Healthloop Virtual Patient Check in

Healthcare reform has placed increased demands on doctors who are already managing increased patient loads. As a result, doctors are spending less time with their patients.

Patients are being asked to take on more responsibility in managing their care. This is particularly challenging before and after a surgical procedure. A patient typically leaves the hospital with a stack of paper discharge instructions about medications, the follow- up visit and a list of symptoms to monitor with directions to contact the doctor if problems occur. Throughout recovery, the patient is often left to figure things out because she "doesn’t want to bother the doctor".  When the patient makes uninformed decisions about medications or readiness to begin an activity level, it can set her back on her recovery path or lead to costly hospital readmissions.

Other than checking in with patients during the follow- up visit, providers are in reactive mode; patients calling with complex problems or heading to the ER.

Since patient satisfaction, care quality and costs are impacted by the current process, providers are motivated to find a solution that virtually supports the patient's needs for guidance, education and shared decision making.

Virtual Patient Support

It all started in 2007 when Dr. Jordan Shlain was treating a patient who wasn’t feeling well. After discussing her symptoms, he gave the patient his cell number and asked to please call him if she felt worse by morning. He discovered a few days later that she had developed pneumonia. From this experience, Dr. Shlain learned that although he wanted to be proactive with his care, he couldn’t depend on the patient to call with an update. His began texting patients asking “do you feel the same, better or worse?” Dr. Shlain did not take any chances and assumed that a non- response from the patient indicated there may be a problem.

After speaking with providers about not really knowing how a patient is doing post discharge, they expressed interest in daily virtual interactions with the patient as a way to increase patient engagement and prevent readmissions. Patients loved the idea of interacting electronically with their doctor on a daily basis since it would give them unprecedented access to communicate concerns and address problems in a quick and convenient way. This was the backdrop that led to the development of Healthloop.

“Since late June, we have been using Healthloop for patients who have hip and knee replacement surgery”, shares Dr. Mohan, Surgeon for a large Integrated Delivery Network. “Our team was looking for a solution that would enable us to share the experience together with our patient. We also wanted to put the patient in the driver’s seat and give them control, while we were in the passenger seat as an observer and navigator.” Dr. Mohan’s orthopedic patients are on Healthloop before surgery and throughout recovery which tends to be 1-3 months.

Dr. Andrew Goldstone, ENT Surgeon at Greater Baltimore Medical Center started using Healthloop in February with his adult and pediatric patients throughout recovery which typically lasts 2-4 weeks. Healthloop electronic communications are delivered to the parents of his young patients for ongoing support. "HealthLoop, in a technologically modern way, tries to mimic the old days when we admitted patients a day or so before and kept them as many days as we or they wanted to stay after surgery. This gave patients and their families a comfort level that most current M.D.s have never witnessed. The same goes with patients who, after ambulatory surgery, pay at the next window and go home. They have no clue how patient friendly it used to be having an extended ’hand holding‘  before returning home. I view HealthLoop as an attempt to recreate that extended comfort,” explains Dr. Goldstone.

Patient Experience

HealthLoop enables the physician to support the patient before surgery and monitor him post discharge and between visits, engaging each patient “as if he is the most important person”. With the goal of delivering guidance when the patient needs it, Healthloop works closely with the provider organization to define the questions that patients ask at each step of the recovery process. Together, they review typical calls at day 1, 2, etc., determine the appropriate response and set up the schedule to deliver the information to the patient right when they need it.

Taking a closer look at the patient experience, Gary is referred by his primary care physician to a specialist about knee surgery. After deciding together to move forward with the operation, the surgeon quickly enrolls Gary in Healthloop to guide him before and after the surgery. Gary receives an email to complete his enrollment including his preferences for receiving Healthloop communications (i.e. email, text). 

Before surgery, Gary answers questions about risk factors and receives guidance and checklists to prepare for his operation. For example, he learns how to to prepare his house to easily navigate when he returns home following surgery.

