Saturday, June 15, 2013

Q&A: John Glaser's 4 facets of patient engagement

June 10, 2013 | Tom Sullivan, Editor

John Glaser, CEO of Siemens Health Services
Having enrolled in a clinical trial — as a healthy participant, no less — Siemens Health Services CEO John Glaser gained a unique perspective on the long, hard journey to patient engagement.
That is only part of what Glaser plans to discuss this week at the Government Health IT Conference and Exhibition in Washington, DC.
Leading up to the show, Glaser spoke with Government Health IT Editor Tom Sullivan about what to expect at his session, why technology is likely to be the easy part of patient engagement, and the four facets of behavior change that will convert people to engaged patients.
Q: What is the overarching theme of your presentation, 'The IT Ramifications of the Era of Accountability'?
The basic premise is that we’re entering into an era of significant changes to the payment system. Bundled payments, episodes, accountable care organizations, all of which are intended to improve the quality, efficiency and safety of care. Now, when you step back and look at this, it’s going to evolve over the course of this decade you see not only new types of applications that people will need, care management systems and things like that, but you’re also likely to see some fundamentally profound changes to the nature of these systems because of the changes that are coming and by that I mean, for example, as the pressure grows to follow the evidence, to master the incredibly broad and growing base of medical knowledge, we’ll see more intelligent EHRs. In other words: Greater use of workflow engines and rules engines and advanced decision and therapeutic treatment algorithms. So we’ll take a bunch of systems that have traditionally supported transactions – write a prescription, document care – we always have to do that but they will become much smarter. We’re going to see a series of fundamental changes to the nature of the IT that businesses put out along with some applications that really haven’t been all that common up until this point.
Q: What’s an example of such a new application that you can envision?
 Some of them are kind of prosaic. So if you look at what percent of the US population today has a personal health record, about 6 percent, that’s tiny. That’ll become 60 percent, so in comes cases it’s that they’ll go from rare to relatively common. In addition, things that are new, if you and I are going to manage a population or a region as an accountable care organization by contract, rather than buy everybody I have a contract with you, you have a contact with me and we bring in, say, two other colleagues and each of us has different technologies. You might use eClinicalWorks, somebody else uses Siemens, somebody else Greenway and the other party Epic. We’re going to need a care management system sitting between all these, and leverage HIE and health analytics to determine who’s off the care plan they have and use workflow technologies to ensure the subsequent care action that need to be taken are taken. So this is the natural evolution, sort of the next step for the progress of disease registries. There will be a new category but you’ll be able to see the predecessors in them; it’s not so radical as to be unrecognizable but it will really be a different order of sophistication that we’ve seen before.
Q: Which is a good way to segue into my next question. Even a modicum of vision points toward a future wherein the digitized healthcare system in America, alongside those more intelligent EHRs you mentioned, big data and hefty analytical tools, creates a world where we can more effectively manage patient populations. But how far away is that, really?
In some ways we do it today. There are Medicare programs for managing people in high-risk populations, people who have multiple chronic diseases or are old or fragile, for example. There are organizations today that manage populations of diabetics, asthmatics, etc., so population management goes on today. Providers do it, health plans do it. We don’t do it as often as we should. And the way that we do it is way too labor intense and is really only achieving fairly modest gains. So it’s not a matter of going from no population management to highly-mature population health, but we don’t do it consistently, we don't do it across enough of the aggregate population and in a way we do it in a very immature fashion. So as we get smarter about putting interoperability in place, or adoption of EHR increases, and we begin to understand what’s behind the hype of big data, we will get better at it and more sophisticated. I think much more like walking up steps or escalators: You don't take on giant steps, you take a series of modest-sized steps and get there eventually.
Q: Which ties into your talk slated for the conference. Among the themes in your sessions description is predictive analytics. What will be your message around that?
