June 2015

Long on Potential, Short on Results
By Susan Chapman
For The Record
Vol. 27 No. 6 P. 20

A recent report characterizes patient engagement efforts as taking a backseat to other HIT priorities. Still, industry experts remain bullish on the concept's promise.

Mobile health (mHealth) technologies are becoming an increasingly hot topic in the health care industry, yet patient-friendly digital technology is lagging behind on the provider side. This slow evolution often leaves patients, physicians, and private-sector companies to embrace mHealth in their own ways, incorporating handheld devices and mobile apps into the health care environment, thus creating challenges for hospitals as they work to integrate the subsequent data into their existing systems.

Lack of Patient Engagement
Chilmark Research's "2014/2015 Clinical Patient Engagement Market Trends Report" reveals that health care organizations are doing little to engage patients between office and hospital visits through digital technology. According to a Chilmark press release, "The basic patient portal, often tethered to an electronic health record (EHR), still serves as the foundation for a majority of digital patient interactions. After interviewing several health care executives, clinicians, and over a dozen technology suppliers with established footprints in the provider space, Chilmark found a mixed market for new approaches to clinical patient engagement, where some provider organizations have yet to adopt even these basic patient portals, [while] others have begun piloting advanced, 'smart' tools."

The data show that patient engagement is not considered as high a priority for health care organizations as other activities such as analytics, integrating clinical networks, and addressing risk-based contracting. The research also reveals a marketplace that is unable to meet customer expectations, which have been shaped by banking and other industries.

The findings further suggest that health care organizations tend to "pick and choose multiple vendors in an effort to meet the diverse clinical and business needs across different departments and patient populations. No one technology vendor has shown an ability to do it all."

"The majority of today's market is operating at a kind of standoff. Provider organizations are relying on their existing vendors to lead the way on new engagement tools, while those companies have been reactive, not proactive, with their customers' engagement needs," said Naveen Rao, the report's author, in the press release. "The more innovative products—the mobile apps, cloud-based care plans, remote monitoring plays—are coming from outside traditional legacy vendors' purview. While some of the bigger vendors are showing signs of updating their products, we expect to see most legacy vendors follow a buy rather than build strategy to address market needs more rapidly."

Overall, the study concluded vendors did not fare well in creating records and offering mobile tools for patient use. For providers, it may be a case of being overwhelmed with other priorities, Rao says. "From what we saw in our research, the industry has a lot being asked of it in terms of requirement for reform. The industry is in a transition phase in that providers and facilities are going to become more and more responsible for outcomes," he says. "It's all changing, and that is causing a huge revamping of how medical practices are being run.

"For example, providers now have to pull together all the data elements relevant to one patient beyond just what is in the EMR. Then, if they're managing this level of care over a huge population, they have to decide who is at the highest risk of readmission, for instance, or of becoming more seriously ill, or at risk of other outcomes that can be very expensive. After they determine all this and prioritize how to manage the population, the engagement piece comes in. From that point, providers can decide what tools to use and how to educate patients. Engagement is the final piece of that process."

Rao believes mHealth is the ticket to creating that engagement. "In the past, there was no follow-up. Now, with mHealth, there is the ability to connect into the patient's home without being there. The data are real time or close to real time," he says.

In particular, Rao views the smartphone as a key to any success. "If the industry really wants consumers on board, then the health care system needs to leverage smartphones. It's not a question of if, but when. The mobile phone is really the foundation for managing our day-to-day lives, and that will soon include our health as well," he notes.

mHealth Challenges
Besides taking a backseat to a dizzying array of issues related to reform, patient engagement efforts struggle with integrating new technologies into a health care environment, namely regarding physician workflow. For example, remote patient monitoring platforms such as blood pressure cuffs, scales, and glucose meters all can present significant hurdles when trying to integrate their information into an EHR.

"It's not just about taking data from a patient monitoring device and putting that into the medical record," says Rob McCray, president and CEO of the Wireless-Life Sciences Alliance. "Utilization of this data changes the jobs of the clinicians, and everyone must adapt. In fact, I believe these new technologies will not be effective until workflow changes to adapt to them. These changes are beginning inside some institutional providers, but whenever people and jobs are involved, there will be resistance."

