Monday, April 28, 2014

NCQA: Health IT Can Be Tapped To Support Patient Engagement

Successful integration of patient engagement tools into health IT systems has "the potential to improve inefficient communication methods and change the dynamic of the relationship between the patient and health care system," according to a new report from the National Committee for Quality Assurance, EHR Intelligence reports. 
However, the report noted that there is not yet a complete framework for boosting patient engagement through health IT systems.

Details of Report

In a survey, the report authors identified six common themes of "opportunities and challenges" related to patient engagement through health IT:
  • Patient engagement is an untapped opportunity with major potential, especially among marginalized groups;
  • Health IT should adopt a user-based model that originates from the needs and preferences of patients;
  • There is a dearth of evidence on the effectiveness of such tools;
  • Patient-engagement tools should be integrated into overall health care IT systems;
  • Patient and consumer trust needs to be fostered; and
  • Leadership and collaboration among stakeholders are necessary to realize the full potential.
The report also detailed four activities that will help the industry identify and develop a cohesive strategy for patient engagement through health IT, including:
  • Developing joint principles that will facilitate the design, creation and adoption of health IT tools that boost patient care, improve overall population health and lower health care costs;
  • Creating and implementing an evaluation framework that focuses on investment and prioritizes consumer choice;
  • Facilitating the creation of a unified health data integration strategy focused on patient engagement; and
  • Demonstrating innovative ways to use IT tools for patient engagement.


In the report, the authors wrote that "[h]ealth IT tools for patient engagement are often disconnected from the health care system and in need of full integration across all opportunities for engagement." However, the report added that successful integration of patient engagement in health IT systems has "the potential to improve inefficient communication methods and change the dynamic of the relationship between the patient and health care system."
NCQA President Margaret O'Kane said the "core idea" of the report is that health IT "should be designed around the needs and preferences of patients." She added that "the question of how to link [health IT] and patient engagement is an area where a unified strategy is most needed" (Murphy,EHR Intelligence, 4/23).

Saturday, April 26, 2014

Empirically Driven Consumer Engagement: The Power is in the Simplicity!

Necessity breeds solutions. mHealth Games, is a perfect example of how creative efforts to solve a problem can generate powerful solutions that work. Picture perfect innovation. Cost effective tools developed by and for those on the front lines. Disruption of the greatest kind.

In August of 2013, I was given an opportunity to design and implement an ICD-10 training program for a large managed care organization in Miami. This is not as easy as it may sound. Most coders, including myself, have been doing it for so long that we think in code. The idea of having to retrain our brains as well as our providers was almost an unimaginable task. Knowing this I quickly realized the one variable that would ensure success was the ability to create content that would engage everyone. But how?

This particular organization spanned 4 states and 3 time zones. Efficiency was critical. The ability to monitor and measure the amount of engagement on a daily or hourly basis would provide the intelligence that I needed to modify, adjust and improve the content. I knew what I needed to succeed, but could I execute?

Creative content is what activates consumers to engage over and over. It is what keeps them coming back. I am not an IT person. I have no technical training at all, other than that which was required to graduate. How was I going to pull this off? I could hire a company who specializes in IT or even e-learning, but would that accomplish my goal? No, although experts in their field, they lacked the experiences of a coder, and that was what I knew I could capture my audience with.

So we started experimenting with tools to engage. The first one took over two weeks. I took the top 200 ICD-9 codes and mapped them backwards and forwards to the corresponding ICD-10-CM codes. I added specific conventions to each mapping and added tips for clinical documentation. I thought I had knocked it out of the park. I sent the final project out and waited for feedback. I kept waiting and waiting, until I finally realized that even as great as the tool was, it wasn’t applicable to what we were doing today.

So, I came up with a better idea and requested the top 20 codes from each of their providers. With this new information I was able to create a personalized training program for each provider. Surely, they would be interested in learning about the codes they use on daily basis and how to mitigate any impact to their revenue. But again, I was wrong. This still wasn’t able to truly engage at the level I needed to succeed.

At this point, I was desperate for a better way and turned to Google to research alternative methods. I spent at least 200 hours reading about technology and how it is being used in distance education. What I found was amazing! Really smart people had created amazing tools that would allow me to work with technology. That was a defining moment! A change in paradigm had occurred. I was no longer dependent upon others to close the gap between what I wanted to create and what I was capable of creating.

