Most of the time, Health IT spawns artificial concepts – born as a result of relentless media hype, each reaches a precocious peak of publicity and then quickly fades away. Buzzwords like RHIO, NHIN, PHR, Chronic Disease Management, etc. were all touted as game changing at one point or other in the past. Now it’s more about patient engagement, HIE, Analytics, Care Collaboration. One stands out in my mind though – Population Health Management (PHM). I think that even though it may be riding the hype cycle like all others, it has signs of legitimacy.
Think of it this way. For decades, we have endured and participated in a healthcare system that is geared towards encounter-based medicine. Patient comes in with complaint X, gets treated and billed for complaint X. Now with changing payment models though, it is important for the payers and providers to broaden their perspective. They need to keep track of patient (member) over a period of time, and keep them out of hospitals/ERs. As a result they need a “Longitudinal Health Record” that spans across encounters. This is what HIEs promise to provide and interoperability standards promise to enable.
From a Health IT vendor perspective, PHM means tools that help user do two things:
This is done by analyzing a population in a given care context. Like HbA1c tests for diabetics. PHM construct is based on the premise of looking beyond those who need immediate care (i.e. are having an encounter) and provide insights on the entire cohort under care.
This is where the analytics graduates into what it should be – Actionable Analytics. The ideal PHM tool will not only help find at-risk individuals, but also make it easy to do something about it. So if the PCP user has found the 50 at-risk diabetics in his/her 1000 patient panel, they now need to send reminder letters or queue them up for some kind of outreach. This workflow integration is what really legitimizes the emerging niche of PHM. Just analytics on it’s own doesn’t cut it.
But the devil is in the details, of course. One can argue why EHRs, the perennial stolid incumbents of health IT world, don’t have this as native capability. The answer is clear if you’ve ever used an EHR. They were (and are) built as transactional systems that focus on the current visit billing and documentation. Doing a parallel meta-analysis of how this patient fits into a population profile and what they need outside the context of this visit is a humungous leap for almost all EHRs. And that is why a new crop of startups have started to focus on this niche.
AmplifyHealth says all the right things on it’s website. They point out the need for finding patients that are going off-track. Like most startups, it avoids putting a live demo video on the site (so frustrating) so I’m going off of what the webpages claim as capabilities. The three areas they speak of:
Patient Management: Seems like this provides ability to create custom lists, akin to registries. That is a valid value-add, aligned with actionable analytics as described above. But the website description veers off into “engage new patients, influence productive behavior, establish relationship” which is confusing. All those belong to the foundational practice management and EHR system.
Measuring Outcomes: This would be the ‘meta-analysis’ that doesn’t come native with EHRs. Tracking outcomes based on measures is just starting to get engrained into the EHR DNA, thanks to the bullying by Meaningful Use regulation. But even that is a very regimented approach to this meta-analysis, and may not suffice for an ideal user. Hence the value-add opportunity.
Client-Sales Support: Very interesting. This seems to be an administrative dashboard for provider groups, self-insured employer groups to analyze of potential savings for a population. So it goes beyond just the clinical aspect of Population Health Management. I can see that as a separate sell to administrative, non-clinical users.
Buoyed by the hype that usually accompanies anything new Health IT, PHM is ready to bask in media limelight. But this may be one of the rare occurrences where there is actual substance underlying the claim to fame. Of course, only time will tell. One thing is for sure – you will see this term splattered across a lot of vendor booths in HIMSS 2014.
On the continuum of healthcare IT solutions, there are two distant ends. One extreme can be thought of as the complex, medical-grade enterprise EHR systems that cater to large institutions and mainly providers. The other would then be a consumer-grade solution that is designed for delivering health interventions to the masses. The latter is where Voxiva‘s offerings lie.
Voxiva provides the technology platform, professional services and support needed for designing and deploying a mobile-based health solution for consumers. When you read that, think beyond the now-hip smartphone app market. Less than a fifth of mobile handsets out there are smartphones. So to reach the remainder, the solution has to encompass relatively simpler mechanisms like feature-phone data entry, SMS and IVR.
There are a number of unique design challenges for creating an engaging public health solution that can work across any/most devices and be delivered through multiple channels to a varied set of end-users. It needs to work synchronously across web, mobile, email. It should support data entry across all kinds of user interfaces (feature phones, smartphones, different mobile operating systems, multiple-languages, etc). It needs to deliver real-time alerts (SMS, voice, email, web portal) and provide real-time analysis for decision-makers. And obviously be scalable and dependable with near-100% uptime. What appears to be a simplistic low-end IT solution on the surface is really a huge undertaking to communicate with an end-user population that is as diverse as it can be.
Voxiva’s real impressive achievement is doing a lot of what they do in international market- specially developing countries. They have created a HIV/AIDS mHealth solution for Rwanda Ministry of Health, disease surveillance solution for Peruvian military, diabetes management program in Mexico, and plenty of others. In US, their most famous offering was Text4Baby (see Multiplyd’s previous review on it), an SMS-based maternal health education service launched in early 2010. Since then, they have diversified into Text2Quit (smoking cessation) and Care4Life (diabetes management). Simple interventions, but designed for massive implementation and adoption. Which is why Voxiva continues to stand out.
