’s HIMSS conference, sure there was talk of patient engagement via portals but the message was one pitched to the Chief Marketing Officer (CMO) and not the other CMO, the Chief Medical Officer.

Yes folks, today the patient portal has very little to do with the patient being an integral part of the care team. No, the patient portal is all about improving consumer/patient satisfaction scores and more tightly linking the consumer to a given HCO. Therefore, is it any wonder then that if a patient portal is not viewed as an integral part of the care process then physicians are unlikely to actively advocate its use leading to a market where consumer adoption and use of patient portals remains at a paltry 6% or so nationwide.

As with anything in life, there are no absolutes and in the case of patient portals there are some stellar examples of HCOs using a patient portal to actively engage their patients. The most publicized example is Kaiser-Permanente with adoption at roughly 35% of all patients served. Primary to K-P’s success is providing its members not only access to their PHI, but also the ability to perform a number of transactional processes, e.g., appointment scheduling, online consults, etc. Up in the Pacific Northwest, the Group Health Cooperative (GHC) has also been very proactive and reports patient adoption and use of their patient portal at over 60% (that’s an order of magnitude greater than the national average!). The May 2010 research paper that GHC published in Health Affairs is pretty clear on what has driven such high adoption: the patient portal is not about marketing, but forging tighter links between the patient and physician to improve the efficiency and effectiveness of care delivered.

Now both K-P and GHC are somewhat unique in the healthcare market for both are “vertically integrated” being both the insurer and the provider. They assume the full risk of managing their patient/member populations and thus will seek out solutions and concepts that will lower medical loss ratios (MLRs) and keep their members in less costly care settings. Therefore, it is to their benefit to actively engage members in managing their health and both of these organizations have found their patient portals to be a critical piece in the engagement puzzle. With pending changes in payment models moving from fee for service to bundled payments, HCOs of all sizes will need to adopt business strategies similar to KP and GHC, including deeper, more meaningful patient engagement.

Thus, it is with disbelief that some of the recent comments to proposed Stage 2 Meaningful Use requirements state that it is unreasonable to expect physicians to have 20% of their patients using a patient portal. Now, we do agree that it is silly to ask every physician practice in the country to provide a patient portal, but it is not unreasonable for large physician practices, hospitals and clinics to provide such. Unfortunately, it appears that the medical establishment does not see the writing on the wall; that their future success is not contingent upon another marketing initiative but in truly and thoughtfully engaging the patient as part of the care team for if they were to do so, as KP and GHC have demonstrated, achieving that 20% target is not beyond reach.

Is your HCO rising to the challenge?

 

Share

KP Flexing EMR Data for Public Health

informatics_TRDon’t vaccinate your child for whooping cough and put them at a 23x greater risk of contracting this nasty disease.  That is the finding of a research report released today by Kaiser-Permanente (KP).  Last week Chilmark Research had the opportunity to speak with the lead researcher, Dr. Jason Glanz of KP on this research project and lessons learned.  Our interests lied in better understanding how the research leveraged the KP EMR.  Here is what we learned.

First some quick background:

Whooping cough is actually on the rise having hit a low of ~1,000 reported cases in 1976 and in 2004, over 25,000 cases were reported.  The rise is believed to be caused from two factors: teenagers contracting the disease as vaccine loses effectiveness and secondly, lack of full set of vaccines to infants (requires three successive shots).  While whooping cough is not that dangerous for teenagers and adults, it can be life-threatening for infants and small children, however, is preventable.

Goal & Methodology:

One of the primary goals of the research was to determine if parents who refuse to give their children the full set of vaccinations put their children at greater risk.  While there is the assumption that this is the case, Dr. Glanz wanted to determine what is the level of that risk in quantifiable terms.  In doing so, the hope is that pediatricians will have better, evidence-based research at their disposal to assist in educating their customers (parents) the risk they put upon their child when refusing a vaccination.

Digging into the data of KP’s EMR in Colorado, the researchers extracted the records of children over an 11 year period (1996-2007) to look for cases of whooping cough and correlation to vaccine refusal.  Over 100K records were reviewed. Once the data was extracted and reviewed, SAS statistical tools were applied for analysis.

Why this is important:

As we march down the EHR adoption road with a $36B wind at our back, compliments of Uncle Sam, a critical issue is: What do we, as tax payers who are ultimately paying for this, get in return?

Part of the answer may lie in research such as this that leverages massive amounts of data in an EHR (or in the future a network of EHRs) to determine with a high degree of confidence such issues as behavioral risk, adverse drug events, effectiveness of various treatments to demographic subsets of the population, etc.  This could have a massive impact on future healthcare practices resulting in better, more effective and potentially personalized care.

For example, in this whooping cough example researchers found that the demographic most likely to refuse a vaccination is Caucasian, upper middle-class and well-educated.  Knowing that information in advance will assist educators in crafting educational content targeting that demographic.  If, on the contrary, it were primarily a Hispanic population, content could be generated in both Spanish and English.

By no means a slam dunk:

While it is great to hypothesize on the potential that prudent, secure and safe use of health record data to perform such studies will create a new revolution in healthcare research, it is far easier said than done.  Today, most EMRs can not readily share data in support of such research efforts.  One can only hope that the future criteria for meaningful use (information sharing) will reflect the need to support this type of research.