After surgery, Gary receives a daily electronic communication with a set of questions to understand how he is feeling (i.e. pain level, specific symptoms, problems with meds, etc.), personalized education materials, activity and medication reminders and a checklist of To Dos. Based on Gary’s feedback and progress, his care plan is updated and his next day’s check-in is automatically prepared. 

Healthloop is designed for two way engagement. If Gary experiences any health problems, these are gathered through his check- in responses and trigger an SMS message to his care team for intervention and support.

With recent integration to Apple’s Healthkit, patient information is extended beyond daily check- in responses to include health tracking data. For example, Gary’s doctor has instructed him to take steps while healing from his knee operation. Gary’s tracker information is combined with his daily check-ins to give his care team more insight into his health status. Concerned about not enough movement, his clinician may call and learn that Gary is not moving enough because of his medication side effects which can be addressed through a prescription change. 

Pilot Feedback; Patients & Providers

Healthloop wants to deliver a truly patient- centric communication channel and uses patient feedback to enhance the solution. After hearing a patient comment that the messages felt “too robotic” and “do not sound like they are coming from my doctor”, the communications were refined to be more conversational.

Another patient commented that the messages were using doctor’s words which resulted in changes to incorporate more patient vocabulary and experience. For example, questions about a blood clot were replaced with “feels like a cramp in my calf”.

Patient Comments

Healthloop has delivered over 57,000 daily check-ins to patients and has received positive feedback about the experience:

Guidance: “I wanted to be able to say ‘I have this” and have someone come back and say that is normal and here is the process. Then all of my negative energy goes away”, “easy way for me to make sure that I was on the track with my recovery”. “The questions promoted me to be more aware of my situation”.

Convenience: “Without Healthloop. I would have called (doctor) 5- 7 times”, “This saved me a trip to my doctor”.

Access: “It was an extension of my doctor so instead of talking to a nurse and having her get back to me, I had a direct conduit to my doctor.”

Provider Comments

Healthloop Clinician Dashboard

“As our team developed our Healthloop, we charted out what a recovery really is. With this, I know what my patient is going through, can emphasize and say with confidence that over half of my patients have their pain under control after day 4”, explains Dr. Mohan. “We also participate in a Medical Destination Program with patients traveling to our hospital, often from out of state. After staying in a hotel for 10- 14 days, they come to see me for a follow-up visit before returning home. We are now thinking about how we can use Healthloop to manage their care from a distance to make sure that the patient has a successful recovery.”

Comments from other providers:

Patient Satisfaction: “My patients told me that they looked forward to their daily Healthloop check-ins because it felt like ‘someone was watching over me’ who really cared”.

Operational Efficiency: “For my practice, the volume of calls from patients has dropped tremendously. I notice it and my staff notices it too.”  “I am thinking about eliminating the 2 week follow-up visit and to just see the patient at the 6 week visit since I can check in on their pain management, incision and any other issues through Healthloop.”

Better Quality: “Helps us pick up complications much sooner. It reinforces a plan with what to do and reminders”, “We are raising the bar on care by ensuring that we are giving the patient the pre and post-surgery education and care that they need”.

Success Measures

Providers using Healthloop are evaluating a set of success factors based on their program goals. In addition to lower costs which is measured over time, providers are monitoring:

Patient Engagement; Patient Satisfaction using the net promoter score.

Better Quality; Benchmarking patient progress, measuring patient’s perceptions of care quality received

Operational Efficiency; Call reduction to the practice 

Regarding patient engagement, some providers are leveraging positive ratings through social media. Patients who give the highest scores (5 Star Ratings) are encouraged to share their ratings and experiences through the link provided to public review sites such as HealthGrades and Vitals. Patients who give average or below average score are asked to explain how the provider can improve. Patients have commented on everything from old waiting room magazines to being put on hold for too long when they call.

With Healthloop, “my patients tell me that they are happy with the surgery because I was right there with them. I also notice patients are much more relaxed during their follow-up appointments. That is so important to me”, Dr. Mohan concludes.

