Dave deBronkart or ‘epatient Dave’ who I have the had the honor of meeting, is an extraordinary man and inspires millions of people around the globe with his amazing saga of conquest over cancer, after having been given the grim prognosis of “you have 24 weeks to live”. Dave is the quintessential ‘ePatient’ and has been a personal source of inspiration for me.
So who precisely is an ePatient*?
The Society and the Journal of Participatory Medicine define ePatients* as “individuals who are equipped, enabled, empowered and engaged actively with their physicians in their healthcare decisions“, with the express objective of improving their relationships with their doctors and the quality of healthcare services they receive to improve outcomes.
For most of us this is aspirational and easier said than done. As one of the earliest adopters of the Microsoft Health Vault quoted in the Washington Post way back in 2008, I have written extensively about my personal experience with Personal Health Records (PHRs) and the adoption challenges daunting patients in my blog.
The Psychology of Patient Adoption and why most new Products and Services fail to win Mind and Market Share
The life-cycle of PHRs and their less than stellar adoption are well understood when viewed thru the seminal lenses of ’Eager Buyers and Stony Sellers – Understanding the Psychology of New Product Adoption’ by John T. Gourville, Harvard Business Review (HBR), June 2006, via this 2×2 matrix below.
Gourville argues that the greater the level of change in customer behavior demanded by a new product or service, the greater the barrier to customer adoption,despite the hype and ‘value promise’ offered by the new product or technology.
Gourville further makes the point that ‘producers of innovation’ often overestimate customer adoption by a factor of 3X while consumers au contraire, allocate significant value to their current product or service that is often 3X over and above the new product or service being offered.
According to him, for most mainstream customers to adopt new innovation, they demand a value proposition that is virtually 9 -10X times that is delivered by their current product or service, to justify their ‘switching costs’, that most innovators or vendors are oblivious to! This is often why over 70-80% of new technology or software products fail to ‘cross the chasm’ into the mainstream market!
The Life Cycle of Personal Health Record (PHR) Adoption – from the Microsoft Health Vault to Apple Health and the Apple Watch
Let us apply this framework to the PHR adoption life cycle, shown in the figure above.
SURE FAILURES (High change in customer behavior needed for low perceived benefits): Early PHRs like Microsoft Health Vault, Dossia and Google Health (now defunct) have not seen stellar adoption, since they demanded significant changes in behavior (collect paper based records, scan and upload them, manually enter data that was hard to retrieve) from patients. Adoption was also severely impeded by what I have referred to as the ‘Adoption Paradox’ i.e. the old and the ill who needed PHRs the most were often the most technologically challenged to adopt them.
LONG HAULS (High change in customer behavior needed for relatively high benefits over the long term): Microsoft had indeed impressed me with their persistence re: the Health Vault and have significantly innovated to deliver a level of interoperability and integration with EMRs, PHRs and wearables that have driven up adoption, but not proportionate to the investments made and expectations (have never seen Health Vault adoption numbers from Microsoft, have you?!).
EASY SELLS (Low Change in Customer Behavior needed with modest benefits):Arguably, the only PHR that has seen adoption in the millions is Kaiser Permanente’s My Health Manager. My Health Manager, Kaiser’s PHR, is linked to its electronic health record and contains a subset of the clinical data in the EHR. Kaiser Permanente HealthConnect® securely links data for 9.1 million patients and 16,000 physicians in more than 600 medical offices and 38 hospitals.
The PHR also offers Web portal features such as the ability to request prescription refills and appointments, view lab results, and have e-mail consultations with physicians. More than 63% of eligible Kaiser members use My Health Manager. According to Terhilda Garrido, VP of health IT transformation and analytics, in an interview with InformationWeek Healthcare, “Patients value and love the convenience of having their own information readily available to them at any point in time from wherever they want to have it”.
Through My Health Manager, members can view their medical record, email their providers, check lab test results, order prescription refills, and manage appointments from their computers or handheld devices. The benefits of My Health Manager adoption go beyond member loyalty. According to a 2011 Kaiser Permanente study,nine out of 10 patients with chronic conditions agreed the website enables them to more effectively manage their conditions. Patients also reported that the website helps them make informed decisions about their health and makes it more convenient for them to interact with their care teams.
This is an amazing value proposition for Kaiser Permanente’s ePatients, but what about the rest of the US patient population, especially ‘Patients like us‘?
What are the key challenges to PHR adoption for the rest of us?
