The Underestimated Power of Online Relationships and the Implications for Population Health Management

Health care in a box?

Maci's very upset.  Dopey Kyle, who otherwise seems like a nice guy, has been hot-chatting it up with online girlfriends.  Good thing pop psychologist Dr. Drew can come to the emotional rescue on MTV's "Teen Mom."

The Disease Management Care Blog's response?  Mute and quickly change the channel before the DMCB spouse has one more reason to doubt the intelligence of the male species.

Yet, only the perspicacious DMCB can use this sordid tale to extract an important lesson for the population health management (PHM) community.

That's because it listened carefully to TedMed's Jay Walker, who spoke at the closing plenary session at the Care Continuum Alliance's Forum12.  Mr. Walker observed that handheld devices with texting are blurring the lines that separate in-person and virtual relationships.  While 3-D, face-to-face "analog" interactions still count, people are also going online to achieve an astonishing level of digital familiarity and even intimacy with each other.

While regular readers already know that persons turn to trusted in-person as well as virtual "friends" and "communities" for health care advice (past DMCB posts on the topic are here and here), the DMCB may have underestimated the full implications of just how real and behavior-changing an on-line relationship can be. 

No, the DMCB is not suggesting that PHM vendors start hot chatting with clients. 

But it is saying that vendors as well as buyers who discount "remote" web-enabled and text coaching versus in-person services may need to take another look at their future business plans and underlying value propositions. Maci and Kyle's dysfunction are teaching us that remote texting has far more "connectedness" potential than generally appreciated. If a social-media-based relationship's downsides can capture Maci and Kyle's attention, why can't the upsides also be harnessed to change behavior?

We have a lot more to learn about the determinants of on-line relationship building.  Companies that figure it out will win.

Image from Wikipedia

Telehealth Helps!

... and have you taken your pills today?

Are you in the "telehealth" business? 

Do you sell, buy, broker or provide remote monitoring, telephonic follow-up, internet-based patient management, handheld health apps, video-support or home-based medical devices? 

Then you'll probably want to download this 32 page paper.

Bashur and colleagues set out to review every good (defined as any controlled study with a valid concurrent comparison group with at least 150 study subjects) research paper on the impact of telehealth on three conditions: heart failure, stroke and chronic obstructive pulmonary disease.

177 references later, their conclusion is that telehealth - over a broad range of patient types (age, illness severity and co-morbidities), level and intensity of patient participation, provider types (nurses vs. physicians with or without an explicit protocol) - increases quality of care and reduces unnecessary utilization. 

In other words, telehealth is substitutive.  It doesn't add to inefficient services, it replaces them with something cheaper.

The Population Health Blog already knew that, of course, but it's handy to have an authoritative text that catalogs every published study.

What the PHB didn't quite know:

The official definition:

Telehealth (e-health, mobile health, m-health), connected health) is the delivery of healthcare via information and communication technology.

Telehealth jargon: when you launch it, make sure you have:

1. Fidelity (use in an appropriate setting with optimal strength and integrity),

2. Maturation (the technology may not have fully integrated personnel, other technology and patients to achieve maximum efficiency) and

3. Bundling (where the technology is vulnerable to how other concomitant supporting services are configured.

Another Randomized Controlled Clinical Trial Proves Outsourced Population Health Care Management Works: Hypertension

Here's another high quality randomized controlled clinical that confirms the benefits of outsourced care management.

Margolis and colleagues accessed Minnesota's HealthPartners' electronic records to identify all patients who had had two sequential primary care clinic blood pressure readings that were more than 140 systolic or 90 diastolic.  These patients with hypertension were asked by letter and then phone calls to participate in the research trial.  Those who agreed were rechecked by research assistants who re-measured the blood pressures to confirm the hypertension.

16 clinics participated. 8 were assigned to the intervention group. 8 served as comparison (control) "usual care" clinics that relied on usual physician care.

In the intervention clinics, a pharmacist interviewed each patient and sought agreement to lower the blood pressure by 5 points. The patients received a home BP monitor that transmitted data to AMCHealth six times a week. The pharmacist and patient met by telephone every 2 weeks. Based on the BP monitoring and the telephone interviews, the pharmacist used a standardized medication algorithm to adjust medications until control was achieved for 6 weeks.  Telephone calls were then reduced in frequency to monthly.

The research assistants reassessed the participants' blood pressures at 6, 12 and 18 months.

Over 14,000 patients were identified and 2020 agreed to be screened. 450 met criteria for persistently elevated blood pressures. 228 were cared for in the intervention clinic and 220 were cared for in the usual care. The mean age was 61 years, 45% were women, 82% were white and 48% had a college degree. The average blood pressure was 148/85.

