Entries in Clinical & Quality (33)


All Things to All People Isn't Working

By Kim Bellard, July 18, 2014

When it comes to hospitals, we may need to paraphrase Lincoln: they can treat all of the people some of the time, and some of the people all the time, but they can't -- or, rather, they shouldn't -- try to treat all of the people all of the time.

US News & World Report just released their annual "Best Hospitals" rankings.  They evaluated nearly 5,000 hospitals against a detailed methodology

What struck me was that, out of those nearly 5,000 hospitals, only 144 scored a national ranking in even one specialty.  None -- I repeat that, none -- ranked in all 16 specialties.  Only Boston, Los Angeles, and New York had more than one Honor Roll hospital.  Several states have no hospital with a national ranking in any specialty.

There's a lesson there.

A few days ago Clayton Christensen, the Harvard-based guru of "disruptive innovation," told Forbes that the U.S. health industry is "sick and getting sicker."  He offered several suggestions for what he thinks need to change, but I want to pick one in particular, his emphasis on cutting administrative waste.  

It is not unusual to cite administrative waste as a problem in our health care system, but Christensen comes at it from a different angle.  As he said:

An increasing proportion of [health care] cost is spent on administrative and overhead activities that are not productive in any way.  They exist because we assume every hospital should be able to do everything for everybody. But that’s not possible if we want quality and efficiency. Overhead creep is the result.

Toby Cosgrove, the CEO of The Cleveland Clinic, gets it as well (or at least, says the right things).  As he recently said at the Aspen Ideas Festival: "What we need to understand is that not all hospitals can be all things to all people."

Cosgrove noted The Cleveland Clinic's expertise in cardiothoracic surgery, done on a scale that he believes results in care that is cost-effective and of high quality.  They draw patients for these services not just from their metro area, their region, or even just the U.S., but also internationally.  He wants to see a future where we get patients to the right physicians, rather than trying to have expertise available everywhere.

Given the solid data on the importance of volume/experience, then, why are each of my local hospitals trying to make themselves the leader in, say, open heart surgery?  Or in cancer, neurology, or sports medicine for that matter? 

Somehow it is hard for me to believe they've got my interests -- the patient's interests -- as their top priority.  

Becker's Hospital Review recently hosted an Executive Roundtable on affiliation, and I was struck by a comment one of the hospital CEOs made:

There are too many tertiary facilities' values are not aligned with rural hospitals' values: Their goal is to pull patients out of smaller communities, which is not what smaller communities are looking for in an affiliation. Keeping patients close to home is what's important.

Wouldn't you like to think that doing what is best for the patient is what's important? 

The point is, most of us don't live in places where we should be expecting that we're going to get the best care for every condition locally.  Nor should we expect that even the "best" hospital/health system for some conditions are best for other conditions as well.  Who is treating you where for what matters.

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


May I Speak to the Doctor's Computer? 

By Kim Bellard, June 25, 2014

There's a new provocative study in Computers in Human Behavior that suggests we may be more likely to tell the truth about personal matters, such as health problems or medical history, when talking to a virtual human instead of to an actual human.  I'm not sure if these findings threaten to set back the patient-physician relationship 10,000 years, or promise to advance it fifty years.

The article -- It's Only a Computer, by Lucas, Gratch, King, and Morency -- tested participants' willingness to disclose information to a "virtual human" on a computer screen.  When the participants believed the virtual human was fully automated instead of being controlled by a human, they reported lower fear of self-disclosure, were less likely to shade the truth in order to create a good impression ("impression management"), and were rated as being more willing to disclose information.  The key to the behavior was their belief that no human was involved, whether or not a human was actually acting behind the scenes.

The virtual human idea is not pie-in-the-sky, good only for research studies.  Versions of it are already being tested, such as by Sense.ly, whose digital health avatar was profiled by MIT Technology Review a year ago.  It captures patient information via an avatar, which can respond to patient statements or data and can even answer questions.  

Clearly, we're entering a new world.

The kind of artificial intelligence that might power these avatars/virtual humans can also be used to assist physicians instead of competing with them.  IBM, of course, has been touting Watson in health care for several years now.  As Wired recently reported, there are a number of AI efforts out there to assist physicians. 

