New Care Models For Mhealth: Major Sections

New Care Models
technology
roI payment
legal and polIcy
StandardS and InteroperabIlIty
New Care Models for mHealth

Major seCtioNs
Provider Usage: A Guide to Implementing Mobile Monitoring 1-04 mHealth & Consumer Engagement: Leveraging Consumer Empowerment and Connectivity in a Clinical Setting 1-13 Chronic Disease: Engaging Patients through mHealth 1-28 Introduction to Global mHealth Initiatives: Lessons Learned 1-32
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prIvacy and SecurIty
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ments in technology, and a continuing quest to deliver high-quality care in the most cost-efficient manner. That has led to new approaches, such as accountable care organizations (ACOs) and bundled payments, in which various providers work together to provide the most appropriate care at a set price. In most cases, that means a renewed focus on preventative and primary care in order to reduce costly hospital admissions and emergency room services. Other factors driving the focus on primary care include growing recognition of the importance of managing chronic pediatric and adult diseases like diabetes and hypertension to reduce overall strains to the healthcare system. Prevention and primary care services are also vital to helping the nations aging Baby Boomer generation maintain their independence and high quality of life as long as possible. Care plans are developed in such a way to improve compliance to medications and regimens in order to help patients manage their conditions, slow the progression of serious conditions, and maintain their quality of life as long as possible. Helping people take care of themselves and manage their conditions dramatically reduces the strain on healthcare, especially in the out years of chronic conditions such as diabetes. Under the Affordable Care Act (ACA), innovative technology is seen as an essential component of a stronger, better integrated, and more accessible healthcare system. For example, the Centers for Medicare & Medicaid Services (CMS) provide incentives for providers to move to electronic medical record (EMR) and electronic health record (EHR) systems. This is an essential step forward in the new collective mod
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hrough the decades, information technology (IT) tools and systems have played
els of healthcare delivery, since a consistent set of patient data can be moved easily from one provider to another. Related technologies include sophisticated databases, data mining, and business intelligence tools that provide clinicians with better data for treating patients. Data analytics is proving imperative in helping healthcare providers understand diseases and what motivates patients to comply with care plans. These IT initiatives also give providers fresh insights in terms of operating more efficiently and improving the overall quality of care. To offer one example, Miami Childrens Hospital used data-mining tools to substantially reduce asthma hospitalizations, thereby improving the quality of care, while reducing costs for families and third-party payers. Another emerging IT system is enterprise data warehousing (EDW), which incorporates clinical / patient, financial, and operational data. It allows for tracking operational metrics and correlating financial measures with clinical outcomes. The ability to have data for a given patient across multiple healthcare providers allows for a more complete picture of the patients condition and treatments and opens the door to more personalized delivery of care. In the future, mobile technology may hold the key to improving access to specialized medical services, more effective preventive care, better monitoring of chronic conditions, and improved patient outcomes. Through the development of interactive mobile applications (apps) for smartphones, tablets, and
a critical role in supporting evolving models of care and reimbursement structures. Under the traditional fee-for- service (FFS) approach, IT support revolved around billing and collecting funds from patients, insurers, and Medicare/Medicaid. IT provided services to improve the efficiencies around the transactional administrative aspects of the business. While there was some experimentation in capitated payments and health maintenance organization (HMO) models, fee-for-service continued to be the dominant approach for most providers.
Today, that traditional landscape is changing dramatically, driven by federal healthcare policy, advance-
Topics covered in this section of the Roadmap include:
How care providers will use technology How consumers engage in care Lessons learned from global health Impacts of mHealth on chronic disease management
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laptops, healthcare providers can deliver personalized services to patients and families at home, at work, at play, or when traveling. In this way, the rapid development of mobile apps will allow for a dramatic expansion of telemedicine and telehealth services. All of these technology initiatives support the new models of healthcare delivery, such as preferred tier networks and ACOs. After all, these models are geared toward prevention, primary care, and delivering a continuum of services strategies that benefit from the EMR/EHR and shared visibility of operational and financial data. From a different perspective, payers also benefit from the new generation of IT tools, which provide transparency and accountability when making bundled payments to multiple providers. Regardless of the future direction of the nations healthcare model which now seems to be firmly on the path toward consolidated, coordinated care IT tools, applications, and systems will provide an ever-evolving platform for the effective delivery of clinical services, operational excellence, and financial reimbursement.
Measuring and Benchmarking: Opportunities for Mobility in Care Delivery

authors
Wayne Guerra MD, MBA

Chief Medical Officer and Co-Founder iTriage
Stacy Block
Senior Marketing Manager iTriage
Changes to physician licensure Surveys show apps as a first stop for M.D. seeking information Further adoption of mobile technologies into the meaningful use of Health IT Increase in patients using mobile to communicate (Move to a menu item in meaningful use)

Marcus Gordon, MBA

VP of Account Management Brightwhistle Inc.
Paul Z. Seville, MD
Oregon Health and Science University Student
Dr. Norma I. Lopez

Physician Consultant Physician to Physician EHR Strategies, LLC
Kelsey Q Wright
Johns Hopkins Bloomberg School of Public Health International Health-Health Systems, MSPH
Track how patients use apps Fitness, health monitoring and chronic disease management
Clint McClellan
Senior Director of Strategic Marketing Qualcomm Life, a Qualcomm Company
Track how clinicians use mobile (HIMSS Analytics)
Andy Schoonover
CEO Valued Relationships, Inc (VRI)
Top 10 mobile hospitals as Newsweek category (include most wireless hospital as a ranking) Increase of mobile for patient population monitoring (Not just EHR sourced)
Eleanor Chye
Executive Director, Mobility Healthcare and Pharma Mobility Product Management AT&T Business Solutions
Jonathan Levoy
Alego Health VP of Business Development & Technology
Use mobile to track patient experience, satisfaction, and quality
Salli Duncan
VP of Operations Valued Relationships, Inc
mhiMss staff liaisoN
Thomas Martin, MBA

Manager mHIMSS
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New Care Models
Provider Usage: A Guide to Implementing Mobile Monitoring

CoNteNts
Care Transition: From Hospital to Home 1-04 Integration into Clinical Workflow1-05
Care Transition: From Hospital to Home

Numerous factors are driving significant changes in healthcare delivery, including new care models, shifting reimbursement structures, and the advent of Accountable Care Organizations (ACOs) and population health management At the same time, we are seeing an explosion of personal connected health devices and increasing demand for patients involvement in managing their own health and wellness
Technology Is Empowering Consumers

These factors all point to wide-ranging opportunities for the application of health technologies in many areas of care delivery From pre-care to post-op, hospital discharge, and rehabilitation, technology is changing, empowering, and enhancing patientprovider interactions Today, patients can book doctor appointments, or learn about symptoms, procedures, and medications online A proliferation of chronic disease management programs, which allow remote monitoring of individuals with conditions such as hypertension and diabetes, are improving quality of care and outcomes Study after study reinforce the power of monitoring patients in their homes
See Patient Seeks Care graphic on page 1-07.
In the case of heart failure, for example, remote monitoring programs are proving to reduce hospital readmission rates by up to 50%: The Connected Cardiac Care Program offered by the Center for Connected Health at Partners HealthCare, reduced hospital readmission rates by nearly 50% for non-homebound patients with heart failure
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Results from a Veterans Health Administration telehealth program showed a 19% reduction in hospital readmissions and a 25% reduction in the number of bed days of care A remote monitoring program offered by the Ontario Telemedicine Network, part of the Canadian Ministry of Health, achieved a 65% reduction in hospital admissions, 72% reduction in Emergency Room visits and a 95% reduction in walk-in clinic visits for patients with congestive heart failure or COPD Geisinger Health Plans interactive voice response post-hospital discharge telemonitoring solution demonstrated a 44% reduction in 30-day hospital readmissions
and can extend to an individuals family or caregivers In addition, secure patient website portals have become an important vehicle for delivering education, information, and support to individuals to improve awareness and encourage positive behavior change
See Patient Transitions to Chronic Care Monitoring Unit graphic on page 1-10.
Integration into Clinical Workflow