According to The Agency of Healthcare Research and Quality (AHRQ), an estimated “44 million people 18 and over suffer from mental disorders.” Further, “major depressive disorder is the leading cause of disability among adults”. This is a major concern for healthcare providers throughout the United States. As more patients struggle to manage their mental health condition, they are showing up in emergency rooms, where they are finding staff and systems ill equipped to deliver the specialized care that they so desperately need. This missed opportunity not only creates a negative experience for patients but also drives up healthcare expenses for providers.

Novant Health, one of the largest healthcare systems in the country (15 hospitals, 350+ physician practices in NC, SC, VA, & GA), is proactively helping behavioral health patients, reducing readmissions and preventing costly emergency room visits.

In 2013, Novant Health partnered with behavioral analytics company Ginger.io on a successful depression program in a Novant perinatal clinic. In 2014, Novant Health expanded the partnership with Ginger.io to address the unique needs of adult patients with depression by developing a customized care solution for this historically underserved population. 

Ginger.io Depression Patient Survey

The Ginger.io Behavioral Health Program initially enrolled patients who were already engaged in a partial hospitalization program or an intensive outpatient program at the Forsyth Medical Center. In an effort to complement the standard support groups and therapy 3-5 days a week over a 12-month period, Novant Health offers patients the continuous sensing smartphone. Patients download the smart phone app solution from Ginger.io to “connect the dots” between their behavior and their health and “stay in touch with the care team between visits”, according to co-branded patient communications from Novant Health.

The smartphone app actively collects information from the patient about symptoms and medication. Based on the patient’s specific behavioral health condition (e.g., depression), she receives personalized questions to gather a specific set of data. The mobile app also passively gathers data in the background on her mobility, social interaction and sleep patterns. The patient’s active and passive information is then combined and fed into Ginger.io’s analytics engine to identify which patients are in need of intervention and to share that information through an alert with care staff. After receiving a dashboard alert, a licensed mental health professional (e.g. nurse, social worker or case manager) contacts the patient to discuss what is going on in the patient’s life based on her responses and behavior—what Ginger.io refers to as a “behavioral signature”.

Novant Health is already receiving positive feedback and insights from both clinicians and patients.

“Most innovation in Behavioral Healthcare in the past 20 years has been primarily focused on pharmaceutical development,” explains Dr. Todd Clark, Director of Behavioral Health Sciences at Novant Health. “This was necessary for treating patients in the acute phase, but there has only been minor progress related to services detecting mental illness upstream. The Novant Health Innovation Team led by Matt Gymer has created a platform in our healthcare system to leverage the cutting-edge advantage of Ginger.io for our behavioral health population. Ginger.io has revolutionized our ability to connect with patients in real time, even remotely, and allows us to provide patients with the most appropriate and timely care. This not only puts the patient on the most optimal pathway for treatment and recovery, but it also increases the number of treatment options for the patient—rather than the overused default option of the local emergency department. Ginger.io has flexed to meet our system’s particular needs, and our patients have expressed a high degree of engagement with the service.”

Patients appreciate the opportunity to reflect on their mental state and the proactive contact they receive when experiencing challenges in their day-to-day life.

According to one Novant Health patient, “I look forward to the surveys. For the first time in my life I feel that someone truly cares if I live or not. Someone cares how I feel and helps me work through those feelings. I feel I have purpose in my life again.” This is a powerful endorsement from a community in need.

Ginger.io Behavioral Health Program Expansion

Novant Health expanded the program in June to an outpatient drop-in assessment center and mobile crisis unit and then again in September to psych inpatient and psych outpatient clinics. Although these patients come into care during a crisis moment, it is important that they leave with a new tool for ongoing support and empowerment.

Based on qualitative feedback Novant Health from the clinicians and patients using the mobile monitoring solution, care teams have decided to share historical survey responses and behavior patterns with patients through a provider-facing dashboard displaying past data and care alerts. Doctors/Care Managers can share this information with the patient to discuss behavior patterns, life situations, triggers and treatment plans. 

