A decade ago, not long after the newly established Office of the National Coordinator for Health Information Technology started touting population health management as a major benefit of electronic health records, Sutter Health affiliate Palo Alto Medical Foundation (PAMF) recognized that it would have to start paying closer attention to the health of populations.
Ten years later, population health management is a central part of PAMF’s strategy. The organization has realized that people who make proper lifestyle choices are less likely to develop chronic diseases and more likely to control the conditions they already have. Since most of this happens far away from the doctor’s office, PAMF has been experimenting with home-based patient monitors and fitness trackers and learning how to manage all the data these gadgets produce.
Compiled by Neil Versel, Contributing Writer
Think patient-generated data offers little clinical value? Think again. Palo Alto Medical Foundation is incorporating this data into its care plans, and it’s having a powerful impact on population health.
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A decade ago, not long after the newly established Office of the National Coordinator for Health Information Technology started touting population health management as a major benefit of electronic health records, Sutter Health affiliate Palo Alto Medical Foundation (PAMF) recognized that it would have to start paying closer attention to the health of populations.
Ten years later, population health management is a central part of PAMF’s strategy. The organization has realized that people who make proper lifestyle choices are less likely to develop chronic diseases and more likely to control the conditions they already have. Since most of this happens far away from the doctor’s office, PAMF has been experimenting with home-based patient monitors and fitness trackers and learning how to manage all the data these gadgets produce.
Here, Martin Entwistle, director of PAMF’s Druker Center for Health Systems Innovation, discusses how the organization is incorporating patient-generated data into its overall care plans.
Q: How did you decide that deriving clinical value from patient-generated data was worth pursuing?
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A: Our original focus was more on disease management, with the recognition that we needed to help individuals drive toward better goals and outcomes, but at the same time manage a wider population that may have chronic diseases like hypertension or diabetes. Evolving in parallel, we also have been running programs for risk management and health improvement, with the thought that we should be engaging those people and driving them to take responsibility for their health.
About four to five years ago, we recognized the importance of bringing them together. We need to do a better job of managing everybody on a continuum, which is the reality of the way people experience their disease and conditions. We generally start healthy and fit, then, over time, unfortunately, we begin to build up preconditions and then the overt conditions.
We wanted to get individuals to better engage in areas where they have to track information. The original use case was diabetes, since people with diabetes already have glucometers and are already measuring their glucose values. What if we were able to get that data uploaded so that we could feed it to the care team so they know what’s going on and actually provide feedback to the individual so that they know whether or not they’re on track? Patients would then make better decisions and change their behaviors to drive outcomes.
Q: This can be done with devices that patients purchase on their own?
A: Yes. The concept that individual patients and others could be purchasing their own devices connected to ours is pretty appealing. The Microsoft HealthVault model actually got me very interested. You can connect to a range of devices, and we don’t have to be responsible for those devices. It certainly works in terms of getting the data back, but you do need a HealthVault account, and we do want to be able to manage and own certain rights to the data. Some of those issues are fairly significant barriers to a large health provider like ourselves, so whilst the model worked, I’ve been looking around for alternatives.
Q: How willing were your patients to use technology like this?
A: We’ve been very careful not to present this as a technology solution, but as a lifestyle solution instead. For example, we show how a solution like this can help a patient manage their condition better by tracking blood pressure at home. We focus on how this practice will help the patient understand things they might be doing that are contributing to their blood pressure being out of control. That can also help the physicians because they can see what’s really going on day-to-day at home. It shifts the dialogue.
Now, that said, technology does play a big part because a lot of this work is conducted over a smartphone. Patients also need to be willing to engage on the Web with the Epic personal health records to interact with the care team.
Interestingly, it takes some people about four to six weeks to get into this because you’re asking them to do something different, like regularly take their blood pressure maybe twice a day. Some people do find that a barrier, but for others, it becomes a habit. Repeatedly doing home monitoring is not for everyone, but there are a number of people we’ve now had under management for more than two years who are still regularly uploading their blood pressures.
Q: What do you do for patients who don’t seem to be receptive to home monitoring?
A: A key part of this is that each individual has a nurse care manager providing oversight. In fact, they have a face-to-face, one-on-one visit at the commencement of these management programs. Thereafter, we try to do everything remotely, but this helps them build a relationship with their care manager who’s constantly tracking what’s going on.
We have a dashboard designed in a way that helps us focus on the individuals who particularly need the nurses’ support and intervention. We actually triage people into different categories.
Q: What adjustments have you made along the way in response to what clinicians have told you?
A: I believe most physicians would like to have the data interpreted. They don’t want the data just sent to them. They want it to be plotted so they can see the trend lines.
Now, I might want to go to the next level. If I think something is not right, I would probably want to drill down and look at the data points, but otherwise there’s a lot of data for me to sift through to find out what’s going on. Interpreting the data, presenting the data, and creating alerts to data points that are out of range or trends that are moving in the wrong direction is going to be really important.
There’s a discussion going on about how physicians can have some control over the process and when the data should be turned on. We’ve been very respectful of that and we’re only turning it on in controlled situations.
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We want to avoid having noise in the medical record, and we want to make sure that the physician is aware of the information put into the record. It’s not really in anyone’s interest to just push data back if it’s not going to get acted on the way it should be.
Q: Where do you envision this program going in the next few years?
A: We’re very excited about what we’ve learned. It’s certainly given great insight into the value of this whole movement of consumer-driven data. It can give the care team greater insight into what’s happening with patients, and it can certainly help a patient understand where they stand and take more responsibility for their health. It can also get people engaged in programs of care.
For example, the Peninsula Coastal Region in Sutter provides a wellness program to its employees. We have about 500 people actively involved in the program. As a pilot, we gave people the opportunity to select a tracker, link it into their wellness record, and start tracking data. Then we thought we would go one step beyond that and run a group challenge.
We subsidized Fitbits and encouraged employees to participate in a fitness challenge using the trackers. People really got on board and started walking in groups. When the challenge concluded, a number of the groups continued with the behavior, which is exactly what we were trying to do — drive a sustainable behavior change.
That’s why this is exciting. We need people to get engaged in changing behaviors, particularly around being fitter, eating better, reducing stress — all the things that are part of wellness programs and are key drivers for chronic disease improvement.
Creating healthy habits is a key part to managing chronic conditions — whether it’s hypertension, heart failure, or diabetes. If we can get people to change their behavior, they can contribute to their outcome.
A decade ago, not long after the newly established Office of the National Coordinator for Health Information Technology started touting population health management as a major benefit of electronic health records, Sutter Health affiliate Palo Alto Medical Foundation (PAMF) recognized that it would have to start paying closer attention to the health of populations.
A: Our original focus was more on disease management, with the recognition that we needed to help individuals drive toward better goals and outcomes, but at the same time manage a wider population that may have chronic diseases like hypertension or diabetes. Evolving in parallel, we also have been running programs for risk management and health improvement, with the thought that we should be engaging those people and driving them to take responsibility for their health.
We want to avoid having noise in the medical record, and we want to make sure that the physician is aware of the information put into the record. It’s not really in anyone’s interest to just push data back if it’s not going to get acted on the way it should be.