Wired also notes that companies are trying to keep their products viewed as offering recommendations instead of making decisions, which would push them over into FDA approval and regulation.  We probably will get there, but that step will be a big gulp.

Some experts believe people will improve their health behaviors -- e.g., get more exercise or lose more weight -- if they know they are being monitored.  Others fear people will end up forgetting about their trackers and will slide back to their previous behaviors. 

The plethora of tracking devices poses issues not only with the sheer volume of data generated, but also with integrating the disparate data from multiple operating systems into a unified record. 

The idea that health information is only collected at a medical office or lab, and that patients should wait to act on it until a human can talk to them, is simply no longer viable.  The data are increasingly going to be available 24/7, and when it means something important there have to be mechanisms to act upon it in real-time.   Maybe that is through alerts to physicians, who then initiate contact with patients, or maybe the wearable ecosystem can trigger its own alerts and advise the user what is going on using avatars and other automated mechanisms.

A recent op-ed by Dominic Basulto in The Washington Post stated that "Google and Apple want to be your doctor, and that's a good thing."  Mr. Basulto concluded:

Companies like Apple and Google can help to break down the notion that health has to be something offered by a monolithic company with a confusing set of rules and terms. It might just be the case that mobile health care facilitated by wearable tech will turn out to be better than traditional doctors.

I think it is a stretch to say that mobile health will be "better" than traditional doctors, but I think these and other technological options can certainly radically change when, why and where people need to see physicians or other health care professionals.  And that's good.

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


Stopping on Green 

By Laurie Gelb, June 9, 2014

The intersection greets you with a green light, but an accident blocks your lane. You brake instinctively, disregarding an official signal to proceed. Contradictory stimuli define our lives. 

Cut to health care’s adherence doctrine. “Ask your doctor. Take your medication as prescribed.” In what other subject area is it optimal for end-users to follow instructions without having internalized a rationale and therefore knowing when and how to ignore them? If you’re repairing something and the instructions say “use an inch of duck tape” and it takes two, do you stop working or use more tape?  You make a split-second decision in the moment. 

We expect to kludge. Every day, most people take action that is unprecedented for them, slightly different, under new circumstances or seen in a new light. When a wall-mounted sink falls off, most of us can imagine that we should use the main water shutoff even if we’ve never used it before. And if we came to a screeching halt at every choice about food, drink, OTC, rx, exercise, surgery, medical equipment, caregiving, parenting, safety, environmental controls, etc., we couldn’t function. Certainly, some health decisions merit more than a second for consideration, but that doesn’t mean they get it, whereas some receive more consideration than they deserve.

You might ask, why is understanding the rationale for and exceptions to instructions so important, considering that patients can consult a clinician that knows both well? But you know the answer: seldom is the clinician or the network next to patients as they make critical choices to act, avoid, deny, even everyday re-evaluation of instructions about meds, diet, exercise, procedures, lifestyle, rehab.The vast majority of decisions that drive health outcomes are unknown, unseen and uninfluenced by content and service providers. And our constituents, knowing their own context better than anyone while facing their own toppled sinks, must often take what is for them unprecedented action. 

As the green light illustrates, we haven’t abstracted information until we can act optimally when things go wrong, or when conditions differ from a perfect world. The necessity of lifelong learning applies to health care in spades, while the evidence base for preaching “follow” (along with paternalistic clinicians and arsenic cosmetics) reeks of mold.

Memorizing that 2x2=4 doesn’t mean that you understand arithmetic. When a toddler repeats words, she hasn’t yet learned the language. We should want health care choices made by reason, not rote. Since any ongoing regimen, including observation, should be re-evaluated periodically, the notion of “set it and forget it” doesn’t apply. 

Few life choices entail a greater emotional investment than your own and loved ones’ health, while typical messaging dispassionately informs you that following the rules offers the best odds.  Yet the “exceptions” are so ubiquitous as to be cliché. Long-distance runners drop dead of early MIs as grizzled sun-worshippers light up into their 80s.  The “what you get is what you follow” thesis merits growing skepticism as truisms (fats block arteries, calcium strengthens bones, exercise prolongs life) emerge as increasingly complex and non-curvilinear propositions. Moreover, today’s patients face competing risks and lifestyle choices that their ancestors never knew. 