This is where the fun begins. I had found the tools and now it was time to really start creating engagement. Had I of known the complexity of trying to learn new software, design games and teach ICD-10 -  I may not have taken the challenge. This is actually much harder than it sounds, but the results were well worth the time, talent and energy!

The learning curve was steep and fast. I can not tell you how many times I considered quitting, but then I would look at the results and I knew this had the potential to change everything! Why? Because these games are not just games. They are published using the xAPI or “experience API”. This means that we now are able to learn as much about our learners as they are learning from us!

Consider, the power of one game and the insight of data it could provide. The traditional tracking methods of pass/fail have now been replaced by the ability to visualize when a learner has both interacted with the concepts and mastered them. Thus creating an individual path to success!

These are the tools of the future! They create the foundation for the new learning health care system, but most of all they provide high value at little cost. We already know that games activate consumer engagement, but the time to market and cost of production complicated the process and reduced the return on investment.

Over the last few weeks, I have spent hours upon hours discussing the potential impact on consumer engagement and the potential value of taking mHealth Games to the next level. I have listened to stakeholders from every end of the ecosystem describe their version of how, why, and what this expansion could look like. Opportunities that I never thought possible have been discussed with people who can actually make them happen. But what if we choose to grow organically, where we continue to have to the freedom to create, deliver, modify and improve? After all we have just begun.

The single greatest take-away from this week was how every conversation of “growth” had the same plan, “By partnering with us, we will be able to bring in engineers and you won’t have to design games anymore!” But doesn’t that defeat the entire purpose of this journey?

Kameron Gifford
mHealth Games

Video games of to adapt to players' mood

Video games of to adapt to players' mood
San Francisco, April 26 (IANS/EFE) A team of engineers at Stanford University has developed a hand-held controller that allows video games to adapt to a player's level of engagement.
For instance, if a player's heart rate, blood flow, rate of breath and other physiological signals show he or she is bored with an unchallenging game, the controller can gather that information from the individual's hands and increase the level of difficulty.
When players are engaged, their heart rate and breathing generally become faster, Gregory Kovacs, a professor of electrical engineering at Stanford and head of the laboratory where the prototype controller was developed in collaboration with Texas Instruments, told EFE.
The engineers removed the back panel from an Xbox 360 controller and replaced it with a 3-D printed plastic module equipped with sensors that measure gamers' blood pressure, heart rate, temperature and breathing rate and depth.
Users' arms and hands transmit signals that indicate what is happening internally, the professor told EFE.
Created in Kovacs' laboratory under the leadership of doctoral candidate Corey McCall, the controller has sparked the interest of several companies in the video game and entertainment industry.
This non-invasive system for measuring autonomic nervous system activity has numerous applications beyond the world of gaming, Kovacs said, noting that it could be used to prevent traffic accidents.
Sleepy drivers continue to be a major cause of car crashes, he said, adding that many lives could be saved by using sensors on the steering wheel to monitor motorists' level of alertness.

How IT is Driving Changes in Community-Based Healthcare


By John DeGaspari

Friday, April 25, 2014

The Next Generation of Healthcare: Games and E-Learning – high value, low cost!

Games drive engagement through consumer activation. We know this! They are a fantastic way to challenge learners and keep them engaged and interacting with the content at hand.

So, how do we improve on something that is already awesome? We embed it in a learning ecosystem that drives improvement through partnerships with all stakeholders. This new learning environment sets the stage for providers, patients and caregivers to connect and communicate - anytime, anywhere, any place and on any device.

As we move towards a healthcare system that reimburses for value instead of volume we will need tools that can capture this next generation of care.  We will need to automate the processes of education and learning much like the electronic claims we send today. All of this data will then need to be interpreted to understand and truly visualize the path to wellness. That feedback will allow us to refine the process and continually work to improve the delivery of care.

But what if we can already do this through fun, engaging, and cost effective e-learning games? I believe we can! With the help of new technology, such as the xAPI, we can now track and measure all those things that were so hard to track before.

These short games below can capture up to 32 data points vs. the traditional check boxes, and take days to get to market instead of months. Imagine the possibilities. 

