In an interesting twist, Cleveland Clinic and Microsoft’s HealthVault Grp announced a partnership this morning to address chronic disease management. The interesting twist is that Cleveland Clinic was the showcase beta customer for Google Health, which was announced by Google’s CEO Eric Schmidt earlier this year at HIMSS. Like their counterpart in Boston, Beth Israel Deaconess Medical Center, who was part of the initial Google Health public roll-out in May and who has since also established a link to HealthVault for their PatientSite users, Cleveland Clinic is taking an agnostic approach to the major platform plays with this agreement.
The Cleveland Clinic-HealthVault announcement is distinctive in that it focuses on chronic disease management, via telehealth, through use of HealthVault’s unique Connection Center. With some 50 devices from 9 vendors, the Connection Center allows the consumer to upload device data (e.g., glucose readings, heart rate, blood pressure, weight, peak flow, etc.) directly to their HealthVault account. In the Cleveland Clinic project, which began last week (Nov. 3rd), uploaded biometric data from HealthVault compliant devices will automatically be pushed to Cleveland Clinic’s EMR and subsequently exposed to the physician for patient tracking and follow-up.
Had a call this morning with Microsoft and one this afternoon with Cleveland Clinic who both shared further details on this announcement:
A target of 460 Cleveland Clinic patients will participate representing three distinct disease categories; hypertension, diabetes and heart failure. The roll-out is across the Cleveland Clinic Integrated Delivery Network (IDN) and not just hospital patients. Clearly, they are focusing on the big chronic disease categories that result in huge costs that many believe better telehealth monitoring can mitigate.
- Hypertension patients, of which there are 400, will measure blood pressure only.
- Diabetes patients, of which there will be 30, will use five devices to measure glucose, blood pressure, peakflow, pedometer and weight.
- Heart Failure patients, the remaining 30, will use four devices to measure blood pressure, peakflow, pedometer and weight.
Pilot will initially be for an extremely short 90 days. Cleveland Clinic expects to have all patients active within 4-6 weeks. Not sure what they can accomplish in 90 days, maybe Cleveland is just hedging their bets to see if patients actually comply with the prescribed measurement and upload regime. Assuming that all goes well, one can guarantee that this pilot will be extended for at least a year, if not longer, as that is the only way they will be able to provide some demonstrable results that are publishable (something that Microsoft emphasized) and ultimately may influence future legislation (e.g., CMS funding), health plan reimbursement (P4P), and broader adoption among other Integrated Delivery Networks (IDNs).
Devices are being provided for free to trial participants. The only requirement, beyond the obvious willingness to diligently take their measurements, is that they have a Windows-based (XP SP2) computer and broadband access. Unfortunately, many heart disease patients are among the elderly and it is questionable as to how many have this capability. Still, the point here is to demonstrate, not solve all the problems and it is a good start.
Cleveland Clinic is training patients on the use of the devices(s), and data upload process to HealthVault, that is subsequently pushed to Cleveland Clinic’s EMR. Part of that training includes clearly notifying the patient when a particular reading should prompt a call to their doctor or even 911. Along with providing the device(s) and training, the physician will prescribe to the patient their measurement protocol (e.g., 2x/day, 3x/week, etc.) unique to that individual and the condition they are managing. Patients trust their doctors so receiving the package directly from their physician during an office visit makes a lot of sense and should encourage use and hopefully compliance. It will be interesting to see how compliant patients are to the prescribed compliance regiment as this is often a critical stumbling block. Will incentives be required?
Cleveland Clinic put in the upfront effort to understand how best to incorporate this new data stream into a physician’s workflow to minimize the burden. Specifically, the physician will receive a weekly notice notifying them that their patient(s) biometric data is ready for review. One click later and the physician is in the EMR reviewing their patient’s data for that past week. Prior to this pilot, Cleveland has experimented with other telehealth systems, but none were able to provide this level of integration with the core EMR system (always a stand-alone, silo’d operation) and thus saw little adoption among physicians. This is absolutely critical! Having spoken to many physicians about the success, and most often failure of telehealth initiatives, it nearly always circles back to lack of true integration to existing practices/workflow. Looks like this pilot tackles that issue head-on.
So what is the Business Case?
Wrapped up my conversation with Cleveland Clinic’s CIO, Dr. Martin Harris, (thanks again Martin for your time) by asking him: So what is the business case for this initiative? He outlined two areas where they see a benefit to Cleveland Clinic:
Service Case: In moving to this model of combining telehealth with traditional in-office visits they intend to completely re-design the office visit resulting in a better, more engaged and customer friendly process. This process will lead to higher customer service ratings, customer recruitment and higher customer retention – all important top-line metrics. They also see a service case for the physician as such a “system” will allow the physician to deliver a higher level of proactive care with their patients. Its all about market differentiation, distinguishing themselves in an increasingly crowded market – one that will only get more competitive.
