Richard Gibson MD, PhD, Research Director Gartner
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This presentation by Gartner discusses emerging consumer technologies in healthcare. It is confidential and proprietary. The presentation covers general education and triage applications, patient portals, fitness trackers, sleep and nutrition apps, remote monitoring devices, telehealth, and the value of patient engagement through technology. It argues that patients expect their providers to know their preferences and that connected technologies allow for more appropriate and engaged care.
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Richard Gibson MD, PhD, Research Director Gartner
- 1. CONFIDENTIAL AND PROPRIETARY This presentation, including any supporting materials, is owned by Gartner, Inc. and/or its affiliates and is for the sole use of the intended Gartner audience or other intended recipients. This presentation may contain information that is confidential, proprietary or otherwise legally protected, and it may not be further copied, distributed or publicly displayed without the express written permission of Gartner, Inc. or its affiliates. © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Perspectives on Emerging Consumer Technologies in Healthcare Richard Gibson MD PhD Research Director
- 2. 1 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. 0% 10% 20% 30% 40% 50% Healthcare Social & Environmental Factors Genetics Individual Behavior Contributors to Risk of Premature Death Schroeder SA 2007: NEJM. 357:1221-8.
- 3. 2 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. General Education, Reference Material, Triage Applications Photo: Sharecare.com
- 4. 3 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Healthcare Provider Applications
- 5. 4 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Patient Portals: EHR-tethered and Independent
- 6. 5 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Patients who have accessed their electronic health records YES NO Source: https://www.accenture.com/us-en/insight-research-shows-patients-united-states-want-heavy YES NO
- 7. 6 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. 82% of patients opened a least one of their notes 1-8% of the patients said the notes caused confusion, worry, offense 70-80% reported – Having better understanding – Taking better care of themselves – Feeling better prepared for visits – Feeling more in control – Taking medications better OpenNotes: Seeing the provider’s full visit note http://www.rwjf.org/en/how-we-work/grants/grantees/OpenNotes.html Robert Wood Johnson Foundation 2010 19,000 patients 105 GPs
- 8. 7 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Fitness Trackers
- 9. 8 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Fitness Wristbands Blue=Shipments in US Green=Installed Base in US Adults under age 70 with device 17% US 9% UK 5% France and Germany
- 10. 9 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Sleep and Alertness Source: neuroon.com
- 11. 10 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Nutrition, Weight, Output Source: clixlogix.com/wp-content/uploads/2015/06/imcalories.jpg
- 12. 11 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Apps used in the last year (US 2016 n=474) 0% 10% 20% 30% 40% 50% 60% Other Chronic condition management Medication tracker Health/condition tracker Patient portal app Symptom navigator Diet/Nutrition Fitness Source: https://www.accenture.com/us-en/insight-research-shows-patients-united-states-want-heavy
- 13. 12 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Getting Data by Optical Character Recognition Used with permission from Validic Pulse Blood pressure Weight Peak flow rate Blood glucose
- 14. 13 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Use Data Broker to Collect and Standardize Stream of Consumer-Collected Data Used with permission from Validic Validic Cloud Platform Health System Patient Portal
- 15. 14 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Mobile phone ECG Source: AliveCor
- 16. 15 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Mobile phone spirometer Source: Sparo Labs
- 17. 16 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Internet of Things Appliances Bed sensors Activity sensors Gait sensors Pill box dispensers RFID (radio frequency identification) enabled pills Home devices Source: informationmediary.com/ecap
- 18. 17 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Medication Adherence Source: xhale.com
- 19. 18 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Mobile device applications: Geisinger’s Rheum App – completed by patient Used with permission from Geisinger Health System
- 20. 19 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Autism and Apple’s ResearchKit Source: autismandbeyond.researchkit.duke.edu
- 21. 20 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Use of Electronic Health Tools 0% 10% 20% 30% 40% 50% 60% None Other Remote monitoring Online support communities Remote consultation Smart scales Social media Wearable technology Electronic health records Mobile phone/tablet app Websites 2016 2014 Source: accenture.com/us-en/insight-research-shows-patients-united-states-want-heavy
- 22. 21 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Office Visits vs Virtual Visits Kaiser Permanente Northern Calif 2008-2013 http://www.californiahealthline.org/picture-of-health/2014/how-many-virtual-doctor- visits-were-conducted-at-kaiser-permanente-northern-california
- 23. 22 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Video Visits: In-network, pre-arranged
- 24. 23 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Video Visits: Retail, on-demand Source: American Well
- 25. 24 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved.marketresearchstore.com/news/global-telemedicine-market-set-for-rapid-growth-to-118 $14B $35B
- 26. 25 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Home Diagnostic Station Source: Coaguchek.com Source: ptsdiagnostics.com INR (anti-coagulation) Hemoglobin A1C cholesterol
- 27. 26 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Precision Medicine Initiative
- 28. 27 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Patients expect their providers to know their preferences Patients will provide a better history when they have time at home In value-based payment, care can be delivered by most appropriate method If they care enough to send in readings, they are going to take care of themselves Tech allows family & friends to provide care and interact with professional team Better community care requires a connected patient Patient engagement leads to loyalty Summary: What is the value of Patient Engagement?
