Interview conducted by Alex Green
As part of our Innovator Series, Signify Research was able to meet up with Dr. Michael Marino, DO, MBA who is Chief, IS Operations/Clinical Systems, at St. Joseph Health, an Integrated Healthcare Delivery System. I spoke with Dr. Marino about how St. Joseph’s was pioneering the use of technology for patient engagement, population health management and telehealth.
- St. Joseph’s has rolled out a sophisticated patient engagement solution from Hart (www.hart.com) that goes well beyond Meaningful Use requirements
- The provider is also using a risk stratification tool from Verscend (www.verscend.com) that aids maximizing the benefits from the patient engagement outreach
- It is also working with Jvion (www.jvion.com) and Clearsense (www.clearsense.com) to integrate data on social determinants of health into the stratification process
- St. Joseph’s experience in using solutions from the large EHR vendors to address patient engagement, population health and telehealth has been disappointing to date
- Medtronic (www.medtronic.com) has been used to pilot a number of remote patient monitoring telehealth initiatives and St. Joseph’s has a partnership with MDLive (https://welcome.mdlive.com/) to enable the roll out of telemedicine video consultation services
Can you tell me about how St. Joseph’s has been leading the way in terms of its use of innovative technology?
A good place to start is how we’ve been developing the use of patient portals as they relate to patient engagement. Initially Meaningful Use ushered in patient portals but the requirements were set so low that the major EHR vendors developed solutions that had very limited use. Providers only had to put in place a simple portal and sign people up, but there were no requirements to ensure that the portal was useful and that people were using it. This will change with Meaningful Use 3, but in the meantime we’ve been developing our portal so that it actually has benefits for patients and is used regularly.
A basic portal where a patient can only look at their discharge instructions for example, isn’t going be a portal that a patient will want to interact with regularly. In order to make portals more sticky and of use to a greater share of the population, St. Joseph’s partnered with a development company that had a fair amount of experience in the more of the social elements of healthcare. It was a start-up company called Hart (www.hart.com). What Hart offered was an app that allowed patients to aggregate their daily activities with their medical information.
What we’re seeing in the locations we’ve rolled this solution out is if you add the social components of wellness; such as step tracking, sleep tracking, adding challenges within friendship or other social groups, on the same portal that patients can get their annual cholesterol check booked, then the overall use of the portal increases massively.
Once patients are used to using the portal for the wellness tracking functionality, they then start to use it for other things such as online scheduling of appointments, reviewing discharge instructions, booking and holding their place in a queue in the urgent care unit without having to physically turn up and wait in a room. The results have been pretty dramatic. In some of our employee centred clinics where we’ve rolled out the Hart system patients are now typically hitting the portal once a week, whereas before it may have been once per year. The Hart app functionality is integrated into our legacy EHR solution so the data from both can be aggregated.
Why didn’t you use your EHR provider’s portal solution?
We use Meditech’s EHR solution across all of our hospitals. At the time we made the assessment, Meditech had its standard portal that had been designed to hit meaningful use. However, it was three shades of blue. It didn’t offer much beyond the standard meaningful use requirements. For example, you could download a CCDA or you could see your discharge notes, but you couldn’t feedback into it. St. Joseph’s want to embrace where the trends are going with wellness and the Meditech solution just did not meet that need.
Is the data that’s obtained from the patients wellness monitoring used when you stratify how to manage that patient and the population as a whole?
This is where the big opportunity is. However, the difficulty we’re having is that there is no good evidence as to how to react to this data. So you have patients tracking their steps, but from a clinical point of view you there is no evidence as to what the appropriate amount of steps is. There are benchmarks that say 7,000 steps, 10,000 steps, etc. but in reality, these are just arbitrary numbers that do not relate to a patient’s existing physical condition. If you’re 6’ 2” and weigh 200 lbs and consuming 3,500 calories per day, how much you should actually be walking? There is a similar issue with sleep. A lot of people are really interested in tracking their sleep. But what can you do with the information? The science hasn’t caught up with the consumer yet on just what are the right amounts to be targeting. This is where we could potentially be supported more by the solution vendors.
How will you expand how the portal will be used going forward?
The most important element is still how you manage people to do the right thing. For example, it’s flu season, have you remembered to get your flu shot? For a diabetes patients how can we use the portal to ensure they are having an A1C every six months? We have these kind of reminder services in place now, but have just not yet rolled it out. This is the kind of thing that’s really going to change healthcare. Historically healthcare has been much more about me sitting in my doctor’s office and you coming to me with a problem. I’ll do a great job of interacting with you but once you go away, that’s where the interaction ends. The portal and patient engagement will change this approach.
At St. Joseph’s we have a comprehensive set of disease registries which we use to reach out to people using a manual process. For example, doctors use the drug registry to monitor if a patient has had their basic metabolic panel to have their potassium checked. In the current process a letter will be sent out to remind the patient if this has not occurred. However, what we’re now starting to do is using the portal and patient engagement tools to transition this to a computer driven process, to remind people via email, text, etc. With a computer-based system there is a lot more opportunity to keep nudging patients, ultimately driving better adherence and compliance, particularly if there is a simple call to action that can also then be followed electronically. Paper-based systems are a lot more arduous. We’re using Hart for this again. It’s ready to go and we’re just getting a critical mass of people signed up before we launch.
Do you have in place any solutions that build in risk stratification so that you know where to focus?
