This is the second in a series of blog posts recapping HIMSS’19; you can read all our coverage here.  

My primary purpose at HIMSS’19 was gathering information and ideas for our upcoming report on the front door to care. This report will take a close look at the evolving ways patients first enter the healthcare system. Whether from retail health, telehealth, remote patient monitoring, or remote care apps, HIMSS was full of changing ideas and approaches. The conference had a utilitarian focus, looking less at generic or abstract buzzwords to get people excited, and more at what can be done right now to engage providers, payers, and ultimately patients.

My biggest takeaways:

Telehealth, Remote Monitoring, and Virtual Care can significantly erode established HCO business models, or complement them.

Health systems have invested a lot into controlling referrals and leakage. While the PCP remains the central organizing hub of most healthcare, the growth of retail and remote health could lessen the PCP’s centrality in traditional referrals networks.

Unlike the Teladoc model, which employs contracted providers to provide a turnkey outsourced telehealth service, newer entrants offer operational platforms and back-end systems so HCOs can staff and run their own telehealth programs. This allows them to retain control of the patient experience. It’s an easier model for an HCO to understand and use, but whether they adopt such solutions before their competition is an open question.

Behavioral health might finally get its due through Virtual Care apps.

Between shrinking reimbursements and scarce providers, behavioral and mental health care have been the first service line on the chopping block for a while now. PCPs have become the go-to provider for too many behavioral health needs, occupying increasing amounts of time and stretching their expertise thin.

Several of the telehealth and remote health platforms I saw last week had behavioral health components. There were a few well-executed apps dedicated to mental health and wellness, mainly with a CBT/DBT focus and some with solid clinical results. Helping PCPs manage this care and mitigating the effects of comorbidities on patients is an important part of addressing PCP workload and job satisfaction, as well as patient engagement. These virtual care offerings can help struggling PCPs get their patients the help they need, while still working within tight budgetary and scheduling restrictions.

Telehealth, Remote Monitoring, and Virtual Care can significantly erode established HCO business models, or complement them. The question is whether health care systems will recognize that in time.

Performance improvement services are becoming a core component of analytics products

With my background in healthcare performance analysis and improvement, I wanted to see how analytics is evolving to become more effective and efficient.

The future of analytics platforms looks less like pre-built dashboards or reports and a lot more like what Visiquate offers. Its embedded employees work directly with customer end-users to execute Agile-inspired improvement sprints supported by their analytics and reporting. Vendors are coming to grips with the challenge of operationalizing analytics for value and performance improvement. The value proposition behind both improved reporting software and process improvement is pretty well understood. Figuring out how to fit it all into an annual budget in an era of shrinking margins is the real hard part here.

Leveraging data to produce specific, actionable recommendations remains a challenge.

A fascinating conversation about AI at the Geneia booth on Tuesday afternoon summed up the current state of AI and machine learning in the clinical world. While access to existing and new kinds of data is increasing and the ability to integrate it is getting more sophisticated, AI and ML still aren’t the clinical tools many expected them to be. Only imaging, an area where the datasets are complete and the challenges are well understood, has really begun to heavily leverage AI/ML. Everywhere else, the barriers to gathering appropriate context and rendering predictive clinical recommendations have yet to be overcome.

Coaching Technology

While the landmark health reform laws enacted in 2009 (HITECH Act) and 2010 (Affordable Care Act, or ACA) have begun transforming certain aspects of the US healthcare system, they have not had a meaningful impact on behavioral and mental health care delivery. Patients in need of these services already face an uphill battle in terms of social stigma and making a decision to seek out care, yet our system compounds such challenges through poor benefit design, uneven IT adoption, and lack of care coordination. An emerging fleet of technology solutions focused on behavioral health care has the potential to improve care, though they are not without their own set of challenges.

> Providers lack adequate incentives to adopt patient-facing digital mental health care tools. This is due both to omission of non-psychiatric mental health specialists in the Meaningful Use program as well as the slow adoption of value-based contracts.
> Vendors of new technology have not placed a premium on making their platforms interoperable with legacy software. New startups have focused most of their efforts on developing self-contained tools geared towards the employer market rather than emphasizing document exchange, shared care plans, or tools for the population health manager to manage mental health needs.
> Given the fragmented nature of the delivery system for mental health care, the market for mental health care IT is quite immature. While there are ample opportunities for one-off improvements (primary care, substance abuse facilities, Veterans Affairs, higher education, employee programs, etc) – only those health systems who can underwrite their own reforms will be the ones taking action.

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The Revolution

One of the trending topics in healthcare right now is that of the “consumer revolution.” With so many changes happening – the way care is being delivered, who is paying for it, how technology is influencing decision making from doctors to insurers to individuals – the time is ripe for a rethinking of the traditional model of “the doctor will see you now.”

Over the course of 2014, it’s become clear that this trend is here to stay. What’s not yet clear is how exactly these new models will impact the industry. This month’s domain monitor, offers a high level look at some of the specific models and enabling technologies that are slated for a big year of growth in 2015. We will also outline some of the major implications for industry incumbents and break down how various segments of the healthcare market are (or are not) preparing for this sea change.

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Consumer Engagement 

Traditionally, consumer engagement has been more of a marketing and business function, while patient engagement has remained a clinical prerogative. These lines will begin to blur over the course of the next few years, driven largely by the addition of tens of millions of enrollees via HIX, crowded and relentlessly competitive markets jockeying for brand loyalty, and continued consumerization being adopted by health plans, employers, and other industries. Patient-satisfaction scores are already closely linked to hospital CEO salaries, and both public and private payers will maintain or increase the importance of such metrics over the course of this decade. While IT will play a mounting role in extending HCOs’ presence virtually to improve communication and access to care, rolling out adequate customer support for new technology platforms will be a key component as well.

