Smartphones for Health? A survey

Last month, Consumer Health Information Corporation released the results of a survey of 395 smartphone consumers. It was a good first effort to dig into a very murky, but important question: how will folks use their smartphones to manage their own health? 


They reported a number of findings:

• 74% of smartphone apps are abandoned by the user before they use it 10 times.
• Most health apps do not comply with public health guidelines.
• In spite of these failings, most consumers were willing to pay a few dollars for the app.
• Respondents preferred text messages over other methods of getting health reminders.

This last finding is a bit problematic. Apparently the survey included only electronic methods of communication (phone calls, e-mails, app messages, etc.). However, none of these methods has ever been shown to improve health outcomes or lower costs. On the other hand, personalized first class mail is quite effective and has been proven in large scale clinical trials to change patient behavior for the better.

I guess that's what happens when you survey cell phone users on Facebook - they tell you they like using cell phones! But whether health apps will truly change our health awaits a more rigorous evaluation, including a large randomized clinical trial.

Patient Portals and Equity

Mita Goel, David Baker and the good folks at Northwestern University report in the Journal of General Internal Medicine about use of the patient portal in their large, academic practice in Chicago. Of 7,088 patients invited to open an account on the portal, 69% enrolled. However, older patients and minority patients were significantly less likely to use the technology.

Once they were enrolled, race and ehtnicity didn't seem to be associated with how the patients used the portal. However, younger patients were less likely to initiate a request for refill or advice, perhaps because they have fewer medical issues. Likewise, men used the system less than women, reflecting the general tendnecy for women to seek health care more often than men.

The good news for engaging patients and exchanging health information is that over 2/3 of patients in this large, complex population took the opportunity to enroll. Patients want to connect. The bad news is that it might not help resolve the racial and ethnic divides that continue to bedevil health care and American society - it might even make them worse.


Goel M, Brown T, Williams A, Hasnain-Wynia R, Thompson J, Baker D. Disparities in Enrollment and Use of an Electronic Patient Portal. Journal of General Internal Medicine 2011; Online first at http://dx.doi.org/10.1007/s11606-011-1728-3

Sharing Information and Patient Engagement

The original motivator for electronic health records and exchanging health information (way back in the dark days of the late 20th century) was to make it easier, safer and cheaper to take care of patients.  The push came largely from managers looking to reduce the transaction costs of care and providers trying to reduce the administrative overhead of care so they could spend more time dealing with patients.

However, the more I deal with health information systems, the more I see that the best and highest purpose is not for management or even professional use. Rather, it is for patients. Giving patients their own information, (in the right format, via the right medium, at the right time, and from the right source), does more than enable them to make better decisions, it engages them in their care. It motivates them, educates them, energizes them, and empowers them. Whether any specific bit of information is, by itself, critical to the patient's care is not the whole story. The mere act of sharing the information with the patient turns the patient from a passive passenger on the health care bus to the driver, choosing the destination and calling the stops.

What happens when you engage patients with chronic care by sharing their personal health information with them?
1) They like it. Really, really a lot. HIE with patients is a big satisfier.
2) It generates scheduled care, notably primary care.
3) It reduces the need for urgent and emergency care and hospitalizations.
4) It saves a huge amount of money.

(Oddly, it seems to do all this without improving the patient's disease control, their physiologic state. The mechanism for this is unclear, but more on that later.)

It's early days yet and exactly how best to share information, which information, and so forth is by no means completely clear. However, there are some very well documented examples that work and are ready for deployment now.

If you would like to learn more about this, you might want to check out a recorded webinar featuring yours truly:

Does Improving Patient Engagement Result In More Appropriate Utilization

View more videos from vermedx

I'll also be doing a presentation at the Spring Managed Care Forum in Orlando on April 15.

Does Improving Patient Engagement Result in More Appropriate Utilization

Please join me for a webinar tomorrow:

