What makes a digital health product worth the investment?

 

She needed a blood transfusion, and fast.

When Alice Mutimiutugye, 23, checked into the hospital in Nyange, Rwanda, she had lost a lot of blood due to complications from malaria. None was available at the remote hospital. She was transferred to a second hospital where doctors used an app to order blood.

Within three hours, it was delivered by drone.

“At first when I told people it’s a drone that saved my life, they were not convinced,” she said. “After seeing the site with my own eyes, I had the facts that I needed. Without the blood, I wouldn’t have made it.”

Alice MutimiutugyeThe transfusion was made possible by a company called Zipline. Through the company’s app, doctors can place on-demand orders for 148 different vaccines, blood products, and medications, which Zipline delivers by drone.

Like WELL, Zipline participated in the Techstars Accelerator. Founded in 2014, Zipline’s mission is to provide instant access to vital medical supplies to everyone on the planet.

It’s a lofty ambition. But does it work?

That question is at the heart of a 2019 World Health Organization recommendations on Digital Interventions for Health System Strengthening. The purpose of the report is to equip health policy-makers and other stakeholders, such as healthcare systems, with recommendations and implementation considerations for making informed investments into digital health interventions.

“Amid the heightened interest, digital health has also been characterized by implementations rolled out in the absence of a careful examination of the evidence base on benefits and harms,” the report’s authors stated.

In addition to its thorough discussion of the topic and official recommendations, the report offered a brief set of five criteria for looking at digital health. Here’s our take on how to put these to work in your organization.

#1 Effectiveness

The most critical question when you’re looking at any technology is, “Does it work?” What are the key outcomes and how certain are they? Also, what kinds of undesirable effects are likely?

“In the world of startups, there is often a lot of hype. There’s a lot of overpromise and under-delivery,” says John Halamka, executive director of the Health Technology Exploration Center at Beth Israel Deaconess Medical Center.

He says you have to watch out for companies who say they “have a product that will.”

“Either you have a product that does or you will have a product that will. You can’t have a product now that will,” he says. “Don’t buy the PowerPoint of brochureware. Buy results based on personal experience of going deep with companies and maybe even do some co-development.”

As for Zipline, it has increased the use of rare and specialized blood products by 175% and reduced waste and spoilage by over 95% — a real problem for hospitals in both developed and developing nations. Additionally, a report commissioned by the government of Rwanda found that several hospitals served by Zipline eliminated maternal deaths due to postpartum hemorrhage altogether.

#2 Acceptability

Second, it’s important to ask whether the intervention is acceptable to clients and to health workers. Both matter. And both need to be measured.

For example, stereotypes persist that digital health interventions, such as texting, won’t be acceptable to seniors. But research shows texting is effective at engaging older adults in everything from appointment reminders to medication management.

For health workers, the question of acceptability is equally important. One of the most significant changes in healthcare in the US in the last decade has been widespread implementation of electronic medical records. While it might be an effective solution, it isn’t always acceptable to the people tasked with implementing it. More than half of doctors pointed to the EHR and other IT tools as the cause of their burnout, according to a KLAS – Arch Collaborative report in 2019.

#3 Feasibility

Whether you’re launching drones into remove villages in East Africa or deploying artificial intelligence robots to deliver minimally invasive heart therapy, if it’s not feasible it’s not going to get off the ground.

The WHO guidelines advise considering the resources, infrastructure, and training requirements to determine the feasibility of implementing an intervention.

At WELL, those factors are a critical component of our integration process and we work with healthcare systems to identify the lift required from their technology departments and end users.

#4 Resource use

This criterion addressed the question of what resources are associated with the intervention and whether they’re cost-effective. The WHO commission emphasized the importance of ensuring investment in digital technologies doesn’t inappropriately divert resources from alternative, non-digital approaches.

For example, telehealth is often seen as a way to reduce healthcare spending. But it doesn’t always work that way. A study published in the journal Health Affairs in 2017 found that patients sought telehealth appointments for minor ailments that they otherwise would not have seen a doctor for, thus increasing healthcare spending. On the other hand, telehealth improves access to care.

“In all of healthcare logistics, you’re always trading off waste against access,” said Zipline founder and CEO Keller Rinaudo in a TED Talk in 2017.