Ample data is now available to demonstrate the benefits of personal connected health technologies The next step is to seamlessly integrate this data into a providers clinical workflow
See Patient Enters Hospital graphic on page 1-11.
As a result, more and more individual patient data is being collected and transmitted, making it increasingly important that the data be actionable and secure, and that patient privacy is protected Actionable data means that it is presented to both providers and patients in a format that is quickly and easily accessible, and displayed in a meaningful and understandable way
See Patient With A Planned Procedure At A Hospital graphic on page 1-08.
Clinical Applications
As there are myriad devices and technology platforms available, there are also countless clinical applications to improve efficiencies of care coordination For example, clinical decision support systems can assist physicians at the point of care, to evaluate several patient data points when making diagnosis or treatment decisions Other technologies can monitor for adherence to medication or treatment plans, or the reconciliation and monitoring of prescriptions With electronic medical records, remotely monitored patient data, and digital information becoming prevalent, predictive analytics solutions can help healthcare providers to improve patient care, support population health management, and lower costs Hence, the integration of data from various sources with electronic medical records (EMR) and provider health IT systems will become critical
Health technologies are also helping the elderly and individuals with a long-term disability live independently, and are providing vital support for patients recovering from acute conditions, including cancer, joint replacement surgery, and pregnancy Personal health and video technologies are impacting clinical diagnostics in such areas as sleep apnea, cardio telemetry, and wound care
See Patient Requiring Long Term Care graphic on page 1-09.
Engaging patients in their health and wellness is an important component in todays care continuum Health technologiesfrom wireless blood pressure cuffs that automatically upload readings and text messaging programs that remind patients to take their medication, to virtual visits conducted via video that connect providers to remote patientsare providing valuable options to facilitate and personalize patient engagement,
How do we put big data to work for healthcare providers? To start, several components must be in place: Patient-collected data must be aggregated and presented in an actionable format for clinicians, and available via established provider channels, such as EMRs Clinical interventions must be based on established standards of care Telemonitoring and connected health programs such as remote monitoring for chronic disease management can efficiently and effectively be managed by nurses or third-party organizations Physician involvement should be on an as-needed basis For patients being discharged from the hospital, successful remote monitoring programs can be integrated into clinical practice to increase patient engagement, adherence, and clinical outcomes
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Once a patient is identified for home monitoring by his or her treating clinician at discharge, a third-party agency can install remote monitoring equipment in the patients home, and provide training and ongoing technical support Then, using these remote monitoring tools, a patients vital signs are collected and transmitted via a landline or cellular hub to telemonitoring nurses Clinical parameters are established by the clinician, so treating physicians are engaged only when a patient falls outside of set boundaries, enabling medical staff to focus on patients requiring immediate clinical intervention Clinicians can create individual parameters and care plans for their patients, and have real-time access to remote monitoring data Patients also receive adherence reminder calls if vital signs are not uploaded One major barrier to the widespread adoption of
remote monitoring programs is the lack of internal provider resources to sufficiently monitor and respond to data uploaded from patients homes, including alerts indicating that an individual is outside of clinical parameters Third-party agencies specializing in the implementation and management of remote monitoring programs can offer important resources for providers Trained telemonitoring nurses review patient data each day, and involve providers on an as-needed basis, to best utilize existing healthcare resources and reduce healthcare costs Many providers are employing external resources to manage these programs with great success
See Early Patient Discharge // Supplied Monitoring Kit graphic on page 1-12.
authors
Andy Schoonover
Executive Chairman Valued Relationships, Inc (VRI)
Salli Duncan
VP of Operations Valued Relationships, Inc
Clint McClellan
Senior Director of Strategic Marketing Qualcomm Life, a Qualcomm Company
Paul Z. Seville, MD
Jonathan Levoy
Alego Health VP of Business Development & Technology
In summary, connected health programs have been proven to decrease re-hospitalization rates, increase patient satisfaction, and improve patients ability to self-manage their conditions For clinicians, remote monitoring programs can reduce the burden on administrative and clinical resources and improve efficiencies for managing the clinical needs of chronically ill patients at home The right mix of clinical care and proven technology has the potential to significantly and positively impact healthcare
Thomas Martin, MBA

Manager mHIMSS
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Patient Seeks Care
Patient identifies a health care need (e.g., rash, ache/pain, etc)
Patient uses mobile app to diagnose potential problem (e.g., iTriage, medgle)
Patient uses app to communicate with his/her own physician to figure out course of treatment (e.g., pingmd)
OR patient uses telemedicine solution to connect with a clinician who can assist in diagnosis and treatment (e.g., American Well)
If patient has no physician, uses application to identify one based on parameters (e.g., zocdoc, itriage)
Patient goes to MD office and checks in online (e.g., phreesia) and gets messaging about care
Patient receives diagnosis and goes home with app that explains treatment and aftercare
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Patient with a Planned Procedure at Hospital
Once the patient has recovered, Payer issues the patient a chronic disease management kit through a disease management company The chronic disease remote monitoring kit could include the exact same medical devices as the 30 day readmission kit: Dedicated cellular hub or smart phone, Bluetooth or BLE sensors- BP cuff, weight scale and SPO2 meter
Patient is contacted via text or outbound reminder to schedule pre-op appointment
Patient receives smartphone app or website that explains procedure, what to expect, and how to prepare.
Patient receives text/outbound reminder to remind them of surgery and to not eat/drink after 12pm
PATIENT ENTERS HOSPITAL Patient gets discharge plan via app/text, etc along with educational content
Patients new meds are eprescribed and delivered with medication reminder device
Patient receives texts/outbound reminder to remind them to take their meds and schedule follow-up appointment with PCP or specialist
Patient receives educational content (e.g., coaching on PT if a knee replacement) via smartphone app or web
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Patient Requiring Long Term Care
Caregiver observes parent/patient with difficulty staying balanced
Caregiver issues a mobile monitoring device and medication adherence device. Caregiver and child receive text and web notifications from both devices to help manage care
Parent continues to worsen so adult caregiver issues motion sensors that monitor patients activities and initiates a text and web notifications if activity is not normal
All alerts are monitored by third party who provides interventions when necessary
Patient deteriorates and receives additional in home support while child receives updates on his/her mobile device as to how parent doing
As patient further deteriorates, is admitted to nursing home where additional passive sensors are utilized
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Patient Transitions to Chronic Care Monitoring Kit
NOTE: There Will be Multiple Business Models 1. The same company might monitor the patient 2. A new company might deliver a new remote monitoring kit
CHF Patient at home is using remote monitoring kit that includes a BP cuff, weight scale and glucose meter
BP and weight rise and trigger an alarm
Alarm Scenarios
1. Call center technician calls patient and determines that the situation is a false alarm 2. Call center contacts patient and helps them return to their recovery protocol 3. Call center advises patient to return to hospital and see their doctor // Doc is prepared with trend data from PHR
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Patient Enters Hospital
Patient feels faint and short of breath
Patient enters hospital
Patient signs in with a tablet and data EHR is obtained
Patient is tracked through the hospital with RFID sensors
Patient is monitored with Sotera-like vitals sensors BP, ECG, HR, Resp. Rate, etc Device uses Wi-Fi
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Patient recovers and determination is made to release patient early with a remote monitoring kit that includes a dedicated hub or a phone that is paired with Bluetooth or Bluetooth Low Energy medical devices // e.g., blood pressure cuff, weight scale, glucose meter, SPO2 meter Note: The Continua Alliance has developed interoperability guidelines that define the interfaces between medical devices and hubs.
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A third party is contracted by payer or hospital to monitor patient for thirty days NOTE: There will be a variety of business models here This party has a 24/7 call center and trained technicians that monitor patient An alarm system is utilized to alert the call center if an out-of-bounds reading is taken Technician monitors patient aided by automatic alerts and will escalate to the doctor or appropriate medical team if the reading is out-of-bounds
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mHealth & Consumer Engagement: Leveraging Consumer Empowerment and Connectivity in a Clinical Setting
CoNteNts
Introduction 1-14 Framework for Consumer Engagement Roadmap 1-14 Current and Future State 1-14 System of Engagement 1-14 Consumer Engagement Current State 1-15 Mobile Technology Use Executive Overview 1-15 Smartphone Market Penetration 1-15 Mobile Web and Smartphone Apps 1-16 Seek Information 1-16 Access Care 1-19 Transitioning Patients in Care: The Role of Communication 1-20 Select Follow Up Care 1-21 Ongoing Personal Health & Wellness 1-22 Consumer Engagement Future State 1-23 Key Drivers of Changing Consumer Engagement 1-23 Review 1-24 Seek Information 1-24 Access Care 1-25 Receive Care 1-26 Select Follow-Up Care 1-26 Authors 1-27
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Introduction
With consumer adoption of mobile devices on a meteoric rise, people are seeking to use mobile technology to better manage their healthcare, and to improve access and connectivity to their health providers Providers are responding to consumer needs by deploying mobile technologies to better engage consumers And as healthcare reform continues to take shape and the stakes increase for providers to drive better clinical and financial outcomes, mobile tools will be leveraged even more to better engage patients The chart below illustrates these and other reasons providers are deploying consumer engagement initiatives
Primary objectives for Consumer engagement initiatives
Improve health outcomes deliver information to patients enable consumers to take more responsibility for their health reduce healthcare costs Improve consumers experience in interacting with our organization 0 10 20 30 (%) 40 59% 59% 57% 50
68% 66%
Framework for Consumer Engagement Roadmap