Click on a game below to launch.  Bird Hunt is a flash game, so you will need a flash browser. The Olympic Mountain Summit game is not. 

Fred was just diagnosed with type 2 diabetes and now he is afraid to enjoy the things he used to. This game combines his love of hunting with diabetes education. 

Johnny Three-Scoops and Earl Strong-Fit will not only be fighting for their individual victories tonight, but the fate of their entire teams may lie in the outcome of this single event. With only 3 events left, and this being the only event in which their respective teams have a real contender, this could decide the gold.

Can you help TEAM HEALTH reach the top first by correctly answering the questions?

For more fun, FREE Games visit our website:

Tuesday, April 22, 2014

Gamification in healthcare isn't just about playing games

There are a number of pilot projects, technology startups and other developers who are playing around with gamification in healthcare. It's not yet clear whether this approach -- mixing self-monitoring and entertainment -- is yielding the type of traction and adoption that will ultimately lead to sustainable patient behavior modifications and improved health outcomes. Still, I suspect there will be significant growth in this area over the next several years as more patients adopt a consumer mentality about their health and wellness.
For example, people using the Pact mobile app by GymPact risk losing money if they don't follow through on their commitment to exercise. The app requires them to set a personal goal to eat right and exercise several times each week. The users also designate a financial amount that they are willing to lose if they don't follow through on their promise. Those who faithfully exercise earn money that gets paid by those who don't keep their "pact," creating an ecosystem where some users are paying others.
We have only seen the beginning of how gamification principles will help patients improve their health.
The Pact app and its approach to improving health has some parallels to online gambling. Some people simply enjoy the entertainment aspect of online gambling, while others may have an addiction or are highly motivated by the desire to earn money. Similarly, there are people who are compelled to exercise and lose weight, while others are casually exercising to maintain an average level of fitness.
The concepts and principles of gamification are all around us, whether we recognize them or not. Many people are naturally competitive and like to compare themselves to others. That is why companies like to host walking competitions and measure their employees' performance and progress by giving them wearable activity trackers like Fitbits. This desire to compete is also why television shows like The Biggest Loser are so popular. So, even if you are not the type of person to spend countless hours on playful games like Angry Birds or FarmVille, we are all wired in a way to enjoy and to be motivated by the core principles behind gamification.
Accenture reported there are seven key elements behind gamification: status, milestones, competition, rankings, social connectedness, immersion reality and personalization. As consumers become more engaged with their own health, they will take greater responsibility for managing their own condition. People who have diabetes will feel the need to learn more about their condition, their medications, and how they can improve their self-management.
Those who are healthy can stay that way by becoming more knowledgeable about disease prevention, age-appropriate screenings, and maintaining active lifestyles. As people gain more knowledge and insight about their conditions, they will want to set goals, measure their progress against those goals, reach milestones, and compare their performance against certain benchmarks. If patients take these steps to be actively engaged in staying healthy, they will apply gamification principles whether they realize it or not.
We can't forget about those who enjoy smartphone games and spend many hours tapping on screens to play mind-numbing (but thoroughly entertaining) games. For these individuals, adding a gaming element to disease self-management could reduce their apprehension toward the medications and treatments associated with the condition. There are also examples of this targeted at children. Muppets Band-Aids incorporated a quick response code on the Band-Aids so a parent can scan the code with their smartphone to show an entertaining video to a toddler who just scraped his knee. When Kermit the Frog starts singing about feeling blue, will the child forget about his scraped knee? There is a more serious example of the Pain Squad iPhone app that is designed to help children dealing with cancer track their symptoms so their clinical care team can do a better job to manage their pain.
Simulation games such as PatientPartner are aimed at helping patients improve their medication adherence. By walking through a virtual role-playing game, patients can learn about the various clinical outcomes that may result if they fail to adequately manage their health conditions. Monster Manor is a game that engages young children with diabetes to be better at taking their insulin and to have fun while they are doing it.
We have only seen the beginning of how gamification principles will help patients improve their health. As healthcare providers, payers and innovators find successful ways to engage patients by applying gamification strategies to both children and adult patients, we will see a shift in population health that is driven by more engaged and motivated individuals. Gamification will motivate some patients to receive ongoing feedback, reminders and status updates about their progress in caring for their own health.
About the author:Joseph Kim is a physician technologist who has a passion for leveraging health IT to improve public health. Dr. Kim is the founder of and is an active social media specialist. Let us know what you think about the story; email or contact @SearchHealthIT on Twitter.

