Online Decision Aids Save Money and Improve Compliance

A recent Wall Street Journal Article talks about the role of electronic shared decision making tools in improving treatment compliance and reducing costs. (http://online.wsj.com/article/SB10001424052970203674704574328570637446770.html?mod=djemHL)

The article speaks to the growing body of research which shows that both patients and providers benefit when patients are well informed and play a significant role in deciding how they are going to treat or manage their health conditions. When patients are informed of their treatment options and participate in the treatment decisions, they are more likely to stick with the treatment regimens and have more confidence in the treatment plan.

Decision-aid programs appear to save money in the long run. Studies show that when patients understand their choices and share in the decision-making process with their doctors, they tend to choose less-invasive and less-expensive treatments than they would have otherwise received.

Web Based Tools Improve Diabetes Outcomes

A recent study reported on the Canadian Medical Association Journal (CMAH) concludes that a web based electronic tool with personalized patient information that is shared with the patient and the provider improved diabetes care and clinical outcomes. ( http://www.cmaj.ca/cgi/reprint/181/1-2/37).

The study involved 511 patients and 46 family physicians and nurse-practitioners and offered web-based tools integrated with 5 different types of electronic health records, an automated telephone reminder system and a mailing of color-coded materials to half the study sample.

Sixty two per cent of patients improved with the intervention compared with 42.6% in the control group and intervention patients reported greater satisfaction with their diabetes care.

While we have much more to learn about the role of web based tool for managing chronic disease, this is another data point that suggests that these tools when properly developed, deployed and supported can improve clinical outcomes for consumers. It suggests again that personalized, web based, information and tools (information therapy) which are deployed in a manner that leverage the provider-consumer relationship can improve outcomes.

Patient Engagement, Stimulus Funding and Social Media

The $19B health care stimulus bill provides incentives for providers to install electronic health records (EHR) and for meaningful use of the data to improve health care.  The Department of Health and Human Services (HHS) has been charged with administering the HIT stimulus dollars. HHS commissioned a Health IT Policy Committee which in turn formed a Meaningful Use Work Group to define what constitutes meaningful use. Providers and vendors have largely been waiting for the definition of meaningful use before making any tactical and strategic decisions for the implementation of health care IT improvements.

Yesterday, (16 JUN09) the Meaningful Use Work Group published their proposed definition of meaningful use which could have significant impact on the use of social media to improve health care.. (See http://healthit.hhs.gov/portal/server.pt?open=512&objID=1269&parentname=CommunityPage&parentid=2&mode=2&in_hi_userid=10741&cached=true#MeaningfulUse). In the proposed definition, engaging patients and their families is one of the policy priorities. The objectives tied this priority are to provide access to patient specific educational resources by 2011, upload data from home monitoring devices by 2013, and patients have access to self management tools by 2015.

There are many companies that have developed social media applications that would help achieve some of these objectives. Companies like Voxiva (www.voxiva.com), and Cielo (www.cielomedsolutions.com) have applications for patient outreach from the providers office that are connected to EHRs.  Companies like Mycareteam (www.mycareteam.com) and Diabetesease (www.diabetease.com) have standalone on-line care modules for diabetes that are consumer driven — not connected to the EMR. And disease management companies such as Healthways (www.healthways.com) and Healthdialog (www.healthdialog.com) have payor and employer provided sites that provide online education and self management resources.

So which social media applications are positioned the best to grow as the stimulus dollars flow? I see five main elements of the definition that define the strategic opportunity:

1. The solution provides tools that engage patients and their families. This is really what social media is all about — engaging people through online tools. Successful applications will use all the available social media tools (blogs, chat, RSS, SMS, email, widgets, social networking, podcasts, media sharing, wikis, etc.). While some of the online applications I mentioned before use some social media tools none that I have seen integrate all of them into a total experience that engages through multiple modes.

2. The solution is personalized — read data driven. The best applications will be driven by clinical decision support systems or by the EMR. Remember, this is about meaningful use of technology so there must be some connection to the EMR for the application to help meet that objective. This will make it difficult for standalone consumer driven applications that help manage a condition to measure up.

3. Connected! The 2015 objective specifies the ability to upload from home monitoring devices. Connectivity needs to happen at both ends — at the EMR when the solution is prescribed and at home, work or wherever the consumer is through the phone.