Current and Future State
This Roadmap outlines both a current and future state of consumer engagement Yet the lines are blurring between the two with the difference being just a matter of degreethe degree of deployment and adoption of existing mobile technology by consumers and providers, the degree of adoption of various social media, provider transitions from fee-for-service to integrated accountable care, and the like Current state focuses predominantly on 1) identifying how consumers engage mobile and social media today; 2) how consumers make healthcare decisions; and 3) provider tools and key considerations when determining how and why to engage consumers The future state then turns toward understanding consumer engagement from the providers viewpoint, key drivers changing consumer engagement, and new ways in which providers can engage consumers and patients
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Source: National eHealth Collaborative
System of Engagement
In addition, this Consumer Engagement Roadmap uses a System of Engagement cycle that follows from the time the consumer seeks healthcare through the period when the consumer becomes a patient and receives care, to ongoing personal wellness management The premise of the system is that people always consider themselves to be consumers of healthcare throughout all stages of the care continuum with the power to make their own care choices The System of Engagement cycle includes: Seek Information, Access Healthcare, Receive Care, Select Follow-Up Care, and Manage Personal Health & Wellness
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Seek Information Manage Personal Health & Wellness
convergence: 1) increasing mobile technology market penetration and increasing consumer adoption of smartphones; 2) consumers increasing demand for convenience, control, and empowerment; and 3) consumer increase in using mobile technology to seek medical information and access the healthcare system
Access Care System of Engagement
Smartphone Market Penetration

Smartphone penetration has officially reached critical mass in the US, with over half of all US adults owning one However, while smartphone adoption is growing at a rapid pace across all demographics, age and income play a role in the levels of adoption When age and income are both taken into account, older people with higher incomes are as likely to have a smartphone as
Select Follow-Up Care
Receive Care
the younger generation For example, those age 55-64 making over $100K a year are almost as likely to have a smartphone as those in the 35-44 age bracket making $35-75K per year And smartphone adoption rates are continuing to accelerate, which is good news for providers serving all age and income brackets With smartphone use reaching critical mass across all populations, smartphones and mobile applications (apps) are poised to become the foundation for consumer engagement throughout the entire System of Engagement As such, healthcare technology companies and providers are ramping up their mobile health information and healthcare strategies and mobile app development to better engage and connect with consumers and patients
Minutes Spent Per Month (Billions)
Note on Wellness definition: With the provider Roadmap in mind, the focus of wellness in this section will be on medical wellness versus overall prevention In addition, chronic disease management will be included only at a high level in this section The following definition of wellness will be used here: the process of maintaining or returning one to a physical, mental, and emotional level of fitness that is commensurate with ones daily level of function and activity
total Mobile app and web duration on android and ios
120 100 80 60 40 20 0 Mar-2011 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar-2012
Consumer Engagement Current State

Mobile Technology Use Executive Overview
Now is the perfect time for providers to adopt mobile strategies to engage, empower and connect with consumers We have entered a period of exciting
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Mobile Web and Smartphone Apps

What is particularly interesting is that consumers are currently using mobile to access both the Internet and smartphone applications in support of seeking health information and health providers The Cybercitizen Health US 2012 study from Manhattan Research revealed that 75 million people will use their smartphone to access health information in 2012 compared to 61 million in 2011 The convergence of mobile and Web technology is leading people to access the mobile Web more than traditional personal computer (PC) Web The Pew Research Center found that US mobile Internet penetration, defined as either e-mail or the Web, reached 55% in April 2012, with over half the people using mobile Web versus mobile email With that said, mobile app use is far outpacing the use of mobile Web
Seek Information
Manage Personal Health & Wellness
Receive Care
Seek Information
The first stage of the System of Engagement is Seek Information In this part of the healthcare journey, consumers are not actively engaged with providers and have not yet accessed the health system At this stage, they are
initiating the decision process Yet providers can still indirectly engage consumers by making information available through different media, from billboards to mobile apps Traditionally, consumers and patients have relied on traditional media sources, such as TV, radio, billboard, and print advertisements, as sources of information for health and wellness1 In addition, they have sought information and advice from peer groups, known as traditional word-of-mouth marketing Over the past five to ten years, the Internet has grown as a source of health information, with websites such as WebMD flourishing for in-depth medical problem searches According to March 2012 Pew Internet Research studies on health, the Internet, and mobile, 80% of Internet users, or 59% of US adults, look online for health information and 17% of cell phone owners, or 15% of adults, have used their phone to look up health or medical information A more recent study estimates that 75 million people will use their smartphone in 2012 to access health information2 In just the last few years, though, with the explosive growth of smart mobile devices, there has been a paradigm shift of consumers using mobile to seek health information This shift is occurring because people are demanding more convenience and to seek health information and want take action on that information (ie, schedule an appointment) In addition, the rise of social media (Facebook, Twitter, YouTube, Pinterest, etc) as a source of information and influencer of behavior has augmented the basic use of the Internet to seek information According to a 2012 PwC report entitled Social Media Likes Healthcare, of 1,060 US adults (interviewed), about one third of consumers are using the social space as a natural habitat for health discussions
1 For the purpose of this section, Health and Wellness includes care from traditional providers with the incorporation of changes to personal behavior or wellness The Cybercitizen Health US 2012 study from Manhattan Research
The convergence of ever-present, ubiquitous Internet availability, mobile devices, and social resources is perhaps the most disruptive set of factors to ever affect the provider-consumer (patient) relationship Consumer Preference and Usage As a result of changes to how consumers seek health information, looming questions for providers have emerged: where are consumers looking for health information; what are they looking for; how are they using these new tools for making informed decisions, and how are they using these tools to access the healthcare system and engage with providers? The when is becoming obsoletewith the availability of always on sources such as desktop and mobile environments; consumers are searching for and expect answers around the clock The why is particularly interesting and impacts the what and the how consumers seek health information Specifically, we see different informationseeking paths emerging: 1) based on whether consumers are looking for health information at the point of medical need; and 2) for future use of information We will review these paths below, but essentially, we find that mobile apps that enable consumers to self-manage their healthcare are commonly used to seek health information at the point of medical need And we are seeing a combination of self-help mobile tools and social media outlets being used by consumers who want to store health information for a future action A consumer typically follows a four-step process known as AIDA (Attention, Interest, Desire, Action) when forming an opinion about making a purchase for a product or serviceand healthcare is no different During the attention, or forming an opinion phase of a consumers decision-making process, there are numerous factors upon which consumers draw For the past 50
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Growth in Mobile Visitors (%)
years, the primary sources of (content) information has been traditional mass media, such as TV, radio, billboard, print, direct mail, as well as word-of-mouth marketing However, recent research has shown a major shift in how healthcare consumers search and receive healthcare-related information The greatest shifts in consumer engagement appear in the mobile (mHealth) and social arenas When it comes to health information such as symptoms, diseases, and procedures, consumers have traditionally sought out expert and trusted sources, including their medical providers, books, and for the past five to ten years, the Internet (eg, WebMD) Mobile/Smartphones to Manage Health Information People are adopting mobile technology to give them convenient and actionable health information Historically, consumers predominantly used traditional media and even the Internet to seek health information As noted in the AIDA model, consumers now look to take action on that information and are turning to mobile applications to bridge the gap between information gathering and making a purchase In the healthcare realm, this means consumers are using mobile tools that help them make better healthcare decisions, determine the appropriate level of healthcare, access the healthcare system, and connect them with providersor make a purchase of healthcare We will address this transition from seeking healthcare to making the purchase, or accessing healthcare, in the next section According to a comScore MobileLens study, the health information segment has the highest percentage of mobile user growth, with a 134% year-over-year increase Additionally, 59% of those polled in an Economist study expect mHealth to impact how they seek health information
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Mobile audience Growth
likelihood of information found via social media affecting health decisions

Seeking second opinion from another doctor 45% coping with chronic condition or pain 42%
BI Intelligence 134%
76%
approach to diet, exercise, or stress management 42% choosing specific hospital/medical facility 41% choosing specific doctor
Health Information
Other Major Growth Sectors
41% taking certain medication 34%
Source: comScore Mobilens, 3 mon. avg, ending Dec-2011 vs. Dec-2010, U.S.
Social Influence Social influences and influencers also contribute to the consumer healthcare purchasing process Information is researched more deliberately in mobile and social environments, and prior to making decisions, consumers may socialize (or get peer, real-time feedback) about their intent Review management sites such as Yelp, Healthgrades, and Vitals, in addition to the search engine review sites (Google Plus, Bing, etc) all offer a forum for patients to communicate about their experiences and preferences with respect to hospitals, physicians, and clinics As social influence exerts a greater role in decision making via mobile devices, providers will need to pay close attention to what consumers are saying about their services This, in turn, can lead to more productive reputation management and ultimately downstream referrals through digital word-of-mouth marketing
undergoing specific procedure or test 33% choosing health insurance plan 32% n=1,060
Source: PwC HR Social Media Consumer Surveu, 2012
With an aging population, caregivers (including family members, friends, live-in nurses, assisted living facilities, etc) continue to remain a potent source of influence for health-related decisions In addition, these caregivers also support children, as well as children and adults with disabilities This group is so prevalent, according to a 2012 Pew Research Report, that Thirty percent of US adults help a loved one with personal needs or
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Caregivers are highly social, both online and offline.