Molly Woodriff, a senior associate at HITLAB, believes mHealth technology can enable more fluid workflows. "When mobile technologies are integrated well, they can create benefits and facilitate improvements in care and patient outcomes," she says. "Right now, there are some usability issues that mHealth can help alleviate. For instance, HITLAB partnered with the University of Miami to evaluate an EHR smartphone app that the university developed to enable physicians to input new patient data and dictate notes through their smartphones, which are connected to the EHR. Although all the numbers are not available to report yet, the technology provided more convenient EHR access, streamlining workflow and offering evidence that it can improve patient outcomes over time. I think this is a solid example of how mobile solutions, when they actually fit into clinical workflow, can be more efficient for providers."

The increasing popularity of consumer-driven health monitoring devices such as Fitbit and HealthKit is affecting the mHealth landscape. While these devices and apps are touted as benefiting individual users, they also impact health care organizations in terms of data collection and analytics.

mHealth in Action
Richard Milani, MD, chief clinical transformation officer at Ochsner Health System in Louisiana, notes that HealthKit, which is embedded in Apple's iOS, is designed not so much to integrate with health care organizations as to interface with individuals. "It's a way for the consumer to collect data and store information all in one place," he says. "That is one of the things about the rapid evolution of wearables and/or home devices. The idea behind HealthKit is to put all the information in one area on one's iPhone, and to prevent users having to open other apps to store or access different pieces of information."

While Milani says HealthKit could potentially interface with all EHRs, it currently works with only one. "That said, if all the data are organized nicely, the individual could theoretically choose to enter it into his own health record," he says. "In this way, HealthKit offers a convenience factor: Individuals can pick and choose what information to include in their own medical records."

The National Learning Consortium (NLC) offers information to help consumers understand the value of integrating patient-generated health data such as treatment history, symptoms, and lifestyle into their medical records. The data can offer a clearer picture of a patient's overall health by filling in gaps between hospitalizations and office visits. On the provider side, the NLC advises an organizationwide approach that educates patients on how best to submit their data.

"It's very important if we are going to be successful in managing diseases like heart failure, for instance, for patients to become involved in their care," Milani says. "Seeing a physician in her office several times a year is just not enough. Imagine balancing a checkbook only a few times a year. Diabetes and other diseases are ongoing problems. Health care providers need data that are in real time. That's where the real promise of patient-generated health data is, and our government is asking for help with this."

"Patient-reported and sensor-generated data are critically important to our goals of precision medicine and health care reform. However, getting there is not straightforward," says Michael S. Blum, MD, chief medical information officer at the University of California, San Francisco. "If you think about examples of things patients are beginning to do—integrating blood pressure, heart rate, glucose levels, and step counts into the record—that creates challenges because there is very little validation of the devices and data, and even less ability to integrate it into clinical workflows. It's not as much of an issue with FDA-approved devices, but when you think of more consumer-oriented devices, there is no real assurance that they are accurate. That's an issue if you are integrating the data into the EHR. You don't want junk data in the record; we need data and information that's reliable."

Currently, patient-generated data are "dumped into a bucket" in the EHR without becoming meaningfully integrated into the record or the organization's workflow, Blum notes. "There needs to be much more careful thought and planning as to how these data get into the record, who needs to see the data, and how the information will be used," he says. "Streaming data from a continuous blood glucose meter or heart rhythm monitor will not get in front of a physician all the time, and dumping data into flow sheets that never get looked at is not helpful either. There needs to be thoughtful analysis of the data and how they will, and can, be used.

"How can we get the right data and information to the right person at the right time to best serve the patient?" Blum continues. "That space between the device, smartphone, or a health care cloud and the EHR is still not worked out—we call it the 'the last mile' problem. We're going to be getting huge amounts of data that need analysis and integration into a workflow. If we don't get this part right, there will be tremendous frustration on the patient side and possibly bad outcomes if important data are buried in the record and missed. Several organizations are currently building the future for that process."

However, it's not clear whether regulatory efforts are moving things forward. While standards are important, there can be unintended consequences. For example, take discharge summaries. "We used to send the discharge summary to the referring provider on the day of discharge with all the relevant information. Now, there are standards mandated by the federal government about what must be included," Blum says. "[As a result,] the discharge summaries have grown from two or three pages to 100 pages long due to the requirement that every lab test be included. The doctors are furious. That does not seem like progress to me."

