Clinicians Embracing mHealth – but not so much if patients are involved

By Clive Riddle, September 12, 2014 

Although lagging behind many other service sectors, healthcare clinicians do continue to their march towards the inevitable professional embrace of mobile apps, social media and other web applications – typically as long as that embrace falls short of interacting with their patients. 

Wolters Kluwer Health just released survey results on nurse practitioner use of mobile health, social media and the web. The survey was conducted on their behalf by Lippincott Solutions. 

The survey found that 65% of nurses currently use a mobile device at work for professional purposes at least 30 minutes per day, and 95% of healthcare organizations allow them to consult websites and other online resources for clinical information at work. 

The survey findings also indicated:

  • 83% of nurses perceive that their organization's policy allows patient care staff access to web sites, including social media, to access general health information regarding patient conditions
  • 48% of respondents that access health information say their organization encourages nurses to access online resources; while 41% allow for occasional use; and 5% only as a last resort
  • 89% of healthcare organizations allow nurses to use online search engines at work
  • 60% of respondents say they use social media to follow healthcare issues at work
  • 86% say they follow healthcare issues on social media outside of work
  • 20% of nurses use mobile health apps for two hours or more per day
  • Among those who use mobile devices at work, Nurse Managers, at 77%, are more likely to use them than Staff Nurses, at 58% 

But their report notes that “73% of healthcare respondents say that organizational policies strictly prohibit direct patient care staff to have social interaction with patients on social media and social sites, compared to 51% say that organizational policies prohibit direct patient care staff to have access to their organizations’ own social media pages.” 

A Walters Kluwer survey of physicians last year found that 21% of doctors didn’t use smartphones in their practice, 46% used them less than 25% of the day, and 33% used them more than 25% of the day. Regarding use of tablets, 39% of doctors didn’t use tablets in their practice, 37% used them less than 25% of the day, and 24% used them more than 25% of the day. Of those who did use mobile devices at work,  24% use mhealth apps; while 33% used their smartphones to communicate with patients, and  17% used their tablets for patient communication. 

While many integrated systems like Kaiser have structured electronic interaction with patients into their system, basic impediments for many continue to be a lack of reimbursement, as well as legal concerns about doing so. 

Yet it is exactly that interaction that their customers are asking for.  For example, Harris Poll results just released for a survey commissioned by Wellocracy found that 66% of those who have used a wearable mhealth tracker or app in the past 12 months ndicated that they would be interested in receiving personalized feedback on their health data from a trusted health expert, such as a doctor, nutritionist, fitness trainer or licensed lifestyle coach, and of those respondents: 75% would be willing to pay for personalized feedback and coaching from a doctor, and 73% from a nutritionist, nurse or dietician.


Healthcare (Health Care) in a word (or two)

By Clive Riddle, September 5, 2014

MCOL has launched a survey, albeit a little tongue-in-cheek, on solving a great question for the ages:  do we spell it healthcare (one word) or health care (two words)? You can click here to take the survey, and see real-time results, or click here to check out a one-minute video on the topic.

Early results from the survey to-date indicate a slight preference for one word: 44.7% have said one word; 31.6% have said two words; 13.2% have responded that it depends on the context; and 10.5% have answered that either is fine. Remember though, respondents work within this industry (more on that to follow.)

How have others weighed-in on this conundrum?  Major news organization, medical journals and the AP consistently use “health care” in two words.  Many major blogs have taken the same position, such as The Incidental Economist (Feb 2013) and Archelle On Health (May 2011).

But many  either take the position of one word, while lamenting the times they are a-changing, or they argue the both uses are acceptable, depending upon the context.

One of the most quoted blogs regarding this topic comes from Michael Millenson’s The Doctor Weighs In, in his August 2010 post - “Healthcare” vs. “Health Care”: The Definitive Word(s) .  Millenson makes the case that learned authorities use two words, but goes on to say: “So why isn’t that the end of the issue? Because conventions are not set in concrete. For example, at the time the Internet first became popular, the AP preferred the term “Web site” over “website” because the World Wide Web is a proper name. “ and acknowledges one word use is on the way up: “However, I think a tipping point for fusing “health” and “care” was reached with the federal legislation setting up the Agency for Healthcare Research and Quality at the end of 1999.”

Are the times a-changing? Certainly a review of Google search results placing both terms within quotations, indicates two words is the clear winner:  109 million results versus 47.8 million – a ratio of 2.28 to one.  When the results are filtered to only display content created in the past twelve months, two words still easily wins: 15 million results versus 9.4 million, but the ratio reduces to 1.6 to one.  The times it would seem are changing – but not at the rate of Bob Dylan record sales in Greenwich Village in 1961.