Caregivers are more likely than other internet users to take advantage of social tools related to health:
44% of online caregivers have read someone elses personal health story online, compared with 29% of non-caregivers 28% of online caregivers who use sites like Facebook have followed their friends personal health experiences or health updates, compared with 21% of non-caregivers who use such sites 26% of online caregivers have looked online for someone with similar health concerns, compared with 15% of non-caregivers
household chores, managing finances, arranging for outside services, or visiting regularly to see how they are doing And, according to the same report, eight in ten caregivers have Internet access, with nearly 88% using the Web and social circles as sources of health-related information In fact, caregivers are more likely than others to use online social tools to acquire health related information and are more active health consumers
See table on left.
Key Considerations and Decisions Providers are facing challenges on how to best leverage mobile technologies to engage consumers at this stage of the System of Engagement Prospective patients and their caregivers are currently searching online, on mobile devices, and in social circles, for health-related information Increasingly, third-party vendors and developers are creating tools and resources to reach audience groups via mobile platforms These tools provide health information and engage consumers When selecting third-party solutions, providers should consider whether those third-party solutions meet these requirements: Aligns with your organizations strategic goals, such as to: 1) engage and acquire new patients; 2) engage existing patients; and 3) serve as a community education resource Maximizes visibility among consumers/prospective patients, not just existing patients (ie, solution has its own strong brand and user market to reach those not yet loyal to your organization) Integrates with or compliments your own brand IT investment: how much of your IT departments resources are required to implement and maintain the solution?
When evaluating facility centric solutions, providers should consider the following: Consumer reach: search engine optimization/search engine marketing (SEO/SEM) to reach prospective patients; Ease of use for engagement; Multi-site vs single site; Scalability; and Adaptability and integration Examples of in-house and third-party tools include: Broad health information apps: symptoms, causes, treatments; Hospital-specific information; and Emergency room (ER) information: wait times Challenges While mobile technologies are rapidly becoming more available to provide the health information consumers are seeking, there is still limited deployment of technology that provides convenient, actionable information consumers are seeking at the point of medical need Additionally, notifying the surrounding community of the availability of these tools, and getting adoption of these technologies, can create significant barriers to successful consumer engagement
Caregivers are active health care consumers.

Caregivers are more likely than other internet users to read online reviews of drugs, clinicians, and medical facilities: 38% of online caregivers have consulted online reviews of particular drugs or medical treatments, compared with 18% of non-caregivers 21% of online caregivers have consulted online rankings or reviews of doctors or other providers, compared with 13% of non-caregivers 20% of online caregivers have consulted online rankings or reviews of hospitals or other medical facilities, compared with 12% of non-caregivers Statistical analysis shows that being a caregiver has a significant association with an internet users likelihood to consult such reviews It is not just that caregivers are more likely to be older, more highly educated, and living with chronic conditions (groups likely to do this type of research) Being a caregiver is independently associated with higher levels of a variety of health information-seeking behaviors
Source: Pew Internet
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Seek Information
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Access Care
As already noted, the first step in the System of Engagement is seeking health information However, as consumers seek greater empowerment in managing their own healthcare, they want to be able to easily and conveniently use that information to access the appropriate level of care needed for their medical needs So what constitutes access? We define it as transitioning from providing health information to providing the direct tools that consumers need to select the appropriate level of care, along with these consumers with care providers Decision Support There are two types of decision support paths that lead consumers to connecting with a care provider (eg, go to the emergency room or urgent care clinic, or make an appointment with a physician) The first type of decision support actually falls into the seek information stage, in which consumers are simply looking for health
information through word of mouth, online, through social circles or via mobile apps The direct decision support referred to in this Access Healthcare section refers to those decision support tools that help consumers directly link health information to provider selection and provider access Typically, consumers look up health information and then make a decision to seek care They then research care providers through the channels mentioned above, and then they call a provider to make an appointment, or in the case of an emergent need, drive to the ER or urgent care clinic A variety of mobile resources are now available to consumers, which in a few keystrokes will provide consumers with: Direct pathway between a symptom and an appropriate provider to treat that symptom; A local provider that meets their specific criteria; Review about other patients interactions with a provider; Real-time feedback from other consumers about a provider or treatment option; The power to locate the closest ER with the shortest (posted) wait times; and The ability to notify an ER or urgent care clinic of a pending visit or make a real-time appointment with a physician
Consumer Decision Support Examples Appropriate level of care options based on symptoms, ER wait times, physician listings:
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Provider Access Examples ER early check-in services, online and mobile physician appointment requests:
Without this linkage, consumers may continue to access inappropriate levels of care, unnecessarily increasing the cost of care or negatively impacting patient outcomes And, even for consumers not seeking immediate medical attention, the likelihood that they seek medical attention at all decreases with the lag time between finding information and being able to reach a provider to make an appointment
cognitive, emotional, and physical abilities, which may impact the quality of information that a consumer can give to the 911 representative Ambulance/ER Ambulances usually take the patient to the nearest ER with some degree of triage for determining which facilities can handle the patients issue However, while bed counts and ER activity status are given a cursory evaluation, ultimately the ER usually gets overwhelmed, needing to triage patients at the ER, leading to longer wait times for those patients with less severe injuries This constant diversion of attention based on activity level creates a hectic and putting-out fires mentality that leads to errors, repeat labs, long wait times, and overall suboptimal quality of care Care Hand-off/Transition
Seek Information
Challenges Online appointment scheduling is becoming more commonplace, but there is still very limited linkage between symptom/health research and decision support tools that identify providers that treat the consumers problem For consumers who are seeking health information at the time of medical need, this broken link could have an impact on patient outcomes Further, tying clinical decision support to access is still a relatively new concept with only a few innovative companies (eg, iTriage) developing mobile solutions that engage consumers and provide direct decision support tools with immediate access to the appropriate level of care
Receive Care
Transitioning Patients in Care: The Role of Communication

