The transformation of health care for patients

Information and communication technology, digiceuticals, and digitally enabled care

Elizabeth Downes, DNP, MPH, MSN, BA (Clinical Professor and MSN Program Director), Ann Horigan, PHD, RN (Assistant Professor), & Patrick Teixeira, MBA, BSN (MSN Student)

Journal of the American Association of Nurse Practitioners


Abstract

The way patients access care and interact with health care systems is rapidly changing through the use of information and communication technology (ICT). Health care is being transformed through digital innovations, such as wearable technology, remote monitoring, patient portals, mobile applications (apps), and new service models such as telemedicine and virtual visits. Through a review of the current literature, this article presents the use of digitally enabled tools and ICT, including electronic health records, telehealth, remote patient monitoring, and mobile health apps. These effective and innovative digitally enabled tools have expanded options for patients interested in actively engaging in their own health. Information and communication technology can improve health outcomes, enhance the patient experience, and curtail costs. Providers must stay fluent with ICT options to best collaborate with patients. Although providers recognize that patient-centered care can improve effectiveness and efficiency, many have been slow to incorporate digital therapeutics, or “digiceuticals,” into practice.


The way patients access care and interact with health care systems is rapidly changing through the use of information and communication technology (ICT). Health care is being transformed through digital innovations, such as patient portals, wearable technology, remote monitoring, and mobile apps, as well as new service models such as telemedicine and virtual visits. These effective and innovative digitally enabled tools have expanded options for patients interested in actively engaging in their own health. Information and communication technology is a global phenomenon that readily uses wireless technologies, “leapfrogging” other technologies in low-income countries. This, in effect, gives those who need it, quick and ready access to care and enhances the opportunity for digitally enabled tools to improve and strengthen health systems (Uddin et al., 2015).

Information and communication technology fosters patients' involvement in the management of their own health (Singh et al., 2016) and offers opportunities to deliver quality health care beyond traditional settings. Although providers recognize that patient-centered care can improve effectiveness and efficiency, many have been slow to incorporate digital therapeutics, or “digiceuticals,” into practice. The purpose of this article was to discuss the concept of the “Internet of Things” (IoT) and the increasing use of digitally enabled tools and ICT, including electronic health records (EHRs), telehealth, remote patient monitoring (RPM), and mobile applications (apps) for health.

There are many aspects to the digital transformation of health care. The “Internet of Things” is a system of interconnected devices, embedded with electronics, software, and sensors that create a network and transfer data. Examples include an exercise tracker sending the daily number of steps to a smartphone or remote monitoring for signs and symptoms of worsening heart failure. The IoT related to health can be grouped into the eHealth field. As defined by Eysenbach (2001), “eHealth …is the intersection of medical informatics, public health, and business referring to health services and information delivered or enhanced through the internet and related technologies” (p.1). Eysenbach's description continues, identifying attitudes that facilitate the adoption of and barriers that interfere with the adoption of eHealth. He states eHealth is “…also a state-of-mind, a way of thinking, an attitude, and a commitment for networked, global thinking to improve health care locally, regionally, and worldwide by using information and communication technology (ICT)” (Eysenbach, 2001, p.1).

Electronic health records

The most widely used component of e-health may be EHRs, which were supported by the Health Information Technology for Economic and Clinical Health Act. Electronic health records offer coordinated care and communication among providers. With tools like decision support, remote access, electronic prescription transmission, and data tracking, EHRs offer a promise to significantly reduce clinician workload and medical errors while saving the institution major expenses.

Information and communication technology can help achieve what was known as the “triple aim”; improving health outcomes, enhancing the patient experience, and curtailing costs (Berwick, Nolan, & Whittington, 2008). However, the triple aim has since been expanded to the “quadruple aim,” the fourth focusing on achieving joy, well-being, and resilience among providers and care teams (Bodenheimer & Sinsky, 2014). When this measure is factored in, EHRs are seen as failing and leading to provider “burn-out” (Bodenheimer & Sinsky, 2014). Electronic health record design dissatisfaction may lead to misuse of templates and the “copy and paste” function (Winn, Shakir, Israel, & Cannada, 2017), “alert fatigue” (Ancker et al, 2017), and increased provider stress (Bodenheimer & Sinsky, 2014). Moreover, EHRs may also create a barrier between patient and provider (Rose, Richter, & Kapustin, 2014) and decrease clinician productivity (Jones, 2012). Fortunately, creative corrections are emerging (Bristol, Nibbelink, Gephart, & Carrington, 2018 Hochman, 2018 Jones, Heaton, Rudin & Schneeder, 2012 Unni et al., 2016).