* Ease of data capture and data entry
* Interoperability with EMRs and EHRs like Cerner, EPIC, MEDITECH et al, as well as the plethora of wearables in the market like Fitbit, Garmin, Pebble, et al
* Analytics to enable self-service data discovery and visualization to provide meaningful and actionable insights to patients to change unhealthy behaviors like smoking, diet and lack of exercise.
Given the proliferation of mHealth apps addressed in one of my earlier blogposts,one of the earliest apps that endeavored to address the data capture, data entry and to a certain extent, the device interoperability and personal data visualization challenges was Tactio Health from Montreal, Canada. They offered iOS and Android based health apps that enabled patients to capture data from wearable devices like Fitbits, certified blood pressure monitors and weighing scales and display the data on a personal health dashboard in a meaningful way. Tactio Health also enabled reporting of this data thru a printable PDF that one could share with their doctors in a face to face conversation. However, given lack of EMR/EHR integration, Tactio Health’s PHR adoption has been far from spectacular, leading them to reposition themselves as a ‘remote patient monitoring systems vendor using mHealth apps and off-the-shelf connected health devices’.
Will Apple crack the code on the ‘last mile to the patient’ PHR adoption to truly empower ePatients for Personal Health Management?
SMASH HITS (Low Change in Customer Behavior needed with significant and measurable benefits offered): It is my prognosis and vision that the new Apple Health app (bundled with iOS 8) built on the Apple Health Kit platform for interoperability with EMRs and devices and wearables, coupled with the soon-to-be-introduced Apple Watch will effectively address the ‘last mile to the Patient’ barriers and deliver a ‘Smash Hit’ thru wide spread adoption from Patients like us.
Why drives my confidence in the Apple Health Platform, app and watch? Having experienced every generation of PHR solution, mhealth device and app that was introduced with much hype and fanfare only to join the ranks of the ‘Long Hauls’ like the Samsung Gear Fit and many others. The Samsung Gear Fit had an amazing form factor, had a heart rate monitor built in and could precisely tell me the number of steps I had walked every day, but alas offering little by way of a personal health dashboard for me to manage my health thru data driven insights.
* Ease of data capture and data entry enabled thru both pre-built device and integration with most wearable devices in the marketplace via the Apple Health Kit, but also the ability to directly enter data into the iPhone App or set fitness goals on the Apple Watch with the ease and simplicity one anticipates from Apple.
* Interoperability with PHRs, EHRs, EMRs and other mHealth Apps enabled thru pre-built integration with EPIC and its myChart Patient Portal for instance, but also assuring complete control to the patient. For instance, I can choose to share only my blood pressure and cholesterol data with my doctor, with all of my health data securely backed up in the iCloud and protected via biometric sensing on my iphone. The Mayo Clinic Health app leverages Apple Health for selective, secure data sharing with their EHR while empowering patients for personal health management (see screenshot below).
* Analytics and visualization via the Personal Health Dashboard embedded within the Apple Health app on the iPhone (it is time to extend this to iPads as well) albeit limited is far better than anything I have seen or experienced in the marketplace thus far. Apple Health on the Apple Watch enables people to select their fitness activity, set measurable goals and track them through out the day. GPS and Wi-Fi integration with the personal health dashboard on the iPhone enables visualization of one’s performance against those goals over time, and report on these for meaningful engagements with doctors, caregivers and family. Sophisticated self-service data discovery and visualization capabilities are lacking today, but does not preclude the patient from leveraging best in class solutions like Tableau and similar platforms to become‘true data and insights driven ePatients’.
Apple’s Vision of becoming ‘the mHealth Solution of Choice for Personal Health Management’
Apple understands and appreciates the ‘Psychology of Customer Adoption’ better than any company on earth. This is the legacy and leadership of Steve Jobs that has culminated in Apple becoming ‘the most valuable brand on the planet’ and amply evidenced by their financial performance.This paradigm and their approach to innovation extends to their Apple Health strategy and execution as well, in my humble opinion.
Apple aspires to enable every step/use case/workflow of the personal health management lifecycle or continuum, as illustrated in the figure above. As well, the Apple Health Kit will enable mHealth apps developers, healthcare IT vendors, healthcare providers like the Mayo Clinic (screenshot of the Mayo Clinic Health app built using Apple Health below), health insurance payers and life sciences companies to develop their apps on Apple’s platform (delivered via the app store on iTunes) to measurably extend their current value proposition for the patient. This I predict, will be driven by the already phenomenal adoption of the iPhone and the impending adoption of the Apple Watch slated to launch in the first half of 2015 once Apple has address the rumored battery life challenge. This is likely to be accelerated given the ‘De Novo’ requirements just announced by the FDA to accelerate time-to-market for innovative mHealth apps and devices.