4. Critical mass. Applications that are designed to educate or self manage only one condition will have a hard time surviving. If providers are going to integrate a social media application into their systems they will need to integrate it into their practice. A solution that provides patient engagement, education and connectivity for multiple conditions will have more value for the provider and will be significantly easier to implement and maintain.

5. Leverages the patient-consumer relationship. If consumption is the goal, the solution needs to be prescribed by the provider the way any other therapy is prescribed.  See posting on information therapy (http://socialnetworkingforhealth.wordpress.com/2009/06/17/enabling-change-through-information-therapy/)  or visit The Center for Information Therapy (http://www.ixcenter.org/).

While the definition is only proposed at this point I think it begins to frame the strategic opportunity for health social media applications. Should the definition be approved and implemented, EMRs and providers will become critical leverage points that could redefine both the distribution model and the product development needs for social media health applications.

Enabling Change Through Information Therapy

There is a lot of talk these days about consumer centered health — also referred to as patient centered health. Essentially the idea revolves around the concept that consumers or patients are the key heath care decision makers. This is more than semantics. It is a fundamentally different way to look at the health care delivery model.

Consumer centered health care recognizes that providers are only one source of information consumers will use to learn about their condition. Consumers can and do readily learn about their condition and the treatment options from the internet. It also recognizes that due to the growth of high deductible health plans, many consumers face different economic burdens with different treatment options. The ability to learn about their condition from many different sources and the potential for vastly different out-of-pocket costs for different options means consumers need be the key decision makers in their treatment plan. Consumers are essentially buying a treatment and like any other buying decision they need good information to make good choice.

The model of the past was a provider centered approach where providers were the decision makers and the consumers followed the decision. This may have been an appropriate care model when patients had few treatment options for a particular condition, had little information available to them and had minimal economic stake in the selected treatment plan. But things have changed. With the proliferation of medical technology there are now many different treatment options for a condition including drug therapies, medical technologies, surgery and behavior change solutions. Information about options is more readily available and each of these paths could have a different economic impact.

With the increasing adoption of high deductible health plans as cost savings measures, different treatment options carry different economic burdens. 20% of Americans now participate in some sort of high deductible health plan and another 15% or so have no insurance coverage at all. Consumers need to consider the outcomes but they need to consider them in the context of the cost. Surgery may be the most effective but it also may carry the highest risks and the greatest out-of-pocket costs. Drug therapy may be less expensive but may carry unwanted side effects and drug to drug interaction problems. Behavior change may be the least expensive but may be too difficult to initiate and maintain. Consumers need to make educated choices about the options and if behavior change is the selected path, consumers need to be committed to make the needed changes. They need to be committed to what they are buying.

Social media can help Consumers make better, more informed decisions by giving them more information about their options. Online video, blogs, social networks, online support groups and other social media provide information that people can use to make informed decisions. In most cases, these media provide the information in terms that the consumer can understand from people who have faced the same decisions they are facing. Unfortunately, some of these media have an agenda. As an example, Pharma companies support social networks for people using their drug. While these sites may present an unbiased view the tie to a particular manufacturer is a dangerous one.

The introduction of information therapy by the provider can support the shift to consumer centered health. We are all familiar with the term drug therapy where the provider prescribes a drug for a given condition. Information Therapy is where the provider prescribes information as a therapy for a condition. Information therapy could be shared decision making tools to help the consumer make a better decision on the options available. It could also be a behavior change plan to help a consumer define and comply with a plan to manage their chronic condition through behavior changes such as diet and exercise.

Information therapy prescribed by the provider provides three main benefits to consumers. First, it provides the information needed to truly assess and weigh the options available both from an outcomes and a cost perspective. Second, it can make less expensive treatment paths an option where they weren’t before. For example, information therapy that contains a personalized web and mobile driven toolkit for helping consumers self manage their diabetes or high cholesterol through behavior change could be just as effective and much less expensive than drug therapy. Without such a toolkit, behavior change may not work but with it behavior change is more likely to succeed. Third, it is integrated through and leverages the provider-consumer relationship so it strengthens the relationship rather than fragmenting it.