Currently, there are many ways in which providers and patients can interact in order to facilitate care At the many points in which care providers interact with patients, there are multiple touch points in the ecosystem 911 For emergency situations, consumers need to dial 911 on their phones to connect with an operator who, in a very monotone and impersonal manner, will try to elicit information from the consumer at a time when contextual stress and anxiety are excessive, leading to limits on
Hand-offs and transitions are inefficient and prolonged The primary means of transition is through verbal communication with the patient or caregiver with instructions either to call for a follow-up, or an appointment is scheduled without consideration to patient circumstance Written instructions are provided, but many times these are not easy to read and, because of the entire ER experience, patients may misplace their follow-up information The primary care provider may or may not be notified of the situation, based on patient needs Labs, ER reports, and other studies are usually not available to providers when the patient arrives for follow-up This usually necessitates that either staff call the ER for further information, or labs are redone, or the patient, if stable, is asked to follow-up at a later date This causes frustration for both the providers and consumers, along with inefficiencies that could easily be avoided using todays technologies
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Family Members Family members, friends, and caregivers may be unaware what has happened to their loved ones When communication is established, it usually happens through a chain of phone events in which one caregiver calls another This increases the risk of misinformation (as a result of poor recall or not understanding clearly the situation) and communication delays How Providers Will Use Mobile Tech Providers are currently using mobile for a variety of health-related activities In particular, they have used apps to assist in medication prescribing and management such as ePocrates, Skyscape, Medscape, and others However, many of these apps do not work well together Furthermore, many providers are not aware how to choose apps that have been vetted and are fit to use in the clinical setting, especially if these apps are subject to HIPAA regulations Communication Texting (unsecure) Many providers are using and want to use texting to communicate and collaborate with other healthcare providers and patients because it is efficient and easy to use However, many of these devices and applications are not HIPAA compliant Yet providers continue to use them either because they are not aware of the devices or apps HIPAA compliance, or the convenience is great enough that they are will to take the risk The benefit of texting is that it is an asynchronous technology, allowing both parties to respond when needed Talking Many providers are still calling patients to address questions or inform them of results However, because this synchronous technology requires that both parties
be present at the same time, phone tagging is at time inevitable Email Some providers have used email to communicate with patients Technology is currently in place to allow secure transactions and communications between caregivers and patients However, excessive email has overwhelmed many providers, leading many to miss important messages if not closely scrutinized Efforts to limit spam and prioritize emails have also been challenging
The question remains, what do consumers do in order to facilitate their own follow-up care? And, how can providers remain compliant by providing a proper, meaningful set of instructions that will enable their patients to take charge of their own health? Patient Discharge Environment In many provider settings, a patient and/or his or her caregiver(s) are handed a sheet of paper with instructions upon discharge These instructions might include what medications to take, what type of physical therapy might be needed, how often to rest, what type of specialist to see, etc However, once a patient leaves a hospital or provider setting, they revert back to consumer status and the onus is on him or her or the caregiver to comply with the discharge instructions Perhaps the consumer might receive a follow-up phone call from a provider, but generally a big gap in communication and compliance remains from the point of patient discharge to the points necessary for follow-up care While it is relatively easy for patients to get their medications, how do they seek a specialist for their follow up care? And at what point does that specialist become engaged in the patients follow-up protocols? Patient Decision Path Todays patients have many opportunities in which to seek information The digital environment, including active search, social, and mobile, are becoming increasingly influential channels for patients From the moment a patient or caregiver identifies a need (or condition), she/he begins individual, self-directed research or begins the social wheel process
Seek Information
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Select Follow Up Care

The current healthcare operating model (payer/provider/ physician/patient) places an emphasis on the services rendered and the services received Within the scope of patient care, there is usually an emphasis on the best interest of the patient, with a focus on outcomes However, a critical missing line, which healthcare reform, accountable care organization (ACOs) development, etc, will attempt to address, is the manner of follow-up care a patient should receive once he or she has left a specific provider Today, a person is typically responsible for securing his or her own follow-up care
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Challenge The social wheel provides an excellent framework of understanding how consumers make follow-up care decisions based on social and expert influences However, there is a certain amount of time required to seek recommendations and opinions of influencers This lag time may result in consumers being less compliant in following through on getting their follow-up care In the future, mobile will need to enable consumers to be able to make more immediate follow-up care appointments
Seek Information
wwwbrightwhistlecom For an active health consumer, one who identifies the need to seek a specialist (either through a primary care physician recommendation or a self-diagnosis), his/her points of influence might look like this: Gets a referral (in-network) from a primary care physician (PCP), but desires a second opinion; Seeks recommendation from friends and family; Is open to take action; Frequent user of Facebook; and Opinions matter to him or her and reviews facilitate this process It is critical to understand the consumers frame of reference during this process, as research referenced earlier clearly indicates that digital environments are growing points of persuasion
low adoption rates, Google has already shut down its PHR Microsoft is making inroads via partnerships with healthcare providers, so there will likely be wider adoption in the future once electronic transfer PHR data to provider EMRs becomes more mainstream Patient portals present their own barriers to widespread adoption today Many providers have launched proprietary and self-contained patient portals in efforts to meet regulatory requirements, improve patient satisfaction, and drive patient loyalty Patient portals allow existing patients of a hospital or health system to access their medical information associated to care by that provider, and some provider PHR functionality Yet, for the most part, these portals are system-inclusive, requiring consumers who are likely to be a patient at various, unaffiliated health systems to use multiple patient portals in order to view all of their care information As such, todays patient portal models do not meet the needs of consumers who want a ubiquitous repository for all of their personal healthcare information, and as a result is seeing limited adoption Mobile Enabled Access to Personal Health Information Despite the current low adoption rate of patient portals by consumers, mobile-enabled access is slowly becoming the disrupter to the entire ecosystem The plethora of consumer-controlled apps in a mobile environmentapproximately 13,000 as of August 2012have provided the entire healthcare ecosystem with information at their fingertips What was once a distant probability is now a stark reality The ability of physicians to take notes, submit scans electronically, all for patients to see in the palms of their own hands (and on their own devices), real-time The opportunity for the instant exchange of information that would foster a more efficient continuum of care is available
Receive Care
Ongoing Personal Health & Wellness

Today, consumers have two options to view and store their personal health and medical information: 1) personal health records (PHRs); and 2) provider patient portals By and large, consumer adoption of both electronic tools is still limited PHRs allow people to input their own personal health information, store it, and access it in a readily accessible manner Microsoft HealthVault and Google Health had been the two largest and most well-known PHRs in the market However, due to the
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For example, an end-user (patient and/or caregiver) would be more inclined to use a mobile personal health record (rather than a desktop version) that does more than offer convenienceit actually fosters engagement Launched just a few months ago, the PocketHealth mobile health app gives users the ability to control and manage their personal healthcare dataas well as data for family members or others for whom they provide care While many of these types of applications currently exist, the increase in adoption is required in order to see the interaction between providers, payers, and consumers rise
Integrated Accountable Care
Regulatory Requirements
Consumer Empowerment/ Choice
Healthcare Costs
Consumer engagement
Consumer Engagement Future State

As noted in the previous section, the lines are blurring between current and future states of consumer engagement via mobile technology and social media The differences are primarily the degree of widespread availability and consumer usage of mobile tools and provider implementation and utilization of these mobile engagement tools There will, however, be a significant shift in how providers engage consumers throughout the System of Engagement That shift will be driven by 1) changes in the healthcare delivery model, with the transition from fee-for-service to new integrated, accountable care systems; 2) increasing consumer empowerment and choice, driving healthcare selfmanagement; 3) regulatory requirements around Meaningful Use and patient outcomes; and 4) continuing and increasing need to lower the overall cost of healthcare
Key Drivers of Changing Consumer Engagement

