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.

In October 2012, Mercy Hospital Springfield of Missouri, and two other health systems launched a Centers of Excellence program with a major retailer to provide spine care for associates and their family members covered by the company’s medical plans. When an associate chooses to receive care at a Center of Excellence, they do not pay any out-of-pocket costs. In addition, the retailer picks up the tab for travel, lodging and food for the patient and caregiver. Mercy was chosen based on three factors: ethics, quality and value. Mercy Hospital is a Stage 6 Hospital in the HIMSS Analytics EMR Adoption Model (EMRAM).

The following October, Mercy Hospital Springfield added another contract with the Pacific Business Group on Health (PBGH), which includes large employers like Walmart and Lowe’s. This agreement established a Center of Excellence for knee and hip replacements.

With patients coming in from other parts of the country for various procedures, it became apparent to Mercy that patients needed some information before arriving in Springfield, Missouri. “One of the challenges that we addressed was how to effectively deliver patient education and a good patient experience when the patient is not in front of us,” explained Pam Holt, director of Patient Education and Care Management at Mercy. “We needed a way to empower remote patients with information about what will happen and what to expect during their surgery. Easing patients’ anxiety and ensuring they are comfortable is a top priority for us.”

Mercy selected EmmiEngage, a patient engagement solution which provides an interactive health information platform certified for Stage 2 Meaningful Use for Patient-Specific Education. Each patient in the Destination Program receives an email from Mercy. The email contains a unique link enabling access via the web or mobile to customized videos with simplified medical information. Patients can view the videos many times and share them with friends and family. “Some of our older patients may go to their adult children’s homes because they don’t have a computer or they just want to watch the video together,” said Holt. “Plus, the back-end system allows our clinicians to know if patients have reviewed the educational information. If they have not, we’ll reach out to ensure the patient gets that prior education and is prepared for surgery.”

When traveling for care, it is particularly important for patients to prepare for discharge before hopping on the airplane. “For example, if their bedroom is upstairs, they may want to use a spare bedroom downstairs during their recovery,” Holt explains. “This information helps them think about their needs ahead of time. In fact, that’s good preparation for all of our patients, which is why we use this tool for patients who are local as well those who travel here.”

EmmiEngage provides a personalized informative overview. It is not intended to take the place of conversations between the patient and their doctor, but instead supports the relationship between them. “At Mercy, we view the solution as a technology to relay ‘general treatment’ information in an approach that suits patients’ learning style. However, we know that each patient has a unique set of circumstances that will impact their surgery and only their doctor can deliver those specific instructions,” described Holt.

Patient Related Measures

Mercy greatly values patient feedback and the responses to the program reinforces the belief that this approach is working.

“I was very impressed with the presentation!  It was most helpful.  Some things I already knew and it gave me some new ideas of what I can do to help myself.  I have a lot more questions I will be asking my doctor the next time I see him.”

“The video was very informative and insightful. I feel I am going into this procedure with a better understanding of the procedure I am facing.”

“Rather enjoyed knowing what will happen and the risk involved. Very helpful overall”.

In addition to qualitative feedback, Mercy monitors specific patient related success measures. “We know that 85% of patients are consuming educational content through their portal.  Ten percent have asked questions and 15% have contacted their doctors after reviewing the educational information. From a patient experience standpoint, 80% of patients report that the portal programs answered questions that the patient would have asked their doctor,” Holt added.

Mercy clinicians also value using technology to support patients prior to their surgery. “Patients who view a program are more prepared for their procedure and have a better understanding of their health. The benefit is two-fold: it pays off in saved clinic time and helps the patient feel more comfortable about their care,” concluded Dr. John Brown, Mercy Family and Travel Medicine.

Patient education is a key component of Meaningful Use Stage 2 but also there is growing evidence that effective patient education can impact patient outcomes as well as improve patient engagement and satisfaction. Providing these tools for patients, whether remote or local, as part of a risk sharing agreement or through traditional reimbursement, is an effective approach to patient engagement.

