Patient Engagement

Walgreens: Purveyor or Provider?


An intriguing question emerged from last week’s merger announcement from Walgreens Boots Alliance and Rite Aid.  Led by CEO Stefano Pessina and his largely European executive team, will Walgreens be purveyor focused on retail sales or provider engaged with a transforming U.S. health care system?

The signals are mixed.  A tea-leaf reading of last week’s investor call suggests Walgreens is destined to be a purveyor, focused on selling products and services.  Today, however, Walgreens announced a big technology move that points to a provider future, closely integrated with payers and providers.

Purveyor or provider?  Read on.

Tobacco:  To Sell or not to Sell

“Are you considering eliminating tobacco,” Barclays Capital analyst Meredith Adler asked Walgreens president Alex Gourley during the investor call as the company fielded questions about earnings and the merger.

Gourley had just praised RiteAid for its new, sales-increasing wellness format, saying it was an opportunity for Walgreens, which also is seeing success with its new health, wellness and beauty positioning.

“It seems pretty clear,” said Adler, explaining her question, “that providers and payers feel uncomfortable working with a retail pharmacy that still sells tobacco.”  In the background was the 2014 tobacco sales halt of CVS Health, which boasts 49 clinical affiliations, including Cleveland Clinic.

Gourley’s answer:  No.

Walgreens would instead continue investing in smoking cessation.  Anyway, he noted, only about three percent of all tobacco sales occur in a drugstore.  He did not pivot to emphasize how Walgreens is working with providers and payers, notwithstanding tobacco sales.

A tea-leaf saying “purveyor”? Perhaps.

Outposts in Seattle

Gourley could easily have drawn the analyst’s attention to a Walgreens announcement just two months previously.  In August, Walgreens and Seattle-based Providence Health & Services launched a new “strategic clinical collaboration.”

Providence will own and operate clinics in 25 Washington and Oregon Walgreens stores under its Providence and Swedish brand names.  The first three will open in early 2016, with the remainder following in two years.

Rite Aid made a similar move in the Seattle market in May when it announced a joint venture between its RediClinic subsidiary and MultiCare Health System.   The joint venture will operate clinics in 11 stores staffed by board certified MultiCare Nurse Practitioners in collaboration with MultiCare affiliated physicians.

Seattle, home to only three CVS stores, will provide a sheltered environment for Walgreens and Rite Aid to test the strategy of developing “deeper and more strategic relationships” with health systems.  In particular, Providence is quite a catch, having directly contracted with Boeing to provide health care for the aircraft maker’s employees.

The EpicCare Connection

However, the nation’s 1,000 CVS MinuteClinics dwarf both Walgreens 400 Healthcare Clinics and Rite Aid’s small number of in-store RediClinics.  Surpassing 25 million patient visits since the opening of its first clinic, CVS says it is opening three new MinuteClinics a week.   Aiming for 1,500 clinics by 2017, CVS is acquiring all of Target’s 1,660 pharmacies and 80 clinics.

CVS is converting all of its MinuteClinics to the market leading EpicCare electronic medical records (EMR) system.  Used broadly across health care, Epic also has strong interoperability with other EMR systems.   This will provide seamless data exchange with most American hospitals.

“EpicCare will help us work more closely with physician practices as part of the medical home team, facilitate co-management of patients, and advance our mission to make health care more accessible, convenient and affordable for Americans,” said MinuteClinic chief medical officer Nancy Gagliano, M.D.

Dr. Patrick Carroll agrees.  Today, the chief medical officer for Walgreens Healthcare Clinics announced the clinics would begin moving to EpicCare early next year.  “As our clinics play an increasingly important role in health care, supporting the health care system, provider practices and patients’ medical homes, care coordination can be critical,” he echoed.

So, a provider future for Walgreens?  It certainly looks like it.  “This will benefit our patients, clinic providers and partners, and serves as an instrumental part of our strategic growth plan [emphasis added],” explained Carroll.

Confusing Signals

However, as recently as May, Walgreens quietly shuttered 35 clinics, a move two former employees described to Crains Chicago Business as signaling “uncertainty whether Walgreens really wants to spend more on primary care and in particular upgrading the clinics’ electronic medical record systems.”   Today’s announcement erases some of that uncertainty, at least with respect to the EMR system.

In Seattle, Walgreens will provide in-store space, overseeing any needed build out.  Providence will be using its own Epic system.  “Patients will experience a seamless patient experience through our existing electronic health record system, providing direct connectivity to the clinics and billing systems, which will ensure better continuity of patient care and collaboration among providers,” said Providence senior vice president of physician services Mike Waters.   Now, Walgreens will be able to connect directly.

Convincing Collaborations

In Seattle, a provider land lord; in Tampa, still a provider.  There, Walgreens partners with a multi-specialty practice, assuming risk in an accountable care organization (ACO), Diagnostic Clinic Walgreens Well Network.  Serving 7,500 patients, the ACO saved $1.5 million or 2% in costs.  However, Walgreens has exited ACO partnerships with Baylor Scott & White in the Dallas-Fort Worth area and New Jersey’s Advocare.  The company continues a clinical affiliation with Baylor Scott & White.

Meanwhile, Walgreens has launched additional collaborations with CHE Trinity Health, a 30-hospital, Michigan-based system, Arizona Priority Care, a unit of California’s Heritage Provider Network, and Mercy Health – Cincinnati.  Leading Trinity Health is former Medicare official Dr. Richard Gilfillan, chair of the Health Care Transformation Task Force; Mercy Health is part of the nation’s largest not for profit health system, Ascension Health; and Arizona Priority Care specializes in accountable care.

In Baltimore, Walgreens has a long-standing relationship with Johns Hopkins Medicine (JHM).  The company provides grants for population health research overseen by a joint committee.  Two years ago, it opened a store, including a Healthcare Clinic, adjacent to the JHM campus.  In this case, Walgreens’ board certified nurse practitioners staff the clinic, although they and company pharmacists can work with JHM faculty.

Rite Aid’s Health Alliance program should dovetail nicely with Walgreens provider collaboration initiatives.  The program brings together physicians, pharmacists and special care coaches to provide care and support to individuals with chronic and poly-chronic health conditions, helping them achieve health improvement goals established by their physicians.

Eight provider organizations currently are participating in Health Alliance, which leverages Rite Aid’s population health subsidiary, HealthDialog.  Another 11 reportedly are be interested.  On average, patients participating in the Rite Aid Health Alliance are 36% more adherent to their medications; they have lost an average of 7.7 pounds; they have a 39% reduction in blood pressure; and they have lowered their blood sugar by 36%, reports Drug Store News.

Big Bet on Consumer Technology

Rite Aid is also bringing Cleveland Clinic physicians into some of its Ohio stores via telehealth start up HealthSpot.  Installed in the stores is a kiosk, enclosed for privacy, which includes a video connection with a physician and the capability to take and transmit vital signs to the physician.

Opting for mobile, Walgreens is using the Pager platform, designed by an early Uber architect, to connect customers with physicians.  It also is relying on the MDLive platform for telemedicine, and working with WebMD on a wellness app, and with PatientsLikeMe enabling people to share medication experiences with each other.

