Patient Experience and Satisfaction Aren’t the Same as Engagement

Healthcare’s inexorable march toward value-based care has brought with it a focus on what’s best for the patient. Instead of routinely pushing people from one billable appointment to another, providers of all types are, to varying degrees, beginning to understand that more care doesn’t necessarily equal better care.

This shift in policy and philosophy is certainly welcome, and long overdue, but healthcare organizations (HCOs) must be sure to push their good intentions in the right direction.

hospital waiting roomTake, for instance, the hospital waiting room. The longtime dumping ground of year-old magazines, well-worn chairs, and grainy television sets has been transformed into a bright, comfortable, and almost welcoming place. Swanky waiting rooms have spread throughout the hospital, too; patients can sit in comfort as they await exams or consultations in various internal departments.

You’d have a hard time finding anyone who prefers the older, dingier waiting rooms. But the esoteric improvements mask a more fundamental issue: HCOs are focusing too much attention on patient experience and satisfaction, trying to compete with hotels, and not enough on honest-to-goodness engagement. Instead of spending so much time, money, and resources on making waiting comfortable, hospitals should address why patients are waiting.

The rationale for this misplaced focus isn’t hard to find. In a world of quality metrics, HCAHPS scores, and innumerable “top hospital” rankings, the need and desire to improve experience and satisfaction is certainly understandable. However, a good waiting experience isn’t the same as a good care experience – or, for that matter, a good understanding of how to make the right decisions to improve health and well-being and spend less time waiting to receive care in the first place.

Nice waiting rooms are, well, nice, but they remain a holdover of the fee-for-service world. Think about your auto mechanic. The free Wi-Fi, fresh coffee, and clean bathrooms aren’t there to entice you to leave; they entice you to come back (and spend money) the next time your engine starts making funny noises. If anything, a posh waiting room is a form of revenue cycle management (RCM), since it’s all about bringing repeat customers through the door.

Waiting rooms don’t improve engagement. That’s why Geisinger Health System CEO Dr. David Feinberg wants to “eliminate the waiting room and everything it represents,” namely a way to build up inventory for doctors at the expense of the patient. The larger issue is that value-based, coordinated care will only succeed when patients are truly engaged in their care. Admittedly, this is a struggle.

As it is, HCOs have enough trouble improving the patient experience, according to a recent Kaufman Hall survey. They know they need to do something, but they say they lack the “strategic insight” to figure out what it is, not to mention the capability to implement such a strategy. This survey did not ask if they had had the capability to upgrade their waiting rooms, but I’m willing to bet they did.

Engagement itself is another giant step forward. It’s hard to fund (big-money donors prefer to see their names on a building instead of, say, an app or program) and even harder to implement (the n=1 strategy of precision medicine means that interventions must be specifically tailored to vastly different patient population segments). Plus, engagement technology must link to a larger value-based technology strategy, which itself requires a shift away from the point solutions so prevalent in healthcare and toward solutions that meet specific clinical or operational requirements within healthcare’s new value chain. Most HCOs lack “strategic insight” into what this entails, too.

Whatever the future holds for value-based care, insurance reform, electronic health records, the private practice, the standalone hospital, or the industry as we know it today, the chief goal of practicing healthcare will remain constant: Keeping patients as healthy as possible for as long as possible so they get as much out of their lives as possible. To that end, HCOs would be wise to not keep patients waiting.

Stay up to the minute.

“As biometric data becomes cheaper and easier to collect through smart sensors, devices, and mobile apps, expect to see more innovations in consumer health.”

-Alicia Vergaras

Health 2.0: Ten Years On

295202-2For my young daughter, 10 yrs is nearly a lifetime – but for myself, nary the blink of an eye. So it felt this week while attending the 10th annual Health 2.0 conference, one part so much time has past, another just a flash. Over those ten years I have had the pleasure and at times frustration of attending nearly every Health 2.0 event.

The pleasure comes from the excitement of seeing so many dedicated people all trying to do their part, in some innovative way, to improve the healthcare system. The energy they exude is contagious. As a result, Health 2.0 often feels like the antithesis to the staid and conservative annual HIMSS conference. I come to this event to see what lies on the horizon, I go to HIMSS to see what is happening now.

But that excitement and a certain naiveté has also been frustrating. Frustration comes from having seen a profound lack of reality among a significant percentage in attendance. Is it the Silicon Valley effect? Too often start-up companies seemed oblivious to the countless challenges present in this convoluted market and lacked a deep understanding of what is needed. But being altogether all in the same place, these energetic founders of young companies all drank from the same fountain – the cheerleading was deafening. Come back two years later and most had fallen to the wayside.

In its early years Health 2.0 was heavily weighted towards frustration. Beyond the naïve-istic cheerleading, there was a lack of diversity, of heterogeneity in the audience. It was an event about, for and ultimately comprised of start-up health companies. There were few, if any providers – maybe a couple on stage at some point.

But as the HITECH Act took hold and federal dollars came in to encourage EHR adoption, broader interest in the digitization of healthcare accelerated. The floodgates opened and investment dollars came pouring in to the digital health space rising from the low $100’s of millions in 2007 to some $5B projected in 2016 much of it going to start-ups.