Instead of preaching reliance on catechisms that may or may not apply to a given situation, how about skill-building in decision-making directly, including the rationale for caring at all, transcending health calculators and guidelines. Economic studies show lower costs for the “engaged.” It can’t be an innate urge to obsess about health care that engages them, since hypochondriacs entails higher costs. The truly engaged understand enough to add value to their care.

Let’s not seek “informed consumers” a la the cereal aisle, who can only consume the information and care we provide, but informed patients, caregivers, clinicians, administrators and payors, who can collectively lift all boats. Clinicians can ask better questions to optimize outcomes, while EHR designers find better ways to incorporate the answers. Payors can better align provider and patient incentives. Patients and caregivers can ask better questions as well, while acting optimally on the stimuli life presents. 

Our “best” patients are not necessarily the most compliant with our every word. Instead, they ask realistic questions and probe for the best kludges so they can best apply what they know to what they don’t. Indeed, exploring disease information on one’s own has been associated with greater adherence in the traditional sense, time and again. Our “best customers” and the caregivers that support them understand that intention is not action, there is no free ride in health care and sometimes they must preserve their own health and even lives by stopping on green. 

Last week’s Modern Healthcare piece on the Cleveland Clinic illustrates, hardly for the first time, that even marquee institutions mislay part of the achievable.  By the same token, the lives we can save or improve by helping decision-makers to do their best work are incremental to the followers who leave more to chance.

Next installment: what are quick wins for patient satisfaction [sic], disease management and e-health if/as we rethink the adherence doctrine?


How do you Define Population Health?

By Clive Riddle, March 7, 2014

This week, the inaugural issue of Population Health News was published. In their Thought Leaders Corner, a number of members of their national advisory board answered the question – how do you define population health? Here’s what the experts had to say:

Fred Goldstein, M.S., Founder and President of Accountable Health, LLC; and Executive Director of Population Health Alliance says “A population health management program is one that strives to address health needs at all points along the continuum of health and well-being through the participation of, engagement with and targeted interventions for the population. The goal of a population health management program is to maintain or improve the physical and psychosocial well-being of individuals through cost-effective and tailored health solutions.” (Fred cites this description is from Population Health Alliance, formerly the Care Continuum Alliance)

Thomas Graf, M.D., Chief Medical Officer, Population Health and Longitudinal Care Service Lines at Geisinger Health System offers this definition:  “Population health is the ability to define and understand the health status of every individual patient and proactively deploy medical resources to support those patients, whether it is to push resource to them where they are, or effectively connect them to the optimal resource in a patient specific manner, accelerated by technology.”

Paul Grundy, M.D., MPH, FACOEM, FACPM, the Global Director of Healthcare Transformation for IBM and President of the Patient-Centered Primary Care Collaborative (PCPCC) elaborates that  “population Health is ‘the health outcomes of a group of individuals, including the distribution of such outcomes within the group.’ For me, the ability to deliver population health requires a place in the delivery system that acts as the system integrator where the data flow about the population and is held accountable. We ask the house of primary care to give us a set of principles for this system integrator that is known as the patient-centered medical home (PCMH).  The medical home is defined as a ‘healthcare setting that facilitates partnerships between individual patients and their personal providers and when appropriate, a patient’s family. It lies at the center of the effort to address population health through the provision of integrated and coordinated, team-based care. It is a delivery organization that fosters clinician-led primary care with comprehensive, accessible, holistic and evidence-based coordination and management. PCMH builds the infrastructure through which data flow and is held accountable as the system integrator for POPULATION HEALTH.”

David Nash M.D., MBA, Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University observes that "population health recognizes that the social determinants of healthcare, like poverty and education, are the key drivers of a society's well-being. Medical care is responsible for 15% of a society's quality of life.”