Digital healthcare is the way forward

The focus of modern healthcare is around lifestyle issues such as obesity and diabetes. Picture: PA

Published on the 16 April 2014

Patients can be taught self-care, says Grant Cumming

A new building named the Alexander Graham Bell Centre, located on the campus of Moray College UHI in Elgin, will be officially opened in June to further the pioneering work already being done in the area on digital healthcare or e-health. Detailed attention has been paid to the internal architecture because the centre’s purpose is to bring together – and create a flow of ideas between – people working in digital healthcare in the public and private sectors as well as medics, social workers and academics.

Drawing on the “social physics” ideas of Massachusetts Institute of Technology, professor Alex Pentland, among others, the centre will be a hub for developing new and innovative ways of providing healthcare using information and communication technology (ICT).

Social physics outlines how human behaviour is driven by the exchange of ideas and learning from each other. It also identifies how large amounts of very specific data available on the internet through different types of computer technology can be used to help this process.

For example, one in four people in Moray consults the internet prior to visiting their GP, giving doctors an insight into the value of highlighting credible sources of information to patients which might allow them to look after themselves.

We can no longer afford to deliver healthcare under the existing model. Our system was built to deal with infection and while we will always have infection, the focus of modern healthcare is around lifestyle issues such as obesity and diabetes.

The traditional model is reactive when we need to be concentrating much more on preventative and personalised medicine – we need new ideas on how we engage with a person and their wellbeing throughout their life and that is what the centre is there to generate.

In part, the challenge is subtly to alter the behaviour of patients. As well as Alex Pentland’s, the work of behavioural economists Richard Thaler and Cass Sunstein on nudging people to take action and that of psychologist Daniel Kahneman, whose global bestseller Thinking Fast and Slow contrasts fast, instinctive and emotional thinking with slower, more logical thinking in human decision-making, has been influential.

We can teach people to look after themselves. We need an element of nudging – persuading people to take action, for example by highlighting the dangers of smoking. We also need budging – making people take action, for example the ban on smoking in public spaces. We can use information and new technology, perhaps even gaming, to create, for instance, a fun way to exercise to get a message over to some groups.
The internet is now a social web where we can order goods and interact with people, where information within documents can be linked and disparate databases mined for more information.

We must look at how we can connect and collaborate and use that technology to improve the delivery of healthcare, and where better to develop that format than here in Moray?

Moray has already won global recognition for its excellence in the field of digital health, hosting a World Health Organisation conference on the subject in 2012. And two of the four projects in the UK to have received substantial funding under the DALLAS (Delivering Assisted Living Lifestyle at Scale) scheme are in Moray.

They are:

n Year Zero, an online application which enables people to manage their health information and includes an online family tree, a digital version of the red book that is given to all parents to record their child’s health and Rally Round, a social networking and planning tool to connect family, friends, carers and health and care professionals.

n Living It Up, which uses connected TVs to give people access to health and community information within their own homes. Moray is the test bed area for the project.

It is hoped that the Alexander Graham Bell Centre will further enhance the area’s reputation for digital healthcare.The centre has conference facilities, eight classrooms, custom-built corridor learning pods for students, a community hub and cafĂ©. It also has a mock hospital ward, a resuscitation training room, research facilities and space for new enterprises.

The whole place will be a melting pot for ideas, a safe space in which we hope we will be able to redesign how we deliver healthcare.

• The £6.5 million Alexander Graham Bell Centre has been funded by Highlands and Islands Enterprise, Moray College UHI, NHS Grampian and the European Regional Development Fund. 

Professor Grant Cumming, Consultant Obstetrician and Gynaecologist, Dr Gray’s Hospital, Elgin is one of the medical professionals behind the creation of the centre.

