The Nemours App for Asthma is the first product from Nemours's Center for Health Delivery Innovation, released as part of a new digital health strategy that provides all digital assets on a single platform for users.
Older patients might get a huge chunk of the country's healthcare dollars, but when it comes to the future of digital health, it's young people who will undoubtedly drive the trends. That's especially true for children's healthcare, where the patients and families are young.
"Families are comparing us to Amazon and Google and their banking app," says PJ Gorenc, operating officer of the Nemours Center for Health Delivery Innovation. "They are on the younger end of the spectrum and many of them are digital natives who don't know a world without convenient access to any of the organizations they interact with."
That's why last week, Nemours Children's Health System launched the Nemours App for Asthma. It's the first product from Nemours's Center for Health Delivery Innovation, and is part of a new digital health strategy that provides its tools on a single platform.
"A lot of health systems are trying to have a telehealth program, have a meaningful patient portal, and provide patient education," says Gina Altieri, CPA, senior vice president and chief of strategy integration at Nemours Children's Health System. "But what's unique to what we're trying to do is leveraging all of those assets so that it's seamless to the patients and families."
Although an asthma app is the first, many other apps are in the pipeline. So far, Nemours has spent just over $1.5 million on the platform that's being developed.
Ahead of the app's launch at last week's U.S. News and World Report Healthcare of Tomorrow conference in Washington, D.C., Gorenc and Altieri talked about Nemours' digital health strategy. Here's part one of that conversation. It has been edited for clarity.
HealthLeaders Media: Walk me through what's coming for patients and providers and what's the impetus for doing it now? What are the metrics for success?
Gorenc: We're starting with an application developed for supporting families for children with asthma. The idea is to design the experience for the families in order to support care for the chronic condition. We also want to route people to the appropriate level of care at the right moment and to support that relationship between the family and the clinician, so that there's a better understanding with what's happening with the patient in between visits.
We went about it that way because we wanted to bring together a lot of the existing digital assets that we already have that weren't really as well integrated as they could be, and certainly weren't presenting for the families the kind of experience that people are starting to expect given their experiences in other industries and their digital interactions.
We're really looking ahead. We've started to have some value-based arrangements with payers, but we're looking ahead to more and more value-based compensation models being enacted throughout the health system.
And we want to partner with our families in such a way that they are following their care plan and communicating with their clinician and sharing data back and forth to make sure that, in this case, asthma … is well controlled so that they're reducing the overall use of the system, which obviously is better for the family, better for the payer, and better for Nemours in our value-based payment model.
Gina looked ahead and said we need to be getting ready for this now. Because, as those agreements come across the table, we want to be ready with our infrastructure to play in that world.
Altieri: You mentioned metrics. From a strategic perspective, we have Nemours True North, which helps [patients] receive the care [they] need and want exactly when [they] need and want it.
Part of our True North is to measure a variety of specific True North metrics. We measure child and family experience. We measure quality and safety by measuring healthcare-acquired infections and medication errors. We [also] measure delivery.
This kind of an app provides immediate access, another thing that the millennial consumer looks for. And then we also measure costs and people and growth. So, we use our highest-level strategy to, in a sense, direct the things that we need to be doing, so that's what we're measuring, or will be measuring.
HLM: Can you tell me what those existing digital assets were or are and tell us how you've merged them?
Gorenc: We have our patient portal, called MyNemours, based on Epic's MyChart. We have a telehealth application that is called Nemours CareConnect. We have an outpatient education interface, which is branded KidsHealth. We have our consumer-facing site for the organization at Nemours.org, and finally we have a reading readiness program called Nemours Reading BrightStart!, and that is based on the idea that literacy is itself a large indicator of health outcomes.
And so, they were all freestanding digital entities if you will. A Nemours family would have to know where to go for which resource.
About two years ago at this point, Gina had pulled together all of the groups that support those entities and said, we're going to integrate not only the digital face, but the organizations that support them.
With the asthma app, we are pulling generously from each of those properties as it becomes relevant in the experience that we're designing, and that becomes our model for integration going forward.
HLM: So there will be on app on your smartphone. What will you see when you open it?