Walgreens has been a leader in using technology to engage its customers.  Its app is the third most downloaded retail app in the U.S. and the number one brick and mortar pharmacy app, reports mobihealthnews.  Fourteen million people visit a Walgreens app or website each week and Walgreens fills more than one mobile prescription every second.

Walgreens’ Epic Catch-Up

However, until the EpicCare announcement today, Walgreens lagged in using technology to engage providers.  Its electronic record system could not easily communicate with other systems, forcing stores to use secure fax and email to communicate with physicians and other providers.   That raised serious questions about the future of its provider collaborations and role as a provider.

Now, EpicCare means Walgreens can be more than a purveyor.  It can also be a provider, fully integrated into the new health care.

Scaling the Limits of Scale: The PBM Path to Value-Based Health Care

Scaling the Limits of Scale: The PBM Path to Value-Based Health Care
Scale has its limits, as the nation’s two largest pharmacy benefit managers (PBM) are discovering.  Express Scripts and CVS Caremark each process more than a billion prescriptions a year.   That is not enough for big customers Anthem and Aetna.  Both are likely to alter dramatically or not renew long-term contracts set to end in 2019 with the PBM behemoths.

PBM Optionality for Anthem, Aetna

Anthem and Aetna say they now have “optionality” because Cigna and Humana, which they are respectively acquiring, both have PBMs.  That optionality goes well beyond the scale Aetna would enjoy as the fourth largest PBM.  It can put the pharmacy benefit, integrated within each organization, on the path to value-based health care.

Both the Humana and Cigna PBMs align well with the quality and outcomes focus of value-based health care.  Humana’s PBM primarily supports the company’s Medicare Advantage (MA) and Part D programs, with MA accountable care arrangements delivering better outcomes than traditional Medicare.

Meanwhile, Cigna has pioneered outcomes-based reimbursement arrangements with pharmaceutical manufacturers.  Previously overseeing Cigna’s PBM was none other than Aetna CEO Mark Bertolini; Cigna CEO David Cordani will serve as chief operating officer of the new Anthem.

In their sights is UnitedHealth Group (UHG), which brought its PBM business inside from Medco at the start of 2013, trigging Express Scripts’ anticipatory acquisition of Medco in 2012.    UHG says its OptumRx PBM focuses “on connecting total condition spend and pharmacy’s impact across benefits,” a process it calls “synchronization.”

More explicitly than Anthem, Aetna has said it will integrate Humana’s PBM, along with its “growing health care services business,” even characterizing it as an “Optum-like business.”

Value beyond Scale

UHG’s Catamaran acquisition earlier this year, while adding scale, also significantly included Catamaran’s RxClaim processing platform.  OptumRx plans to integrate the adjudication platform with its medical and pharmacy claims synchronization.  UHG promises to create value “beyond the scale … resulting from integration,” by linking “demographic, lab, pharmaceutical, behavioral and medical treatment data” to encourage healthy decisions and improve compliance with pharmaceutical use and care protocols.”

In fact, the very tools used to leverage scale to get lower prices, such as formulary exclusions, can potentially work against reducing total costs.  In securing a substantial discount from AbbVie for Viekira Pak, Express Scripts excluded Gilead’s Harvoni from its 2015 formulary.  Viekira Pak is a four pill a day regimen to Harvoni’s adherence-friendly one pill for curing hepatitis C.

Not surprisingly, given their focus on overall costs, Aetna, Anthem, UHG and Cigna all included Harvoni on their formularies and do not publish exclusion lists like Express Scripts and CVS Caremark.  Instead, they typically establish clinically based prior authorization criteria.

For the latest high-cost drugs to hit the market, Express Scripts is following the health plans on their value path.  Instead of excluding one of two new anti-cholesterol drugs, known as PCSK9 inhibitors and list priced at $14,000 per year, it announced coverage for both this week.

As the health plans did with Harvoni, Express Scripts will implement rigorous prior authorization procedures.  The company says it negotiated good pricing with Amgen for Repatha and with Sanofi and Regeneron Pharmaceuticals for Praluent, enabling it to cover both drugs.  Perhaps it also heard from customers unhappy with price-driven drug exclusions.

Wanting More, Customers Become Competitors

Clearly, some very big customers – Aetna, Anthem and UHG – want something more than scale from traditional PBMs like Express Scripts and CVS Caremark.  Beyond scale, they want a pharmacy benefit that contributes to reducing total costs through better outcomes, consistent with achieving overall value-based payment goals.

Building PBM paths to value-based health care for themselves, Anthem, Aetna and UHG will also sell against volume-based models like those of Express Scripts and CVS Caremark, and against health plans that fail to integrate pharmacy and medical claims for actionable intelligence.

Employers and the Limits of Scale

Their strategy blueprint could easily have come from the Harvard Business Review article “The Limits of Scale.”  Hanna Halaburda and Felix Oberholzer-Gee argue that, when rapidly scaling companies neglect to take into account differences among their customers, performance declines.  On that premise, they suggest how challengers and incumbents can take advantage of customer differences.

Among PBM customers with differences are employers, which provide health coverage for 147 million Americans.   The National Business Coalition on Health is uneasy with the growing use of exclusionary formularies.  It advises members to “base selection criteria for formularies on clinical outcomes to ensure that pharmaceutical costs do not decrease at the expense of rising medical costs.”

Employers are becoming more actively engaged in managing the pharmacy benefit, even developing their own formularies and negotiating directly with pharmacy retailers.  Caterpillar’s Daren Hinderman told an NBCH panel last year, “I don’t want to have a conversation [with PBMs] on rebates; I want to have a conversation on how I can keep my employees more compliant with medications they need to stay healthy. We decide what’s best for our employees. It’s a transparent process.”

NBCH also urges members to “verify that pharmacy and medical benefits are aligned, and link data between the two in order to evaluate cost and outcomes across both types of benefits and the entire health-care spectrum, not just through the lens of pharmacy.”  As Dr. Mark Fendrick of the University of Michigan Center for Value-Based Insurance Design told the NBCH panel, “I’d prefer to spend more on statins than on stents.”

Obstacles on PBM Value Path

Mapping the PBM path to value-based health care is one thing, building it is another.  Aetna and Anthem still must face a gauntlet of government and legal reviews before they can complete their acquisitions and commence integrating the Humana and Cigna PBMs.

OptumRx must complete its integration of Catamaran, which in turn is still integrating the data platforms of its acquisitions.  Furthermore, OptumRx and Catamaran both use different versions of the RxClaim platform and, for Catamaran, medical claims synchronization remains down the road (or path).

Meanwhile, the Catamaran acquisition has roiled a PBM industry where many participants use Catamaran’s RxClaim platform – including Cigna!  They were content to compete with Catamaran, despite using its technology.  However, will they be similarly comfortable with OptumRx and UHG in the technology driver’s seat?