- 29. 28 © 2016 Gartner, Inc. and/or its affiliates. All rights reserved. Gartner delivers the technology-related insight necessary for our clients to make the right decisions, every day. Perspectives on Emerging Consumer Technologies in Healthcare Richard Gibson MD PhD Research Director Thank you!
Editor's Notes
- Presenter's Name Presenter's Name
- One of the most important conclusions from this slide is that most of the discussion about improving health has been about the sector that has the least impact on premature death: health care. In the US that is a $3 trillion dollar question. I am in favor of consumer, member, and patient engagement but we need to remember that social and environmental factors are responsible for twice the amount of premature death as healthcare. One wonders what the price tag would be for that improving social and environmental factors. It has been known for years that personal habits are the greatest single determinant of health and disease. Precision medicine research will track individuals’ habits and correlate them with outcomes. As we move to move value-based payment, it will be important to bring the patient onboard in managing their habits. As the proportion of the population that has their genome recorded, more people will find evidence that they are at risk for certain diseases. We will learn more about the interaction of genetics with the effects of the environment and personal habits. If a person knows that their genetics predispose them to a certain illness and that a change in personal habits may decrease the likelihood of an unfavorable outcome, more people are likely to get involved in managing their individual behavior.
- Many general medical information sites have been available on the Internet for years but they are still useful. Further they can be combined with patient portals, proprietary tools, and other applications for increased benefit. Encyclopedic sites for explanation of symptoms, conditions, diagnostic studies, medications, procedures, and other treatments Symptom checkers and triage advisors: should I be worried? Do I need to go to the Emergency Department? A recent article in the BMJ reviewed some of these applications and found that they tend to err on the site of caution. Study used 45 standardized patient vignettes and looked at triage advice: 1) seek immediate care; 2) seek non-emergency evaluation; and 3) proceed with self-care. Triage advice was judged correct 57% of the time, with an over-emphasis of recommending immediate care. Care must be taken to NOT provide diagnosis because that gets careful review by government agencies. MelApp tried to categorize assessment of moles based on size, asymmetry, border irregularity, color, changing appearance (https://www.ftc.gov/enforcement/cases-proceedings/132-3211/health-discovery-corporation-melapp-matter) and recommended professional appraisal. But it was never tested and the FTC stopped them and fined them. But these applications are coming back with increased testing and formal review.
- Healthcare providers and payers can license proprietary healthcare encyclopedias for use of their members. In addition they can provide provider biographies and referrals based on a number of criteria including proximity, gender, near-term availability, languages spoken, specialty, narrow subspecialties, and the like. Providers can link laboratory test results to specific encyclopedia entries. If a symptom-checker or triage advice application is used, the provider can offer appointment slots in regular offices, urgent care, or can suggest emergency departments. If urgent care or emergency department visits are suggested their web site or mobile app can show driving directions and wait times. Wayfinding inside the hospital: This ecosystem includes technologies such as indoor GPS and mapping, mapping apps, location and condition sensing technologies, parking management systems, and mobile phone applications to show emergency department and urgent care wait times and to offer referral physicians.