Patient portals

Electronic health records enhance communication with patients via patient portals, secure websites that interface with the patient's EHR, and offer direct messaging between provider and patient. Health care reform and digital advances will continue to transform the ways patients interact with the health care system and their own records.

Although portals may facilitate patient engagement and self-care, current research indicates that patients' satisfaction with and ability to use a portal varies (Irizarry et al., 2017). There is demand for portals to integrate clinical and financial data and allow real-time, responsive scheduling. Concerns about security, health literacy, and cultural barriers can deter use. When looking at patient portals, every EHR entity has different methods and features, with associated concerns regarding implementation. Some of the largest setbacks are usually avoidable with adequate preparation and rollout. By being vigilant of protecting information as well as providing information on how to use the patient portal, providers can have better buy in from clients potentiating better results.

Beyond present day patient portals, more advanced solutions can motivate patient interaction. “Patient Portal 2.0” will support interaction across diverse care settings, social collaboration, and healthcare wearable technologies (Paget, Salzberg, & Hudson Scholle, 2014). Opportunities for patient involvement are increasing through smart phones, tablets, wearables, and other web-enhanced devices that may obviate patient portals as they exist today. Furthermore, there is a growing interest in the use of avatars and virtual agents for e-visits and personalized health coaching as well as other gaming-type innovations (LeRouge, Dickhut, Lisetti, Sangameswaran, & Malasanos, 2016).

Telehealth

The term “telehealth” is used to describe a range of activities including diagnosis and management of health conditions, counseling, and education via technology (Center for Connected Health Policy, 2013). Telemedicine has a more narrow scope, referring to provision of remote clinical services and includes virtual live-interactive visits (evisits) or asynchronous (also called Store-and-Forward) transmissions of images for specialists' consultations over secure email (Center for Connected Healthy Policy, 2013). Providers estimate that 10% of office visits could be replaced with evisits (Pricewaterhouse, 2014).

Telehealth is already demonstrating success throughout the world. It has been successfully used for dermatology (telederm) in Botswana (Kamsu-Foguem & Foguem, 2014), Egypt (Saleh, Hay, Hegazy, Hussein, & Gomaa, 2016), and the United States (Coates, Kvedar, & Granstein, 2015). Telehealth has shown a significant impact for senior populations from improvement in health to reductions in hospital readmissions and promoting independent living (Khosravi & Ghapanchi, 2016). Telehealth offers the advantages of savings in time and cost and is well accepted by patients (Bashshur, Howell, & Krupinski, 2016).

Although providers recognize the benefits of telehealth, concerns about security, interoperability, reimbursement, and the inability to work across state lines are perceived as barriers (Pricewaterhouse, 2014). There are gaps in federal and state guidelines for telehealth, leading to privacy risks and security threats (Hall & McGraw, 2014). This lack of security and privacy measures needs to be addressed to avoid the inadvertent transmission of sensitive information before systems can be trustworthy. Among the unique barriers are the variations for reimbursement that can involve both the originating site (where the patient is) and the distant site (where the provider is). Medicare primarily reimburses for live-interactive visits when the patient is in a health care facility. Rarely are home visits or asynchronous visits reimbursed, although this varies state-by-state and by insurance.

Finally, telehealth can potentially increase disparities. It is possible that telehealth could be limited to clients with a computer or phone with a camera and an associated data plan that allows for this functionality. These limitations will need to be addressed as the interest in and benefits of telehealth will potentiate its use. Presently, patients already want to communicate and access their providers easily through different electronic resources (Bashshur et al., 2016).