But what about context?

While many make the case that usage is driven by context, there isn’t agreement about what that context is.  Some say one word is used by those in the business when communicating to each other, and two words is for use with the general public. The Metropolitan Philadelphia Chapter of HFMA concluded in The Great Debate of Our Industry: Healthcare vs. Health care “so there still is no final answer here. Both health care and healthcare remain acceptable term.”  The author seems to go for the context route, stating” the single word healthcare may show you are an industry insider, and I save the term health care for those who write about our industry from the outside.”

In the March 2008 Medical Malprocess Blog post Health Care or Healthcare?, an often mentioned approach regarding context -  in which two words refers what a patient receives, and one word refers to a system:  “Health care as two words refers to what happens to a patient. …Healthcare as one word refers to a system or systems to offer, provide, and deliver health care (two words).”, in Healthcare vs. health care tells us the times are a-changing but context depends upon international use: “Healthcare is on its way to becoming a one-word noun throughout the English-speaking world. The change is well underway in British publications, where healthcare already appears about three times as often as health care and is used as both a noun and an adjective. Many American and Canadian publications resist the change, meanwhile, and health care remains the more common form in North American newswriting, as well as in government and scholarly texts. In many cases—such as on health-related U.S. government websites—health care is the noun (e.g., “your health care is important”) and healthcare is the adjective (e.g., “find a healthcare professional”), but this is not consistently borne out, and both forms are widely used both ways. Many publications and websites seem to have no policy on this at all. Short answer: Outside North America (Australia goes along with the U.K. on this one), use healthcare. In the U.S. and Canada, make it two words (unless you want to help speed the compounding process).”

What to make of all of this? Google search results, and purists would agree that two words is still king – for the general public, but eventually it would seem one word will take hold – although perhaps not as rapidly as some might think. During this transition – context will drive usage, and those in the business of healthcare might be more comfortable with one word with conversing with each other.


What Is Amazon Up To? 

By Kim Bellard, August 27, 2014

Back in April, PwC and HRI issued a report that asked what new entrants might be healthcare's  Now it appears that it might just be Amazon itself.

What we "know" is that unnamed "Amazon leadership" met in late July with Howard Sklamberg, FDA's deputy chief for global regulatory operations and policy, and other unnamed "various FDA leadership."

That's it; everything else is speculation.  Not much of a story perhaps, but, hey, without speculation there would be no point of blogs, and then I'd have to spend my time doing something else.

Still, the speculation is interesting, especially with a company like Amazon that has repeatedly demonstrated its ability to disrupt markets.

They already outsource their cloud services (Amazon Web Services, or AWS), their distribution capabilities, and their payment systems, the latter now being expanded to in-store payments, going up against the likes of Visa and Mastercard.  In a smartphone world dominated by Apple, Samsung and other established manufacturers, they fearlessly have introduced their own version, the Fire.  I could go on in various other spheres, but the point is clear -- they're not afraid of anyone.

So now health care?

Here are three ways that I would love to see if Amazon could add value to health care:

Reviews: OK, all you Amazon shoppers -- and there are a lot of us -- how many of you buy a product (even if not on Amazon) without first checking out the Amazon reviews?

Their reviews already cover various medical supplies/devices sold on Amazon, but wouldn't you love it if those reviews applied to, say, physicians or hospitals?

Recommendations: Amazon is noted for their personalized shopping recommendations, based on user's shopping and purchase history on the site and a lot of Big Data collaborative filtering.  Whether it is a recommended item, the "also viewed" products, or the "frequently bought together" combo suggestions, the recommendations are pretty effective in helping boost Amazon's sales.

Imagine if Amazon applied this to health care products, services, and even providers, recommending ones that they believe might best fit you, and possibly helping map out the various steps of a treatment plan (as they are "frequently bought together").

Medical tourism:  No, I don't mean the out-of-country packages of lower-cost health care services often thought of as medical tourism (although I'm not excluding them).  I mean more broadly making services or packages of something that consumers actively shop for, and breaking the traditional pick-the-closest doctor/hospital mindset that most consumers have gotten used to.

It's fun to speculate what Amazon might do, but the real benefit of them coming into health care in a bigger way would be that they might do something truly unexpected and unique, without health care industry blinders limiting their creativity.

