For many consumers, there are few things more exciting than purchasing something electronic. Dismantling the carefully thought-out packaging, peeling the tacky plastic off a screen unblemished by fingerprints, and seeing that well-known logo flash across the display for the first time can be a satisfying experience on several different levels.
The simple delight of possessing something cutting edge certainly plays a part in it – thirty-nine million “unboxing” videos on YouTube can’t be wrong – but gadgets these days also affect their users in a deeper way.
The latest and greatest cell phones, tablets, fitness trackers, and smart watches help their users extend their capabilities and alter their interactions with the rest of the world. With these new devices, users can access something, play something, manage something, or learn something that they couldn’t before.
They can find information with the flick of a finger. They can share their every moment through pictures or videos or updates with their friends. They can listen to their heartbeats – or the heartbeats of their spouses hundreds of miles away. They can open an app to watch their pets snoozing at home while they are stuck in the office all day. They can turn on the air conditioning in their living rooms in anticipation of coming home from the gym.
They can do more, know more, share more, and control more. They become connected.
Consumer-focused technology giants know exactly how powerful that feeling can be, and they do a masterful job of stirring up connection-envy in their advertising and their marquee unveiling events. Leveraging the basic human need for knowledge is good for business, and has completely transformed the way society works in just a few short years.
But while this growing network of consumer devices – the Internet of Things – is flourishing in almost every area of modern culture and community, it hasn’t gained much traction in one of the places where it could do the most good: the healthcare industry.
That may be because healthcare has been “particularly unsuccessful at engaging its patients,” suggests Drew Schiller, CTO and co-founder of Validic, a digital health platform developer, and it’s not too difficult to see why.
It’s hard for patients to get excited about healthcare. It’s expensive, inconvenient, and often invasive. Many patients only contact their providers when they are sick or in crisis, which makes navigating the care continuum an onerous and unpleasant task for the people on both sides of the phone call.
Developing and maintaining good lifestyle habits that can help keep patients out of the office is equally challenging, especially when dealing with chronic diseases that demand constant attention to complex medication regimens, healthy diets, or challenging exercise plans.
The Internet of Things has the potential to change this dynamic by relieving some of these burdens for patients, but they may not be addressing the root causes of detrimental patient behaviors.
Current engagement strategies have focused primarily on motivation. Tracking steps is supposed to encourage patients to take the stairs instead of the elevator; daily reminders to take the right pills at recommended intervals is supposed to keep nonadherence at bay; counting calories is supposed to remind users of the long-term impacts of scarfing down that tempting breakfast pastry.
For some patients, these basic accountability measures can help them stop themselves from veering off the straight and narrow. But for others – especially those who already feel overwhelmed with the self-discipline and organizational skills required to manage multiple chronic diseases or reach a specific goal – that one-ounce wristband can start to feel like a one-ton weight dragging them down.
Because when it really comes down to it, guilt is not engagement. It results in feelings of failure and isolation, not connection. And that is one of the areas where the healthcare IoT has come up short.
“These are just gadgets when a patient uses them in isolation,” said Tamara StClaire, Chief Innovation Officer of Commercial Healthcare for Xerox. “We need to figure out a way to aggregate the data so that it can become part of the holistic patient health canvas. The patient needs to be able to port that information and deliver it to the right stakeholder within the ecosystem.”
Then, that stakeholder has to figure out what to do with the data and how to create a positive environment for the patient that fosters lasting, meaningful change.
That is easier said than done, of course. The obstacles in the way are many and varied. On the provider side, a lack of health data interoperability, subpar EHR usability, and preoccupied executives fighting for financial stability make it difficult for the average clinician to pay much attention to futuristic promises of effortless chronic disease management and intelligently targeted alerts.
For patients, tepid interest in the limited functionality of current healthcare-specific offerings, including widespread frustration with malfunctioning apps and uninspired data analytics, is delaying the development of a truly useful Internet of Things.