Novant Health recently rolled out the Ginger.io technology in their main Psychiatric Clinic in Winston-Salem. Psychiatrists are giving the smartphone app tool to their patients and viewing the dashboard to respond to patients in need. The doctors will also use the information gathered to enrich their conversation with the patient during their office visit. 

Novant Health continuously evaluates the value of the program through key quantitative metrics including patient satisfaction and engagement, operational efficiencies and outcomes improvement based on clinically validated measurements such as PHQ-9.   

In the future, Novant Health plans to extend the Ginger.io Behavioral Health Program to five other regional hospitals across their health system. The expansion is intended to deliver “a remarkable patient experience,” according to Matt Gymer, Corporate Director of Innovation at Novant Health.

Clinicians are interested in expanding the use of the Ginger.io platform to help them identify patients earlier, understand triggers for their symptoms and proactively provide needed support. This important behavioral health initiative aligns closely with Novant Health’s ability to innovate solutions to deliver proactive care to patients and customize services. 

Dr. Eugenia Chan sat patiently waiting for her fidgety first grade patient and her frustrated mother to answer her question. "How was the new medication working to help Janie with her ADHD"? Janie's mom hadn’t had a chance to fill out an ADHD behavior questionnaire in the chaotic waiting area, so she tried to summarize her impressions since their last doctor’s appointment a few months ago.  She hadn’t heard specific feedback from Janie’s teacher, and had also forgotten to give the ADHD questionnaire to her teacher so that they would understand how she was doing in school.

In 2011, Dr. Chan, MD, MPH, a developmental-behavioral pediatrician and health services researcher in the Division of Developmental Medicine at Boston Children’s Hospital, felt that she needed a better way to monitor her patients and gather insight into how they were doing with their medications and treatment plans.  With a grant from the Croll Family Foundation, Dr. Chan collaborated with Dr. Eric Fleegler, MD, MPH, a pediatric emergency medicine physician and health services researcher in the Division of Emergency Medicine at Boston Children’s Hospital, on the development of a new software tool, eDMC (electronic Developmental Medicine Center).

Their goal was to gather and interpret the information from parents and teachers more effectively and gain a more comprehensive view into patient behavior between visits. The doctor determines when the system will email the parents, typically a week or two before the appointment. When the parent receives the email with a link into the software platform, she logs in and answers a set of questions about symptoms, school performance, quality of life, global functioning and improvement since the beginning of the treatment. The parent gives the email addresses of the patient’s teachers and other important observers of the child (e.g., sports coaches, behavioral therapists, tutors) to the clinician to get them set up in the system so they can answer similar questions.

Clinicial InterfaceWith this information, Dr. Chan is able to determine how her patient is doing throughout the day, week and over time. During the visit, she shares this information with her patient and family, points out trends and discusses what has transpired. On the graphs, each line shows data from a different caregiver; parent, teacher and coach. The clinician can also drill down to see specific symptoms and their ratings that are incorporated into a score. With the treatment plan in mind, the clinician evaluates the data and focuses in on any discrepancies to determine what is really happening. This exchange supports her clinical decisions and enables her to participate in shared decision making with her patient and his family.

“I’ve already started using the system to work with my adolescent patients who want to go off their medications. When I agree to let them try coming off meds, I suggest that we use the questionnaires to monitor results. At the next appointment, patients are often surprised to view parent and teacher ratings and comments, that she was ‘disruptive’ or was ‘unable to pay attention’”, describes Dr. Chan.

Another feature of the platform is the ability to notify the clinician when there is a “red flag” patient problem that may require action (i.e. severe depression). Even though parents are made aware that this is not a real time monitoring system, there is someone responsible for ensuring that clinicians have seen the red flag alert.

Parent InterfaceSince the program started, over 3,000 pediatric patients have participated.  One parent comments on the value that she sees with the system, “it is very easy to use and I like that we save the time at the doctor’s appointment and all of the information is there”. Dr. Fleeger adds that the system “transforms how patients are interacting with their clinicians. At the appointment, the clinician can show them the graphs and tables on the computer to understand where they are and have a fruitful conversation”.   Dr. Leonard Rappaport, Chief of the Division of Developmental Medicine at Boston Children’s, says that the platform “is the first major improvement we have made in individualized care for developmental disorders in the past two decades.”

