User-centered design of contingency management for implementation in opioid treatment programs: a qualitative study

Contingency management (CM) is one of the only behavioral interventions shown to be effective for the treatment of opioid use disorders when delivered alone and in combination with pharmacotherapy. Despite extensive empirical support, uptake of CM in community settings remains abysmally low. The current study applied user-centered design principles to gather qualitative data on familiarity with CM, current clinical practice, and preferences regarding the implementation of CM in community-based opioid treatment programs.

Participants were 21 leaders and 22 front-line counselors from 11 community-based opioid treatment programs. Semi-structured interviews were about 45 min long. Transcripts from each interview were coded by independent raters and analyzed using a reflexive team approach. Frequencies of responses were tallied, and queries were run in NVivo to identify exemplar quotes for each code.

Results indicated low familiarity with CM, with less than half of the respondents defining CM correctly and over 40% of respondents declining to answer/ did not know. Abstinence was the most commonly recommended CM target, yet over 70% of respondents indicated that urine screens only occurred monthly. Attendance was also a popular recommendation, with respondents suggesting a range of possible indices including counseling, dosing, and/or case management sessions. Regarding the ideal role to administer CM prizes, program directors and supervisors were most commonly recommended, closely followed by front-line counselors. The most commonly suggested strategies to afford CM incentives included soliciting community donations and offering non-financial incentives.

User design principles to understand workflow constraints, target user needs, and simplify the intervention guided this qualitative investigation of CM implementation in opioid treatment programs. Findings highlighted the potential value of flexible, organization-specific definitions of CM attendance and non-financial incentives, as well as active involvement of clinical leaders and supervisors to promote buy in among staff/patients. Respondents were generally optimistic about their ability to fundraise or solicit donations to overcome cost-related barriers of CM. Implications for CM implementation strategies, including the use of targeted leadership coaching focused on sustainability, are explored.

The full article can be downloaded below.  

Protecting healing relationships in the age of electronic health records: report from an international conference

We present findings of an international conference of diverse participants exploring the influence of electronic health records (EHRs) on the patient–practitioner relationship. Attendees united around a belief in the primacy of this relationship and the importance of undistracted attention. They explored administrative, regulatory, and financial requirements that have guided United States (US) EHR design and challenged patient-care documentation, usability, user satisfaction, interconnectivity, and data sharing. The United States experience was contrasted with those of other nations, many of which have prioritized patient-care documentation rather than billing requirements and experienced high user satisfaction. Conference participants examined educational methods to teach diverse learners effective patient-centered EHR use, including alternative models of care delivery and documentation, and explored novel ways to involve patients as healthcare partners like health-data uploading, chart co-creation, shared practitioner notes, applications, and telehealth. Future best practices must preserve human relationships, while building an effective patient–practitioner (or team)-EHR triad.

The full article can be downloaded below.  

Why An Aging Population Means Healthcare Customer Experience Must Adapt

America is getting older, and the healthcare system is buckling under the pressure. The double whammy of people generally living longer and the massive Baby Boomer generation creating the “largest-ever population of older adults in America” has necessitated a level of experience innovation in the healthcare industry that simply has no precedent.  

Thankfully, there are a lot of brilliant minds working on a solution to this problem, identifying and addressing the needs of health consumers, medical providers and insurers all at once in order to create a smoother system for all.

In the final article of a three-part series, I interviewed three leaders in the healthcare industry for whom addressing the experience of the aging population is a top priority. 

The full Forbes article can be viewed at this link.  

The Power of Empathy In The Customer Experience And The Patient Experience

I'm aware, as I'm sure you are, that certain positions and industries have poor reputations for empathy and communication. These include airport security personnel and, most maligned of all, telecom/cable customer service staff. (I should make clear that I'm not subscribing to these stereotypes myself, either as a consumer or as a customer service consultant. My own experiences with TSA personnel have been largely pleasant. Likewise, in the cable industry, you can read my writings here about one wonderful employee–Jerry Biggs–at Comcast, and here about customer-focused upstarts in the telecom/cable industry including Scottsdale-based Nextiva, which has gone so far as to trademark the term Amazing Service.)