This investment influx led to more sophistication among the start-up companies attracted to Health 2.0. The organizers responded in kind with the content becoming more robust and the audience more diverse in the ensuing years. The hyperbole has also been turned down several notches. Health 2.0 is now a dynamic conference, with an excellent line-up of speakers and topics discussed. Sure, there remains a certain odd “campiness” to the event, but that is part of its charm.

While this event has matured and expanded, one thing does strike me as puzzling: Why are there so few of the mainstream vendors of HIT at this event? Is Health 2.0 seen as just some odd side-show to the grander market (e.g. HIMSS)? Is there a country club bubble that more traditional HIT vendors reside in with little desire to look down the street to what may be marching their way? Is it simply a lack of attention, wherewithal or interest to the dominant theme at Health 2.0  – consumer/patient/member engagement and empowerment? If it is the latter that is a sad commentary on incumbent HIT vendors.

As we articulate in our latest report and have done so elsewhere, the future success of population health management programs will be highly contingent upon far deeper consumer engagement. Thus, if I were leading strategy for one of those incumbent HIT companies, I’d surely send someone to Health 2.0 to ensure that my company gets out of the bubble to see what might be next and more importantly, who might be a target for partnership or future acquisition as we develop our consumer, patient or member engagement strategy.

Like the Health 2.0 event, Chilmark Research also got its start in 2007. Together, in our own ways, we are each trying to move the needle in healthcare to ultimately improve the consumer experience. Much has transpired in this brief decade that makes it seem long upon reflection but short in action. The industry is going through a profound transformation. Just as we are moving to digital health, the industry may indeed be slowly pivoting, as athenahealth’s Jonathan Bush stated: to “network health.” Looking ahead, I wish Matthew, Indu and the broader Health 2.0 team another decade of success, joining us in pushing the boundaries to ensure that the this sector meets the promise that a truly network model of health may offer.


Finally, Some Concrete Use Cases for Telehealth

A recent report has gone great lengths to explain how and to what extent telehealth can improve outcomes, and it is well worth a read if your healthcare organization (HCO) plans to explore investments in telehealth services now or in the future.

No, I’m not talking about The Wall Street Journal declaration that telemedicine is transforming healthcare. The top-fold placement of the story was indeed nice, as was the accompanying interview suggesting that technology in general can improve population health, but the article wasn’t exactly news to the healthcare industry. (Not to sound like a hipster, but I wrote my “telemedicine is changing healthcare IT” article back in 2012, before it was cool.)

As it turns out, the report in question is a technical brief from the Agency for Healthcare Research and Quality (AHRQ) that examined 58 research studies to find evidence of telehealth’s effectiveness across both clinical areas and technical functionality. In a nutshell, the interventions with the greatest impact on outcomes tend to target chronic conditions.


Evidence of Effectiveness for Telehealth Functionality and Clinical Areas (Source: AHRQ)

The table at right summarizes the findings. Here are four additional observations.

  • AHRQ defined telehealth as “the use of technology to facilitate an interaction between a patient and the healthcare system or interaction between two or more providers when the interaction was directly related to an individual patient’s care.” The key phrase there is healthcare system, as it implies that a relationship between the patient and the HCO already exists. This strikes a blow to direct-to-consumer apps, but it also indicates that creating yet another siloed venue of care won’t benefit patients or providers.
  • To treat Type 2 diabetes, communication and counseling work well, but RPM does not. This makes sense. The Diabetes Prevention Program (DPP) model, which the Centers for Medicare & Medicaid Services (CMS) wants to take national, emphasizes counseling in the form of weekly in-person group visits, with topics such as barriers to healthy eating and physical activity. Monitoring, on the other hand, serves as a constant reminder to someone that he or she is sick; it’s not a tool for motivating behavior change.
  • In the words of AHRQ, RPM is an effective use of telehealth because “it makes new or significantly different forms of information and treatment available that can supplement and extend office-based care rather than replace face-to-face interactions.” Simply changing the mode of care delivery isn’t enough to improve outcomes. Telehealth must change the form of care altogether. This should offer pause to any payer, provider, or vendor that thinks simply digitizing an in-person care encounter will flip the healthcare industry on its head.
  • Chilmark Research usually advocates faster adoption of technology as opposed to perpetual pilots, but any telehealth use case that hasn’t had a demonstrable effect on cost and utilization – we’re looking at you, teledermatology – should be subject to scrutiny. Take tele-triage: Does it direct patients to the most appropriate care setting or, in the absence of licensed medical professionals and/or evidence-based protocols, does it just funnel patients to the ED?

Teladoc’s recent, pricey acquisition of HealthiestYou begins to confirm our prediction that the telehealth market is ripe for consolidation. As the moving and shaking continues, HCOs must avoid the perils of shiny objects that address single episodes of care and instead seek telehealth partners that improve outcomes for chronic patients while controlling costs. The former will make headlines, but the latter will transform healthcare.

Design Healthcare for People at Their Worst

Much of the rhetoric surrounding healthcare innovation is happy. Smiling young people run along a river on a sunny day, then check their FitBits. Smiling parents hold iPads while they connect to a smiling pediatrician over video chat. Smiling nurses use state-of-the-art equipment as they treat plain-faced but nonetheless hopeful patients.

At its core, though, healthcare is not happy. Sick people want to get better, not receive constant reminders that they are sick. Medical professionals want to help patients, not select an ICD-10 code from a pull-down menu. No one wants to think about what it will all cost.