Much like UHG’s acquisition of Catamaran and its technology, Rite-Aid did the same when it acquired EnvisionRx.  The PBM had previously acquired Laker Software, also a claims platform supplier for many PBMs.  Again, the comfort question arises, in this case over Envision and Rite Aid as the drug retailer pursues its path to value-based health care via innovative alliances with health care providers.

Making the Laker and RxClaim platforms particularly valuable has been the PBM industry’s reliance on a hodge podge of decades-old, antiquated platform technologies.  With each acquisition, scaling PBMs have patched together instead of invested in their platforms to maximize short-term synergies, at the cost of limited flexibility and lower efficiency.

PBMs Miss Technology Revolutions

Meanwhile, multiple revolutions have coursed through the systems development world since the PBM industry acquired its mainframes and data centers in the late 1980’ – early 1990’s.   When relational databases followed soon thereafter, PBMs adopted them for after-the-fact data analysis, but not broadly for real time use with claims processing platforms, which now are antiquated and fragmented.

More recently, graphical user interfaces have greatly streamlined the programming of business intelligence applications.  It is now easier for more people, more efficiently to translate their expertise into innovative systems.  No longer must visionaries exclusively funnel their solutions through highly specialized programmers and coders.  Now, the visionaries’ can become coders, their hands on the programming controls, unleashing new applications across the entire economy, including the PBM industry.

PBM Platform for Value-Based Health Care

One such visionary has developed a PBM solution for value-based health care.  His name is Ravi Ika.  “The solution is holistic, unlike that of any other existing PBM.  It reduces overall pharmacy cost, converts specialty from ‘buy & bill’ to ‘authorize and manage,’ and lowers avoidable drug-impacted medical costs,” explains Ika.

Before turning his attention to the PBM industry, he created a comprehensive, integrated payer platform now provided by ikaSystems, which he founded to transform the payer operating model.  Spanning all payer departments and business lines, it decreased administrative costs for health insurers by as much as 50% and reduced avoidable medical costs.

In 2013, Ika launched RxAdvance, a full service PBM, which similarly operates on an integrated, end-to-end platform – one designed specifically for value-based health care.   Combining pharmacy, medical, and lab data, the platform – called PBM Collaborative Cloud– enables real-time engagement.  This engagement occurs with physicians at the point of care, pharmacists at the point of sale, and patients via mobile cloud.  It also engages payers clinical and pharmacy staff through their workflows.

Better decisions by these stakeholders – driven by platform-generated, actionable intelligence – can reduce avoidable drug-impacted medical costs, optimize utilization, facilitate better specialty drug management, and decrease overall pharmacy costs.

PBM Processes Reimagined

“We started with a clean slate,” observes Ika, who says he and his team reimagined PBM processes to streamline workflow before building the platform.  Redefining the human role, they automated as much as possible while, on the other hand, increasing opportunities for engagement, what-if modeling, and informed decision-making.  The platform also enables market and regulatory changes configurable by the business user, as well as system-driven compliance management.

Ika built the platform from the ground up using a unified data model.  In information technology parlance, that means the platform’s standards are universal enough to encompass a large scope of data and types of data with high scalability.

In PBM language, the platform includes everything from pharmacy claim adjudication, formulary management, benefit design, enterprise reporting and analytics, to pharmacy network and rebate contracting, medication adherence and therapy management, specialty management, transparency, compliance, and adverse drug event management.

From Existing to Ideal Formularies

For example, the platform includes algorithm-driven artificial intelligence to manipulate, with plan sponsor engagement, the complex and interdependent variables associated with formulary management.  Incorporating habitual member and prescriber utilization patterns, in addition to other data, it derives an ideal formulary with optimal financial and clinical outcomes.  The system then maps a transition plan from an existing formulary.  The platform also accommodates an unlimited number of formularies and supports real time dynamic modeling and changes coupled with full transparency.

Better Medication Therapy, Adherence Outcomes

For medication therapy management (MTM), the platform taps patient medical claims and disease conditions, against which the system overlays a prescription listing for easy use by prescribers.  In addition, each new prescription triggers a dynamic analysis to determine patient eligibility for a comprehensive medication review (CMR), which the system prepopulates for efficient prescriber use.

After the CMR, RxAdvance advisors rely on system alerts to intervene with patients to ensure medication adherence.  For high-risk patients, RxAdvance will install an electronic, patent-pending pill station at their residences and resupply it with disposable pre-filled pill trays.

Integrated with and wirelessly connected to the company’s platform, the device assists with monitoring adherence and vital signs.   The company says the device has improved adherence to more than 93%, including patients with multiple chronic conditions who are taking an average of 15 medications a day.

The Centers for Medicaid and Medicare Services (CMS) recently underscored the PBM need for physician-led, point-of-care MTM capability when it announced a new Medicare Part D MTM model.  Currently, highly fragmented PBM MTM relies on pharmacists “chasing” patients without closing the loop with prescribers, thus failing to secure meaningful health outcomes, according to Ika.

Ika points to the RxAdvance specialty management program as another example of his platform’s capabilities.  As it does for MTM, the platform integrates prescriptions, medical claims and disease conditions to create an action plan for all stakeholders.  Case managers use a dashboard to prioritize their outreach to patients, prescribers and pharmacists.  Because the platform integrates medical, pharmacy and lab information, it helps facilitate appropriate utilization.

Risk Sharing

One of the hallmarks of an organization configured for value-based health care is its ability to share risk.  The RxAdvance unified data model platform enables it to share risk for both pharmacy and avoidable drug-impacted medical costs.  For pharmacy, it is prepared to assume both up and down side risk based on its cost management performance against a risk cap set below a national benchmark projected increase.

The company can also compute a baseline trend for avoidable drug-impacted medical costs using prior years’ medical claims data.  RxAdvance and its client then set a target and, if the PBM lowers actual avoidable drug-impacted medical costs, it will share in the savings.  According to Ika, this sort of risk sharing is unique in the PBM market.

Ika reports that RxAdvance is currently implementing full PBM services for three clients, replacing national PBMs.  “The Collaborative PBM Cloud platform is making for a very smooth launch,” he notes.

RxAdvance has gotten a head start along the PBM path to value-based health care, scaling the limits of scale.

Telemedicine: Bad for Antibiotic Stewardship?

telemedicine2Sandy Walsh is a breast cancer activist and, assuming she is like one in seven adult Americans each year, a sinusitis “survivor” too.

She served as the first-ever consumer advocate on the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) panel that recently updated the adult sinusitis clinical practice guideline.

Patient Education and Watchful Waiting

Novel, too, was the panel’s emphasis on patient education and its expansion of watchful waiting (without antibiotic therapy) as an initial management strategy.  The latter now applies to all patients with uncomplicated acute bacterial rhinosinusitis (ABRS) regardless of severity.  The prior guideline limited the antibiotic-free approach only to patients with “mild” illness.

Patients may not even need to see a doctor.  “For the first time we’ve really made it crystal clear how to self-diagnose your own bacterial sinus infections without going to the doctor, with a high degree of accuracy,” Dr. Richard Rosenfeld told National Public Radio.  He led the AAO-HNS guideline panel.