Vince Kuraitis, J.D., MBA, Principal and Founder of Better Health Technologies, LLC explains that “definitions of population health usually focus on improving the health and health outcomes of a population. That said, the understanding and point of view of population health managers will vary greatly. Consider three highly variable factors in populations: 1. What's the COMPOSITION of YOUR POPULATION? The answer will vary depending upon whether you are a health plan, a physician practice, an employer or the government. 2. How STABLE is your population? How long do you expect it to remain with you? If you are a health plan, you will expect 18% to 20% annual churn in membership and an average tenure of around three years. If you are Medicare, your members will be with you for the rest of their lives. 3. Are you at FINANCIAL RISK for the health of your population? Upside risk? Downside risk? What are the details?   These factors will affect the economics of a population and in turn, the type and timing of potential interventions. Population managers will consider ROI as a primary metric for evaluating success. While this might seem narrow, it's very real. For example, if you are a health plan, you are more likely to invest in a congestive heart failure disease management program that has potential to identify patients and interventions that will keep patients from being admitted to a hospital within the next one to three years. If you are Medicare, you might consider a diabetes prevention that promises to reduce eye or foot problems over the course of 15 years.”

Finally, Al Lewis, Founder and President of the Disease Management Purchasing Consortium International, Inc. informs us that “population health is the provision of free (or financially incentivized) health-related tests, education and support services to groups who are (rightly or wrongly) believed—due to demographics, claims history or even company/health plan policy—to be at risk for chronic disease or chronic disease exacerbations absent those interventions, whether or not such interventions are requested by the employee or member.”

The second issue of Population Health News will include additional responses from Population Health Thought Leaders. Stay tuned.


Effectiveness of SMS in healthcare

By Krista Burris, January 28, 2014

Healthcare is at a tipping point and as such, unprecedented efforts are being made to improve health outcomes and foster efficiencies in healthcare delivery. What seems promising with the current reform and transformation efforts is the convergence of existing mass markets influencing healthcare innovation. For example, leveraging mobile phones to track, monitor, and engage patients in lifestyle and self-health management. Mobile text messaging communication in particular has proven to be an effective way to foster desired behavior change in patients and improve the way in which care is delivered by capturing important data that is actionable.

The need for improving outcomes and creating efficiency becomes increasingly important in the context of the coverage expansion in the Affordable Care Act where millions of Americans will enter the system, utilizing more healthcare resources. In particular, the Medicaid expansion is projected to result in a total of 75.6 million enrollees for 2014, an increase of roughly 19.5 million as a result of the ACA[i]. Leveraging mobile text message communication to facilitate convenient and efficient communication among patients and providers, as well encouraging desired behavior change by providing patients with educational tools to improve health outcomes, is encouraging to achieve on the triple-aim objective of healthcare reform[ii].

The opportunities to innovate using mobile technologies among the low-income and underserved populations are robust. A review of several research publications as well as surveying key constituents within the healthcare ecosystem serving these populations[iii], it is clear that the unmet needs plaguing the healthcare safety-net and contributing to waste include poor appointment attendance[iv], poor medication adherence[v], and poor health literacy[vi].

Extending the successes of current mobile text message patient engagement strategies to each of these unmet needs has the potential to reduce waste and inefficiencies in the system by improving health literacy and self-health management of low-income and underserved populations.

SMS text-messaging has shown a positive impact on fostering the desired behavior change in patients. A review of existing studies show that text messaging can support improvement in appointment attendance, increased medication adherence, and enhanced literacy through educational content outreach.

SMS text message appointment reminders

Patients failing to attend their scheduled doctor visits contribute to inefficiencies and misused resources[vii]. In general it is found that a reminder, whether it be by text or phone, is helpful in improving attendance, however SMS technology is a more cost-effective approach[viii].

A 2012 study analyzing the effect of SMS text reminders to reduce nonattendance for hospital outpatient visits found a significant difference in the attendance rate of patients who received a text reminder compared to patients who received no reminder[ix]. The results concluded that the attendance rate for patients who received text message reminders over the 4 month period were significantly higher (79.2%) compared to the attendance rate of those who received no reminder (35.5%).

Another study measuring the impact of SMS appointment reminders for outpatient clinic visits in Brazil found that text message reminders reduced nonattendance rates, improving patients’ care and ensuring the right care at the right time[x]. The nonattendance reduction rates for appointments at the four outpatient clinics studied were 0.82% (p= .590), 3.55% (p= .009), 5.75% (p= .022), and 14.49% (p= < .001).  These results suggest that text is an effective and efficient way to ensure patients attend their scheduled clinic visits and do not have interrupted care.