Currently the clinician can copy patient level summary information from the system into the EMR. Although the platform is web- based, Dr. Chan mentioned they were creating a mobile interface for access through smartphones and tablets.

Expanding ICISS Health; More Patients & Populations

In 2012, Dr. Chan and Dr. Fleeger renamed the platform the Integrated Clinical Information Sharing System (ICISS Health) to be more generalized for expansion into other pediatric patient populations.

 “We have extended the ICISS Health platform to additional clinics at Boston Children’s that treat patients with ADHD, as well as private practices affiliated with Boston Children’s, and we are expanding into new conditions such as autism, asthma, depression and epilepsy”.

For each new condition, they have convened a cross disciplinary team to define the data that need to be collected to support decisions. “For example, we are working closely with clinicians from the Boston Children’s Autism Center to devise a questionnaire for patients, since there is no standardized set of questions for this patient population” explains Dr. Chan. “For asthma, we would like to invite the school nurse to participate and provide insight into frequency of nurse office visits and rescue medication use by the patient, and whether they used the patient’s asthma action plan.”

The team at Boston Children’s is in the process of collecting information to evaluate the ICISS Health platform impact on patient health outcomes and healthcare utilization and costs. Dr. Chan also mentioned their interest in calculating potential cost savings from the platform by identifying problems early and intervening in time to prevent emergency department visits and hospitalizations.

“As we think about the future of the platform, we are interested in going beyond the electronic questionnaires to capturing and integrating information from devices and mobile applications”, Dr. Chan concludes.

Geisinger has been investing in mobile technologies to engage patients and their families in their care since 2011. In my blog post last year, I shared Geisinger’s texting programs, mobile data capture and experiences with their first mobile app to support Cardiac Rehab.

Geisinger continues to explore new technologies to involve patients and to improve the patient and physician interaction.  “Mobile apps are just another way to drive patient engagement. We think we will have better adoption by patients if we use technology that they have already adopted in their lives”, explains Chanin Wendling, Director, eHealth, Geisinger Health System. “Our goals are to improve patient outcomes and reduce costs.  We pursue patient engagement because of studies from folks like Hibbard & Greene 2013 and Veroff & Wennberg 2013 that show that engaged patients have better outcomes at lower costs.  We want to provide patients with tools that help them understand their condition and follow their care plans so they can stay as healthy as possible.”

Piloting Mobile App Supporting Bariatric Surgery 

Geisinger Get 2 Goal Mobile AppGeisinger began piloting their second mobile app Get~2~Goal in September, 2012 to help manage patients’ surgical weight loss expectation and provide a journal for tracking weight loss after the surgery. The Get~2~Goal app presents the patient with personalized weight management goals using her own entered data (e.g. age, weight, height). She can monitor her weight loss towards that goal and see how she is doing compared with other patients like her. 

The app was developed by Geisinger’s Obesity Institute in collaboration with Bucknell University’s computer science staff and students. 

Patients have shared positive comments including:

   “Great App! Surgery on Tuesday, so this will be a great motivator”

   “I like it. It's very helpful and lets you know whether you're on the right track or not weight wise. So far I'm doing above average. Woo hoo to us!”

The clinical sponsor for the Get~2~Goal project was Dr. Christopher Still, Director of Geisinger Obesity Institute and Medical Director for the Center for Nutrition & Weight Management. He uses the app when discussing bariatric surgery with his patients and, recommends that they download it to their mobile devices. Dr. Still has observed an improved patient/physician interaction when a patient sets realistic weight loss expectations with the guidance of the clinician. “This app allows patients and their physicians to discuss patient specific outcomes regarding gastric bypass surgery. It is important for both the patient and their physician to have real expectations and assess the risk/ benefit of the procedure.”

