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Using Health Information

Technology to Engage

and Empower Patients

Steven Wilson 2015

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Acknowledgements 2

Personal Profile 3

Executive Summary 4

Introduction 6

Aims and Approach 7

Health Information Technology 8

o Telemedicine

o Electronic Health Records

o Patient Portals

o Mobile Health

o Wearable Technologies

o Social Media

Case studies 13

o Veterans Administration

o Kaiser Permanente

o Mayo Clinic

o National Partnership for Women & Families

o Centre for Digital Health Innovation

o Apple

Discussion and Key Learning Points 35

Appendix 41

o List of organisations visited

Contents

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I would like to take this opportunity to sincerely thank the Winston Churchill Memorial Trust for funding my Travel Fellowship to the United States. It has been an honour to represent the Trust and to meet with so many wonderful people on my travels. The Churchill name is much revered in the USA and sparks a great reminder of Anglo–US cooperation and friendship. In every single case I found those that I met with to be welcoming, interested and keen to share his or her experiences. In my travels across the country from Washington DC to San Francisco I have heard about some great areas of innovation, good practice and new ways of working. I made some fantastic contacts, opportunities for future collaborative work and many, many new friends. I would also like to acknowledge the huge support and encouragement I have received from Healthcare Improvement Scotland. It was great to have the time out to immerse myself in the Fellowship experience and have the extended "space to think".

“Success always demands a greater effort”

Winston Churchill

Acknowledgements

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I am a Senior Programme Manager with Healthcare Improvement Scotland, leading

the planning, management and delivery of national quality improvement

programmes across the health sector in Scotland. As an Accreditation Team Leader

with International Society for Quality in Healthcare (ISQua), I also work with survey

teams across the world to evaluate international healthcare organisations, ensuring

they meet the highest standards and best practice. I have a Master’s degree in

Leadership for Health Quality Improvement from Birmingham University and an

honorary research fellowship with Dundee University. I am qualified as a green belt

in Lean Six Sigma and a Member of the Chartered Management Institute.

“The best way to predict the future is to create it”

Peter Drucker

Personal Profile

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Health information technology (HIT) is a broad concept that encompasses an array of technologies to store, share, and analyse health information. If implemented effectively HIT has the potential to improve the quality of health care, prevent medical errors, reduce health care costs, increase administrative efficiencies and decrease paperwork. From my interviews, demonstrations and discussions with experts in the field I have identified a number common critical success factors for the implementation of health information technology:

Leadership

The vision and ongoing support of senior clinical leaders is critical to the successful implementation of health information technology. Without this committed clinical leadership in place, HIT implementation is likely to fail.

Innovation Healthcare organisations must create the right environment and culture where innovation and creativity thrives in every corner. Experience shows that people will be most creative when they feel motivated by interest, enjoyment, satisfaction and challenge of the job. Leaders must use the skills of networking, coaching and facilitation for creativity and innovation that are both empowering and inspirational.

Co-design Enabling person-centred care through health information technology needs a different approach. We must engage and involve patients throughout the development process from identifying needs through to final testing. Lets design around the needs of the user, not the demands of the technology.

Collaboration For health information technology to become widespread, healthcare organisations, government and industry must work together to clear the roadblocks. The ability of all these parties to collaborate in more productive ways is essential to speed translation of ideas and observations into benefits for patients.

Regulation Innovation and regulation have a tenuous relationship. While the base goal of regulation is to keep a level playing field, the base goal of innovation is to disrupt the status quo. It is essential that we adopt a balanced and risk based approach to HIT

Executive Summary

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regulation that both supports continued innovation and assures appropriate patient protections.

Education With the widespread use of health information technologies, there is a growing need to educate healthcare providers on the use of technological innovations. Appropriate health information technology education is critical to ensure quality documentation, patient privacy, and safe healthcare.

Balance

Face-to-face communication has been and will continue to be the foundation of the clinician-patient relationship - there is no app for empathy and compassion.

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Although the healthcare delivery and funding systems are very different, the

endeavour to better engage and empower patients in their healthcare is a high

priority for both the UK and US. Successful patient engagement is equal parts

innovation and empathy. A growing body of evidence demonstrates that the

foundation of the “triple aim” of improved health outcomes, better care and lower

costs is built upon engaged patients who are actively involved in their healthcare

experience. As a result, many healthcare organisations are focusing on improving

patient engagement by providing better education about conditions and

encouraging greater involvement in care decisions. When a patient and clinician

work together to consider the patient’s condition, treatment options, medical

evidence, benefits versus risks, as well as patient preferences, they can craft an

achievable and effective treatment plan.

A range of innovations, from wearable tech and mobile apps to patient portals and

electronic health records, appear poised to improve the patient experience by

streamlining administrative tasks and providing clinicians with data to enhance the

care process. For such technology to have an impact, though, patients must use it,

clinicians must accept it and healthcare organisations must integrate it — as well as

the basic principles of patient engagement — into their strategic plans.

We are in the 3rd age of digital technology: the 1st age was about automation and

efficiency; the 2nd about information; and the 3rd is about social collaboration. Digital

is about engaging, involving and empowering people. As Eric Topol of Scripps Health

put it, “the digitisation of human beings will make a parody out of ‘doctor knows

best.’”

Introduction

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Aim

To identify the opportunities available and the challenges to be overcome in using

health information technology to engage patients in activities that improves

understanding of health and disease, and links them to health providers and

resources.

Objectives

To identify low cost/high impact health information technology solutions for

healthcare organisations to build relationships, share knowledge and provide

better access to experts

To identify best practices and leading edge work in the use of health information

technology for patient engagement

Work with clinicians, managers, patient groups and policy colleagues to translate

the findings from this research into solutions for the NHS Scotland context and

culture

To build and maintain strong collaborative relationships between US and UK

rural healthcare providers

Approach

During July and August 2015 I visited a range of healthcare providers, information

technology companies, academic bodies and patient advocacy organisations across

the United States to explore the use of information technology to better engage

patients in their healthcare.

Aims & Objectives

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Digital health comprises the technologies supporting an essential shift in methods,

attitudes and actions regarding health and wellness in our society today. It’s also

helping to reduce inefficiencies in healthcare delivery, improve access, reduce costs,

increase quality, and make medicine more personalised and precise. The underlying

lexicon of Digital Health is extensive and includes all or elements of mHealth (aka

Mobile Health), Wireless Health, Health 2.0, eHealth, Health IT, Big Data, Health

Data, e-Patients, Wearable Computing, Gamification, Telehealth & Telemedicine,

Precision Medicine, plus Connected Health.

