Making Digital Connections with Patients between Visits

April 14, 2015

It's time to "bridge the gap" with patients between patient visits. Here's how technology is helping one practice do it.

The traditional care model, through which primary-care physicians check in with patients in the office during regularly scheduled visits, is "not going to work anymore."

That's according to Danny Sands, chief medical officer at Conversa Health, Inc., who co-presented a session with Philip Marshall, MD, chief product officer at the health IT company, during the Healthcare Information and Management Systems Society (HIMSS) Conference in Chicago.

During their session, "Staying Connected with Patient-Generated Health Data," Sands and Marshall said it's time for physicians to "bridge the gap" with patients between visits. 

Sands said the shift toward value-based payment, the need to reduce healthcare spending, the growing elderly population, and a looming physician shortage are all factors driving the push for more interaction and health information feedback from remote patients. "We have got to figure out how to scale our healthcare system," he said.  

Another factor driving the push, he said, is the increasing number of patients with multiple chronic conditions. "If we are dealing with an epidemic of chronic conditions ... we need a new model for healthcare," said Sands. "What we are doing is not working. It's expensive, we are not getting the quality we want; we are not getting the engagement we want."

So how can physicians better engage with, and receive more health information from, remote patients?

Sands said it's time to "space out" visits a bit more, improve health literacy, and have frequent "light touches" with relevant patient populations between visits to monitor progress, blood pressure, pain, medication adherence, and so on.

Frequent check-ins  

When attempting to acquire patient-generated health data (PGHD) from remote patients, Sands said it is critical to consider work flow. The information received from patients should be automated, simple for patients to provide, and it should not overwhelm the physician. Too much information is not a good idea, he said, but if you can help create information from the data then that is going to be useful.

While remote health monitoring devices such as those that track patients' steps or calorie intake are popular among patients, they don't necessarily provide the type of information that physicians need to receive from patients on a daily basis, said Marshall.

During their presentation, Sands and Marshall pointed to a pilot PGHD study that Conversa partnered with in which an adult primary-care practice explored how it could receive health information from 1,300 chronic disease patients.  The patient population they decided to start engaging with more outside the office, was a

They practice started by analyzing the EHR data of that patient population, and pulling it through the system so that they could profile each patient and target a "set of rules" on what to ask them when checking in with them remotely, and how often they should reach out to these patients.

They then arranged for the patients to receive a digital alert indicating it was time to answer the questions related to their condition and/or share biometric data through "digital check-ups." Once patients completed the questions, the data then went straight back into the EHR.

"Seamlessly integrating into the EHR was absolutely a kind of critical requirement for us, the practice would not have had it any way and frankly we wouldn't have either," said Marshall.

The practice then used the data to determine if a clinical intervention was necessary, and if they should be checking in with patients more or less often.

The results:

• About 73 percent of the patients in the pilot completed one or more digital check up, and 81 percent stayed engaged after the first check up.

• Twenty-nine percent of the patients had a clinical intervention during the pilot in order to get them back on track, said Marshall, adding that many of these issues had to do with medication adherence and most of them could be fixed by a quick call.

• Seventy-two percent of the patients stayed on track or improved during the pilot.

".. As we push for value-based care and increased provider capacity, we have to more efficiently manage this gap and bridge patients and providers," said Marshall. "It is possible to automate this process, by knowing the patient, knowing their profile, knowing which rules will be triggered in what situations."