Not seeing a doctor for a sinus infection might actually have its advantages.  The doctor a patient sees, not the patient’s condition, largely determines treatment, according to an Annals of Internal Medicine study published this month.  Physician preference or “style” largely determined antibiotic use, not patient related factors like fever, age, setting, or comorbid conditions.

Telemedicine and Antibiotics

What happens when telemedicine makes physicians more accessible, convenient and less expensive to “see” for ailments like sinusitis?   Antibiotic prescribing rates for acute respiratory infections were similar regardless of whether the encounter was face-to-face or via telemedicine, according to a JAMA Internal Medicine study published this month.

That the prescribing rates were similar represents an improvement – of sorts.  A study published two years ago, also by JAMA Internal Medicine, found that telemedicine physicians were more likely to prescribe an antibiotic.

Other research shows that acute respiratory tract infections account for 75% of all outpatient antibiotic prescribing.  Half those prescriptions are unnecessary because a large portion of those infections are likely viral, not bacterial.

Even more troubling, telemedicine physicians in the 2015 study were more likely to use broad-spectrum antibiotics, raising concerns because “overuse increases costs and contributes to antibiotic resistance.”  The study suggests telemedicine physicians may have been prescribing more conservatively due to limited diagnostic information.

To decrease antibiotic prescribing, the study’s authors want telemedicine operators to change physician behavior with timely feedback.  They also recommend “direct education to patients to influence demand.”

Do It Yourself for Patients

Sandy Walsh, the consumer advocate, is ready with patient education — specifically “do-it-yourself” diagnostic tools for sinusitis sufferers.  She and her co-authors have written a plain language, adult sinusitis summary, including patient information sheets, based on the new AAO-HNS clinical practice guideline.   The summary, already available online, will appear in the August issue of Otolaryngoly – Head Neck Surgery.

According to Dr. Rosenfeld, the key to this “do it yourself” approach is learning how to tell whether the infection is viral or bacterial.  As he told NPR, if you have been sick less than 10 days and you are not getting worse, it is most likely viral and an antibiotic would have no effect.

If you do not improve or get worse in 10 days, it is probably bacterial.  Still, Dr. Rosenfeld advises that, even then, an antibiotic would play little role in what is largely a battle between your body and the infection.  “There’s a good chance you’re going to get better on your own,” says Dr. Rosenfeld.

Integrate Telemedicine and Education

Telemedicine providers would do well to follow Dr. Rosenfeld’s example.  Fully integrate patient education as first line therapy for sinusitis, help patients learn how to diagnose and care for themselves, and reserve antibiotics for true need.   Make telemedicine good for antibiotic stewardship.

And, get the help of consumer advocates like Sandy Walsh!

King v. Burwell: 12 Keys to Effective Communications

Supreme Court - King v. BurwellIn King v. Burwell, if the Supreme Court rules for King, as many as 11.7 million Americans will wonder how the decision affects them.  That’s right – not just the 6.4 million directly affected, but everyone who gets coverage through an exchange, state or federal, subsidized or not.

They will be looking to their insurers, physicians and hospitals for answers.   In fact, even some of the 169 million Americans getting coverage at work may also wonder, so their employers should brace for questions, too.  For most Americans, there will likely be more confusion than clarity.

Yes, policy wonks, political operatives and health care insiders already know the justices could eliminate subsidies in the 34 states using the federal exchange, hitting southern states the hardest.  They also know that the subsidies, averaging $268 per month, reduce premiums by an average of 72% to about $105 per month.

However, the entire issue will be news to most Americans when the decision comes down, especially if it is for King.  In fact, as many as 37 percent of voters do not know or have no opinion on the case’s core issue of subsidies, according to a Morning Consult national survey released last week.

The justices could hand down a decision any day.  So, if you are a physician, hospital, insurer, or employer, or engaged with patients and health consumers, prepare to communicate.

Here are 12 keys to effective King v. Burwell communications for your organization:

1.  Convene a high-level, cross-functional response team to assess the decision’s impact, identify affected stakeholders and their concerns and develop a response strategy.

2.  Establish a set of guiding principles to align actions and communications with your organization’s mission, values and brand promise.

3.  Develop key messages based on your guiding principles to help all stakeholders clearly understand your organization’s approach.

4.  Decide as soon as possible whether your organization will support state or federal policy solutions that will restore subsidies.

5.  Create a communications map illustrating how internal and external stakeholders will present or receive questions to ensure all gaps are closed.

6.  Provide general explanations to patients, members, employees and consumers regarding how the decision does or does not affect them, based on their state, insurance type and any subsidies.

7.  Address, one-on-one, individual patient concerns regarding continuation of care and ability to pay. (If you are a provider, see HFMA for guidance.)

8.  Help patients and consumers develop personal response plans, utilizing available community, government and private sector resources.

9.  Encourage patients to maintain care until they speak with their physicians and develop a personal response plan.

10.  Ensure employees and partners have a ready answer to initial questions based on the key messages, plus guidance to refer patients, members, friends and neighbors to your website for more.

11.  Meet immediate patient and consumer needs for information with a quick response and ongoing follow up, internally and externally, via statement, spokesperson and website.

12. Adopt a transparent attitude, responding as completely and forthrightly to questions and requests for information.

A free planning tool is available at Planning Effective Communications on

New Patient Family Advisors Move Health Care, Not Flower Pots

Patient family advisors Beth Daley Ullem, Chrissie Blackburn and Kim Blanton at the 17th Annual National Patient Safety Foundation Congress plenary session, From Experience to Engagement:  How Three Patients are Leading Patient Safety

Patient family advisors Beth Daley Ullem, Chrissie Blackburn and Kim Blanton at the 17th Annual National Patient Safety Foundation Congress plenary session, From Experience to Engagement: How Three Patients are Leading Patient Safety

Don’t ask Kim Blanton, one of the new breed of hospital patient family advisors, where to put the flower pots.  Politely, she will say she doesn’t care.  Instead, she told last week’s National Patient Safety Foundation (NPSF) Annual Congress, “Give advisors meaningful work meeting a true need.”

For more than a decade, hospitals have been establishing volunteer patient family advisory councils.  Most function as useful sounding boards, providing feedback on brochures, commenting on building designs, adjusting form language, assisting with patient satisfaction programs and arranging flower pots.

Meanwhile, consistent with NPSF recommendations, a small but growing number of institutions are now including patients and families more broadly in shaping the delivery of care. These advisors sit on safety committees, assist root-cause-analysis teams, participate in clinical redesign initiatives, support quality improvement projects, and serve on governing boards.

When North Carolina’s Vidant Health asked Blanton to be an advisor five years ago, her first meeting was about end-of-life care.  Since then, she has interviewed candidates for senior positions like chief medical officer and worked on reducing heart failure readmissions. As a long-time cardiac patient, Blanton brought a unique perspective to the development of a transitional program that helps patients care for themselves at home.

Advisors on Staff

Increasingly, hospitals are even hiring advisors, as University Hospitals Case Medical Center in Cleveland did when it appointed parent Chrissie Blackburn as its first principal advisor on patient and family engagement.