- Although this technology has been around for 15 years, I think it is useful to start here because it is still powerful. By EHR-tethered I am referring to the patient portals that come with an enterprise EHR that give a view of the professional EHR to patients. Some of the pros of EHR-tethered patient portals: Access to formal diagnoses and medication names You can request refills You can schedule appointments You can ask questions of staff and providers Some of the cons of EHR-tethered patient portals: Only covers care at that office or facility or business group May not have much ability to enter your own data May not be able to link your record with your EHR entries at other facilities
- This was an study started in 2010 and sponsored by the Robert Wood Johnson foundation that looked at the effects of providers putting their full clinic visit notes online in the EHR patient portal instead of just diagnosis, medications, vital signs, and the like. It involved more than 19,000 patients and 105 Primary Care Providers in Boston, Seattle, and rural Pennsylvania. 82% of patients opened a least one of their notes A small number of the patients said that the notes caused confusion, worry, or offense 70-80% reported Having better understanding Taking better care of themselves Feeling better prepared for visits Feeling more in control Taking medications better Close to 100% of patients and providers wanted to continue with OpenNotes Currently there are about 6 million patients registered on portals that provide access to full notes The effort has just received another $10 million of funding
- People track their number of steps and stairs climbed in a day – sometimes with accelerometers in their Apple Watches and Fitbits and sometimes with more accurate geo-tracking apps on their mobile phones. This is augmented with sensors in their shoes and clothing. In 2014 Fitbit held 76% of the fitness tracker market. But only half of Fitbit’s 20 million registered users were still active as of First Quarter 2015. (http://www.startribune.com/strong-sales-but-high-abandonment-for-fitness-trackers/312734521/) John Hancock Life Insurance policyholders can earn up to a 15% discount on premiums if they automatically upload their exercise data to the insurer. (Gartner G00272036). Fitbit and other companies have platforms that are HIPAA-compliant so that wellness companies don’t have to implement extra data protection themselves. Smart Wristbands could be replaced by Sports Watches, Smartwatches, Head Mounted Displays, Smart Shirts, and Smart Socks.
- The blue columns show the shipments in each year. The green columns show the total installed base. Which is expected to reach 130 million units by 2020 in the US. In the US 17% of adults under 70 had such a device. 9% in UK, 5% in Germany and France.
- Consumers can track their sleep and alertness with motion detectors on their wrists and on their beds and brain wave detectors on their foreheads and temples.
- Movement detectors like Fitbit and geotracking applications like Strava estimate caloric output based on body weight, distance, speed, and elevation change. Other apps can record what people eat and mobile apps can estimate caloric intake from photos. Bluetooth-connected scales can record weight.
- Many of the personal and home devices are connected by Bluetooth. But even if they aren’t applications can convert a photo taken of the device screen to numbers that can be entered into the application.
- Although it is a side feature of patient engagement, many of the devices and applications we discussed today will be collecting data that could be useful to Providers and Payers. Gartner recommends that its clients look to join forces with a data broker who can interface with devices and applications and keep up with connecting to the fast changing technology. Companies like Validic and Payoda. They will cleanse and pre-process the data and supply standardized data through a single, organized interface to the EHR or analytics systems. Continua Health Alliance organizes health systems, technology manufacturers, and fitness companies to select one set of connectivity standards and to identify and close connectivity gaps. Their website (http://www.continuaalliance.org/node/77) shows 73 vendors or products as certified. The Alliance has some big names participating. Board of Directors come from Fujitsu, Intel, Oracle, Orange, Partners HealthCare Center for Connected Health, Philips, Qualcomm, Roche Diagnostics, Samsung Electronics, Sharp and UnitedHealth Group.