Remote patient monitoring

Remote patient monitoring is the use of digital technology to transmit health data from patients to providers in different locations. Remote patient monitoring has been shown to meet the Institute for Healthcare Improvement's “triple aim,” which calls for reductions in costs and improvements in the health care experience and health outcomes (Center for Connected Health Policy, 2013). Remote patient monitoring is a successful strategy for managing both communicable and noncommunicable diseases. Examples of use in the ambulatory setting include RPM of direct observed treatment for tuberculosis (Hoffman et al, 2010) and to assess temperatures of patients with Ebola (Steinhubl, Marriott, & Wegerich. 2015). Several studies describe the use of RPM at home to improve care of patients with heart failure and chronic obstructive pulmonary disease (Rubio, Parker et al., 2017).

Remote patient monitoring is also used in critical care. Tele-intensive care units (tele-ICU) connect critically ill patients in remote hospital to health care teams, intensivists, and resources at a central ICU tele-unit. In the United States, over 10% of ICU beds are supported by tele-ICU with associated improved clinical outcomes (Kahn et al., 2016) and cost control (Chen et al, 2017).

Barriers to RPM center around initial costs which are substantial for tele-ICUs including construction and staffing (Chen et al, 2017). Devices for ambulatory RPM can also be costly for the individual with reimbursement guidelines being unclear (Morrissey, 2014). Remote patient monitoring is dependent on wireless technology that can add an additional cost to the user with limited operability in rural areas. Furthermore, the possibility of continuous flow of data requires interoperability that may not yet be available (Rahmani et al, 2018).

Although current legislation requires interoperability from EHR companies, this is difficult to achieve. Because each company's operating system is proprietary, finding a way for systems to interface and assigning responsibility for this is a challenge that is part of any EHR installation. An additional barrier is the vagueness of government requirements. Ultimately, this affects client care. When systems interface well, patient information populates into the provider's EHR system or has a read-only option so the provider can have the necessary information. If this is not done well, or not achieved at all, the provider may not have the information needed to best care for their clients.

Smart phones and apps

Mobile phones are used throughout the world to support health efforts (Chib, van Velthoven & Car, 2015). Text messaging is used for unidirectional medication reminders and interactive daily educational text messages. Results indicate that while the impact is limited, texting may be more useful for communicable diseases and contraception than chronic diseases (Smith, Gold, Ngo, Sumpter, & Free, 2015 Piette et al., 2015). Meanwhile, the use of smartphones and mobile apps is increasing.

According to the Pew Research Center (Pew, 2018), more than three-quarters (77%) of the US adult population owns a smartphone. In 2015, 62% of owners of smartphone used their phone to get information about a health condition (Smith, 2015). Many Americans are “smartphone dependent,” meaning they rely on their smartphone to access the Internet. Pew also reports that younger adults, minorities (15% of African Americans, 22% of Latinos), and low-income Americans are more likely to be smartphone dependent (Pew, 2018). Among the smartphone dependent, 10% have no other access to the internet. An additional 15% have limited access to the Internet. This necessitates the use of smartphone-enabled technology (Smith, 2015) as among smartphone owners, the use of smart phones to manage health is rapidly increasing. A study by Accenture (2015) indicates that 33% of US consumers are using mobile health apps, compared with just 16% in 2014. Many Americans (66%) state they would use a mobile app to manage health-related issues. Apps prescribed by providers (sometimes referred to as “digiceuticals”) are more likely to be integrated into daily use by patients. Apps that are downloaded without their provider's involvement are more likely to be abandoned or less consistently used (Makovsky, 2015).

Health care providers recognize the potential for health care–related apps in managing health and many are willing to prescribe a variety of apps to help patients better manage chronic disease and to monitor vital signs, symptoms, or sleep (PricewaterhouseCoopers Health Research Institute, 2014). With the rapid increase in health-related apps (from 165,000 in 2015 to 315,000 in 2017, and over 200 apps appearing daily) (Lowes, 2017), it can be difficult for providers to determine which are best. App rating services, such as Ranked, iMedical Apps, and IGetBetter, assess apps and provide reviews through crowd sourcing and by including information from providers and customer scores, download volume, prescribing patterns, and engagement metrics. Even with these rating services, there is limited evidence to support the safety, security, and clinical effectiveness of most apps. Many apps also lack evidence-based behavior change theory and integration with EHRs (Riley et al, 2011 Wilhide, 2016).

