During the Voice.Health Summit in Boston last week, innovators gathered to explore opportunities, discuss issues and to experience different voice technology use cases.

BCH John Brownstein shares voice health use casesJohn Brownstein, Chief Innovation Officer at Boston Children’s Hospital is excited about the opportunity for healthcare to lead other verticals with this empowering technology which many of us use every day – Alexa tell me… Siri what is… ?

Since the year 2000, the health technology industry has evolved from websites (e.g. patient portals) to mobile applications (mhealth) and now to voice and conversational assistants. There are many use cases which help patients and providers in different settings.

• In hospital, the doctor asks to see the patient’s latest lab results.
• Following a hospital discharge, the patient interacts with his virtual robot to record side effects from his new medications.
• Preparing for an outpatient visit, a patient verbally responds to the pre-visit questions to share with her doctor.
• Days after a remote monitoring visit, a patient asks additional questions to help her manage her asthma.

Although voice health technology is in the early adoption stage, health innovators are convinced that these virtual voice assistants can address real problems -- the shortage of healthcare professionals, clinician burn out, inefficiencies in patient care, lack of patient engagement and the inability to personally support patients along their health journey outside of the hospital. Nuance’s Peter Durlach stresses the importance of using these technologies to free up the clinicians to take care of patients.

Voice has many unique benefits for healthcare. Dr. Rupal Patel, CEO VocalID describes the convenience (e.g. hands free), the capability to capture information and insights about the user (e.g. gender, size, bio- markers) and ability to generate trust through continuous listening and personalized responses. Other benefits include the ability to capture context (e.g. surroundings, urgency and intent) and empower the user (e.g. patient feels a sense of control). Amazon’s Emily Roberts, Sr. Marketing Manager adds the value of capturing “moments of the day” by incorporating voice into other devices (e.g. smart home/refrigerator, car).

Voice Health in Action

During the Voice.Health Summit, we saw what “voice-first” can deliver in five different care setting exhibits. Here are some interesting examples of use cases to bring value to patients and/or the care team.

1. Hospital/Patient. With the Joint Commission’s focus on “accurate screening and assessment of pain”, Dr. Samir Tulebaev, Geriatrician and the Center of Nursing Excellence at Brigham and Women’s Hospital are working with Orbita’s CEO Nate Treloar on the development of a post- operative pain management voice assistant. The patient tells her bedside teddy bear Briggie (which has a built in microphone) that she is in pain, describes where the pain is and indicates if the pain is intolerable. Her nurse immediately receives a secure text message to respond.

2. Hospital/Clinical. Cedars-Sinai uses Sopris Assistant to record, summarize, approve and place the patient care note into the EHR. The AI summons the listening technology, drives the summary and produces the intelligent note for physicians. Cedars-Sinai helped Sopris Health create an experience and workflow catered to hospitalist.

3. Senior Living & Home Health. Caregivers can engage an aging patient with the AI powered LifePod virtual assistant which serves as a personalized companion, delivers reminders, and monitors daily activities. LifePod’s CEO Stuart Patterson emphasized the importance of “proactive voice” which shares and captures essential information without relying on the person to ask (i.e. reactive voice).  

4. Consumer Home. Anne Weiler, CEO Wellpepper, the winner of the Alexa Diabetes Challenge, engages a patient who is recently diagnosed with type 2 Diabetes. She uses her voice to weigh herself, scan her feet for ulcers and track her care plan tasks. This voice assistant gives the patient an opportunity to proactively engage whenever she wants.

5. Vocal Biomarker Lab. Sonde Health is interested in capturing and using a patient’s voice samples as health measures for different physical (e.g. sinus congestion) and mental health conditions (e.g. depression, suicide risk). 

Lessons from Voice Health Innovators

As with any new technology, there is a lot to learn from the pioneers.

Real Problem Definition: Sara Holoubek, CEO Luminary Labs emphasized the importance of deciding who (e.g. newly diagnosed) and what (e.g. help with self-management) as a first step to focus the development planning process.

