Patient Engagement in Pediatrics - 3 case studies

Innovative Children’s hospitals are investing in technology tools to engage patients and families during their stay, post discharge and through ongoing monitoring. We asked three leading children's hospitals about the technologies that they have invested in to improve care quality and patient/family satisfaction.

 The three hospitals are:

  • Boston Children's Hospital
  • National Children's Hospital in Washington, DC
  • Children’s Health, Dallas Texas.

 

Interviewed:     Kelly Dunn, Boston Children’s Pediatric Nurse Practitioner, Vandna Mittel, Product Manager, Innovation Program, Boston Children’s Hospital

Interviewed by: Sherri Dorfman, CEO, Stepping Stone Partners  

Boston Children’s Hospital (BCH) is focused on delivering an excellent experience at every patient touch point. They were looking for a convenient way to check- in with the parents/guardians post discharge to ensure a successful return home. The team at BCH developed DisCo, a Discharge Communication Platform which sends families either a text message or an email with 3 questions within 24 hours of discharge.

Boston Children’s Hospital has conducted two pilots using DisCo. For both pilots, the family was approached by the nurse prior to discharge, informed about DisCo and invited to participate. Eligible participants spoke English, had a smart phone, an email address and were interested in being part of the pilot. Participants elected to receive and respond to three questions (i.e. have prescribed medications, scheduled follow- up primary care doctor’s visit, have any concerns) via text or email link.

Disco App
After the parent/guardian responded to the survey, their information was displayed on the DisCo web-based provider dashboard. The nurse practitioner viewed responses and contacted the patient/guardian to resolve a reported problem.

Disco Provider view
DisCo was not designed to replace the pediatrician but instead to provide an additional layer of support for the discharged child and their caregivers - with real time follow up with a member of the medical team.  This process was previously more difficult for nursing staff and for parents and other caregivers at home. 

Pilot Overview:

Pilot 1: Conducted April 2013 - October 2013, enrolled 140 patients on the general pediatrics and short stay floor.

  • About 52% chose to communicate via text, 48% by email.
  • 65% of enrolled patients or 91 participants responded to the email/text communication.
  • Within this group, 12% or 17 patients reported issues.
  • Parent/guardian issues and questions were about medications, follow- up visit and a new symptom
  • “Six participants has an unplanned re-presentation to BCH- ED or inpatient within 7 days of discharge”. Four of these didn’t respond to the survey post discharge.
  • 82% of participants felt the DisCo tool was helpful.

Pilot 2: Conducted June 2014 - October 2015, enrolled 554 patients on additional floors

  • Pilot 2 was designed to expand DisCo to additional settings and more providers
  • 72% or participants chose text messaging and 28% selected email
  • About 52% of enrolled participants, 286 patients responded to the survey
  • Only 5% of total enrolled, 30 participants, reported issues
  • 99% of participants felt the DisCo tool was helpful.

Pilot Insights:

  • One touch communication was limiting: After discharge, parents were only sent one electronic survey to determine if there were any issues. Parents experiencing problems after that time needed to reach out to their pediatrician.
  • DisCo available in one language limiting. The Boston Children's population speaks a different languages but DisCo is only available in one language. This may have impacted enrollment.
  • False Positive with Parent’s problem response. A few parents reported an issue, but when a clinician called, they said they were fine. This may be because the parent selected “yes” to the third question (i.e. have a concern that you would like to discuss) after quickly responding “yes” that they have the medication and have set up the doctor’s appointment.
  • PCP likes the extra care for patients. Several of the attendings at BCH are also primary care doctors. They have commented on appreciating the additional oversight that this tool offers to their patients.
  • More Pilot 2 Participants elected to receive via text. Parents/guardians chose to receive the survey link through text over email. This may be because pilot 2 was conducted in the past year when people are more comfortable with smart phone technology.

Boston Children’s Hospital envisions expanding the use of DisCo to other departments. This entails customizing the three questions to fit the patient population and patient transition point.

