Inception Health Team Creates Pyramid Model for Deploying Digital Therapeutics
The Froedtert & Medical College of Wisconsin Health Network created Inception Health six years ago and built a multi-disciplinary team to collaborate with innovative companies to develop and scale up digital solutions across the health network. In a recent presentation, three Inception executives discussed their progress in deploying digital tools for 29 different conditions.
Based in Milwaukee, the Froedtert & Medical College of Wisconsin regional health network includes eight hospital locations, nearly 2,000 physicians and more than 45 health centers and clinics.
Speaking last week at the OnRamp Healthcare Conference, Mike Anderes, P.T., M.B.A., chief innovation and digital health officer for Froedtert Health and president of Inception Health, noted that digital therapeutics is a term that can be either very general or very specific. He noted that Inception thinks about in this way: For many medical conditions, there's a behavioral component, or there are decisions that the patient or consumer can make that have an impact on their outcomes. “Just as we think about pharmaceuticals affecting biology, we can think of digital therapeutics affecting behavior,” he said.
“We think because so many medical conditions have a behavioral component or decisions that patients make, it's important to have some tool that you can give them that can help them with that decision making,” Anderes said. How these things are delivered is actually really variable, he added. “We've seen digital tools that are basically chat-based, almost like you're doing a text message back and forth. We've seen it where it's an app, something that's really an encapsulated program that uses some of the different features and functions of a mobile phone to connect other devices or make that a more holistic experience. We haven't seen virtual reality and augmented reality become a way to deliver digital therapeutics,” he noted. “At the far end of the spectrum, you'll see some organizations have built hardware that's integrated with software into one package for a specific disease.
Across the country, we are starting to see more and more spending in this space, Anderes said, “and with that spending comes better tools and more integrated experiences. We're seeing payers, pharma, health providers, employers, and of course, big tech, all investing in this space,” he added. “Everybody is trying to own a piece of this emerging technology. This is a very complicated space that we feel is going to make a significant impact in the coming years on overall healthcare outcomes based on the talent and money and the diversity of approaches that are being taken.”
Earlier this year, Brad Crotty, M.D., chief digital engagement officer for the Froedtert Medical College of Wisconsin Health Network, and the chief medical officer for Inception Health, discussed with Healthcare Innovation the organization’s efforts to build up a digital health formulary, including created decision support tools in Epic around recommending such a service.
At the OnRamp Healthcare Conference, Crotty painted the broad picture of how they hope digital can help improve people’s health. “When we think about the clinical care that we provide within our four walls as a as a health system, or as a clinic, we account for about 20 percent of a person's overall health,” he said. “Health is essentially quality of life and longevity of life.” The other components that make up the other 80 percent are things like behavior — whether you smoke or not, for example, or whether you follow a particular healthy diet, whether you exercise, also the social determinants of health in the built environments, some of which are modifiable, some of which for many people are not modifiable, he explained.
“What’s really exciting about digital therapeutics is an ability to get outside of the four walls of the healthcare that we provide, that we know about, and actually get into the home, through a smartphone or through a computer and to be able to influence, to be able to interact, be able to help support people along their health journey,” Crotty said. “This is really an area that we in the healthcare system have not been able to get into in the past. Hopefully, we can start to expand that 20 percent into that other 80 percent by starting to influence things like behavior.
Inception uses a pyramid as a model in terms of thinking about patients and care teams interfacing using digital tools. “At the base of the pyramid, we consider digital is providing education and support for self-service,” Crotty explained. “This can be patient education; it also could mean adjusting medications following a simple algorithm. There's been research over the last few years about being able to adjust blood pressure medicine just by algorithm and having the computer program help people follow through. We also have an FDA-approved digital therapeutic that we have been using to help people adjust their insulin doses based on what their blood sugar levels are. People are able to do that entirely within the application without intersecting with another care provider. The more that we can enable self-service with support and with guardrails, making sure that we're doing it in a safe, appropriate manner, that's what we consider a base layer of digital support.”
