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The Promise of Patient Self-Monitoring: An App a Day Won’t Necessarily Keep the Doctor Away
EDITORIAL The Promise of Patient Self-Monitoring: An App a Day Won’t Necessarily Keep the Doctor Away n finance, “beta” is a measure of a stock’s volatility in relation to the market.1 By definition, the market has a beta of 1.0, and individual stocks are ranked according to how much they deviate from the market. A stock that swings more than the market over time has a beta above 1.0. Because beta is a measure of risk, a beta greater than 1 generally means that the asset is volatile. All chronic diseases are not alike. Some, such as diabetes mellitus and hypertension, can be slow and indolent in the expression of their symptoms and morbidities, which we term as “low-beta” diseases. Other conditions, such as inflammatory bowel disease and cirrhosis with encephalopathy, are “high-beta” conditions that are not as forgiving in their disease progression.2,3 Often patients with chronic disease surface only when they recognize that they are in trouble and realize that they cannot repair their situation themselves. The difference is that patients with high-beta diseases can rapidly deteriorate, resulting in hospitalization and complications.4,5 For example, patients with inflammatory bowel disease are typically of young age and frequently minimize their own deteriorating symptoms; as a result, they may present too late at which time morbidity has occurred and significant medical and/or surgical care must be provided. Ranking patients with chronic diseases according to their beta can help the physician to identify those conditions that require more than a passive approach to medical care. For decades, most physicians have not been at financial risk. The traditional practice business model has been “passive–reactive,” waiting for patients to contact the physician with new or intensifying symptoms. This traditional practice model rewards physicians based on relative value units billed, one where the relative value unit/minute is greater for procedural compared with cognitive services. The passage of the Patient Protection and Affordable Care Act (Public Law 111-148)6 as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152)7 has led to significant changes in the provision of and payment for health care. Slowly but surely, the delivery of health care is being restructured as hospitals merge, physicians join with others and/or are acquired, and procedural services are revalued downward. Along with this has been the rise of population health, defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”8 In early 2015, the Centers for Medicare and Medicaid Services announced that the goal of the
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Department of Health and Human Services is for 50% of Medicare payments in alternative payment models by the end of 2018 to be achieved through investment in alternative payment models, advanced primary care medical home models, new models of bundling payments for episodes of care, and integrated care demonstrations for Medicare-Medicaid enrollees.9 The passage of the Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114-10)10 adds a value-based risk component to population health. In order for physicians to thrive under this new framework, the passive–reactive model must evolve into an anticipatory–interactive model. Along with this change in how physicians are reimbursed has been an explosive growth in information technology and consumerism. Rather than managing individual patients when they get sick, the thought has been that if patients are engaged in their own health, outcomes will improve. Managing an entire patient population, with the goal of minimizing costly interventions, such as emergency department visits, hospitalizations, imaging tests, and surgery, requires methods to effectively reach those patients who generate most health costs, and to focus on prevention and the challenges of chronic illness.11 How gastroenterologists restructure their practices in response to these changes, risk-stratifying their patients according to the beta of each patient’s disease and proactively implementing outreach as appropriate, will be a significant differentiating factor in whether gastrointestinal practices can maintain their independence. Riaz and Atreja12 present a comprehensive review of personalized technologies in chronic gastrointestinal disorders with an emphasis on self-monitoring. More than two-thirds of Americans are interested in using mobile phones and health apps to maintain their health and almost 80% are willing to use wearable devices and remote health sensors. With more than 165,000 Android and iOS apps dedicated to mobile health, the authors present an innovative schematic of the journey of a patient with newly diagnosed inflammatory bowel disease and how the patient is able to access various resources seamlessly delivered remotely through mobile apps, telemedicine, and sensors, enabling the patient to become a more engaged health consumer. The authors have developed HealthPromise, an app that helps to track patient’s symptoms, quality of life, follow-up, and interventions in real time and provides point-of-care interventions from physicians. Tools such as this that incorporate remote patient monitoring are on the cutting edge of patient engagement, leading the patient to be an active participant in their own health. Van Deen et al13 present the results of a prospective observational study, collecting data from patients with Crohn’s disease and ulcerative colitis to develop and Clinical Gastroenterology and Hepatology 2016;14:1751–1752
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validate a set of questions and a scoring system to monitor disease activity remotely using mobile technologies. Patient-reported disease activity was shown to be an independent predictor for clinical disease activity and symptom changes in both groups of patients. Ulcerative colitis clinical disease activity highly correlated with endoscopic disease activity, whereas correlation between Crohn’s disease symptoms and endoscopic findings was poor. Despite intensive follow-up by dedicated nurse care managers, completion rate of laboratory and stool testing was 48%, emphasizing that patient engagement and compliance must be maintained if remote health monitoring is to be successful. This is clearly a new age in patient care, one that will be highly dependent on the assessment of the beta risk of the individual patient, and how that drives the use of mobile health technology. Simply engaging patients with smart phones, wearable sensors, and telehealth is not enough, however, if there is no evidence that these efforts lead to an improvement in health outcomes, avoidance of potentially avoidable complications and unnecessary services, and an overall decrease in the cost of care. To succeed and to provide value to physicians and healthcare professionals, health apps must be integrated with the provision of care; otherwise, the data they produce and the opportunity they present are lost. LAWRENCE KOSINSKI, MD, MBA Illinois Gastroenterology Group Elgin, Illinois JOEL V. BRILL, MD Predictive Health, LLC Paradise Valley, Arizona
References 1. Sharpe W. Portfolio theory and capital markets. New York: McGraw Hill, 1970. 2. Natarajan Y, Kanwal F. Pay for performance in chronic liver disease. Clin Gastroenterol Hepatol 2015;13:2042–2047.