However, evidence is increasing to support the use for apps, and recommendations for development have been proposed (Wilhide, 2016). A report on the clinical evidence of apps indicates that data now exist for using apps in the management of diabetes, depression, and anxiety such that clinical guideline writers may soon include apps in standard of care recommendations (Lowes, 2017). Resources for providers to distinguish between apps are becoming more available (Higgins, 2016 Jake-Schoffman et al, 2017). Furthermore, regulatory agencies like the Federal Drug Administration (FDA) and the Federal Trade Commission are monitoring the changing landscape of mobile technology (U. S. Federal Trade Commission, 2018). The FDA differentiates between lower-risk products (like calorie or steps counters) and higher-risk devices (like an app to control an insulin pump), which have greater risk to patient safety, should the app malfunction. The proposed FDA Center of Excellence on Digital Health will support oversight of digital health and concerns about cybersecurity (U. S. Federal Drug Administration, 2018) and influence the development and use of digiceuticals.

Generation gap narrowing

Although millennials are more than twice as likely to use a mobile app to manage their health compared with Americans aged 65 years and older, this is changing (Smith, 2015). Smartphone use among Americans aged 65 years and older has increased from 18% to 42% since 2013 (Pew, 2018) and as Baby Boomers reach their 60s and beyond, the use of smart phones among seniors is expected to increase. The use of digital tools will expand as Baby Boomers continue to move into digital life (Smith, 2015). In fact, technology for individuals aged 65 years and older already provides effective tools to manage health, whether their goals are to preserve health or to age in place.

Aging in place promotes seniors living in the residence of their choice as they age. It includes services that change as their needs do. Person-centered ICT, including sensors, geographic positioning systems (GPS), apps, and remote monitoring, can potentiate aging in place (Blackman et al, 2016 Ience et al, 2017). Sensors and GPS can help locate reading glasses, and report falls and even location should a senior wander. Remote monitoring can link to pace makers, measure glucose, blood pressure, heart rate, and weight, while saving time and reducing stress and costs related to traveling to a medical appointment. Reminder apps can alert seniors (and others) about medications (Seto et al, 2017). A review by Wildevuur and Simonse (2015) indicates that ICT can positively impact a person with one of the “big five” diseases (diabetes mellitus, cardiovascular and chronic respiratory diseases, cancer, and stroke) and reduce hospitalizations for some patients. Mobile devices and telehealth offer the potential for controlling costs. For example, encouraging medication adherence, whether by telehealth or reminders, can increase compliance and decrease complications and a need for higher levels of care, ultimately saving on cost.

Conclusion

As digitally enabled tools continue to become popular and more sophisticated, patients are looking to providers for assistance as they seek to manage their own health. Wearable technologies and other RPM devices will provide clinicians with insight into a patient's daily routine and health status. An estimated 77% of American adults have smartphones (Pew, 2018). The explosive growth of mobile technology has left very few industries unchanged, and in health care, these changes have touched stakeholders in profound and lasting ways. The opportunities presented in EHRs, telehealth, mobile applications, and other ICT have altered how clients and providers interact, as well as the degree of these interactions. Information and communication technology provides new and effective tools for patients to address their own health goals, whether those goals are to preserve health, improve fitness, or age at home. There is growing evidence that patients' involvement in their own health is linked with better health outcomes, improvements in health behavior, and lower health care costs (Greene, Hibbard, Sacks, Overton & Parrotta, 2015). Providers must stay fluent with ICT options to best collaborate with patients toward the triple aim. By streamlining the client experience, assuring trustworthiness, security, and privacy while continuing to provide client support once they leave the office or log off, client health can be assessed, maintained, and improved beyond the examination room.


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