They haven't asked for my advice -- and please feel free to get word to them that they should -- but what I'd urge Amazon

  • Keep it retail: Amazon made its reputation as a retail company, and yet health care has stubbornly resisted being truly retail -- Remember your roots!
  • Make people mad: I hope the AMA, AHA, and the state medical boards are furious, that individual health systems and health care professionals are scared to death, and there generally is a lot of arm-waving and teeth gnashing.

If everyone is applauding, Amazon didn't go far enough.

If all Amazon wants to do in health care is to make it easier for us to buy even more of the things we already buy too much of, and pay too much for, I wouldn't be surprised, but I will be disappointed.  We have plenty of companies who can help us tinker around the edges of the status quo, but all too few companies

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting


Towers Watson 2014 Employer Survey Results

By Clive Riddle, August 22, 2014

Towers Watson has just released results from their annual Health Care Changes Ahead Survey which “offers insights into the focus and timing of U.S. employers’ plans and perspectives related to their health benefits, and their efforts to better manage costs and employee engagement.”

Their headline takeaway? “U.S. employers expect a 4% increase in 2015 health care costs for active employees after plan design changes… If no adjustments are made, employers project a 5.2% growth rate.

Towers Watson’s Randall Abbott tells us “in the current economic climate, affordability and sustainability remain dominant influences on employers’ overall health care strategies. Expense management and worker productivity are equally critical to business results. While employers are committed to providing health care benefits for their active employees for the foreseeable future, persistent concerns about cost escalation, the excise tax and workforce health have led to comprehensive strategies focused on both year-over-year results and long-term viability for health care benefits and workforce health improvement. The emphasis is on achieving or maintaining a high-performance health plan. And CFOs are now focused on a new gold standard: managing health cost increases to the Consumer Price Index. This requires acute attention to improving program performance.”

Here’s some key employer responses from their survey findings:

  • 73% of employers said they are somewhat or very concerned they will trigger the excise tax b
  • 43% said avoiding the tax is the top priority for their health care strategies in 2015.
  • 81% plan moderate to significant changes to their health care plans over the next three years
  • Pharmacy-only cost trend is projected to be 5.3% after plan changes (6% before changes)
  • 48% are considering tying incentives to reaching a specified health outcome such as biometric targets during the next three years ( 10% intend to adopt it in 2015)
  • 37% are considering offering plans with a higher level of benefit based on the use of high-performance or narrow networks during the next three years (7% in 2015)
  • 34% of employers are considering telemedicine during the next three years (15% in 2015)
  • 33% are considering significantly reducing company subsidies for spouses and dependents during the next three years (10% have already done so; 9% intend to do so in 2015)
  • 26% are considering spouse exclusions or surcharges if coverage is available elsewhere during the next three years; (30% already do so; 7% expect to add it in 2015)
  • 30& are considering caps on health care coverage subsidies for active employees, using defined contribution approaches during the next three years (13% already have them; 3% are planning them for 2015)
  • 50% are considering full-replacement ABHPs (Account Based Health Plans) during the next three years: (17% offer only an ABHP today; 4% intend to do so for 2015, and another 28% are considering it for 2016 or 2017)
  • 76% are exploring the use of personalized digital technologies, including mobile health applications and fitness wearables

Towers Watson included a number of questions measuring the private health insurance exchange opportunity:

  • 28% have extensively evaluated the viability of private exchanges
  • 24% said private exchanges could provide a viable alternative for their active full-time employees in 2016.
  • 64% said evidence private exchanges can deliver greater value than their current self-managed model would be a top decision factor
  • 34% said adoption of private exchanges by other large companies in their industry would be a top decision factor
  • 26% said an inability to stay below the excise tax ceiling as 2018 approaches would be a top decision factor
  • 99.5% have no plan to exit health benefits for active employees and direct them and their families to public exchanges, with or without a financial subsidy.
  • 77% are not at all confident public exchanges will provide a viable alternative for their active full-time employees in 2015 or 2016.

Of course it should be noted Towers Watson has their own private exchange product, OneExchange, that serves more than 1,100 employer clients with active employee and retiree options. Towers Watson just announced that during “the first half of 2014, 45 major U.S. employers launched OneExchange for full-time, part-time or retired employees. This is the largest number of employer implementations outside the typical fall enrollment period in the private exchange’s eight years of operation.” Major new clients they listed included GameStop; International Paper; Northrop Grumman; and the State of Rhode Island.


