Get­ting Pa­tients More In­volved

New IT and tech­niques seek to im­prove the dis­mal per­for­mance of pa­tient-fac­ing apps.

Health Data Management - - CONTENTS - BY MAG­GIE VAN DYKE

The next gen­er­a­tion of pa­tient-en­gage­ment tools holds prom­ise for get­ting con­sumers more ac­tively in­volved in their own health­care.

When wear­able track­ers were in­tro­duced, Joseph Kvedar, MD, thought the tech­nol­ogy would solve one of health­care’s thorni­est prob­lems: Get­ting pa­tients to choose healthy disease-fight­ing be­hav­iors, such as walk­ing af­ter din­ner in­stead of sit­ting on the couch.

Re­search on pa­tient en­gage­ment in­di­cates that peo­ple who are ac­tively in­volved in man­ag­ing their health tend to have bet­ter health out­comes than those who are less en­gaged. They are also less likely to visit the hos­pi­tal or emer­gency de­part­ment, spend­ing fewer health dol­lars.

Pa­tient en­gage­ment is con­sid­ered a linch­pin in pre­vent­ing and man­ag­ing chronic dis­eases and con­di­tions, which ac­count for 86 per­cent of U.S. health spend­ing. But Kvedar, vice pres­i­dent of Con­nected Health, Part­ners Health­Care, quickly learned that en­list­ing pa­tients is not as sim­ple as rec­om­mend­ing a one-size-fits-all fit­ness tracker or smart­phone app. While some peo­ple are mo­ti­vated by chart­ing their daily ac­tiv­ity or food in­take, many are not.

“Most peo­ple are not wed to their step count the way I am fas­ci­nated with it,” Kvedar says. “I’m one of those peo­ple who re­ally en­joy num­bers and track­ing. But for most, feed­back loops alone are not compelling.”

Ac­cord­ing to a 2016 sur­vey by Gart­ner, the aban­don­ment rate for fit­ness track­ers is 30 per­cent. Pa­tient por­tals have fared even worse. While 88 per­cent of hos­pi­tals of­fered por­tals in 2015, only 15 per­cent of pa­tients used them, found a re­port from the U.S. Gov­ern­ment Ac­count­abil­ity Of­fice.

Ev­i­dence is also mixed on whether th­ese tools pos­i­tively im­pact health out­comes. A 2018 meta-anal­y­sis found no sig­nif­i­cant im­pact on six out­comes, in­clud­ing weight and blood pres­sure, among pa­tients who used re­mote mon­i­tor­ing tools.

Rather than being de­terred by th­ese less than stel­lar re­sults, Part­ners Health­Care and other health­care or­ga­ni­za­tions push­ing for in­creased en­gage­ment are build­ing on lessons from be­hav­ioral psy­chol­ogy, user-cen­tered de­sign and other fields to ad­dress past mis­takes and de­ploy sec­ond-gen­er­a­tion en­gage­ment tools.

Make it compelling

One rea­son pa­tients avoid por­tals and aban­don ac­tiv­ity track­ers is that the tools of­ten are not compelling enough, Kvedar says. “Ev­ery minute, our brains are fo­cused on some­thing,” he says. “For our health to be compelling, it has to dis­place some­thing else, whether that’s a game of Candy Crush or some­thing you’re do­ing at work.”

Based on years of work de­vel­op­ing tech­nol­ogy-en­abled care pro­grams, Kvedar has iden­ti­fied three fac­tors that help make con­nected health tools compelling:

• Make it about life. “If my com­mu­ni­ca­tion to you is, ‘You’ll have a heart at­tack in 10 years if you don’t get your high blood pres­sure un­der con­trol,’ that’s much less compelling than fo­cus­ing on rel­e­vant, near-term goals like being more pro­duc­tive at your job,” Kvedar ex­plains.

• Keep it per­sonal. Al­go­rithms can pull in many types of data (e.g., lo­ca­tion, weather, wear­able data) to send per­sonal mo­ti­va­tional mes­sages to pa­tients.

• In­clude a so­cial el­e­ment. Known as the sen­tinel ef­fect, most peo­ple try harder to achieve health out­comes when they know they’re being mon­i­tored, par­tic­u­larly by some­one whose opin­ion they care about, such as a physi­cian or fam­ily mem­ber.

Part­ners Con­nected Health in­cor­po­rated th­ese prin­ci­ples into a soft­ware pro­gram that en­cour­ages peo­ple with type 2 di­a­betes to be more ac­tive. Ini­tially, the al­go­rithm in­cor­po­rated four data streams: ac­tiv­ity lev­els from wear­able track­ers; lo­ca­tion; weather; and the pa­tient’s in­ter­est in being ac­tive, as mea­sured by the trans­the­o­ret­i­cal be­hav­ioral model (i.e., pre­con­tem­pla­tion, con­tem­pla­tion, prepa­ra­tion, ac­tion, main­te­nance).