#5 Gender, equity, and rights

This final criterion encompassed evidence or considerations on whether or not an intervention would reduce health inequities.

“To improve health and reduce health inequalities, rigorous evaluation of eHealth is necessary to generate evidence and promote the appropriate integration and use of technologies,” the WHO Bellagio eHealth Evaluation Group observed.

Reducing inequalities does not necessarily involve philanthropy. Zipline is a for-profit company and now delivers more than 65% of Rwanda’s blood supply outside of the capital, Kigali, reducing health inequalities for rural Rwandans.

WELL is a validated patient communication platform

At WELL, we have a product that does. And we have the case studies to prove it. WELL has proven effectiveness, acceptability, feasibility, resource use, and ability to help reduce health disparities through better communication. We look forward to partnering with your healthcare system to deliver meaningful results. ♥

Why patients don’t like portals…and what to do about it

 

Some doctors love them. Most patients don’t.

According to Taya Irizarry, a strategy consultant at Highmark Health who has conducted research on portals, “the only reason that patient portals got a kickoff in the beginning was because they were part of HITECH’s meaningful use criteria.” Portals were seen as a way to support patient engagement, which theoretically might lead to better health outcomes.

Theoretically. As yet, Irizarry said, there’s little concrete evidence that patient portal use leads to better outcomes.

“Just because an organization has a portal does not guarantee patient engagement. Just because you build it, it doesn’t mean that they will come,” she explained. “The real crux of people using patient portals is that they have to see them as being valuable.”

The patient perspective

It doesn’t seem like patients see the value. A new, large-scale study found that, even among patients who had health insurance and who had been to see a doctor in the past year, 63% had not used a portal during that time.

Only about 60% of the study’s 2,300 participants were even offered the option, but a significant number of non-users had other reasons for avoiding their portals. Both in terms of patient preferences and physician communication, “we’ve got some real challenges there,” said Denise Anthony, a professor of health management and policy at the University of Michigan and lead author of the study.

This particular research uncovered three main reasons that patients avoided portal use. Some said that they preferred to speak to their doctor directly. Others cited concerns about privacy and security. Another group felt that accessing the portal was a technological challenge.

While you might expect that last group to be primarily made up of older people, Anthony said that wasn’t the case. No one age, ethnic, or socioeconomic group was particularly likely to cite technological problems as a barrier keeping them away from patient portals.

The problem with portals

People may not actually be that technologically illiterate. The problem may lie with portals themselves.

“They’re big, they’re heavy, they’re full of a bunch of medical jargon, they’re hard to use,” Irizarry said, explaining that patients are often overwhelmed by the sheer amount of medical information available in a traditional portal.

According to Irizarry, that has a lot to do with the way that the HITECH act measures patient engagement with the portal. “There’s no measure of how good the patient portal is, no measure for quality, no measure of utilization rate,” she said. “It’s just ‘have people signed onto the patient portal?’”

So what can healthcare organizations—and everyone else—do?

First of all, Anthony said, doctors have to address patient concerns head-on. Providers can assure their patients that portals have excellent security and privacy measures in place, and make clear that “this is not going to impede their relationship with their provider; it’s expected to enhance that.”

Brochures and other educational materials need to tell not just how to use a portal—in step-by-step, jargon-free language—but why. Explaining that a portal can be used for both communication and health management, and helping patients imagine how they personally might use the tool, is a great beginning.

Both Anthony and Irizarry suggested having a staff member available to walk patients through the portal setup. Especially for “an older population who doesn’t have a college education, that might be really useful,” Anthony said.

Increasing the value

But portals themselves need some work. “The original idea was, ‘the more information, the better,’” Irizarry said. “There’s a long sidebar, with ten different links to things. So you click on laboratory results, and it’s every lab result you’ve ever had. There are test results, with numbers that you may or may not understand.”

Patients still want that information, said Pamela Kallmerten, a clinical associate professor at the University of New Hampshire. “They just don’t want the actual provider’s office notes, with medical jargon and that kind of thing,” she said. “They would rather have an office visit summary. They want embedded links, so they can click on a lab result and find out what [a specific term] means. Information in its pure form is not patient-friendly.

