In its 2023 Standards of Care, the American Diabetes Association says technology is now a vital part of care management, and all people living with diabates should have access to those tools and platforms.
The American Diabetes Association is emphasizing the value of healthcare technology in diabetes care management in its 2023 Standards of Care.
The revised standards, issued this week, include a section devoted to technology, including continuous glucose monitoring (CGM) devices that allow people living with diabetes to check their blood glucose levels at any time, automated insulin delivery systems and digital health tools that offer coaching and access to resources.
The guidelines recommend that anyone living with diabetes have access to FDA-approved technology to manage their chronic condition, especially seniors and underserved populations. The ADA also points out that technology can be used to improve access to care and care management for those dealing with health inequity, or barriers to care caused by social determinants of health.
“ADA’s mission is to prevent and cure diabetes, a chronic illness that requires continuous medical care, and the release of ADA’s Standards of Care is a critical part of that mission,” Chuck Henderson, the organization's chief executive officer, said in a press release. “This year’s annual report provides necessary guidance that considers the role health inequities play in the development of diabetes, particularly for vulnerable communities and communities of color disproportionately impacted by the disease. This guidance will ensure healthcare teams, clinicians and researchers treat the whole person.”
Digital health technology has been a part of care management for people living with diabetes for years, though the ADA and other organizations, such as the Centers for Medicare & Medicaid Services (CMS) and US Food and Drug Administration (FDA), have been careful to support only technology that passes strict protocols and has proven to improve clinical outcomes.
The ADA's acknowledgement of the value of technology may mark an import step in the value-based care movement.
Earlier this year Kevin Sayer, CEO of digital health company Dexcom, one of the leaders in the diabetes technology space, said the industry is moving on from highlighting the next big thing and focusing more on integration and interoperability.
"Everybody wants everybody to be interoperable and talk to everybody else," he said. "The only way that these platforms are going to be successful going forward is if all the technology works with each other and people using it are engaged."
"It isn't even technological any more," he added. "What people are looking for is access."
Sayer says the diabetes care industry is now transitioning to overall health and wellness, not just tools and platforms that solely address diabetes. That's why a company like Livongo, which was launched by former Allscripts executive Glenn Tullman to help people living with diabetes like his son, has since evolved to address other chronic diseases, as well as integrating with primary care and behavioral healthcare services.
"We've come to understand that the patient's healthcare journey starts long before they were diagnosed with diabetes," Sayer said. "And it involves a lot more than just [diabetes tools and platforms]. It's all about access now, and that can be complex. We have to learn how to make access easier."
Cherry Health is using EHR technology to launch new services and view and share data with other providers as it transitions away from fee-for-service care.
Federally Qualified Health Centers (FQHCs) are a breed apart. Incorporating multispecialty practices with primary care, behavioral health, and even dental care, these 1,400 providers across the US see some 30 million Americans a year, many insured by Medicare and Medicaid.
One such FQHC, Cherry Health, covering western Michigan and headquartered in Grand Rapids, serves more than 65,000 patients annually via a network of more than 80 providers and 800 healthcare professionals. The patient population is 55% Medicaid, about 15% Medicare, perhaps 20% uninsured, and a very small percentage of commercial payer coverage.
Like many other FQHCs, Cherry Health has partnered with NextGen Healthcare for its electronic health record platform. NextGen is now leveraging the cloud to allow providers to share performance metrics and learn from each other.
This should help Cherry Health as the nation's FQHC network, supported by funding from the Health Resources and Services Administration (HRSA), continues to get squeezed, and value-based payment models are just around the corner.
"The reason that we stayed with NextGen was due to the flexibility in our different specialties," says Glenda Williams, chief information officer at Cherry Health. "We can have one integrated health record, that we don't have all these separate systems that all of our staff need to look up to be able to care for the patient."
Glenda Williams, chief information officer at Cherry Health. Photo courtesy Cherry Health.
The technology also helps with another critical issue affecting healthcare: Stress and burnout.
"Our strategy has been to talk to our providers to identify what additional technologies we can put in place to help them so that they're feeling less burned out," Williams says. "Whether or not that is from a technology standpoint, from my side, or whether or not it's from a staffing side from our CMO side, maybe they need extra help. Maybe they need a different workflow. It's really about identifying what needs they have and coming up with a solution."
