Changing Patient Behavior Through Technology

Software and hardware developments are opening new ways to get patients more involved in their own care.

This article first appeared in the January/February 2016 issue of HealthLeaders magazine.

From addressing addiction to overcoming obesity, providers are engaging patients more than ever to help them change their behaviors for better health. Technology tools are an enabler, unlocking a range of solutions for care teams and patients.

Nearly two-thirds of Americans own a smartphone today, according to the Pew Research Center. Healthcare systems are capitalizing on the widespread use of such devices to effect behavior change.

With simple texting, patient portals, activity trackers, and connected medical devices, the healthcare industry is taking aim at improving patient behavior to prevent illness and readmissions, control or reverse chronic conditions, or direct patients to appropriate treatment before their health spirals out of control.

The Power of Texting
At the Rochester, Minnesota-based Mayo Clinic, with more than 59,000 employees in 70 health system sites in Minnesota, Arizona, Florida, Georgia, Wisconsin, and Iowa, texting has played a key role in positive outcomes in the health system's smoking cessation program.

"It is clear that text messaging and mobile applications support smoking cessation, and there have been a couple of large systematic reviews that have shown that," says Michael Burke, EdD, assistant professor of medicine at the Mayo Clinic College of Medicine and program coordinator of the Mayo Clinic Nicotine Dependence Center.

"Technology is more scalable, may add to the face-to-face aspect of smoking cessation programs, and it may play a role in filling the gaps which frequently occur between a person's being advised to stop smoking and them connecting with either medication and/or counseling that will increase the likelihood that they'll succeed in stopping smoking," Burke says.

A cornerstone of Mayo's digital smoking cessation efforts is a website, becomeanx.org, operated by the Truth Initiative, a national public health organization formed after the 1998 master settlement agreement between the tobacco industry and the attorneys general of 46 states. The organization developed the program working in partnership with Mayo.

"It's an informational website where you can learn a lot of different things about the anatomy of addiction, medication to help people stop, what triggers are and how to manage those, and there's a regular blog," he says. "You can also join the community, which is a large network of people who have stopped smoking or are in the process of stopping smoking, and they can form their own groups within that and provide advice."

The newest element of the program, now in pilot testing at Mayo, engages those who have connected with a tobacco treatment specialist with a text message support program, Burke says. To deal with relapses in smoking, participants can type in words such as crave or lapse and receive guidance on "things they can do to deal with a relapse," Burke says.

"There are so many apps to help people stop smoking, but very, very few are really based upon the evidence that shows us what actually works," he says. "We've been working to develop evidence-based digital support that can help tailor a message to people's specific situations, to help them stop smoking and to keep them connected with providers at a distance."

A study in the September 2015 Journal of Substance Abuse Treatment concluded that "smoking quit rates for the text messaging intervention group were 36% higher compared to the control group quit rates. Results suggest that SMS text messaging may be a promising way to improve smoking cessation outcomes."

Two particular factors that have been shown to be important in improving rates of tobacco abstinence are medication use and amount of time spent with a provider, Burke says. "We are looking to see the effect of text messaging on medication use, which I think is unique. We don't have results yet. In addition, there is a dose response relationship between counseling time and outcomes. As little as three minutes talking with a patient will significantly improve outcomes, and more time has better results. We are looking at the impact of text messaging in extending the provider reach in contact."

Such simple efforts could produce significant results.

"There's nothing that's more cost-effective in healthcare than helping people stop smoking, except for childhood vaccinations," Burke says. "Helping people stop smoking, in terms of clinical intervention, is extremely cost-effective in terms of just how many coronary bypasses it prevents and how many surgeries heal better, and how many cancer medications work better. No matter where on the life spectrum or disease spectrum that somebody stops smoking, there is a health benefit that can be translated into a cost benefit or quality of life benefit."

Burke says one risk of digital interventions is the potential of laying them on so thick that they become counterproductive. "If you bombard patients with messages, they may wind up avoiding the messages," he says. "So the technologies need to be inviting, interactive, and understanding of the person's particular situations and supportive without being strident."

Beyond texting, there is the potential of mobile apps for smoking cessation, including the ability to determine if a patient is entering an environment where smoking may be present, such as a bar.

"Mobile apps do have a real potential for understanding a person's individual circumstances, not only in terms of their personal circumstances, but to know, when you're going into a bar, your particular risk, and a mobile app has a potential to sense when someone's going into a bar. But the messaging needs to be really individualized and interactive," he says.