“Digital health is a check engine light for your body”

The rate of digital health adoption amongst clinicians and healthcare organisations is

growing rapidly in the United States. Over the last few years, two major pieces of

legislation have been passed, the Health Information Technology for Clinical and

Economic Health provision of the American Recovery and Reinvestment Act and the

Affordable Care Act, which have provided unprecedented levels of financial support

for health information technology adoption and implementation, primarily in the

form of financial incentives for providers, and emphasised the importance of this

technology in delivery system reform.

The focus has now begun to shift from simply turning on the technology to using it in

a way that improves the quality and efficiency of care. Social technologies are

becoming common tools in the business of US healthcare. Use of these technologies

has gone beyond marketing, public relations and branding functions and they are

now being used for education, support, collaboration, communication and

engagement. More recent uses also include surveillance, gaming, care coordination,

research and intelligence.

The list of those who may benefit from these social tools is multifaceted. Patients

and carers are supporting each other on public social media channels; clinicians are

collaborating, communicating and accomplishing the work to be done on a daily

basis; and most importantly, healthcare leaders are engaging their communities and

increasing transparency as patient expectations shift.

Health Information Technology

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Telemedicine

Telemedicine seeks to improve a patient's health by permitting two-way, real time

interactive communication between the patient, and the clinician at the distant site.

Telemedicine may be as simple as two health professionals discussing a case over

the telephone, or as complex as using satellite technology and video-conferencing

equipment to conduct a real-time consultation between medical specialists in two

different countries.

There are three main categories of telemedicine:

Remote patient monitoring - allows patients with chronic diseases to be

monitored in their homes through the use of devices that collect data about

blood sugar levels, blood pressure or other vital signs. The data can be reviewed

instantly by remote clinicians.

Store and forward technology - stores clinical data, as well as X-rays and other

images, and forwards the data to other locations for evaluation.

Interactive telemedicine - allows clinicians and patients to communicate in real

time. Such sessions can be conducted in the patient's home or in a nearby

healthcare facility.

Research by the American Medical Association shows that roughly 1 billion doctor

visits occur each year in the United States, and of those, 70 percent are unnecessary

and could be avoided by consulting with a clinician by phone, email or text. Deloitte

has estimated that within the next few years, one of every six patients will be seen

virtually.

Electronic Health Record (EHR)

An EHR is an electronic version of a patient’s medical history. The EHR can include

demographics, progress notes, medications, vital signs, past medical history,

laboratory data and radiology reports. The EHR automates access to information and

has the potential to streamline the clinician's workflow. The EHR also has the ability

to support other care-related activities directly or indirectly through various

interfaces, including evidence-based decision support, quality management and

outcomes reporting.

Meaningful Use is a Medicare and Medicaid program in the US that awards

incentives for using certified electronic health records to improve patient care. To

achieve Meaningful Use and avoid penalties, providers must follow a set of criteria

that serve as a roadmap for effectively using an EHR.

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Patient Portals

A Patient Portal is a secure and private web-based portal. It enables patients and

healthcare professionals to exchange documents, images, results and messages.

Patient Portals help patients become more involved in their care by helping to

provide a clear understanding of what they need to do, which in turn can result in a

better patient experience and improved health outcomes.

A Patient Portal can empower and engage patients by:

Providing secure access to their health information

Improving communication with their care providers

Helping them to take responsibility for their own health

Providing easy access to relevant and current reference information

As part of the Meaningful Use Stage 2 requirements, healthcare providers in the US

must have at least five percent of their patients using an online patient portal to get

incentive payments.

Mobile Health

Mobile health, or mHealth, is defined as the delivery of healthcare services via

mobile communication devices. It has the potential to address one of the most

pressing global challenges: making healthcare more accessible, faster, better and

cheaper. Unlike many other forms of communication mHealth will likely have a

greater effect on how care is delivered for three reasons:

Mobile devices are ubiquitous and personal

Competition will continue to drive lower pricing and increase functionality

Mobility by its very nature implies that users are always part of a network,

which radically increases the variety, velocity, volume and value of

information they send and receive

Despite clear consensus from most stakeholders that mHealth has significant

potential to support patient self-care and reduce the demand on healthcare systems,

its use has yet to be mainstreamed – 80% of apps are abandoned in two weeks. The

EU’s Green Paper on mHealth [Summary report on the public consultation on the

Green Paper on mobile health, published 12 January 2015] identified seven major

areas of concern with mobile health apps that need to be addressed before the

technology can go mainstream. These were: (i) the need for clarity on levels of data

security to protect public and patients, (ii) lack of appropriate governance of lifestyle

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(non-medical) health apps, (iii) possible threats to patient safety, (iv) lack of

transparency about who lies behind an app, (v) lack of clinical input and integration

with healthcare systems, (vi) lack of clarity about whether health apps produce

positive outcomes, and (vii) the ill-funded nature of the entire enterprise that

surrounds app development. Reflecting on my Fellowship experience, there is one

key reason missing from the EU list. We haven’t yet seen the full potential of

mHealth because more often than not health apps are developed in isolation from

their intended users: patients and the public.

We need devices that are easy to use and that promote on-going customer

engagement. Developers must take the time to explore and understand the EHR

vendor's API. Mobile health tools and technologies must integrate into the existing

healthcare environment in a cost-effective and timely manner.

Wearable Technologies

The terms ‘wearable technology’, ‘wearable devices’, and ‘wearables’ all refer to

electronic technologies or computers that are incorporated into items of clothing

and accessories which can be worn on the body. These wearable devices can

perform many of the same computing tasks as mobile phones and laptop computers

With wearable technology, learning more about yourself has not only become high-

tech but also real-time. From devices and apps that help you track heart rate and

food consumption details to gadgets that monitor your mood and even surrounding

air, the "quantified self" is a reality for the everyday person.