Cherry Health is transitioning from fee-for-service to value-based care, says Cynthia Duncanson, the organization's chief financial officer.
"We do get paid on a fee-per-service basis, and our incentives are relatively low compared to what our program income is from the Medicaid fee-for-service payments," Duncanson says. "But we are getting ready to transition within the next year or two to an alternative payment methodology for our primary care medical population, where it will be per member per month, completely crosswalked between that fee-for-service with a little bit of incentive, all the way over to mostly incentive. Medicare's also crosswalking us in that same direction as well."
In 2022, in anticipation of this change, Cherry Health implemented NextGen's population health tool, Williams says.
"My strategy is having access to data and using the data to make our decisions," she says.
NextGen has added an extra tool in this regard, by establishing a national collaborative of FQHCs using its EHR several months ago, according to Srinivas Velamoor, executive vice president and chief growth and strategy officer at NextGen Healthcare. More than 60 have signed up so far, and NextGen expects that number to grow beyond 100.
"They all have common issues in terms of having visibility to metrics, like no-shows, and making sure they're looking at the same quality measures," Velamoor says. "They are very eager to understand how they're doing relative to others in the country that look like them, and not just focus on their own performance."
Williams says the collaborative will allow FQHCs to be more innovative in solving the clinical problems they face.
"Why reinvent the wheel if someone else has already has a solution in place?" she says.
For example, in addressing no-shows, the FQHC can separate patient populations out into groups, identifying those who don’t have e-mail addresses, or those who prefer phone calls or text messages, so as to better target its messaging and marketing campaigns.
"We're the first FQHC to have that dual designation," she says.
This will allow Cherry Health's providers, including physicians, nurses, physician assistants, and community health workers, to move from station to station within clinics while the patients remain in one place, instead of traditionally being shown into room after room, Duncanson says.
The challenge of making all these changes requires close communication between Williams, Duncanson, and the rest of the leadership team.
"We're constantly collaborating," Duncanson says.
"We're just two doors down from each other, and we've got a standing meeting to go over any issues that we may have, and we produce monthly reports that we share," Williams says.
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The Cancer Support Community is partnering with Equiva Health on a program to equip rural residents living with cancer with a cellular-enabled tablet that gives them access to resources and care providers.
The Cancer Support Community is launching a telehealth program aimed at improving care management for cancer patients living in underserved parts of the country.
CSC, the largest professionally led non-profit cancer support network, is partnering with New York-based CRM company Equiva Health on the program, with a pilot project scheduled to launch this month in Minnesota. Through Gilda's Club Twin Cities, a CSC network partner, participating residents will get a cellular-enabled tablet allowing them to access resources and connect with caregivers.
“From my own experience growing up in rural Virginia, I know firsthand the challenges that you’re met with when living in a remote rural community,” CSC CEO Debbie Weir said in a press release. “We must overcome rural access barriers by advancing telehealth solutions that can seamlessly connect people to resources, to support, to their communities, and to the oncology community at large.”
The project is the latest in a series of digital and connected health programs aimed at improving care management for those living with cancer beyond the hospital, clinic, and doctor's office. Many use remote patient monitoring tools or telehealth platforms to provide on-demand resources and links to providers, with the idea that remote monitoring can allow providers to identify treatments that don’t work and modify care plans on the fly, improving short- and long-term outcomes.
These services are especially important for patients in rural and other underserved areas who have difficulties accessing care. Research by the Centers for Disease Control and Prevention (CDC) has shown that people living with cancer in rural areas have a higher mortality rate than those living in urban regions.
The program will also take into account a patient's ability to access connectivity for the devices. Those who qualify will be invited to apply for the Federal Communications Commission's (FCC) Affordable Connectivity Program (ACP) through an ISP provider.
The University of Maryland Medical Center's mobile integrated health community paramedicine (MIH-CP) program, which sends specially trained paramedics to the homes of selected patients after hospital discharge, saw increases in first-fill prescription rates and medication adherence, according to a study.
A mobile integrated health community paramedicine (MIH-CP) program launched in Baltimore by the University of Maryland Medical Center helped improve medication adherence for patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), according to a new study.