For example, one department is interested in potentially using the tool to reach out to the parent/guardian prior to a procedure to ask if the patient has stopped eating by the specified time, stopped taking medications and has any questions.

 

Children’s National Health System, Washington, DC

Interviewee: Brian Jacobs, MD – VP, CMIO and CIO, Children’s National Health System

Interviewer: Christina Caraballo, HIMSS Connected Health Committee

Overview:

Children’s National is looking at innovative approaches to engage patients and their families by leveraging technology.  Children’s National Bear Institute is dedicated to improving clinical pediatric outcomes by providing innovation and value driven care.

Research shows that parents have a strong desire to be a part of the care team, yet often feel unprepared to navigate their child’s care and be effective advocates.[1] Parents often find it difficult to engage with clinicians & struggle with understanding and retention of complex healthcare information.[2] 

Patient Readiness to Engage:

Children's National

Children’s National Engagement: Focus on Technology

  • Hand Held and Bedside Apps and Monitors
  • Rounding Tools
  • Quality Boards
  • Patient Portals 

Children's National Mobile Platform
MyBearGuide -
Mobile Patient Engagement Platform

Wayfinding - Helps patients and families navigate from their current location to any other desired location within the hospital

Food and More - Displays various food and amenity options

Visit Children’s - Displays various transportation options for visiting Children’s

Wait Times - Displays estimated wait time for a patient to be seen in either Emergency Department

Children's National Wait Times

Family Centered Rounds

  • Rounds with case presentation & discussion in front of family with their involvement in medical decision making
  • 48% of academic pediatric hospitals conduct FCRs
  • 93% of parents like to participate in morning rounds
  • And Yet … Only 40% of Families Participate
  • Why is this????

 

MyBearGuide – Future

  • Family-Centered Rounds
    • Introduction to rounds
    • Searchable dictionary for commonly used medical terms
    • Alerts (i.e. text message) to inform parents when the rounding team will visit
    • Drag-and-drop list of patients to be seen

Hand Held Apps (Doc Journal)

  • Innovative app which provides a way for patients and families to better engage with their care team
    • Health information entry
    • Pharmaceutical references
    • Journaling
    • Acquire images

Children's National App

Quality Boards

Children's National Quality Boards

Patient Portal

Functionalities:

  • Education
  • Appointments
  • Results
  • Rx Renewals
  • Ask Questions
  • Record (meds, allergies, visit summaries, etc.)

Children's National Portal

Patient Portal – Google Analytics

Children's National Analytics

Specialty Clinic Patient Portal Experience National (Implemented July 2015)

  • Invitations since go-live: 3,916
  • Accounts Claimed: 490
  • Claim Rate: 13%
  • Average national claim rate: 32%

Why Do Patients Not Use Portals?

  • “Did not know it was available”
  • “Physician never spoke to me about it”
  • Challenging groups (children, adolescents, elderly, mental illness)
  • Confusing user interface
  • Not compelling enough

Is Engagement & Satisfaction Enhanced?

  • 42 patients/families from 3 units enrolled.[3]

Children's National satisfaction

Children’s National Conclusions

  • Improved patient engagement is associated with enhanced provider relationships, communication, satisfaction and care.
  • Education regarding importance of engagement needs to be built into the hospital and clinic-based workflow.
  • Patients and families need intuitive tools to assist in their understanding & retention of health & healthcare information.

 

 

[1] Barello S, et al. Nursing Research & Practice 2012, Hindawi Publishing Corp.

[2] Cohen E, et al. Pediatrics. 2011;127:529-38

[3] Takei R, 2015 Abstract Children’s National

 

 

Children's Health, Dallas, TX

IntervieweesJulie Hall-Barrow, Ed.D.,  Pete Perialas, Peter Roberts

Interviewer: Jon Mertz, Vice President, Marketing, Corepoint Health

Design thinking is about empathy, and Children’s Health is developing and implementing technology and processes centered on the patient experience. Chris Durovich, CEO, is inspiring a vision of reaching the whole family in the care of a patient, meeting them where they are and offering them more control of their lives. This vision has sparked a lot of innovation at Children’s Health – from population health to telehealth to mobile health. With design studios to gain insights directly from patients, Children’s Health is putting empathy into action.