Blackburn, who also addressed the Congress, is the creator of the ETeam® program, a communications tool for point-of-care patient and family engagement.   Reporting directly to the chief executive officer, she has been piloting the program in several units and is currently developing a module for hospital-acquired infections.

In 2008, Children’s Mercy Hospital in Kansas City hired parents Sheryl Chadwick and DeeJo Miller as family centered care coordinators.  Seven years later, Children’s Mercy has more than 300 advisors embedded on committees, task forces and teams throughout the hospital.

Chadwick and Miller attribute the broad involvement of advisors to a 2012 policy change “placing patients and families at the center of decision making.” By 2014, the number of participating advisors had more than doubled.

Leading a Congress workshop, they reported a parent saying she “feels like a peer on the team.”   Last year, the Caregiver Action Network ranked Children’s Mercy among the nation’s top 25 organizations for patient and family engagement best practices.

Similarly, Vidant Health is doing more than sponsoring a top-level advisory council, according to Blanton.  “Advisors partner with care units on the front lines, working with staff, going to meetings and participating in rounds.”

During the ten years she has received care and provided advice, Blanton says she has seen progress. “It’s a whole lot better.  There are 150 advisors like me, helping to make it better,” she explained.  Vidant fully integrates advisors on teams and committees, engages patients and includes advisors on root- cause-analysis teams.   Last year, the health system reviewed its extensive patient engagement experience, dating from 2000, during a recorded North Carolina Network Consortium online event, Engaging Community: Patient Advisory Councils.

Transparency- Engagement’s Frontier

Both Children’s Mercy and Vidant Health provide advisors with training, especially on the importance of maintaining patient confidentiality.  Still, engaging so many advisors on a daily basis, from the C-Suite to the front lines, requires a strong commitment to transparency.

In fact, the level of that commitment defines patient engagement’s frontier.

Hospitals and health systems are beginning to add patient and family representatives to their boards.  However, some are only doing so up to a point.  One asked its patient representative to leave when discussing adverse events, according to Beth Daley Ullem, a parent who joined Blanton and Blackburn on the NPSF Congress stage.

Ullem, who works with boards on improving patient safety, said there is “such a gap in the information patients are given.  There is such variability on outcomes, but patients are unable to access outcomes and safety data.  To get to value based health care we need outcomes and pricing transparency.”

In fact, the most recent report of the NPSF Lucian Leape Institute, Shining a Light – Safer Health Care Through Transparency, called for “extreme honesty with patients and their families from start to finish.”  The report, distributed to all Congress participants, concluded that the “current status of transparency between clinicians and patients in most organizations is less than optimal.”

Apologize, Disclose, Resolve

When failures in care result in harm, the report advises clinicians to embrace apology, disclosure, and early resolution.  Presenting a successful model at the Congress was the Massachusetts Alliance for Communication and Resolution following Medical Injury.  Also making progress in this area have been the University of Michigan Health System and the University of Illinois Medical Center at Chicago.

Although the report recommends involvement of willing patients and family in root-cause analyses of medical errors, it does acknowledge the practice merits further discussion, experimentation and research.  In fact, the practice could turn out to be controversial, judging by comments from the Michigan Health and Hospital Association Keystone Center during a Congress presentation.

The Center is coordinating an initiative among the state’s hospitals to increase patient and family engagement.  Kicked off in October 2013, with a white paper, the effort now involves networking activities, leadership engagement, materials development and a measurement process.  The latter includes patient, family, or caregiver participation in root cause analysis.

Two Decades of Progress

Still, the patient safety movement has made considerable progress on patient and family engagement since October 1996, when the NPSF debuted at the first Annenberg Center patient safety conference in Rancho Mirage, California.

The foundation officially got underway shortly thereafter on January 1, 1997, began work on a research grant program and concluded the year by announcing a survey finding 100 million Americans had been touched by medical error as patient, family or friend.  Meanwhile, the Joint Commission implemented a new “accreditation watch” program for institutions experiencing a major error or near miss.

“The initiatives were good,” Linda Golodner told USA Today, but “doctors must start treating patients with respect for real change to take place.”  Then the president of the National Consumers League, Golodner added that patients would detect some problems on their own if they had more information.

Now, with more information, patients and families are doing more than detecting problems.  They are part of the solution.

Learning Patients Climb the Curve

Increasingly in healthcare, a patient is expected to be a full-fledged member of his or her care team.  There he or she is, surrounded by experts who have gone to medical school, nursing school, pharmacy school and so on.  Is there a patient school? No, not really.

So, how does a patient truly function as a full member of the care team?  How can a patient really be “engaged,” “empowered,” or “active?”  He or she can, but only by learning how to be a patient in the new patient-centered healthcare.

We must therefore pay special attention to the needs of the Learning Patient, helping him or her acquire the knowledge and skills needed to play a meaningful role on his or her care team.  When not directly engaged with members of that team, it also means becoming more adept at caring for his or her own health and performing self-service therapy and monitoring.  In addition, it further involves becoming an effective advocate for quality and in managing costs. This goes way beyond traditional patient education, although that remains part of the equation.

Of all the other care team members, nurses play a pivotal, intermediary role in helping the Learning Patient.  Clinically trained and compassionately disposed, they translate the complexity of medicine to often anxious patients simply, compassionately and accurately.  They become teachers, quickly assessing differing learning styles and immediate concerns.

Curiously, the term Learning Patient does not appear to be widely used, based on a thorough Google search.  The most prominent mention occurred in an article regarding rheumatology patient self-administration of subcutaneous therapy.  The authors categorized the patients as struggling, learning, participating and independent.

On a vastly larger scale, the Institute of Medicine has been pursuing a Learning Healthcare System initiative.  Its principal focus has been on more insightful data analytics to establish evidence based best practices and foster “learning” of these practices by the overall health system.   The initiative has included workshops and publications on patient engagement in this endeavor.

Healthcare’s transformation is creating new needs for and thus redefining the Learning Patient.  This redefinition is occurring between helping patients and caregivers manage home care tasks — much of which is already occurring — and the large scale IOM efforts.

There’s more to this than the Learning Patient.  If, indeed, care is to be patient centric, then everyone that interacts with that patient has a lot of learning to do.  This involves the other members of the care team: physicians, providers, payers, practitioners, pharmacists, caregivers, drug makers, device makers, as well as information technology.

Thus, healthcare’s transformation creates learning curves for all to climb.

Smartphone Spring: The Great HealthIT Democratization

A great democratization of health information. That’s what the nation’s departing HealthIT Czar, Farzad Mostashari saw on the horizon last week when he bade farewell to his team at the Office of National Coordinator (ONC).

Over the next 12-months, he wrote in a valedictory email, individuals will become empowered to download their own health information. Investors will continue to pour venture capital millions in new health management tools. The landscape is changing, forever, he observed.

Meanwhile, the mobile devices that Ernst and Young Chief Technology Officer Mal Posting calls – in speaking of mHealth — “the nerve endings at the end of a vast information network” are spreading far beyond the hands of the advantaged.