Monday, April 21, 2014

The serious business of gamification

If you’re interested in changing behaviour in your workplace, helping employees or customers to develop new skills, or spurring innovation, you may want to consider the approach known as gamification. If that scares you – given that the word is ugly and sounds as if you would just be encouraging staff to play video games – Brian Burke, a vice-president at technology research firm Gartner Inc., says you should relax.
Gamification is actually not about playing games. Games are about entertainment. Gamification is serious stuff, using game mechanics such as badges and awards to digitally engage and motivate people to achieve their goals.
“It’s not entertainment. It’s motivation,” Mr. Burke said in an interview.
He points to the Boy Scouts, which has long used badges to motivate youngsters, and Weight Watchers, which uses a points system and social encouragement to nudge dieters. Both are examples of gamification from the days before the term was even coined. “It provides them with the encouragement, motivation, and clear path to achieve a goal,” he said.
Mr. Burke stresses that when using gamification, it is vital that the emphasis not be on organizational goals but on motivating people to achieve their own goals. When those personal objectives are aligned with the organizational goals, you can hit the gamification jackpot.
Behavioural change is the most common use for gamification. It comes in handy because new habits must be created to change behaviour, and gamification can excite us to adopt those practices.
In his book Gamify, Mr. Burke notes that Spanish bank BBVA used gamification to encourage customers to use its online services. The BBVA Game, which has 80,000 users, rewards players for completing challenges that educate them about Web banking, encouraging them to use the service. Points are awarded, which can lead to prizes. It has led to a 5-per-cent increase in BBVA’s Web-banking users, who spend 60 per cent more time on the site. Because online banking can be easier than going to a branch, the game is aligned with customers’ needs. But it’s also aligned with BBVA’s needs, because it reduces costs.
Samsung Electronics focused on customers with its social loyalty program, dubbed Samsung Nation. Customers are rewarded with points, levels and badges for watching product videos or commenting on Samsung products. The program has doubled the number of items placed in online shopping carts.
A key to success for behavioural change is to increase complexity over time. The BBVA Game starts by encouraging customers to watch instructional videos and then try simple operations such as checking an account balance. As users become more confident with the help of coaching, they move to more complex tasks such as paying bills.
Gamification can also help people to build their skills. Learning new skills often requires a repetitive process of lectures and practice, which gamification can handle. Or if the skill is best learned in an experiential way – such as being presented with a problem to solve – gamification can provide a vehicle for collaboration with others.
There have long been games that can teach new skills, such as Where in the World is Carmen Sandiego? (a series of video and computer games and TV shows designed to stimulate kids’ interest in geography, cultures and history). But Mr. Burke says those are games first, and skill-builders second. Gamification puts the skill-building first.
U.S. organizations such as Capital BlueCross are using it to educate members on the complexities of health care. The U.S. Department of Health and Human Services applied a gamified solution to educate health-care practitioners on best practices about privacy and security.
A key element of design is to create theory-practice loops. Players are provided with instruction, a challenge, and feedback on their efforts. “Gamification breaks the learning process into small, achievable steps and provides constant feedback and encouragement throughout the process,” Mr. Burke writes in his book.
To spur innovation, gamification can encourage people to submit innovative ideas, evaluate proposals and then collaborate to refine the idea into reality. Quirky, a crowdsourcing product-development company that has more than 6,000 inventors as members and has launched more than 400 new products since 2009, uses gamification in this way.
Mr. Burke says the process can be captivating. During his research he found himself hooked as he submitted a name for an anti-theft rucksack – one of 1,400 possible choices – and watched his suggestion bounce up and down in the Quirky rankings.
While he is an enthusiast, Mr. Burke warns that the biggest challenge facing companies is to understand the limitations as well as the opportunities of gamification. “A lot of organizations are pursuing opportunities that are unlikely to be successful with gamification,” he said. Faced with a problem, they throw some points at it and hope a solution will materialize. But you need to figure out how a point system might work, how to employ collaboration, and whether what you are designing can hold for the long term as well as short term.
But if you get it right, he believes you can harness the power of game design to great benefit for your organization.
Harvey Schachter is a Battersea, Ont.-based writer specializing in management issues. He writes Monday Morning Manager and management book reviews for the print edition of Report on Business and an online work-life column Balance. E-mail Harvey Schachter

Sunday, April 20, 2014

"The Case of the Bad Blood Sugar" - Help Detective Wells solve this case!

 Mr. Bad Blood Sugar and his gang of carbohydrates have initiated a crime wave of epidemic proportions! 

Detective Wells is hot on their trail, but he needs you to help find the clues that will solve the mystery.

Click the image above to launch the game!