Mobile technology and social media will enable consumer engagement in this new landscape They will meet consumer need for more empowerment, convenience, and control and will support provider clinical and financial goals Enabling Consumer Empowerment Smart mobile devices for everyday needs will become the norm, empowering people with the actionable decision support, convenience, and control they desire With regard to managing healthcare, mobile technology will empower consumers to take a more proactive approach in assessing their symptoms and selecting providers, accessing healthcare systems, and connecting with care providers for ongoing care management Supporting Accountable Care, Regulatory Compliance, and Cost Reduction Many providers will move from a fee-for-service model to an ACO system that will hold them accountable for patient outcomes throughout the care continuum In addition, in order to lower the cost of care, many health systems will become plan sponsors as well As
such, consumer engagement will be about influencing consumer choice to drive patient acquisition, steerage, network retention, care coordination, and healthcare cost reduction Because consumers will still be empowered to choose their care providers, there will be no guarantee that they will stay in a single network for all their care needs Mobile technology will help providers engage consumers at every provider selection point and influence their decision to enter and stay within a network Once that consumer is acquired and retained, providers will then be able to truly engage that person as a patient and transition to patient engagement Mobile technology will also help providers improve patient engagement, including providing access to medical information, communicating with care team members, and facilitating care coordination To summarize, providers will be able to leverage mobile technology to engage consumers that will not only drive consumer and patient satisfaction, but also support the health systems financial and clinical goals For providers, mobile technology will: Provide consumer decision support (helping them find the most cost-effective care); Influence consumer choice; Steer to lower cost in-network providers; Provide access to the health system and connection to providers; Retain patients in the health system or network; and Support ongoing health management engagement
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Review
Let us review how these mobile consumer engagement tools will work in the System of Engagement
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Provide Consumer Decision Support
Support Ongoing Health Management
Influence Consumer Choice
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Consumer Engagement
Retain Patients in Health System or Network Steer To Lower Cost, In-Network Providers
Seek Information
Using the new Future State lens, consumers will continue to use mobile technology to seek healthcare information like they do today but more regularly They will use their smart mobile devices to access mobile Web and mobile apps One major difference, however, will be that consumers will demand even more convenient tools that consolidate health information resources to help them better manage their healthcare And these single source mobile websites and apps will be more prevalent, offering symptom checkers, disease and medical condition information, procedure information, ER wait times, physician and healthcare facility information, PHR information, healthcare cost information, and the like There will also be an increased use of mobile technology to find actionable information, or health information that leads to action, such as making appointments or accessing lab results directly from a smartphone From a provider perspective, the same social media and Web/mobile solutions that are emerging today will continue to allow providers to engage consumers, acquire new patients, and increase existing patient
satisfaction Mobile technology will evolve, though, to better help providers lower the cost of healthcare and steer consumers to the appropriate level of care Again, this will be especially important for providers that have transitioned from a fee-for-service model to an accountable care system New mobile technology will provide: Better consumer decision support; Influencing consumer choice; and Steering to lower cost of care Below is an example of a mobile tool that helps achieve all three objectives: provides decision support around the level of care options; influences consumer choice with a pop-up alert about the more expensive care selected; and steers the consumer to a lower cost of care with information about an alternative care choice (urgent care)
Provide Access To The Health System And Connection To Providers
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Consumer Decision
Seek Information
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Access Care
Consumer Preference Mobile devices will become mainstream tools for consumers when seeking to access care Mobile appointment setting, which is technologically available today but adopted on a relatively small scale by providers, will become widely adopted by providers and widely used by consumers Furthermore, more mobile appointment setting solutions will be integrated with the leading EMR systems, providing a streamlined patient scheduling process and back-end operational efficiencies for physicians and medical facilities Providers, though, will need to weigh the importance of EMR integration with the stand-alone value of patient acquisition In the future, consumers in rural areas or without easy physical access to healthcare will also be able to access more healthcare via mobile telemedicine, mobile video consultations with physicians, and other rich, interactive mobile technologies
Let us go back to the new consumer engagement model that discusses engagement from the providers perspective Direct access tools such as mobile appointment setting will conveniently connect consumers/patients to providers However, it is even more critical to understand how mobile technology will help providers influence consumer choice, steer people to lower cost, and in-network care, and then provide that convenience access (eg, appointment) to the healthcare system Look at a scenario in which a consumer has become a member of an accountable care system That networks providers may be tempted to assume that the consumer is now a patient of that system, but this is not the case That person will always, first and foremost, consider himself a consumer of healthcare, empowered to make care choices So the next generation of mobile tools will need to empower consumers with choice, but also provide better decision support tools Provider Tools Meaningful Use requirements and financial incentives/ penalties around patient outcomes will be incentive for providers to offer those extra in-network/out-ofnetwork decision support and access tools that influence consumer choice Mobile technology will bridge the gap between consumer choice and accountable care mandates with tools that 1) engage the consumer; 2) provide care and cost information to aid decision support; 3) steer the consumer to lower cost, in-network care; and 4) connect the consumer (eg, appointment) to an appropriate provider In this accountable care member scenario, mobile technology will enable a consumer to first log in as a member of that accountable care organization (ACO)
prior to beginning the health information-to-provider access path Rather than limit the consumer to just the narrow network of providers in that ACO, the mobile tool maintains the breadth of consumer choice but clearly distinguishes between in-network and out-of-network options Example
Key Considerations

Consumer preference and choice; Appointment setting tools patient acquisition value vs EMR integration; Consumer engagement vs existing patient engagement; Patient acquisition and steerage goals; and IT resources required to build and maintain mobile patient engagement platforms
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Seek Information
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In the Future State, mobile devices will strengthen care coordination among integrated care team members as well as between the care team and the patient Mobile tools will enable patient-provider communication and provide patient access to clinical care information and care plans Some mobile devices will also link to proprietary provider patient portals In effect, mobile devices will extend the patients access to care information and drive more engagement by the patient in the management of his or her care Since this care model section is about consumer engagement versus being about patient engagement and provider-provider care coordination, we will just highlight a few key ways mobile technology will engage the patient in the care process (Other, equally as important, care tools such as remote monitoring devices are not covered in this section) Below are examples of mobile technology care coordination tools for patients Note that these tools may be located directly on a mobile app or reside within a health systems proprietary online and/or mobile patient portal If the tools are in a patient portal, then the
d
mobile device will simply serve as a convenient access point and link patients to the portal Third-party mobile tools supplement the proprietary tools by providing consumers/patients with personalized, one-stop-shop healthcare management home bases and may include quick links to personal health records, patient portals, health coaches, medical monitoring devices, and the like While some of these capabilities exist today, Future State evolution will include mobile devices enabling the sharing of information between patient and provider for better care coordination and empowering the patient to make better decisions independent of a care manager Examples of mobile-enabled care coordination and care compliance tools include: Clinical inboxes: providing patient access to clinical information such as test results, discharge instructions, and care alerts from provider to patient; Secure email: two-way patient/provider communication and provider email messaging; Prescription refills; and Personal health record: letting patients view their PHR, select desired information, select a provider with secure messaging enabled, and then securely transmit information
Seek Information
Receive Care

As noted in the Current State, selecting follow-up care refers to consumers taking steps to identify and secure additional levels of care upon or after completing an initial episode of care Examples of the initial episode of care include an ER visit, an urgent care clinic visit, a primary care doctor visit, a specialist visit, or even a retail health clinic visit Follow-up care might include any primary or specialist physician visit, imaging center visit, or surgery Referring back to the new consumer engagement model, additional layers of service and functionality will be added to mobile devices to help steer and retain patients in a health system or network Social media is an emerging and ubiquitous way to help foster provider-patient engagement As referenced earlier in the social patient decision path, consumers will continue to rely on social channels to help them make informed decisions about their healthcare needs By understanding how consumers make healthcare purchasing decisions, providers will be able to communicate on social channels such as Facebook, Twitter, and Pinterest, as well as specialized social
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channels such as Patients Like Me, in order to drive engagement and end-user decisions that positively affect mutual interest It is important to re-emphasize here that many providers consider people to be patients once they have a patient record However, as consumers of care, people do not necessarily consider themselves to be patients just because they were provided a single episode of care from a health system Therefore, providers will need to continue to think of their patients as consumers of healthcare who have the choice to select follow-up care in or out of the network As such, all of the previously discussed mobile consumer engagement tools (see below) will continue to play an important role in influencing consumer choice, and steering and retaining the patient in network Here is a brief recap of provider objectives in the new consumer engagement model and what future mobile platforms and tools need to support: Provide consumer decision support; Influence consumer choice; Steer to lower cost, in-network providers; Provide access to the health system and connection to providers; and Retain patients in the health system or network
Look at a few examples of mobile care follow-up tools that providers may use to engage consumers/patients at the time of discharge to steer and retain them in network Mobile discharge instructions: discharge instructions that include making an appointment with a specific provider steers the consumer back into the network The mobile tool may be a secure email with attachment, may include a link to a patient portal, or may include a link from within a third-party, mobile healthcare management tool Reminders can be added to the mobile calendar for the follow-up appointment and prescription pick-up and refill Provider-to-provider appointment referral tools that enable one provider to quickly refer a patient before they leave the premises to another provider May replace a traditional call center model; May drive in-network referrals regardless of whether the referrer and referee providers utilize the same EMRs; Increases network compliance; Improves care coordination/outcomeskeeps control within the ACOincreases patient compliance; Decreases costs for ACO provider members; and Increases consumer/patient engagement mobile appointment scheduling tool that empowers patients to manage appointments (view/reschedule/cancel) If the provider does not choose to work with the patient to select follow-up care at the time of discharge, then that patient automatically reverts back to consumer status and uses the same information and care decision path options described earlier
Key Considerations and Decisions When considering which mobile solutions to deploy to help steer and retain patients in network when they transition from one episode of care to the next, consider: The timing of helping a consumer/patient select follow-up care: at time of discharge or after patient has left the premises, and the relative risks of retaining the patient in your system; The cost savings achieved by replacing a call center model with a mobile provider referral model; and The various providers in the network that you will need to adopt the mobile solution for maximum referral opportunities
authors
Wayne Guerra MD, MBA

Chief Medical Officer and Co-Founder iTriage
Stacy Block
Senior Marketing Manager iTriage
Marcus Gordon, MBA

VP of Account Management Brightwhistle Inc.
Paul Z. Seville, MD
Thomas Martin, MBA

