For any Digital Health Solutions aimed at Providers/Physicians being the end users, it should have components of Automation &/or Elimination of existing workflows in place for it to have significant positive Clinical &/or Financial impact. Our industry is set to grow at a record pace when it comes to TME Total Medical Expense and more than 1/3 of it is identified as waste. Today providers spend close to 50% of their weekly hours on non face to face administrative tasks.

As a physician evaluating any new solution for most there are 4 key questions which come to play
1) Does the Solution really work?
2) Will I get paid for using it?
3) Will I get sued for using it?
4) Will it work in my workflows/ office / practice?

Would love to see Digital Health Solutions tackle these challenges in increments to improve provider workflows and experience.

What a great question, and not one that I think is easy to answer. A search of MedEdPORTAL (an open access journal with medical education resources from the AAMC) revealed only one publication in this area, an activity to train NP, PT, and OT students in geriatric telehealth (mededportal.org/publication/10...). Clearly there is a lot of space for innovation and collaboration in figuring out how to teach topics in this area to various health professional trainees.

I will confess that as chief medical resident, I hardly did any teaching in this area. While important, this does not show up on licensing exams or boards, and the evidence base is limited. How do we bridge this gap?

Thanks!, We started our course with a Pilot of 17 students as part of our scholarly inquiry track. So far, so good..

Not yet, however, the burden is on us (the believers) to show results

Dr. Worsham, what examples are you thinking of? We think what were are doing at Lemonaid Health is attempting to do just that - lemonaidhealth.com/

Dr. Liu-- I think your company is a great example of innovation in this area--an app that could let a patient work with a provider to manage a simple condition from their couch or the bus is certainly in demand, especially with younger folks. Patient-facing apps built into EHRs or other telehealth apps provided by other healthcare organizations are allowing for more of this type of simple communication (essentially text messages) for simple issues. Not everyone has figured out a way to pay for this yet, but because it's so convenient, clearly these types of services will become more popular.

What about other apps like fitness trackers, sleep trackers, mood trackers, diet/calorie trackers, GPS-based running apps, etc., in addition to glucose and BP tracking apps? Patients are certainly using these apps and changing their habits based off of them, and they have data for us which while not-perfect can be useful. We have talked a little about this in other questions, but I would love to hear from folks-- do you ever recommend any of these types of apps to your patients? Do you actually make clinical decisions based on the data patients provide?

We find that physicians are wary of these technologies because of the perception of additional work

From discussing digital health technologies with my colleagues, it seems to me as though physicians are not as eager to adopt additional digital health tools as patients; again, as Dr. Dicker said above, this is due to a perception that their workload will increase. The often-cited tool that we have already implemented are patient portal messages, which many providers cite as increasing their workload as they are obligated to respond.

That being said, patient willingness to adopt digital health technologies cannot be generalized in broad strokes. Patients who experience acute issues may or may not engage with tools such as their patient portal or view their electronic medical record, as opposed to those with a chronic condition. Logically, this makes sense, as patients with chronic conditions may be more likely to benefit from utilizing these tools to increase their ability to self-manage their care.

That being said, studies undertaken by our group (in collaboration with folks at the NCI) have found that individuals with multiple chronic conditions (2+) are significantly less likely to engage with their electronic medical record and patient portals. We hypothesized that this may be due to increased complexity of care, fractured care, or the presence of multiple versions of the same tool or portal (i.e., they see providers at different institutions, and each has its own system which does not interact with those of other institutions). Alternatively, these individuals may be older, may not be digital natives or adopters, or may have physical challenges that hinder their ability to use digital tools, and subsequently may not engage with available digital health technologies.

As described in the posts above, people's willingness to adopt health IT seems to depend on the perception of how usable and useful the tools are. Typical EHR/EMRs and PHRs/patient portals are in their infancy, as are attempts to make them interoperable. Systemic time constraints on face-to-face interactions between patients and many physicians, along with administrative workload demands and the added operational costs, are also real obstacles to receptive adoption.

I believe, however, that health IT tools can evolve and mature in positive ways IF guided by critical feedback from clinicians and patients, and if workflows and payment structures change to reduce such time constraints, and if operational cost is minimized. When this happens, next-generation health IT will exist in a more sensible healthcare system and be accepted by most because it will be more usable and useful in: (a) delivering higher value care, (b) engaging and activating patients, and (c) supporting clinical research. Discussions like this have the potential to ignite such positive change.

I agree that the distinction between the two terms is tough to discern as used in dialogue today. Personally, I subscribe to the WHO’s definitions, which state that "telehealth" refers to medical- and health-related support services delivered remotely using computer assistance (education and training, administrative and management services) and that "telemedicine" refers to actual clinical services delivered remotely using similar technology. While I currently use these definitions, I do see these terms merging in the future to the point of being truly interchangeable, with such use becoming less of an argument over semantics.