The next level of the pyramid he described is where there is interfacing with care teams through a health coaching functionality. “We have seen examples where digital can support providing care to more people, because you can really target who you need to reach out to and who's actually doing okay,” Crotty said. “You could think about building a program for weight management, for example. If you had a digital program that tracked people and can see that they were checking in and following through with their care plan, you could say, yes, you're doing okay. But if someone's not being able to follow through with that care plan, and they need a little bit of extra attention, maybe you want to call that person, maybe we want to set up a virtual visit with them to really dig in and see what's going on.”
At the top of the pyramid, digital can provide a more effective way for professionals — physicians, nurses, and pharmacists — to help guide patients. “An example is our program in diabetes, where patients can be using the software to track what they are eating and what their blood sugar levels are,” Crotty said. “Then we can have our diabetes nurse educator looking through those logs and providing some guidance to patients based on the live data. So rather than starting at the top of using digital just as a way to have those professionals augment interactions, we've been looking to see how we can provide better support for patients with as little professional guidance as necessary as long as it's safe and appropriate. What we're really trying to do with digital is, within safe and appropriate boundaries, enable people to create and follow through with their care plans at home.”
So what kinds of things does Incepton look for in a digital therapeutic? “One is that it's evidence-based,” Crotty said. “The program needs to be rooted in a clinical guideline or an evidence-based body of work. When we look at behavioral health interventions, when we look at obesity interventions, when we're looking at diabetes interventions, we are looking to see that the digital therapeutic follows the current practice of medicine, the current evidence, and particularly bringing in different evidence-based approaches on things like behavior change, behavioral economics, some that come from the sociology literature, not necessarily just from the medical literature. We want to see that it is safe, and that it follows FDA guidance as appropriate. We want to see that people have done research to not just claim but to really demonstrate that they can show both safety and effectiveness.”
Erica Smith, PharmD, director of the enterprise care coordination team, noted that when they first began using these digital tools, there was inconsistent workflows with each tool, with regard to how to offer the tool to patients and for providers to be able to follow up on progress. “We quickly realize to get any sort of scale using these tools, we would need some sort of coordinated integration engine that could provide a consistent experience for clinicians seeking to order or prescribe a digital tool and a consistent experience for the patient in how to get started, or share information back with their clinician,” she said. They partnered with an integration company called Xealth to build consistency in the ordering, activating and monitoring workflows. That has helped with the evolution from having single provider-based conversations at a visit to more bulk or automated ordering, she added.
Smith gave a few examples of digital tools in use. The first is a diabetes tool that's best for patients who test their blood sugars regularly and are willing to engage in an active period of time of more intensive management to help get their blood sugars under better control, she said. “This a perfect rationale to have the ordering workflow be at the discretion of the clinician, in this case, a provider pharmacist or RN. Upon order placement, the patient gets an email to register. They have to share what type of glucometer or blood glucose meter they use. And then they get a kit tailored to them shipped to them with hardware that allows them to share their blood sugars back and forth with their clinical team.” From a formulary perspective, you want this option to surface for patients who are most likely to benefit and need that level of support, she explained.
Another example she gave is when a patient transitions home from the hospital, there are common issues that come up within one to two days, three to five days out, and some things you want to check in on one to two weeks later. “We were able to leverage our agreed-upon system of care for our patients being discharged home to receive a digital engagement tool that anticipates these common scenarios and questions, provides education and patient check-ins, and then can trigger alerts for clinical follow up,” Smith said. “We were able to set this up to automatically trigger for patients and weave it into both our enterprise care coordination teams support model, as well as across our primary care team workflows.”
She said they currently have 29 conditions with requisite digital tools in the formulary. “In some cases, we have multiple tools for a specific condition. Diabetes is the classic example, because not every diabetic has the same needs, and those needs can evolve over time.”
Measuring the impact of these tools can be tricky, Smith noted. “It’s really important to be clear upfront about the problem you're trying to solve. That helps you get to the right solution, rather than having a solution and then going and seeking a matching problem. As we consider measuring value, there are different perspectives that digital can bring. We think of it as a balance of the patient perspective of value, the clinician or provider perspective, the health system or funding source, and then a population health perspective. In the early days, we really focused on tool utilization, both from the clinician’s and the patient's lens. But measuring that incremental clinical benefits and population penetration, like how much can we rely on this tool to help serve our patients, as well as return on investment, are active areas of both research study and performance monitoring.”