Thursday, April 17, 2014

The European Commission has launched its long-awaited mHealth consultation, and hinted that policy action could be forthcoming as early as 2015.

mHealth consultation launched

The European Commission has launched its long-awaited mHealth consultation, and hinted that policy action could be forthcoming as early as 2015.

European Commission vice-president Neelie Kroes was unequivocal in her support for the emerging area: “mHealth will reduce costly visits to hospitals, help citizens take charge of their own health and well-being, and move towards prevention rather than cure. It is also a great opportunity for the booming app economy and for entrepreneurs,” she said.
Outlining benefits from better use of mHealth services the Commission said the technology would: put patients in control, enabling them with greater independence and helping to prevent health problems; make healthcare systems more efficient, with huge potential for cost savings; and create opportunities for innovative services, start-ups and the app economy.
The European app economy is already worth €17.5 billion and has generated 1.8 million jobs, thus the economic issue is an important one.
In addition, the Commission says that if the full potential of mHealth is “unlocked” it could save a further €99 billion in healthcare costs across the EU, providing issues like mHealth app safety, usage of data, etc. are addressed.
It is now more than two years since the first mobile health app was registered in the UK as a medical device. Subsequent developments of significance to the Commission include strategies in the USA, where for example the FDA took a tailored approach to mobile health app regulation last year.
The three month consultation will run until July and the Commission hopes to engage with a wide variety of stakeholders, including patient organizations, healthcare professionals, app developers and mobile device manufacturers.
European Commissioner for Health, Tonio Borg said: “mHealth has a great potential to empower citizens to manage their own health and stay healthy longer, to trigger greater quality of care and comfort for patients, and to assist health professionals in their work. As such, exploring mHealth solutions can contribute to modern, efficient and sustainable health systems.”

Sunday, April 13, 2014

Nearly 9 out 10 Adults May Lack the Skills Needed to Manage their Health and Prevent Disease

What is health literacy?

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.1
Health literacy is dependent on individual and systemic factors:
  • Communication skills of lay persons and professionals
  • Lay and professional knowledge of health topics
  • Culture
  • Demands of the healthcare and public health systems
  • Demands of the situation/context
Health literacy affects people's ability to:
  • Navigate the healthcare system, including filling out complex forms and locating providers and services
  • Share personal information, such as health history, with providers
  • Engage in self-care and chronic-disease management
  • Understand mathematical concepts such as probability and risk
Health literacy includes numeracy skills. For example, calculating cholesterol and blood sugar levels, measuring medications, and understanding nutrition labels all require math skills. Choosing between health plans or comparing prescription drug coverage requires calculating premiums, copays, and deductibles.
In addition to basic literacy skills, health literacy requires knowledge of health topics. People with limited health literacy often lack knowledge or have misinformation about the body as well as the nature and causes of disease. Without this knowledge, they may not understand the relationship between lifestyle factors such as diet and exercise and various health outcomes.
Health information can overwhelm even persons with advanced literacy skills. Medical science progresses rapidly. What people may have learned about health or biology during their school years often becomes outdated or forgotten, or it is incomplete. Moreover, health information provided in a stressful or unfamiliar situation is unlikely to be retained.

Why is health literacy important?

Only 12 percent of adults have Proficient health literacy, according to the National Assessment of Adult Literacy.  In other words, nearly nine out of ten adults may lack the skills needed to manage their health and prevent disease.  Fourteen percent of adults (30 million people) have Below Basic health literacy.  These adults were more likely to report their health as poor (42 percent) and are more likely to lack health insurance (28 percent) than adults with Proficient health literacy.6
Low literacy has been linked to poor health outcomes such as higher rates of hospitalization and less frequent use of preventive services (see Fact Sheet: Health Literacy and Health Outcomes). Both of these outcomes are associated with higher healthcare costs.

Key research study findings on the relationship between health literacy and health outcomes:

Use of preventive services

According to research studies, persons with limited health literacy skills are more likely to skip important preventive measures such as mammograms, Pap smears, and flu shots.1 When compared to those with adequate health literacy skills, studies have shown that patients with limited health literacy skills enter the healthcare system when they are sicker.2

Knowledge about medical conditions and treatment

Persons with limited health literacy skills are more likely to have chronic conditions and are less able to manage them effectively. Studies have found that patients with high blood pressure,3 diabetes,3-5 asthma,6 or HIV/AIDS7-9who have limited health literacy skills have less knowledge of their illness and its management.