SMS text message medication reminders

Patients’ failure to adhere to their medication regimen can lead to unnecessary disease progression and complications. This contributes to waste in the healthcare system including preventable visits to the emergency room and increased utilization of other healthcare resources. Researchers have evaluated the impact of SMS text reminders on promoting medication adherence. The results are promising, suggesting text as an efficient and effective way to ensure patients take their medication.

The World Health Organization conducted a review of trials and studies that evaluated the effectiveness of mobile text medication reminders for HIV patients on anti-retroviral therapy drugs[xi]. The overall conclusion was that patients who receive text message reminders had a significantly higher adherence rate to their medications compared to patients that did not receive any kind of reminder. For conditions such as HIV where medication adherence is critical in preventing or stalling disease progression towards AIDS, as well as other comorbidities, the use of SMS technology can enable proper compliance of medication needs.

A study reviewing SMS reminders for diabetic patients concluded that text reminders improves adherence to oral antidiabetics[xii]. In the study 56 patients were confirmed to receive text reminders to take their medication, compared to 48 patients who received no reminder. Medication of both groups was measured using Real Time Medication Monitoring (RTMM) of oral antidiabetics in terms of (1) days without dosing; (2) missed doses; (3) doses taken within predefined standardized time windows. Patients' experiences were surveyed through questionnaires. The results found that patients who received reminders had a higher rate of adherence including a higher rate of taking their medication in the predefined time interval of receiving the reminder. The study also concluded through the patient survey questionnaire that patients found the reminders helpful.

SMS text message delivering educational content

SMS text-based education is emerging as an effective way to engage patients in better self-care. Lack of education around basic health information leads to approximately $106 billion to $238 billion in economic burden each year[xiii].  Text message outreach with educational content can be an efficient way to improve patients’ health literacy.

The Center for Connected Health in Boston reported in a study that text messaging improved treatment adherence and self-care for dermatology patients suffering from atopic dermatitis[xiv]. In the study, 25 patients received daily text messages over a period of six weeks. The text messages included treatment reminders and educational content pertaining to their health condition. At the end of the six week study, patients reported and improvement of treatment adherence of 72% and roughly 68% of the patients reported an improvement in self-care behaviors to help their conditions.

Two other studies evaluated the use of text messaging in improving self-care and desired behavior change for Type 1 diabetic patients[xv]. One study tailored text message communication to self-management goals, as well as untailored content such as newsletters and tips from other patients. The results showed that the patients enrolled in the text program were engaged in interacting with the technology. The participants seemed to enjoy the community aspect of the technology through the ability to connect with their provider and peers. The second study evaluated the use of text message technology among families of children with type 1 diabetes. In this study, the parents received informational messages pertaining to their children’s care needs. The study results concluded that the text messages were helpful and aided in better dialogue between parent and child around the disease condition.

Ensuring proper self-care is important for patients living with chronic disease as much of the care needed to manage these diseases occurs outside of the clinic and provider supervision. Providing patients with easy and consistent access to information to better understand their conditions and comply with proper care practices can lead to improved health outcomes.


Mobile text communication can be a cost-efficient and effective way to engage patients in the desired behavior change to improve appointment attendance, medication adherence, and self-care management of disease. As the healthcare system transitions to a focus on improving health outcomes, engaging patients in the management of their health is critical. SMS text messaging is a low-cost way to facilitate engagement and enhance the health literacy of individuals living with chronic conditions and other health challenges.

[i] National Health Expenditures Projections 2010-2020. Forecast Summary. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/proj2010.pdf.

[ii] The triple-aim is a framework developed by the Institute for Healthcare Improvement to address experience of care, population health (improving outcomes), and per capita cost of healthcare services; It is generally accepted that the Affordable Care Act uses the triple-aim as a core principle to design healthcare transformation: “Moving toward the “triple-aim”: The Affordable Care Act and the implications for payment and quality reform”. http://www.ehcca.com/presentations/pfpsummit6/dentzer_1.pdf.