As reported in a recent issue of Exploratory Research in Social and Clinical Pharmacy, an MIH-CP program, which sends specially trained paramedics to the homes of selected chronic care patients following discharge from a hospital, increased first-fill prescription rates by almost 20% for CHF patients and 25% for COPD patients in the first 30 days. In addition, the program boosted medication adherence by 8% to 14% over 60 days.
The results show promise for an innovative program that's designed to improve chronic care management at home, reduce adverse health events and cut back on 911 calls by so-called "frequent flyers," or patients who often need emergency healthcare services and rack up large healthcare bills.
The Maryland program was coordinated through the health system's Epic electronic health record platform in a partnership with digital health company DrFirst, and focused on pharmacist-led interventions.
“These results are particularly exciting because patients with chronic health conditions are at greater risk of poor outcomes if they don’t take their medications as prescribed,” Colin Banas, MD, MHA, chief medical officer for DrFirst and one of the study’s authors, said in a press release. “Pharmacist-led programs like this have a long history of improving medication use. As value-based care and risk-based contracts grow in prominence, healthcare organizations are turning to innovative ways to manage care for high-risk patients, so they have better health outcomes and stay out of the hospital as much as possible.”
The health system identified high-risk patients with CHF or COPD as they were discharged from the hospital and assigned them to the MIH-CP program for follow-up care. That care includes home visits by a team of community paramedics and a pharmacy technician and a virtual care link to pharmacists, community health workers and a physician or nurse practitioner.
Some 83 patients took part in the six-month study, with 43 assigned to the MIH-CP program and 40 to traditional follow-up care.
The study's authors note that patients with CHF or COPD run a high risk of hospital readmission due to acute exacerbation, leading to high healthcare costs and penalties from the Centers for Medicare & Medicaid Services for preventable rehospitalizations. Part of the problem is that many of these patients don’t follow doctors' orders on medication management.
"Efforts to integrate inpatient and outpatient medication regimens remain critical for the prevention of medication non-adherence during transitions of care and help to identify medication non-adherence at timepoints," the study concluded. "Transition of care programs such as MIH-CP, which incorporate pharmacists as part of the team, support the identification and resolution of critical medication-related problems and medication non-adherence. These types of programs can provide much-needed care and support for a largely underserved community."
Health systems across the country are experimenting with MIH and CP program in various forms and targeting different patient populations. Some create a program through their own EMS services, while others partner with local EMS providers and other community health programs.
Home visits run the gamut as well, with care providers offering chronic care management services, addressing social determinants of health, even just chatting for a while with someone who might be home-bound and lonely.
The GIThrive platform combines gut bacteria analysis and trigger food identification with app-based personalized action plans, food diaries, educational materials, and 24/7 personal support from registered dietitians and health coaches, backed by a multidisciplinary team of gastroenterologists, microbiome scientists and other clinical professionals.
"When you look at different chronic conditions where digital health has really tried to make an impact, you've seen a lot of organizations and solutions focus on people suffering from diabetes or behavioral health issues," says Bill Snyder, chief executive officer at Vivante Health. "There's been a big gap in the solutions that that work with patients who suffer from chronic digestive issues."
Vivante Health clinicians are licensed in all 50 states with type II NPI (National Provider Identification) numbers, Snyder says.
Bill Snyder, chief executive officer of Vivante Health. Photo courtesy Vivante Health.
"We're very focused on supporting the existing care ecosystem," he says. "We're not looking to replace gastroenterologists, because there's great work that they do. What we're doing is front-end work. We're evaluating acuity. In many cases, we're finding high-acuity patients and telling them, you really need to get in to see a provider in a brick-and-mortar clinic, or see a gastroenterologist, because you're presenting with some pretty high-risk potential condition attributes."
The organization partners with health plans and self-insured employers to make its program available to members and employees.
"58% of our membership today does not have a formal diagnosis, but they've come to us with an average of 3.9 symptoms," Snyder says. "That can be for different reasons. From some, they don't have access to the care they need. For others, maybe they've seen providers, but haven't been able to get a diagnosis, and haven't been able to get any symptom reduction. Or for others, maybe they haven't seen a provider, and they really should."
The GIThrive app acts as a point of intake. Users are asked questions about their symptoms and condition, if they are taking medication, and if they're working with a provider. Vivante then assesses the user's acuity and builds an evidence-based clinical protocol based on that information.