Accounting for only 7.2% employment in healthcare, Home Healthcare is perhaps one of the lesser known and advertised sub-markets in the industry. It serves patients who prefer to stay at home but need ongoing care that cannot easily or effectively be provided solely by family or friends. These providers deliver a wide variety of health care and supportive services like professional nursing, physical therapy, occupational therapy, social work, nutritional care, medical equipment supplies, etc.
According to the National Association for Home Care, about 12 million people in this country receive care from more than 33,000 home health care providers. The market is made up of few large, publicly traded companies (see LHCG, AFAM, AMED stocks for example) and many small/mid-size players. The challenges faced by these companies are typical of those with field-based employees: scheduling the visits, then figuring out if their employee actually visited the patient, if they did then what was the real time and mileage, ensuring the data collected during visit is archived and accurate, etc.
Which brings me to CellTrak. It was founded in 2006 and delivers mobile-based automation to Home Healthcare agencies. I think it’s a brilliant application of healthcare information technology for alleviating self-reported information issues and paper-processes in a niche market. Given that everyone carries a phone today, using mobile modules to increase compliance and productivity makes a lot of sense for a field-based business. Some examples of the modules available:
Care Plan Management
GPS and Directions
Time and Attendance
Travel Time and Mileage
Alerting and Messaging
Solving logistical issues like location, time capture, attendance, inventory etc. is pragmatic. But providing modules around clinical care is the more interesting strategy from my perspective. Usually, software solutions that enable care documentation and collaboration are associated with either care-delivery enterprises (e.g. fixed location hospitals using EHRs) or with patients themselves (e.g. PHRs). Neither of those have a particularly critical need to be consumable in a mobile form-factor- that is just a nice-to-have functionality. CellTrak has found a special need where the inherent care delivery workflow necessitates even the clinical Healthcare IT solution to be exclusively mobile. It is a good example of the hidden corners within the complex maze of healthcare system which require thinking outside the traditional bounds.
Other examples of using exclusively mobile-based electronic health records are mostly restricted to public health context in developing countries (see ChildCount for example). That skew is mostly due to the field-based nature of public health and mobile being the primary means of connectivity in emerging economies. With CellTrak, we see the same technology paradigm tackling the problems of a conventional health industry segment in a developed country.
CellTrak partners with some EHR (Cerner, Allscripts) and wireless providers (AT&T, T-Mobile, Sprint, Verizon) currently. I expect that the future iterations of most enterprise EHRs would include incorporating a solution like CellTrak which enables running operations in the field and seamlessly connects health information to/from a mobile workforce.
Lately everything I find interesting has something to do with mobile platform. “mHealth” is the buzzword for it. Seems like most of new patient-oriented healthcare IT ideas have been conceived on the premise that mobile phones plays a key role in health-related data input and/or visualization. Or it could be that I’m just biased and need to look for news in other places 🙂
Child Count is an mHealth platform developed by the Millennium Villages Project aimed at empowering communities to improve child survival and maternal health. It facilitates the activities of field-based community health care workers in Africa. Using any standard phone, these workers are able to use text messages to register patients and report their health status to a central web dashboard that provides a real-time view of the overall community health. This enables an automated system that helps reduce gaps in treatment (sms-based rapid diagnosis, follow-up reminders etc.).
ChildCount is open-source. It’s built with RapidSMS, a framework that manages data collection, complex workflows, and group coordination using basic mobile phones. This short video does a good job of explaining the overall project and technology.
Public Health interventions are often based on simple logic, but have far-reaching effects. Screening regularly for malnutrition, malaria, diarrhea, etc. requires relatively simple documentation and measurements- making it perfect for sms-based communication. Even keeping a simple registry of births, deaths, immunization status enables local health teams and organizations optimize their efforts. Care delivery organizations in developed countries should also think about integrating the mobile platform into their services- its a great way to interact and keep in touch with patients. Medication adherence is a good example. NCPIE‘s 2007 report states that poor medication adherence is almost a crisis, costing $177B annually. Almost any population care management topic (outreach, screening, compliance, etc) would be a good use case.
Child Count is in good company -there are many interesting mHealth applications out there that deserve mention. The mHealth wikipedia page has a good running list of some applications. I’ll continue to post about what I discover and like.
RapidSMS is a SMS-based (text message) framework that manages data collection, complex workflows, and group coordination using basic mobile phones — and can present information on the internet as soon as it is received. So far RapidSMS has been customized and deployed with diverse functionality: remote health diagnostics, nutrition surveillance, supply chain tracking, registering children in public health campaigns, and community discussion.
Text4baby is a service that delivers periodic text messages to expecting mothers reminding them of basic healthcare needs. It’s a free mobile information service designed to promote healthy pregnancy, and given that US that the second worstIMR of all developed countries, it makes sense. Women who sign up for the service by texting BABY to 511411 will receive free (i.e. not charged to the receiver’s account) SMS text messages each week, timed to their due date or baby’s date of birth.
91% of US residents have a cellphone, compared to 22% that have internet connectivity. Educating pregnant women and new moms with information they need to take care of own and baby’s health is a powerful preventive measure. So there is reach and utility in this idea, no doubt.
Note: Found interesting background about Voxiva. They started in 1999 with the idea that mobile phones were going to play an important part in health going forward. They now have a technology platform and provide mobile health solutions in about 14 countries (mostly developing countries like India, Mexico, Rwanda, Peru). They market and sell to public health agencies and government providers usually, but are moving into pharma and provider networks now. An insightful interview with their founder here.