In January 2013, University Hospitals Rainbow Babies & Children’s Hospital launched the Rainbow Care Connection, a pediatric accountable care organization (ACO) with a $12.7 million CMS innovation grant to support children in Northeast Ohio, a third are enrolled in Medicaid. This innovative ACO has developed several successful mobile health initiatives to drive care collaboration with patients as part of their Physician Extension Team. This blog focuses on two key mobile health initiatives; iPads Minis for children with complex chronic conditions and HealthSpot^SM, a community- based telemedicine kiosk.

iPad Mini For Care Collaboration

“We wanted to help children with chronic medical conditions, especially those who have difficulty speaking or getting around.  For children that cannot walk, it is challenging to get them to the office. By giving them an iPad Mini, these children are able to communicate with their care team including physicians, nurses, social workers and dieticians”, explains Dr. Richard Grossberg, Medical Director of University Hospitals Center for Comprehensive Care. “Our goal with this project is to reduce office and ER visits with this video connectivity.”

In partnership with UH’s Rainbow Care Connection, the Center for Comprehensive Care strives to pioneer innovative ways to support children with complex chronic conditions, which can often seem overwhelming from a family’s perspective. As medical care continues to grow more complex, healthcare professionals acknowledge that families may need support beyond the clinic and hospital walls in order to be successful.

Children with complex chronic conditions make up about 5% of children who access health care services but account for up to 50% of Medicaid dollars spent. “We were looking for an additional layer to outpatient care; providing families with an opportunity to manage less acute issues in the comfort of their own home”, Dr. Grossberg shares. “Launched in December 2013, we felt that video calls would be the most innovative and cost effective solution to accomplish this and have currently distributed 10 iPad mini devices to families.”

How do video calls work? A family uses their iPad mini to conduct a “video call” with the office. During their telemedicine visit, a Comprehensive Care nurse helps the family triage what is happening and can resolve or escalate care to a physician/nurse practitioner or acute care setting when needed. Additional applications of the video call are being trialed including conducting nutritional counseling and education by UH’s Comprehensive Care dietitians and therapeutic counseling completed by their Comprehensive Care social workers.

After the video call, the visit summary is documented and sent to the patient’s PCP.  If a video call is escalated to include an ED or hospitalization, the UH acute care team has full electronic access to all of the video calls and assessment notes.  Having the necessary tools to help guide a family though those moments when their child’s complex conditions go awry and help them overcome barriers to care is critical to helping families receive better care, achieve better health and gain a healthcare partner to share in their patient experiences.

HealthSpot^SM Station

UH’s Rainbow Care Connection aims to reduce ER costs by finding new ways to support patients who go the ER with minor medical problems.   

“Since we know that 70% of Medicaid patients in the ER can be managed in a less acute setting, we were looking for an alternative to provide access to care after hours. We wanted to test offering a solution in a community setting to see if this population would feel more comfortable getting after hours care in their own neighborhood rather than from a medical setting. We felt that telemedicine would be the most cost effective solution to accomplish this”, shares Dr. Andrew Hertz, Medical Director of University Hospitals Rainbow Care Connection. We had already piloted a HealthSpot^SM kiosk running in our clinic and were ready to place a kiosk into a community setting”, Dr. Hertz explains.

“We decided on the HealthSpot^SM kiosk vs other telemedicine units because of the incredible patient experience provided by the HealthSpot^SM unit, including diagnostic equipment and the ability to transmit real-time vital signs and physical images.” Dr. Hertz and his team thought carefully about where to place the kiosk. “We started with a zip code analysis of patients coming into our ER to select potential locations and met with Community Neighborhood Association Leaders to discuss options. We chose the Friendly Inn Settlement (community building) in Cleveland and launched the program in October 2013.”

How does the HealthSpot^SM kiosk work? A patient and their family members step into the fully enclosed kiosk with a medical assistant who helps support them during their high-definition video conference visit with the doctor who may be located a few towns away. “Our doctor is on the computer screen, with video and audio connectivity to instruments (i.e. scale, blood pressure cuff, stethoscope, otoscope, thermometer, dermascope, pulse oximeter) and decides which tools to use and when by unlocking the door at the right time. It is cool when they unlock it. It is magical to see the door open and the instrument there. Our patients and their families see what physician is seeing as they use their different devices. It is a wonderful educational experience”, describes Dr. Hertz.

