This is the fourth of a series of blog pieces I am doing to sum up my experience as a judge for the Ensuring Safe Transitions from Hospital to Home Challenge. Developers were asked to come up with a mobile app that would empower patients and reduce preventable hospital readmissions. Each of my blog pieces will look at one or two design issues that were not explicitly covered in the evaluation materials, but which struck me as important.
Don't underestimate the power of a phone call
One of the judging criteria was "Demonstrate creative and innovative uses of mobile technologies", but few of the apps seemed to remember that smartphones can be used to make and receive telephone calls in addition to their many other features. Of the 29 applications reviewed, only a handful made good use of telephony as part of the care transitions improvement suite. The most sophisticated telephony solutions were from legacy vendors of call management software. Interactive Voice Response (IVR) is a mature technology that we all are familiar with, so it was a little surprising that more vendors did not think to deploy it as part of their solution mix. Of course we all have horror stories of bad implementations of IVR, so you need to be sure it works well before you roll it out.
Some of the apps used computerized outbound robocalling to collect monitoring data ("Say or type your weight."). Since my pet peeve is inadequate pain management, I consider regular monitoring of pain levels to be part of collecting vital signs, but none of the apps seemed aware of pain managment as an important post-hospital goal. Beyond simple data collection, IVR can be used to help increase adherence to medication plans, reinforce exercise programs, or give an extra boost to whatever protocol a patient needs to stay out of the hospital. An IVR can be coupled with a real-time risk assessment algorithm that watches for red flags as the datastream comes it. If today you report that your blood pressure is out of range you could immediately be told "Your blood pressure is a little high. Let me connect you with a nurse to check on how you are doing." The call center software could then roll the caller over to a live person for an immediate second-level review.
Including telephony services as part of the app package is also important from the point of view of reducing disparities in medical care. In the U.S., people with below-average-incomes end up holding the short end of the stick on most measures of primary care access, coordination, and doctor-patient relationships. A lack of health insurance intensified the disparities, with uninsured adults often forgoing needed care. But even with insurance coverage, below-average-income Americans under the age of 65 are still more likely to report access problems and delays than insured, above-average-income adults. [Learn more: The Commonwealth Fund: The U.S. Health Care Divide: Disparities in Primary Care Experiences by Income]
One recent market research report predicts that about 65 percent of the U.S. population, or over 200 million people, will have a smartphone and/or tablet in 2015. The headline on that report could just as easily have said that by 2015, about 35% of the U.S. population will still not have a smartphone or tablet. We can't afford to have a digital divide in the quality of care transitions. Not everyone can afford a tablet computer, but almost everyone has access to a telephone. People at lower income levels, and those with lower levels of tech literacy, can be reached via telephony services more consistently than with any other contact method. Similarly, since the availability of smartphones is greater than for tablets, the smartphone form factor should be prioritized about tablets if you want to minimize disparities in availability of your app.
Dialing for dollars
Call centers do cost money, however. They require a centralized database, good phone systems, and (ideally) 24x7 staffing. But the traditional centralized model of high-cost call centers is being challenged by cloud-based, distributed labor pools that use web-based management software to enable customer support from a widely-dispersed labor force. (One example of a vendor in this category is Zendesk Voice.) This is an emerging third-party business opportunity for telephony vendors that can service multiple healthcare systems.
When you add the expense of a telephony layer to your app you need to revisit the question of who makes money when hospital readmissions are avoided. Who benefits when somebody does not go to the hospital? This is an important part of the economic puzzle. Unless a hospital can show that by preventing a readmission they will reduce costs that will offset the cost of a call center, there is no economic motivation to provide the service. On the other hand, if the service can be developed on a subscription basis or pay-as-you-go model, the incremental cost and effort needed to set up a call center can be absorbed by some other player in the system who can be compensated on a pay-for-performance model. Pay-for-performance will lead to increasing need for these types of highly-efficient cost-minimization services.
Coming Next: And the winner is...
Also see: Part 1: The ONC Care Transitions Tech Challenge: Thoughts from a Judge
Also see: Part 2: My Rant on Patient Education
Also see: Part 3: For Mobile Apps, Size Does Matter