Based on that protocol, Vivante Health's remote care team of health coaches and registered dietitians support patients as they work on alleviating their symptoms or seeking in-person care.
Vivante Health also offers an optional microbiome analysis and, beginning in 2023, will incorporate more third-party tests, such as full lab panels.
Snyder says Vivante Health has helped thousands of patients since its launch two years ago.
A large proportion of Vivante Health's patients do not need to be referred into a brick-and-mortar facility, Snyder says. Instead, Vivante Health's team works with these patients to identify trigger foods and provide services such as medical nutritional therapy and cognitive behavioral coaching.
The benefit to employers is reduced emergency room visits and improved medication adherence, he says.
"From a patient outcomes perspective, they're coming back and saying, 'I feel better, my symptoms are reduced, I have a much better idea of how to improve my digestive health, and my overall health and well-being is improved as well,'" he says.
Vivante Health is also attracting attention from traditional health plans and is looking forward to moving ahead with some of those relationships in 2023, Snyder says.
Another tool in Vivante Health's toolbox is GI Mate, a handheld breath hydrogen monitor. The device, which measures hydrogen concentration in a user's breath, can help identify lactose intolerance and several other digestive disorders.
Prior to joining Vivante Health, Snyder spent nearly 12 years at Humana, ultimately heading up the insurer's Chicago office. After Humana, he headed sales at Virta Health, which treats type 2 diabetes through a physician-led remote care team, including individualized nutrition therapy.
"I've always being doing entrepreneurial things," he says.
Snyder left Virta to join Vivante because "there's a huge opportunity here to impact a lot of lives in an untapped space." A family member who suffered from digestive symptoms and conditions impressed upon him the toll that can take on a life day to day, he says.
One challenge to growing a digestive health-oriented provider is the stigma attached to the condition.
"We hear it time and again that people were nervous about accessing care, nervous about talking about it," Snyder says. "It's unfortunate that it still occurs."
One of Vivante Health's investors is Intermountain Ventures, an arm of the integrated health system based in Salt Lake City.
"Just having the opportunity to talk about Vivante Health with Intermountain's gastroenterology team, and some of their other practitioners, so they could understand what we're building, was phenomenal," Snyder says.
The biggest challenge of his job is keeping the patient first, he says.
"It's heavy lifting, and it's a lot of work," he says. "The great part is, it is definitely a great mission that people get behind and are excited to be pushing forward."
A new survey from the Merritt Group finds that CIOs value input from key industry and thought leaders, as well as the media, when purchasing technology. And industry events are popular again as well.
Healthcare CIOs considering their next big technology purchase are looking to media and key industry and thought leaders for input on what to buy. And they're not all that interested in Twitter, Facebook, or the latest whitepapers.
That's the takeaway from a survey of 20 CIOs conducted by the Merritt Group, a marketing and PR firm. It speaks to the challenges faced by health system leaders as they sift through the ever-growing vendor landscape to find the right tool or platform.
According to the survey, 90% of CIOs say the endorsements of key opinion leaders and industry influencers add weight to their purchasing strategy, and 70% use the media to influence their decisions. Some 80% get their healthcare news from the media—trade publications, medical journals, professional organizations, and business press—while only 40% look at social media and 20% listen to podcasts.
In a blog accompanying the survey, Shea Lawless, a public relations account executives for the Merritt Group, says the survey results are a sharp turn-around from a previous survey that saw CIOs rank the media as the least favorite source of information.
"This points to the fact that CIOs aren’t looking to the media for [healthcare technology] vendors touting their solutions," she wrote. "Instead, they turn to the media for the seismic trends that will affect their business and patients. Healthcare technology vendors should focus on producing thought leadership content on these trends to educate the media and position themselves as trusted sources."
After media, the outside forces impacting buying decisions drops off. Only half of the CIOs surveyed say pressure from their health system affects what they buy, while 45% are swayed by what their competitors are buying, 35% pay attention to the "buzz around new diseases," and a quarter heed pressure from consumers or patients.
And after a few years of disruption caused by the pandemic, CIOs are interested in the live event circuit again. Three-quarters of those surveyed say they get product and vendor information from events.
