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This past weekend, I explored the health section on my smart-phone and saw the log of my heart rate from the smartwatch on my wrist. Pulse readings from months past glowed warmly in easy-to-read and interactive graphs. The heart rate information captured by the watch was easy to understand and is a clear opportunity for medical providers to help patients. Wearable smart-watches connected to smartphones are the tip of the technological iceberg for patient monitoring. Access to health data solves an age-old problem; getting patients to follow doctors’ orders. Wearable devices, connected monitors, and smartphone health apps used in combination with telehealth can help us to improve the health of our patients by enhancing patient engagement. The wave of new monitoring tools means significant opportunity for engaging people in their health. Access to information is empowering and the proliferation of new ways to see, understand, communicate and monitor health-related data has really opened new doors for patients, as well as for their physicians.
Behavior change is at the core of improving health outcomes. Diet habits, medication adherence, exercise, and patient activation are examples of the opportunities for behavior change which have already happened. The growing array of options for monitoring health comes at a time when doctors and healthcare delivery systems are also changing how they do business. In value-based contracting, the management of health and chronic disease is now more about what happens between visits. Pay for performance models incentivize physicians based on patient outcomes, regardless of visit status. Because healthcare delivery is evolving, it is time to understand and take advantage of the options available to help people take ownership of their health outcomes.
"Access to information is empowering and the proliferation of new ways to see, understand, communicate and monitor health-related data has really opened new doors for patients, as well as for their physicians"
At the heart of the proliferation of health monitoring is the smartphone. Mobile internet technology, mainly smartphone apps are the medium by which patients become informed about their health. Apps take advantage of the ubiquitous internet connectivity that we all now enjoy and have broad public appeal. Apps that track, remind and monitor mindfulness, chronic disease control, exercise, diet, tobacco cessation, substance abuse assistance, telehealth, women’s health, sleep, pregnancy, and early childhood development are a few of the prominently represented areas of development. The challenge for providers is to understand the apps their patients are using, take advantage of patient engagement tools, and work out how to best integrate the data in the apps in their practice. For instance, the Family Health Centers at NYU Langone is developing a co-branded app for tracking pregnancy because the data on downloads of apps among pregnant women is compelling. We want our patients to benefit from our clinical protocols and services early in their pregnancy. Making use of that data can provide meaningful decision-making when that data is useful. A key component to adapting to this new world is workflow redesign, staff training and repurposing to help providers capture and integrate health app-related data in a meaningful manner.
Devices that capture health-related data now provide much more data for the monitoring and management of chronic disease. Smartphone apps rely on the input of data on the part of the patient, either entered manually or through the sensors in place in the phone—such as accelerometer data, camera recording, or through sound—, but data that is provided through connected devices represent deeper and richer data on critical health-related data. Wearable devices, such as glucose meters download blood glucose data for rapid review and interpretation. Digital scales, blood pressure cuffs, and other biometric devices significantly improve the ways that smartphone tools can be used. We have implemented retinal photography at many of our Family Health Centers sites and the improvement in diabetic retinopathy monitoring using this technology has been profound. The proliferation of new data points has required new workflows, but the overall experience has been excellent. Frequent monitoring of data such as retinal images, blood pressure, and blood glucose has required new workflows and training for staff to manage, providers to interpret and patients to understand. In particular, making meaningful treatment decisions based on this data is a skill that must be developed over time.
Monitoring all this patient data is the final and most challenging aspect of the explosion of new technology. Patient monitoring workflows in electronic health records (EHRs) are critical. Since EHRs are now widely accepted and patient portals are in place for most medical offices in the US, the interface between existing EHRs and smartphone app data must take off. Portals provide access to information previously primarily accessed by providers. Patients can now view and ask questions about lab, radiology and other test results.
In some cases, they can see the notes written by their providers. Patients can request refills, seek help with new symptoms and can also submit information regarding their health that the provider does not have access. With planning and a well-developed workflow, the patient portal can become a vital tool for better patient monitoring, allowing connected providers to follow up on patient symptoms and make sure patients achieve desired treatment goals. This onslaught of information is daunting and requires workflows for receiving, reviewing and collating that information. A clear understanding of staff roles in this setting is critical.
Although most people have smartphones today, there is still a significant population for whom technology can be intimidating and underused. People struggling with limited literacy, poverty, educational attainment, distrust of the healthcare delivery system, developmental disabilities, and other factors, do not make use of technology at the same rate as others. The Primary Care Plus program, a home visiting program recently initiated at the Family Health Centers at NYU Langone, makes use of in-home community health worker intervention coupled with a physician and nurse practitioner providing both in-home and telehealth encounters. The key to success in this predominantly Medicaid population is helping to facilitate telehealth encounters through the use of in-home staff intervention. The staff work with patients in their homes to specifically contribute to promoting the use of these new technologies by helping patients to set up EHR portal access, make use of glucometers and facilitate app related monitoring.
Devices that record biophysical data are now in the pockets of most people. Monitoring patient outcomes is now in the hands of patients, the people for whom it makes a real difference. At NYU Langone, we’rebuilding upon on our initial experience with these new tools when working with patients who have a chronic illness, helping them to take ownership of their medical conditions through monitoring. As providers, we understand the importance of engaging with our patients when those measures of health are uncontrolled, which is key to improving their overall health.