What’s exciting about wearables and wireless monitoring devices is their potential to

empower consumers to make meaningful changes and improvements to their

health, on their own. What’s more, the current generation of wearables can

empower those with chronic conditions to better monitor and manage their

conditions. It has been estimated the wearable technology industry will see a five-

fold increase over the next ten years, from over $14 billion to over $70 billion

Social Media

Social media allows healthcare providers to connect and engage directly with

thousands of people and organisations, be seen to understand and take on board

their viewpoints and involve them in local solutions. It also allows them to reply to

questions and comments and, in some cases, challenge misinformation. This creates

a much more transparent and healthy environment for debate and discussion.

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Social media in healthcare changes the traditional one-to-one patient-doctor

dialogue to one-to-many and many-to-many dialogues between doctors-patients,

patients-patients and doctors-doctors at a phenomenal speed. This fundamental

change in how people in the healthcare ecosystem interact with each other opens

up the possibilities for many novel applications of social media in healthcare such as:

Patients and doctors interact via social media to promote awareness about

diseases, precautions and other health-related information with each other

Patients use social media to meet their health-related wants, needs and

preferences

Online applications like WebMD offer platforms for both consumer and clinician

moderated health related conversations

Clinical investigators and research organisations use online communities to

recruit volunteers for clinical trials

Public health and regulatory agencies use social media tools for public health

campaigns and announcements

Web applications are used for treatment, clinician and hospital selection

comparisons

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Veterans Administration

The first visit on my Churchill Fellowship travels to the US was to the Veterans Health

Administration in Washington DC. The Connected Health Team at VA gave me an

excellent insight into how the application of health information technologies are

transforming VA’s delivery of health care and its effect on patients’ health outcomes.

These technologies are used to maximise patient-provider encounters by effectively

managing information to ensure patients and clinicians have the information needed

to customise patient care to meet the unique requirements and preferences of each

Veteran.

Connected Health Programme

VA defines Connected Health 'as extending the reach of healthcare, empowering

patients, and supporting healthcare teams through virtual systems of

care'. Connected Health is powered by consumer health technologies that engage

patients and connect them to their health care teams, enabling the extension of the

health care relationship beyond the traditional in-person encounters that for so long

have been the centerpiece of patient/provider interactions.

The VA is a leader in virtual access for patients. Here are the stats for 2014

▪ 1 million+ prescriptions refilled online per month

▪ 1 million patients used VA secure email with providers

Case Studies

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▪ More than 2 million Telehealth visits were made

▪ 150,000 patients were case-managed by home telehealth

▪ 250,000 patients used clinical video telehealth between VA clinics

▪ 4,000+ received Clinical Video Telehealth visits directly into their homes

▪ 380,000 used store and forward telehealth technology

▪ 1 million patients used Blue Button to download Electronic Health Record data

The VA Vision for Health Information Technology

Patient Focused

▪ Makes the home or local community the preferred site of care

▪ Provides the right care - in the right place - at the right time

▪ Helps coordinate care across the continuum

▪ Accessible as part of patient-facing virtual services

▪ Offers just-in-time care

▪ Supports both patients and caregivers

Forward Looking

▪ Functions across platforms and devices to be accessible across a wide range of

patient-centered electronic systems and devices

▪ Flexibly incorporates new modalities of care

▪ Moves beyond simple transfer of data and communication to include knowledge

management

▪ Identifies VA as the national leader in the use of innovative technologies to

promote patient-centered care

Results Oriented

▪ Demonstrates reduced utilization of health care resources

▪ Promotes VHA as health care provider of choice

▪ Focuses on patient self-management and shared decision-making and improved

outcomes

▪ Uses patient-facing technologies to capture routine activity and outcomes data

What are the lessons learned?

▪ Patients must be able to connect to their healthcare provider easily through the

internet to receive both synchronous and asynchronous care, via a web browser

or mobile device

▪ Healthcare providers must move away from a focus on devices and hardware and

towards a focus on the patient experience of care, independent of device

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▪ Self-service tools on personal devices should be prioritised

▪ While security, privacy, performance and usability remain paramount; policies

and processes must mirror industry-standard development practices

Virtual Access must:

▪ Be fully integrated into the electronic health record

▪ Focus on empowering the patient with the tools, data, and access they need to

self-manage their health and wellness

▪ Take advantage of present and future communication technologies

▪ Be sustainable from a cost perspective

▪ Include connections with other providers and health systems

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Kaiser Permanente is the USA's largest nonprofit health plan with 9.6 million

members. They employ 17,400 physicians, 48,000 nurses and operate 38 hospitals

serving 8 states and the District of Columbia. Kaiser has invested over $9 billion in

developing their electronic health records system (KP HealthConnect) that stretches

across every department and every Kaiser patient.

Kaiser Permanente’s patient portal, My Health Manager, is directly connected to KP

HealthConnect. By providing members with 24/7 online access to their health

information and critical, time-saving tools, including online appointment scheduling,

prescription refill and secure email messaging with doctors, Kaiser empowers

members to manage their health care and the health care of their family members.

Currently more than 4.4 million members in Kaiser Permanente’s 9.1 million-

member network are using Kaiser’s online health management platform.

Use of the EHR and online portal to support care management and new modes of

patient encounters appears to be having positive effects on utilisation of services

and patient engagement. For example, three-quarters or more of online users

surveyed agreed that the portal enables them to manage their health care

effectively and that it makes interacting with the health care team more convenient.

Researchers at the UCSF and Kaiser Permanente followed nearly 18,000 Kaiser

patients with diabetes for five years and found those who requested statin refills

exclusively via the patient portal decreased medication non-adherence by 6 percent.

Patients who used the Kaiser portal also decreased their risk of high cholesterol

levels by 6 percent. Interestingly the average age of the research population was 62,

and 40 percent were non-white minorities.

Unfortunately many patient portals still pivot around the material relevant to the

healthcare system (the medical record) rather than those activities that are closer to

people’s health needs. Patients want a relevant individualised experience and

information from their portal rather than a one-way interface to the EHR. They

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should be able to provide structured data back to their care team, in a way that

complemented the evaluation of their progress.

What are the big challenges to introducing patient portals?

▪ Outspoken resisters

▪ Inadequate budget and resources

▪ Variable support from sponsors

▪ Lack of skills in implementers and champions

▪ Multiple major initiatives deployed concurrently

▪ Adoption of paradigm shift

▪ Impact to daily operations

What are the Kaiser key success factors?

▪ Change management strategy

▪ Effective communication

▪ Sponsorship and champions

▪ Decision making at right levels

▪ Input from patients, families and carers

What does Kaiser see as the future for online healthcare?