In addition, there’s little support when something goes wrong: patients who lose their passwords or have technical difficulties need some assistance. Education can help there, Kallmerten added: in one study she conducted, a patient even suggested offering a community class on portal use and troubleshooting.

That’s also an area where vendors can help: “Vendors could develop some kind of embedded link with a service, where the patient could enter a live chat room,” she suggested.

Even if there’s a lack of evidence to support specific outcomes, Kallmerten said, portals are still an important way to engage patients in their care. “It’s the opportunity to not only share information but to enhance communication with the provider,” she said. “You have more of a conversation, so you can come up with a shared decision.” ♥

See how Cedars-Sinai increased patient enrollment in MyChart by 19% using WELL

Communication is more important than ever in a value-based care system

 

You may love it or hate it. You may still be fuzzy on what it actually means. But there’s no question that value-based care plays a growing role in the healthcare industry.

Rangaraj Ramanujam is a professor of Management at Vanderbilt University, where he studies the effect of provider communication on patient safety. “Value, plain and simple, is patient outcomes per dollar spent,” he said.

There’s reason to embrace the concept. A brand-new report from Humana found that patients in a value-based care setting were more likely to have preventative screenings, manage chronic conditions, and adhere to medication regimes. They were also less likely to visit the emergency room or be admitted to the hospital.

Humana’s report is well in keeping with the main goal of value-based healthcare: to ensure that healthcare providers are paid for the quality of the care their patients receive, rather than the volume of the medical services they provide.

Finding the “value” in value-based care

But what constitutes high-quality care, and who decides? It’s a complex question, but according to Ramanujam and to Denise Kennedy, a clinical assistant professor at Arizona State University’s College of Health Solutions, patients are an increasingly important part of how “value” is determined. “Satisfaction surveying has been part of health care for many years, but today it’s taken on even greater importance,” Kennedy said. “First and foremost, we measure patient satisfaction to understand and improve the overall experience.  It’s the right thing to do for our patients. Secondly, in value-based payment models, patient satisfaction data impact an organization’s revenue.”


How are we delivering on value? It’s through people. And if that’s getting lost, any pursuit of value is not going to be sustainable.

— Tim Vogus
Professor of Management, Vanderbilt University


For example, the Centers for Medicare and Medicaid Services’ (CMS) Hospital Value-Based Purchasing Program, which emerged out of the Affordable Care Act, is designed to improve healthcare quality and the patient experience. The reimbursement a hospital receives from CMS  depends in part on its scores on the best-known patient satisfaction survey, the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS). “One goal of the Affordable Care Act was to create a more consumer-driven healthcare purchasing experience,” Kennedy said. To that end, she explained, CMS has made hospitals’ patient satisfaction scores—along with mortality and infection rates, and a number of other quality measures—publicly available to patients. “All of that information, as well as paying more out of your own pocket, helps you as a consumer make better healthcare decisions and spend your dollars more wisely. The end result, hopefully, is to provide higher quality care at a lower cost.”

Communication’s role

But what, exactly, will make for satisfying patient experiences? Ramanujam says that healthcare providers often focus their efforts incorrectly. “Doctors think patients are going to be more satisfied if the process is efficient. And yet when you talk to patients, one of their expectations is, ‘We would rather spend more time with the provider, talking about our condition and learning more about it,’” he said. “It seems like it’s about time, but it’s really about communication.”

And studies have repeatedly shown that good communication—from doctors and other medical staff—is vital to patient satisfaction. Effective communication even leads to better patient outcomes, a major feature of value-based care evaluations.

While traditional research has focused primarily on doctor-patient communication, Kennedy pointed out that responsiveness and empathy from non-clinical staff—mainstays in customer service—are particularly important in stressful healthcare settings. “Staff who work in housekeeping or appointment scheduling also are on the front line interacting with patients. They have many opportunities to connect, improve the overall patient experience, and impact the financial health of the organization long-term,” she said.

In addition, a 2016 Accenture report found that 51% of patients would switch healthcare providers to receive great customer service. And a 2016 study found that 96% of online patient complaints are related to quality of service, rather than medical care. (53% of those, the largest category of complaint, were about communications issues.)