Apple Health and the Apple Watch are Category Killers in mHealth Wearables with a potential impact not unlike that of the iPod, the iPhone and the iPad on the MP3 player, smart phone and tablet market spaces respectively, in my humble opinion.”
Apple Health Case Study: The Mayo Clinic App
Created in collaboration with Apple and in consultation with Mayo Clinic patients, the Mayo Clinic app (above) empowers patients, thru compelling capabilities:
* View select Mayo Clinic health data through the Apple Health dashboard
* Find health information more quickly
* Contact their care team directly through secure messaging
* View and manage details of their appointment schedule
* View Mayo Clinic videos on their iPhone, iPod and iPad
Mayo Clinic app users can trust that their data is secure. App users have full control of their personal health information, and can decide what, if any, data is stored in the Apple Health app. To make the data-sharing process easier, Mayo has developed an easy-to-understand privacy statement for app users.
According to Tim, Cook, CEO, Apple, “There has also been incredible interest in HealthKit with over 600 developers now integrating it into their apps. Consumers can now choose to securely share their health and wellness metrics with these apps and this has led to some great, new and innovative experiences in fitness and wellness, food and nutrition and healthcare.”
How will Apple Health on the iOS 8 and the Apple Watch deliver value for Patients, Providers, Payers, and Life Sciences companies?
While far from exhaustive, here is my early listing of value added use cases and workflows that will be enabled thru the Apple Health Kit and delivered potentially as third party developed apps for Apple Health on iOS X and the Apple Watch for:
PATIENTS – PERSONAL HEALTH MANAGEMENT:
* Personal Health Dashboard enabled by PHR in the iCloud
* Data Capture from multiple devices and wearables thru blue tooth device integration with additional data entry via Apple Health
* Lower search costs for Physicians, treatment and medications
* Secure data entry/data sharing via Patient Portal (e.g. EPIC’s MyChart), PHR, Provider App (e.g. Mayo Clinic Health App) or EHR integration with secure and selective data sharing with physicians and care givers
* Tele-health/ tele-medicine engagement and Physician appointment scheduling
* Medication ordering and medication adherence
* Chronic condition monitoring and wellness management
* Caregiving for Seniors and chronically ill relatives
* Data capture and sharing via Patient Portal and EHR integration like EPIC and myChart, and other EMRs
* Secure sharing of reports for Meaningful Usage compliance
* 360 degree patient communication re: treatment schedule, medication, costs and post-discharge documentation
* Continued education to build Patient Loyalty and enable Patient Relationship Management (PRM)
* Analytics re: patient risks for Population Health Management;
* Remote Patient Monitoring, medication adherence and compliance for patient risk management and reducing 30 day re-admission rates
HEALTH INSURANCE PAYERS:
* Bi-directional communication thru integration with Payer Portals with potential provision of Tele-Medicine and Tele-Health services
* Data capture thru integration with PHR in the iCloud
* Lower search costs of finding Physicians and Providers in the networkand estimated cost of treating conditions to abet Patient decision making
* Claims management with transparency into claims, reimbursements and payments and communication thereof
* Rich analytics for Employer Risk Management
LIFE SCIENCES – PHARMA AND MEDICAL DEVICES COMPANIES:
* Enabling patient education and engagement for communities focused on specific therapeutic conditions like Diabetes, COPD, et al
* Clinical Trials Engagement and Communication via integration with PHR in the iCloud
* Alerts and event management by Medical Devices Providers to collaborate and communicate with Patients with implanted class 1 devices
* Remote Patient Monitoring, medication adherence and compliance
I hope what I have offered here is an analysis and insights driven vision for the future of Personal Health Management enabled by Apple Health and the Apple Watch for ‘Patients like Us’.
Is this vision pragmatic and realistic or way off the mark? Recent reports from Reuters reveal that over 60% of the top 23 healthcare providers in this countryare already testing or adopting the Apple Health Kit to help doctors remotely monitor patients with chronic diseases like diabetes, that offers robust validation of my hypothesis and vision above.
I welcome your comments and feedback here and on Twitter at @HITstrategy.
Disclaimer: The perspective and views expressed in this Blog post are my own and do not represent those of my current or previous employers.