But even within most hospitals and IDNs, including KP, there is insufficient attention paid to how to structure the EMR to support research projects such as this example.  In the whooping cough case example, Dr. Glanz stated that one of the most time consuming processes in the research was the examination of records by researchers to determine if a parent exercised the exemption clause to refuse the vaccination for their child.  An outcome of this research, is a new field in the pediatrician’s EMR that they will check if the exemption clause is exercised by a parent.  This will automate future analysis of data sets for this critical variable.

Extending this example further, what do hospital and IDN CIOs need to be thinking about today in their EMR implementations to insure that data for such research is more readily collected and analyzed at some future point in time?  While it may be impossible to predict all potential use cases of EMR data, CIOs would be wise to start in areas where they have develop, or will develop strong competencies of care (e.g., cardiology, urology, oncology, pediatrics, etc.). They would also be wise to actively solicit the involvement/representation of their internal research group in defining attributes for the EHR prior to install.

Share

What’s in All Those HealthVault Slides Anyway

Yesterday, I pointed the reader to the Microsoft site that had the slides posted from last week’s HealthVault Developer’s Conference. This afternoon I reviewed the slide decks, all of them, and here is what I learned.

From the Technical Track:

Quite a bit of information provided, most of it designed to update the audience on progress the HealthVault team has made since the initial launch last October. There is a lot of repetition in the various technical decks, so if you are going to choose one to download, go with the HealthVault Architecture Overview as it really has all you need to know, with one minor exception.

As for key messages in the technical track, they are as follows:

  • Greatly simplifying the sign-in/sign-up process for the consumer (I tested it and it really is a substantial improvement). Also making more general improvements to the UI (user interface).
  • Build-out of data types with 20 new ones since launch and 12 more pending. This is quite important for developers of personal health applications (PHAs) that will sit a on top of HealthVault. Still, looking at those data types that they have today, it is hard for me to understand the logic of the choices made. Comes across as somewhat of a free-for-all. Most likely driven by existing partner needs.
  • Ability to directly connect to clinical data. This is through their work with such partners as AllScripts, KRIPTIQ, and Eclipsys. Still no Cerner, GE, McKesson and most importantly, Epic, who did not even send a representative. Remember, its Epic’s My Chart that powers the Kaiser patient portal My Health Manager that Kaiser and Microsoft will be working on together to link My Health Manager to HealthVault.
  • Restatement of basic design principles: Inclusive of standards, Commitment to “Openness” (they have signed on to the Open Specification Promise (OSP)) and CodePlex support (supporting both Java and Ruby).

The most interesting slide in all the technical session slides was the following one (it is not in the Architecture Overview slide deck, but one titled: Platform Adoption) that lays out their overall platform strategy. This gives an extremely clear picture of their thinking and where they are headed.

For example, Consumers are put one target market of six shown, though one may argue that the “Employer” column may share much in common with the Consumer. And what is quite puzzling is: Where are the payers? It oul seem to this analyst that if you are targeting employers, the leap to supporting payers is not that big as employers and payers have very similar needs, particularly when it comes to managing population health and encouraging healthy behaviors.

From the Business Track:

While I found the technical slides to have some real nuggets of information, was quite surprised at the dearth of information found in the business session slides. Most of the information was very simplistic. With all the marketing muscle at Microsoft, I expected something better.

But in and amongst the weeds, I did come across some very interesting information in the presentation entitled: “How We Make Money”.

This slide deck begins with a shot of the MSN.com Health & Fitness site, with a HealthVault widget from the American Heart Association embedded on the site demonstrating personalization, how they intend to leverage existing Microsoft properties and sell Web property “real estate” to partners. This theme was extended to the HealthVault search engine.  In this case it looks like Microsoft intends to re-brand HealthVault Search as a subset of the Microsoft existing search engine,  live.com

It appears that Microsoft intends to have HealthVault be subsumed into these existing properties, which see far more traffic then HealthVault does today. I did a quick Alexa analysis comparing first three health-centric websites, HealthVault, RevolutionHealth and WebMD. HealthVault doesn’t even show-up in the rankings.

Did another Alexa analysis, this time adding live.com and msn.com (couldn’t get a read on the sub-site health.msn.com) and as one would expect, these two properties see lots of eyeballs, which could give far greater exposure to the HealthVault property/brand.

Remains to be seen if that will ultimately be the case, but HealthVault clearly is not getting much traffic today, so it certainly can’t hurt. But then again it may have the affect of diluting the HealthVault brand.

But this is where all those partners come in (there are 36 software partners and 9 device partners up and running today). In a somewhat brazen and even arrogant manner, the HealthVault folks are adopting a marketing strategy that they refer to as an “ingredient branding strategy” Think Dolby, Intel Inside, etc. What they are looking to do with the ingredient strategy is have all their partners put the HealthVault label (web tile for websites, logo on device packaging) and let the partners push the HeathVault brand.

This is ludicrous.

In a market as small, immature and nascent as this one, with so many challenges ahead, it is hard to believe that Microsoft is depending so strongly on its partners to take the HealthVault brand to market. Really quite bizarre and something they should rethink.

Tomorrow, will have see the last post on this event and will have highlights from interviews wth several who attended this event.

Share