As I noted in my recent post on self-service medicine, BI Intelligence forecasts that the next 100 million new smartphone users will be older and/or lower income.  Currently, about 60 percent of the US population owns a smartphone, according to Pew Internet and ownership growth is accelerating from 572,000 to 583,000 per week.  By the end of 2013, there will be about 13 million new smartphone users in the US.

In fact, smartphone makers are racing to introduce lower price handsets to satisfy demand from consumers and service providers who want to add more subscribers.  While much of the growth in low-price handsets has been in emerging markets like China and India, US demand is picking up.

For example, Nokia recently introduced its Lumia 625 priced at $290, which is a third of the cost of its highest end model.  Notably, Nokia touts the phone as the first “accessibly priced” 4G device so, although introduced first in emerging markets, it appears designed for use in developed markets with 4G networks like the US.

But, Nokia has some catching up to do.  Even cheaper still is the new Moto X from Google’s Motorola division, introduced this month and costing $199 on a two year contract.  Motorola says it will be rolling out even cheaper smartphones, especially for emerging markets and prepaid use in the U.S.

Other smartphone makers are quite active too. Lower cost versions of Samsung devices, such as the Galaxy S4 mini, are heading for emerging and prepaid developed markets.  However, the company is facing stiffer competition at the low end of the market from local and smaller producers.. And rumors of a low cost Apple iPhone abound.  In fact, recent news reports suggest that, at Apple’s anticipated September 10, introduction of a new high end model, it will also launch a new lower cost smartphone.

Lower cost smartphones and more affordable prepaid service plans are playing off each other, resulting in further cost reductions and enhancements for both.  According to a study by the NPD Group, 32% of all smartphone sales were for prepaid models by the beginning of 2013. As a result all the major carriers are rolling out more affordable prepaid smartphone plans, even on their fast 4G and LTE networks.

What about app pricing?  It’s going down, too.  According to the mobile analytics firm Flurry, the average app price has fallen significantly over the past four years. Meanwhile, the number of free and ad-supported titles continues growing.  Currently, 90 percent of all apps are free.  Of those that are not, iPhone apps average 19 cents and those for Android, the most popular operating system on lower cost phones, average 5 cents.

Clearly the smartphone spring is well underway.  In the United States and globally, it’s helping to drive the democratization of information.  Presumably, the smartphone spring will also drive the democratization of health information. In fact, there currently are 15,000 medical apps on the market, growing 25 percent annually.  The question is, will the smartphone spring ultimately bring on a health information spring.

The potential is there, especially with widespread accessibility.  But, as I noted in my most recent post – “App or Apt” — smartphones, their apps and related technology must be adapted to users, especially patients.   In that post, I shared suggestions from the Wireless Innovation Council and Mobiquity.  These included individualized solutions, appropriate interventions and outcomes for each user, personalized communications, and low effort data collection.

Additional guidance has also come from Dr. David Lee Scher, an expert on mobile and digital health and formerly a cardiac electrophysiologist:

  • An app must address a specific problem to be considered useful.  Otherwise, it will not be used.
  • Technology design must include physician input.
  • Final app construction must fully consider usability and the user experience with the focus on specific users accomplishing specific tasks.
  • Knowing the healthcare landscape is critical to creating a strategy for adoption.
  • Build to regulatory specifications.

Expansion of global smartphone ownership beyond the current 1.08 billion out of 5 billion cellphones, by itself, will not automatically lead to widespread use in healthcare.  The key, as I said, will be the extent of integration that truly adapts to the healthcare system, especially the people in that system, particularly patients.

One vision of such full integration has healthcare apps included as a mandatory requirement of some insurance plans.  At the risk of higher premiums, patients could be required – for example — to access an app before going to see their doctors.  Diabetics might need to check glucose levels and send the results to a remote monitoring station.

As explained by Merrill Matthews of the Institute for Policy Innovation and Edward M. L. Peters, CEO of Open Connect Systems, “this innovative approach focuses on information, rather than “brick and mortar” services. As information and technology get ever cheaper, policyholders and insurers can take advantage of them directly, thereby reducing costs and improving health outcomes.”

“Not everyone would take advantage of such a policy, but if health insurers were able to offer one at a significantly lower price, millions of Americans might jump at the chance. In an age of near-constant connectivity, where people use apps to manage everything from travel directions to dinner recipes to bank accounts, insurance policies that encourage consumers to embrace technology and information may be the key to bending down the health care cost curve,” they concluded.

Meanwhile, in the world’s biggest democracy, the Indian government is pushing smartphone makers to produce Made in India smartphones costing less than $100.  Said one government official:  “A fully-functional smartphone is no longer an object of desire but an instrument of empowerment,” with telemedicine one of uses.

But, the same rule requiring adaptive integration applies on the subcontinent, just as it does to healthcare in the US or anywhere.

Ovum analyst Shiv Putcha cautions that equipping the population with cell phones is not enough.  He says the government would have to develop a “broadband ecosystem” with mass mobile content and applications development in local languages so that people even in rural India would use the mobile platform to go online.

1.2 billion people, speaking 447 different languagesHoli smartphone spring!

App or Apt: What does the learning patient need?

My 90-year old dad, now two months with a new aortic valve courtesy of Penn Medicine, was puzzled – and perhaps impatient.  “My energy still escapes me,” he asked, wondering when the new valve would make a difference.  The doctors had said give it time, but he still puzzled.  Maybe it’s the meds, some new, others with different dosages.

So, he started reading the fine print, going line by line through the labels, information sheets and other documents accompanying each of nearly a dozen medications.  He also took another look at the materials provided by the Penn team.  He’s keeping track of when he takes each medication and how he feels throughout the day.

His conclusion so far:  Each medication has a purpose despite any side effects, and that he’ll give it time as the doctors advised.  And, he’ll continue with cardiac rehab, walking the block to the sessions and increasing his time on the treadmill with each session.  He’ll also take his research and “charting” with him when he next sees his internist and cardiologist to get their advice.

What he’s done is exceptional, as I’ll explain below, but not unexpected.  You see, he’s a Greatest Generation naval veteran of the 1944 Battle off Samar in the Philippines.  After the war and some time back home in Ohio, he enlisted in the Air Force, where he was a sergeant and a flight engineer.  Reading, following and documenting detailed procedures was part of the job.  Now, he’s surrounded by books.

How he learned about his medications was “apt” for him.  There’s no “app” for it.  In fact, he’ll have nothing to do with new-fangled computers, smartphones or tablets, though he likes emails that emerge on hard copy from a printer at his home.

Here’s the point:  Successfully helping a patient learn doesn’t start with the information or the knowledge.  Neither does it start with the teacher or the tool, be it a website, app or flashcard.  Instead, it begins with and must be apt for, ie. adapted to, the patient.  Unfortunately, this fundamental principle of adult learning – it’s all about the learner, not the teacher – is too often neglected.

Therefore, starting with the patient, here’s what adapting to the patient will need to consider.  It’s sobering.