For information therapy to succeed it must leverage and be integrated with the provider-consumer relationship. It should support the relationship not fragment it. Consumers need doctors but consumers also need information to make complex decisions or to make difficult behavior changes. Doctors need patients to trust them but they also need patients to be committed to their treatment plan. They also need consumers to be educated enough to identify problems in the treatment plan. Information therapy can build trust, loyalty, awareness and commitment. All these are elements necessary for a successful relationship that grows and adapts.

Economics and technology are causing the shift to a consumer centered health care system and there is no turning back. The emergence of social media tools can make this shift a successful one if these tools leverage and are integrated with the provider relationship through the expansion of information therapy.

Can Social Networking Improve Care Management?

One of the biggest challenges in improving healthcare is to get people to take ownership of their health. Some state this challenge as health is more than a state it is something you do – it’s both an activity and an outcome. Taking ownership means both empowering and engaging people…empowering them with the information and the confidence needed to mange their health and giving them the vehicles that enable engagement.

While doctors and caregivers are in many ways miracle workers, the traditional business models they work from don’t often foster patient empowerment and engagement. In fact they too often produce the opposite effect — disengagement and dependence. Patients don’t have enough time with their providers to effectively transfer enough knowledge about their disease and how to best manage themselves back to health so they depend on the provider to manage the disease for them. The predominant reimbursement model that pays providers won’t pay them for the time spent to transfer this knowledge to their patients. So we are left at a stalemate — patients with out enough information to self manage and providers without the compensation model to provide the education to their patients that enables self management.

Social Media can break this stalemate by connecting people to an environment that both empowers and engages. Empowerment is a process that involves exchanging information with peers and experts. You give information that is valued by others and you take information that is helpful to you. That give and take feeds a cycle of empowerment and engagement that leads to better informed patients. On average a physician might spend a couple of hours a year over four visits with a diabetic patient while the patient spends the other 361 days a year and countless hours without much of a support structure. Internet based social networks focused on helping people manage their conditions can provide the support structure that makes those two hours with the physician yield better results.

Social support through peer and expert internet support groups has been a successful strategy for improving outcomes. Numerous studies support this conclusion. The World Health Organization in a 2005 diabetes study showed that participants in internet based peer support groups significantly reduced their HbA1C levels. A 2008 study of internet support groups for patients with rheumatoid arthritis, osteoarthritis, or fibromyalgia found that participants felt more empowered, better informed, had more confidence in their providers and better acceptance of their treatment. The study also found that 58% of participants visited the site daily and 93% visited at least weekly. The confidence and participation rates show that people participating in these groups are positioned to take control of their condition. They also show that internet support groups can enhance the medical home model by increasing confidence in the provider team and the prescribed treatment regimen.

Engagement through social networking empowers people become partners in their care and treatment process – to become full partners in their care team. Once they become full partners in their health they are able to take ownership of their conditions and possibly self manage with the help and guidance of their providers. The effect is to shift much of the responsibility of managing conditons from the providers to the newly empowered and engaged patient.

In conclusion, social networking enhances the medical home model and can produce better clinical outcomes by enabling patients to self manage their conditions and become fully informed and participating members in the care team. This participation can lead to the following outcomes:

• Better managed conditions leading to fewer complications
• Earlier identification of problems or conditions that require intervention
• Earlier identification of comorbdities that could lead to complications
• Optimum use of the care provider by enabling them to focus on patients that are not compliant or who need skilled intervention and less time spent with patients who are successfully self manging their conditions
• More confidence in the provider and treatments prescribed.

While more data needs to be analyzed and more studies may need to be done we see compelling evidence that the use of social networks when properly structured and deployed can lead to better outcomes. Over the course of this blog we’ll take a closer look at existing studies and deployment models to determine how social networks can be structured and deployed to produce better outcomes.

I welcome your comments.

Social Networking for Social Change

Social networks are permeating every facet of daily life.  Old high school friends are reconnecting on Facebook while CMO’s are promoting their brands on Twitter.  Unemployed workers are finding job leads through Linkedin while sites like Youtube and Digg continue to receive millions of visitors a day.  As the rise in adoption of social networking continues, how do we beging to analyze the impact of these new technologies in the healthcare sector? In particular, how do we make sense of these tools and how they can facilitate patient care, virtual support, and improved health outcomes?

The articles in this blog will attempt to explore the possible answers to these questions and more.  Stay tuned!