Likewise, when I’m serving as a patient experience consultant, which is part of my overall customer service consultancy, I spend time devising ways for both frontline and clinical staff to improve their interactions with patients and patients’ loved-ones. Here, one specialization with an (earned or unearned) reputation for tone-deafness is surgery. To the extent that this rap is deserved, it’s understandable.  The appeal of going into surgery as a young doctor is partly its cut-and-dried aspect: you either achieve clear margins or you don’t.

But the people whom a surgeon cuts into are exactly that: people.  And while I would never advise a prospective patient to choose a surgeon with shaky hands or board-validated competency complaints (even if the doctor is sweet as the day is long), the ideal surgeon includes both parts of the package: clinical competence and empathetic engagement skills for interacting with patients and the families who love them.

The full Forbes article can be viewed at this link.  

Why Treating Patients As Consumers Can Improve The Healthcare Experience

The healthcare industry is the fifth biggest in the United States, contributing more than $1.2 trillion to the Gross Domestic Product. But according to the Siegal+Gale Global Simplicity Index, healthcare ranks dead last out of 25 industries in the United States for simplicity of experience. Whether it's interminable wait times, never-ending stacks of paper forms to complete, confounding language, or overly complex insurance plans, the healthcare industry has become one that U.S. consumers love to hate.

As customer experience continues to evolve as the last true competitive differentiator in most industries, it stands to reason that the experience must improve in healthcare in order for the existing players to survive.

In the first of a three-part series, I interview Geeta Wilson, the founder and CEO of Consumer Society, an early-stage tech and experience design company building an enterprise experience management technology platform to connect all of the major industry players – insurance companies, healthcare professionals and consumers. The discussion centers around the idea to change the industry's nomenclature from "patients" to "consumers" and why that is critical to improving the overall healthcare experience. Part 2 will look at the digital health consumer, and part 3 will examine the aging population and the resulting changes in demand for a healthcare experience.

The full Forbes article can be viewed at this link.  

Physicians See More Pay Tied To Patient Satisfaction And Outcomes

Physician practices are seeing more of their pay and bonuses based on “value-based metrics such as patient satisfaction and outcome measures,” a new analysis shows.

The shift away from fee-for-service reimbursement that has historically paid doctors based on the volume of care they deliver is a trend escalating as health insurance companies and the federal government shift to value-based models like bundled payments and accountable care organizations.

The full Forbes article can be viewed at this link.  

As Healthcare Goes Digital, Consumer Engagement And Experience Improve

The healthcare industry in the United States has long been a dichotomy in its embrace of – and resistance to – technology. While some of the world's finest technology is used to diagnose and treat all manner of illness, patients often have to complete paper forms in the waiting room and many doctors still take notes on paper medical charts.

The move to digital has been well under way in most other industries, creating an expectation of a consumer experience in which healthcare has fallen behind. After all, today's competition is every other experience the customer has had recently.

In the second of a three-part series, I interview several leaders in the healthcare industry who are approaching the digitization of healthcare from different angles. Thomas Swanson is the Head of Industry Strategy and Marketing in the Health and Life Sciences division of Adobe. Geeta Wilson is the founder and CEO of Consumer Society, an early-stage tech and experience design company building an enterprise experience management technology platform to connect all of the major industry players – insurance companies, healthcare professionals and consumers. Richard McCreary is the Vice President of Product Development for Consumer Society after working at health insurer Humana for nearly 14 years.