The design studio alone is innovative. Eli Stefanski, who is with the Business Innovation Factory and partners with Children's Health on these initiatives, sums up their design thinking approach well:

“We have a host of prototypes and programs that we test and co-create with families, but more importantly, the families actually deliver the final program or approach. It isn't just us saying, ‘Thank you so much for your ideas,’ but taking it one step further and saying, ‘Okay, what is it that you can do to help deliver this program?’ We create a deeper level of engagement.”

Children’s Health is setting the example for new investments and capabilities within a population health model, all centered on the patient. Key initiatives include virtual health, remote monitoring and house calls.

Virtual Health

A recent nationwide survey of primary care physicians found that 57 percent of practicing physicians are prepared to conduct video visits with their patients. With a ready mindset, Children’s Health launched a three-prong approach to virtual health. The first focus is on all employees of Children’s Health; the next is their pediatric partners, and the third area is on the consumer.

Many health care employees have limited time to schedule care when they need it. With the virtual health approach, employees can go to a virtual health console in a Children’s Health facility, and after that initial visit, they can use their mobile device to visit with a care provider. More than convenience, care is delivered when an employee needs it.

To expand beyond the hospital’s four walls, Children’s Health is extending their virtual platform to over 300 pediatric partners. With solid early results and positive feedback from participating physicians, the implementation momentum will continue. A key value point is to reduce the number of urgent care visits and to maintain a clinically integrated approach to patient care and service.

Children’s Health is taking a consumer convenience approach to virtual health. The goal is to meet patients where they are. While pharmacies are a part of the implementation, schools are included as well. For two years, Children’s Health has provided telemedicine visits in urban, rural and independent school districts across the Dallas-Fort Worth area.

As Julie Hall-Barrow, Ed.D., vice president of virtual health and innovation, said:

“Child wellness and learning are linked, and it is a really big focus for us. If you're not well, you can't learn. We're trying to ensure kids get the health care they need in a prompt manner so they continue to learn and participate.”

Engaging patients where they are and when they need care is central to the innovation principles at Children’s Health. A result of this approach is also a complete health record for an individual. Pete Perialas, senior vice president of population health, emphasized,

“We want to reinforce the patient-centered medical home. These kids and their families look to us as a partner and support services organization. Just going to urgent care or the first doctor that will see you erodes the whole concept of the core triple aim. By adding virtual health, we'll be able to deepen that patient and family relationship, which is good for everyone.”

Children’s Health is looking beyond the normal school term and applying a similar virtual health approach to summer programs. Virtual health is the glue to keep the patient-centered medical home together – delivering care when they need it, where they are.

Patient engagement principles that serve as a rallying point are:

  • Convenience
  • Accessibility
  • Deeper relationships
  • Connect with the patient through the continuum of care, delivering quality at each step
  • Deliver on the triple aim in a more modern way

Remote Patient Monitoring

Children’s Health is expanding their virtual health technologies to monitor remote patient health management activities. An example scenario is a child who has a life-threatening kidney or liver disease. They come to Children’s Health for a transplant and then go back to their hometown.

After the transplant, there are numerous follow-up visits to the surgeon and other providers. Over time and as the patient improves, the distance and inconvenience of travel can often result in no shows. With virtual health, those follow-up visits can happen more consistently.

The same principles apply to remote patient monitoring. The transplant group was the first pilot, working closely with Dr. Dev Desai, chief of pediatric transplant at Children’s Health. Two groups of patients were included with the pilot; post liver transplant patients (at or close to discharge) and adolescent kidney transplant patients. With a large group of adolescent transplant patients who have been on medications for a significant amount of time, transitioning to self-care can be challenging. Adolescents are fearless, so utilization and adherence to their medications are an issue. Missing their anti-rejection drugs will have big impacts. Nationwide, re-transplantations in this population is beginning to rise. Remote patient monitoring can help solve this potential issue.

