Does the solution provide the right information to the right people in the right formats through the right channels at the right point(s) in the workflow (the Clinical Decision Support (CDS) 5 Rights). If not, can it be adapted so that it does? If you think about one of the key challenges of digital solutions, interoperability, vendors often skirt this question to highlight all of the amazing features about their app, for example, but if the information is siloed on a smartphone or required separate sign-on from the care team, then it's missed hitting all of the CDS 5 Rights.
Here is a great article on this topic: nam.edu/wp-content/uploads/201...
Organizations should take a longer and more holistic view in their their procurement questions/criteria for vendors. Cost and being "best in breed" for a select use case is really a siloed/narrow approach to deciding on the right vendors/solutions. Better is to consider dimensions such as life-cycle costs, interoperability with other systems currently in place or to purchase as a suite of products, breadth of use cases, usability, effect on productivity, etc.
What a great resource you provided! I downloaded to distribute and have our team read.
Patients plan a huge role in successful adoption of digital health solutions, but they have to know about it first, and feel that they will derive value from using it. A thoughtful approach around patient identification is imperative. You need to avoid scenarios where the "ask" to the patient to adopt a new technology is clearly divorced from other more pressing issues in their life/health (ie a diabetes app when the patient has a new cancer diagnosis). You also need to help the patient understand how this new technology benefits THEM, not just their doctor or the health system. Cascading the knowledge and ability for local care teams/providers to articulate that value proposition to patients is a clear challenge in scaling these tools. Ensuing the metrics patients care about (Does this save me time? Does this help reduce my cost? Do I like using this tool?) are measured with each tool deployment and that this is shared with clinicians can lead to greater confidence. Patient interviews and stories collected and shared with their approval can be incredibly powerful drivers for both patient facing marketing, but also internal clinician buy in.
It is ALL about the patients since they are being asked to assist providers in their care. Monitoring asthma or COPD patients with metered-dose inhalers does not require much effort from patients since the sensors are on the MDIs and activated by compressing the canister. Using IVR technology to assess asthma control requires patients to enter responses from their phone at a specific time at the convenience of the patient. Since adherence monitoring is primarily for patients with severe disease (frequent emergency care and hospitalization), it is not too difficult for providers to suggest that the monitoring will be helpful in improving asthma control and QoL. Most patients appreciate the supplemental care and will welcome closer contact with the clinician team. A few will not accept believing that the treatment is too intrusive. However it is not unusual that some of these individuals will reconsider if severe symptoms persist.
It definitely depends upon the technology and which stakeholder it impacts.
If a provider, it better save time- not add to it. If the UX isn't designed for a three year old to be able to run it, find another solution. Great design should lead to easy. Not complex and constrained to a process of check boxes...
If a patient, it's not one size fits all.
Ask how they'd like to engage with all technologies to identify preferences. The tech solution should accommodate the patient. Not our practice or ourselves.
For staff, it is tricky. They are the bridge between patient and provider interactions. If the tech adds or changes work for them, but significantly improves the patient/provider experience, I'd find it worthy of implementation.
Stakeholders need to be involved from the start. Invest enough time listening to their concerns on the front end. Then, address them as they come up in the implementation of the tech so they know they were heard. Often, they come up with a better solution along the way.
Using the Design Thinking (DT) processes to guide the development of health IT apps is a way build a solution with a good UX that addresses workflows and user needs based on going user feedback. I recently posted and article to LinkedIn (below) about how DT can be applied to behavioral health app development.
linkedin.com/pulse/design-thin...
I think many people would agree that digital solutions should accommodate the patient. However, in the instances where that does add work for the care team but is in the best interest of the patient; how do you get them on board?
Digital monitoring is designed to directly or indirectly identify disease states that need to be under better control and prevent further exacerbation. Once identified, clinicians will be able to "intervene early" and prevent the development of disease complications. The net result could be a healthier patient with improved quality of life.
Clinician monitoring interventions will take extra time at a specific cost which were not required if the patient had been doing well. However intervening early may avoid emergency care or hospitalization at significantly greater cost. Reimbursement models developed by Medicare (ACOs and Merit-based Incentive Payment System- MIPS) focus on prevention and value of care and less so on fee-for-service.