Outcomes Case: One of the objectives of the pilot is to see if Cleveland Clinic can consistently improve the outcomes/health of its chronic care patients that will result in fewer hospital readmissions and/or complications. If all goes as planned, Cleveland Clinic believes that it will be able to use these positive results to request better reimbursement schedules (more income) from health plans. This certainly makes logical sense, but to date, health plans and CMS have been reluctant to support such programs – more of a wait and see approach. Hopefully, Cleveland Clinic will start showing some impressive results in a year or so and get those health plans on-board.
Final Note:
A couple of weeks ago I poked Microsoft about their lack of support for the telehealth consortium, the Continua Alliance. Sean Nolan responded stating a primary reason was Microsoft’s desire to move quickly (consortia always seem to move at a snail’s pace). Looks like that has paid-off as Google Health and Dossia cannot, today, support such capabilities as demonstrated above, though they are on the path having joined the Continua Alliance and Google demonstrated modest capabilities at the recent Connected for Health Symposium.
Looking ahead, we forecast 2009 to be a year of pilots which begin to demonstrate the utility of the platform model (Dossia, Google Health, & HealthVault) in support of telehealth and how telehealth technology and practices are best integrated into existing clinician workflow. Look to 2010 to see actual reimbursement models and P4P programs begin to take shape in support of promotion and adoption of telehealth.
Maybe I’m cynical, but I don’t think this is going to lead to the breakthroughs you predict for 2009 and 2010. Here’s why:
1) Service redesign is the most important part of making telehealth work, and it takes a lot more than IT. I know what their CIO said, but did their COO/CFO commit to this too? What plans does Cleveland Clinic have in place not only to change their office visits, but also what happens in between? Imagine a physician who sees a patient’s blood pressure is too high – what enables that physician to easily take action (talk with the patient (either in person or through other means), increase the dose of the blood pressure med, get a prescription to the pharmacy, arrange for follow up lab tests) to address that high blood pressure reading? Furthermore, have they changed compensation for their docs so that their productivity is not reduced if they spend time on this instead of office visits? How does this work for patients followed by PCPs and specialists – who is responsible for managment?
2) There already are lots of studies showing that telehealth works when applied to the right patient population, even without EMR integration. Why do you think that another small study of fewer than 500 patients will make a difference?
It is possible to use telehealth to improve care for people with chronic illnesses, but it is going to take more than putting the vital signs readings in an EMR/PHR.
I strongly agree with Mike Cantor’s comments but overall, good move by HealthVault and Cleveland. I make the following comments from a public health perspective – Australia.
– The business case needs to be based on measurable evaluation data and be able to be extraplolated to estimate systemic impact, not just local elements.
– telephone triage was not mentioned and would seem to be a key issue to limit unnecessary clinician workload.
– In Australia where some 85% of GP’s have computers and a practice managment system (Medical Director, for example) the need is for seemless integration to the already established work flow.
– In public health jurisdictions there is no direct link between GP activity and hopsital avoidance as the two sectors are often funded separately.
Services like HealthVault will put pressure on the system and this is good. One ICT issue is when a patient comes to a GP and hospital with their USB key are demands upload.
Mike & Michael,
Great to get some comments from those in the field that address this problem day-in, day-out and you do raise some valid points. in response, here are a couple of thoughts:
1) Agree that the business case for adoption and use of telehealth by physicians must take into account current workloads, work processes and compensation models – it simply will fail otherwise. Such processes must account for follow-up with a patient as required, whether by phone, email, or other method. In speaking with Dr. Martin, Cleveland Clinic’s CIO, he related the example of a heart failure patient who, based on biometric readings, is collecting fluid around the heart, a common occurrence, for which a doctor would be able to prescribe a diuretic without the patient actually having to visit the clinic. Better service for the patient and eases the workload (no office visit) for the doctor. In such a case, the compensation model is of interest, but at this time, Cleveland Clinic is unwilling to go into the details of such models. We’ll have to wait and see.
To your point Michael, telephone triage is part and parcel of the complete program and will be the responsibility of the care team (physician(s), nurses, etc.) and not the sole responsibility of a single doctor.
2) So why do we believe there will be accelerated growth in telehealth? Two reasons:
a) The market for healthcare services is becoming more competitive with numerous entities (retail clinics, corp. campus clinics, medical tourism, online and telephone-based services, regional and national hospitals, the list goes on) all striving to get a piece of the action. For Cleveleand Clinic and other like-minded institutions, telehealth offers them an opportunity for differentiation providing healthcare with a higher “services touch” leading to higher customer retention and attracting new customers.
b) Microsoft has enormous resources at its disposal to push the concept and certainly has a vested interest to see this work. With some 50 devices now compliant with HealthVault, we now have a critical mass of device choices that previously were unavailable in the market, all networked through a common platform for data aggregation and subsequent push to a physician/care team.
And Microsoft is certainly not alone. In 2009 we will begin seeing a number of devices entering the market that are compliant with the Continua Alliance interoperability standards. This alone should provide a boost, but when coupled with the platform plays from either Dossia or Google Health (they both signed on to the Contnua Alliance in Oct.), we see something quite similar developing to what HealthVault is currently offering.
As both of you rightly point out, simply aggregating and pushing data into a physician’s EMR does not readily address workflow and compensation issues. While these are challenging and will take plenty of forethought, they are not insurmountable.