Manager mHIMSS
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Introduction
Many lessons can be learned from the history of successes and failures in relation to mobile health (mHealth) deployment As an industry, mHealth has the opportunity to learn from other industries and countries that have tread roads that mobile health has not While the application of mobile technologies in healthcare may lag behind other industries (ie, the banking industry), the opportunity to gain perspective and avoid reinventing the wheel serves as an opportunity to create a successful mHealth initiative for the future Chronic disease management poses as a way to utilize mHealth to help patients better manage their health For example, remote monitoring devices can help patients record their own health status and instantaneously send images or information to physicians This keeps patients out of the physicians office, allows time for the physician with other patients or care-related activities, and ultimately helps reduce costs by keeping patients out of the hospital Involving patients with chronic diseases in their healthcare has been difficult and largely unsuccessful both in terms of engagement and retention Engagement is important since chronic disease drives and remains a significant portion of overall healthcare costs1 Compared to other countries, the US historically has not managed chronic diseases well, even though the US delivers high-quality acute care Even with the latest surge in electronic medical record (EMR) deployment and mHealth initiatives, chronic disease management still falls short Three broad categories can help summarize some reasons: financial incentives, organizational management, and patient engagement
Chronic Disease: Engaging Patients through mHealth

CoNteNts
Introduction 1-28 Financial Incentives 1-29 Organizational Management 1-29 Patient Engagement 1-30 Future State of Chronic Care 1-31 Authors1-31 References 1-31
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Financial Incentives
The current healthcare system has traditionally provided incentives for fee-for-service This rewards the provider for patient volume, not quality One solution to address this issue is to transform the healthcare delivery system to fee-for-performance Will accountable care organizations (ACOs) be the catalyst for fee-forperformance? If so, could it assist in creating incentives for providing quality care? Delivering high quality care is costly, requiring support staff and expensive technology (reporting tools, EHRs, enterprise performance management systems or EPMs, diagnostic equipment, etc) All of these can drive up costs quickly These investments will need to provide long-term gains (return on investment or ROI) for both patient quality outcomes and provider reimbursement It will be imperative to figure out not only how to monitor these advances, but also how to ultimately measure them ACOs will incentivize potential chronic disease management through mHealth by focusing on patient value rather than volume Through electronic sharing of information, increased methods of communication and collaboration, as well as access, this initiative will ultimately help reduce errors with patients and providers not relying solely on memory through immediate data management and recordkeeping practices Furthermore, care is improved as replies to patient questions are answered more quickly These quicker responses allow patients to make the appropriate adjustments earlier in the illness cycle, mitigating illness deterioration mHealth also allows the physician to respond more promptly when reading medical tests, resulting in a more efficient workflow process In all, these
factors help keep patients healthier, therefore keeping them out of the hospital, and overall decreasing costs Another more subtle point, but arguably as important, is the increase in patient productivity seen by keeping the patient healthy This translates to less time away from work and more time being a productive member of society Qualitatively, this may translate into improvements in self-esteem and social relations Overall, ACOs offer many potential benefits, not only for the patient, but also for the hospital as a business through cost savings and efficient practices While the benefits many not be seen immediately, they can be seen longer term
Organizational Management
High-profile procedures provide clout and prestige to healthcare organizations This creates a cycle of attracting high-caliber providers and researchers As a result, these centers are usually rewarded with more grants and other monies and, ultimately, a better competitive advantage Unfortunately, chronic disease management does not garner the same level of attention and reward as acute care typically does Organizational and financial incentives to promote and improve chronic diseases may not be financially sustainable unless there is a change in grants available and financial incentives for providers By creating a system that focuses on managing populations of patients rather than individuals, the impetus will ultimately help drive these initiatives in organizations and communities
Involving healthcare decision makers has been challenging from a couple of key perspectives: Administrative: There is a need to ensure that technology is aligned with the business strategy and that the investment made will yield not only an ROI, but will also add value to the business Provider: Most providers need to be assured that technology will improve patient care while continually providing top quality care This means improving efficiency, decreasing errors, and making sure the technology is easy to use Technology must meet the needs of many stakeholders, but of the two defined above, garnering the trust and support of providers is paramount, as they are the ones who ultimately decide to use the system or not The early involvement of providers as equal participants in decision making is key Not only are provider champions needed, but equally important are the provider disruptors Many times provider champions are volunteers, meaning that they have some interest in technology already, and thus expose a potential bias A disruptor, or someone normally adverse or skeptical of technology, will be key as some who plays devils advocate and will be quick to see the flaws These various roles will help balance each other and form a more accurate view of what users are looking for when technology decision making is being done
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Patient Engagement
mHealth technologies are creating the opportunity to address many of the personal and emotional issues at play in the management of chronic diseases Diseases such as diabetes, hypertension, obesity, congestive heart failure, asthma, chronic obstructive pulmonary disease (COPD), and mental health issues are examples of chronic conditions (along with their co-morbidities) that can be managed by mHealth While advanced monitoring capabilities exist for these diseases, challenges include nontechnical and technical factors Non-technical: mHealth enables individuals to learn on their terms in a manner that is intuitive to the user As the mobile device is portable, this allows the user to quickly search for information at the time the information is needed While mobile technology does provide instantaneous information, it can be overwhelming, especially to new users Some examples of barriers users may face with modern technology include: Denial: Patients are in denial or uncomfortable managing issues through mobile devices Fear: Patients fear results related to the outcome of monitoring health Effort: Chronic disease management can take time to log or input information on a daily basis Lack of education: Patients are not given time to understand their disease state or condition and feel overwhelmed This inevitably feeds a cycle of fear, lack of effort, and denial Patient education and management need to focus on information and content with coaching that is individual and real-time Solutions need to be tied to the clinical care team (ie , not standalone) so that all caregivers are informed and can provide timely and relevant information to the patient
Comparison of technologies used to access the internet in terms of cost, speed, and quality
Hardware dial-up modems cable modems/dish cellphones Smartphones Costs low high low low/med Speed and Data low high low low/med Quality low high low low/med
Technical: From a technical standpoint, users may not necessarily know how to fully utilize their mobile devices This is imperative when it comes to using and managing health information through various apps or monitoring devices And with so many options for health management solutions, it is obvious how a user can become overwhelmed With possibilities ranging from connected devices to video coaching to text reminders, the key will be rationalizing and providing the right information to users based on the specific chronic disease the patient has Considerations such as age, co-morbidities, and the disease state will be crucial to maximizing the latest medical technology and ensuring the cost and ROI of the solution are worthwhile in the first place Complexity: While mobile technology adoption is increasing at significant rates, use of mobile apps and newer technologies are still new to certain populations such as the elderly iTriage is one example of an app iTriage has partnered with the American Heart Association to integrate risk scoring This method of evaluation is exciting as it provides a much-needed
mechanism for personalized healthcare assessment However, these scores should be taken as a guide, and not as an absolute indication of risk In other words, these scores should provide patients with some idea of their health risk and what next measures should be taken For example, if the score is high, and we assume that the higher the score, the greater the risk, the patient should be prompted by the app to seek healthcare advice sooner than later Therefore, patients need to recognize that mobile devices do not replace physicians and should seek care when and where appropriate Cost: In the past, access to computers and the Internet had been limited because of cost and accessibility But as smartphones are more affordable and adoption is at an all-time high, users can now access the Internet anytime and anywhere In fact, accessing the Internet through a mobile device has surpassed that of computers The true concern from a cost perspective will be from the provider side and ensuring that the information and time physicians are spending still equate to cost-effective, high-quality care With the combination of established medical records,
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technology impact on Chronic disease

Chronic Disease type 2 diabetes hypertension hyperlipidemia congestive heart Failure hIv/aIdS mental health Role of Apps med med med low med med Role of Platforms low low low high low low Role of Smartphone Add-ons high high high med low low
provider data and now patient data can be entered through mobile devices, creating a large volume of accurate and more granular information The information can be data-mined first for better understanding of disease management and user demographics or for secondary uses, such as in research With more information for research, better recommendations can be formulated and provided through clinical decision support at the point of care The key is not just real-time data, but the trending data with its emergent patterns noted for behavioral modification Only through behavior modification can we hope to realize the goal of improving the prevention arm of healthcare, ultimately leading to cost savings
Future State of Chronic Care

mHealth is expected to pave the way for patients with chronic diseases by increasing accessibility through smartphones and allowing patients to benefit from real-time information This would allow patients to communicate in other ways not previously available, such as text, video-coaching, and mobile apps However, one of the most important and cutting-edge options available is the access to health-specific mobile applications Examples include monitoring and managing blood sugar readings for diabetics or body-mass index (BMI) and weight for obese patients These applications are inherently more intuitive and easier to use, especially as they continue to evolve This removes a barrier of complexity, incentivizing continued use of the application with easy-to-track information for both the provider and the patient The continued exposure to information and resources can translate to patient empowerment and
better self-management of healthcare issues Healthcare providers who are willing to communicate with patients who prefer this mode of healthcare management may not only improve patient retention, but also increase the number of new patients seen The increase in new patients can be attributed not only to word of mouth, but also word of app In other words, patients will share good provider experiences with other patients through mobile technologies, such as texting, email, and other applications with communication capabilities Over time, with additional innovations, adoption, and acceptance of mHealth technology, everyday healthcare habits will be drastically different than they are today The hope is, as more patients with chronic diseases begin using the new-found mHealth initiatives, that mHealth will help manage and prevent diseases, ultimately leading to reduced hospital admissions and cost savings, while still providing high-quality care
authors
Paul Z. Seville, MD
Dr. Norma I. Lopez