Providers can take advantage of health prevention via digital health and can be reimbursed for their efforts.
If digital solutions are expected to make improvements, how much willingness is there to enter into a risk-based contract on those improvement gains?
Ive found many health tech companies very progressive in pricing models. They understand the new costs to a practice offer a significant barrier to entry. Let alone change in workflows. As such, many companies only fees are a part of the shared savings. Nobody wants to spend significant resources just to connect to the tech solution.
I think it's important to be balanced in how much value the vendor can help in supporting a health system deployment. However, as teams have needs and reach out to vendors for basic support- could be educational materials, demos, data- responsiveness is important. Additional partnerships around deployment could be value added, but it is important that that is done closely and carefully so that clinical teams have a clear understanding of who owns which piece, and how does this vendor help us as the care team solve the patient facing issue. I think the other piece is taking feedback from clinicians and health system implementers to heart, and using that feedback in a timely way to help improve their product.
Providing adherence digital health solutions goes beyond the technology. The technology allows: 1) diagnosing adherence status and 2) recommending clinical decision support strategies to overcome patient barriers. Providers need to be trained in communication skills (motivational interviewing and shared-decision making) to enhance the effectiveness of the delivery of the intervention(s). Vendors can assist in implementation and adoption of the comprehensive adherence digital health package by providing communication skills training which can be acquired in person and/or online.
Thanks you Dr. Weinstein for highlighting that support goes beyond just device or system support. It's so important that the care team has the resources to utilize the technology as a supplementary tool and not a solution in it of itself.
Surveying physicians pre- and post- implementation, and then using that feedback to improve the digital health solution, can also provide value. We recently committed to using this survey with our physician clients and making it available to anyone else who wants to use it. To download the survey, visit: marketing.geneia.com/2018/joy-...
You can also view the results from our national survey on physician satisfaction at:
geneia.com/news-events/press-r...
As with any change, it's important to try to involve people in the decisions that affect their work if you want them to be engaged. So one best practice would be engaging front line care team members in designing how the technology will be implemented and their subsequent role in working with it. You also want to identify clinicians who want to try this out, and who can connect to the value it could provide them or patients. Forcing a square peg in a round hole can be damaging all around so if certain specialties or sites don't want to be involved in the early deployment of a new technology it can be better to move on vs. force the issue.
Another is ensuring clear accountability and expectations up front. What are the goals, what does the ramp up period look like and what are we basing expectations off of? If those things are determined together with the operational units affected, then routine iterative design and accountability can be managed more smoothly.
I also think with anything new- it's important to have thoughtful planning, but also commit to implementing with an iterative PDSA approach instead of "perfection". As bumps in the road come up, which they always do, the care team can then be engaged along the way in the decisions and process to move forward.
And lastly, as I mentioned above the actual "do-ers" need to be involved in the design, and the executive sponsors need to be kept informed and asked to serve in the role of breaking down barriers. Role definition clarity can be very important if you run into barriers between work units that needs to be escalated to sponsors, or on the flip side if you have sponsors making operational decisions with their (usually) inherently more limited understanding of impact on day to day workflows.
In addition to ensuring different roles and viewpoints are represented throughout the implementation in terms of the expanded care team, I would offer that it's important also to be aware of the broader group of stakeholders in the project - including both those who affect and who will be affected by the solution. These range from leadership, funders, technical experts, and vendors on the one end to care teams and patients on the other. Consider their level of power/influence and interest/engagement in the change and tailor training, communication, and intervals of engagement accordingly. Consider patient-centered design strategies as well.
One training technique that we've found effective in our projects is to have care team members test the digital solution as if they were a patient; this experience often elicits opportunities for improvement prior to rolling out to actual patients and enables care team members to relate first-hand to what they may be asking of others.
The Conference Room Pilot works well for training team members about a new digital health solution. The concept is to mimic the real-world implementation of a solution, in a conference room, instead of in a live hospital environment. This creates a bit of a low-budget 'simulation center' for the solution. The conference room can simulate a patient room, with a computer, 'patient' etc all being simulated within its confines. You can then train key team members in that simulated environment multiple times until the process becomes sticky.