Thus the recent Healthcare Experience Refactored (HxR) conference in Boston challenged those building the healthcare technology of tomorrow to design apps and devices for users who are at their worst, not their best – to bring empathy into the user experience, to make systems simple, and, ultimately, put the “care” back in “healthcare.”

As we all know, it’s a laudable mission but a difficult one. A billion-dollar innovation is a mere drop in the bucket in a $3 trillion (and growing) market. On top of that, the most impactful and necessary innovations – improvements to clinical workflow and data integration – garner little attention alongside this week’s latest fitness apps or wearable tech updates. Consumers (and the media) care less about the accuracy of the heart rate monitor or pedometer because, look, the watch band comes in fuchsia now!

Clinical workflow and data integration matter because the narrative matters. STAT News recently ran a thoughtful piece lamenting the loss of the patient story in healthcare’s rush to implement electronic health record (EHR) systems. Digitization has no doubt benefitted an industry bogged down with paper, but boiling down a patient’s medical history to a series of bullet points and billing codes fails to capture that patient’s motivations, goals, and obstacles in their journey to better health and wellness. It also chills the patient-physician relationship, as the conversation is interrupted to input information or wait for load screens to disappear.

For too long, the end users of healthcare IT have been treated as an afterthought as paper-based and manual processes are simply replicated using a screen, mouse, and keyboard. With no thought given to workflow or usability, pull-down menus, lists, free-form text fields, and customizations abound – not to mention frustration. That’s why it’s time to kill the patient portal, ditch the cluttered EHR, scrap the standalone schedule, and smash the fax machine.

Healthcare applications and devices in all their forms must be designed for end users, not outdated workflows. They must return joy to the practice of medicine and allow patients to live with their conditions, not cope with them.

Above all, systems should serve patients, physicians, and nurses when they are at their very worst – in the moments following a crushing diagnosis, for example, or the final hours of a double shift in the ED. If users can stand the systems then, there’s no telling what they can do when they are happy.



Bringing Digital Health to Those Who Need It Most

Between my current life as an analyst and my former life as a journalist, I’ve sat in a lot of keynote addresses, conference sessions, and presentations touting the latest and greatest consumer healthcare products. No matter whether I’m impressed, puzzled, or bored, I always ask myself, “Would Mom and Dad use this?”

My parents embody the archetype of technology laggards. Their watches are not smart. Their television is not high-definition. Their internet is wireless and high-speed, but only because it was part of a package deal with their cable provider. Their music is stored on CDs, their movies on DVDs, their photos in physical albums and shoeboxes. Their household appliances do not send data to the cloud. If you want to communicate with them, you must use the Phone feature of your handheld mobile device.

In other words, the answer to the question I always pose is inevitably “No.” Many Americans, I reckon, would answer the same way. And that points to digital health’s biggest problem.

Take the recent Consumer Electronics Show. Amid all the pomp and circumstance, very little from CES applied to people like my parents. Under Armour’s $400 Health Box? It’s for athletes with money to burn, not seniors on Medicare collecting Social Security. Fitness-tracking headphones? The next time my parents carry music anywhere will be the first. A tricked-out medication reminder? Maybe – but can someone taking 10 pills afford 10 smart pill bottles? An app-connected pregnancy test or smart baby monitoring kit? Those ships have sailed long ago.

I focus on the needs of my parents for two reasons. First, they and their peers are the immediate present and future of healthcare – more numerous and longer-living than previous generations and, as a result, in need of healthcare services the likes of which the industry is unprepared to accommodate.

Second, study after study has confirmed that those who occupy the top of the healthcare cost pyramid – those with multiple comorbidities or complex chronic conditions – tend to be older, less affluent, and less health literate than the population at large. Yet digital health appeals to the young, the affluent, and the health literate. Instead of targeting Mom and Dad, startups target people like me – and then wonder why, after several months, we abandon the “solutions” and go on with our lives.

I understand the reticence to develop and market technology solutions to a demographic that’s reluctant to embrace tech in its own right, as Gen Xers and Millennials have done. In 2016, it’s a great way to drive a tech business into the ground.

However, as with so many problems plaguing healthcare, the answer to increased adoption among older, needier patients isn’t more tech, more advanced tech, or even different tech. Just as communication is at the heart of successful care coordination, communication – in the form of education and training tailored to the individual needs and wants of each patient – sits at the heart of successful consumer health adoption and use.

So many digital health solutions assume that simply leading users to water will not only convince them to drink – and convince them of the benefits of drinking – but somehow immediately make them proud, confident, and frequent visitors to their watering hole, even though there are thousands of other watering holes, some even crocodile-free or under a shady tree. That doesn’t work. As an Accenture recently reported, a whopping two percent of hospital patients use mHealth solutions that hospitals have wasted millions of dollars developing or acquiring, in large part because patients don’t know how to use them – if they even know they exist at all.

Which begs the question: Have these health systems even worked closely with their staff on how these apps will facilitate clinical workflows, quality metrics, and outcomes? If the clinical staff is not on board in promoting these apps, patients won’t be either.

Healthcare continues to innovate in parallel paths, with the work of small startups and consumer tech brands (who get tech and consumerism) occupying a completely different space than the work of large healthcare organizations (who get patients). The longer that happens, the longer that events such as CES will be filled with innovations that truly don’t matter in a clinical context and are highly unlikely to ever make it into the hands of patients – like my parents – who actually stand to benefit from them.