A new report by Argus Insights clearly illustrates the disconnect between the IoT’s potential and its current reality. After reviewing input from 136,000 wearable device users, the report found that consumers may enjoy using their devices, but are highly unsatisfied with the apps and interfaces that are supposed to allow them to access and use their own patient-generated health data.
Source: Argus Insights Wearable Ecosystem Report
Apps that crash, devices that don’t sync their daily data, notifications that don’t perform correctly, and analytics interfaces that fall far short of expectations make it difficult for consumers to actually leverage their wearable devices and sensors for improving their health.
Many apps also fail to provide an integrated view of patient data. It’s hard to get an accurate picture of one’s activity and progress if the diet tracking app doesn’t take into account how many calories have been burned on the treadmill that day.
These superficial experiences are not truly helping patients make changes to their health, and are not necessarily creating value for healthcare providers, either.
“A lot of the IoT is really just froth at the moment,” StClaire says. But it doesn’t have to stay that way.
Unlocking the secrets of meaningful consumer engagement
Healthcare is a slow-moving industry, and one that is bound by rules that most other sectors don’t have to think about.
“We have a lot of restrictions in healthcare that have prevented us from moving as quickly as other industries,” said Fatima Paruk, MD, MPH, Chief Medical Officer at Allscripts Analytics.
“Rules like HIPAA are necessary, of course, because they ensure that we first do no harm. But as much as those regulations are there to protect people, they have been one of the reasons why we haven’t moved as fast as the retail segment, for example.”
“Amazon and Facebook and companies like that have taken all the data at their disposal and used it to advance their fields, but that’s one thing that healthcare has not been able to do yet.”
The health system is catching up quickly, however, as providers, payers, and developers start recognizing the need to treat their patients like consumers.
The financial pressures of value-based reimbursement, the inexorable march of high deductible plans and massive copays, as well as widespread dissatisfaction with the astronomical costs of basic services, are leading patients to revolt against the notion that they have no choice about how, when, and where they receive care.
More choice breeds more competition, and that means providers will have to develop consumer-facing attractions, like sophisticated patient portals, expanded care access, or advanced use of the IoT, to woo patients to their facilities.
Healthcare organizations may be able to do this by taking some important cues from the retail world’s success with locking in brand loyalty and selling the idea of a better lifestyle, not just a single piece of shiny new tech.
“As we start to build this idea of the consumerization of healthcare, I think we can leverage the engagement that these consumer electronics companies are generating to create a more proactive patient overall,” Schiller said.
Paruk agrees that the tech giants have already hit on the key to fostering the connected consumer. “One of the lessons we can take away from companies like Apple is the idea of instant satisfaction,” she said.
“If you want something, you can have it, and it’s basically idiot-proof. You don’t need any specific skill set to find an app in the store, download it, and install it. We need to take the same approach to healthcare.”
More data, more problems
Even if the healthcare industry manages to the problem of turning patients into consumers, providers and developers are still left with the conundrum of how to leverage patient-generated health data for clinical care.
And each step along the way to achieving the ultimate patient experience is fraught with its own particular difficulties.
“The last forty years in healthcare have existed within the paradigm of evidence-based medicine, which is great,” explains Schiller. “But evidence-based medicine says, ‘I know that this is the right choice because the research says that when I prescribe this treatment protocol, I can expect this set of results.’”
“The problem is that we don’t have that body of evidence when it comes to patient-generated health data. So one of the things we’re trying to do is create that dataset now.”
Unfortunately, that dataset basically includes everything a patient can possibly produce during his or her journey towards health. EHR data, claims data, pharmacy activity, social media posts, messages to providers, two or three or four different wearables, monitors, sensors, and apps, their socioeconomic data, and even their internet search queries can all contribute to crafting a detailed portrait about a patient’s status, challenges, and opportunities.
The infinite variety of possible sources of insight means data scientists have their work cut out for them, Paruk says. “All of a sudden, we have all these different sources of data, which are all a little bit the same but also very different. You have to normalize it and comb through it before you can even start to draw conclusions about your patients.”