Patients use the HealthSpot^SM kiosk to take care of minor ailments and get check-ups, as an alternative to an emergency room visit. A parent/guardian can accompany a child from age three to 18 during their visit to the UH Rainbow HealthSpot^SM station during weekdays from 5:30 – 11 p.m. and weekends from 1 – 11 p.m.

Since the launch of HealthSpot^SM, Dr. Hertz and his team at UH have met with over 50 patients, with problems including rashes, fever, strep throat and pink eye. 

After the remote appointment with the doctor, the visit summary is documented and sent manually to the patient’s PCP. “Our physicians currently document the visit on paper and fax it to the PCP who may be outside of the UH network. Over 50% of these patients are not in UH Rainbow’s system so we share their information like a retail clinic. We have an interest in having HealthSpot^SM integrate this visit information into our hospital EMR,” explains Dr. Hertz.  

“Anytime we can spend time with a patient in their own environment, we can better understand and address their needs.” Dr. Hertz adds that by understanding why patients choose the ER as their source of care enables his team to identify opportunities to change that behavior and meet patient needs.  Certainly, having after-hours access to quality care in the inner city is valued by patients since the ER is often their only after-hours option. 

Patients and family caregivers have had a very positive experience with the telemedicine visit within UH’s HealthSpot^SM  kiosk. 85% have indicated that if they did not have the HealthSpot^SM  visit, they would have gone to the ER. Over 90% would use it again. Here are some comments around value of the visit to them:

It's convenient and less time consuming.

I love the equipment and technology.

The one on one with the doctor.

That you get to see what's going on inside the little areas most doctors won't show you. 

Close to home and speed of service.

Very helpful for my community.

Future Opportunities for UH Patient & Family Engagement  

The team at the UH Rainbow Babies & Children’s Hospital Rainbow Care Connection is already planning ways to use the HealthSpot^SM kiosk to bring care access to other patient populations. “Next we want to use telemedicine to enhance access to care in rural areas, where there are not a lot of specialists or after hours care options. We are planning to place a kiosk in a community building or a school”, Dr. Hertz adds.   

In addition to expanding the HealthSpot^SM kiosks, Dr. Hertz is interested in finding patient engagement tools that will help patients receive care through their phones to support the lower social economic population that tends to own mobile phones rather than computers. “No one has developed the mobile app for patients to receive care through smart phones which would enable a ‘meaningful clinical interaction’,” concludes Dr. Hertz. 

Sharp HealthCare, a Malcolm Baldrige National Quality Award winner, continues to provide a superior patient experience by investing in technologies to bring better care to patients and their families.

Last October, Sharp Memorial Hospital, a Sharp HealthCare hospital, began piloting GetWellNetwork's Interactive Patient WhiteBoard™ in their cardiology unit to communicate and collaborate with patients and their families about their care throughout their stay.

"Our goals for the pilot were to engage patients in their care, deliver information they need, help them understand their treatment plan, provide a way for them to interact with their care team and prepare for their discharge,"  explains Verna Sitzer, MN, RN, CNS, Manager, Nursing Innovation and Performance Excellence at Sharp Memorial Hospital.

Patients use the Whiteboard to learn about their care team, their day (i.e. goals, schedule, discharge activities) and participate in the personalized communication area to journal and share information. Patients use their Whiteboard to see tasks that need to be completed such as viewing educational videos that have been ordered and filling in a discharge planning questionnaire. A summary of the patient’s education activity and discharge information is accessible to the care team for review and follow up.

Sharp uses GetWellNetwork’s Interactive Patient Whiteboard to help care providers engage, educate and empower patients along the care continuum. This patient-centered platform, delivered across mobile devices, computers and televisions, enables Sharp to implement a new care delivery model called Interactive Patient Care (IPC). Based on the premise that a more engaged patient is a satisfied patient with better outcomes, GetWellNetwork’s IPC combines the tools, process and people to activate patients in their care, transform clinical practice and advance key performance measures.