[iii] Feedback from the healthcare community includes discussions with senior leadership of San Francisco Community Clinic Consortium, including St. Anthony’s Foundation.

[iv] Kaplan-Lewis, E. Percac-Lima, S. “No-show to primary care appointments: why patients do not come.” Journal of Primary Care and Community Health. July 2013. http://jpc.sagepub.com/content/early/2013/07/26/2150131913498513.abstract.

Anecdotal feedback from St. Anthony’s Foundation reported an approximate $250 loss in revenue from each no-show appointment.

[v] Nichol, M.B. Knight, T.K. Priest, J.L. Wu, J. Cantrell, C.R. “Nonadherence to clinical practice guidelines and medications for multiple chronic conditions in a California Medicaid population.” Journal of the American Pharmacist Association. 2010. http://japha.org/article.aspx?articleid=1043767.

[vi] Somers, S. Mahadevan, R. “Health Literacy: implications of the Affordable Care Act.” The Institute of Medicine, Center for Health Care Strategies, Inc. 2010. http://www.iom.edu/~/media/Files/Activity%20Files/PublicHealth/HealthLiteracy/Commissioned%20Papers/Health%20Literacy%20Implications%20of%20Health%20Care%20Reform.pdf.

[vii] Hasvold, P.E. Wootton, R. “Use of telephone and SMS reminders to improve attendance at hospital appointments: a systematic review”. Journal of Telemedicine & Telecare. 2011. http://www.ncbi.nlm.nih.gov/pubmed/21933898.

[viii] Chen, ZW. Fang, LZ. Chen, LY. Dai, HL. “Comparison of an SMS text messaging and phone reminder to improve attendance at a health promotion center: a randomized controlled trial.” http://www.ncbi.nlm.nih.gov/pubmed/18196610.

[ix] Prasad, S. Anand, R. Use of mobile telephone short message service as a reminder: the effect on patient attendance.” International Dentistry Journal. 2012. http://www.ncbi.nlm.nih.gov/pubmed/22251033.

[x] da ,Costa TM, Salomão, PL. Martha, AS. Pisa, IT. Sigulem, D. “The impact of short message service text messages sent as appointment reminders to patients' cell phones at outpatient clinics in São Paulo, Brazil.” 2010. http://www.ncbi.nlm.nih.gov/pubmed/19783204.

[xi] Sharma, P. Agarwal. P. “Mobile phone text messaging for promoting adherence to antiretroviral therapy in patients with HIV infection.” The WHO Reproductive Health Library. The World Health Organization. 2012. http://apps.who.int/rhl/hiv_aids/cd009756_sharmap_com/en/index.html.

[xii] Vervolet, M. van Dijk, L. Santen-Reestman, J. “SMS reminders improve adherence to oral medication in type 2 diabetes patients who are real time electronically monitored” In J Med Inform. 2012;81(9); 594-604. http://www.ncbi.nlm.nih.gov/pubmed/22652012.

[xiii] Vernon, JA. Trujillo, A. “Low Health Literacy: Implications for National Health Policy.” Rep. Washington: George Washington University, 2007. http://sphhs.gwu.edu/departments/healthpolicy/CHPR/downloads/LowHealthLiteracyReport10_4_07.pdf

[xiv] Pena-Robichauz, V. Kvedar, J. Watson, A. “Text Message as a Reminder Aid and Educational Tool in Adults and Adolescents with Atopic Dermatitis: A Pilot Study.” Dermatology Research and Practice. 2010. http://www.connected-health.org/programs/dermatology/research-materials--external-resources/text-messages-as-a-reminder-aid-and-educational-tool-in-adults-and-adolescents-with-atopic-dermatitis-a-pilot-study.aspx.

[xv] Franklin, V. Greene, A. Pagliari, C. “Patients’ engagement with ‘Sweet Talk’- A text messaging support system for young people with diabetes.” Journal of Medical Internet Research. 2008. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2483928/#!po=2.50000.

Wangberg, SC. Arsand, E. Andersson, N. “Diabestes education via mobile text messaging.” Journal of Telemedicine and Telecare. 2006. http://www.ncbi.nlm.nih.gov/pubmed/16884582