Building Mobile Apps Ourselves

In addition to experimenting with Cardiac Rehab and Get~2~Goal apps, Geisinger wants to expand into apps for different chronic conditions and set out to research the market. “We were disappointed with what we found. Most vendors had apps focused only on one chronic condition. Although vendors had plans to expand into other chronic conditions, we had a hard time picking a reasonable partner based on their stated direction”, Wendling explains.

Wendling feels the mobile health app market is still in the early stages. She explains that vendors are approaching her organization with a business model that just doesn’t scale. “If a vendor charges us a rate of $10+ per member per month, how do we make that work for patients with multiple conditions? We have over 75,000 patients with hypertension and 30,000+ with asthma. Although the app will not be appropriate for all of these patients, the costs add up rather quickly.”

After evaluating many mobile apps, Wendling points out that the patient experience is not thought through. She has asked vendors about how patients can personalize their app.  “I may be a patient who works night hours so why shouldn’t I be able to set the time of the reminders to fit my schedule? Also, why can’t I select the method of receiving the reminders, through email or text messages”, adds Wendling.

The final reason that Geisinger has decided to build mobile apps internally is because integration is important. “We’ve found that many solutions do not integrate with our EMR which is essential since we need to incorporate the patient information into our clinical workflow” Wendling explains. “Although it is not unusual that the early innovated apps do not integrate with the EMR, vendors do recognize that they need to get there.  So any app we purchase, we would most likely have to do the integration ourselves anyway.  We haven’t made any decisions that we will always develop our own apps.  If we see something out in the marketplace that works and we have the budget, we will go for it.  We just may need to wait a little longer until the marketplace matures.”

Mobile App Development Journey

As their first venture into internal mobile app development, Geisinger selected a simple procedure and defined key capabilities which are replicable across more complex procedures. With the new Colonoscopy mobile app scheduled to be launched next month, patients can prepare for their procedure through: 

• Education: explains what will happen during the procedure
• Shopping: lists can be created and transferred as a note to the mobile phone
• Reminders: for days before the procedure directing the patients to steps that need to be done
• Pictures: visual guides of their bowel movement during the preparation process

 “Geisinger’s colonoscopy mobile app is unique among health care related apps in that it provides a personalized experience for the patient.  From prep instructions based on scheduled appointment time, interactive ’am I ready for my procedure’ section to the ability to easily set reminders/alerts; this app takes advantage of a lot that mobile technology has to offer.  As a gastroenterologist, my hope is that this app will allow patients to feel more empowered and in control of their bowel preparation; typically the most difficult part of the colonoscopy experience. We know that with improved prep comes better outcomes and thereby, over time, lives saved. I feel that modern health care needs to embrace mobile technology as a rapidly growing and exciting tool to improve patient care”, explains Dr. Amitpal S Johal, Director of Endoscopy, Geisinger Medical Center.

“We are looking into other surgical procedures which can use this same set of capabilities. One area that we are considering is Vascular surgeries since we work closely with our Vascular department at Geisinger”, shares Wendling. 

Future Mobile Health Roadmap

As they look to the future, Geisinger is working on enhancing current mobile apps and is exploring the use of mobile to support patient care before, during and after a hospital visit.

The next version of the Get~2~Goal app is under development. Geisinger is improving the patient experience through a better user navigation, the capability for patients to enter their own weight loss goals, and the addition of recently developed calculations for other bariatric surgery outcomes (i.e. likelihood for remission of diabetes).

Geisinger is also looking into ways that mobile devices and apps can help patients pre, during and post hospital stay. They are starting with their Janet Weis Children’s Hospital which treats kids with complex conditions such as cancer, heart or neurological issues. Geisinger understands that being in the hospital is scary for the child and their family. “With mobile apps, children and their parents will be able to prepare for the surgery, use an iPad during their hospital visit to capture pain levels and then track their recovery at home”, describes Wendling.

In the future, Geisinger is planning for a personalized patient experience. “Our dream is to be tailored in our patient care.  Given the patient’s profile, s/he will have technology options and tools to gather preferences and schedules to guide the care plan. We want to use this information to also match the appropriate intervention”, Wendling concludes.

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