A complex legal, ethical and clinical issue with shades of grey. Technology stakeholders should NEVER control (or view) PHI, imo; even the brief exposure of PHI at that occurs at HISPs is a problematic (end-to-end encryption sent point-to-point makes more sense). Physicians (and other clinicians) should have access to all PHI relevant to a patient, of course. Nevertheless, from an ethical perspective, patients should be in control of their PHI and be enabled to determine the specific data that can be accessed by particular persons for specific purposes. This assumes the patients are conscious/aware, literate, able to set health goals, understand and evaluate their health situation, and take constructive action if desired; if not, their guardian/health proxy should be in control. As such, all relevant PHI, regardless of the source, should be funneled through the patient’s PHR (and/or with the patient's explicit consent) before being sent to others. While patient control has the risk of withholding data from clinicians that may result in impaired care, it would likely increase patients’ trust and their willingness to engage in care process. If, however, failure to distribute certain PHI to certain recipients poses serious population health risks, patient consent and control should not be required, but patient notification should be.

Data inputs have to be controlled from the standpoint of storage by the developer, “how many varchar can be typed into this field?” However this begs the question of what “type of control” is being questioned, business use, access, authentication?

As a practical note the developer would have modeled, done interviews and requirements analysis to be able to represent the application in a use case describing the business owners in UML to constrain the ownership to those that had the need to know based on business rules of separation of privilege, a concept codified by Hippocrates.

Concept is similar to tissue. A patient who has a biopsy for cancer, that material is the patient’s. They can request the block, slides etc. That single data point, by itself is of little value commercially, when combined with many data points and outcome, then it may have value. The concept for collecting data should be clear as to what it may be used for.

There can be multiple types of data "control." They may include reference to where data are stored, who has access to (receives) them, how they are used, how much value they have (individually and in combination with other data), and whether they are identifiable (able to be associated with the patient's name). So, is there any situation in which a patients' PHI can exchanged with a patient consent (no patient control)?

For example, is it ethical to share de-identified patient data for public health surveillance or clinical research without patient knowledge?

Should clinicians be allowed to share identified PHI with members of the care team without notifying the patient every time a referral or request for information is made?

Should sharing of a few data points that have little value in themselves have the same level of control as multiple meaningful data, e.g., from a complete C-CDA?

Should anyone other than the patient be allowed to sell patient data for commercial purposes?

And what about informal clinical notes and psychotherapy session notes?

As a provider of the technology that alerts notifies and tracks adherence data the powerresides with the patients. We provide
a dashboard to the patient and the patient then determines to share with muliple physicians, their pharmacist and with the option to share with family members. Our role is to provide the digital tools so that the individual can control the data. Our goal to provide atients and physicians the ability to see in real time whats going on with their patients as a group or individually

There’s the obvious problem that control of information is a hard problem due to granularity. This prompts the kind of questions that I hear Stephen asking.

The fact is that information is also consumed on the control plane and there is a strong necessity to simplify; normally done by making systems self healing and run by logical business rules.

All the stakeholders should be able as necessary to navigate these data sets based on a need to know.

The problem that was discovered was that the social aspect of shared knowledge had to be segregated and segmented versus the back channel of information in a community of people that normally work and informally socialize with each other. The Hippocratic oath covered that until it didn’t.

One practical approach developed so far is to tag embedded information with security labels, which can implemented fairly simply with email headers. That is specific to S/MIME.

The extension of security tagging (other than the email example) is being developed in the HL7 security working group.

Thus “patient centric” has a logical access and permissions layer as well as other dimensions that can extend, such as the environment.

Going the other direction, from the general to the particular, the control systems are typically “evolved” and measurable, id est inherent natural homeostasis of multiple smaller systems of which researchers have discovered built in limits, and then corresponding control problems when particular patterns lock in outside of those limits.

At this 20,000 ft level information systems, (and all complex systems) exhibit similar behaviors, in the way that complex climate systems are similar mathematically to other systems, and diseases and disorders in general.

Thus the patient is a strange atttactor of the information in the system (not so much as a computable defined software object, which is how IT regards it, something to be assigned a number and name that is unique).

There are several different scientific and human factors considerations that need to be addressed when determining how best to measure and evaluate digital health tools for clinical use.

Clinical considerations include: 1) The end goal of the tool’s use must be well defined. Is it for treatment or diagnosis of a disease? Does its use drive or inform clinical management?; 2) The health or disease entity which the tool targets should be considered (i.e., is it a critical or serious disease? Is it non-serious? Focused on illness or health?); and 3) Has the tool been validated clinically and analytically? The FDA’s draft guidance on Software as a Medical Device (SaMD) does a really nice job of defining each of these considerations and how they might be addressed: fda.gov/downloads/medicaldevic...