“Before you even think about doing analytics or developing a population health management program or figuring out how to improve the system as a whole, you have to clean up a mountain of dirty data.”
Standardizing and normalizing that data, especially when it comes from consumer devices that are not necessarily concerned with the ability to interoperate with electronic health records, is one of the biggest obstacles in the way of creating a meaningful IoT for healthcare.
“Let’s think about sleep data, for example,” said Schiller. “Some devices might say that the user got into bed at one time and woke up at another time. Others will use intervals, or divide the night between light sleep and heavy sleep.”
“What we need to do is bring all the data together and create some parameters around it, so that when I deliver a sleep record to a provider, it always looks the same. Then you can take it into the system, provide some context, and make comparisons. You can only do that when you can trust that the data represents the same thing each time no matter what device it comes from.”
"[Patient-generated health data] needs to be a first-class data citizen, but only if we handle it intelligently."
Application programming interfaces (APIs) and internet-based data standards like FHIR are supposed to be the bridge between IoT devices and the EHR, but data normalization is just the first step.
“What we need to do is take the insights from the big data and push them out to providers at the point of care, and make it really easy to understand that this patient with this pattern of HbA1c readings is going to develop diabetes in five years unless you do this, this, and this to intervene today,” Paruk asserted.
“If we can make that process so easy that it only takes the EHR user two or three clicks to enact those interventions, then we’ve done our job.”
Unfortunately, the sorry state of EHR usability is yet another hurdle for healthcare. Clinicians who are already feeling as if their EHRs are the enemy are unlikely to be thrilled by the prospect of additional data streams that may or may not be relevant to patient care, and EHR developers have not yet figured out how to integrate PGHD without shattering the workflow.
“PGHD needs to be kept somewhat separate from clinical data, because we do different things with them,” explained Brian Carter, Executive Strategist at Cerner Corporation. “I’m not going to use the weight reading from someone’s Bluetooth scale in their home to calculate the dosing for a very complicated chemotherapy drug. I need a different clinical measurement for that.”
“But we do need to have both types of data in the same workflow, because providers won’t use it if it takes too much effort,” he continued.
Similar to web search results, every additional action required to complete a task in an EHR makes it exponentially less likely that users will engage.
“There are studies that show if information is even one click removed from the main EHR interface, they’re not going to use it,” said Carter. “I think the degradation rate is something like 90 percent after having to go one click deep.”
“So we think it needs to be a first-class data citizen, but only if we handle it intelligently. We need to reduce the noise and deliver a lot more signal. Because I can’t justify putting data on the first page if it’s not interesting.”
Deciding what’s interesting – and who will find it interesting – is equally challenging. What may be important for a primary care provider isn’t critical for a cardiologist and has no relevance to an orthopedist.
“[PGHD] is this messy, undefined stack of data that doesn’t sit within the EHR system,” said Ben Jonash, Principal at Doblin, the design and innovation arm of Deloitte LLP. “The number one reason why clinicians don’t like PGHD is the hassle factor. It’s too much work to determine whether they’re being sent a signal or just too much noise.”
“A primary care physician isn’t going to sit and stare at a live feed of your blood glucose monitor,” he added. “They want to see digital therapeutics incorporated into a better way to deliver medical care.”
Integrating the IoT into the value-based ecosystem
Providers may feel as if developing technological and workflow competencies required to make good use of the Internet of Things is secondary to all the other initiatives crowding their plates, but everything from EHR adoption to big data analytics to patient engagement are just pieces of the same puzzle.
The ultimate goal of all these efforts is to reduce costs sufficiently to create a sustainable long-term financial environment. CMS and many private payers are already deeply entrenched in the process of introducing value-based reimbursement, risk-based contracting, bundled payments, and accountable care strategies to the provider community.
These new financial levers require healthcare organizations to take a hard look at how they operate as care partners, technology adopters, and service-oriented businesses.