Patient Privacy Concerns
As organizations work to advance patients' digital access to health care services and records, privacy is top of mind. "We are always concerned with who can see the data, what the information is being used for, and how secure it is," Blum says. "It's getting increasingly challenging to keep nefarious parties like hackers out, and health care doesn't have the extra resources to defend itself."

Regarding HealthKit, Milani says privacy concerns are mitigated because patients control data entry. However, Vivek Reddy, MD, chief medical information officer at the University of Pittsburgh School of Medicine, says caution still should be heeded. "Data storage occurs both on mobile devices and in the cloud," he says. "People lack understanding of how cloud storage works. They don't realize that even if they wipe their devices, the data still reside in cloud storage." Consequently, even if individuals self-select information to integrate into the EHR, the fact that data are stored in the cloud could make them vulnerable.

Storage services that meet the business associate (BA) standard must agree to guarantee HIPAA compliance. In addition, BAs must encrypt protected health information while it's stored and transported. However, some cloud-computing enterprises can't meet HIPAA's security requirements.

"From a privacy perspective, when a patient uploads information into the cloud, the traditional HIPAA privacy protections don't apply, because the information has not yet touched a covered entity and is thus not protected health information," Blum explains. "But once it reaches that covered entity, then HIPAA kicks in. That creates an especially interesting dynamic for patients who use mobile apps."

Woodriff says mobile vendors face challenges in the health care arena. "I think it is often difficult for companies to adapt their technologies to comply with HIPAA privacy and confidentiality regulations when health care is not their primary user market," she says. "It's a challenge. We see this in many of our studies that collect data through handheld and wearable devices, yet require HIPAA compliant systems; sometimes it's a mismatch. As we blend those two areas—health research and mobile technology—how companies deal with privacy and confidentiality will definitely be challenged, especially at the rapid pace technology is changing."

McCray says the onus for protecting health data lies at the organizational level. "I believe the biggest privacy risk exists in the locations where data is aggregated, and so the operators of those data management platforms have the highest level of responsibility for managing the integrity of their systems. This does not absolve the operators of individual connected health devices from responsibility. However, the aggregators are in a position to establish the framework for all users, including rules designed to reject connections from insecure services such as connected medical devices and services. The largest population level privacy risk is what they do after receiving the data," he says.

McCray notes that the systems used to collect health data can be just as secure as those used for financial data, noting that the level of security depends on requirements set by the market. "The fundamental technologies are exactly the same as we use in everyday life," he says. "Digital cellular communications are harder to hack than the analog systems they replaced, and the equipment to do so is much more expensive. Across industries, IT systems can be scaled up or down with regard to privacy depending on what end users—be they health care organizations or individuals—demand."

When security protocols become tighter, usability tends to suffer and patient utilization declines. From a policy perspective, McCray says organizations implementing mHealth seek the sweet spot between security and usability. "More engagement and connectivity of patients and people is good, a huge social good. We all believe that," he says. "On the other hand, we have to examine the restrictions we put in the way. How hard is it for people to participate? How much data can we effectively analyze? There is definitely a trade-off between ease of use and security."

Blum believes organizations seeking to increase patients' digital access must first focus on privacy and security. "It can't be an afterthought. App developers, for instance, will lose customers instantly if their app is not secure," he says, adding that the lag in mHealth adoption may have to do with questions surrounding where information ultimately ends up and who sees it. "For instance, it could be used by the provider or by people who have their own agendas, people who are not as beneficent. Consequently, mobile technologies must be developed with patients in mind, not for disclosing information to third parties for the developers' benefit.

"Beyond that, over time, with the increased use of mHealth by health care providers and patients alike, there will be incredible opportunities to fully understand both patients and diseases, and this information will be able to transform people's lives for the better. Patients will want to participate in that type of endeavor, to benefit others," Blum continues. "Overall, there are so many interesting possibilities to consider when envisioning where mHealth technology will ultimately take us. It really is an incredibly exciting time."

— Susan Chapman is a Los Angeles-based writer.