▪ Designing Experiences

▪ Data-Driven Personalisation

▪ Emotional Engagement

▪ Access care anywhere, anytime

▪ Seamless Transactions

▪ Social Integration

▪ Synched Devices

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Kaiser Permanente Garfield Innovation Center

For a tech geek like myself, the Kaiser Permanente Garfield Innovation Center is a

real Aladdin's cave. Situated in San Leandro, this sprawling warehouse is the largest

healthcare innovation centre in the country. Simulated spaces include an entire

medical-surgical unit complete with nurse stations, various patient rooms, critical

care room, labor and delivery room, operating room, emergency bay, family waiting

room, interventional radiology suite, and more. Here, the entire care process can be

analysed, role-played, questioned, tested, and refined under one roof.

Healthcare teams from Kaiser start the process by making sure they are solving the

right problem. To do this they conduct field research, observe system and user

needs, and assess current and emerging technologies. Once the problem and

opportunities for change have been identified, Garfield Innovation Center is the ideal

space to try out new ideas. This is where clinical teams come to explore the

possibilities while participating in hands-on activities such as simulations, technology

testing, prototyping, and product evaluations. After thorough testing in a safe

environment, successful initiatives undergo final refinement at Kaiser Permanente

medical centers, offices, and clinics across the US.

Kaiser Permanente has recently rolled out three high-tech hospitals in Northern

California to provide patient-centered healthcare. These hospitals incorporate a

variety of innovations - from way-finding applications to state-of-the-art MRI

equipment - but two technologies, in particular, have been critical to their efforts to

improve the patient experience. These include Interactive Patient Care (IPC) and Real

Time Location Services (RTLS). IPC is a hospital room technology hub where patients

can view a Care Board to see their schedule, care plan, care team and health

education videos. Patients can also order food from a customised menu, control the

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lights, blinds, temperature and music in their hospital room. They can access the

Internet for email, social media and on-demand free movies. RTLS cuts down on non-

clinical nurse activities by tracking, mapping and reporting the location and status of

moveable devices or machines.

Here are another couple of the fantastic innovations I was privileged to see when I

was with the team in San Leandro.

The futuristic looking HealthSpot Care4 Station is a fully enclosed kiosk used by

Kaiser to deliver primary and specialty care in a private setting in neighborhood

pharmacies, supermarkets or the workplace. The sound proof, private 8-foot x 5-foot

kiosk houses a chair and desktop with a touch screen interface and video screen. The

kiosk is equipped with diagnostic equipment including blood pressure cuff,

thermometer and otoscope. There’s also a camera to capture your height and a scale

captures your weight when you step on the floor. The hands-on virtual visit with a

doctor takes 15 minutes on average and includes diagnosis and sending a

prescription to your pharmacist, if necessary. A medical record of the visit is saved

and accessible to the consumer via a website. A medical assistant is on-site to

answer any questions, disinfect and keep the diagnostic equipment in hygienic

working order. The kiosk is also equipped with a UV light that sanitises the

equipment. This marriage of medicine and technology allows Kaiser to care for

patients in regular everyday settings without the requirement to travel long

distances.

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Roving about the Innovation Center on wheels, I met the InTouch Health robot that

lets doctors see and talk with patients, families, and staff in the intensive care unit in

the middle of the night. From their home computers, doctors guide the robot,

connected via secure video, to virtually respond to urgent needs in a matter of

minutes. During a three-month pilot of the InTouch robot, doctors at the Kaiser

Permanente Medical Center in Fremont, CA, reported fewer night emergencies

because ICU physicians virtually were able to catch issues before they became big

problems. Doctors formed stronger relationships with the late-night shift nurses,

enhancing nurses’ ability to detect issues early. Family members visiting in the

evenings also valued the chance to talk to doctors.

Innovation @kpinnovation

Kaiser Permanente is widely recognised for its leadership in harnessing health IT to

improve quality and care delivery. The Kaiser Permanente Innovation team was

established in 2010 as a first-of-its-kind experiment to explore the value of human

centered design in health care. Through a combination of innovation and the science

of improvement, the process is grounded in ethnography, creative thinking, rapid

prototyping, and iterative testing.

What they do is watch people, take notes, snap pictures, and make sketches. Some

of what matters will be physical or logistical: Who stands where, does what,

communicates most or least or best? What tools are used? Are they used easily,

effectively, gracefully? How are they carried? If they’re not carried, are they

conveniently positioned? What about the subjective evidence? They'll ask nurses

how they feel about what they’re doing and patients how they feel about what’s

being done. They will try to get some sense of the atmosphere—colour, light,

energy, mood. Information that may at first seem unimportant can later mean a

lot. The goal is to find hidden clues to the nature of the problem at hand and some

line of inquiry for progressing toward possible solutions - in this context the

innovation at Kaiser flourishes!

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The Mayo Clinic

The Mayo Clinic is unlike any other hospital I’ve visited across the world. It is located

in the small city of Rochester (pop. 111,000), about a two-hour drive from

Minneapolis, Minnesota. The Clinic was founded in 1887 and grew out of a

partnership between providers and administrators. That commitment to

interdisciplinary collaboration, along with the team approach adopted by clinic

founder William Mayo and his sons Will and Charles, continues to define the

institution’s culture. Early medical innovations attributable to Mayo, such as the

common medical record and the tumor-grading index, exemplify its highly pragmatic

ethos.

Every year more than 500,000 patients come to the Mayo Clinic from across all 50

US states and nearly 150 different countries. The Dalai Lama has visited the Mayo

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Clinic for check-ups, Middle Eastern royalty come to the Mayo Clinic for long-term

treatment, and politicians and wealthy captains of industry are not unusual sights in

Rochester. Each Mayo clinic patient benefits from the expertise of more than 3700

doctors and scientists working together to understand and meet the needs of their

patients.

Doctors in the United States are usually paid fees for each service they provide. The

more procedures and tests they order, the more money they pocket. There is

widespread agreement among health policy analysts that many of these procedures

are unnecessary, raising costs in ways that often do nothing to improve patient

health. By contrast, the Mayo Clinic pays salaries to all of its doctors. No matter how

many tests or procedures are performed, they take home the same amount of

money.