- AliveCor’s cardiac monitor snaps on the back of the iPhone and captures a single-lead waveform. It can then upload a secure image to the cloud in PDF format. This will certainly have an effect on the current ambulatory ECG monitoring business. Challenge of capturing the cardiac rhythm when you are having symptoms. With a mobile phone always nearby, it is more likely we will catch evidence of dysrhythmias. This month in the PeerJ online journal, Eric Topol MD et al published a study looking at 160 people with HTN, DM, and cardiac arrhythmia. Study group was given a connected BP machine, a glucometer, or this cardiac arrhythmia detector, plus a wellness program with frequent check ins for 6 months. Result: No difference in short-term health services spending. The study group felt a little more that their health was not due to chance.
- Here is a lung volume meter by Sparo Labs. To my knowledge, it is not yet released. Of course symptoms of wheezing and shortness of breath are important to assessing the severity of asthma exacerbations, but the single best way to know how much trouble someone is in is the Peak Flow. Peak flow or Forced Expiratory Volume is the most objective way to determine asthmatic status and the need for continued home treatment vs the need for emergency intervention.
- The Internet of Things refers to devices, appliances, and many other objects in our homes and offices that are able to send and receive information wirelessly. A number of those devices are of interest in healthcare. There are a range of devices placed about the home that can help monitor conditions or detect onset of conditions. The dramatically growing Internet of Things will make it easier to network home devices within a healthcare application. Various appliances around the home such as the refrigerator or closet can detect a change in a person’s typical daily pattern. This could be used as an early warning signal that someone’s activity is diminishing and allow prompt diagnosis and intervention. Bed sensors could detect someone who is not getting up as expected or not sufficiently changing positon in bed putting them at risk for skin breakdown. Sensors in the floor can track gait – not only a proxy for activity – but also more specifically noting subtle changes in gait that might be suggestive of stroke, vertigo, or other central nervous system dysfunction. Electronically monitored pill dispensers can determine if someone is taking their medication on time or even taking their medication at all. RFID-enabled pills can track whether the pill, which left the pill box, actually made it into the gastrointestinal tract.
- This is from Geisinger Health System in Pennsylvania. On a touch screen, the patient fills in their own assessment of their symptoms such as joint stiffness, joint swelling, pain, and fatigue. The data are then moved by a interface into Cerner, Epic, and Allscripts EHRs. Considering other mobile applications: Some of these are purely applications on the mobile phone. Others collect data from some other personal device and allow interaction with the user. Depression monitors work based on use of the phone, use of the Internet, choice of words in social media, and speech patterns. Medication effect and side effect trackers involve patient data entry. A company called Ayasdi and the Michael J Fox Foundation are using the mobile phone to detect and monitor tremor.
- This chart shows virtual visits significantly increasing while in-person visits hold steady. They liberally define “virtual visits” as any telephone conversation or secure email. Kaiser states that in 2016, their Northern California region virtual visits are expected to outnumber in-person visits. (http://www.modernhealthcare.com/article/20141204/BLOG/312049976 As noted with eVisits, there is concern that the growing diversity in telehealth platforms may disrupt the maintenance of a complete record in the EHR of the patient’s regular provider or providers. Of course many patients are seen by providers on multiple, different office EHRs where that problem persists even without eVisits. Suffice it to say that we need to strive to make the information in the patient’s regular EHR available to the eVisit provider. When the eVisit is concluded, the patient’s regular EHR needs to be updated. This ideal state will be not be fully realized until we solve the interoperability problem.