"Anecdotally, we have also heard that many events held since COVID-19 are not reaching the same scale and having the same impact they used to," Lawless said in her blog. "Despite that, CIOs still find it to be an important element of their purchasing decisions, so marketers must keep that in mind."
As for vendor-initiated content, 75% of CIOs surveyed say videos work for them, while 65% are partial to case studies and 60% like either vendor websites or webinars. What doesn't click for them are social media (only 40% are interested) and whitepapers (30%).
The senior vice president of care transformation and innovation for the multi-state health system says successful change begins with a focus on processes and workflow.
Editor's note:This article appears in the March 2023 edition of HealthLeaders magazine.
For Michael Schlosser, MD, MBA, the key to innovation and transformation lies in workflows. Figure out how care is delivered first, then improve that process through new technology or strategies.
"We focus a lot on workflows because that's where the changes are going to occur," says the senior vice president of care transformation and innovation at HCA Healthcare. "You'll get better outcomes when you focus on the process first."
Schlosser is at the helm of a pretty big ship. Nashville-based HCA Healthcare comprises 186 hospitals and roughly 2,000 sites of care in 21 states and the UK. The organization set its sights on the health system of the future in 2021, when it created the Department of Care Transformation and Innovation (CT&I) and put Schlosser, then its chief medical officer, in charge.
"Looking down the road is what our office should be doing," he says. "Healthcare moves slowly and changes slowly, so we have to [plan carefully] to make that happen."
Michael Schlosser, MD, MBA, senior vice president of care transformation and innovation at HCA Healthcare. Photo courtesy HCA Healthcare.
To Schlosser, innovation has always been part of the healthcare landscape, even if it does take a while for unconventional ideas to be accepted. But transformation is a new concept, fueled in large part by the challenges created by the pandemic. Health systems and hospitals jumped on the digital health and telehealth bandwagon in droves as COVID-19 took over, and while the technology itself worked well, many organizations had trouble making it interoperable. Workflows and processes weren't well thought out, and care teams struggled to adjust.
"We need to focus on operational transformation," he says.
"Wd caught lightning in a bottle," Schlosser adds, looking back over the past few years. "The pandemic had created an environment interested in … change, which was different than the way things generally happen in healthcare. Adjusting wasn't easy."
As the pandemic fades (hopefully) into the rear-view mirror, he says, healthcare organizations have to adjust their strategies to look forward rather than just keeping up. New technologies and ideas that have proven their value need to be stitched into the fabric of the organization, not bolted onto the side like a new room added to a house. And that means pulling all of the different departments together, from IT to nursing to marketing and PR, to ensure that buy-in is complete and workflows are designed that benefit both provider and patient.
That could be a challenge for a health system as big as HCA Healthcare, but Schlosser says the size and breadth of the organization also offer unique opportunities. The health system has designated two Innovation Hub hospitals, UCF Lake Nona Hospital in Orlando and TriStar Hendersonville Medical Center in Hendersonville, Tennessee, which serve as two unique and individual sites for designing and testing innovative concepts.
"They have the bedside experience to serve as labs," says Schlosser.
But that doesn't mean those two hospitals are the only testing grounds. Schlosser says inspiration is "both structured and unstructured." It's discussed in advisory groups, eyed in other sources outside healthcare, and given the chance to grow in CT&I.
"We've become the funnel for innovation all over the organizations," he says.
As an example, HCA Healthcare identified a particular pain point in the managing of staff and scheduling and the assignment of care teams.
Schlosser says CT&I studied how patients were assigned care teams, built data science tools to create a patient-by-patient grid of care needs, then developed AI software to predict traffic and, in essence, "fill in the blanks" where care gaps surfaced. Working with Google, they created an automated scheduling platform that identifies and matches staff and their capabilities with patient care needs and procedures that need certain competencies.
"It's an iterative design format: Input from stakeholders was crucial at every stage of the process, and this process had several stages," he says. "We decided to test this in the labor & delivery space first because it's bit like a hospital within a hospital, with a lot of opportunities for improvement."
Schlosser says the platform is now in use in three hospitals and has shown improvements in staff satisfaction and time savings. As they measure how the platform optimizes each hospital's staffing and improves patient care, he says, they'll look to expand to L&D units in other hospitals and, eventually, other departments.