Myself and Lee Aase, Director of the Mayo Clinic Center for Social Media

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The Mayo Clinic Center for Social Media was set up in 2010 to coordinate and focus

the Clinic’s various social media initiatives and programs. Lee Aase and his small

team of 6 use social media tools and technologies to help patients become better

advocates for their own care. The Center’s philosophy is based around the firmly

held belief that individuals have the right and responsibility to advocate for their

own health, and it is the team's responsibility to help them use social media tools to

get the best information, connect with providers and with each other, and inspire

healthy choices. The Mayo Clinic is putting this philosophy into practice across all of

the big social media platforms - Twitter, Facebook, YouTube, Google+, Pinterest, and

Flickr.

So why do they excel?

1. Senior leadership support

Use of social media for engagement and experience management, can be a hit or

miss proposition without the right strategy, support and resourcing. Executive

commitment is essential when it comes to launching and growing your social media

strategy. CEO of the Mayo Clinic John Noseworthy understands the power of social

media and is a strong advocate for the potential it offers to engage patients in their

healthcare.

2. A focus on great content

The Mayo Clinic use a range of social platforms to explain what they do,

answer questions, and allay concerns. They regularly share educational materials

and other resources, establishing themselves as the clinical experts and helping to

connect with and engage patients. They introduce Mayo Clinic staff and the work

they do, giving patients a chance to 'meet' their doctor before they attend the clinic

in person.

It's a great way to share patient and staff stories to demonstrate expertise and

personalise the healthcare process - this can help reduce the fear factor, something

that often keeps our patients from making or keeping appointments.

3. Innovation and creativity

The Mayo Clinic are constantly looking at new and innovative ways of interacting

with their patients through social media - and encouraging patients to communicate

with each other through social media.

Redefining how we obtain health information online, the Mayo clinic has partnered

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with Google to present search results in a clearer and more accurate format. Health

consumers will see a box alongside their search results filled with enhanced

information culled from throughout the web, verified by multiple clinicians and,

finally, signed off by doctors from Mayo Clinic. This is just one example of the

innovative work going on all the time at the Mayo Clinic Centre for Social Media.

Where next?

Through social media tools & technologies the value of engaging in clear, open, two-

way communication at every point of care has become abundantly clear. Active

engagement between healthcare organisations, patients, families and carers has a

demonstrably profound impact on experience, compliance, and clinical outcomes. At

the Mayo Clinic social media plays a key role in facilitating this constructive

engagement. It's through these 'real-time' tools patients are now able to comment,

participate and engage at every point along their own care pathway. Social media

provides the tools for patients and clinicians alike to join the healthcare conversation

beyond constraints of time or geography.

“In the very near future, social media will be

considered part of routine healthcare operations and

our day-to-day lives.”

Mobile Health at the Mayo Clinic

Today's healthcare landscape is shifting dramatically, driven by changing healthcare

policy, advancements in technology, and a continuing quest to deliver high-quality

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care in the most cost-efficient manner. mHealth – also known as mobile health – is

the practice of medicine and public health supported by mobile devices such as

mobile phones, tablets and the wireless infrastructure. Data from mHealth can

inform, assess, anticipate, and aid in interventions while monitoring and

coordinating patient health status and care.

Mayo Clinic's flagship mobile app was created in collaboration with Apple and in

consultation with Mayo Clinic patients. App users have full control of their personal

health information, and can decide what, if any, data is stored in the Apple Health

app. The app allows users to:

▪ View Mayo Clinic health data through the Apple Health dashboard

▪ Contact their care team directly through secure messaging

▪ View and manage details of their appointment schedule

▪ View Mayo Clinic videos on their iPhone, iPod, and iPad

Mayo’s flagship mobile app has recently been updated to include access to radiology

images and Touch ID, as well as compatibility with Apple’s Passbook.

Touch ID

Apple users can easily and securely authenticate access to the Mayo Clinic app on

the go. The patient’s fingerprint is the password and with a touch of the home

button on the device, the Touch ID sensor quickly reads the fingerprint and

automatically logs into the Mayo Clinic app.

Passbook

Upcoming appointments appear as a pass within the Passbook app. Patients can see

their appointment details from the lock screen of their Apple device with a simple

swipe of the appointment pass.

Radiology images

Unique to the Mayo Clinic, patients now have anywhere, anytime access to their

radiology images and reports within the Mayo Clinic app. This gives patients

flexibility and greater access to their health information. These images are for a

patient’s information only, and not meant to be used for diagnostic purposes.

Whilst it's still early days for mobile technology in the delivery of health care,

evidence supporting the huge potential to impact the delivery of better health care,

lower costs and improve patient outcomes is apparent. mHealth can empower

clinicians to more effectively engage patients and provide secure information on

demand, anytime and anywhere.

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Innovation at the Mayo Clinic

The Mayo Clinic Centre for Innovation is transforming the delivery and experience

of healthcare. By applying a creative, problem-solving design thinking approach

they're aim is to revolutionise the experience for Mayo Clinic patients and staff.

The Center for Innovation fuses design principles with the scientific method to

uncover human needs in the health care environment, which include empathy,

creativity, systems thinking and a human-centered focus. Design methods include

ethnographic and observational techniques, visualization, prototyping, sketching,

storytelling, brainstorming and more. The complement of design allows the center to

think beyond what it normally does and serve as a translator for ideas and

possibilities.

The innovation team takes a 3-prong approach to all of their work

▪ Connect Bring people together in new ways inside and outside of Mayo Clinic

▪ Design Identify opportunities and realise solutions that transform care delivery

and experience

▪ Enable Facilitate and accelerate innovation across Mayo Clinic

The Center for Innovation works with a "Think big. Start small. Move fast.™"

philosophy - something I think we can all aspire to!

▪ Think Big First, by thinking big and tackling important problems, the team at

Mayo Clinic is able to help insure broad organisational support for its

projects

▪ Start Small Then, by starting small, complex challenges are reduced to

manageable size, allowing the team to get immediate traction and

tangible results

▪ Move Fast Finally, by committing to moving fast, hypotheses can be tested

quickly and interest in particular innovation projects remains high.

The goal is to implement a major prototype of the concept within six

months of launch

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The team has an undivided focus on the customer and customer experience, and

constantly asks 'will our actions have the potential to profoundly impact the

experience and delivery of health and health care?'

All of us are caught in a situation where the current system doesn't work and this

brings tremendous frustration - innovation in healthcare has never been more

important.