The Parallel Paths of Healthcare Innovation

How you define healthcare innovation depends on the setting.

Sometimes it’s a handheld device that lets a physician examine your throat during a video visit, an online eye test, or a patient and caregiver engagement platform that looks a lot like Facebook Messenger. Sometimes it’s computerized physician order entry, a mass email to employees participating in a wellness program, or a patient portal that lets a mother manage care for her children and her spouse as well as herself.

The first set of examples comes from Health 2.0. The second set comes from the Cerner Health Conference. To butcher a cliché, one is from Mars and the other is from Venus. However, these events illustrate two parallel paths of healthcare innovation – and if the industry is going to advance into 21st century in any way, these paths must come together.

The companies at Health 2.0 – startups straight out of Silicon Valley and Silicon Valley – work outside the traditional healthcare system. They stay small but think big. They develop first and ask questions later, even if it means clinical workflows, provider partnerships, and business models take a backseat to rapid innovation.

The companies at the Cerner Health Conference – large healthcare organizations (HCOs) as well as the host itself – work within the traditional healthcare system. They stay big but think small. They ask questions first and develop later, even if it means rapid innovation takes a backseat to clinical workflows, provider partnerships, and business models.

Neither approach is wrong. Healthcare needs a steady drip of new apps, devices, and services as well as the occasional flood of new software releases. The former offers a glimpse into the future of healthcare, when consumers are in charge of their care (and their records) and HCOs strive first and foremost to keep people healthy. The latter makes the present a little more bearable, bringing decision support, care coordination, and population health tools to HCOs as they adapt to shifting reimbursement models and other market pressures.

At the moment, though, both approaches exist in a bubble. HCOs and traditional players were few and far between at Health 2.0; Allscripts exhibited, and Cigna, United Healthcare, and the Cleveland Clinic spoke, but small firms with limited industry exposure dominated the agenda. (To be fair, that’s the whole point of Health 2.0.) Likewise, startups were scarce at Cerner’s event; the exhibit hall was a Who’s Who of enterprise IT and hospital IT stalwarts. Only Livongo staffed a booth at both conferences.

These parallel paths of innovation need to come together. Both approaches have much to teach each other. Sure, startups want nothing less than to flip traditional healthcare on its head, but they have the backing of doctors and patients who understand the system. Sure, large providers by their very nature represent traditional healthcare, but they have clinical staff who see firsthand why the system needs to change.

This will be a process, to be sure. Traditional players (providers, payers, and vendors) must balance remaining wary of far-out ideas with giving their all to the next BetaMax, LaserDisc, or Coleco Vision. Open platforms are a good start, but the proliferation of worthless stuff on the Apple and Google stores shows that careful curation of medical apps will be necessary. At the same time, startups looking to grow rapidly must balance tethering themselves to a single big player (and restricting themselves) with partnering with anyone (and seeming desperate).

If nothing else, the two sides need to talk. Health 2.0 is growing up, and its next step should be putting its startups in front of the Kaisers, Intermountains, and Geisingers of the world. Meanwhile, events such as the Cerner Health Conference should do the same and invite companies such as MedWand, Opternative, and CareSync, which respectively make the telehealth device, the online eye exam, and the messaging platform mentioned at the beginning of this post. Only then will the parallel lines change course and start to come together.

Bringing Enthusiasm to the Consumer Health Tech Revolution

You can’t travel too far on the Internet without tripping over an article, report, survey, or commentary lamenting the state of engagement in the healthcare industry. A lot of this talk focuses on the poor quality of technology that healthcare organizations (HCOs) use in their feeble efforts to engage with patients. “Why can’t healthcare be like (insert just about any other industry here)?” these pieces ask, listing the various apps, services, and websites that make it swell to be a consumer in 2015.

Sure, healthcare technology leaves a lot to be desired. Most portals serve not as an engagement tool but, rather, as a line item on an RFP or meaningful use checklist. Few healthcare apps serve such a significant purpose that consumers use them as often as they check social media, email, or texts. Few services mimic the convenience of booking travel, ordering pizza, or setting up your 401(k) without having to put on pants.

A recent study in the Journal of Medical Internet Research pinpointed a key part of the problem. Healthcare app developers often assume that all patients have “unlimited enthusiasm” for tracking their data, and that all physicians readily accept that data when neither statement happens to be true. Booking vacation is one thing; tracking blood glucose on an infrequent basis, only to have a physician cast aside that patient-generated data in lieu of what the machine says, is another thing.

The rapid advance of consumer technology has, in a way, hindered engagement efforts. Throw some cool stuff at consumers, HCOs and startups seem to say, and we can call them “engaged.” Tell patients about the portal! Show them how to pay for parking on their phone! Sign them up for our fitness challenge! Give them Schrute Bucks for eating salads!

The problem, as colleague Naveen Rao detailed during last fall’s flu season, is that healthcare’s engagement problem goes much deeper than tech.

A couple weeks ago, it was my turn. I walked into my doctor’s office for my annual physical at 2:45 p.m. At 2:50 I stepped on the scale. At 2:55 I gave up on tying a knot behind my head, leaving my gown wide open in the back. At 3 my doctor walked in (right on time, to his credit). At 3:05 I was making my appointment for next year. I felt less like a patient and more like a widget that had zipped across an assembly line so fast that the foreman and his team might get that performance bonus after all.

