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Why Passivity Is Key to the Healthcare Internet of Things

The healthcare Internet of Things may have to learn how to fade into the background if patients and providers are to benefit from patient-generated health data.

- Passivity might seem like the very opposite of what providers want to see in an engaged patient, but when it comes to the healthcare Internet of Things, the best thing patients can do for themselves is to do nothing at all.

Healthcare Internet of Things and patient-generated health data

Automating the collection, reporting, and analytics of patient-generated health data will help to reduce barriers to action, improve data integrity, and allow providers to integrate results more seamlessly into their workflow, says Gerard Nussbaum, Director of Technology Services at management consulting firm Kurt Salmon.

By helping patients take a hands-off approach to maintaining wellness, the growing web of interconnected wearables, home monitors, mHealth apps, and other devices that comprise the Internet of Things may become a truly useful tool for healthcare.

“Any time you remove a barrier, you make things easier,” Nussbaum said to HealthITAnalytics.com, echoing the sentiment that has underpinned the majority of current approaches to healthcare reform.  “When it comes to the ability to get data out of patients, clearly it’s going to be easier to automate a process than to require a concerted effort from them every day.”

Words like “seamless” and “streamlined” are often used to describe the desired outcomes of reducing obstacles for both patients and providers, whether they are roadblocks to care access, patient engagement, health information exchange, medication adherence, or education.

Stakeholders are hoping that the complex process of retooling workflows and relationships to extract the maximum value from a minimum of effort will result in greater efficiencies, lower costs, and better patient outcomes.

Health IT tools, including EHRs, clinical decision support modules, population health management software, patient portals, and HIE networks have played a significant part in improving safety and managing patients.  As vendors and developers begin to heed industry calls to focus more intently on usability and interoperability, these foundational systems are requiring users to do less while delivering more actionable insights.

Now, with the rapidly growing interest in consumer-facing monitoring and engagement technologies, the Internet of Things is hoping to prove its own value by becoming the primary way patients and providers stay connection between office visits – and making their services so simple to use that patients don’t even have to think about them.

Designing systems that are both engaging enough to hold a patient’s attention but passive enough not to frustrate users into leaving their wearables at home each morning or deleting their mHealth apps is no easy task, however. 

How can developers strike the right balance between engagement and passivity?  Can the healthcare Internet of Things become forgettable in all the right ways?

What do patients want from their IoT experience?

Patients might not always know the magic word that will help them cultivate and sustain healthy behaviors, but they certainly know what they don’t want from an app, device, or interface that is supposed to help them achieve their goals. 

In a recent study from the Journal of Medical Internet Research (JMIR), patients responding to a survey about their mHealth app use were incredibly clear about what turns them off: hidden fees, shady data sharing procedures, subpar functionality, and a generally lackluster user experience.

A similar report from Argus Insights found widespread dissatisfaction with apps that were supposed to make it easier for patients to track their fitness, diets, sleep patterns, and other health factors.  Technical glitches, broken notifications, and analytics capabilities that don’t provide enough information or insight were among respondents’ top complaints.

In the JMIR study, more than forty percent of users specifically cited the time and energy it takes to input their data as a reason why they discontinued the use of certain apps.  A similar number said their interest in maintaining their data faded over time, which indicates that these activities are not delivering enough value to warrant the effort.

That may be, in part, because apps and wristbands cannot produce results in isolation, says Ben Jonash, Principal at Doblin, a division of Deloitte LLP.

“I don’t think digital therapeutics is about having a shiny app that suddenly solves everything,” he commented.  “It’s about a thoughtful integration of digital tools and behavior change mechanisms that can integrate with overall care programs.  You can’t just ask patients to do this themselves and coordinate everything with their care team.”

But wearables, monitors, and the apps that support them have simply not become indispensable to the majority of patients who might benefit from them, added Grant McLaughlin, Vice President at Booz Allen.

“Once you actually find an app that you can use, and you use it every day to help you do something, and you find the value in it, then it has become invaluable to you.  You absolutely cannot live without it,” McLaughlin said last year.

“But that’s what we’re struggling with.  How do we add value in the context between the consumer and the provider?  If we can get to the crux of how to make the conversation between consumers and providers more valuable, and if technology can enable that, then I think we’ve struck gold.”

Understanding the allure of automation

How can healthcare crack the code that makes an IoT activity irresistible?  As with so many other aspects of the health system’s development, it may help to take a hint from other industries, Nussbaum said.

“It used to be that the television ratings companies made you fill out a log of everything you were watching,” he explained.  “You had to write down each program and mail the log back in.  If you didn’t do that, no one knew what you were watching.”

“If your three-year-old wandered into the room and turned on cartoons, he’s not going to be filling out the log.  Or what happens when you changed the channel in the middle of the news on Sunday because it was boring?  Would you fill out the log again?  Probably not.  So that becomes data that is lost and can’t be used.”