Very important. Single Sign on is helpful. Integrating solutions into the EHR helps reducing double or triple entry, streamlined workflows and creates a better experience for the provider and patient. It can be costly and time consuming to integrate, so prioritization of digital health solutions is key. Often a Proof of Concept can be conducted (30-60 days) without integrating, to ensure that there is feasibility, impact and user engagement. However, even PoCs should be conducted if there is organizational alignment around the potential for the solution to be eventually integrated into permanent workflows.
Integration into the EHR is certainly important in many ways. It is ideal if information can flow both ways - including the capability to draw information from the EHR and also to push streamlined and relevant information back into the system. Having to log onto a separate system or do any type of double entry is a big barrier for adoption for any digital health solution. I would also emphasize the importance of gaining an early understanding of system integration needs in a broader sense. From an IT perspective, integration with billing or scheduling systems (if not part of an EHR enterprise system), population health, or reporting systems can be important. And, as technology is often an enabling tool for supporting the work of interdisciplinary care teams, it is important to integrate with on-the-ground workflows. In my experience, doing process mapping together with key users and stakeholders has been a good way to understand the current and ideal workflows, and to pinpoint all the intersecting systems which would need to be integrated.
If the EHR is serving as the mainline for patient data, all digital health solutions need to be able to integrate safely and seamlessly with the facilities EHR. EHR companies are more often providing a more open source environment for other digital health solutions, but I believe more could still be done to better serve both the patient and the provider.
Thank you for mentioning short-term Proof of Concept Omkar. In the development of the Digital Health Implementation Playbook, we heard this was a critical link between full scale integration and new technology. Do you have any other tips on how to ensure clinical operability while staying open-minded to new innovation?
The biggest frustration I've experienced using or seeking healthcare for myself or my loved one, is to have to be the sherpa of everything about me or them: In addition to my entire medical story (aka detailed medical history), I have to know / keep track of / carry with me all my medical data, including accurate up-to-date medication lists (Rx and OTC), test results, provider communication, contact information, and so on.
To feel sick then admit it's time to engage with "the system" of care - whether in the practice, urgent care, emergency department or upon admission - patients have to essentially brace ourselves to recite all the pertinent answers to the questions we'll be asked by all those on the front line, just to access the actual care.
I get that everyone is just trying to do their job, but after that 1st encounter, patients typically have to do it over, and over, and over again, especially with our medication list. As a medical mom case manager I hacked shortcuts for myself: while waiting (because, Healthcare), I'd hand-copy the same dated list with Jameson's DOB, MR#, Allergies, etc. onto multiple colored index cards) so I could hand one to each of the next 3-4 people I'd encounter.
Repeat this over even one admission (or 60), for yourself or a loved one (or 4) and it's exhausting. If we could, together, knock down this barrier, for us as patients and for all clinicians across the continuum from hospital to primary care, from home to school nurse, specialty office, and beyond, what a game-changer it would be.
As my son wrote in a soon-to-be published essay about seeking mental health care, the act of seeking care alone when you don't feel well is already hard. Having to repeat extensive details, as the system seems to require, every single time, is like advanced trigonometry. To quote all the patients before us, there has got to be a better way, and I think that Way is Integration of the EHR, across the entire continuum of care.
Critical!
Lack of integration of the fragmented elements of healthcare consumption is the biggest impediment to driving out waste and increasing value.
Thank you so much for providing the perspective of the patient in these situations and demonstrating how lack of integration creates challenges and barriers from all angles!
One strategy that we are very excited about it is the concept around having one platform that integrates many digital therapeutics that could be prescribed for a patient. This tool (Xealth) can be used to have a much more scaled integration process from the health system perspective such that the new tools being prescribed for patients integrates with Xealth, which is already integrated into our EHR. Point of care decision support can be used to remind providers of the tool(s) in specifically targeted populations and once prescribed, the data from the digital tool shows seamlessly in the patients chart in the EHR.
Integration is critical as others have eluded to when considering scaling beyond small scale, intentional and motivated pilot teams.