Here are a few pictures of the wonderful glass-enclosed, reconfigurable space they

have at Mayo Clinic Center for Innovation

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The National Partnership for Women & Families promote fairness in the workplace,

reproductive health and rights, access to quality, affordable healthcare, and policies

that help women and men meet the dual demands of work and family. The National

Partnership recognise that Health IT alone will not solve the problems facing health

systems, but its implementation and effective use can provide a foundation for

improvement. Information technology can empower individuals with the

information and electronic tools necessary to be active partners in their own care.

Health IT can help patients and carers make more informed decisions; be better

connected; generate and share important health information; and set, track and

achieve personal health goals.

In order to meet patients wherever they are along a continuum of engagement and

health, we must leverage a variety of health IT solutions and tools capable of

supporting different phases of health, consistent with shifting needs and priorities.

The National Partnership have outlined 7 strategies to engage patients and families

in their health and care using information technology:

▪ Continue to adopt and use Electronic Health Records to improve patient care,

experience, access and use

▪ Integrate more convenience features as standard features of patient portals

▪ Strengthen and expand electronic access to and use clinical health

information throughout new models of care delivery

▪ Enhance functionalities for patients to communicate with and share

information with health care providers and others

▪ Build robust functionality to support patients and families in health and care

planning

▪ Foster trust with patients by showing how their health information is stored,

exchanged, used and protected

▪ Build tools and systems that recognise demographic diversity, with particular

attention to language and cultural competency issues

Here are a couple of six word memoirs from US patients about health information

technology?

"Help me help you help me"

"My whole team on the same page"

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University of California Centre for Digital Health Innovation

The Center for Digital Health Innovation (CDHI) at University of California San

Francisco use their expertise, connections and scientific rigour to better innovate the

future of healthcare. CDHI collaborates with innovators from UCSF and beyond to

envision, realise and evaluate new digital health technologies. Similar to the Digital

Health Institute (@DHIScotland) in Scotland, CDHI works with a range of startups

and companies looking for consultation or looking to evaluate their product in a

clinical environment, bringing together innovators, thought leaders, and other

partners from the digital health community to foster new connections and ideas.

Andy Auerbach and the team have four key areas of focus at CDHI, to:

Innovate: bringing ideas to life through a range of development services. CDHI

support includes online resources, consultation, funding support, or full incubation

opportunities.

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Validate: evaluating the usability, adoptability, and impact of technology solutions

on clinical and educational outcomes, as well as healthcare value.

Integrate: focusing on the interoperability of technologies, data storage and

analytics, device and data interface standardisation, security/privacy services, and

electronic health record integration opportunities.

Educate: learning from others and helping to create the next generation of digital

health and healthcare leaders. CDHI host events to engender collaboration between

the UCSF community, startups, industry, and capital partners.

Here are a couple of examples of the great collaborative work I heard about on my

visit to the UCSF Center for Digital Health Innovation

Health eHeart

Working with the American Heart Association, CDHI has supported the development

of Health eHeart. This is a clinical trials platform using social media, mobile

technology & novel realtime sensors to revolutionise heart disease. Through this

study the team hope to

▪ Develop new and more accurate ways to predict heart disease based on

measurements, behaviour patterns, genetics, and family and medical history

▪ Understand the causes of heart disease (including heart attack, stroke, heart

failure, atrial fibrillation, and diabetes) and find new ways to prevent it

▪ Create personalised tools the public can use to forecast when they might

develop heart disease or, if they have it already, when they might be getting

worse

Blip

People with diabetes need to be able to see their data in order to learn from it. That

means being able to easily collect it and see it in context of our day-to-day lives. Blip

is a simple, visual hub for diabetes data, where everything shows up, where all of the

insulin pumps, monitors, tests, meals, exercise and sleep information start to make

sense. It makes it easier for patients to get data from their devices, even if they are

from different manufacturers. Blip is useful for people who want to dive into their

data. It’s a communication tool for patients and clinicians to talk about and learn

from the device data. Using messaging tools, Blip lets school nurses, teachers,

families and doctors see the same thing at the same time and adjust treatment

accordingly.

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University of California Mission Bay Hospital

Myself and Seth Bosker (UCSF's Associate Chief Medical Officer)

Seth showed me around the new UCSF Mission Bay Hospital. The 878,000-square-

foot facility is actually three hospitals in one: the 183-bed UCSF Benioff Children's

Hospital San Francisco, the 70-bed UCSF Bakar Cancer Center and the 36-bed UCSF

Betty Irene Moore Women's Hospital, along with the UCSF Ron Conway Family

Gateway Medical Building.

Through some fantastic patient-facing interactive technology UCSF is moving the

culture towards shrinking the health literacy gap. Most patient rooms in the medical

center come equipped with a tablet and a large screen monitor that allow the

patients to connect and keep up to date with friends, family, coworkers and

classmates outside the hospital, reducing stress and anxiety for the patient.

The implementation of information technology at Mission Bay reflects the

uniqueness of UCSF and the fantastic building they have built. In addition to

empowering patients with information, education, and entertainment, they are

using technology to promote a very broad definition of health that includes

emotional wellness, opportunity for reflection, and human connection. The in-room

platform enables personalisation by theme, language, and age; connection through

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social media; and access to patients’ own cloud-based entertainment. Patients can

upload photos of their key support network onto their in-room system to give them

warmth and strength.

In addition to the full electronic health record and automated medication delivery

system at Mission Bay, Seth and the team have introduced the Voalte next-

generation communication system, through which voice call, text messages,

traditional “pages,” and alarms are transmitted to mobile smartphones. Another

area, which is closely related to patient engagement, is telehealth. Patients at

Mission Bay have full access to all the expertise throughout UCSF Health System —

no matter where the patient or doctor is located. They also have the largest

deployment of transport robots, which roam the halls delivering supplies and patient

meals - all very space age!

Patients and families in the San Francisco Bay Area use, and in many cases create,

technology applications to empower people in banking, travel, retail, and many

other areas of their life. These same people desperately want to use technology to

empower themselves in healthcare. This transition from “you’re a patient in my

hospital” to “I’m a doctor in your room” is not an easy one. Clinicians are slowly

learning to function in a world where their patients can use UCSF apps to access a

critical lab result before they have an opportunity to see it. We are slowly pulling

back the curtain and using technology to democratise medical information for

patients and families - with sometimes conflicting evidence and uncertainty.