The full Forbes article can be viewed at this link.  

eHI's Policy Guy Summarizes Comments on ONC & CMS Interoperability Proposals

June saw the end of exhaustive and exhausting comment periods on interoperability-focused proposed rules from the Office of the National Coordinator for Health IT (ONC) and the Centers from Medicare and Medicaid Services (CMS), discussed in my prior blog. The annual CMS Medicare hospital payment proposed rule also touched on interoperability issues and the physician-focused annual proposed rule is expected imminently.  In the U.S. Congress, there was also renewed activity to fill in the interoperability puzzle, including provisions in a Senate HELP Committee approved bill on cost reduction that would build on the Blue Button 2.0 expansion in the recent CMS interoperability proposed rule, as well as interest in expanding HIPAA to non-covered entities to address privacy and security concerns with application programming interfaces (APIs) and apps. There was also House action to remove statutory restrictions on federal consideration of a national patient identifier.

ONC and CMS Information Blocking and Interoperability Proposed Rule Comments

The ONC and CMS interoperability proposed rules stimulated many comments (including from the eHealth Initiative). The ONC proposed rule received over 2,000 comments, many if not most, on price transparency, the subject of a June 25 Executive Order. ONC has formally targeted November 2019 for a final rule, although a later release is likely given the number and tenor of comments, including calls for second round of proposed rulemaking.  

Common issues in comments on the ONC interoperability and information blocking proposed rule were:

• Broad support for increased patient access to information, standards-based open APIs, and reduction of information blocking;
• Likely significant burdens on information blocking-relevant “actors,” especially complexity and compliance costs;
• The Information Blocking definition is too broad and the need for specific guidance to develop compliance plans;
• Definitions of Health Information Network and Health Information Exchange are too broad and confusing;
• The focus on Electronic Health Information (EHI) should be scaled back to HIPAA Protected Health Information (PHI);
• The proposed information blocking exceptions cover the right categories, but requirements are too detailed and rigid, although some see exceptions as loopholes;
• Pricing and contracting limits are too restrictive, requiring extensive documentation, and could distort markets (the Federal Trade Commission agreed);
• The scope (which products and developers) of information blocking liability for health IT developers; and
• The effective dates and timelines for developers and implementers should be extended.

Trusted Exchange Framework and Common Agreement (TEFCA) Draft 2

The ONC Trusted Exchange Framework and Common Agreement (TEFCA) Draft 2 received far fewer comments (about 125) by the June 17 deadline, including from the eHealth Initiative. A common theme was for ONC to be more consistent with congressional intent to support and not disrupt or duplicate existing exchange networks and frameworks and their in-place trust agreements. There were also calls for ONC to reconcile the TEFCA with HIPAA privacy and security regulations and with forthcoming information blocking and open API regulations. There was particular attention to how Individual Access will be implemented, including the role of apps and APIs, as well as how to implement Meaningful Choice, which would enable individuals to opt out of the TEFCA.

Comments also emphasized that the Recognized Coordinating Entity (RCE) to be designated in August by ONC should have considerable leeway to work with stakeholders to refine and implement the policy and technical aspects of the TEFCA. The RCE will be a nonprofit organization assigned to develop, update, implement, and maintain the TEFCA Common Agreement. The RCE will also work with ONC to designate and monitor the Qualified Health Information Networks (QHINs) that will be the backbone of nationwide queries, modify and update the accompanying QHIN Technical Framework (QTF) that will govern QHIN-to-QHIN interactions, and engage with stakeholders through virtual listening sessions.

Following its review of these TEFCA Draft 2 comments, ONC intends to:

• Finalize and publish final principles for the Trusted Exchange Framework (TEF);
• Have the RCE issue for public comment, after ONC approval, Draft 1 of the Common Agreement, which will include Minimum Required Terms and Conditions (MRTCs) developed by ONC and Additional Required Terms and Conditions (ARTCs) developed by the RCE and approved by ONC;
• Have the RCE issue for public comment, after ONC approval, Draft 2 of the QTF;
• Have the RCE issue for production, after ONC approval, Final Version 1 of the Common Agreement (to be published in the Federal Register);
• Have the RCE issue for production, after ONC approval, Final Version 1 of the QTF;
• Have the RCE designate and monitor QHINs that sign and adopt the Common Agreement—QHINs would “flow-down” Common Agreement provisions to their Participants and Participant Members;
• Have the RCE implement an ONC-approved process to determine QHIN compliance with the Common Agreement;
• Have the RCE implement a process to update the Common Agreement, as needed, for ONC final approval and publication; and
• Have the RCE propose strategies to sustain the Common Agreement at a national level after expiration of the four-year term of the Cooperative Agreement.