Note that most of these considerations require quantitative evaluation methods.

While the clinical considerations are of great importance, a digital health tool is, in my opinion, relatively useless unless it is designed with the target audience in mind. Evaluation of a digital health tool for clinical use must also ensure that the interfaces are provider-friendly (that is, that they provide the right data at the right time to the right clinician in an easily digestible manner) and patient/consumer/user-friendly (is it easily accessible to the individual who needs to use it on a regular basis, and is the interface intuitive enough that using the tool is easy and fast). Evaluation of these more subjective than some of the clinical evaluation methods, and may require mixed methods, such as surveys (quantitative or qualitative), interviews (qualitative), or focus groups (qualitative).

Evaluating the digital tool as a whole is key—just because you build it, doesn’t mean that they will use it.

Patients (and providers) have become very accustomed to and accepting of the use of videoconferencing technologies for personal interactive communications. When secure videoconferencing is (appropriately) applied to healthcare, supported by remote examination tools and monitoring devices that comport with the standards of in-person care, and when that digitally acquired data is integrated seamlessly into the patient's electronic medical record, physician satisfaction (along with efficiencies) should be expected to improve.

Recognizing the value of improved access to high quality care, we have experienced an exponential increase in requests to provide telehealth services.

One caveat - payment models must also align with the delivery methods.

Sadly, there is little room for further decline in physician satisfaction. If healthcare continues to be built around what Geisinger's former CEO, Glenn Steele aptly described as "perverse financial incentivization" then what little impact digital health incorporation may have on healthcare will be unlikely to influence professional satisfaction positively. On the other hand, by completely re-imagining new, patient-centric systems of care that take advantage of what digital technologies can make possible then the role of the physician can revert back to one that rewards spending time with their patients as an expert diagnostician and educator.

We have come a long way when it comes to measuring and reacting to patient satisfaction vs todays environment which is evolving around patient engagement and experience journey in healthcare. Unfortunately when it comes to physician satisfaction we are going through the same journey and Burnout is at its highest which makes digital health implementation very challenging if not done with positive provider experience in mind. I believe as long as we work on enabling provider and patients by giving them time back in their interactions to create more face to face value, digital health stands a great chance improving provider experience and satisfaction over time. I do agree that we are far from there as today satisfaction is probably at the lowest amongst the care provider and we have an uphill battle in front of us.

Digital health has the potential to engage patients with chronic disease to manage their disease. If digital health tools help them to learn about the disease and encourage favorable behavior changes, physicians might feel even more satisfaction.

Improved satisfaction should be the result of an efficient digital experience where:
1) Clinical facts, findings, observations, assessments, care needs and planning are patient-centered and readily captured in-stream - typically by the clinician.
2) Other items - e.g., quality, performance, administrative, operational and cost parameters and value-based determinants - are captured out-of-stream, by automated processes and/or non-clinician data entry.
3) Clinician data review is algorithmically optimized to be: timely, concise, relevant, readily comprehensible and immediately actionable.
4) User experience is tailored/optimized to the service, specialty and individual, combining visual presentation, keyed input, pointing devices, with voice commands and input.
5) A proper balance is maintained between structured (coded) entry and capture of simple unstructured narrative.
6) Prompts, notifications and alerts are evident but not obtrusive.
7) True interoperability is achieved, evident to each end user, and includes these vital characteristics...
8) Data from multiple feeds is visually integrated and readily traceable to the source.
9) Data is verifiably accurate, and can be shown as unaltered from source content.
10) Data retains, and can be shown in, full clinical context.
11) Data attribution is evident: including provenance, authorship (and credentials), purpose of capture.
12) Data is consistent, easily compared and trended.
13) Data relationships are clear and correlated (as between): encounters, chronology, complaints, symptoms, diagnoses, problems, allergies, assessments, clinical decisions, orders, diagnostics, therapies, cares, results, medications, interventions, observations, care plans...
14) Data is clearly presented as past (then), present (now) or future (anticipated).
15) Who did what when, where and why is unambiguous.

Great question. What we have documented is that there are basically two factors. The data has to be presented in a simple format. Examle our takemedsnow.com service you get an excel
spreadsheet that provides physicians with a simple dashboard .
It the patient is taking their medication as prescribe the physician will see a green indicator and you can look at 50 patients at a time. This takes seconds and you can review patients that are not compliant and send them a message. The second factor seems to the age of the physicians. Physicians near retirement are less likely to use the new digital tools available to them. This quick look in we believe saves time and focus the attention on those
not using the latest tools. Which are free to physicians.