Granted, I don’t need the level of engagement provided by a care coordinator, a lifestyle coach, or a visiting nurse. I don’t have a condition that requires frequent monitoring. But the industry has a problem if someone who doesn’t need a reason to get up at 7 a.m. on a Saturday for a 14-mile group run in the humid August sun and then grab some kale at the farmer’s market on the way home nonetheless can’t find a reason to log into a portal, download an app, don a wearable, or rally behind the next “Uber for healthcare.”

Healthcare isn’t bad at engagement because it lacks technological solutions; it’s bad at engagement because it’s bad at engagement. Whatever the reason – the effects of the fee for service system, recalcitrant patients, poor bedside manner, or a general aversion to change – most HCOs struggle to connect with consumers on even a rudimentary level. Rather than feel like partners in the care process, consumers typically associate fear and trepidation with the healthcare experience.

Technology can certainly change this. An equal number of articles, reports, surveys, and commentaries proclaim with no shortage of optimism that healthcare is on the verge of Big Things. Telehealth, mobile health, wearables, genomics, analytics – the list, of course, goes on, each product poised to help achieve the Triple Aim, if not change the world.

Before the industry starts throwing all this tech at patients, though, it needs to better understand how to deliver solutions to those with limited enthusiasm. For a growing number of HCOs, compassion is the key to engagement. This strategy is based on the outrageous notion that patients are more likely to listen to physicians and nurses who show that they care.

Understanding what patients want, instead of telling them what they need, can go a long way toward creating programs that reduce readmissions, cut costs, and improve treatment. It’s important to remember that what patients want isn’t complicated, either – wearable devices that actually work, portals that actually do something, test results that actually make sense, and clinical staff who actually respond to their inquiries. Solutions to these problems may not be as sexy as Uber for healthcare, but they will build enthusiasm, boost engagement, and show patients that they are indeed partners in the care process.

Inside Peek at Forthcoming PHM Report

imagesOver the last several weeks, I have been working feverishly to finish our first major report on Population Health Management (PHM), which is now in production. It may appear that we are a little late to the party in providing thoughtful research and analysis on this topic, but honestly, PHM is so nuanced, solutions remain immature and industry best practices have yet to develop, that upon reflection, timing of this report seems just about perfect.

Following are just a few of the insights gleaned from this report.

PHM is Top of Mind
Population health management is now at the forefront of strategic initiatives being undertaken across the healthcare industry. Prompting these strategic initiatives is the massive shift in risk, via payment reform, from payers to providers that is likely to completely redefine the health care delivery system in the U.S.  However, the challenge is that by and large, the healthcare sector today is ill prepared to make this transition to a PHM model of care delivery.

There are a number of challenges that stand in the way of healthcare organizations’ (HCOs) adoption of PHM-centric strategies:

  • Few HCOs have the requisite expertise in PHM and the technology infrastructure to support this transition.
  • The dynamic shift from fee for service (FFS) to value-based reimbursement (VBR) models leaves providers in a difficult situation of having to invest in PHM for the future, with little if any near term returns on investment (ROI).
  • IT solutions to support PHM initiatives remain immature requiring HCOs to take a portfolio approach to investing in a range of best of breed solutions to support their PHM strategy.
  • PHM will require a significant change in IT architecture from an almost exclusive reliance on systems of record to adoption of systems of engagement.
  • No single vendor today offers a fully comprehensive PHM solution suite, though countless vendors will try to convince HCOs otherwise.

Our PHM Perspective
For the purposes of this forthcoming report, we define population health management as:

The proactive management of the health of a given population by a defined network of providers who are financially linked, in partnership with community stakeholders (e.g. social workers, visiting nurses, hospice, patient, caregivers/family, etc.).

Within that short definition there are three important concepts. The first is that providers will move from the current passive management of patient and population health to one that is proactive. Second, that PHM occurs among a defined provider network that is financially linked, in most cases via a contract with a payer or self-insured employer entity. Lastly, that the care team extends beyond the provider(s) to include a community network of stakeholders that play a role in the care of a patient.

While Still Immature, Health IT to Support PHM is Evolving Rapidly
The healthcare industry has been slow to move to a digital, data-driven model of care delivery. It has only been in the last six years that a serious effort has been made industry-wide, via federal incentives, to adopt electronic health records (EHRs) to support the creation of a digital, patient health record. Proficiency in the use of EHRs is slowly improving. However, the industry struggles with a host of issues, from clinical data quality to interoperability across a heterogeneous EHR landscape, to supporting dynamic care teams, all of which will create significant challenges for any PHM program.

On the IT vendor side of the fence, while countless vendors claim to have a PHM solution, none can provide a complete solution today. Therefore, HCOs will be left with the challenge of knitting together best of breed solutions to enable their PHM strategy. Core PHM technology capabilities must include:

  • Analytics for risk identification/stratification, performance management, quality and gaps analysis,
  • Clinician Network Management/Health Information Exchange (CNM/HIE) infrastructure to distribute and share intelligence across all stakeholders,
  • Electronic Health Record (EHR) as a core system of record for patient information,
  • Care Management capabilities that optimize care resources within the community served, ensuring care delivery maintains continuity regardless of care setting, and
  • Patient Engagement tools that seek to empower the most critical stakeholders – the Patients – in proactively managing their health.

The EHR will play a key role in PHM initiatives as a core system for the patient record, but a number of HCOs today are unfortunately using the EHR as the core solution for PHM.