Rates of hospitalization

Limited health literacy skills are associated with an increase in preventable hospital visits and admissions.10-13 Studies have demonstrated a higher rate of hospitalization and use of emergency services among patients with limited literacy skills.12

Health status

Studies demonstrate that persons with limited health literacy skills are significantly more likely than persons with adequate health literacy skills to report their health as poor.10, 12 14

Healthcare costs

Persons with limited health literacy skills make greater use of services designed to treat complications of disease and less use of services designed to prevent complications.1, 11-13 Studies demonstrate a higher rate of hospitalization and use of emergency services among patients with limited health literacy skills.10-13 This higher use is associated with higher healthcare costs.15 16,

Stigma and shame

Low health literacy may also have negative psychological effects. One study found that those with limited health literacy skills reported a sense of shame about their skill level.17 As a result, they may hide reading or vocabulary difficulties to maintain their dignity.18

Partner with mHealth Games to promote health literacy and begin improving health outcomes today!

Friday, April 11, 2014

Data is at the heart of Somerset's integration masterpiece

South Somerset’s Symphony project constructs morbidity profiles for a range of long term conditions – showing the true cost and the extent of multi-morbidities. Andrew Street, Panos Kasteridis and Jeremy Martin explain
Nurse treating patient
Many people have complex and ongoing care needs and require support from multiple agencies and various professionals
Since the inception of the NHS, an ever-present challenge has been to improve integration of care within the health and social care system.
Many people have complex and ongoing care needs and require support from multiple agencies and various professionals. But care is often fragmented and uncoordinated, with no one agency taking overall responsibility, so it is often left to individuals and their families to negotiate the system as best they can.
‘It is designed to establish greater collaboration between primary, community, mental health, acute and social care, particularly for people with complex conditions’
In South Somerset, the county council, district hospital, community provider and clinical commissioning group have set up the Symphony project to develop a model of integrated care intended to both improve services and boost efficiency. It is designed to establish greater collaboration between primary, community, mental health, acute and social care, particularly for people with complex conditions.

Colloboration at heart

The project is based on the principle of collaborative care, centred on the needs of individual patients, facilitated by integrated financial arrangements and better pathway management. This means that all of the different organisations involved in delivering services will need to work together to deliver a tailored package of care.
Collaborative working is to be incentivised by a shared outcomes framework, with joint responsibility for all organisations to deliver the outcomes and linked financial structures under an “alliance contract”.
To be able to realise these ambitions, arrangements need to be targeted initially at a subset of the population that would be expected to benefit most from integrated care. We developed broad criteria to identify groups most amenable to integrated care:
  • The number in the group needs to form a sufficiently large “risk pool” so that those with high costs are offset by those with low costs.
  • To realise savings, initial focus should be directed toward groups for which current expenditure is relatively high.
  • Those using services across diverse settings are more likely to be benefit from integrated care.
  • There needs should be local consensus that changes to the care pathway are feasible.
We assessed the first three of these criteria by examining patterns of health and social care utilisation and costs for the local population of 114,874 people in 2012. The Symphony project has built a large dataset comprising information about each anonymised individual in the south Somerset population. The dataset has three key features:
  • it links acute, primary care, community, mental health and social care data;
  • costs are assigned to each individual according to the type of care they have received in each setting;
  • demographic characteristics are available for each individual, including age, gender, socio-economic measures, and indicators of morbidity.  
Each individual’s morbidity profile is constructed using United Health’s RISC tool used locally to predict unplanned hospital admissions. We identified 49 chronic conditions to construct the morbidity profile of each individual in the population. Individuals can, of course, have multiple chronic conditions.