Beyond automated scheduling, Schlosser says he wants to tackle documentation, a key pain point and contributing cause to ongoing national epidemic of staff stress and burnout. This will be done not only through automation, but with technology that can capture patient-provider interactions and insert that data into the medical record. A pilot project at UCF Lake Nona Hospital is using smartglasses to record those interactions, allowing providers more quickly and conveniently review and edit their notes in between patient visits.
Schlosser says it's vital now to map out care transformation and innovation over the next five to 10 years, in particular because of the fluid nature of healthcare innovation. With the end of the COVID-19 public health emergency most likely taking place in 2023, it will be important to keep track of expiring waivers and incentives designed to improve telehealth and digital health adoption, and to adjust plans accordingly to continue supporting those programs.
"We're not focused just on technology, but a strategic understanding of how to redesign and enhance care delivery, and all that goes into it," he says. "Now we have a dedicated, focused, multidisciplinary team who wakes up every day thinking about this."
HealthLeaders Strategy editor, Melanie Blackman, is joined by Anne Klibanski, MD, president and CEO of Mass General Brigham, an integrated healthcare system in Boston, Massachusetts. Dr. Klibanski...
The survey of 1,000 commercially insured consumers finds that they used telehealth because it's more convenient than a trip to the doctor's office, but frequency is still an issue.
Convenience is still the top reason that consumers enrolled in commercial insurance plans use telehealth, and most would like Congress to make sure it stays that way.
Almost 70 percent of respondents to a survey commissioned by America's Health Insurance Plans (AHIP) in October said they've used telehealth during the past year because it's more convenient that a trip to the doctor's office, clinic, or hospital. And almost 80% say telehealth makes it easier for them to access care when they need it.
“Patients and providers accept – and often prefer – digital technologies as an essential part of health care delivery,” Jeanette Thornton, AHIP's executive vice president of policy and strategy, said in a press release announcing the survey of 1,000 consumers, which was conducted by NORC and the University of Chicago. “Telehealth can be just as effective as in-person care for many conditions and allows patients to receive more services ‘where they are.’ That’s why health insurance providers are committed to strengthening and improving both access and use for the millions of Americans who use telehealth for their healthcare needs.”
The news isn't earth-shattering, as many surveys have highlighted consumer preference for telehealth, particularly in the wake of the pandemic. But it does add to the library of evidence that consumers will seek out a healthcare provider or health plan that features telehealth, and it reinforces the need for hybrid care strategies that allow for a choice between virtual and in-person care when available and appropriate.
That's especially true of women, who were almost four times more likely than men to say they used telehealth because they lacked childcare or eldercare services.
Overall, 46 percent of those surveyed said they used telehealth because they weren't able to schedule an in-person appointment, while 24% said they wanted to save money and 23% used telehealth because their doctor's office was closed (a nod to the value of telehealth for after-hours and weekend care).
Among other data points, 85% of those surveyed said there are an adequate number of care providers available to them via telehealth for the needs they have, an indication that virtual care is helping to alleviate the provider shortage and improving access.
And telehealth use among the low-to-middle income brackets is about the same or slightly higher than use in the higher income ($100,000+) bracket. That might mean telehealth is helping to address gaps in care experienced by lower income consumers, or it may conversely highlight the fact that lower-income consumers aren't able or willing to take advantage of telehealth.
The latter would seem more likely. According to the survey, 36% of respondents used telehealth just once over the past year, while 53% used it between two and five times, 4% used it between five and 10 times and 5% used it more than 10 times. This means telehealth adoption is still on the low end, even after the pandemic.
Telehealth use had surged during the pandemic, as healthcare organizations sought to push as many services as possible onto virtual care platforms to reduce traffic at hospitals and insulate both patients and providers from COVID-19. Providers were helped in this fashion by state and federal legislation, as well as waivers from the Centers for Medicare & Medicaid Services (CMS) aimed at boosting access to and reimbursement for telehealth during the public health emergency (PHE). Many of those orders and waivers will expire when the PHE ends sometime next year, which could greatly affect telehealth use as health systems cut back their services.
Telehealth advocates are pressing Congress to make those waivers permanent, and consumers are behind that effort. According to the survey, 73% said Congress should act to make sure those waivers stay in place.