Patient/User Input: Deloitte's Debbie Hays, Specialist Executive discussed the patient journey research for the DeloitteASSIST voice solution which revealed the “challenges and delays” that needed to be addressed while the patient is in the hospital room.

Patient/User Feedback: Karin Beckstrom, Sr. Product Manager ERT Innovation Lab (formally PHT) described using voice to capture patient reported outcomes (PROs) on a daily basis. We ask-- how engaging was it? Are you willing to answer questions on a daily basis? How difficult was the skill? Did Alexa understand you?  

"Flu Doctor" from Seattle Children's Hospital Stacey UlaciaPersonalization: Stacey Ulacia, Sr. Communications Specialist at Seattle Children’s Hospital in partnership with Boston Children’s Hospital, developed the “Flu Doctor” voice skill. This brings more value since it is customized based on the zip code provided by the patient.

Opportunities for Voice to Solve Healthcare Problems

There are many use cases for voice technology to help drive the triple aim. 

UPMC’s Dr. Shivdev Rao believes it would be valuable to use voice to help triage a care situation, and capture information from the patient pre or post exam.

Boston Children’s Hospital Dr. Docktor shared Pediatrics Voice Hackathon examples including one which uses voice to help a patient prepare for his procedure at home with instructions and images that are tailored to his specific health issues (e.g. food problems).  

Cedars-Sinai Medical Center in Los Angeles is collaborating with Sumeet Bhalitia, Founder & CEO Avia to bring voice into the hospital room, giving the patient control over their experience and the ability to get assistance as needed (e.g. bathroom help) with the goal of increased patient satisfaction.  

Recent metrics for Answers by CignaCigna’s Laura Schuntermann, Global Head of Digital Strategy & Partnerships is excited by the growth of voice search. Gartner predicts by 2020, 30% of searches will be voice activated. Laura shared results from the voice solution Answers by Cigna which helps members get the information they need to make better health care decisions.

Novartis’s Robert Stevens, Executive Director of Digital Strategy & Medical Innovation described voice health use cases that help clinicians determine the diagnosis/clinical decision support, check guidelines, send RXs to pharmacy and order follow up patient education.   

Future Voice Health Considerations

Although there is excitement around voice health, innovators are working to remove speed bumps to accelerate adoption:

Addressing Privacy/Security. Several organizations are anxiously awaiting for HIPAA compliant voice devices. There is also a concern that the device is always listening, even without the “wake” word.  

Educating Patients about Voice. A few presenters admitted that patients do not know what they can ask. This means that either they are not using all of the voice capabilities or the patient has an unexpected experience -- Alexa says …. Hmm I do not know that one.

Mayo Clinic's Optimizing Voice Content Creating complete Patient Experiences. Mayo Clinic’s Jennifer Warner, Sr Editor Global Business Solutions explains that voice is additive and does not replace other consumer engagement methods. Therefore, it is important to provide an “omni-channel” experience to engage and support the patient through every touch point. 

Collaborating on Care Design. Maia Ottenstein, Digital Experience Design at Thomas Jefferson University Hospital (DICE/design group within the hospital) is working on the “smart patient concierge” which empowers the patient to access assistance and resources on demand.

It will take a community of patient and clinical stakeholders to define, design and deliver voice technologies that bring real value to the users. It is encouraging to see that these stakeholders are coming together in hospitals, accelerators and innovation hubs to bring these voice technologies to life.  

It all started with a simple question one day, and grew into a trusted health relationship a few short months later. Sarah was very busy at work that crisp fall morning and had only a few minutes to log in and ask about her daughter’s diabetes medication. Sarah was comforted by the response and a bit intrigued when her Health Assistant Harriet introduced herself and explained that she is a resource to help her and her family with any of her health questions or concerns. They began a conversation about her daughter’s condition and a trusted relationship began.

Later that week Harriet made a follow up call to see if Sarah was able to pick up her daughter’s medication and asked how everything was going. Sarah mentioned that she finally got her daughter’s pills and confided that she was completely overwhelmed. Sarah shared that she was recently diagnosed with breast cancer and that her husband was often unavailable as he traveled constantly for work. She explained that she had a hard time getting to her treatments. After their call, Harriet explored and evaluated resources, and scheduled transportation to help Sarah get to her next appointment. Harriet put the appointment confirmation into Sarah’s patient portal and set up a reminder, including date and time, about the ride to her next treatment.