There are two messages here. One is we’ll see more and better use of predictive analytics because if you’re at risk, and it’s not just at risk of readmissions, let’s say a well-managed diabetic all of the sudden tanks, for example. You’re going to be at risk for populations, readmissions populations, disease populations, and when you’re at risk you want to know who out of those hundreds of people poses the greatest risk, so point number one is we’ll see greater use of analytics to predict that. The other point here we take traditionally, and business intelligence analytics is not a new idea, where you took transactions from systems, cleaned them up, put them in a repository, put some good on top to slice and dice and graph — and that’s been our definition of analytics. But that definition in the coming years, it will become much broader to include big predictive algorithms, workflow engines, people trying to slice big data looking for new patterns. So predictive analytics is an example of the expansion of the range of analytics tools we’ll use in the years to come.
Q: Patient engagement is another theme of the show and President George W. Bush’s publicly stated goal of getting every American an electronic personal health record by 2014. Do you anticipate we will succeed in that and once we do, what is the best way to engage patients?
A: No. I think if you look at the meaningful use attestation for Medicare that have occurred to date, 45 percent of the hospitals and 36 percent of the docs, so to assume we’ll get to 100 percent in the net 16 months, I don't think that’s possible. So the 2014 goal put forth by President Bush I don't think is within reach – but if we do it by the end of the decade we ought to feel pretty good. It’s a slow hard journey and lots of things have to happen but it doesn't mean we have to wait for that to engage patients, get them to leverage personal health records now. Things like wearing a Fitbit to monitor your exercise rates, your calorie intake, your sleeping habits, all these help people become more engaged in their health.
Q: And in some ways actually getting most patients engaged in their own care might be the hardest part. All the technology in the world doesn’t mean they’ll necessarily use it. What is the best way to get patients actively engaged?
 In time, this industry will look at it from a technology stance when it’s not obvious how critical the technology is. And I’ll give you an example, Tom. A couple years ago I enrolled in a clinical trial with the Dana Farber Cancer Institute. They were looking at what behavioral strategies are useful in helping people who are fundamentally healthy, that was me, adopt four fundamental behaviors: multi-vitamin a day, eat three or fewer servings of red meat a week, eat five to seven fruit or vegetable servings a day, and walk 10,000 steps. And I did that for 6 six months, made it part of my routine and still do it today even though the trial was over about 3 years ago. So what occurred to me is that I was more engaged in my overall health. Why did I do this? Since I didn't need to, what caused me to do that?
There were four things. One is that there’s a medical rationale, understanding the relationship between walking and health, that doesn’t need much explanation. The second: I had tactical knowledge. In other words, one of the questions for me was what constitutes a serving of fruits or vegetables, for example, do onion rings count? [Chuckle]But I just had to know that very sort of tactical knowledge. The third was technology, a pedometer and web site to record this stuff. So at day’s end I’d record this and if I missed my goals I’d get a call from the health coach asking if I needed some help. And then the fourth was that I had to have a motivational structure. In my case, I’m so Type A that I was going to do it just because I wanted to get an ‘A’. My wife goes to exercise class because she likes the collegiality of her friends.
I look at that trial and think I was an engaged patient, engaged in my health, engaged in changing my behaviors. And the technology piece was perhaps trivial, a $40 pedometer and web site – there’s nothing all that cosmic. The major things were a motivational structure, education, someone who could help with this that or the other. Engaging patients will take all four. What’s unclear to me is how critical the technology will be. And maybe it will be critical but it will be things like Fitbit or pedometers rather than something elaborate.
Q: It’s an interesting point that the technology involved was not, as you said, all that cosmic…
 I went down to my local CVS and bought a pedometer. That said, behavior change is complicated. I think as a country we’re at risk of getting to certain geographies where obesity is so common that nobody worries about it because everybody’s fat. And then it will be even harder to make behavioral change.
Q: Now, the burning question: Did you figure out a way to pull onion rings into the fruits and vegetables category?
My health coach would have nothing to do with that. I struggled and used to say ‘that’s a lot of bananas. I can’t eat that many bananas in a day.’ She vetoed the onion rings so I went for broke and said ‘coffee grows in the ground, how about a cup of coffee?’ No, no, no, no. I was pulling at straws, that’s for sure.
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