Thomas Martin, MBA

Manager mHIMSS
refereNCes
1 Thrall JH Prevalence and costs of chronic disease in a health care system structured for treatment of acute illness Radiology 2005; 235(1):912 doi:101148/radiol2351041768
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Introduction to Global mHealth Initiatives: Lessons Learned

While there has been a significant increase in mobile health (mHealth) initiatives around the globe, adoption levels have varied by country As expected, more developed countries in North America, South America, and Southeast Asia have higher adoption levels in comparison to less developed countries in Africa These new technologies are significant because it means that physicians can provide care when not in the presence of a patient These new innovations present the opportunity to overcome the limitations of geography and access information from a distance Many of the current mHealth projects in low- and middle-income countries (LMICs) fall into multiple target areas, meaning that many of the projects address surveillance, reporting needs, behavior change, education, disease prevention, health promotion, etc Much of the available data on mHealth interventions around the world seem to indicate that most mHealth projects that have an explicit surveillance component are those that have partners in the local/state/ national government or that have partnered with large international organizations such as the World Health Organization (WHO)
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mHealth interventions being implemented by individual non-governmental organizations (NGOs) tend to target more behavior change and educational activities Additionally, many of the mHealth projects currently in place in low- and middle-income countries that address surveillance seem to be intended to bolster inadequate existing health-system infrastructures and promote increased gains in surveillance for the lowest costs Very few rigorous evaluations of these interventions exist, and while some are starting to emerge, there is not much evidence to support replication of most of these projects
Those countries that are implementing these projects can offer rural outreach and surveillance mHealth projects and offer insight into technical specifications, partnerships, and lessons learned The various initiatives in mHealth across the globe can be partially attributed to the shift from desktop-based Internet access to the more current use of smartphones The term Digital Divide had been coined in reference to the inequality in access to the Internet seen just a few years ago The divide was readily apparent in the US and was a result of several factors, some of which are the high costs of emerging technology, user culture, and user education Other countries have had similar struggles for similar conditions, yet different reasons Historically, access to new technology has been the privilege of the wealthy, primarily because of costs As a result, those with the means to use these technologies usually benefit from the functionality and efficiencies they bring Therefore, those without access to such devices experience a disadvantage The chart below highlights various technologies used to access the Internet, and how these have affected access to healthcare both domestically and internationally
Comparison of technologies used to access the Internet in terms of cost, speed, and quality.
Hardware Costs dial-up modems cable modems/dish cellphones Smartphones low high low low/med Speed low high low medium Data Quality low high low med/high
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With the recent advancements in smartphone technology and its ubiquity, most users are now accessing the Internet through these mobile devices rather than traditional desktop and laptop computers A primary reason for this is the advantage of real-time information that can be accessed from anywhere There are several key reasons the US differs from the larger international mHealth adoption
International:
U.S.:
The primary inhibitor of access to healthcare in the US is attributed to the high cost of care A major advantage of the US is the widespread ubiquity of technology A primary use of the Internet is to search for healthcare information ranging from diagnosis to remedies While determining what qualifies as a quality site is a challenge, the Internet has proved to be an invaluable source of information and empowerment for patients However, those without access to Internet service have not been able to enjoy these benefits until recently The advent of smartphones has helped remedy this situation because of their low cost and the rapid improvements in high-speed Internet access In addition, the use of healthcare apps has helped to reduce the challenges in searching for real-time healthcare information
In addition to costs, other countries have had infrastructure issues As compared to the US, some countries do not even have a national infrastructure for making land-line phone calls This is one of the top reasons why many of these countries were more aggressive in adopting cell-phone technology As a result, they have learned many creative ways to use these technologies, particularly for use in healthcare Some of these include: Texting Healthcare portals Telehealth While variances exist across the globe, there are several key barriers to technology use including cost, education, socio-economic status, and access As the costs to own mobile devices such as smartphones have declined, a greater cross-section of users from varied levels of education and socio-economic status use these devices As a result, groups of society who traditionally have not had access to the Internet can now experience the same benefits as those who have always had the benefit What this means for healthcare is that we need to leverage this information and form new ways to reach out to these less experienced users in a manner consistent with their culture This ranges from countryspecific, user-friendly web design and app generation to connected health devices Many nations are beginning to see some of the effects of mHealth on their populations, especially those related to rural health (as this tends to be a challenge for every country around the world) Because physicians and specialists, as well as hospitals and high-tech equipment, are usually located in more urban areas, mHealth has the opportunity to revolutionize care that is provided to those
in a rural setting Here are a few examples of mHealth initiatives: Ninety percent of childbirths in rural areas of Bangladesh occur outside of hospitals or health clinics The launch of a mobile birth notification system that alerts health clinics when labor starts and requests a midwife has shown that 89% of births are now taking place in the presence of medically trained professionals In addition, neonatal deaths in Bangladesh comprise more than half of the fatalities for those under the age of five To improve patient awareness, physicians launched a Moibles4Health initiative that provides information such as how to take care of expectant mothers, early warning signs of infant problems, and the benefits of family planning, to name a few1 To improve access to care to those in Japan who live on sparsely-populated islands or in mountainous areas far from major cities, a new program provided a 3G wireless device to rural residents to record and transmit blood pressure, weight, and distance walked through pedometers Physicians monitored each patients data and were able to provide medical recommendations to each individual The outcomes included significant improvements in patient awareness on the importance of proactive healthcare as well as blood pressure management The first International Workshop on Microsystems Technologies for African Health took place in South Africa in September 2011, bringing together diverse experts from all over the world to discuss strategies for developing medical diagnostic solutions Topics included micro-diagnostic technologies set to make a macro impact in rural areas The presentations by micro-engineers, chemists, physicists, and biochemists focused on microsystems devices,
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microfluidics, and lab-on-a-chip technologies suitable for diagnostics in underdeveloped regions Many competing technologies were described that could be, or have been, applied to HIV/AIDS, tuberculosis, or malaria testing These technologies are designed to be complimented by appropriate biochemical assays that detect diseases using biomarkers Many of the technologies presented can be or have the potential to be connected to a cell phone This could provide an ideal platform for use in regions where medical and transport infrastructures are missing, but where the mobile phone network infrastructure is intact and comparable to developed countries The future state of global mHealth will need to focus on ensuring that all nations share in the benefits of the modern day technology and lessons learned from the many programs using mHealth around the world Countries that have had major advancements should share these best practices so that others may benefit and move forward with their mHealth initiatives Several lessons learned include: Where possible, integrate mHealth surveillance projects with existing public health surveillance programs to complement existing systems and provide additional gains in efficiencies Promote partnerships with local/state/national health officials and governments where it is possible to do so Incorporate an evaluation plan for the project from the beginning Include target communities in the design and pilot phases of implementations to ensure feasibility and acceptability in those specific communities
Promote community buy-in leading up to the project, particularly for rural health projects, so that targeted communities have a good understanding of the benefits of participation Surveillance mHealth projects are usually incorporated into regular provision of care, although frequently surveillance activities are performed by community health workers or by public health officials rather than by formal providers This is a model that is gaining some traction in the US, but has still not been replicated on a large scale Most surveillance projects in LMICs are built using low-cost phones and open-source-modifiable software with a centralized dedicated server Technical specifications may not easily translate to high-income contexts but in the case of rural areas with less bandwidth, the technical aspects of these projects may be helpful to share with project implementers
authors
Kelsey Q. Wright
Johns Hopkins Bloomberg School of Public Health International Health-Health Systems, MSPH
Paul Z. Seville, MD
Dr. Norma I. Lopez

refereNCe
1 West D How Mobile Devices Are Transforming Healthcare Issues in Technology Innovation Center for Technology Innovation May 2012; No 18
Utilizing these key strategies developed overseas will help countries move their initiatives forward and provide better overall healthcare to their communities While many of the challenges present throughout the international community are not repeatable in the US, the deployment of resources is certainly repeatable
Copyright 2012 Healthcare Information and Management Systems Society (HIMSS)

The inclusion of an organization name, product or service in this document should not be construed as a HIMSS endorsement of such organization, product or service, nor is the failure to include an organization name, product or service to be construed as disapproval For more information: www.mhimss.org
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