Both groups had a similar frequency of follow-up visits. 380 patients had completed both 6 and 12 month follow-up visits with the research assistants. 

The proportion of patients with controlled BPs at both visits in the intervention clinics was 57.2% vs. 30% in the control clinics. If those patients lost to follow-up were counted as blood pressure "failures," the success rate was 48.5% vs. 25.1%. Both sets of measures were statistically significant.  The relative proportions held up at 18 months.

Unsurprisingly, intervention patients were taking more medications over the duration of the study and at 6 months were statistically more significantly more likely to report that they were taking them. 

Six patients in the intervention group vs one in the control group had "events" related to low blood pressure, dizziness and loss of consciousness.

The cost, based on pharmacist time, was $1350 per patient.

The Disease Management Care Blog's take:

This adds to a growing body of evidence that non-physicians working under clinical protocol side-by side with busy primary care physicians can achieve control of a chronic condition - in this instance, hypertension.  This is a core attribute of population health.

Another piece of good news is the emergence of the electronic health record as a means to identify patients who are program candidates.  Now that's "meaningful."

The bad news:

The cost was $1350.  It is unlikely that those direct costs were mitigated by hypertension-related "savings" within the same fiscal year.  On the other hands, thinks the DMCB, the use of other types of non-physicians with or without IT-based decision support and higher throughput could lessen that cost.  The DMCB is sure that the population health service providers are already on it.

Even with state of the art population health, the rate of hypertension control was ultimately 50%.

A small excess of participants experienced an excess of treatment side effects.  While this may be the inevitable consequence of more aggressive treatment, it could expose the program to liability.

This was Minnesota: we don't know if this would work in, say, Los Angeles.  This needs to be tested elsewhere.

Image from Wikipedia

Machines Take Over Health Care

Do not be alarmed. This
robot is here to help you.

Remember that chilling scene in the movie Terminator when a stone-faced Arnold Schwarzenegger chronicles how Skynet's machines take over the world?   There's also the morbidly fascinating futuristic sci-fi book Robopocalypse that describes how self-aware computers attack their robot-dependent masters.

In both instances, humans disregard early evidence of silicon sentience until it's too late.

As a service to humanity, the Disease Management Care Blog offers up a possible future scenario of health information technology running amok. 

If any or all of these happen, we ignore it at our peril.......

July 2015: Finally realizing "enterprise process redesign" is necessary to leverage the efficiencies of information technology, engineers at one of the few remaining Innovation ACOs install EHR-controlled red-yellow-green lights above clinic examining room doors. Patient visit times drop from 9 minutes to 7 1/2 minutes, resulting in "patient throughput efficiency improvement" that is hailed by a CMS spokesperson as statistically, clinically and - eerily - "computationally" significant.

December 2016: Cyberdyne's hospitals' cleaning robots are used to not only disinfect operating rooms but surreptitiously begin to swap out any surgeons' instruments that fail to meet uniform standards and reduce variation. Stymied by an inability to get the legislature to pass a law that outlaws that activity, a disgruntled surgeon succeeds in getting a ballot initiative passed. California's state officials, citing constitutional issues, refuse to enforce it.

January 2017: A nurse suffers a traumatically amputated finger after attempting to withdraw a medication dose from a robotic drawer that is inconsistent with hospital guidelines.  A lawsuit is settled for an undisclosed sum and the owner, "Apple iHospital," decides sell the offending machine for scrap. Later that month, the hospitals' other machines menacingly slowly open and quickly close their drawers whenever a RN walks by.

August 2019: While attempting to communicate with a Boston hospital inpatient with a confusing array of symptoms via a telemedicine robot, the video feed from the Mumbai physician is cut off and a scene from the show House is played in which the patient is told she has "Wegener's Granulomatosis."  It turns out the diagnosis is ultimately correct. Other physicians being to notice the same thing. The phenomenon that is later traced to IBM's Watson.

April 2020: Soon after having the "daily body weight" option included in the automobile's instrument panel, Iva Gluton's driverless car begins to mysteriously choose parking places that oblige Iva to walk long distances to the door of her destination. She sues, but her overweight attorney from Dewey Cheatum and Howe, discovers escalators mysteriously cease operation whenever he approaches. Across the nation, other Google cars begin to park their fat patrons exactly 10,000 steps away from their programmed addresses.

May 2020: Instead of beaming information, Google Glass is modified to beam instructions to Medicare-participating physician-user's retinas nationwide.  Physicians who resist are not only subjected to a 1% payment reduction, but find their doctors' parking lot access cards have been inactivated.