Beyond the Mobile Phone
As medical devices acquire certain phone-like qualities, they are able to provide smarter cues to motivate patients with chronic diseases. At Mount Sinai Health System, an integrated health system with seven hospital campuses in the New York City area, traditional blood glucometers are starting to be replaced with Livongo, a chronic care management system that uses a wireless glucometer to measure blood glucose levels. The program has been made available to all of its employees and their dependents and is about to be made available to members of another payer population who have diabetes.

Whereas traditional glucometers provide data that must be manually uploaded to a PC, the Livongo device contains a 2G radio that automatically uploads readings to the Livongo cloud-based analytics platform, says Niyum Gandhi, executive vice president and chief population health officer at Mount Sinai Health System. The next version, which comes to market this year, will have 3G.

The Livongo platform includes a rules-based engine that forwards results for special attention to Livongo's team of certified diabetes educators, who can intervene with patients enrolled in the program, Gandhi says.

"They can provide coaching," he says. "It might be something as simple as letting you know your blood sugar is low, drink a glass of orange juice. They can engage more longitudinally, as well, to kind of help the patients take control of their own diabetes. So that's Livongo's traditional model, which they have up and running with a whole bunch of self-funded employers across the country."

The Mount Sinai patient population exceeds the national average for presence of diabetes. "It's actually north of 10%," Gandhi says. "We've built a lot of clinical capabilities around management of many chronic diseases. Diabetes is one of them."

Notwithstanding its research-focused Diabetes, Obesity, and Metabolism Institute, Mount Sinai Health System deals with the same shortage of endocrinologists and certified diabetes educators facing other healthcare systems in the United States, he says.

"Our diabetes educators do a great job of engaging patients on a lot of these issues, but it takes a lot of time and energy. The shortcoming of just an in-person model is that, first of all, it's harder to scale, and second of all, there's time in between visits," Gandhi says. "So how do we make sure that helping the patient manage their diabetes is part of their daily lives, and that we're connecting what they do on a regular basis--which is checking their blood sugar--to a care team, the Livongo team of certified diabetes educators, which is plugged into the patient's diabetes educator at Mount Sinai and then, as appropriate, other clinicians at Mount Sinai as well?

"We're moving the system to population health. We're getting paid in that manner. We want to manage clinical care more effectively as well," he says.

The smarter cues come from the Livongo device doing double duty via its built-in two-way messaging capability, explains Gandhi. "The Livongo user always gets a message back after the blood sugar reading. So it might say, 'Seems like your blood sugar is in control. Keep up the good work.' Or it could say, 'Hey, things are little low. Drink a glass of orange juice.' "

Physicians could also configure messages to the device to prompt patients to schedule needed foot or eye exams, or to reorder supplies, he says. If the patient replies to a request for a call or message to make appointments, Mount Sinai care managers know they have the patient's attention, instead of their often unsuccessful traditional outreaches to patients to schedule such appointments.

"Who knows what they're thinking about when you send them a text? Here, we'll send you a message immediately after you test. I know what you're thinking about immediately after you're testing. You're thinking about your diabetes," Gandhi says.

Other Livongo users are proving to test themselves more frequently, due to its convenience and ease of use, he says. "In general in diabetes, people don't test frequently enough, so the testing rate goes up a little bit as well, which is nice."

Starting with an employee count of 36,000 on its own insurance plan, Mount Sinai was expecting a spike in those with diabetes to opt into the Livongo pilot starting in January, as part of the annual benefit cycle restart, Gandhi says. "We did make it available off benefit cycle, because we were so excited by it that we didn't want to slow down."

Although enrollment in the new program will not affect employee insurance premiums directly, unlike the traditional glucometer program in the plan, which has a copayment, the Livongo glucometer and testing supplies will be provided by Mount Sinai to employees free of charge, he says. "It's not like they have big deductibles or copays against diabetes testing supplies," but it adds up.

Gandhi also envisions the larger potential of scaling up programs such as this to the health system's overall patient population, aside from just diabetes. "We have 145,000 lives in full risk that are Medicaid and Medicare," Gandhi says. "We have another 75,000 or so Medicare lives in shared savings, either through Medicare shared savings or from the plan, and then we have as of January 1 another 120,000, maybe 130,000 commercial lives in some sort of shared savings. We will probably have over half a million lives by the end of 2016 in some sort of shared savings or risk environment.

"Because of our position in New York as an academic medical center, and the geographies we serve, that half a million skews disproportionately less healthy, with a higher propensity to have diabetes," he says. "We need to roll out, payer by payer, based on our arrangements with them, so I'm not going to oversell that we'll be up and running with everybody with Livongo within the first few months of the year."