Gorenc: Right now for asthma, you get an asthma dashboard. So you're seeing things like air quality index information, and your ability to journal your symptoms and triggers related to an asthma control test that we're asking people to log on a regular basis so that clinicians can see it. You're getting access to all that you would expect to get access to from a patient portal perspective—your appointments, your medication lists and education—but we're adding functionality to that.
So that's really the point of creating this separate entity, to not just provide the medication but also medication reminders since medication adherence is such as issue.
We're also integrating remote monitoring devices so we can help folks to collect information passively about their medication use, or taking home-spirometry or peak flow readings, all around creating an easy way to either passively (or with a minimal amount of effort from the family) track and pass that information back to clinician, so that the care plan can be tailored to recognize what is actually happening with the family at home.
HLM: Will they have access to telemedicine and the patient portal through the app, too?
Gorenc: Yes, absolutely. That's one of the things we recognized early on in speaking with families, particularly when they're newly diagnosed with asthma. There's a confusion; the caregiver doesn't know how to judge an exacerbation.
We hear over and over, "My child is struggling to breathe." They don't know how serious is it, and so the natural outcome is that you wind up with a lot of people showing up in the emergency room. Some of them don't need to be there.
So the idea is if we can give them easy, one-touch access to telehealth, then we can start to use that as a triage mechanism to determine [either], 'You really do need to get to the ED,' or 'We can follow your asthma action plan right here at home and [you should] take your albuterol, and [we'll] check back in with you in a few minutes.'
Altieri: Also, you mentioned medication adherence. A lot has to do with the patient and family's ability to understand what they're supposed to do, so by having access to their patient portal, which provides access to KidsHealth through that portal, they have patient instructions that also have illustrations so that they can see, over and over and over, what it is they're supposed to do.
And they can provide those instructions to any caregiver—whether it's a parent, a teacher, community center, day care—they all can have access to that. And there are also videos in KidsHealth that are embedded in the education that they can receive through the app.
Gorenc: And we developed a series of how-to videos when it comes to different forms of inhalers … you can set up medication reminders, but you can also view how-to videos: Very short, clear videos on proper technique for using that delivery mechanism.
HLM: Why asthma as the first go-round for this?
Altieri: As we mentioned, the value-based care [is a driver]. We looked to see what chronic condition was causing the most activity if you will, or readmission, and the No. 1 diagnosis was asthma, so we thought we would start there.
We also have a group of pulmonologists that were interested and willing and able to participate in the work, so that helps as well.
HLM: When you say "the work," what did they do?
Gorenc: We're using design thinking methodology in terms of getting started and laying the groundwork for what we were building, so that involved setting up a team of advisors who were clinicians—pulmonologists, allergists, primary care, respiratory therapy, nursing—folks who could advise us on the care that they offer and the problems that they see with their patients.
We also spoke with many patient families directly. And, so, in walking through and getting a picture of what that patient journey is like, they've been giving feedback all along to us.
We went away and came up with wireframes, and went back to all those clinicians and the families and said, 'This is what we're thinking about, how does this work?' There's been an ongoing feedback process where every other week we have a meeting to show people what we're developing, so the clinicians have the constant ability to give feedback and to drive what we're doing and suggest tweaks.
We've been meeting with [those clinicians] individually also to do deep-dive walk-throughs…of the entire app as it stands and [asking] is this doing what you want? And going through…the dashboard that we've created for them so they can see the patient record. They've really been a design partner with us the entire way.
Next week will be part two of the conversation with Nemours when we discuss using telehealth as a triage mechanism, the development processes and costs, and how Nemours will measure success.
A new survey highlights the ways that physicians and pharmacists say the opioid epidemic has changed their prescribing or prescription filling behavior.
But for prescribers and pharmacists on the front lines of dealing with patients, other factors beyond education may be at play in their prescribing decisions.
According to a new survey by Medscape, most physicians and pharmacists have refused to write or fill an opioid prescription for a patient. But doing so made 62% of pharmacists and half of physicians fearful that the patient who wanted to prescription would act violently against them for refusing.
In addition, 40% of physicians and half of pharmacists are now more concerned about legal action taken against them regarding opioids, such for liability in an overdose death.