As well as the standard registries that allow us to put people into cohorts, we’re using a platform from Verisk Health, now Verscend (www.verscend.com). Their solution allows us to score patients, put them into cohorts and stratify how these cohorts are managed. We then have nurse navigator teams that actively manage the cohorts based on the information from Verisk’s platform. The fact that St. Joseph’s, and California in general, has been in the risk business for some time means that this isn’t that new. PHM is just an extension of this traditional function of managing risk.
However, the portal and patient engagement tools now mean they can be better managed when discharged and we’re no longer relying on the doctors just stating “Here’s your paperwork, have a nice day, see your doctor in two weeks”.
How important is non-clinical data in this risk stratification process, for example social determinants of health?
Very. On the hospital side, we have two pilots where this is key. For the two pilots we’re working with two different analytics companies that allow us to feed in data, such as social determinants of health, into the decision making and risk stratification process. The two analytics companies are Jvion (www.jvion.com) and Clearsense (www.clearsense.com).
Jvion is made up of a team of former Google engineers that have been collecting data for around a decade, and now have a huge database of population information such as what’s the average income level on my street, how many people are in each household and what are the demographics of those individuals. St. Joseph’s is marrying that up with our EHR data. The example I like to use is if I have a knee replacement, I go back to a very nice household where my wife is a doctor. If a different person has a knee replacement, for example a mechanic, who lives by themselves, in a house with lots of stairs, doesn’t have a support network, doesn’t have easy access to transport, then he needs a different level of post-care support. Both of us could look the same clinically. 55 year old males, 6’ 2”, a little over 200lbs. However, based on this data alone you could end up driving interventions where they’re not needed. The patient that lives alone, dropped out of high school, may not have understood his discharge instructions well, probably does need a home visit whereas I may not. The Jvion platform allows us to feed in other non-clinical information into the decision-making process. Information that can flesh out this picture can be of huge value as we try to maximise the use of our resources.
How do you address the issue that you don’t always have a complete longitudinal view of the patient’s healthcare interactions?
We have care management and coordination tools that we’ve used in the past, such as the solution from Allscripts. It’s not great and it doesn’t integrate well, even into Allscripts platform. I don’t think anybody does this well and that’s certainly a challenge for the vendors to improve their solutions in this area. Vendors will tell you their solution is great and is up to the challenge but they’re not there yet.
We were also an early adopter of Explorys’ platform, now part of IBM. We still have their tools but the difficulty we’d have is that once you get out of the IT conversation and into the operations discussion, the vendors always want you to go after their new shiny tool. Explorys was a perfect example. We’ve had Explorys for four or five years, we run the data, we have all these great registries that have been built within Explorys, but unless it perfectly matches our operations workflow it’s not helpful.
What programs do you have in place around remote patient monitoring?
We’ve been using remote patient monitoring platforms that support the use of blood pressure monitors, weight scales, pulse oximeter and blood glucose monitors, for three and a half years. Initially we developed the solution with Hart; however, after a while they decided this wasn’t an area they specifically wanted to focus on and so now we’re transitioning to the Medtronic (www.medtronic.com) platform.
To date we’ve rolled out our remote patient monitoring solution to a relatively small cohort of a couple of hundred patients. This did significantly reduce readmission in that group and was very successful. Information from the remote monitoring was rapidly getting out to nurse teams and cases were escalated to doctors when needed so that action could be taken to stop readmissions before they occurred. The difficulty we’re having related to the question of when do we stop remote monitoring? Should we monitor three months, six months or should the monitoring continue all the way through the remainder of the patient’s life. We always try to do things that are evidence based. When you go to the literature for evidence around remote patient monitoring best practice, there is very little advice.
In terms of rolling out further, we are looking to expand this cohort. There are two things holding it back, the evidence on when to stop and then potentially restart, and then the issue of how this is paid for and the return on investment.
So what’s your vision for how technology and innovation will be used going forward in St. Joseph’s?
One area where we’re planning on innovating relates to telemedicine. We currently have a partnership with MDLive (https://welcome.mdlive.com/) where we’re increasingly rolling out video visits to patients. We’ve already rolled it out at multiple sites and are working through all our ambulatory sites up to this Spring.
Some patients want old fashioned care with the same doctor and limited use of technology. Others, often with less complicated care requirements, don’t care who they see. If the issue is relatively uncomplicated many want a video visit that’s quick and convenient. At the same time if a patient needs to see a real person they want the tools to quickly figure out when and where to get treated. They want to do this electronically just like when booking a flight or a restaurant.
On the other end of the spectrum, where people truly have lots of health problems, it’s understanding their risk, helping them manage their way through the system, giving them tools so they can track their medicine online and easily access their paperwork. This is where a comprehensive patient portal is crucial.
The minute you tell someone they’re going home from the hospital, that’s the last thing they hear. Immediately the patient starts to think about the logistics of other parts of their life. Picking up the dog, collecting groceries, visiting family, etc. they miss the instructions the doctor is giving on changing the bandage, picking up prescriptions, planning a return appointment with the physician, seeing their regular doctor. With a good portal, that the patient is used to using, you can send this information and build in reminders so that instructions are followed. This is really where we’re focusing our efforts going forward.
About St. Joseph Health
St. Joseph Health (SJH) is a value-based healthcare delivery system that serves residents throughout Northern and Southern California, West Texas and Eastern New Mexico. SJH provides a full range of care facilities including 16 acute care hospitals, home health agencies, hospice care, outpatient services, skilled nursing facilities, community clinics and physician groups. For more information visit www.stjhs.org.
For further details please click here or contact Alex.Green@signifyresearch.net.