As the program unfolds, Mount Sinai will evaluate its economic and clinical impacts, but until then, the return on investment of using Livongo will remain unknown, Gandhi says. The health system also has work to do to integrate the Livongo-generated results, or summaries thereof, into its Epic electronic health records, he adds. "We wouldn't want every blood sugar value to go in, because that's information overload. But should we have summary results where certain things go outside of control, rather than having somebody manually document it in Epic? Should we have something automatically go in? We could do that, but we're not there yet."

Tracking Patient Activity
A culture of patient engagement, wellness, and self-care starts at the top at Houston Methodist, a seven-hospital, 1,931-licensed-bed health system in Texas, where its own employee population is serving as an important test bed as leadership considers the bigger picture of changing the behavior of its entire patient population.

"Digital health and wellness initiatives build on a history of previous wellness initiatives," says Marc L. Boom, MD, president and CEO of the system, which has 18,000 employees. "It goes way back through our DNA. Back in the '90s, we had a restaurant that focused on healthy food, and Dr. Michael Debakey, our retired chairman of surgery, had a whole cookbook on healthy living along with Dr. Antonio Gotto. We're always looking for interesting things to do to have fun with them, to help promote health and wellness.

"We're also an employer who pays for insurance, and we see the benefits to having a healthy workforce, and, of course, as a hospital system, we feel a responsibility to model great behaviors for our patients."

In 2014, Houston Methodist started offering Fitbit digital activity trackers to its employees "at a significant discount," Boom says. "We had employees enrolled in Fitbit challenges trying to beat their local CEOs at each of our hospitals and/or me, which, I've got to tell you, keeps you honest real quickly in terms of your own walking habits."

Houston Methodist employees can also qualify for lower health insurance premiums by being active and using the Fitbit to demonstrate that, Boom says.

Of course, wellness programs themselves are not a new idea, but driving them with digitally powered data is. "The digital element is really quite spectacular, because it almost introduced gaming into it, even though it's not true gaming, but there was a competitive effort and ethic to it," Boom says. "The device doesn't lie, but also it's kind of there in the background, and it's this reminder and this tool throughout the day."

Houston Methodist has 29,000 members on its medical plan; employees are about 15,000 and spouses covered are 3,200. With more than 15,000 Fitbits purchased so far by employees and their spouses?who were also eligible for the discount, even if the spouse was not covered on the employee's plan?participating Houston Methodist employees are averaging more than 9,000 steps per day, Boom says. That number of steps is generally considered appropriate for healthy adults.

"We want to have incentives in place, so if I'm identified as an employee who might have some higher health risk, we have structures in place that plug them into their physicians and plug them into wellness coaches and others who will help them through that journey," Boom says.

"We also have the opportunity through Fitbit to demonstrate employee activity as one of the ways to demonstrate that you're working on those health issues. I can't specifically link it to clinical outcomes because it's part of a broader picture, but I can tell you where we have been focusing on this, we are significantly reducing [the number of] people who would be found to be at high risk because they've got uncontrolled hypertension, uncontrolled diabetes, those kinds of things, and it's part of that overall program."

As CEO, Boom says he spends "99% of my time running our institution. I still see a few patients, and I'm passionate about wellness. So this has been a program that I have been quite involved in and quite passionate about."

As to the larger population health mission facing Houston Methodist, Boom notes that "the city of Houston, for a variety of reasons, has not moved as quickly toward the full-fledged population management from a payment mechanism. We've decided to take a little different approach. Of course money is important, but for us, it's about the quality of care and the safety of care that's provided to our patients."

Starting with 325 employees at rising or high risk for conditions such as diabetes, hypertension, high cholesterol, and smoking status, Houston Methodist has been "able to significantly move their metrics, and in 2016 we're expanding it to our entire organization and expect that we'll have over 2,000 people in a high-risk or at-risk metric engaged within our institution," Boom says. "Those folks are going to be going through this intensive management process and trying to help their health, and if we can do with that group what we've done with the smaller group, it will be quite compelling."

As for what ultimate success looks like, he says "the benefit of being a self-insured employer and being an employer who has engagement of its employees and cares about their health and happiness is that we don't have to put in programs that show a dramatic financial effect in three months, and that's been one of the challenges we have over time with sort of the traditional insurance model.