Putting it all together

“How are we delivering on value? It’s through people,” said Tim Vogus, a professor of Management at Vanderbilt who studies the importance of compassionate behavior—towards both patients and staff—in healthcare organizations. “And if that’s getting lost, any pursuit of value is not going to be sustainable.”

We may understand that patient satisfaction figures into the complex calculation of value, but that doesn’t mean that we’re working to satisfy patients in the most efficient ways. Patients want to be healthy, of course, but they also want to be heard and understood. They want to be treated with courtesy and attention. And they want clear, empathic communication from their healthcare organizations. “It’s not necessarily more attention than we should have been paying all along,” Vogus said. “If you want to deliver high-quality care, it was always essential.”

 

Patient experience vs. customer experience: making the most of healthcare’s consumerization

 

Ask Denise Kennedy and she’ll tell you: healthcare is a lot like any other service. “When customers pay more for anything, regardless of what they’re buying, they expect more,” said the clinical assistant professor at Arizona State University’s College of Health Solutions. “They expect better quality, and they expect better service.”

Insurance companies are restructuring the way benefits work, increasing deductibles and other out-of-pocket costs. That means patients are increasingly paying more for their medical care, rather than insurers. And as this happens, it’s only logical that patients begin to look for the kinds of customer experiences they get in other industries.

“Doctors and clinicians look at medicine as a science. I believe they need to start seeing it as part of the hospitality industry,” said Ron Harman King, CEO of the digital healthcare marketing and management consulting firm Vanguard Communications. “Why can’t we borrow from other industries? Why shouldn’t [checking in at the doctor’s office] be more like checking into a hotel reception?”

What does a patient experience?

But as we move towards a more consumerized system, we need to think about exactly what it is that we’re making more consumer-friendly. We tend to think about “patient experience,” but the truth is that a patient’s journey is much longer than that few minutes spent in an exam room.

Think through the logistics involved that both lead up to and follow those few minutes. There’s scouring provider lists and review websites to find a doctor. Playing phone tag. Scheduling an appointment. Arriving fifteen minutes early to fill out the same old paperwork again. Waiting for the doctor, who’s running late. Unexpected charges and repeated calls from the billing department.

And that’s assuming that a patient is basically healthy.

The fact is that patient experience—the actual care patients receive from doctors—isn’t really the problem. It’s all that other stuff—let’s call it the “customer experience”—that most needs work.

Patients as customers

In 2016, Vanguard studied nearly 35,000 online patient reviews and found that 96% of patient complaints centered around customer service, not quality of care.

Healthcare organizations, focused on greater efficiency and cost control, can make the mistake of seeing extraordinary customer service as a luxury they can’t afford, Kennedy explained. “I teach this to my students to prepare them for the workforce,” she said. “If you’re hiring people, these things are not frills: you need to demonstrate to us that you’re going to perform at a level that’s going to help us communicate the brand, and live up to the brand.”

And good communication is really at the root of the customer experience. In that Vanguard study, 53% of those complaints, the largest category, were about poor communication. It’s often overlooked, even when healthcare organizations do focus on changes to the patient journey. To give just one example, some medical practices are Ubering their patients to the doctor’s office in an attempt to cut down on no-shows, but they’re not asking their patients why it’s tough to get to their appointments. (Evidence suggests that the primary reasons for missing an appointment are based on emotions or comprehension, not logistics.) Even a simple question about an appointment or medical concern requires a complicated call into the office—often with a significant period spent on hold.


Whether it’s customer satisfaction or use of information technology, healthcare has tended to lag behind, and then we learn from other industries.

— Denise Kennedy
Clinical Assistant Professor, Arizona State University


Bringing customer service to healthcare

“Whether it’s customer satisfaction or use of information technology, healthcare has tended to lag behind, and then we learn from other industries,” Kennedy said. Front-office staff members need to learn early on in their careers that “you set the expectations for the kind of experience a patient is going to get in the doctor’s office before they even set foot in the door.”

Beginning with that first phone call, we need to ensure that the process is seamless. Patients need to interact with live office staff during business hours, receive accurate appointment reminders (but not a barrage of them), and have a secure and convenient way to ask basic questions about their visits, physician instructions, and follow-up care.

