Hospitals Rev Mobile Patient Engagement

Providers' willingness to partner with the technology industry to explore collecting personal activity-tracking information demonstrates the value of boosting patient engagement via mobile devices.

This article appears in the July/August 2015 issue of HealthLeaders magazine.

Patient engagement remains an elusive goal for providers, but new mobile technology initiatives by Apple and others are breathing fresh life into the effort, providers say.

Patient portals still struggle to meet the 5% requirement of meaningful use stage 2.

Much of this approach currently revolves around providers engaging with mobile phone manufacturers, such as Apple, and their technology partners. Last fall, Apple rival Samsung revealed digital health partnerships with Cleveland Clinic, Humana, and Stanford University, among others. That followed Apple's initial blitz of partnerships last year with EHR publisher Epic and the Mayo Clinic. During the year following, a growing number of other healthcare providers also revealed alliances with Apple.

What all these announcements share is the willingness of providers to explore collecting personal activity–tracking information, such as number of steps taken as well as other patient-collected measurements from either mobile phones or devices connected to those phones, to boost patient engagement with their providers.

The most dramatic implementation so far of such collection is Cedars-Sinai's decision to permit up to 87,000 patients to add mobile data from six parameters to a special sequestered section of Cedars-Sinai Health System's Epic-based EHR, available through the provider's patient portal as MyCSLink.

"We were pushing to get patients to use our EMR portal, and we've tried to take it to the next level by putting more useful information into it," says Darren Dworkin, chief information officer at Cedars-Sinai. Patients could already visit the portal and download continuity of care documents (CCDs)—essentially, their medical records. But the parameters gathered by Apple iPhones and iPads and connected devices represent the device's own measurements of the patient's steps, weight, glucose, blood pressure, saturation of peripheral oxygen, and pulse.

"We do have to begin to understand that, more and more, the patient record is going to be a shared tool," he says. "We're still in the very early stages of learning and understanding what all of that means."

So far, about 500 patients have taken up Cedars-Sinai on its offer and connected Apple's HealthKit information hub to their Cedars-Sinai health record. In addition, the health system is preparing to launch programs that, unlike the initial HealthKit integration there, will require clinicians to actively monitor the patient-provided data.

"We've been quick to point out to folks that this isn't as new as it sounds," Dworkin says. "Diabetic patients have been keeping logs of their insulin and glucometer readings for years, and they'll bring those paper logbooks in to visit with their physician and have a conversation. Some patients are better record keepers than others, and they may be tracking their weight or their blood pressure or other such things manually. This really just affords them an electronic way of replacing that paper for the patient much in the same way that we've replaced paper for the physician."

So Cedars-Sinai plans to soon launch HealthKit-based initiatives around tracking patients with congestive heart failure, diabetes, and COPD, Dworkin says.

Meanwhile, Dworkin pores over the unmonitored data coming in from the initial HealthKit rollout. "We could already see from the early data that most patients who are connecting devices are connecting fitness bands, and fitness bands are interesting. But healthcare providers have hopes that there will be a much wider array of interesting consumer-grade medical devices that will be available. Blood pressure cuffs are falling in price and becoming more prevalent. Weight scales are actually doing pretty good. I think that's our second-highest utilization.

"As more and more of these devices enter the market, and frankly, drop in cost, I think we'll see a wider adoption and use of those devices and then ultimately more linkages back." Consumers are free to discontinue using one particular kind of device and connect others, he notes.

Inevitably, the question comes up of when the health system will begin to monitor this data across all patient populations. "If you look on our website, there is actually a disclaimer that reminds patients that this isn't monitored data, much the same way that when you go into our patient portal and you type in an issue, it reminds you that if this is an emergent issue, you should dial 911," Dworkin says.

"We've been doing patient-entered information for a while, as have many, many organizations. We're certainly not the first. And all that information when entered is always understood to be not emergent, or nonmonitored information. It's really about facilitating dialogue with the clinical care team, and ultimately at the end of the day, as always is the case, we're relying on the expert clinical judgment of that care team to understand what to do with that data."

Dworkin acknowledges that Cedars-Sinai is building upon the interoperability alliance forged between Apple and Epic, as well as earlier, more pilot-oriented HealthKit deployments at Duke Medicine and Ochsner Health System. "We entered the game a little bit later than the pioneers, so we were able to take advantage of doing it in a slightly different way," he says.