This may sound like fiction in the current healthcare environment, where services are siloed and patients are burdened with making their own decisions around healthcare – often complex and costly. Sarah is relieved to have this service today. She first learned from her employer about the Accolade platform and health advisor service last summer. It wasn’t until she reached out with a simple question to her health assistant that Sarah experienced the true value of having a healthcare advisor on her side.

A 2016 Harris Poll reveals that 84% of working families placed a value on having a single, trusted resource to help support their healthcare needs. Busy families have limited time and resources so they appreciate having one place to go to help them understand their options and sort through their healthcare decisions. 

Personalized Patient Experience

With the Accolade Health Assistant as the single point of contact for her family, Sarah is able to reach out to Harriet for guidance all along her and her family’s healthcare journeys.  Accolade integrates high tech and high touch to deliver a superior patient experience with lower healthcare costs. 

Accolade Health Assistant Harriet accesses the Accolade platform to interact with and personalize her support for Sarah:

Preferred Communication: Harriet engages with Sarah and her family based on their communication preferences. Sarah likes phone calls and email through the Accolade online portal. Sarah’s husband Sam prefers secure text messages since he can send quick messages and follow up later during his business trips.  

Personalized & Proactive Experience: Harriet’s interactions with Sarah are driven by rich patient profile information, which contains contextual information, social determinants of health and service utilization. Sarah and her family’s profiles are updated with data collected over time and more than 150 data feeds integrated into the Accolade platform. The HIPAA-certified approach creates profiles that are continuously analyzed through sophisticated algorithms and health assistant reviews, which allow for personalized conversations around individual health needs, care gaps and obstacles.

A recent Accolade platform trigger prompts Harriet to reach out to Sarah’s husband Sam when she notices that he is still refilling this pain medication many weeks after his knee surgery.  Harriet sent a text to Sam to inquire about his knee surgery. After a text exchange, Harriett suggested that he see his doctor to discuss his persistent pain.

Patient Education & Connected Health: Sarah and her family can access educational information and recommended health apps. Before Sarah’s husband knee operation, Health Assistant Harriet texted Sam with a link to a video and suggested questions to prepare for his surgery and provider discussion. 

When Harriett spoke with Sarah about her daughter’s diabetes appointment and care plan, Harriet informed Sarah about the Livongo mobile diabetes application available through her employer’s health plan. Together, they review the Livongo app, which can help Sarah and her daughter better track and manage her diabetes. With Accolade and Livongo, Sarah is able to share information from the mobile app with her daughter’s doctor, giving him insight into her problems with controlling her A1C levels.

Continuous Connection to Clinical Resources and Support:  Harriett asked Sarah if she would like to speak with an oncology nurse to help prepare her for her upcoming oncologist appointment. Margaret, an Accolade Clinical Health Assistant and RN, joined them on the line and offered empathetic support by asking more about Sarah’s diagnosis, where she was in her care plan with her doctor, whether she had a support network and what was planned for her next appointment. Margaret provided Sarah with questions to ask her oncologist and recommended a follow-up discussion.

Intelligent Engagement: Harriet and her Health Assistant team are continuously alerted by the Accolade platform. On an ongoing basis Accolade gathers, aggregates and models de-identified data to trigger alerts and guide Health Assistants in further personalizing their interactions with their clients.  Health Assistants are prompted to ask questions about health behaviors and emerging symptoms, applying specialized training and skillset. 

Patient Experience Success Measures:

Paul Csigi, Director of Benefits at Philadelphia- based Temple University Health System (TUHS), rolled out the Accolade solution in 2015 and has over 7,000 employees on the platform today.  “So much of healthcare is getting people to the right place at the right time. Accolade has created an experience where our employees build a relationship with an assistant that gives them what they need, when they need it. Accolade takes a single problem that the patient has called in about and creates a relationship to support the family on an ongoing basis. With all of the information about our employees, Accolade addresses the whole person, connects the patient with clinical resources, and continues to reach out. This helps treat our employees sooner, which is less expensive for our organization.”