Television giants, and the companies that serve them, figured out long ago that automating the process of collecting that data would ensure a comprehensive, objective, and accurate set of information to use for their decision making, and invested in developing technologies that make TV show monitoring a completely passive process.

“These days, they have a gizmo that goes on the TV set to figure out who is in the room, what channel they’re watching at what time, and how many programs they have flipped through,” said Nussbaum.  “There’s nothing the participant has to do in order for that data to be collected.”

The challenges and opportunities involved in collecting patient-generated health data are no different, he argues. 

“If I ask someone to record their exercise and sleep patterns in a log, I get mediocre data,” he said.  “It’s inaccurate or it’s incomplete.  But if I’m recording it off their smartphone or tablet, I’m definitely going to know when they went to bed, when they put down the iPad and stopped reading.  I’m going to use a wearable to learn about their sleep patterns or their breathing patterns, right?”

“By using these devices, I’m going to get a lot more data that is a whole lot more reliable than asking a patient to do it manually.  It removes one of those huge barriers.”

Moving from passivity to personalization

Unfortunately, even the most perfectly executed, entirely passive IoT ecosystem might not satisfy patients.  Collecting data is one thing, but patients want to know that their efforts – as minimal as they might be on a daily basis – are paying off.

Patients aren’t the only ones who have to demonstrate commitment to the cause, Nussbaum says.  “You have to give feedback from these activities.”

“The patient wants to be able to look at the nice little graphs and charts that of her sleep data and draw her own conclusions about her habits or her problems.  She can point to the information when she sees her doctor and ask informed questions about it.  It involves the patient.  It’s bidirectional.  That is very important when it comes to engagement.”

The JMIR survey also highlighted the thirst for personalization among IoT users.  “A major theme was that participants wanted apps to provide more specific and personalized recommendations, regarding exercises/activities and what to eat than are currently available,” the study said.

“For instance, a number of respondents noted they wanted an app to assess their health history, and for the app to tell them what exercises they should do and what they should and should not eat.  Generally, they wanted apps that helped them reach specific exercise and nutrition goals rather than just ‘lose weight.’”

Getting providers on board with PGHD

While traditional providers might argue that providing personal recommendations for patients falls squarely under the purview of the physician, and that developing an individual treatment plan requires a great deal more expertise and knowledge than the typical 99-cent app can deliver, other clinicians are happy enough to have as many tasks taken off their plate as possible.

Providers have generally been split down the middle when it comes to the real-life benefits of patient-generated health data and the IoT.  In theory, the idea is a good one.  Surely no physician would turn down the chance to have a comprehensive, real-time report on all their patient’s vitals and activities delivered directly into the workflow with no effort required on either side of the equation.

But the reality of the current PGHD landscape is very different, and developers have had their work cut out for them when it comes to convincing providers that the IoT is worth the investment.  

Patients aren’t the only ones who put a premium on passivity, Jonash points out.

“The number one reason why clinicians don’t like PGHD is the hassle factor,” he said.  “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.  They want to see digital therapeutics incorporated into a better way to deliver medical care.”

That hasn’t happened yet, as researchers from Stanford, the University of Florida, and Medical College of Wisconsin illustrate in a study on the difficulties of integrating PGHD into the clinical workflow. 

Using a pain assessment tool developed for use with the Epic EHR at the University of Florida Health System, the researchers collected provider opinions about how well a patient-facing questionnaire could collect accurate, meaningful data about the patient’s quality of life.

Their comments were generally negative, and included many concerns about the time it would take for busy nurses or physicians to administer the assessment within the confines of a typical visit.

Some of the responses centered on the fact that asking patients about ongoing pain could be distracting if the visit was supposed to focus on an unrelated acute issue.

“The [schedulers] would not want it to be that the patient only comes in to discuss pain when they were actually calling to make an appointment about something else,” one participant said.

“[Providers] don’t want to know about a patient’s depression if they are coming in for a sore throat,” said another. “If it is chronic pain, then they are okay with knowing about their depression.”

Even with a system that was specifically designed for a particular EHR to address a concrete issue, providers had deep concerned about whether or not the time and effort required to add patient-reported outcomes into the clinical workflow would produce measurable benefits.

If such a tailored tool can’t excite providers about PGHD, is there hope that third-party IoT applications could ever measure up?

Once again, the question boils down to passivity, usability, and the ability to deliver personalized results where and when they are required. 

“For electronic health record-integrated patient-reported outcomes to succeed as useful clinical tools, system designers must ensure the clinical relevance of the information being collected while minimizing provider, staff, and patient burden,” the JAMIA study concludes.

If the healthcare Internet of Things can break through the twin barriers of passivity and relevance, it may have a hope of convincing both providers and consumers that patient-generated health data is worth the investment.  Until developers manage to achieve this lofty goal, however, providers may dismiss patient-reported data as much ado about nothing.

Engaging users on both sides of consult room will not be easy, but technologies that focus on delivering the maximum impact with the least possible effort are likely to see the most success in this new IoT environment. 

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