  • Only a little more than one in ten Americans are considered health literate at the proficient level, according to the National Assessment of Adult Literacy.
  • 90 percent of adults have difficulty following routine medical advice largely because it is often incomprehensible to average people, according to studies cited by Orca Health.
  • Patients at all literacy levels, but particularly those with the lowest literacy skills, have difficulty understanding medication directions and warning labels, according to studies cited by the Institute of Medicine.
  • The National Assessment of Adult Literacy found that only 30 percent of subjects with a bachelor’s degree or higher were considered proficient.
  • According to a study in the Journal of the Royal Society of Medicine, 40 to 80 percent of information patients receive is forgotten soon after an appointment, and roughly half of what they do remember is inaccurate.
  • Patients ask an average of 0 – 2 questions during doctor visits, according to studies cited by Orca Health.
  • Viewing rates for web based educational tools are low.  In a recent study published by the Journal of the American Medical Association Internal Medicine, only 6% of patients in the study viewed the online material.

Clearly, most of the nation is on a steep learning curve.  Successfully helping the learning patient up this curve starts with and requires adaptation to the patient.  Here are some examples:

  • Move away from the discharge data dump, following the example of the University of Nebraska Medical Center (UNMC).  Instead, UNMC focuses on active learning based on patient teach back and teaching sheets.
  • Prepare more extensively for primary care patient visits by adding nurses to counsel and spend more time with patients, ordering labs so discussion of them can be part of the visit and looking patients in the eye to motivate healthier behaviors.  Such team based care has proven quite successful at the Red Cedar Clinic in Menomonie, WI.
  • Pick the right time, being aware of patient readiness, and add a human touch advised Jessie Gruman, president of the Center for Advancing Health, in advice for providers recently shared with the New York Times.  Too much information doesn’t help a patient learn.
  • Speak slowly and plainly, encourage questions, rely on pictures and other visuals, keep information digestible and ask patients to teach back, as suggested CareNovateMag based on information from and the Federal Health Resources and Services Administration.
  • Initiate face-to-face patient conversations with clinical pharmacists in community health centers to reduce emergency room visits like Health Partners of Western Ohio.
  • Use pharmacists as discharge process leaders like the University of North Carolina does in an initiative to improve anti-coagulant safety.
  • Rely on videos and pictures, engage in conversations and resolve patient issues or concerns when using social media, according to Nucleus Medical Media.
  • Tell stories when blogging for health behavior change, as suggested by a study published in the Journal of Medical Internet Research.  Doing so is the most effective way to engage the reader and establish credibility across a broad spectrum.  Otherwise, the reader wants the blogger to be like him or her to sustain attention, thus making the range for potential engagement much narrower.
  • Look to the Kahn Academy, which has begun producing patient videos.  Rishi Desai, Kahn medical fellow and Robert Wood Johnson Pioneer grantee calls in “flipping the visit.”   They help patients learn before doctor visits, freeing time for doctors to listen to patients.  This is instead of “teaching” during an appointment with a hurried lecture.
  • Prepare patient education materials that reflect knowledge and respect for the audience, feedback during preparation.  Make them simple, interactive and easy to digest, suggests internal medicine physician Erin Marcus in an article posted on KevinMD.

Now, to the question in the title:  App or apt?  Ultimately, it’s not an either or question. There can, should be and likely are apt apps.  A recent report from the Wireless Innovation Council and Mobiquity outlined best practices for creating behavior changing mobile health apps.  The practices, all aptly tailored for the individual user, include individualized solutions, appropriate interventions and outcomes for each user, personalized communications, and low effort data collection.  Suggested as individualized solutions are self-logging, gamification, social feedback, self-measurement, auto-analytics, notifications, alerts and reminders.

In fact, the health self-management app Boston Medical Center is offering its lower income community – about which I wrote in my last post – just might be such an “apt app.”  Take a look at the check in screen to see why Dr. Robert Sokolove says this app, which relies on peer support, is sort of a Facebook for patients.

Self Service Medicine: It’s Clinical Now!

Self-service medicine – it’s now more than using an appointment-scheduling kiosk, conversing with a phone robot or ordering electronic prescriptions.  Already mastered by many, these essentially administrative tasks – the equivalent of supermarket self-checkout – are looking a lot like false summits to patients climbing the healthcare learning curve.

In truth, the climb continues.  Patients are learning that self-service medicine now includes self-diagnosis, self-medication, self-entered histories, self-care, self-management and self-monitoring, with the latter sometimes relying on clever gadgets attached to app-equipped smartphones.  The clinical realm clearly is no longer off limits to patient self-service.

Not too long ago, clinicians frowned on patients arriving for appointments with print-outs in hand, having researched and self-diagnosed their symptoms on the Internet.   Now, some physicians are encouraging patients to prepare for appointments by consulting reliable symptom checkers, as reported recently by the Wall Street Journal.  These include the widely used WebMD, as well as symptom checkers available from the Mayo Clinic, the American Academy of Pediatrics, and companies such as A.D.A.M, iTriage and Isabel.

Why the turnabout?  As Dr. George Reynolds, chief information officer of Omaha’s Children’s Hospital and Medical Center told the Journal, “We are giving them a much better tool than just googling a bunch of stuff.”  Dr. Mark Graber, president of the Society to Improve Diagnosis in Medicine, observed that “suggesting a range of possibilities to your M.D. might help prevent the premature closure errors that underlie so many diagnostic errors.”  Isabel founder and chief executive officer, Jason Maude, explained that “patients are experts on their symptoms and doctors are experts on working out their probably causes.”

Driving self-diagnosis and self-service medicine into the mainstream will be additional factors closely aligned with self-service expansion throughout the economy.  These include saving time during office visits, more productive consultations and potentially better clinical outcomes, for example in helping doctors think of something they hadn’t considered and preventing diagnostic errors.   In other words, self-service medicine such as self-diagnosis helps drive down provider cost and increases quality.

Inspired by Mary Meeker’s annual Internet trends presentation, HealthPopuli author Jane Sarasohn-Kahn recently observed, “the more consumers can do for themselves in remote monitoring, on-time efficacious care, and safe aging at home, the more providers can manage their risk for that patient’s conditions” within the context of value based healthcare and risk management.  So the more Medicare and commercial insurers (e.g. UnitedHealth Group) move away from fee for service to value or population based reimbursement, the more self-service medicine will grow.

Here are some additional examples:

    • According to Physicians Practice, patient entered histories can effectively address problems with traditional physician-patient interviews identified in a Mayo Clinical Proceedings article.  The Mayo review noted that 50% of psychiatric problems are missed, about 50% of patient problems go unaddressed and patient and physician do no% t agree on the primary complaint 50% of the time.  And, there’s less work for providers.  As Physicians Practice observed:  “Whether you are writing a note, using dictation, or typing into an EMR, documenting the subjective part of the note can be time consuming.  Why not have patients tell (i.e. document) their own stories?
      • The 2013 TEDMED conference in Washington, DC, featured “The Smartphone Physical” exhibit, where attendees saw how a special cell phone case doubled as a one-lead EKG, an attachment snapped pictures of the inside of a subject’s eye and another attachment produced a “picture perfect” magnification of the inner ear.  Harvard medical student Ravi Parikh wrote in the Washington Post that smartphone medical applications cost less, produce better quality results and more fully engage patients – once again, the factors driving expansion of self service medicine. As the curator of the exhibit, Johns Hopkins medical student Shiv Gaglani told Parikh:  “Some of the smartphone devices are already being used by patients to collect and store their data, so when they see their clinicians they can have productive and informed conversations.”