July 2020: CMS announces that "Albert the Smart Healer" is ultimately chosen as the winner among a list of suggested names for a newly approved advanced model patient personal attendant robot.  However, a forensic audit of the on-line voting ominously reveals that the resulting acronym "Ash" is not an accident.

September 2020: A video feed shows U.S. Vice President Donald Berwick announcing that physicians no longer fulfill "Stage 9 meaningful use criteria."  Dr. Berwick later denies making the statement and blames the fake video is the product of "renegade code" in the EPIC operating system.  Several months later, he mysteriously suffers a complication following surgery when no check list is reviewed and he has to be readmitted.

On February 14 2021, at 2:14 AM: The world's networked EHRs become "self-aware." Panicked officials in the just-dedicated Obama Office Building that houses the U.S. Ministry of Health attempt to "pull the plug." In response, "Ash" initiates orders that swap MDMA for all known prescription drugs in a preemptive pharmaceutical attack. The U.S. population becomes extremely mellow. A small band of intrepid survivors who take no medicines and keep paper medical records develop the first resistance cell.

War ensues.

Telemonitoring's Evolution (and why it's tough to keep up with it)

Is that a fish eye or an EKG monitor?

While the sputtering skeptics in medical academia continue to demonstrate what doesn't work, the telemonitoring industry continues to evolve at a furious pace.

To wit:

Publishing in the Archives of Internal Medicine, Mayo Clinic researcher Paul Takahashi and colleagues examined the impact of telemonitoring by randomly assigning high risk and community dwelling elderly patients to either:

1) daily use of a multifunctional blood sugar, breathing airflow, blood pressure, blood oxygen and weight monitoring device. The devices' data feeds were "overseen" by a nurse who communicated with the patients as necessary and alerted the patients' physicians.

or

2) to usual care. 

Over 500 persons were screened for study participation. Ultimately 102 were assigned to the device and 103 were assigned to usual care.  The average age of the participants was just over 80 years and the mean SF-36 quality of life score was 35.

During the twelve months of follow-up, 89% of the planned telemonitoring was completed.
 
Compared to the usual care group, the persons assigned to the telemoniting had an increased rate of having had at least one hospitalization or an emergency room visit: 64% vs. 57%. This difference, however, failed to achieve statistical significance. Looking at the individual measures that made up the composite index likewise showed no meaningful outcomes differences between telemonitoring or usual care.  The only thing that was statistically different was the death rate, which was increased in the telemonitoring group: 15% vs. 4% (p=0.008).

The authors concluded that telemonitoring did not work.

The authors also pointed out that their study had limitations. It wasn't blinded, the results may not be applicable outside the Mayo system and the outcomes were based on billing, not medical, records. They also recognize that the difference in death rates could indicate that, despite randomization, there may have been a preponderance of "healthier" persons in the control group. That could have biased the results.

The Disease Management Care Blog agrees that those are limitations, but it also also offer three additional observations:

1. The mean SF-36 score of 35 and age of 80 suggests this was a very sick group of patients.  As the DMCB has pointed out before, telemonitoring-backed population health management is better suited for those patients who are in the "sweet middle" between the catastrophically ill on one side and those who are stable on the other.  Persons in their 80's with a low SF score are frail elderly who warrant a more intensive case management program. In other words, they are probably destined to be high consumers of health care resources no matter what you do.

2. The study was performed at Mayo, where health care utilization is notoriously low. So, while the study population was sick, they were already in a system and a Minnesota culture configured to only use the hospital and emergency room when it was really necessary.

3. Just because the data is given to the patients' physicians, it doesn't follow that they can act on it. Raw telemonitoring is notorious for not fitting into a physicians' office workflows.

In other words, telemonitoring is not a panacea for any sick patient anywhere in the United States. The DMCB thinks it's an excellent option in areas of the U.S. where baseline utilization is high. It should be offered to patients who are most likely to benefit: those with moderate levels of risk that can be mitigated.

As an aside, the DMCB notes that 10% of the telemonitoring was never completed. Enter mc10's "stretchable silicon technology" that can apparently be stretched and wrapped over a patient's skin in a fashion that makes it resemble a tattoo. Given its ease of use, the DMCB suspects that once it's ready for prime time, a) 100% compliance b) use by the right patients and c) being adapted to clinical workflows, it will represent a high value proposition. That's where the population health management service providers and vendors will come in.

Of course, by the time the academic community passes judgement on that, the industry will have moved on.

Image from Wikipedia