- The categorization of “in-network and pre-arranged” is meant to distinguish the video visit from a spur-of-the-moment request for a retail consultation with a provider across the county. By “in-network” we mean concurrent video visits with providers that the patient usually sees, or in the network of providers usually referred by the patient’s primary provider. It also refers to specialty video services previously contracted for by two provider parties, such as in telestroke. In fact telestroke was the earliest and most-widely adopted form of video visit. It became valuable because of the importance of administering a clot-dissolving drug within minutes of the onset of stroke symptoms. Some stroke symptoms can be subtle and it has been shown that telestroke neurologists produce excellent results when a local stroke expert is not available. After a telestroke video visit and an imaging study to rule out brain bleeding, the drug can be administered in the rural hospital. In one health system’s experience, about 70% of the telestroke patients treated this way were able to remain in the rural hospital. The other 30% had complications requiring transfer to a stroke center. In general, the patient and the family are satisfied because they can stay local knowing that appropriate expertise has been accessed. The patient is treated sooner and has a better chance for recovery. Teledermatology is also gaining traction, especially in providing dermatologist care in a hospital where few dermatologists visit. Studies in that context have shown about 95% of the treatments are the same whether the inpatient dermatology consult is provided in person or via video. Obviously presenting cases needing biopsy for diagnosis are not suitable for a video visit. Telepharmacy allows a licensed pharmacists to dispense inpatient medications in smaller hospitals where pharmacists may not be available 7x24. Telepsychology visits have been shown to be useful in cases of suspected child abuse where experts are not immediately available in rural areas. Video visits are also widely used in other psychiatric settings. Rural patients getting surgery in the city can follow-up with their surgeon by video without having to make a long trip. Patients with severe trauma and burns can be assessed for need for transport to a higher level facility and in a substantial number of cases, an expensive and inconvenient transfer can be avoided. Hospital-to-hospital video visits can also evaluate the need for transfer for seriously ill newborns and children. Currently Medicare covers telehealth visits only when the patient is in a rural Health Professional Shortage Area. Telehealth in general has not yet been demonstrated to save costs.
- The typical product here is a website where a licensed physician can be brought online for a video visit within a few minutes of a patient request. This service is likely to be provided by a physician at some geographic distance from the patient. No previous relationship is required. Visits are typically short and some health insurers now pay for these relatively inexpensive visits, expecting to decrease the number of expensive emergency department visits. Successful retail video visit providers will need sophisticated scheduling and queuing functions. This takes scale so that there are sufficient available providers so that the patient is not kept waiting too long. Again the issue of continuity of care is present and is made even more difficult because the retail video visit provider is unlikely to have access to the patient’s regular EHR. Ideally a summary of the visit would be sent to the patient’s regular provider. Of course most retail video visit providers are either currently doing or planning to do these consultations using the patient’s mobile phone.
- 14% CAGR
- It isn’t too much of a stretch to imagine a plug-in USB stethoscope that would help make the diagnosis of pneumonia at home in someone with a bad cough. Ear cameras are already available that would make the diagnosis of otitis media in a toddler. The same camera viewing the throat could distinguish tonsillar swelling from other kinds of sore throat. With the miniaturization of blood droplet analyzers we can expect many common blood and urine tests to be done at home. Drug levels run at home would offer huge convenience to patients on chronic therapy. A video visit with a mobile phone heart tracing and cardiac enzymes run at home might be able to avoid some ED visits for chest pain. Mobile phone apps requiring coordination, speaking, naming things, and memory might be able to diagnose subtle stroke at home.
- President Obama’s Precision Medicine Initiative is probably the premier consumer engagement effort existing today. With $215 million in funding for 2016 the project intends to sign up 1 million individuals over 3-4 years. The volunteers will receive a history and physical exam, blood work, and submit a sample for genome analysis. The projects aims to collect data about the volunteer’s environment, exposures, and personal habits, which will probably involve substantial use of a mobile phone. Diversity in age, gender, health conditions, ethnic backgrounds, occupation, geography, and socio-economic status is essential to give the big data computing project the best chance of discovering the links to health and disease among genetics, environment, and personal habits.
- If you are a Provider or Payer, you need to figure out what you want to achieve with consumer, member, and patient engagement. A Payer may want to promote healthy habits among its membership with fitness devices, mobile phone reminder apps, and mobile phone video visits. As a Provider, perhaps you are looking for patient loyalty and stickiness. In addition to superior clinical outcomes, you want to provide a delightful patient experience, which can start with wayfinding. As discussed previously, there is a lot we can do to increase shared decision-making between provider and patient.
- So, remember the challenge of kids with asthma that I faced in Forks, Washington? Well now, those families might have a spirometer connected to their mom’s mobile phone and a telemedicine application on that mobile phone so I could see the child on my screen. All of us, mother, child, and doctor would feel better knowing that this time, the child was safe to stay at home with increased treatment at home. No unnecessary ED visits after long car rides. We would like to extend that vision to many parts of healthcare. Thank you.