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Apple

Apple's HealthKit is being tested by more than half of major US Hospitals in a pilot

scheme of the service, as doctors use it to collate data and monitor patients

remotely.

HealthKit is a framework designed to house healthcare and fitness apps, allow them

to work together and collate their data under the Health app. For example, a heart

monitoring app and blood pressure tracking app could send information to each

other from within HealthKit to develop a more comprehensive picture of a patient’s

health. This customised data can then be sent to the patient’s cardiologist via an app

such as Mayo Clinic, which allows remote monitoring. Apple is also working with a

number of partners on the fitness side of HealthKit, through which users can set

goals and track their own progress through a single dashboard.

A large platform collecting billions of data points about hundreds of aspects of our

health on a daily basis will create a powerful information resource for health care

providers and researchers. But in order for that to happen, the data will have to find

a way into clinical systems, like the electronic health record (EHR). To this end, Apple

is collaborating with Epic Systems to aggregate patients' health data from myriad

health applications into the EHR. This allows clinicians to monitor patients at home,

adjust their medication via phone, and ultimately avoid preventable hospital

admissions. In the past, clinicians have relied on patients to log information, bring it

to the clinic where data would be manually input to the system and a course of

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action decided. Using HealthKit we can share information seamlessly between

patient and clinicians to allow real-time, accurate analysis of a patient's health

status.

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Both the US and the UK are struggling with the difficult dance of improving quality,

while increasing access, and doing so in a cost effective manner. Fortunately, digital

health is offering increasingly effective solutions to do so. According to a 2012 report

by the Digital Innovation in Healthcare Working Group, digital is the new “Fourth

Space” in healthcare - a blending of digital and social media use within the

traditional healthcare system, patient empowerment toward self-care, and social

movements focused on preventative health. The result is a significant impact on

quality, access and cost.

However, some of the most important innovations of the coming decades will not be

new healthcare tools & technologies, but the new ways of working together that are

made possible by these new technologies. We must create a culture that encourages

and rewards collaborative working and makes best use of all these new

technologies. Welcomed or not, it is the inevitable future and is becoming the

present in many US healthcare organisations at an amazing pace. At the same time,

there is a choice about whether to deny and react to these cultural and economic

shifts or instead acknowledge and embrace them. And there is a choice as well—for

both organisations and individuals—about whether and to what extent to cultivate

the culture, mind-sets, skills, and knowledge that make it possible to leverage the

enormous potential of HiT, mHealth and social media tools to better realise their

purposes.

Unless patients and carers in the UK are empowered and informed, it will be difficult

to realise the potential of a learning healthcare system. We need new tools to create

a new system, and mobile health and consumer facing apps are a critical piece of the

puzzle. Creating healthy individuals necessitates true patient engagement and

accountability, which means this new system must be easy to use and accessible.

With patients in control of their health using digital tools and the creation of a

system that invests in wellness and the management of chronic illnesses, not only

can we eliminate much of the waste in healthcare today, we will also create more

cost-effective care and healthier, more productive individuals. Information is power,

and by empowering patients with data we can not only improve the patient

experience and clinical outcomes, but also ultimately lower costs.

So how will the patient consultation change in the near future? Well, to be honest, I

don't think it will look wildly different! I'm sure we'll see a lot more online

interaction, and I sincerely hope the power gradient between patient and doctor will

be reduced. No doubt the information generated from mobile tools and wearable

technologies will improve the knowledge both parties bring to the consultation, but

will it change the conversation itself? Digital healthcare is about building the service

Discussion & Key Learning Points

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around the patient, not the structures. Doctors will still have to be compassionate

and caring, and patients will still have to be engaged partners in their health, and

both will have to contend with emotions, psychology, and uncertainty.

Health technology solutions to date have typically digitized existing processes rather

than giving expression to carefully considered new models of care, decision support

and patient engagement strategies. To break through the plateau in adoption and

benefit realisation, clinicians must lead a service-design approach for the

development of solutions that truly empower people in health and care delivery

across the whole system.

Key Learning Points

Leadership

During my fellowship travels I was constantly reminded of the importance of

clinicians and managers working together to lead change. In all of the healthcare

organisations I visited there was a visible commitment of clinical leaders and a clear

passion for quality improvement. Many of those in senior leadership roles in US

healthcare organisations are physicians – certainly more than is the case in the UK.

This is in part due to the investment made in the development of clinical leaders,

and a culture that values leadership roles and sees them as attractive career

opportunities.

Kaiser Permanente and Mayo Clinic are great examples of the benefits of joint

working between physicians and managers. KP has built an organisational culture

that transcends the traditional conflicts between “medicine” and “management.”

There is a mutual commitment to partnership working between physicians and

management that is deeply ingrained in the organisation. A number of factors are

responsible for this success, but three stand out.

Joint leadership

Physicians and management within KP and Mayo have acknowledged their mutual

dependency. Having this propensity for partnership explicitly modeled at the highest

levels of the organisation has guided behaviour at all levels, including frontline staff

and their counterparts in management.

Alignment

Many of the healthcare organisations in the US are highly fragmented, disaggregated

healthcare structures with conflicting incentives and goals among clinicians, insurers,

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and administrators. At KP there is an explicit alignment of mission and strategy,

bringing both sides into a mutually interdependent relationship. The success of

physicians and managers is in the hands of the other, creating a powerful alignment

of interests that transcends professional or cultural differences.

Management training for physicians

At Kaiser Permanente there are a range of leadership development programmes that

ensure physician leaders understand both the bedside and the boardroom and make

competent partners for similarly well-trained managers.

Chief Medical Information Officer

The many health care reform initiatives underway in the US are forcing hospital

information technology and information management departments to evolve and

titles to change. The new names are more than cosmetic, heralding a shift in

leadership roles to meet new realities and priorities.

Chief Medical Information Officers (CMIO), sometimes called directors of medical or

health informatics, are a fairly new addition to the US healthcare sector, but they are

already in high demand, as the healthcare industry transitions to electronic health

records (EHRs).

As the field of health informatics is still developing, the CMIO role will vary from one

organisation to the next. However, most CMIO’s are practicing clinicians and their

responsibilities reflect their dual areas of expertise. On a regular basis, the average

CMIO may evaluate an organisation’s IT systems; design and apply EHR software and

applications; convert and analyze medical and health data; ensure quality of care

across multiple information systems; leverage medical and health data to improve

services and daily operations; and train doctors and other medical professionals in IT

systems and applications. CMIOs, depending on their individual areas of expertise

and training, may also conduct data analytics for research purposes and report

findings to senior management, government, or academic organisations.