Those are just two of the ways that physicians and pharmacists say the opioid epidemic has changed their prescribing or prescription filling and other behaviors, according to the survey, which polled physicians and pharmacists online.
Overall, the poll showed that the opioid epidemic has:
Changed prescribing habits of 73% of physicians
Changed the prescription filling habits of 82% of pharmacists
Had had no impact on prescribing habits of 16% of physicians
Had had no impact on filling habits of 7% of pharmacists
The poll also shed some light on respondents use of and views about prescription drug monitoring programs (PDMP).
It found that 87% of pharmacists and 73% of physicians said they used a PDMP, and most—75% of pharmacists and 70% of physicians—said that PDMPs had a positive effect on changing habits.
Other research has showed that many PDMPs are onerous to use, resulting in many prescribers not using them.
Nurses in poorer health had an up to 71% higher likelihood of reporting medical errors than did their healthier peers.
Many years of research has shown that depression among registered nurses is extremely common. One study published last yearshowed that RNs suffer from depression at almost twice the rate of people in other professions.
Now, new research is linking depression among nurses to a significant uptick in medical errors.
It found that 54% reported poor physical and mental health.
About one-third said they had some degree of depression, anxiety, or stress, and less than half said they had a good professional quality of life.
Researchers also found that about half the nurses reported medical errors in the past five years.
When researchers compared the wellness data to the medical error data, they saw a significant link between poor health, particularly depression, and medical errors.
In fact, nurses in poorer health had a 26% to 71% higher likelihood of reporting medical errors than did their healthier peers.
Depression stood out as a major concern and the key predictor of medical errors, the researchers said.
“Hospital administrators should build a culture of well-being and implement strategies to better support good physical and mental health in their employees,” lead author Bernadette Melnyk, dean of The Ohio State University’s College of Nursing and chief wellness officer for the university, said in a statement. “It’s good for nurses, and it’s good for their patients.”
Melnyk noted several steps hospitals and health systems could take toward creating “wellness cultures for their clinicians,” including limiting long shifts and providing easy-to-access, evidence-based resources for physical and mental health, including depression screenings.
The issue of clinician wellness has gotten increasing attention recently.
However, there’s a stigma around mental health care among clinicians, as evidenced by studies and research into physician mental health.
One study in the Society of Teachers of Family Medicine found that state medical boards ask physicians much more extensive and intrusive questions about mental health conditions than for physical health conditions, and many of those questions violated the Americans with Disabilities Act.
Fearing stigma, punishment, and loss of their license, physicians often don’t report their mental health struggles and don’t seek treatment. In addition, up to 15% of physician suicidevictims did not receive mental health care.
Alleviating documentation headaches would help physicians, but price also has to be right, says analyst.
The use of artificial intelligence (AI) in healthcare might be one of the most promising areas for investment and research.
Among those hopping on the AI train is EHR company Epic, which counts 190 million current patients in its system and plans to use AI to help improve physician documentation.
According to Koustav Chatterjee, a healthcare IT industry analyst for Frost & Sullivan, it's a smart move.
"Epic has catered to a relevant market pain point and rightly aims to help physicians repurpose time for better patient care," he says.
He notes that "many physicians are still opposed to the idea of having to pursue clinical documentation and practice medicine simultaneously" and points to the onerous number of clicks a single physician has to make within an EHR.
Twice this year, Epic has announced its intention to use AI to alleviate that pain.
In March, the company said it was partnering with Nuance Communications to provide computer-assisted physician documentation (CAPD) capabilities embedded within Epic. According to the company, Epic NoteReader CDI uses AI capabilities found in Nuance CAPD technology to automatically provide real-time CDI feedback to physicians at the point of care.
According to data from Nuance, using this technology results in:
36% improvement in capture of extreme severity of illness
24% improvement in capture of extreme risk of mortality
$1,200 revenue improvement per clarified admission
And in June, Epic enlisted M*Modal's AI-powered tools for its NoteReader CDI module. The M*Modal CAPD technology applies machine learning and clinical reasoning across the entire patient record as the note is being created.
"AI plays an important role in both cases as it remains the backbone of Nuance's and M*Modal's Natural Language Processing/Understanding capabilities which allow physicians or CDI team members' to evaluate patient-specific clinical notes on real time and highlight personalized (severity and acuity risk-adjusted) clinical documentation requirements in accordance with payer and regulatory objectives," Chatterjee says.