Chronic disease management carries vast amount of challenges associated with it when it comes to achieving outcomes or targets set forth to define success. In an industry which is heavily dependent on sick care model it becomes very crucial for us to understand Digital Health Implementations and how it can help &/or hinder the goals we are trying to achieve or business cases they are designed to deliver.
Clinical goals are fairly well defined but we have yet to translate those goals in to set of meaningful Individualized/personalized set of goals which for the most part drives behavioral modifications. For a Diabetes management as much as we as clinicians want A1c to be at certain goal, we have seen day in and day out that we carry a tremendous opportunity to link those clinical goals to a personalized care plan and a milestone for particular patient in front of us to drive behavioral changes needed to compliment clinical management we are prescribing.
Digital Health tools are very well situated to just do that. Whether it is done by virtual coach setting nutritional and physical fitness framework or IoT based data driven insights to make better shared decision making to improve outcomes, we as healthcare provider do have the ability to enable positive outcomes and help achieve personalized and clinical goals.
Digital Consumer today behaves totally differently when traveling and shopping and when they get in side our exam room they suddenly do not forget those behaviors. In fact we as providers are digital consumers as well,so why are we not embracing digital health tools and solutions when it comes to providing care advices? Perhaps we are still waiting for evidence based guidelines to make us change our methods of clinical care and as we do see more and more data driven policies and precision medicine becoming widespread it should help us leverage these solutions better.

A good starting point, and stealing from Jeff Bezos, would be to design a system of chronic condition management based on an obsessive costumer focus. Hypertension and diabetes are 2 of the most common primary diagnoses for a primary care physician visit in the US. But why? Do we need to go to college for 4 years, med school for another 4, and then at least 3 years of residency to follow a guideline-based algorithms? If we were costumer (patient) focused I think we would offer those who wish an effective solution that allows for digital home tracking with communications as a primary means of care.
Richard Thaler's, recent Nobel prize winner in Economics, mantra is "If you want to get people to do something, make it easy." We have done the opposite for individuals with chronic conditions. Re-imaging chronic condition management that takes advantage of digital technologies is a first step towards making it easier, and with that, more effective.

Reimbursement models need to be aligned to outcomes that are driven by these tools and technologies. Patients also need to be invested to engage, take responsibility, and to do their part so that the clinician + patient can achieve aligned goals together.

Agree!

Traditional models of care assume a paternalistic model of care; that is, patients are passive actors in the patient-provider interaction. In such a system, information flow is unidirectional, from provider to patient, and behavior change discussions take place only during the office visit. Such interactions take away a patient’s feelings of ownership and power over their own course of treatment for their chronic disease. With digital health tools, patients implementing behavior changes can be more vocal and active in their care, as they are often able to generate their own health data and share these with their provider. This flips the script on the traditional model of care, as information flow becomes bidirectional.

Furthermore, providers may simply state “lose weight” or “exercise more” without providing any resources to support the prescribed behavior change. Patients may flounder if they do not know how to implement these lifestyle changes strategically; in turn, this may reduce their feelings of self-efficacy with regard to their ability to take care of their own health. Digital health tools put the chronic disease treatment process back into the hands of the patient, and may help them better manage their behaviors on a day-to-day basis. Additionally, many tools provide reminders or specific tips to increase accountability and adherence to the behavioral change. This has been shown to lead to sustained behavioral change and increased feelings of self-efficacy (“empowerment”) in engaging meaningfully in their own care. This is critical for those with chronic conditions who have to feel that they can manage their treatment and lifestyle changes long-term to be successful.

give patients choices: games for health, social support, graphics, analytics, music, meetings - should all be available for improving health// quality of life

Partnering with patients as equal collaborators to co-create solutions on how to design digital health interventions that allow users to be active "co-designers" of the solutions they use for their condition...

Digital Health tools come in variety of flavors and for the most part what we have seen works most effective is an ongoing engagement and coaching strategy or collaboration to educate and empower self management of chronic conditions. Patients are already spending a lot of time on internet seeking medical or health information today. What digital health tools provide is ongoing ability to be connected to care delivery systems and data driven insights to help filter out the noise and hopefully stay focused on signaling for ongoing behavioral change.

Our data shows that adherence will only go up if the patient is engaged in the process. However, patients don't always believe that their physician is engaged in their wellness beyond the 10 - 15 minute session review. Our patients are not passive by nature because their have signed up for the service. Yet, 60,000 people died last year beause in most cases forgot to take or double up on their medication. A digital tool must embrace the patient, their Physician, Pharmacists and family members. Active support is the key to giving patients Peace of Mind. If the Pharmacists is seeing that the patient is compliant over 90% of the time for example then maybe sending a store coupon would be a nice reward. The ability to have your medical records & medication tasks with you as you travel any where in the world is where we
need to get to through digital tools