The role of the CMIO has been, and continues to evolve to meet changing

organisational, clinical and population health-related demands with increasingly

capable and innovative technology.

When America sneezes Britain catches a cold - I see the CMIO role as one of the

more exciting evolutions going on within the world of healthcare and something that

healthcare organisations in the UK need to seriously consider.

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Innovation

Healthcare delivery systems in the US and UK are under increasing pressure due to

rising costs and increasing patient expectations. These pressures and the inherent

nature of the industry itself make innovation in healthcare more complicated than in

the consumer products sector. Success requires a range of inter-related technical,

social and organisational factors.

The health service can learn a lot from Apple when it comes to innovation

▪ Empower employees

Apple is run by ideas and not by hierarchy. Putting Apple employees first and

empowering them to understand their own value has helped the company to

produce one groundbreaking product after another. Healthcare providers must

give employees the power to problem-solve and innovate by creating an

atmosphere in which they feel comfortable taking risks and have resources

available to them.

Embrace Failure

Apple is the most valuable brand in the world right now but it has still had its

share of failures. Failure is the foundation of innovation. It’s crucial that the

Healthcare Providers foster a culture that celebrates productive mistakes, the kind

that can stimulate thoughts and generate new paths.

▪ Take calculated risks

Provide tools allowing employees to explore possible scenarios and develop plans

with confidence.

▪ Look outside the healthcare sector for ideas

Innovation can come from without as well as within. This approach, known as

network innovation, has been embraced by companies such as Procter & Gamble,

BT and several drugs giants, all of which have realised the power of admitting that

not all good ideas start at home. Making network innovation work involves

cultivating contacts with start-ups and academic researchers, constantly scouting

for new ideas and ensuring that we do not fall prey to “not invented here”

syndrome, which always values in-house ideas over those from outside.

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Co-design with Patients

The big promise of mHealth is support on demand to help with greater self-care.

Unfortunately patients end up frustrated, with an obvious disconnect between what

they really need and what developers or clinicians think they need. If we don’t put

patients in the driving seat then technology will continue to drive and define

mHealth development.

It is essential that we engage and involve patients throughout the development

process from identifying needs through to final testing – making this the norm,

rather than an unaffordable luxury. IT developers need to spend time and resources

on understanding and measuring user experience with technology mediated

healthcare delivery. Experience shows that engaging patients in this way will help

build a higher level of end-user trust and acceptance. Lets design around the needs

of the user, not the demands of the technology.

Collaborate with Industry With unprecedented challenges such as the ageing population and increasing

prevalence of lifestyle related disease facing our healthcare system, technology

offers the best platform for creating sustainable health and care services that will

encourage people to take ownership of their health. We need to learn from other

industries and apply this to healthcare so we can provide affordable and effective

services that will become valuable additions to people’s lives. The ability of

healthcare organisations, universities and industry to collaborate in more productive

ways is essential to speed translation of ideas and observations into benefits for

patients. UK healthcare providers should continue to forge innovation networks and

link with young information technology firms and universities to incorporate their

diverse skills and knowledge to innovate or incorporate new technologies in the way

they do things.

In Scotland, the Digital Health Institute is leading new energised methods of

collaboration amongst all parties – manufacturers, developers, clinicians and patient

advocates. Creating a platform where these organisations can collaborate is key to

making digital healthcare technology affordable, accessible and successful in the

future.

Reduce Regulation

Beth Israel Deaconess Hospital Chief Information Officer John Halamka describes the

burden of health technology regulation in the US as “crushing”. The plethora of

Federal regulations has replaced innovation and has become the all-consuming

majority of the CIO’s daily work. This level of regulation only succeeds in protecting

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the status quo and hindering or preventing innovation.

New technology often comes from unexpected places and from people that had

previously not been major players in the market. However, this is only possible when

the cost of regulation is low. Having a well defined, risk-based regulatory framework

is essential to the continued success of health IT in both the US and UK.

Upskilling staff in the use of IT

It is vital that healthcare leaders are seen to champion information and digital

capability as core enablers of effective decision-making, service quality, safety,

effectiveness and efficiency. In future all members of the healthcare workforce must

have the knowledge, skills and characteristics that are necessary to embrace

information, date and technology, appropriate to their role.

Beware the Silver Bullet Health information technology is often held up as the panacea for all that ails the

healthcare system, with the argument that it will free up clinicians from various

computational tasks so that he/she can concentrate fully on their patient.

Unfortunately HIT has yet to deliver on its huge potential. Design flaws, poor

execution and inadequate orientation/education all contribute. The field of health

information technology shows real promise but it is still in its infancy.

Even as a huge supporter of health information technology I know it cannot replace

the human elements in medical care, which are so effective in producing the

therapeutic effect – there is no smartphone app for empathy and compassion!

HIT has huge potential to augment healthcare renovation by providing powerful

tools, data and solutions, but patients will always need emotional attention and

empathy from their care team.

We will know that ‘digital healthcare’ has truly reached its

potential when it becomes just ‘healthcare’

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Organisations Visited

Veterans Administration 50 Irving St NW Washington, DC United States

Boston Children’s Hospital 300 Longwood Avenue Boston, MA 02115

Kaiser Permanente Center for Total Health The Permanente Federation, LLC 700 2nd Street NE Washington, DC USA 20002

Mayo Clinic Hospital 201 W. Center St. Rochester, MN 55902

National Partnership for Women & Families 1875 Connecticut Avenue NW, Suite 650 Washington DC 20009

Apple Campus 1 Infinite Loop Cupertino CA 95014

Mobile Health World Conference Seaport Hotel 1 Seaport Lane Boston, MA 02210

University California San Francisco Center for Digital Health Innovation San Francisco

Beth Israel Deaconess Medical Center 330 Brookline Avenue Boston, MA 02215

Garfield Health Care Innovation Center 590 Whitney Street San Leandro, CA 94577-1114

Massachusetts General Hospital Main Campus 55 Fruit Street Boston, MA 02114

University California San Francisco Mission Bay Benioff Children’s Hospital 1975 Fourth Street San Francisco

Appendix

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