Does Improving  Patient Engagement Result in More  Appropriate Utilization?     A special online seminar for senior executives, administrators, practice managers and patient outreach specialists from physician groups, emerging Accountable Care Organizations, Health Systems, Patient Centered Medical Homes, health plans, and government agencies. To register, please click here.                                                               To register, please click here. Answers to Your Specific Questions Have questions on our webinar and/or webinar formats? Please contact us at: marketing@vermedx.com Event Date:  Thursday, March 24th Time:  12:00 pm Eastern The risk-reward dynamic is shifting within healthcare.  Improving patient engagement is widely accepted as a critical foundation for emerging care practices, such as the patient-centered medical home.  As provider-patient interactions evolve, provider groups are realizing more and more that informed, prepared patients lead to more efficient encounters.  This is especially so when managing chronic conditions.  Benjamin Littenberg, MD FACP will share from both academic and actual business cases how low cost, high touch programs can reduce avoidable health utilization and improve patient satisfaction within normal provider practice workflow. Focused Discussion Attendees will learn: · What published, academic research has established about how patient engagement improves the overall clinical experience and what that means for providers? · How large physician-lead groups have implemented technology solutions that better prepare both providers and patients for more effective clinical encounters, and how they measure it? · What are the anticipated impacts - risks and rewards - of pay for performance and health care reform on how providers and patients interact? To register, please click here. Seminar Speaker Benjamin Littenberg MD, FACP   Henry and Carleen Tufo Professor of Medicine, Professor of Nursing, Director of General Internal Medicine Division of General Internal Medicine, University of Vermont Chief Medical Officer, Vermedx, Inc. Dr. Littenberg is the Henry and Carleen Tufo Professor of Medicine, Professor of Nursing and Director of General Internal Medicine at the University of Vermont. He received his medical degree from CaseWestern Reserve University and trained in internal medicine at Hartford Hospital in Connecticut. He was a Robert Wood Johnson Clinical Scholar at Stanford University before becoming Assistant Professor of Medicine at Dartmouth. Following an appointment as Associate Professor of Medicine at Washington University in St. Louis, he assumed his present position in 1999. Dr. Littenberg practices General Internal Medicine in Burlington, Vermont. His research interests center on technology assessment and quality improvement. Recent projects include new ways to measure quality of care in cancer, novel strategies for reporting test results to patients, better approaches to antibiotics in sinusitis, safety improvements in outpatient prescriptions, and strategies to address health literacy. In Vermont, Dr. Littenberg has been active on the Board of the Vermont Program for Quality in Health Care. He has developed statewide registry-based approaches to quality and safety improvement with the Vermont Breast Cancer Surveillance System and as Principal Investigator of the NIH-funded research grant for the Vermont Diabetes Information System which engendered Vermedx.   This event is sponsored and produced by Vermedx, Inc.           89 Beaumont Ave. Given Courtyard, 4 South Burlington, VT 05405 (802) 656-4576 www.vermedx.com       About Vermedx® Vermedx® technology enhances patient engagement by fostering communication between patient and caregiver, and by delivering decision support to health-care providers. The Vermedx system has been proven in a National Institute of Health clinical trial to improve health outcomes and reduce costs. The patent-pending Vermedx technology uses automated blood test reports and notification letters to help providers better care for their patients, and patients better manage their chronic conditions. Vermedx has been used by thousands of patients with diabetes in Vermont, New York, California and Texas. Clients include municipalities, private hospital systems, physician organizations, and managed care organizations. Visitwww.vermedx.com for more information.

Are we persuasive enough?

Joseph Kvedar, M.D. at the Center for Connected Health wrote recently about embedding the basic tools of persuasion into automated interchanges for better health. Messages that take advantage of reciprocation, consistency with personal commitments, expert authority, access to scarce resources, liking the source, and social norming are more likely to be persuasive. Marketers and sales people have long known this. I also agree with him that increased demand for health care as will require some sort of efficiency gains to maintain any semblance of access and equity.

In fact, the gains had by engaging patients in their own care, combined with the efficiencies of automation, are the "secret sauce" behind the success of the Vermedx Diabetes Information System in reducing the need for hospital and Emergency Room care as well as in reducing total costs of care.

His column got me thinking about our own automated messages within the Vermedx system. The letters to patients clearly take advantage of personal commitments and expert authority, but they could make better use of social norming and access to scarce resources. However, we take advantage or another technique that wasn't mentioned: specificity. Vermedx messages include information that is timely, specific, and actionable. Rather than say "You ought to get blood tests regularly," Vermedx tells the patient exactly when the test was due and what to do about it now.

We're going to be working on better ways to incorporate all the positive aspects of the Psychology of Persuasion (or Behavioral Economics, if you prefer) to make even greater gains in health outcomes.

How big a chunk of information do we want to exchange?

John Halamka and Wes Rishel have a very interesting approach to the recent debates on just what it is we might be exchanging in Health Information Exchanges. The problem arises from a tension among the need to care for the individual patient in front of you right now, to put that patient's care in the context of their history over time, and to take a broader view of a population of patients.

The provider with an individual case in the here and now traditionally generates a progress note - a document with whatever he or she thinks is required for the purposes of care. Much of professional education is transmitting the law and lore of what must/may/mustn't go into these documents and how to organize them for their various audiences. In general, they are free text, minimally organized with perhaps a few headings (Chief Complaint, Past Medical History, Assessment, etc.) and highly variable both across and within practitioners. (Some ten years ago, when Medicare mandated the presence of a Review of Systems for most office and hospital visits, the push-back from providers was huge and some actually left the profession rather than comply with this minimal nod towards standardization.)

Caring for patients in context requires the assembly of data across time and space and is the first place that electronic health records really shine. Knowing that the patient has an abnormal cardiogram now is valuable. Knowing that it is unchanged from one taken a year ago by another physician is gold. Sharing  documents across settings and providers accomplishes much of this, although it can certainly be improved upon with a little more granular organization.

At the population level, however, unstructured documents are not all that useful. Searching for the incidence of diabetic foot examination in our institution required natural language processing of many thousands of documents and failed to produce a reliable estimate [Kost, Chen, Littenberg et al. AMIA 2009]. Rather, we need standardized components of documents that can be extracted, transmitted, understood both as stand-alone entities and in the context they arose from, and analyzed for population as well as individual purposes.

Clinical laboratory data have long had these characteristics. A more-or-less complete documentation of a clinical chemistry test will consist of patient identifiers, specimen source (blood, urine, etc.), date and time of acquisition, analytic method, result, and units. However,  even these simple concepts are represented by a bewildering array of formats and definitions. To make matters worse, clinical labs routinely change their analytic methods, units, test names and any of these details, sometimes without even warning the users! A huge amount of effort goes into maintaining the clinical laboratory interfaces at Vermedx to ensure that these data continue to be useful over time.

More complex and less structured data such as pathology reports, operative notes, and discharge summaries are going to require a very large amount of work to make them transmissible and useful at this level. The first steps seem to be to agree upon what the smaller, irreducible units of information should be. This will undoubtedly be the battlefield of yet another IS standards war, but the outcome will have very big implications for how, and even whether, we can exchange health information into the future.