Financial limitations
Such technology is not without its potential pitfalls, however, and many of them stem from financial challenges of "increasing enrollment in high-deductible health plans and poor collection from patients with copay or self-pay arrangements" as well as "flat operating margins and poor account receivable performance," Chatterjee says.
"Most providers are trying to rationalize health IT investments and favoring cost-effective alternatives that are mostly shared-service solutions delivered via different cloud-based operating models," Chatterjee says. "Epic, on the other hand, has historically operated within an on-premise IT ecosystem, which in many cases, required heavy long-term investments."
He also says that Epic has "to get it right" on pricing, too.
"Currently, Epic is offering the NoteReader CDI tool with built-in CAPD functions from Nuance and M*Modal," he says. "However, it is important to note that the price sensitivity for CDI is very high among providers today and it's one of the top reasons for product replacement."
Overall, Chatterjee says Epic is attempting "to transform itself from being legacy to next-generation health IT vendor."
In an effort to curb nutrition-related readmissions, Anthem is offering certain Medicare Advantage plan enrollees home-delivered meals after they are discharged from the hospital.
It’s providing the service in a number of states, including Missouri, Wisconsin, Indiana, and Ohio, starting in 2018.
“Weight loss and poor nutrition are common causes of people not recovering fully from being sick or, even worse, can lead them back into the hospital,” David McNichols, president of Anthem’s Medicare central region, said in a statement. “This home-delivered meal service is part of Anthem’s commitment to ensuring our members receive high-quality, affordable and comprehensive health care.”
Through the service, these enrollees will be eligible to receive up to 20 SunMeadow meals from GA Foods after leaving the hospital. GA Foods delivers meals to members’ homes, unpacks them, and puts them in the freezer for reheating later.
GA Foods also offers ready-to-eat meals that don’t need reheating.
Experts have called malnutrition an‘invisible’ condition, and many people in the United States experience food insecurity. In fact, the USDA said that in 2016, 41.2 million people lived in food-insecure households.
In addition, in 2014, 15.8% of seniors—10.2 million people—faced the threat of hunger, and that number was significantly higher for seniors with a disability or who lived below the poverty line, reports the National Foundation to End Senior Hunger.
There was a continuous increase over the past decade in malpractice claims in which the use of EHRs contributed to patient injury, says a new study.
As EHR usage grows more widespread, so too does the technology’s role in malpractice claims, finds a new study.
The Doctors Company, a physician-owned medical malpractice insurer, found a continuous increase over the past decade in malpractice claims in which the use of EHRs contributed to patient injury.
From 2007 through 2010, there were just two claims in which EHRs were a factor. From 2011 through December 2016, however, that number skyrocketed to 161.
David B. Troxel, MD, study author and medical director at The Doctors Company, noted in a statement that the EHR is typically a contributing factor in a claim, rather than the primary cause.
The Doctors Company says this is its second study of EHR-related claims.
Its latest research compares 66 claims made from July 2014 through December 2016 with the results of the first study of 97 claims from 2007 through June 2014.
Compared with the earlier research, the new study shows that system factors that contributed to claims increased 8%. These factors include things like technology and design issues, lack of integration of hospital EHR systems, and failure or lack of alerts and alarms.
On the other hand, user factors, such as copy-and-paste errors, data entry errors, and alert fatigue, decreased 6%.
Internal medicine, hospital medicine, and cardiology showed marked decreases among specialties involved in claims, while orthopedics, emergency medicine, and obstetrics/gynecology showed increases, the study found.
The study also notes that hospital clinics/doctors' offices remain the top location for EHR-related claim events.
Adoption of EHRs has been relatively fast. Data released last summer showed that only 4% of U.S. hospitals didn’t use EHRs. The Doctors Company study notes that the technology “has great potential to advance both the practice of good medicine and patient safety.”
“However, there are always unanticipated consequences when new technologies are rapidly adopted—and the EHR is no exception,” the study concludes.
A study links dental antibiotic prescribing with C. diff infection, and often, unnecessary prescriptions.