In addition to financial measures, TUHS monitors qualitative feedback from employees. With the Accolade platform outreach (phone or online), TUHS is able to capture the patient’s experience engaging with their Accolade Health Assistant:

“I'd like to thank Temple for the Accolade program. We have been going through some really tough times…..my health assistants have been a big support and a big help to my family in helping to guide us to the right doctors to help with family issues and illnesses. I really appreciate this program. Without it, I'd really be lost.”

With two years of the Accolade solution under their belt, Paul Csigi and his team are considering new ways to support TUHS employees. “I have an employee population with diabetes and heart disease. I am interested in learning more about Accolade’s partnerships to bring patient data into the platform to support these populations.”  Csigi sees the benefit of bringing in data from patient devices and smart applications. Integrating this data with the patient’s medical record gives new insights to Accolade Health Assistants, empowering them to deliver even better support and drive improved outcomes.

Dartmouth-Hitchcock (D-H), an innovative New England healthcare system with 1,000+ providers is committed to creating a “sustainable health system”, which proactively engages patients through new care models to achieve the triple aim.

Over the years, D-H has invested in technologies that empower patients to collaborate with providers through shared decision tools and Telehealth, treating “patients and their families as partners in care”.

D-H has been a pioneer in innovative payment models with both the government and commercial payers.

In early 2015, D-H’s leadership team committed to create a truly patient-centric healthcare organization, which delivers high quality proactive personalized care to the patient beyond the hospital walls.

“Dartmouth-Hitchcock purposefully set out to assemble a team of employees with backgrounds from other consumer industries like hospitality and retail that would augment the world-class capabilities of our clinical staff, to improve the health care delivery experience”, explains Vin Fusca, COO, ImagineCare.

With their consumer- centric “healthcare without boundaries” vision, D-H management has designed a truly “care- driven” solution.  ImagineCare, a cloud- based platform, enables providers to closely collaborate with each patient to meet her care goals at any time and from anywhere.

ImagineCare treats the patient holistically through the active and passive collection of a comprehensive set of patient data. In addition to condition specific evidence-based care pathways (i.e. ImagineCare Hypertension Pathway, COPD Pathway, CHF Pathway, Diabetes Pathway), D-H incorporates a “Core Health Pathway” to capture steps, heart-rate activity, sleep, and stress (Behavioral Health), providing contextual insight into the patient’s health.  

With ImagineCare, the Provider and patient have a window into the latest health status for insight and action. In the background, ImagineCare collects information from the patient (i.e. sensor- based devices, apps), combines it with EMR data (i.e. patient visits, labs, meds) and processes it through complex clinical care algorithms with machine intelligence to pinpoint when the patient is at risk. High tech meets high touch when ImagineCare notifies the RN or Health Navigator to reach out to the patient for real-time support and intervention. 

“ImagineCare leverages the best available technologies to assist with care, but does not replace the importance of the human touch to drive behavior change. ImagineCare seamlessly combines these components to help patients achieve their health goals”, shares Dr. Ethan Berke, Chief Medical Officer, ImagineCare.

 Patient Experience

During her recent doctor’s visit, (patient) Pam decides to participate in D-H’s new ImagineCare Program to help her lose weight and proactively manage her hypertension.

Within 48 hours, Pam receives an email to quickly enroll in ImagineCare and a welcome call to discuss her personal health goals. Two days later a personalized ImagineCare Kit (box) is delivered to her door containing a program overview, a wireless blood pressure cuff and an activity band, devices which fit her selected health goals. Pam follows the instructions to connect her devices to the ImagineCare app.

During enrollment, Pam’s shares her profile information such as personal health goals, challenges, communication preferences, family support, and defines her “medical neighborhood” (i.e. Providers, pharmacy, caregivers). She adds more information when responding to daily questions to create a rich picture about her health needs and resources required to tackle care plan activities.

Anxious about her attempts to lose weight, Pam indicates in the mobile app that she only wants to receive texts to help her stay on track with her weight-management goal.