Pilot Insights

During the Whiteboard pilot, the Sharp team learned about the importance of enabling better communication between the care providers and patients. "Our patients wanted to have critical information and to be able to write down questions for the care team for a more meaningful interaction. Knowing what to expect and when to expect it is important for patients so we made this a priority in the design of the display,” adds Sitzer

One of Sharp Healthcare's big accomplishments was to connect the Interactive Patient Care solution to their EMR to capture the patient's engagement and document progress towards their discharge education plan. “Having this connection was an essential condition for launching the technology throughout the healthcare system. Providers are able to integrate patient education into their daily workflow using the EMR for ordering education videos and obtaining results of the education”,  explains Sitzer

Sharp Healthcare is in the process of rolling out the Interactive Patient Care solution to their other hospitals. Sharp Grossmont hospital implemented it early this year (February) and Sharp Mary Birch Hospital for Women and Newborns will begin this summer (July).

Sharp & Patient Engagement Framework

Last Fall, National eHealth Collaborative (NeHC) launched their Patient Engagement Framework. The Patient Engagement Framework is designed to guide providers along the path for meaningful use. Sharp Memorial Hospital has adopted this framework to further enhance the Interactive Patient Care Solution. Sitzer shares examples below and describes ways they are enabling patients to participate in the care process.

   Stage 1: Inform Me

'We use the Interactive Patient Care solution to send the patient messages about what we need them to do during their stay so they can play an active role in their recovery.  We have them watch a video on hospital safety when they are admitted and recommend other relevant educational information. We ask them if they would like to take a self-assessment of their risk for falling and provide them with a video about fall prevention”, describes Sitzer.

   Stage 2: Engage Me

Sharp Healthcare puts their patients in the driver’s seat and gives them the option of when they would like to be engaged.  Sharp has devised pathways to deliver and gather information from the patient. The 'discharge pathway' presents a set of questions when the patient is preparing for home to determine if there are obstacles that need to be addressed and confirm that all educational information has been viewed and understood.  "Our motto is 'when the learner is ready, the teacher will appear’," shares Sitzer. "We want to give our patients control over their recovery."

   Stage 3: Empower Me

By giving patients the information that they need, Sharp empowers them to participate in the care planning process, enabling them to ask questions of and provide answers to the care team. For example, patients are able to respond to assessment questions, message providers or services about their needs, or respond to focused surveys on their care or service experience. Their responses notify a provider to deliver patient and family- centered care.

   Stage 4: Partner with Me

Care pathways can be tailored to meet various health conditions such as heart failure management.  These modules rely on the patient partnering with providers to meet specific goals. For example within the heart failure module, patients must complete certain videos and comprehension questions to move to the next module or phase so that they get the necessary education and preparation for discharge.

   Stage 5: Support my e-Community

The Sharp Healthcare team is planning to use the Interactive Patient Care system to support patients after they leave the hospital. "We are working on ways we can use this system to provide the patient with personalized education information when home through online and mobile channels," explains Sitzer.

In the future, Sharp Healthcare would like to tie in health-related devices to gather and monitor information about the patient to provide support or to intervene when needed.

Pinnacle Health Social

mHealth + Telehealth World 2013- World Congress

July 24- 26, 2013 in Boston

Join our 2- hour Workshop to explore Social Engagement Strategies that activate consumers to participate in their health; sharing and tapping into peer lifestyle experiences and gaining expert guidance. You will see what healthcare leaders are investing in today, explore social eHealth opportunities for consumer engagement in the future and discuss how to launch a social strategy within your organization.

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• Learn about key Social Engagement trends including social segmentation, social connect (programs & experts) and social data
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Sherri Dorfman, MBA, Chief Executive Officer & Consumer eHealth Engagement Specialist, Stepping Stone Partners

Lucy Reynales, Director, Wellness Layers

Shelley Marshall, Web Marketing Manager, PinnacleHealth