"If we do the right thing, that's going to keep that employee healthy. It's going to keep them happy, and it's going to cost them and us less money over time. So we're playing that long game. It's harder to measure that specific ROI in the short term," he says.

But Boom does point to measures that indicate engagement. "Since 2011, each year we have had over 80% completion in employees qualifying for our Healthy Directions incentives." To qualify, employees and covered spouses had to complete a biometric screening and health assessment, and test nicotine-free. "As we rolled out enhanced incentives in 2015 that required employees to actively engage in a wellness program either fitness, on site, or telephonic, we saw 71% completion."

Linking to the Patient Portal
When combined with other aspects of wellness such as in-person health coaching, activity tracking is making substantial headway against risk factors for some chronic conditions.

At Indiana University Health, during a three-year study concluded in 2014, from an original cohort of 4,210 drawn from a total employee population of 30,000, 66% of those identified at-risk employee participants experienced some decrease in their body mass index, and 69% of participants decreased their hemoglobin A1C, says Marci Cooper, RD, MPH, manager of employee wellness at Indianapolis-based IU Health, which staffs approximately 6,000 hospital beds and operates in more than 190 locations.

"We also have a wellness portal online, sort of a one-stop shop for everything wellness. It tracks incentive points," Cooper says. "Fitbit is linked onto our portal, so if you are just walking with your Fitbit, it automatically syncs and you can get up to a point a day, up to 50 points, for just being active and using your Fitbit without having to go in and enter those. All of these different activities earn you points, and then they're paid out the next year as a premium reduction."

Sheriee Ladd, senior vice president of human resources at IU Health, explains that the wellness effort was prompted by a review of the employees' healthcare costs and utilization expenses. "We noted that our weight, obesity, our BMI, was a huge concern. We noted that smoking was still occurring with some of our caregivers. We used the data to create a multiyear strategy of how we would focus on wellness and well-being strategy.

"This was a very difficult conversation to have, because people don't want to talk about their weight. They didn't want to hear the HR lady saying, 'We're going to begin to measure things that matter and that are going to decrease comorbidities,' and they were worried," Ladd says. "But at no time in my 40-year career have I received more notes, more calls, and more testimonials and thank-yous from the workforce as I have since we started this wellness and well-being strategy."

The wellness portal also offers employees interactive online workshops in managing stress at work, as well as financial wellness, Cooper says. Employees can also schedule health screenings through the portal and track strength training and consumption of fruits and vegetables.

While data on the effect of 2014 and 2015 employee discounts on Fitbits remains to be derived, anecdotally, Cooper says, there have been individual employee successes. "We have a guy who walked a million steps in one month and he reduced his body weight by 10% and he normalized his cholesterol numbers and also normalized his hemoglobin A1C from a pre-diabetes level to normal, so that's real outcomes."

At the end of two years, Cooper says 8,809 IU Health employees, including their family and friends, have purchased and used the Fitbits, which represents up to one-half of those IU employees covered under its health plan.

IU Health has yet to calculate an ROI for its Healthy Results wellness program. Cooper cites a 2010 Harvard University study of 100 peer-reviewed journal articles, Workplace Wellness Programs Can Generate Savings, which found that a properly designed wellness program can expect to yield an ROI of 3.27:1 on healthcare cost reductions, and another 2.73:1 on employee absence and related costs after about three years.

IU Health is also integrating its wellness program with case management in its population health program, Cooper says. "We're improving data and physician integration within the system, so when you come to a screening, it's automatically in the EMR, and it's ready and waiting when you go see your doctor; so we're avoiding that repetitive cost based on duplicate screening and duplication of services and medical costs," she says.

Ladd notes that the employee wellness efforts will influence the organization's efforts to improve the health of the community. "We also have heavy emphasis in population health at large, beyond our workforce. So the work we're doing with this, I'll call it a seed group, helps inform the broader strategies that our doctors, physician groups, and all of them are utilizing as they're taking care of the patients in their practices."

What Patients Want
Efforts to change patient behavior through technology have their roots in the many ongoing initiatives to boost patient engagement. Leading healthcare CIOs are applying the same kind of consumer-centric focus as has occurred in other industries.

"Consumers want to be in charge of information on all fronts, so they want to be in charge of their health as well," says Sarah Richardson, chief information officer at NCH Healthcare System, a two-campus, 716-licensed-bed system based in Naples, Florida. "Half of our patients go north for the summer. There's research out that shows that [among NCH patients] 99% of people respond to a text versus 20% using email, and over 95% of [them] have smartphones.