3. Fortune BE, Golus A, Barsky CL, et al. Linking a hepatology clinical service line to quality improvement. Clin Gastroenterol Hepatol 2015;13:1391–1395. 4. American Hospital Association. Examining the drivers of readmissions and reducing unnecessary readmissions for better patient care. Washington, DC: American Hospital Association Trendwatch, 2011. 5. Hines AL, Barrett ML, Jiang HJ, et al. Conditions with the largest number of adult hospital readmissions by payer:HCUP Statistical Brief #172. April 2014. Rockville, MD: Agency for Healthcare Research and Quality, 2011. 6. Available at: https://www.gpo.gov/fdsys/granule/PLAW-111publ 148/PLAW-111publ148/content-detail.html. Accessed August 5, 2016. 7. Available at: https://www.gpo.gov/fdsys/pkg/PLAW-111publ152/ content-detail.html. Accessed August 5, 2016. 8. Kindig D, Stoddart G. What is population health? Am J Public Health 2003;93:380–383. 9. Available at: https://www.cms.gov/Newsroom/MediaRelease Database/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3. html. Accessed August 5, 2016. 10. Available at: https://www.gpo.gov/fdsys/pkg/PLAW-114publ10/ html/PLAW-114publ10.htm. Accessed August 5, 2016. 11. Population health management: a roadmap for provider-based automation in a new era of healthcare. New York: Institute For Health Technology Transformation, 2012. 12. Riaz MS, Atreja A. Personalized technologies in chronic gastrointestinal disorders: self-monitoring and remote sensor technologies. Clin Gastroenterol Hepatol 2016;14:1697–1705. 13. Van Deen WK, van der Meulen-de Jong AE, Parekh NK, et al. Development and validation of an inflammatory bowel diseases monitoring index for use with mobile health technologies. Clin Gastroenterol Hepatol 2016;14:1742–1750.
Conflicts of interest The authors disclose the following conflicts: Lawrence Kosinski reports ownership and governance with SonarMD, and is Chief Medical Officer of Mutare Health. Joel V. Brill reports options and governance with SonarMD, options and consulting with Endochoice Holdings, Inc, consulting with FAIR Health, and options and consulting with GeneNews. Most current article http://dx.doi.org/10.1016/j.cgh.2016.08.010
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Department of Health and Human Services is for 50% of Medicare payments in alternative payment models by the end of 2018 to be achieved through investment in alternative payment models, advanced primary care medical home models, new models of bundling payments for episodes of care, and integrated care demonstrations for Medicare-Medicaid enrollees.9 The passage of the Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114-10)10 adds a value-based risk component to population health. In order for physicians to thrive under this new framework, the passive–reactive model must evolve into an anticipatory–interactive model. Along with this change in how physicians are reimbursed has been an explosive growth in information technology and consumerism. Rather than managing individual patients when they get sick, the thought has been that if patients are engaged in their own health, outcomes will improve. Managing an entire patient population, with the goal of minimizing costly interventions, such as emergency department visits, hospitalizations, imaging tests, and surgery, requires methods to effectively reach those patients who generate most health costs, and to focus on prevention and the challenges of chronic illness.11 How gastroenterologists restructure their practices in response to these changes, risk-stratifying their patients according to the beta of each patient’s disease and proactively implementing outreach as appropriate, will be a significant differentiating factor in whether gastrointestinal practices can maintain their independence. Riaz and Atreja12 present a comprehensive review of personalized technologies in chronic gastrointestinal disorders with an emphasis on self-monitoring. More than two-thirds of Americans are interested in using mobile phones and health apps to maintain their health and almost 80% are willing to use wearable devices and remote health sensors. With more than 165,000 Android and iOS apps dedicated to mobile health, the authors present an innovative schematic of the journey of a patient with newly diagnosed inflammatory bowel disease and how the patient is able to access various resources seamlessly delivered remotely through mobile apps, telemedicine, and sensors, enabling the patient to become a more engaged health consumer. The authors have developed HealthPromise, an app that helps to track patient’s symptoms, quality of life, follow-up, and interventions in real time and provides point-of-care interventions from physicians. Tools such as this that incorporate remote patient monitoring are on the cutting edge of patient engagement, leading the patient to be an active participant in their own health. Van Deen et al13 present the results of a prospective observational study, collecting data from patients with Crohn’s disease and ulcerative colitis to develop and Clinical Gastroenterology and Hepatology 2016;14:1751–1752