This strategy is doomed to failure.

PHM is not about one provider, one HCO and therefore one EHR. Population health management requires the active engagement of a multitude of stakeholders across a community all sharing data in support of care delivery processes, regardless of care setting. Monolithic, EHR-centric PHM programs will prove unsustainable over the long term.

Other solutions, such as those to address care management and coordination across a community remain quite immature. A number of payer-centric, care management solutions are pivoting to address provider requirements, but by and large, few have been successful to date.

Patient engagement, despite a significant amount of marketing hype, also remains very immature, largely as a result of its relatively low priority for HCOs’ IT investments, and more logistically because of its unclear home in HCOs’ workflow processes.

In the near term, the greatest focus of resources to support PHM will be targeted at analytics and CNM. The adoption of analytics solutions and services is quite strong today, especially among larger HCOs, to assess population risk, stratify that risk and measure performance. Within the industry as a whole though, the ability to attract and retain data scientists is proving challenging. This has created opportunities for solution vendors to provide complete bundled solutions, including sophisticated analytics services.

But performing data analysis is of little use if it is not proactively used. Delivering data insights to the point of care (PoC) will play a crucial role in a PHM program’s success. Leveraging CNM to enable distribution of analytically derived insights to providers across a community has the potential to dramatically improve quality, reduce variability and improve outcomes.

Looking Ahead
The lack of maturity within the healthcare sector in developing and deploying the processes, systems and technologies to support PHM will result in a strong market need for solutions that have a strong services component. However, due to severe resource constraints, healthcare organizations will increasingly look for highly modular solutions that allow them to pursue a piecemeal approach to enabling core functions in support of PHM.

Currently, we are seeing strong convergence on a per member per month service pricing (pmpm) model, often times broken out across an array of modules that a vendor may bring to market. Such a model accomplishes two goals. It allows HCOs to incrementally add functionality that aligns with their PHM priorities and budget constraints. Secondly, this model provides a high degree of flexibility for solution vendors to match pricing to the amount of services provided and is particularly amendable to hosted-service models.

Looking further out, however, HCOs will increasingly look to their solution providers to potentially share in some of the risks as well as rewards that may come from adopting their solutions. Over the course of preparing this report, we came across some examples of such, but this is very experimental at this point in time and such contracts are quite narrow in scope.

There still remain a significant number of questions as to how the PHM landscape, both for providers and their solution vendors will evolve over next several years. This upcoming report is just the beginning of our significant, future research on this topic.

As the market develops, Chilmark will continue to delve deeply into what successful PHM initiatives look like and just as importantly, what are the lessons to be learned from unsuccessful PHM programs. There remains a significant amount of uncertainty in how PHM will develop and it is our mission to assist the industry, through our research, in understanding what path may be the most fruitful for any HCO to follow on its journey to PHM.

Stay tuned – the shift in risk from payers to providers and the adoption of PHM strategies to successfully manage that risk will keep us all quite occupied for some time to come.







#PGHD: Buzzword to Business

datalinkThis week, I read an article from February that provided an overview of the health IT infrastructure required for population health management (PHM). It had thorough examples and some nice graphical depictions of delivery systems and budding ACOs taking on the challenge of marrying encounter data from claims systems with clinical data from EHR to create “a 360 degree view of the patient.”

But two questions arose as I finished reading.

First of all, the article was from February 2013. Over a year ago. As Cora recently reported, progress remains fuzzy in this market, and it seems like little has changed. In these fast-moving times, when a year-old article reads more or less like the rest of today’s web fodder, there’s a problem.

Has our understanding of effective PHM evolved at all over the last 12 months?

Secondly, the talk of a 360 degree view is simply misleading. Claims data anchors us as patients to the transactions we take part in, while EHR data is more robust but rooted largely in what happens in those magical 12 minutes we spend with some nurses and a doctor.

Is there more that goes into “a 360 degree view” of our health?

Yes to both. To the first, patient generated health data (PGHD) is emerging in 2014 as a recognized data layer that is available to be captured and crunched. To the second, we now have dozens of tools to capture patient data in a variety of formats and settings; progress over the next year should be measured in incorporating that data into a longitudinal patient record.

The basic need for PGHD in PHM is one we all understand at this point: A population with diverse, dynamic health care needs presents many blind spots for a system to manage effectively, especially on a person-by-person basis. By creating a window into a patient’s life outside the walls of a clinical setting, as the story goes, these new data sources can assist clinicians in the full scope of care delivery, from prevention to maintenance to post-acute monitoring. Nothing has done more for the #PGHD movement than the surge in wearable computing, with tech titans Samsung and Apple entering what looks to be a sustained slugfest over consumer smartphone health applications and wearables.

Meaningful Use’s Stage Three requirements, while still far from complete, will offer the most definitive guidelines for incorporation of this data into the healthcare enterprise. Encouragingly however, industry seems to have taken the lead here, with early indications from Washington suggesting they will play supporting role to what is already happening in the private sector.

Challenges remain to be sure, but the growing wave of efforts we’ve seen early on in 2014 is particularly encouraging. HCOs of all types are starting to see the value in PGHD, and that they are not going to wait for further guidance before moving forward. There are many types of data sources that are available, each with their own potential benefits and challenges, but across each area steady progress is being made.