And increasingly, we have the ability to influence a patient’s opinion before they ever pick up the phone. The satisfaction (or lack thereof) that people feel when they leave the doctor’s office is increasingly communicated online, and a recent survey found that 70% of Americans take those reviews into account when choosing a doctor. Says King, “The Internet has given patients a public voice to speak about their care.”

How millennials view healthcare differently…and what to do about it

 

First they killed diamonds. Then they went after nightlife. Now, they’ve started on healthcare. We’re talking, of course, about millennials—poised to become the largest and arguably the most influential generation alive today.

According to Dhaval Dave, a professor of economics at Bentley University, they’re more connected than previous generations, more technologically savvy, and more diverse in their backgrounds, interests, and lifestyles. Darshana Shah, a professor at Marshall University’s Joan C. Edwards School of Medicine, said they’ve also grown up surrounded by technology and the information it provides—“the world is at their fingertips” and, thanks to social media, more interactive. “The highlight of the millennials is that they are collaborators,” she said. “They are often more comfortable in group activities than flying solo.”

All these differences mean that millennials go about most aspects of their lives—healthcare included—a little, well, differently.

An unconventional approach

A recent Kaiser survey found that 45 percent of respondents between the ages of 18 and 29 didn’t have a primary care provider, compared with 28 percent of 30- to 49-year-olds. “The conventional model of delivering health care…seems to have been rejected by millennials,” Dave said over email.

That’s not to say they’re neglectful of their health. Instead, Dave said, “they want care efficiently and fast, and are more likely to obtain it through non-conventional sources (walk-in clinics, retail pharmacies, online experts, urgent care facilities, etc.) than their older counterparts.” Dave pointed out that millennials, used to having information at their fingertips, are also more likely to self-diagnose, have medical wearables, and use AI.

In addition, he said, they have a broader definition of “health,” one that includes “healthier and more active lifestyles in addition to treating disease and morbidities.” Shah said they’re also more open to homeopathic remedies and other alternatives.

And they’re cost-conscious. 54 percent of millennials would avoid getting medical treatment because of costs, and 46 percent said they’d switch healthcare providers to get care at a lower price. According to PNC, 41 percent of millennials request cost estimates before receiving medical treatment, compared to 21 percent of baby boomers. “Many of them have just entered the workforce or have student debt,” Dave pointed out.

“The highlight of the millennials is that they are collaborators. They are often more comfortable in group activities than flying solo.” Shah said.

So they’re visiting walk-in clinics, comparing costs, pursuing alternative medicine, and doing their own research. But it’s not just about convenience or money. A 2016 survey found that only 58 percent of millennials trust their doctors, as opposed to 73 percent of the general population. And a more recent survey found that 55 percent of millennials think that online health information is as reliable as what they’ll get in a doctor’s office.

Technology and transparency

How to reach out to millennials? Dave says healthcare will need to be more convenient and technologically savvy, providing care through telehealth and communication through digital media. We’ll have to broaden our idea of health to include things like more physical activity and less loneliness—as insurance companies have already begun to do. And, as Shah explains, doctors will have to be aware that their patients have already researched their systems online and know both the conventional treatments and the alternatives. Patients will have “a lot more options,” she said. “We’ll have to train future doctors to be aware of that.”

According to Dave, healthcare organizations will need to become more transparent about both their costs and the quality of care they provide. That means that they’ll need to grow accustomed to public physician ratings and customer satisfaction surveys. They’ll need to use online forums and social media platforms to reach out directly to a millennial audience.

Shah said that providers and vendors should find ways to embrace millennials’ collaborative spirit. “Vendors will have to build really interactive social media platforms,” she said. And because millennials prize giving and receiving feedback, “the feedback loop has to be built in at every level.” Millennial patients will want to evaluate their doctors, but they also want to hear about how well they’ve adhered to instructions and how they’re doing more generally.

“Given that millennials—the largest growing segment in the workforce—place an especially strong weight on these aspects, the healthcare industry will need to figure out how to innovate in order to provide better value to these consumers,” Dave said.

In other words, the millennial generation may be different, but that doesn’t mean that healthcare is. Like diamonds or nightlife—or any other industry—we need to focus on accommodating this new, more diverse, technologically savvy generation.♥

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