Through the ImagineCare mobile app, Pam answers daily questions about how she is really doing, while her wireless blood pressure cuff and activity band retrieve and send real-time measures. Pam receives nudges, encouraging messages and digital check-ins to ensure she stays on track with her care plan. Yesterday’s text asked Pam if she was okay since she hadn’t provided her blood pressure as expected.

D-H’s RNs and Health Navigators continuously monitor Pam’s health status, review her trends, and respond to risk warnings by reaching out via text which is her communication preference. Since Pam designates her daughter as a personal health representative within the mobile app, ImagineCare’s RNs are permitted to speak with her about Pam’s health.

ImagineCare Success Measurement

ImagineCare is designed to empower a health care organization to right-size provider visits, lower ED utilization and decrease admission and re-admissions. ImagineCare provides a more engaging solution to help health care delivery systems increase quality of care, decrease cost and improve patient experience.  

In addition to these quantitative measures, D-H actively gathers qualitative patient feedback to understand the patient experience. Comments from patients about engaging in the ImagineCare program include:

“I monitor my blood pressure every day, and after a particularly stressful day at the office I went home, took my blood pressure, and five minutes later one of the nurses called and talked me through an immediate care protocol.”

“It has improved my ability to manage my health…The ability to connect with people for support and also send information to my healthcare providers, makes it easier.”

"I am extremely impressed with the ImagineCare phone app. It is very easy to use and seems very intuitive”.

ImagineCare Future

ImagineCare is constantly updating its services and products based on patience engagement data, clinical data, and new technological capabilities coming to market. In a digital health landscape that is becoming more fragmented, ImagineCare will continually create holistic, customer-centered health services to better care for patient populations.

D-H’s team has packaged up the ImagineCare platform for other providers, payers and (self- insured) employers to deliver personalized patient care for better outcomes.  

With the shift to value- based care, health systems are investing in mobile technologies to increase patient engagement and care quality while reducing the cost of care delivery.

Geisinger, an award winning healthcare system based in the Mid-Atlantic with 12 hospitals and a 510K+ health plan, is a leader in patient engagement. Within their organization, the Geisinger in Motion team focuses on strategic initiatives to drive patient engagement by co-creating with patients on digital technology solution design, capabilities and efficacy.

Geisinger’s digital patient engagement initiatives are designed to support three key strategies 1) “understand my health”, 2) “manage my stay or visit” and 3) “control my condition (or specific acute episode)”.

Last fall, the Geisinger in Motion team embarked on a project to enhance their patient education resources, which spans all three patient engagement strategies. Although they already offered a comprehensive set of patient education materials (i.e. handouts, online resources, targeted classes, individual conversations), Geisinger was looking to expand the reach of these resources for patients and their families. 

“The genesis of the idea came from a pilot for patients that were having Lumbar Spine surgery”, explains Chanin Wendling, AVP, Geisinger in Motion. Geisinger focused on this patient population because of the prevalence back pain problems across the nation, the volume of surgeries done annually (approximately 2,000) and high patient co-pays for the surgery.

“For this pilot, we loaded 10 iPads with educational content and loaned them to patients for about 4 months during the time before and after surgery”, Wendling shares. “After the pilot, we realized that we needed to come up with a different approach. CMS prevented us from giving the iPads to their patients, a critical population that we didn’t want to exclude.  In addition, it was very expensive to have enough iPads for all patients and took a lot of work to get the iPads back.”

From the pilot, Geisinger also learned that patients wanted to use a device with everything on it. After evaluating different mobile tools, Geisinger elected to use Apple’s iBook and iTunes University to conveniently package a set of patient resources in one place and enable patients and their families to easily access and consume education content when needed, pre and post- surgery.

Geisinger began by bringing together existing components into the iBook.  ”We had built a number of tools over time and were trying to leverage what we had to deliver a full ‘patient engagement package’ solution”,  adds Wendling.