 PGHD: Early Categories, Benefits, and Challenges

Type of PGHD Benefits Challenges
HRA Widely available; broad industry traction; steady incorporation into PHM engines Limited insight; low frequency of collection; not applicable to all populations
Surveys/PRO Growing source of data; largely untapped potential for insight into pt behavior; actionable info at point of care Integration requires custom wiring; lack of standardization of both instruments and collected data
Device Generated Data Passive monitoring; increasing consumer buy-in; potential for advanced chronic disease mgmt. “Wild west” with lack of standardization and format; aggregation/level of analytics primitive; workflow issues abound

Health insurers have long been folding in HRA data from their employer groups on top of their claims and TPA data to target specific cohorts for patient engagement interventions spanning disease counseling, education, classes, and more. Vendors like Phytel, Truven and several others have been pulling these capabilities into their portals and PHM suites over the last couple of years. These data-sets represent valuable low-hanging fruit for a notoriously backwards swath of publicly-insured care delivery settings, and hold promise for the rapid expansion of state-led Medicaid managed long term care programs.

A more frequent source of between-visit patient data is being captured in short-form surveys and questionnaires administered across web, tablet, and mobile platforms. These data-sets represent valuable insight into behaviors and preferences that have simply not been captured in conventional clinical visits. PatientPoint’s recent partnership with Xerox is one example, while several startups such as Conversa and Roundingwell have incorporated “digital check-ups” into their physician group-targeted offerings. These interventions are more sophisticated than an annual HRA, but require more two-way wiring to push specific questionnaires to specific cohorts and pull responses back to care managers to make them actionable.

Finally, the hottest topic in health IT today is wearables and device generated data. After speaking with a couple of the leading players in this field, Chilmark is encouraged that we will see broad incorporation of wearable device data into some EHRs by the end of the year. PracticeFusion announced alliances with two mHealth plays last month: PracticeFusion announced alliances with two mHealth plays last month: the AliveCor ECG will be available for physicians to use during a patient visit, while the DiaSend app will similarly allow doctors to upload patient-collected directly from a variety of devices into the EHR during a visit. The source we spoke with described this as an admittedly early effort that has some unanswered questions around data granularity, but in a refreshingly progressive approach, one that will be available to their entire customer base at once.

Samsung-backed diabetes play Glooko has likewise entered into a partnership with Joslin Diabetes Center that incorporates glucometer output data on top of a native NextGen EHR via an API, enabling at-risk providers to track patients with less lag. While they’ve indicated they’ve had serious interest from some dominant EHR systems in building out integrations, data currently pulled out of Glooko remains in flat-file, PDF format. There is not yet any industry-wide consensus about what a consolidated CDA would look like here, so we are only seeing the tip of the iceberg of how such data may impact population health analytics.

Early movers’ willingness to wade into these uncharted waters is encouraging, though they face challenges both technical – such as a lack of common standards around the dozens of device data types – as well as organizational – workflow, point of care vs. managing a patient panel.  In a telling sign for the PHM market, these disparate sources of PGHD are being leveraged despite the lack of guidance and the lack of mandate. So while we anticipate data will be piping into EHRs and other enterprise data engines by year’s end, there is still substantial work to be done before these data can be sliced, diced, and made an actionable component of a PHM strategy.

We see this as an early sign that the heretofore fluffy concept of patient engagement now has teeth and is becoming a key piece of the puzzle. That being said, no one single delivery system, vendor, payor, or other stakeholder has yet pulled together these disparate concepts under one definitive PGHD strategy. Chilmark will be delving into more detail around this area amidst the maturing PHM market in an upcoming Insight Report, available to CAS Subscribers, as well as through our forthcoming market trends reports on CAPH and Patient Engagement. Stay tuned for more, and as always, please share your thoughts, insights, examples, objections, and any other comments below.

Patient Engagement: Does the Emperor have any clothes?

Easy to claim, but is it true?

Easy to claim, but is it true? Only time will tell which organizations are getting it right, and which are little more than hype.

“Patient Engagement” has built up increasing buzz over the last few years through dedicated lip service from government, corporations, public leaders, entrepreneurs, and patient advocates. As John alluded to last week, however, patient engagement may be entering a Catch-22: Most everyone agrees it plays a vital role in the modern health care system we purport progress towards – yet the immense hype it’s developed has already begun prompting eye-rolling among health care executives who are skeptical of all the talk.

HIMSS provided a perfect backdrop to explore both the ballooning expectations in this area as well as showcase some of the budding signs of progress. While I agree with John’s central thesis (to date, mostly a heavy marketing push geared towards loyalty rather than engagement), there are some early signs of progress that indicate we are in the early stages of a shift from the ‘talking’ phase to the ‘showing’ phase.

At a presentation by University of Miami Children’s Hospital, we got a peek at what this could look like when done well (PDF). They have designed a complete view of the hospital’s workflow as it involves any ‘patient touches.’ First they break down the various stages of a patient’s interaction with the health care system into five major buckets:

  1. Pre-Arrival
  2. Pre-Treatment
  3. Point of Care
  4. Discharge
  5. Follow-up

Inside each of these intervals of the patient journey through UMiami’s system, there are corresponding “engagement” protocols, tools, and processes deployed. For example, while a patient is in the waiting room, there is a digital check-in system that also addresses medication adherence inquiries, assesses gaps in care, and occupies patients (in this case, children and parents) with interactive waiting room programs. A mirroring process is in place at check-out to follow up on reported gaps or issues, administer a quick experience survey, and recruit for enrollment into any relevant support programs or follow-on visits.

