Connected Health, Connected Reform
Toward a Comprehensive HIT and Payment Reform Strategy
SOURCE: AP/MICHAEL CONROY
A doctor explains a patient's condition to him and his family using an electronic medical record on a laptop.
There is great excitement across the United States now as the Obama administration and congressional leaders debate on an ambitious healthcare reform agenda. There are three major thrusts of healthcare reform efforts under the Obama administration: Adoption of health information technology, universal access, and payment reform. This is both a praiseworthy yet daunting tripartite mission as so many health care reform efforts have centered solely on improved access-only to find this leads to cost increases and magnifies personnel shortages in our health care system.
Payment reform will be a catalyst to transform our broken health care system, but without a more well-rounded health information technology strategy-efforts to date have focused chiefly on the adoption of electronic medical records-health care providers will not have all the tools to truly move to the population-based, health-oriented system that current policymakers envision. Similarly, to move our society to a truly health-oriented culture some fundamental cultural shifts will need to occur. Health information technology can help move that needle, too.
In essence, HIT policy initiatives must be far broader if we are to succeed in fixing healthcare. The key to solving the cost and quality dilemma is to employ strategies that involve patients more in their health care decision making. The idea is to give them as much opportunity to make their own health care decisions regarding wellness and prevention and, along with their doctors, make medical decisions. To help patients do this they need information technology to monitor their own health and “health coaches” armed with the same health monitoring information.
Health care providers today are a scarce commodity and expensive labor, especially when patients usually visit them only after symptoms prompt them to seek medical help. A strategy focused on the adoption of electronic medical records by physicians will not achieve the goal of bringing patients fully into the decision-making process about overall healthy living. For that, another set of tools is required.
We at the Partners Healthcare System in Boston call this set of tools “connected health.” Connected health involves the use of technologies, which predominantly involve messaging and monitoring, to accomplish two broad goals:
- Extend care to patients where they are when they need it
- Give patients the tools that enable them to be their own primary care provider whenever possible, with the help of a health coach.
The conditions that best fit this approach initially are chronic illnesses such as hypertension, diabetes, and asthma. The choice is strategic-these conditions represent the fastest-growing segment of health care demand and account for much of health care costs. Our system applies four core principles in designing connected health programs for these conditions:
- Gather accurate information such as vital signs, adherence to a wellness plan, and certain behaviors.
- Share that information with patients in a context they can relate to.
- Provide coaching based on how patients are performing relative to the information that is tracked, with coaches having access to the same data as the patient.
- Provide the health care provider with only the information required to make the best care decision.
An example of our approach is the hypertension self-management program that our Center for Connected Health studied in collaboration with the data storage company EMC Corp. Employees at EMC were enrolled based on their blood pressure readings at a hypertension screening. The intervention was a blood pressure cuff for home or workplace blood pressure monitoring, a device to get the readings out of the cuff and onto the Internet, and a rich website that the employee used to see blood pressure trends and access educational materials. The site was also customized with automated coaching messages that were determined by the employee’s health status and blood pressure trends.
The results after six months were striking. Less than 1 percent of enrollees dropped out. They uploaded an average of three blood pressure readings per week and logged onto the Website an average of once per week for the duration of the study. Most importantly, the blood pressure readings in the intervention group were significantly lower than those in the control group. This service is now being offered by the Center to other employers as a tool to engage employees in healthier behaviors and lower overall costs of care.
There are many more examples of this approach. We are having great success, for instance, with a diabetes program that allows a nurse clinician to follow the blood glucose readings of a panel of patients and intervene just in time if their readings are out of control. In a way, connected health is the logical, patient-facing extension of the electronic record or the next generation of health information technology.
One stumbling block to implementing this vision is the current predominant reimbursement model of fee for service. In this context, there is really no incentive for health care providers to provide lower-cost care. Units of service drive revenue so workflows and strategies are naturally employed that drive more services per unit time.
The Obama administration’s insistence on coupling payment reform with access reform is laudable. The predominant payment models being discussed at this time are bundled payments, where providers are paid a flat fee for a given condition set for a unit of time, and shared savings where providers are paid a management fee (much as health plans are) and agree to achieve savings goals. These strategies are sometimes described under the banner heading “value-based purchasing.”
Both of these payment models reward health care providers for the quality of outcomes rather than units of service. Our experience at the Center for Connected Health tells us that when confronted with this type of payment scenario, connected health tools are a compelling way to achieve improved population health and efficiency.
Our experience and success to date with connected health are all with the segment of the population that will willingly come forward to participate in this type of program. They are willing to be constantly fed unambiguous health data over the Internet and agree to share that data with their physicians and their health coaches.
But what about those who find engaging in healthy behaviors to be especially challenging? We have some preliminary data at the Center for Connected Health that suggests this group, in general, has worse health outcomes than those who will be part of a connected health program that is likely to emerge in some fashion out of the deliberations now proceeding in Congress. Case in point: We followed heart failure patients on discharge from the hospital. Half were offered participation in a telemonitoring program and half were offered usual care. Of the half offered the program, those who refused to participate had worse outcomes than the control group.
Our sense is that tools such as incentives and other behavioral economic tools will be required to bring this group in. One thing we’ve noticed: once patients are involved in a connected health program their persistence is high. Drop outs are rare.
At the Center for Connected Health we have generated solid data and significant clinical experience to demonstrate that our initiatives to connect patients and physicians can effectively improve outcomes, reduce costs and more effectively manage healthcare resources. As it turns out, our connected health programs can be quite robust and exciting for patients of all age and income groups, as well as for providers, payers and employers. As such, we view connected health as an integral solution in a healthcare reform package, to ensure quality, affordable healthcare for all Americans.
Joseph C. Kvedar, MD, is founder and director of the Center for Connected Health at Partners HealthCare System in Boston, Massachusetts.
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