Multi-morbidity the norm

The data reveals that for people who have a chronic condition it is unusual to have just a single condition: multi-morbidity is the norm, not the exception. Moreover, while it is well known that multi-morbidity increases with age, our analyses demonstrate that it is multi-morbidity not age that most drives health and social care costs. This insight changed the early focus of the Symphony project away from the frail elderly towards adults with multiple long term conditions.
We are also able to look at the annual costs involved in caring for people with particular conditions, according to the different health and social care settings in which they receive care. For example, figure 1 shows average cost broken down by setting for those with a selection of chronic conditions.
The average annual cost for the 45 people with occupational pulmonary disease (OPD) amounts to £14,142, with inpatient costs accounting for the largest proportion. The annual average cost for the 1,062 people with a diagnosis of dementia is £12,314, with the costs of continuing care and social care being most important.
Drilling down further, we can explore the relationship between costs and the number and type of chronic conditions that people have. The accompanying data video illustrates the analyses undertaken for people with diabetes, this being the fifth most prevalent condition in the South Somerset population (5,625 people, five per cent, with total annual costs amounting to £17m. More than 36 per cent of those with diabetes are treated in three or more settings, with inpatient care accounting for the largest proportion of costs (35 per cent), followed by social care (19 per cent) and prescribing (14 per cent).
Out of this 85 per cent of diabetics suffer from at least one other comorbidity and about 35 per cent have three or more chronic conditions. The average annual cost for someone with diabetes alone amounts to about £1,000, but costs increase progressively the more co-morbidities that a person has. We found that the number of conditions is almost as good at explaining costs as markers for particular conditions.

Cost profiles

We constructed similar morbidity and cost profiles for those with hypertension, asthma, diabetes, fractures, coronary artery disease, cancer, chronic obstructive pulmonary disease (COPD), stroke, dementia, and mental health (other than dementia). These showed multi-morbidity patterns and their relationship with utilisation and costs across health and social care settings. These profiles were shared at a workshop with local health and social care professionals and managers designed to inform the selection of the group.
Following the workshop, further analyses were conducted for those with a diagnosis of diabetes or of dementia. Futher analysis was also conducted for those with a combination of a limited set of comorbidities that local GPs viewed as most significant. These were diabetes, cardiac disease, COPD or OPD, chronic kidney disease or renal failure, depression or anxiety, dementia, stroke and cancer.
In South Somerset 1,458 people have some combination of three or more these conditions. They are older than the rest of the population (78 compared to 51 years), and have higher average annual costs (£8,152 compared to £1,094. Figure 2 shows the prevalence and costs associated with combinations of conditions among this group.
Costs involved for caring for people according to comorbidity
Figure 2: Average costs per Symphony group
The average annual cost of £8,152 is indicated by the red circle. Costs vary from the average according to particular conditions. Most notably, costs are about £14,000 if dementia is among the conditions and £12,000 if CKD/renal is a co-morbidity, but there is little difference to the overall average for the other conditions.
The project board decided that those with three or more conditions should form the initial cohort. The reasons for this included:
  • focusing on multiple conditions avoids Symphony being seen as condition or pathway specific;
  • the group of around 1,500 patients offers a reasonable high level of predictable costs variation, provides a sufficiently large risk pool and a more manageable scale than if the focus were solely on diabetes and/or dementia;
  • the group incurs costs across all settings, thereby offering the prospect of strengthening links across health, mental health and social care;
  • there is an opportunity to reduce inpatient costs, which currently account for 38 per cent of total costs;
  • it was felt possible to develop a service for complex patients, while still operating traditional models for those without diabetes or dementia.

Straightforward calculation

The dataset has made it relatively straightforward to calculate the capitated commissioning budget for this group of complex patients. The aim is to start with this initial cohort to demonstrate feasibility and improved outcomes, through the development of personalised care planning and supported self-management.
‘In many parts of the country health and social care data are not combined into a single individual-level dataset’
The hope is to move quickly to a much larger cohort including all patients with long term conditions, using the complex care team as a catalyst to spread a new culture and ethos across the whole health and social care system in south Somerset.
It is a key part of the foundations on which integrated care is being developed in south Somerset. In many parts of the country health and social care data are not combined into a single individual-level dataset.
In those areas where utilisation data have been joined together, information on costs is lacking. In south Somerset analysis of linked data about the use and costs of health and social care for the local population has made it possible to understand existing patterns of care utilisation and to identify for whom and in what way improvements can be made.
Moreover, by maintaining the dataset year on year, it will be possible to assess whether the efforts made to improve integrated care for the local population succeed in realising their ambition.
Andrew Street is professor of health economics; Panos Kasteridis is research fellow at University of York; Jeremy Martin is programme director at the symphony project