Connected Care: Adoption Requires Quadruple Aim Clinical Evidence

The term “evidence based” is used frequently but lacks the specificity and linkage to the Quadruple Aim essential to adoption of innovation, including connected care innovations. While the fundamental components of the Quadruple Aim—better outcomes, improved clinician experience, lower costs and improved patient experience—drive transformation in healthcare, clinical evidence development for connected care often focuses only on one or two of the aims. 

The four components of the Quadruple Aim | Source: Agency for Healthcare Research and Quality

In our recommendation to adopt public health emergency waivers permanently, clinical outcomes, evaluation and patient/provider preferences are key principles, taking a holistic, Quadruple Aim perspective that is needed to support adoption.

 

Connected care and digital solutions make sense and are attractive to adopt when they make care delivery simpler and easier, when they reduce healthcare complexity while also improving health. Incentives to adopt must be clear and aligned for all stakeholders—patients, providers and payers.

• Patients care about ease of use and what use means for how they feel (Quadruple Aims of improved patient experience and outcomes)
• Providers care about patient outcomes and satisfaction, workflow impact, and the role of connected care innovation in delivery of the professional standard of care (Quadruple Aims of improved outcomes and clinician experience)
• Payers (Medicare, Medicaid and insurers) care that “evidence based” is the demonstration of appropriate clinical outcomes accompanied by information on impact of the connected care innovation on costs (Quadruple Aim of lower costs), information that is important, but does not support adoption by patients or providers

Collecting the Right Evidence to Encourage Adoption

The bulk of the clinical evidence published on connected care innovations addresses the innovation’s impact on health outcomes, while pilots of innovations generally examine both costs and outcomes. While important, these evaluations and pilots fall short of the information needed by patients, providers and even payers for adoption.

Even though connected care is a means of exchanging information between patients and clinicians that is fundamental to care directions, medication dosing and coordination of services, evaluations and pilots that document patient engagement and preferences, provider workflows, and the role of these tools to deliver services are integral to standards of care lags. Simply, patients and providers are the integral users of connected care and clinical evidence needs to provide the full range of information for patients and providers to evaluate and use these innovations.

“Only one study has surveyed patients with hypertension in the outpatient clinic setting about use and preferences of ICTs for information and communication.” – BMC Patient Preferences for Using Technology in Communication About Symptoms Post Hospital Discharge

For patients and providers, the lack of evidence addressing their key issues and questions is at the heart of uneven and slow adoption of connected care. Without clear information addressing the patient and provider experience, there is no incentive for patients or providers to adopt these tools because they do not understand how and why they should be implemented into daily work or life. The information needed to adopt these innovations for both patients and providers includes:

1. What does the innovation do for patients, for providers?
2. How can it be operationalized for patients, for providers?
3. Why would patients or providers use this tool?

Currently Available Clinical Evidence and Needed Shifts

The Agency for Healthcare Research and Quality (AHRQ) evidence-based practice center publications on telehealth focused on health outcomes provides the information that all stakeholders need. Later publications, on the role of mobile applications included a limited effort to evaluate patient experience. AHRQ states, with regards to adoption of connected care (e.g., digital medicine tools):

“Today, AHRQ’s resources don’t achieve their full potential for driving care transformation toward the Quadruple Aim because AHRQ and the stakeholders who can benefit from them do not share an understanding of how these resources can be best delivered and used to enhance clinical workflow, information flow, and outcomes.” – Agency for Healthcare Research and Quality ACTS Supports the Quadruple Aim

Even more concerning is that professional standards of care rarely include notation of whether and for which service digital tools effectively provide the service or step integral to the standard of care. For example, in a search of remote monitoring in standards of care for heart failure, remote monitoring is recommended for patients in skilled nursing facilities. It was not part of care guidelines for those who may be living at home. Yet, heart failure is clearly identified by AHRQ as one of the examples of where evidence clearly supports use of remote patient monitoring to improve outcomeIn contrast, the United States Preventive Services Task Force (USPSTF), an advisory task force that conducts evidence review and recommendations on prevention for primary care clinicians, has begun to include intervention modality as part of their evidence review, e.g., how the preventive intervention was provided and when digital tools, online-based services, or telehealth delivery is supported by the evidence. USPSTF recommendations on behavioral counseling to reduce cardiovascular risk, screening for hypertension, and gestational glucose monitoring all include clear notation of remote or digital intervention modalities.

“Face-to-face sessions with or without additional telephone- or web-based or other technology-enhanced components. Group sessions typically included an additional individual meeting for each person.” – USPSTF Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling Interventions

And USPSTF identified recommendations for screening adults for hypertension that include reference to connected health tools.

“Ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) with validated and accurate devices should be used outside of a clinical setting to confirm a diagnosis of hypertension before starting treatment. Ambulatory blood pressure monitoring involves wearing a programmed device that automatically takes frequent blood pressure measurements over the course of a day (or day and night); HBPM involves patients measuring their own blood pressure at home with an HBPM device.” – USPSTF Hypertension in Adults: Screening

What evidence do patients and providers need to adopt connected care?

• Impact on outcomes that improve quality of life and outcomes: hospital admission reductions, days of normal activity, biophysical indicators of controlled disease progression, improved compliance with medication or other prescribed therapy
• Ease of use: patients/consumers can and will use the app or device consistently and with few errors and little need for technical assistance
• Workflow: patient-generated health data reported to the clinician is useful, is easy to read, and can be incorporated into a busy, in-person practice with ease

As long as pilots, studies and professional standards of care seldom provide the information or analysis needed to navigate the use of connected care for patients or providers, we should expect slow adoption.

Collaborating for Clinical Evidence Development

All stakeholders need to collaborate to document and develop evidence on connected care innovations aligned with the Quadruple Aim. Information on how the innovation incorporates into provider workflow, the ease of use for patients/consumers; and impact on quality of life (not just improved health) must become routine parts of clinical evidence development.

Publications that focus on how and if connected care (e.g., digital tools) effectively delivers services that are part of the professional standard of care will be needed if they are to be a routine part of care delivery. Without such information, professional standards will continue to solely document in-person services, without mention of the use in other settings. Routine and daily use of these innovations by all health stakeholders requires robust information addressing workflow, ease of use, outcomes, quality of life and costs.