Efforts have been made to curb the use of unnecessary antibiotic prescribing among many healthcare specialties, but one seems to be out of the loop: Dentists.
New research presented at IDWeek 2017 suggests that antibiotics prescribed by dentists may contribute to Clostridium difficile (C.diff) infections, which are often linked to antibiotic use.
Furthermore, many of the antibiotics they prescribed were likely unnecessary, the researchers said.
"Dentists have been overlooked as a source of antibiotic prescribing," Stacy Holzbauer, DVM, MPH, lead author of the study and career epidemiology field officer for the CDC and Minnesota Department of Health (MDH), said in a statement.
MDH researchers interviewed 1,626 people with community-associated C. diff between 2009 and 2015.
Of those, 57% reported they had been prescribed antibiotics; 15% of those were for dental procedures.
Those who were prescribed antibiotics for dental procedures tended to be older and more likely to receive clindamycin, an antibiotic that is associated with C. diff infection.
Other research in the Journal of the American Dental Association suggested that “dentists and dental specialists are significant contributors to outpatient antibiotic prescriptions in the United States.”
The JADA study found that in 2015, “As a group, general dentists and dental specialists were responsible for more than 2.9 million antibiotic prescriptions, higher than levels for several other medical and allied health care provider specialties.”
An earlier MDH survey found 36% of dentists prescribed antibiotics in situations that are generally not recommended by the American Dental Association.
That tracks with the trend overall: At least 30% of antibioticsprescribed in the United States are unnecessary, research shows.
C.diff isn’t the only thing to worry about: JAMA Internal Medicineresearch showed that 20% of hospitalized patients who received at least 24 hours of antibiotic therapy developed antibiotic-associated adverse drug events, such as gastrointestinal, kidney, and blood abnormalities.
The new MDH study also highlights the disconnect between doctors and dentists. Of those patients who had received antibiotics for a dental procedure, 34% had no mention of antibiotics in their medical charts.
There has long been a divide between dental and medical care, and experts agree that further collaboration is needed between the two.
The program also reduced hospital admissions and increased the use of primary care doctors.
A community-based program that helped high ED users get things like household resources, access to transportation, and help applying for assistance programs reduced ED visits and hospital admissions, finds new research.
It also increased the use of primary care doctors, according to the study published in the journal Health Affairs.
"Many programs have tried to tackle the problem of high utilizers of hospital emergency departments. These are usually people who are on Medicaid," the study's first author Roberta Capp, MD, an assistant professor of emergency medicine at the University of Colorado School of Medicine, said in a statement. "But this is the first program to show that care coordination actually works."
Capp and her team used and evaluated Bridges to Care (B2C), an ED-initiated, community-based program. It was one of four sites funded by a CMS Innovationsgrant. The program was led by Rutgers University Center for State Health Policy and developed in collaboration with four Colorado stakeholders including an urban academic hospital, a network of 13 local federally qualified health centers, a mental health clinic and a community advocacy organization.
The B2C program targeted Medicaid-eligible high ED users, defined as adults who had two or more ED visits or hospital admissions within the last 180 days.
These patients got a personally tailored, 60-day care plan that included housing help, refugee services, and access to transportation. They also got help applying for insurance and disability benefits, setting up medical appointments, and filling prescriptions, among other services.
During the six months after B2C enrollment, the participants had:
29.7% fewer ED visits
30% less hospitalizations
123% more primary care visits than the control subjects
"There is a perspective from multiple stakeholders that high users of the ED are difficult patients," Capp said. "But this study shows that patients use the ED because of there are serious barriers to care.”
Those barriers can include multiple chronic diseases, including mental illness, the authors said.
Although care coordination has been shown to reduce costs, other programs aimed at reducing ED usage have been only hospital based and have had mixed results, the researchers said.
The difference with the B2C intervention is that it combines active ED outreach with multidisciplinary, community-based services, including a care coordinator, a health coach, a behavioral health specialist, a community health worker, and frequent home visits.
"We believe that our success stems from bringing together different healthcare systems, breaking down silos between disciplines and focusing on continuity of care in the outpatient setting," Capp said.
"We learned that active outreach in the ED is key to ensuring successful high utilizer and enrollment and engagement," the study said.