Development time to integrate HealthKit into Epic at Cedars-Sinai has been measured in weeks, not months or years, Dworkin notes.

At Ochsner, Chief Clinical Transformation Officer Richard Milani, MD, heads up the 19-hospital system's care delivery redesign effort. "We have a process where we onboard individuals with heart failure once they enter the hospital," Milani says. "We phenotype them. They go home with a wireless scale that's connected to us. We're monitoring their weight and other things on a daily basis. If we start seeing changes that are probably not going in the right direction, we're in contact with them. This is seven days a week. And we've seen about a 45% reduction in readmissions over a year-and-a-half period as a result."

Such work predated Ochsner's integration of HealthKit, with weight scales directly communicating to Ochsner servers. But a new initiative to better control hypertension is based on HealthKit, and the weight scales in the previous monitoring program are also now integrated via HealthKit, Milani says. "Hypertension is the leading chronic disease on the planet, and Louisiana is the fourth worst state in the nation for prevalence," he says.

One benefit of HealthKit is the reliability of Apple's hub, Milani says.

"The entities that are in this space sometimes are not recognizing that they need to make sure that their connectivity and their servers are working," he says. "That's working in the healthcare world, which means daily, hourly, as opposed to, 'It's been down for a week, oops,'—that kind of thing. HealthKit has been a solid performer and is very durable and reliable."

The monitoring programs at Ochsner are part of its new integrated practice unit care redesign, which is focused on just the desired outcomes, unlike previous, more broadly aimed medical home redesigns, Milani says. It also enables providers to collect more than three or four data points per year on patients, unlike the previous models that did not incorporate such data from HealthKit.

Traditional portals going mobile

This summer, the Centers for Medicare & Medicaid Services will issue new file rules expected to reduce the patient engagement requirement, but while the industry waits for those rules, at providers such as Advocate Health Care, recently launched patient portal initiatives are gaining momentum, and mobile hasn't even kicked into gear as expected—so far.

At Advocate Health Care, approximately 125,000 patients are now using a patient portal that launched in 2014, and it is gaining roughly 2,000 more patients per week, says John Norenberg, vice president of information systems in physician services at the 12-hospital system based in Downers Grove, Illinois. About 33% of patients invited to register for the portal ultimately join it, he adds.

Like many portals, Advocate's provides lab results, secure messaging, bill payments, and appointment scheduling, viewing, and cancellation. In addition, patients can look up information on their currently prescribed medications.

A recent upgrade also enables patients to link devices from Fitbit, Withings, and Jawbone, storing the data in a section of the portal called a health journal, to record activity, weight, and other readings such as blood pressure, Norenberg says.

"We feel good about that number," he says regarding portal users. "It's an indicator that the market is ready. We also did quite a bit of work with our clinicians and our office staffs to have them heavily promote the portal as a much more convenient way to interact with the physicians and office staff, and that seems to have helped."

In just two months, the mobile version of Advocate's portal has already attracted approximately 3,200 patients, as well, as measured by Google and Apple app store downloads, Norenberg says. "We thought it would be more positive, but I guess the Chicago market is slower on the uptake with these kinds of tools than the coasts are."

Anecdotally, many patients who try the mobile portal tell Advocate providers they will rely on the app and not call the office, "because this just works," he adds.

Norenberg notes that, personally, he really doesn't like phone apps, "but I really like this one, which is weird for an IT guy. It is a massive time-saver for me."

Likewise, his own primary care physician at Advocate has come to prefer using the portal to communicate with patients—a big cultural change from a year ago, Norenberg says.

Norenberg recently visited his physician to be seen for a respiratory bug, and after being prescribed an antibiotic, the physician asked him to check in the following Monday via email. "I asked him why, and he said, 'Because it's the most efficient way for us to work with you. It's the best use of my time and the best use of your time.'

"I was shocked, because a year earlier, our doctors were kind of nervous about this thing called the portal, and now we have the doctors actively promoting it as the best way to communicate with them, so I think we're onto something."

Reprint HLR0815-9

This article appears in the July/August 2015 issue of HealthLeaders magazine.