The thesis claims that building this baseline connection to the patient using a set of tools pulls them into a workflow that is subsequently easier to maintain through a continuum of online messaging, reminder systems, and follow-up care. A central tenet of this approach is consistency: use the same format and the same branding in these efforts to ensure patients feel they are a part of something, rather than a widget.

If a personal episode of care I endured last fall in Austin is a barometer of progress, we are very far from the ideal: Typically, patients are directed to some half-baked portal to pick a doctor, usually through their insurer, which has no effect on the amount of paperwork that needs to be filled in at the doctor’s office or the subspecialty referral clinic. Once the care is delivered in the silo (team of one), the payment vultures descend, with the referring doctor’s office, the specialists’ billing department, and insurance companies snail-mailing multiple paper documents in the following weeks and months. To wit, none of that pile of papers inquires about the patient’s current health status – it just scares them away from making an appointment the next time if it’s at all avoidable.

So in our eyes, patient engagement is about more than a turnkey solution, or a whiz-bang app. It is an approach. In our fragmented payment and delivery system, seamless experiences are the exception, not the norm. It follows then that meaningful, comprehensive engagement platforms won’t emerge until HCOs change the way they operate.

We are realists here at Chilmark Research, so while we won’t offer a take on how much water has been poured into the glass, we are working on a more detailed analysis for this month’s CAS subscribers about the drivers and trends that might produce a more comprehensive approach to patient engagement by next year’s HIMSS conference.

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 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.

As part of the process of setting our broader research agenda at Chilmark Research, we do a significant amount of secondary research combined with more limited, but highly focused primary research. We use this research to identify the “white spaces” where there appears to be a demand for some thoughtful, in-depth research and reporting that only an analyst firm such as Chilmark can provide. During that process, however, we often uncover some interesting trends similar to the HIE Snippets of the previous post.

Chilmark continues to follow the patient engagement realm, from mHealth Apps to PHRs, patient portals and personal health platforms such as Dossia and HealthVault. Recently, we have been receiving a significant number of inquiries from healthcare organizations that are developing IT strategies to meet Stage 2 meaningful use criteria to provide patients online access to their personal health information (PHI). We are also beginning to hear very early rumblings by a few forward thinking organizations on the use of new technology platforms, particularly mobile, to more deeply engage patients in managing their health in conjunction with impending value-based contracts. There have also been several announcements lately of roll-outs of Epic’s mobile patient engagement platform My Health. Lastly, earlier this week we had the pleasure to attend GE Healthcare’s Centricity Business National User’s Conference where we sat in on several patient engagement presentations. Following are some of the trends we are seeing that will be foundational to our future research on the topic:

HIE Vendors not up to task: A number of large healthcare organizations that have grown organically and through acquisition have a multitude of legacy IT systems from numerous vendors (not everyone is going Epic) in place. These organizations are now looking to link these systems together with an HIE solution and while they are at it, want to be able to provide patient access to their PHI. Problem is, most leading HIE vendors that have proven solutions for interfacing to multiple systems typically have poor patient-centric solutions. There are exceptions to every rule and companies such as RelayHealth and Kryptiq offer quite capable patient portals combined with secure messaging. But for those HIE solutions that lack such capabilities, healthcare organizations are having to look elsewhere to fulfill this need which is bringing business to MEDSEEK and Intuit Health.

Patient Portals interface first to transactions: Several of the presentations at the Centricity event were given by organizations with distinct clinical and administrative systems. Maybe it was just the venue, it was a Centricity Business Users’ Conference after all, but in each presentation on patient engagement the patient portal was driven from the admin-side. Sure, the portal could provide labs and some basic clinical data but it was really designed to help with the pre-registration process, appointment scheduling, secure messaging and Rx refill requests. Each organization we spoke to have plans to bring clinicals (some had Epic for clinicals, others Cerner) into the portal in the future to facilitate care processes for the truly sick, but that is a second order priority. This raises the question: Will front-end admin solutions, like Centricity’s Business Suite, become the core patient portal at the expense of those developed and offered by those from the clinical side of the fence?

Still in very, very early stages of mHealth App adoption: As mentioned previously, a number of organizations (Group Health Collaborative, Kaiser-Permanente, Stanford, UPenn Medical Center, etc.) have announced the release of an mHealth App for patient engagement, virtually all of them, My Chart instances. These releases are basically a mirroring of what is being done with patient portals mentioned above – enable transactional processes. We have yet to see anything, at any organization that has gone beyond pilot stage (e.g.WellDoc in Baltimore) in the deployment of a mHealth App to address a large at-risk population. This is puzzling for as we move to value-based contracts and accountable care, healthcare organizations will need to seriously rethink how they deliver health to chronic disease patients not just in the exam room, but at the patient’s home, in their car at work, wherever they may be to ensure compliance. mHealth can play a very effective role here but organizations’ reluctance to adopt is a chicken and egg scenario. There is not enough evidence to prove efficacy of mHealth Apps but if they don’t adopt, the evidence will not present itself. This will eventually break-thru, the question now is simply, when? And based on what we have seen in healthcare IT adoption to date, it could be a much longer wait than many VC firms and entrepreneurs currently have in their financial models.

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?