Based on a review of the TEFCA Draft 2 and the companion ONC Notice of Funding Opportunity for the RCE, it is likely that the revised Common Agreement, the QTF, and initial QHINs will all roll-out during 2020.

Implications for eHealth Initiative Members

The flurry of federal activity in June sets the stage for expanded healthcare interoperability in the U.S. and for a more complex regulatory environment.  Key changes to prepare for include:

• Expanded nationwide query-based access to health information, initially at the “document” level (e.g., C-CDA) and later at the level of individual data elements, using standards like HL7® FHIR®. This access will accommodate queries by patients and their designees;
• Regulatory drivers to reinforce private sector growth in standards-based APIs for granular, patient-focused, health data access, again relying on HL7® FHIR®;
• Pressures for federal and state privacy and security protections to follow the shift to an API/app ecosystem;
• Increased recognition of the need to enhance patient matching, with a robust federal role;
• Continued tensions between federal government prescriptiveness and reliance on private sector dynamics, recognizing that the latter can be driven by high-level federal initiatives around areas like value-based payment and information blocking; and
• Implementation of federal laws and regulations on information blocking that will transform the digital health space, resulting in both increased data liquidity and a complex and costly compliance environment, potentially rivaling what we have seen with HIPAA.
   

Mark Segal, PhD, FHIMSS, Principal, Digital Health Policy Advisors, LLC. Member and Past Chair of the eHI Policy Steering Committee. July, 9 2019. Twitter @msegal111

eHI thinks Mark Segal is a super cool guy and is providing his opinions for informational purposes only. The opinions presented, do not represent those of eHealth Initiative, our members or the Foundation.

 With Rural Health Care Stretched Thin, More Patients Turn To Telehealth

A recent NPR poll of rural Americans found that nearly a quarter have used some kind of telehealth service within the past few years; 14% say they received a diagnosis or treatment from a doctor or other health care professional using email, text messaging, live text chat, a mobile app, or a live video like FaceTime or Skype. And 15% say they have received a diagnosis or treatment from a doctor or other health professional over the phone.

The full NPR article can be viewed at this link. 

The medium, the message and the measure: a theory-driven review on the value of telehealth as a patient-facing digital health innovation

By what measure should a policy maker choose between two mediums that deliver the same or similar message or service? Between, say, video consultation or a remote patient monitoring application (i.e. patient-facing digital health innovations) and in-person consultation? To answer this question, we sought to identify measures which are used in randomised controlled trials. But first we used two theories to frame the effects of patient-facing digital health innovations on – 1) transaction costs (i.e. the effort, time and costs required to complete a clinical interaction); and 2) process outcomes and clinical outcomes along the care cascade or information value chain, such that the ‘value of information’ (VoI) is different at each point in the care cascade or value chain. From the trials, we identified three categories of measures: outcome (process or clinical), satisfaction, and cost. We found that although patient-facing digital health innovations tend to confer much of their value by altering process outcomes, satisfaction, and transaction costs, these measures are inconsistently assessed. Efforts to determine the relative value of and choose between mediums of service delivery should adopt a metric (i.e. mathematical combination of measures) that capture all dimensions of value. We argue that ‘value of information’ (VoI) is such a metric – it is calculated as the difference between the ‘expected utility’ (EU) of alternative options. But for patient-facing digital health innovations, ‘expected utility’ (EU) should incorporate the probability of achieving not only a clinical outcome, but also process outcomes (depending on the innovation under consideration); and the measures of utility should include satisfaction and transaction costs; and also changes in population access to services, and health system capacity to deliver more services, which may result from reduction in transaction costs.

The full article can be downloaded below.