Using the Internet of Things, as well as other big data sources, to develop more sophisticated portraits of patient behaviors isn’t just beneficial for the individual patient-provider relationship. It’s also a foundational competency for the type of population health management techniques required for success with value-based reimbursement.
“I think a lot of providers are missing that part of the picture,” said StClaire. “When I ask someone where they sit financially, they can only give me a really rough view. But if you look at where we are with CMS and where they have said they want the value-based curve to be, it becomes clear that providers need a much more accurate view of how to bend their own cost curves to make sure they’re in the black with their contracts.”
Source: Xtelligent Media
“In order to do that, they need to take a hard look at their data – especially when it comes to patient attribution. Not everyone has a full grasp on that. What cohort do you really need to think about when it comes to risk-based contracting? Before you can start talking about population health management, you need to know who your patients are.”
By clearly defining high-risk patient populations, providers can better understand who will benefit from additional patient engagement activities, and where to focus resources for investments in the technologies to get patients where they need to go.
“If you can put a price tag on it – if you think about population health management in terms of profit and loss, you can know what your investment has to be,” she added. “You can determine what the ROI is. I think that could give physicians and organizations the confidence to invest in these population health management programs. That will give them the visibility they need to understand how to meet their financial obligations.”
Engagement, encouragement, and effectiveness
Building stronger patient relationships is just as important as bolstering financial ones. Chiding patients into compliance may not work, but using positive reinforcement with patients who are already motivated enough to shell out $200 for a wearable device can be a much more effective approach.
A new study published this month in the Annals of Family Medicine adds evidence to the idea that patient engagement isn’t just a technology issue. Researchers developed a scoring system to gauge how effectively providers worked with their patients to support behavior change, and the results were, perhaps, not that surprising.
"Six months later, how many [patients] are using these tools as an integrated way to change their health?"
Clinicians who spent more time with their patients, took on a counseling and coaching role, provided validation and encouragement, and avoided threatening lectures when patients make mistakes were more likely to see positive outcomes and greater patient satisfaction.
Successful clinicians emphasized patient ownership of their own health, identified small, achievable goals, conducted frequent follow-up visits, and truly partnered with their patients to encourage better health.
“A patient may have gotten a Fitbit or Apple Watch as a Christmas present, but if you talk to the vast majority of them six months later, how many are using these tools as an integrated way to change their health?” Jonash asked.
“The challenge isn’t necessarily the front-end of a patient experience. It’s not about enticing them to play with these gadgets. It’s about creating the right habits and reinforcing the message and linking these strategies back to what matter. It’s about making sure you’re not completely dependent on the patient to self-manage the situation, because most people just can’t do that.”
The highest scoring providers in the patient engagement study have taken that idea to heart.
“I try to make [the patient] be the manager. I give them advice and what I think is the best course of action, I try to make them as responsible as I can. I want them to take ownership,” said one family physician.
“Trying to get those little improvements is good to get the patient’s momentum going, but bombarding them with ten solutions isn’t going to help. I try to meet them where they’re at, with baby steps,” said another.
Integrating the Internet of Things into this positive approach can supercharge the patient-provider relationship and start to generate that feeling of connectedness that all patients ultimately crave.
The combination of IoT tools, big data analytics, and a caring attitude can help providers overcome the fundamental problem that often prevents patients from sticking to their wellness plans: providers don’t know what happens with their patients once they step outside the office.
By using patient-generated health data as a way to fill in the gaps between regular follow-up visits, clinicians can provide the accountability, motivation, data interpretation, and care planning that are currently missing from IoT apps and devices.
Adding human accountability to the chirpy reminders and easily-dismissed alarms of apps and wristbands may be the missing link between the IoT and better health.
As financial incentives shift to encourage better patient engagement and technologies start to mature to the point of usefulness for patient management and accountable care, the industry may be able to overcome the many and varied obstacles preventing the IoT from unlocking a new era of high-quality, sustainable care.
“I really believe that the day has come for healthcare,” Paruk said, “where we now have the ability to harness that technology to really move forward and make the lives of our patients and providers better.”