An ini­tial study found that the soft­ware got pa­tients walk­ing more, which im­proved their blood sugar lev­els com­pared with a con­trol group. “Each day, per­son­al­ized, con­tex­tual mes­sages were sent, en­cour­ag­ing en­rollees to be more ac­tive,” Kvedar says. “For in­stance, the soft­ware might send a mes­sage like, ‘To­mor­row is go­ing to be rainy, and we no­ticed that when it’s rainy you’re not as ac­tive. Here are three things you can do in­doors to be more ac­tive.’”

The pro­gram con­tin­ues to be tweaked. Mes­sages ini­tially sent by text are now pushed out via a mo­bile app, for ex­am­ple, and ad­di­tional data from users’ smart­phones, such as song lists, are also being used to fur­ther per­son­al­ize mes­sages. Part­ners Con­nected Health is work­ing with Sam­sung to de­velop the next gen­er­a­tion of per­son­al­ized dig­i­tal and mo­bile solutions for health and well­ness.

Lo­ca­tion, lo­ca­tion, lo­ca­tion

“I think the key to en­gage­ment is re­ally un­der­stand­ing where peo­ple are at,” says Ju­dith Hib­bard, re­search pro­fes­sor, Health Pol­icy Re­search Group, Univer­sity of Ore­gon. “They’re not all ready to be proac­tive about their

health and take charge.”

Hib­bard de­vel­oped the pa­tient ac­ti­va­tion mea­sure® (PAM®), which as­sesses pa­tients’ knowl­edge, skill and con­fi­dence for man­ag­ing their health. A PAM sur­vey, li­censed by In­signia, can be given to pa­tients to de­ter­mine where they fall on a four-level ac­ti­va­tion scale:

• Dis­en­gaged and over­whelmed

• Be­com­ing aware but still strug­gling

• Tak­ing ac­tion

• Main­tain­ing be­hav­iors and push­ing fur­ther

Hib­bard be­lieves dig­i­tal health tech­nolo­gies are bet­ter at engaging peo­ple who are al­ready in­volved in their own health man­age­ment. “Peo­ple who are less ac­ti­vated have lit­tle con­fi­dence, and you need to help them de­velop some ba­sic skills,” she says. “You prob­a­bly want to use your staff to reach out to less ac­ti­vated pa­tients.”

Rec­og­niz­ing that pa­tients have in­di­vid­u­al­ized needs, Atrium Health, for­merly Caroli­nas Health­Care Sys­tem, is com­bin­ing re­mote mon­i­tor­ing us­ing the Twine Health plat­form cou­pled with a hu­man health coach. Pa­tients in the health sys­tem’s sub­scrip­tion-based pri­mary care prac­tice, Proac­tive Health, de­velop care plans with their physi­cians and meet reg­u­larly with a health coach, ei­ther face-to-face or vir­tu­ally, to pin­point per­son­al­ized health goals. The plan and goals are in­cor­po­rated into Twine, which sends pa­tients re­minders (e.g., to take med­i­ca­tion) and tracks progress to­ward goals.

Re­sults to date for this tai­lored coach­ing ap­proach are promis­ing. In a group of pa­tients with un­con­trolled hy­per­ten­sion, ap­prox­i­mately 80 per­cent reached their tar­get blood pres­sure within 30 days com­pared with 30 per­cent re­ceiv­ing stan­dard care.

The cus­tom­ized goals are key, be­lieves Lind­say De­neault, di­rec­tor of

com­mer­cial­iza­tion for Atrium Health’s In­no­va­tion En­gine. “While the clin­i­cal care team can rec­om­mend a course of ac­tion, it’s not re­ally go­ing to stick un­less it fits into the fab­ric of the pa­tient’s life,” she says. “The pa­tients are the only ones who can pro­vide in­for­ma­tion about their val­ues, pref­er­ences, life­style, cur­rent knowl­edge about their illness and the progress they’re try­ing to make.”

Atrium Health also en­cour­ages pa­tients in the pro­gram to set small, in­cre­men­tal goals (e.g., one veg­etable a day), which re­flects the “tiny habits” be­hav­ioral model de­vel­oped by Stan­ford Univer­sity psy­chol­o­gist BJ Fogg. This ap­proach can help build con­fi­dence in those who are dis­en­gaged, says Hib­bard. “It takes pa­tience and time, but the im­por­tant thing is to start peo­ple on that jour­ney rather than just la­bel­ing them as non­com­pli­ant.”

So­cially proac­tive

Re­search by the United Health Foun­da­tion shows that so-called so­cial de­ter­mi­nants of health, in­clud­ing poverty, un­sta­ble hous­ing and lack of so­cial sup­port, in­flu­ences 50 per­cent of health out­comes. Th­ese fac­tors in­ter­fere with a per­son’s abil­ity to man­age his or her own health. “If you can’t feed your fam­ily, you’re not go­ing to fo­cus on your in­sulin shots,” Kvedar says.