Ten Things to Know About Ebola Today:

Clive Riddle, August 15, 2014

While Ebola is only rampant in Africa, cases are now out-migrating, and Ebola is finally starting to get the increased  attention of the world it needs.  For those of us half a world away, we typically want to condense this information down to how it might ultimately indirectly or directly affect us. Unfortunately, some of that attention is overly shaped by fear, misinformation or even political agendas.

The CDC is a great resource site on Ebola Hemorrhagic Fever ,  including Ebola Virus Disease Information for Clinicians in U.S. Healthcare Settings.  NPR has a post today interviewing Jeanine Thomas, on why the Ebola decision has relevance for the U.S. health care system.  Much of the dilemma in West Africa is due to their lack of healthcare resources compared to more industrialized nations, as discussed in a Science Daily article posted yesterday, Ebola outbreak highlights global disparities in health-care resources, which pulls from NIH and New England Journal of Medicine content.

Perhaps a best first step for non-clinicians in the business of healthcare, is to become more conversant in the current state of affairs for Ebloa. As Lee Norman, MD, chief medical officer for The University of Kansas Hospital, reminds us, “the current Ebola Virus Disease is the deadliest on record but it is important to understand key elements of this virus. He and the University of Kansas Hospital have just released an excellent summary in the regard: 10 things to know about Ebola, we’ll repeat in its entirety:

  1. Cases Are Out-Migrating From Africa: This is happening due to the fact that infected or ill people are traveling out of those countries in Africa with Ebola outbreaks. Cases found outside of Africa may likely go up as the number of people leaving outbreak areas increases when aid-workers and others return to their home countries.
  2. No Cases of Human-to-Human Transmission Outside of Africa: There has been no human-to-human or other transmission to humans outside of Africa.
  3. Ebola Is Not Transmitted By Air, Only Via Bodily Secretions: Ebola is not respiratory, so it is not transmitted through coughing or breathing. These infections are occurring because of people who are exposed to bodily fluids of infected individuals.
  4. Ebola Is Not The Most Infectious Disease: As infectious diseases go, Ebola virus isn't inherently the most infectious nor is it the least infective from person-to-person. Measles and chickenpox, for example, are easier to spread. So are influenza and MERS.
  5. High Mortality Rates Due to Geography: The mortality rate is quite high in Africa Ebola cases, partly because of the chaos, instability, and unrest of the governments there, and very directly related to the fact that their access to standard treatment supplies (IV solution, tubing, syringes, and protective equipment) is not universally available. Ebola cases identified and treated in westernized nations, and those with modern infection control practices, will have a much lower rate than those seen in most African regions.
  6. Likelihood of Breakouts In Areas Outside of Africa: Meticulous infection control practices in modern hospitals will make it more unlikely that human-to-human transmission will occur in these settings. While expensive and advanced bio-containment units provide the highest level of infection control, it is unlikely that these units will be widespread throughout the world.
  7. No Approved Immunizations and Treatments: There are no approved immunizations to prevent Ebola virus infection. There are no approved treatments for Ebola virus infection. There are experimental antibody treatments, as well as an antiviral medication not approved for Ebola. But whether either or both are safe or effective for widespread use is not known. "Compassionate use" or "experimental use" of the above treatments is tempting, because no targeted, specific "conventional treatment" exists. But widely adopting experimental, unproven medications as "the new conventional therapy" has its own difficulties: Is it safe? Is it effective? Is it costly? Are there unanticipated "down-sides" to using them? A WHO ethics panel has given the go-ahead for this, something it has never done before.
  8. How Animals Play a Role: The non-human vectors that can harbor Ebola virus (fruit bats, non-human primates) are widespread in areas far removed from Africa. As such, it bears watching whether those vectors begin to harbor the virus. The WHO has an excellent map showing the parts of the world with these vectors.
  9. Alert Levels: The WHO and CDC both recently increased their respective alert levels. State and local health departments throughout the U.S. and world will certainly seek guidance as to the adoption of best "local practices" to guide hospital and care providers. The guidance by the CDC as to how to manage exposed individuals and those who might be incubating the infection are quite specific and helpful. They will certainly change as time goes on.
  10. What We Don't Know About Ebola: There are things unknown about Ebola. For example:
  1. Can a person have had a low-level infection and not know they ever had it? Probably, based on serum testing.
  2. Does a person who has had it and survived develop lifelong immunity? That is unknown at this point. The various strains of Ebola are enough different antigenically that there may not be cross-immunity.
  3. Is there such a thing as a "chronic carrier state" in humans where a person can shed the virus and be infectious for a long period of time, even when they themselves have no illness or symptoms? That is also unknown at this point.
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