The fund aims to provide financial help to hospital employees in Puerto Rico who have experienced significant property loss or damage from the recent hurricanes.
Hurricanes Irma and Maria have left millions of people in Puerto Rico—including the island’s hospital employees—in desperate need of shelter, food, clean water, and medical attention.
That’s why the American Hospital Association has activated The Care Fund, which will provide financial help to hospital employees in Puerto Rico who have experienced significant property loss or damage from the storms.
“Not only were hospital employees throughout Puerto Rico faced with the difficulty of taking care of their patients during the hurricanes and their aftermath, but they also experienced their own personal losses and had to leave the care of their families to others,” according to The Care Fund’s website.
Many hospitals have been open since the hurricane but are operating on generators and supplies are running out, according to media reports.
The AHA has contributed an initial $50,000 to the fund, and is seeking further donations via thecarefund.net.
The AHA says it’s working with The Puerto Rico Hospital Association and hospitals throughout Puerto Rico. Its 501(c)(3) organization will collect contributions in a segregated account and will distribute the funds to hospitals in Puerto Rico.
Each hospital will identify the employees with the most significant needs and disperse the funds accordingly, AHA says.
“Hospital employees in Puerto Rico have shown the courage, strength, resilience, and compassion of caregiving,” says a statement on TheCareFund.net. “They need our help now.”
The AHA notes that the Florida and Texas hospital associations also continue to seek donations as they recover from Hurricanes Irma and Harvey.
Researchers say that new payment models in radiation oncology should also consider measures to address behavioral health.
Cancer patients with pre-existing psychiatric diagnoses had 208% higher follow-up ED costs than patients without them, according to a new study from Mayo Clinic.
Those patients also had 193% higher follow-up hospital outpatient costs and 190% higher follow-up hospital inpatient costs.
That’s why researchers say that new payment models in radiation oncology should also consider measures to address behavioral health. Doing so would reduce the total cost of care during and after radiotherapy, they assert.
Mental and behavioral health conditions are often associated with chronic conditions, from cardiovascular disease, to diabetes, to arthritis, and healthcare providers are increasingly including mental health care with their routine medical care.
"Psychiatric health is an essential component of comprehensive cancer care,” the study's lead author Mark Waddle, M.D., a radiation oncologist at Mayo Clinic's Florida campus, said in a statement. "However, little has been done to quantify the impact of pre-existing psychiatric conditions on the cost of cancer care."
The researchers examined costs for acute and follow-up for patients with and without psychiatric comorbidities who received radiation therapy at Mayo Clinic's Florida campus between 2009 and 2014.
Researchers studied the cost of care for 1,275 cancer patients over five years. Of those patients, 9.9% had at least one pre-existing psychiatric diagnosis.
Researchers then collected acute and follow-up costs as all costs for these patients for zero to six months and for six to 24 months after the cancer diagnosis. They subcategorized these costs into clinic, ED, hospital inpatient, and hospital outpatient costs.
They discovered that acute and long-term costs were higher in the group with pre-existing psychiatric diagnoses.
The three largest differences in costs were follow-up ED costs, (208% higher), follow-up hospital outpatient costs (193% higher), and follow-up hospital inpatient costs (190% higher).
Although age, race, sex and treatment modalities were comparable among the groups, the psychiatric group had a higher median number of comorbidities (five versus three), as well as more respiratory cancer diagnoses than the nonpsychiatric group (31% versus 17%).
"Our study suggests that interventions to improve anxiety, depression, alcohol and drug dependence and other psychiatric comorbidities not only offers a chance to improve clinical outcomes, but also provides an opportunity to decrease costs not only for patients but for the U.S. health care system as a whole,” Waddle said.
Other research also presented at the American Society for Radiation Oncology’s Annual Meeting uncovered high rates of undiagnosed depression among cancer patients.
Those researchers examined 400 cancer patients who received treatment at the University Hospital Cancer Center in Newark, New Jersey, between 2013 and 2016, assessing depression using the Center for Epidemiologic Studies Depression Scale.
Among the 40% of patients at the center who were diagnosed with depression, three in four had not previously been told they were depressed. Female patients and disabled patients were more likely to be depressed.