Further down the road, telemedicine programs will grow into more complete, branded offerings, and consumer loyalty will gain new meaning as we enter an era of home-based eldercare where families and caregivers play an elevated role in monitoring and support.

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Couple of weeks back had the opportunity to talk to the CEO and CMO of Healthagen, developers of the iPhone app, iTriage a new, consumer-facing app with some interesting twists, including partnerships with Coalition America, HealthGrades and TelaDoc.  iTriage can be found on the Apple iTunes store for less than a dollar.

The co-creators of iTriage, who happen to be ER docs, developed the app to address a very real issue they saw everyday in their day jobs: The huge information gap that consumers have in choosing what level of care is appropriate for a given symptom.  In developing iTriage, they wanted to marry “symptomitology” with diagnosis and from there recommended best care procedures/treatment plans and who is most appropriate to conduct those procedures for that given diagnosis.

How it works:

iTriage always launches with the question: Is this an emergency? If one answers yes, app automatically calls 911.

Once one gets past the “emergency question,” iTriage presents a very long list of symptoms alphabetically with search bar at top. Search on say chest pain, viola, there it is.

After clicking on given symptom  (we’ll use chest pain) one is provided an extensive list of possible causes (33 popped up for chest pain) which are often highly technical terms e.g., costochondritis, hiatal hernia, etc. and some more basic terms such as lung cancer. Within “Possible Causes” iTriage does offer a filter to limit selection to common, pediatric and life threatening causes.

Click on a Possible Cause and you are provided a number of fields to further drill down and understand the disease including standard work-up and treatment which may prove very useful in a clinical encounter.  Standard work-up and treatment guidance is based on best practices (the developers of iTriage set-up a review board to oversee and approve work-up & treatment write-ups found in the app).

To some extent, much of the above can be found in other iPhone apps such as A.D.A.M., SymptomMD and WebMD, though none of those apps do it as extensively and comprehensively as iTriage.

But where iTriage really gets interesting is assisting the user in the next step, where do I go to get treatment.  Once one goes through the above self-triage steps, you can click to “Advice Line” which takes you to an embedded TelaDoc page where one can initiate a call to TelaDoc to get fee for service advice on your symptom(s)/condition.

In addition to geting advice, one can also click “Find a Facility” and based on the disease you have self-identified, iTriage suggests which facility is most appropriate (see figure) and then leveraging the GPS capabilities of the iPhone locates the facilities within a given radius and provides directions from current location to the one chosen. Currently, iTriage has over 67,000 facilities listed within its proprietary directory.  iTriage also has established a partnership with physician/hospital rating service, HealthGrades allowing the user to access information (like TelaDoc, for a fee) on specific facilities listed.

Nice features, especially for someone who travels as frequently as I do.

The Business Model:

Certainly the company will make some money selling the app, but at $0.99, they’ll need to sell a lot.  They’ll also have some revenue sharing with their partners Coalition America, TelaDoc and HealthGrades.  But what they are really banking on is listing services, much like the Yellow Pages, but in this case listing healthcare provider services, probably geo-located, within the app. Company emphatically stated that they will not rely on referral fees.

The Good, Innovative Aspects of iTriage:

1) Comprehensive list of symptoms and diseases with vetted work-ups and treatment options.

2) Unlike most iPhone apps, which are siloed.  iTriage founders have done a mash-up of sorts leveraging partners to create a richer, more complete experience and of course, service.

3) Puts a lot of power into the hands of the consumer.

4) Low cost to end user to promote adoption, this could easily get viral.

5) Full HIPAA compliance to appease the privacy and security community.

And the Not So Good, Needs Improvement Category:

1) Interface is challenging and does not appear to be designed with the average consumer in mind.  Far too many of the diseases listed for a given symptom are in obscure medical terminology that is difficult to decipher.  This may be fine once a medical professional has confirmed a diagnosis and one wishes to know standard work-up and treatment, but as an entry point into self-triage, not so sure this is the best approach.  The filter feature helps to simplify searching on diseases, but while his may shoprten the list, there remains the technical jargon.  More graphical capabilities are needed – A.D.A.M. & WebMD have done a good job here that iTriage would be wise to emulate.

2) iTraige would also benefit from a built-in Natural Language Processor (NLP) allowing a consumer to enter common terms to search for a disease rather than a very long pick list.

3) Invoking the services of partners, particularly HealthGrades and medical bill negotiation service Coalition America is less than ideal. Right now, it is basically a punch-out to the Home Pages of these partners’ websites.

The Wrap:

A lot of utility in a small, cheap app that one can have with them wherever they go and tons of promise for the future as they expand partnerships and functionality to include such things as average costs of procedures, medication checking, etc.  In its current form, it is certainly a good app to have when traveling, and if having fallen ill with no idea where to turn – iTriage can be a great resource.

But this app, in its current version, requires a sophisticated user and takes some practice (too much in our book) to navigate effectively.  The developers have many plans in store for the app and will be releasing at least two more updates prior to Apple’s launch of the new iPhone OS 3.0, which is expected this summer. Let’s hope those versions focus on usability, the GUI and better embedding of partner services, rather than adding anymore features of which they have plenty for now.

ADDENDUM:

Just as we were geting ready to publish this, came across a presss release from Healthagen sent out today, 4/16/2009 announcing that iTriage will now have a cost estimator to assist the user in identifying potential cost of care.  Another nice feature Healthagen, but please, let’s get that interface cleaned-up.