Using a tablet creates a better user experience, so all of the devices are Bluetooth-enabled (e.g., blood pressure, weight, O2 stats). The data is synced to the tablet and then sent to a Children’s Health. By having the data collected and communicated, the patient visits are more productive since the physician has all the current data.

Getting real-time data from where the patient is located enables the care team to be more predictive without having the patient visit the hospital.

Also, with transplants, after their initial discharge, they usually come in twice a week for 4 to 6 weeks. Children’s Health can eliminate one of those visits with a virtual visit. An essential benefit from the virtual visit is they get better information because the child is in their natural surroundings. Kids are more comfortable in providing information when they are in their homes and the risk of encountering new infections is reduced.

Another benefit is better patient education. As with all transplants, medication changes may be necessary. to the care team at Children’s Health follow –up with patients to ensure they understand the new regimen and recognize the pills via phone.  Recently during a follow-up call the nurse was asking the adolescent if they had incorporated their beige pill. The patient was unsure if they had a beige pill. Using the RPM video system, they had the patient show their medications and clarify that the “off white” one is the beige pill being questioned. More clarity of instructions and importance happens by adding video to the follow-up care.

Virtual health and remote patient monitoring deliver more complete care while engaging young patients and their families in more comprehensive ways – a win-win for higher quality care and better patient engagement.

House Calls

At times, a physician or clinician need to be physically present. An on-demand service model is woven into our society. House calls are not new, although they are less prevalent today than many decades ago. Children’s Health jumped into the modern house call through a strategic investment in Mend, a Dallas-based concierge service for families.

Taking this approach incorporates convenience and develops deeper relationships with patients. Meet them in a place that is convenient for them – more than a statement, it seems to be a mantra at Children’s Health. Patient engagement increases with this mindset.

After a Mend visit, the next follow-up could be virtual. Melding the approaches keeps a health care system engaged with an individual and vice versa.

Pete Perialas says it well, “We are looking at this approach as another arrow in our quiver of how we connect with consumers, bringing health and wellness to the community in a way that works for them.”

Innovation Applied to Patient Engagement

Woven through the initiatives at Children’s Health are the concepts and practical application of design thinking, innovation, trusted agents, and building deep relationships with patients. With innovation, the Children’s Health approach starts with:

  • Is this a good idea?
  • Does it improve outcomes?
  • Does it improve the consumer experience?

If the answer is yes, then the conversation focuses on risk and evaluating a better way to keep an individual and family healthy. Follow-up questions include:

  • Does it improve the health and wellness of this individual?
  • Will it reduce claims?
  • Will it reduce future expense?

All good questions as better strategies are explored and implemented to engage patients.

Trust is a vital element. Trust is needed in the community – with patients and their families, with physicians and nurses, and with insurance companies.

As Peter Roberts, president of population health and insurance services, stated, “Trusted agents in the community are essential. A nurse in a school is a trusted agent. A specialty physician in the cancer program is a trusted agent. Your local primary care physician is a trusted agent. By building these relationships, we gain access to families where they are, and in return, they gain access to the highest possible quality of care.”

As Children’s Health exemplifies, trusted agents and design thinking serve the patients very well.

About Children’s Health℠

Children’s Health℠ is the seventh-largest pediatric health care provider in the nation and the leading pediatric health care system in North Texas, providing a full spectrum of health care services—from daily wellness and primary care to specialty visits and critical care. Holding eight disease-specific care certifications from The Joint Commission, Children’s Health has been consistently named one of the nation’s top pediatric providers by U.S. News & World Report. The Children’s Health system includes the flagship hospital Children’s Medical Center Dallas, as well as Children’s Medical Center Plano, eight specialty centers, 20 Children’s Health Pediatric Group primary care practices, nine Our Children’s House rehabilitation facilities, home health, physician services and the Children’s Medical Center Research Institute at UT Southwestern. For more information, please visit www.childrens.com.

Keywords: 
patient engagement, pediatrics, Mobile Apps