How­ever, Kvedar be­lieves mo­bile health ap­proaches are well suited for help­ing pa­tients with so­cial and eco­nomic chal­lenges, pri­mar­ily be­cause mo­bile phones have be­come ubiq­ui­tous across in­come lev­els. One study found that 89 per­cent of home­less res­i­dents had a mo­bile phone, and 60 per­cent wanted to re­ceive med­i­ca­tion re­minders via their phones. “The mo­bile phone has be­come the new equal­izer,” Kvedar says.

At Chicago’s Rush Univer­sity Med­i­cal Cen­ter, providers are writ­ing elec­tronic or­ders for free food, cloth­ing, hous­ing and other re­sources for pa­tients in need. The or­ders are au­to­mat­i­cally sent to NowPow, an elec­tronic data­base of com­mu­nity-based re­sources de­vel­oped at the Univer­sity of Chicago. A NowPow al­go­rithm searches for the best­matched re­source and sends the Rush pa­tient a text de­scrib­ing where and how to ac­cess the rec­om­mended ser­vice.

Rush has in­te­grated NowPow into its Epic EHR us­ing Fast Health­care In­ter­op­er­abil­ity Re­sources (FHIR), HL7’s data ex­change stan­dard. “In the olden days, peo­ple used in­ter­faces,” says Shafiq Rab, se­nior vice pres­i­dent and CIO. “We use FHIR.”

The tech­nol­ogy also tracks whether pa­tients ac­cess the NowPow rec­om­mended re­source and sends re­minders when they don’t. In a recent month, 218 Rush pa­tients used NowPow, which can also con­nect peo­ple to smok­ing ces­sa­tion and fit­ness classes as well as other health re­sources.

Shared de­ci­sions

Shared de­ci­sion mak­ing (SDM) is an en­gage­ment tech­nique that helps pa­tients make treat­ment de­ci­sions that align with their val­ues and pref­er­ences. “It is con­sid­ered a meet­ing of two ex­perts,” ex­plains Kelly Reeves, BSN, RN, clin­i­cal and qual­ity re­search nurse, De­part­ment of Fam­ily Medicine, Atrium Health. “Pa­tients are the ex­perts on their val­ues, goals and pref­er­ences, and the providers bring their ex­per­tise about the disease and treat­ment options.”

Sev­eral years ago, clin­i­cians, pa­tients and re­searchers at Atrium Health be­gan de­vel­op­ing an SDM ap­proach to help chil­dren and par­ents with de­ci­sions around asthma care. Rec­og­niz­ing the strain on pe­di­a­tri­cians to in­cor­po­rate time-in­ten­sive SDM dur­ing clinic vis­its, Atrium Health de­vel­oped an in­ter­ac­tive, dig­i­tal health coach­ing ex­pe­ri­ence called Caroli­nas Asthma Coach™, which col­lects pa­tient-re­ported out­comes and pro­vides tai­lored ed­u­ca­tion about asthma, based on clin­i­cal guide­lines, to set the stage for SDM.

“To help pa­tients and care­givers en­gage in SDM and their care process, it is key to not only help them un­der­stand the un­der­ly­ing disease, but also trans­late the guide­lines in a way that makes sense,” says An­drew McWil­liams, MD, med­i­cal di­rec­tor of Atrium Health’s Cen­ter for Out­comes Re­search and Eval­u­a­tion. “Then they come to their visit pre­pared with ques­tions spe­cific to their sit­u­a­tion and val­ues.”

Caroli­nas Asthma Coach in­cor­po­rates a sports theme, and uses an­i­ma­tion and hu­mor to en­gage young pa­tients and care­givers. The in­ter­ac­tive plat­form col­lects key in­for­ma­tion about a pa­tient’s symp­toms, trig­gers, treat­ment goals and pref­er­ences. This en­ables the tool to tai­lor ed­u­ca­tional mes­sages and pro­duce a per­son­al­ized “asthma visit play­book” that can be printed out be­fore a clinic visit.

The play­book starts with a list of topics to dis­cuss with the pe­di­a­tri­cian, such as whether a con­troller medicine needs to be pre­scribed. It also pro­vides an asthma med­i­ca­tion de­ci­sion aid, which pe­di­a­tri­cians use to ad­dress a pa­tient’s or care­giver’s med­i­ca­tion con­cerns (e.g., side ef­fects, costs).

Atrium Health is work­ing to in­te­grate the tool into its EHR and provider work­flows, and partnering with oth­ers to pi­lot and com­mer­cial­ize the so­lu­tion. □

‘While the clin­i­cal care team can rec­om­mend a course of ac­tion, it’s not re­ally go­ing to stick un­less it fits into the pa­tient’s life.’

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