Underlying each of these examples of self-service medicine, from self-diagnosis to self-service physicals, is a technology platform for use on the Web but typically also available via a smartphone.   So, with the growth of self-service medicine, how many people, unable to own smartphone or access such a device or the Web, will find themselves on the wrong side of a healthcare “digital divide?”

Not as many as might be feared.  According to the Pew Internet Project, 85% of U.S. adults use the Internet, 91% own a cell phone and 56% own a smartphone.  Of these, 31% of cell phone owners and 52% of smartphone owners have used their phone to look up health or medical information.  Notably, Pew, observes that young people, Latinos and African Americans are significantly more likely than other groups to have mobile Internet access.

However, some are concerned that smartphone prices may go up, hampering widespread access, due to a pending decision by the International Trade Commission in a battle between Apple and Samsung over Samsung smartphone imports.  The controversy is arcane, involving Apple’s claimed exclusive rights to the rounded rectangular touchscreen design.  If the ITC rules in Apple’s favor, the concern is that prices could go up.  That could impact the next 100 million new smartphone users, who BI Intelligence predicts will be older and/or lower income.

Meanwhile, Boston’s safety net hospital, Boston Medical Center (BMC) will offer low-income patients access to the OneHealth online and mobile platform to promote self-management of chronic diseases, offer peer support and engage them in between office visits.  As BMC’s Dr. Robert L. Sokolove told MobiHealthNews, “Many of our patients can’t use a desktop because they don’t have a desk, but they do have smartphones.”

Patients Have Stopped Going to the Doctor

Patients have stopped going to the doctor.  Instead, the doctor is going to patients, intercepting them at work, at home and in grocery stores, malls, offices, shopping centers, drug stores, big box stores and on farms. In person and electronically, they’re showing up where patients live, work, shop and play.

They’re not alone.  They’ve got the whole team and more:  Nurse practitioners, physician assistants, nurses, pharmacists, community health workers, self-management trainers, iPhone app, cell phone text reminders, etc.

“Location, location, location,”

That’s how Direct Primary Care (DPC) pioneers Dr. Randy Robinson and Mason Reiner explained it in their recent Physician News Digest article:

“In today’s intense working environment where 85.8% of males and 66.5% of females work more than 40 hours per week, DPC addresses the burden of traveling for care. By locating near commercial centers, and integrating email, text messaging, and telemedicine capabilities into the practice, DPC can deliver convenient, time-efficient, high-quality care – a benefit for patients as well as employers.

When a hemoglobin A-1c lab test for a patient comes back grossly elevated, scheduling a 15-20 minute conversation about proactive diabetic management is a necessity. The only difference, utilizing DPC, the physician is in his or her office and the patient is at work as well as on a break. The vast majority of effective primary care is knowledge transfer, communication, and continuity.  The physical point of service is no longer necessary for billing purposes.”

Their characterization of primary care bears repeating:  “The vast majority of effective primary care is knowledge transfer, communication and continuity.” In other words – mutual learning for both the learning physician (about the patient) and the learning patient (about his or her condition). They emphasize that care will neither be patient centric nor physician centered but relationship centered.

The movement of care closer and closer to the patient can only accentuate this relationship-based learning.  In fact, the greatest long term value will come from patients learning to better care for their health and manage their conditions and from physicians and clinicians avoiding the inefficiency and misdirected care that can come from limited knowledge of their patient’s complete situation in context.

How can this closer relationship and mutual learning occur when, paradoxically, patient and physician are located miles apart, but joined by a high definition, telemedicine connection? In fact, patients and physicians are saying that virtual doctor visits may be better than in-person visits.  Reasons include greater convenience, a virtual waiting room that’s better than a real one, greater patient engagement from screen sharing, more convenient record keeping and a feeling by patients that their doctors pay more attention to them during virtual visits.

America’s military medical services have been using telemedicine extensively.  In fact, they are beginning to move from fixed base connections to using smart phones.

In Cleveland, physicians are examining patients remotely in connection with initiatives at University Hospitals, Cleveland Clinic and other institutions, according to a story in this week’s Cleveland Business.   Telemedicine candidates could include people in poor, urban centers or those in rural communities, according to the report.

One 77 year old patient was quoted in the story, saying “it was essentially the same experience as a visit to the doctor, but there was (my doctor) sitting at his desk, and here I was in my apartment.  It was amazing and very enlightening to me. The quality of the image is amazing.”

Meanwhile, in California, big agricultural companies have begun operating free clinics for workers on the farm. As California Healthline reported, “Paramount Agribusinesses, partnering with Kaiser Permanente, recently opened a 1,500-square-foot health and wellness center at its clementine plant in Delano and a temporary facility at its almond-processing plant in Lost Hills.”

“We’re backing up the healthy products we create by offering our employees much better than standard coverage,” said Danny Garcia, director of human resources at Paramount Citrus, according to the publication.

In Indianapolis, three employers are sharing a clinic set up in the Cumberland Crossing shopping center. Interviewed by Indiana Business, Dan Marchetti, Chief Financial Officer of Urschel Laboratories explained: “We see this as being both conveniently accessible and a great cost-savings to our workforce and their families.  Urschel is a global leader in food cutting machinery.

For rural areas across the country, Wal-Mart expects to install primary care clinics in its stores within five years. According to the Advisory Board’s Lisa Bielamowicz, MD, about a third of provider’ patients shop at Wal-Mart on a weekly basis. “It’s the cheapest place to buy groceries and ammunition, and it could become your most formidable competitor,” Dr. Bielamowicz said, as reported by Becker’s Hospital Review.

Already well known are clinics established by Walgreens, Target and CVS in their stores.  At Walgreens, the role of nurse practitioners will be expanded up the full level of education and licensure.

Taking medicine to patients is more than a US phenomenon; it is occurring worldwide, especially in developing countries.  The UN has just launched a campaign to recruit a million health care workers in sub-Saharan Africa. Already, these grassroots health advocates equipped with smart phones and other technology are making a difference in Rwanda and Tanzania. They are helping patients learn about and to manage their conditions – and to know when higher level care is needed.  And, in Zambia physicians from around the world are seeing patients via telemedicine connections.

So, whether you’re in the most remote areas of Africa, miles away from but connected the Cleveland Clinic, at an Indianapolis shopping center clinic, Dr. Robinson’s direct primary care practice in Elkins Park, Pennsylvania, or any number of pharmacy based clinics….you’ve stopped going to the doctor because the doctor, nurse or other clinician has come to you.

And, that means there’s a lot of learning to do.

Thank you for reading.