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.

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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According to CDC research, over 30% of U.S. adults have Metabolic Syndrome, a set of five risk factors including high blood pressure, high blood sugar, large waist size, high triglycerides and low (good) cholesterol.