1752 Kosinski and Brill
Clinical Gastroenterology and Hepatology Vol. 14, No. 12
validate a set of questions and a scoring system to monitor disease activity remotely using mobile technologies. Patient-reported disease activity was shown to be an independent predictor for clinical disease activity and symptom changes in both groups of patients. Ulcerative colitis clinical disease activity highly correlated with endoscopic disease activity, whereas correlation between Crohn’s disease symptoms and endoscopic findings was poor. Despite intensive follow-up by dedicated nurse care managers, completion rate of laboratory and stool testing was 48%, emphasizing that patient engagement and compliance must be maintained if remote health monitoring is to be successful. This is clearly a new age in patient care, one that will be highly dependent on the assessment of the beta risk of the individual patient, and how that drives the use of mobile health technology. Simply engaging patients with smart phones, wearable sensors, and telehealth is not enough, however, if there is no evidence that these efforts lead to an improvement in health outcomes, avoidance of potentially avoidable complications and unnecessary services, and an overall decrease in the cost of care. To succeed and to provide value to physicians and healthcare professionals, health apps must be integrated with the provision of care; otherwise, the data they produce and the opportunity they present are lost. LAWRENCE KOSINSKI, MD, MBA Illinois Gastroenterology Group Elgin, Illinois JOEL V. BRILL, MD Predictive Health, LLC Paradise Valley, Arizona
References 1. Sharpe W. Portfolio theory and capital markets. New York: McGraw Hill, 1970. 2. Natarajan Y, Kanwal F. Pay for performance in chronic liver disease. Clin Gastroenterol Hepatol 2015;13:2042–2047.
3. Fortune BE, Golus A, Barsky CL, et al. Linking a hepatology clinical service line to quality improvement. Clin Gastroenterol Hepatol 2015;13:1391–1395. 4. American Hospital Association. Examining the drivers of readmissions and reducing unnecessary readmissions for better patient care. Washington, DC: American Hospital Association Trendwatch, 2011. 5. Hines AL, Barrett ML, Jiang HJ, et al. Conditions with the largest number of adult hospital readmissions by payer:HCUP Statistical Brief #172. April 2014. Rockville, MD: Agency for Healthcare Research and Quality, 2011. 6. Available at: https://www.gpo.gov/fdsys/granule/PLAW-111publ 148/PLAW-111publ148/content-detail.html. Accessed August 5, 2016. 7. Available at: https://www.gpo.gov/fdsys/pkg/PLAW-111publ152/ content-detail.html. Accessed August 5, 2016. 8. Kindig D, Stoddart G. What is population health? Am J Public Health 2003;93:380–383. 9. Available at: https://www.cms.gov/Newsroom/MediaRelease Database/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3. html. Accessed August 5, 2016. 10. Available at: https://www.gpo.gov/fdsys/pkg/PLAW-114publ10/ html/PLAW-114publ10.htm. Accessed August 5, 2016. 11. Population health management: a roadmap for provider-based automation in a new era of healthcare. New York: Institute For Health Technology Transformation, 2012. 12. Riaz MS, Atreja A. Personalized technologies in chronic gastrointestinal disorders: self-monitoring and remote sensor technologies. Clin Gastroenterol Hepatol 2016;14:1697–1705. 13. Van Deen WK, van der Meulen-de Jong AE, Parekh NK, et al. Development and validation of an inflammatory bowel diseases monitoring index for use with mobile health technologies. Clin Gastroenterol Hepatol 2016;14:1742–1750.
Conflicts of interest The authors disclose the following conflicts: Lawrence Kosinski reports ownership and governance with SonarMD, and is Chief Medical Officer of Mutare Health. Joel V. Brill reports options and governance with SonarMD, options and consulting with Endochoice Holdings, Inc, consulting with FAIR Health, and options and consulting with GeneNews. Most current article http://dx.doi.org/10.1016/j.cgh.2016.08.010