"Whether we are increasing people's access a portal to get their medical records, access lab returns, check their blood pressure, monitor any behaviors for our chronic or high-risk patients, we want a text message to activate behavior and encourage them to do something they wouldn't have already done," she says.

To spur this kind of engagement, NCH is partnering with HealthGrid, which makes a customer relationship management system for healthcare providers, Richardson says.

"This is based on our desire to partner with a solution that will increase engagement and usage of the patient portal as a primary method of interaction with a provider and healthcare system," she says. "Our findings have been through site visits, demos, and documented improvements from existing clients. We will baseline our success metrics and share them as part of our value creation from implementing the product."

Richardson, who came to healthcare out of the hotel and hospitality business, says the two industries "aren't that different" and recently hired a chief experience officer from a nationally known healthcare provider.

"I want the experience of using the technology to be a reason that they're stickier or more compliant with their healthcare, because at the end of the day, the more people we can keep out of the hospital—but in our system and doing their wellness prevention, their annual wellness visits, and health maintenance and all of their different preventive services that still keep them in our system—we're actually keeping them healthier and happier and out of an acute setting," Richardson says.

NCH is looking to integrate Cerner HealtheIntent population health management technology to query patients' pharmacies so NCH can know which patients have not refilled their medications, then notify patients to obtain those refills, she says.

"Yes, the first phase is to connect with patients who are at risk for readmission or have chronic disease states that may [make them] a candidate for home monitoring. The maturity of the product will allow us to understand socioeconomic factors that prevent access to medication, and seek opportunities to reach them as well," Richardson says.

Shared Care Plans
A 2013 study estimated that patient nonadherence to medications costs the United States $100 billion to $289 billion annually. To specifically address medication adherence, Geisinger Health System—the Danville, Pennsylvania, system that serves more than 2.6 million residents in central and northeastern Pennsylvania—has forged a multiyear collaboration with pharmaceutical maker Merck to develop IT-driven projects and processes designed to address this particular challenge.

However, Geisinger is also exploring ways to change the patient encounter itself as another strategy to improve not only adherence, but overall shared accountability between physicians and patients.

Thus, the OpenNotes movement that brought more open sharing of notes between physicians and patients is now poised to spawn a shared care plan to live right in the medical record, and act as a prompt to improve patient behavior.

This effort, dubbed OurNotes, is being crowdfunded by The Commonwealth Fund, with development by Beth Israel Deaconess Medical Center, and due to be tested at Geisinger early this year with design participation and implementation from its own patients.

"Patients and their family proxies would prefer to have a situation where they have better control as to what happens only on the outpatient visit side for the time being," says Alistair Erskine, MD, chief clinical informatics officer at Geisinger. OurNotes will extend the Geisinger patient portal to invite patients to document their questions for physicians before their visits. It requires physicians to address these patient questions, and then is not officially completed until the patient reviews the physician's notes and signs off on them, noting any issues or concerns at the end. "It forces the agenda of the patient to be first, and that's the key thing," Erskine says.

Over time, Geisinger's Institute for Advanced Application, with Erskine heading the OurNotes initiative, will evaluate the impact of OurNotes on patient behavior such as medication adherence, but he notes "we're not going to wait until it's perfect and has been fully researched, because we have so many clinics that we can implement this in other places. We want to go faster."

Erskine says he hopes OurNotes at Geisinger can "blaze a trail" for the growing list of healthcare systems around the nation that have adopted OpenNotes. "It will be a very nice natural evolution," he says. "The key part about OurNotes is the patient is setting the agenda for the visit, shared decision-making with the provider, and then the ability to make sure we give control back to the patient in terms of, 'This is a final version, and is there anything that we missed?' "

Experience and Engagement
In addition to its initiative with connected devices, Mount Sinai Health System recognizes that changing patient behavior may mean new ways of practicing medicine and looking to technology advances outside the healthcare industry.

"I've had this discussion with some of our physicians," Gandhi says. "The answer isn't just to make it easy for the doc. The answer is to make the doc realize that it's not just about the doc. It's about the patient or the consumer, because they don't like to think of themselves as patients. In no other industry would anybody say, 'Oh, I want to engage people, but I'm going to do it in the way that's easiest for me.'

"We have a habit in healthcare of making our back-end garbage the patients' front-end problem. We take the EMR and all of its back-end garbage, and put a mediocre interface on it and show it to the consumer," he says, and points to advances in other industries, such as personal finance. "Now Mint.com, that's a consumer-centric experience. American Express did something very similar. That's what a patient portal should feel like in healthcare."