The Lumbar Spine patient education solution encompasses:  

• Comprehensive set of interactive videos, animations, images  
• MyGeisinger Patient Portal- 350k+ users with access to their patient record, visit notes and pre-visit prep
• MySurgery: Lumbar Spine reminder mobile app – Developed for the iPad loan pilot, this app reminds the patient of activities that need to be done pre and post- surgery
• Health (electronic) questionnaires for Lumbar Spine outcomes & medication reconciliation – These have been in place for a several years

Patient Education Experience & Engagement

When Geisinger patient Lisa decides to have lumbar spine surgery, she receives a handout explaining how to use her mobile device (iPhone, iPad) to access a suite of patient engagement tools through iTunes University or to download an iBook. Lisa’s friends and family can also access the educational materials to help her throughout surgery prep and recovery. The handout instructs Lisa to contact the Nurse Navigators listed with any questions.

Patient Lisa engages electronically with these educational resources which contain animations, videos and interactive components. She moves through the chapters covering “meeting the care team”, “learning about the surgery”, “diet and medication guidelines”, “what to do before surgery”, “what to expect day of and after surgery” and even ”Navigating the Geisinger Medical Center”.  

Within the course, patient Lisa is encouraged to download the Lumbar Spine App to receive reminders about pre and post- surgery activities such as diet and medication requirements, what to expect during the hospital stay, things to watch for post- surgery (e.g. fever), how to address pain, exercise and sexual activity. Three and twelve months after surgery, Lisa receives a notification and logs into her patient portal to complete health questionnaires about her Lumbar Spine recovery outcomes and medication. All of the information that Lisa enters flows into the EMR so that the care team can monitor her recovery.

“We have received very positive response from our patients who like accessing these resources all in one place. It helps by setting expectations, reinforces materials discussed at clinic visits, reminds them of important steps and gives them a reference to share with family and friends.  Since the 3 month visit tends to be difficult to schedule and not all providers feel it is necessary, the questionnaire responses let the team check in with the patient and follow-up if there is a need”, describes Wendling.

Geisinger has expanded this education offering beyond Lumber Spine with iBooks for Pediatric Concussion and NICU (for parents).  “Pediatrics was the initial area for our IPS project (iPads while patients are in the hospital). We learned about the high-volume of print materials that are handed out in the NICU and realized that we needed to give parents a better tool”, Wendling explains.  

The Geisinger in Motion & IT teams continue to tackle resource issues and have "more ideas than we can execute”. Currently, they are working through a set of operational issues for tracking and measurement: 

Activity Tracking-Fitbit/Withings: Although it was part of iPad pilot (e.g. 10 patients were given a Fitbit), it is not currently in iTunes University. “We are waiting on a project where the ability to get patient generated health data from wearables will be available in the patient portal and then can automatically be uploaded into the EMR”, Wendling shares.

Measurement: “We completed and posted the Lumbar Spine course in December with an access code but then had to work with Apple to get qualified as an education institution in order to make it available publicly. From iTunes University, there have been about 30 downloads of the Lumbar Spine, 20 downloads of each of the NICU books and 16 of the Concussion. This is a public system so it is really hard to determine who is downloading. We are using survey data to better understand the profile of our users”, Wendling adds.  

In the future, Geisinger plans to bring out bariatric surgery education through iBook and iTunes University. “Obesity is a significant health issue in Pennsylvania and the components around healthy weight and eating can also be used for other conditions such as diabetes, heart failure and hypertension. We hope this will be a building block as we expand our education resources to support patients and families”, concludes Wendling.

WELLBE PLATFORM FOR PATIENT ENGAGEMENTWith an aging population and increase in chronic conditions including obesity, the demand for hip and knee operation is increasing dramatically. A study in the Journal of Bone & Joint Surgery estimates by 2030 “demand for total hip arthroplasties to grow by 174% to 572,000 and demand for primary total knee arthroplasties by 673% to 3.48 million procedures”.

PATIENT CREATES CARECIRCLE ON WELLBEDuring the initial visit to the surgeon’s office, patient Patty is given information about Wellbe, a personalized care plan for her pre-and post-surgical journey. She signs up with the Nurse Navigator and receives a Welcome email. Patty shares this information and invites her family ‘Care Partner’ to join her CareCircle to access her resources.