Digital Medicine is a nationally recognized, clinically proven program revolutionizing how we treat chronic conditions combining digital tools and engagement with a dedicated care team.

Ochsner O Bar Supports Patient's Digital Health needsIn 2015, Ochsner Health launched its first Digital Medicine Program for Hypertension. Since publishing success outcome measures in The American Journal of Medicine, Ochsner’s Chief Clinical Transformation Officer Dr. Richard Milani, and his team have built on the framework to support patients with chronic conditions (e.g., Diabetes, COPD) and Maternal care. Over 30,000 patients have participated in an Ochsner Digital Medicine Program.

With the cost of chronic care, including indirect costs (productivity loss) reaching $3.7 trillion a year, Ochsner is focused on better managing chronic care through three key levers: medication management, behavioral change, and frequent data collection from home.

Milani believes that a successful Digital Medicine Program must:

• use the latest guidelines for medication management, important because ideal medications are always changing, and a certain medication may be more effective for one patient (profile) than another.
• be designed with behavioral science to impact lifestyle change, which includes everything from delivering the right type and timing for nudges to aligning patient needs with right level of high touch care support.
• leverage data captured and presented within a reasonable time so that clinicians can respond before the patient’s health becomes a problem.

Dedicated Team, Centralized Monitoring

Ochsner’s Digital Medicine programs are supported by a dedicated team of over 60 professionals, including clinicians, coaches, pharmacists, physical therapists, behavioral scientists, IT developers, technology engineers, user experience, content specialists, data scientists and advanced analytics.

Team members help patients throughout their program journey, with onboarding, educating and ongoing care support.  An important benefit of having one Digital Medicine team is that the program can be personalized to the patient’s specific needs (e.g., required monitoring devices) and supported by the same clinician and coach.

EMR Foundation  

“The technology foundation of our Digital Medicine Programs is the EMR Epic,” explains Milani.  “Our patients are given clinically validated devices approved for the program, with device data flowing into the EMR.”

Ochsner has evaluated and selected a set of devices for this program for each condition, which patients are required to use to connect into the Program. Ochsner distributes the devices and is the point of contact for any technical issues.

Patients access their Digital Medicine Program through the Epic portal My Chart (via website and patient mobile app), where they can view trends on device measures, access educational information, complete assessments, and exchange messages with the Digital Medicine Care team.

“For our clinicians, we have designed dashboards which help triage and prioritize patients based on incoming patient health data including Social Determinants of Health,” says Milani “We have set up alerts for our program care team based on selected physiological and inputted measures.  Other providers of the patient’s care can access information in Epic, including a Monthly Report.

Patient Digital Medicine Program Experience

Ochsner Digital Medicine Patient After a referral from his physician, patient Peter (not his real name) is invited through Epic to participate in Ochsner’s Hypertension Program. Participating in the program means that Peter can reduce time off from work and save time driving time for some appointments.

Peter has the option of having the device(s) and program setup information mailed to him, or if nearby, Peter can stop by Ochsner’s O Bar – a physical location that allows patients to test drive more than 100 Ochsner-approved health apps and purchase devices. There’s a technology specialist behind the counter to answer questions and give app demonstrations. (Think genius bar to support patient health technology).  

Once Peter sets up his blood pressure monitor, his measures are sent to his care team. If any measures are out of range, his care team will reach out to discuss any possible changes needed. Peter’s coach sets up personalized messages regarding lifestyle changes needed and reminders to keep him on track with taking his medication and taking his readings. Peter can communicate with his coach via SMS texting, My Chart messages or via phone.  

“We are seeing that patients prefer to communicate asynchronously with their clinicians and coaches, so we are giving them the tools to do so,” says Milani.

Digital Medicine Program Success

“We evaluate success based on a few key measures,” says Milani. “We look at outcomes and are seeing a consistent 2-3 times improvement in control rates with our program. We also look at Net Promoter Scores (NPS) and we are getting very high patient satisfaction scores of 87-90.”

Ochsner recently conducted a pilot program (beginning in June 2020 and ongoing) to investigate how digital medicine with remote patient management can improve outcomes for Medicaid patients battling chronic diseases like Hypertension and Type 2 Diabetes. The results were statistically and clinically significant. Enrollment in Ochsner Digital Medicine brought nearly half of all out-of-control Hypertension patients under control at only 90 days, which was 23% more likely than usual care. Control rates continued to improve as patients remained in the program during its first 18 months. More impressively, 59% of people with poorly-controlled diabetes achieved control over their condition as part of the digital program – a rate twice as high as usual care.

Most patients achieved control of their hypertension and diabetes within 90 days of beginning the program, even those who had poor control prior to enrollment.

In addition to improving health outcomes, participation in the digital medicine program resulted in high patient satisfaction, with a net promoter score greater than 91 for Medicaid participants. This is consistent with the high patient satisfaction with digital chronic disease management programs at Ochsner among non-Medicaid patients.

“We're offering patients compassionate human care combined with the power of technology, and we’ll continue to expand these programs to help more patient populations”, Milani concludes.

Success in their words

Patients:

“My care team has been really helpful. They’ve explained things to me… offered me suggestions. I really like the fact of daily accountability. I’ve lost about 103 pounds. I feel better. I have energy that I didn’t have a year ago.”

“I know I’m sleeping better–my hair, my skin, my vision–just different things that you start to notice that we take for granted that are all tied into our blood pressure and blood sugar. I’m a living testimony that it (the program) works! I know for a fact Ochsner Digital Medicine has saved my life.”

“I feel like this is more normal. Someone’s got my back and… I will be able to use [the program] for the rest of my life.”

“The Ochsner Digital Medicine Care Team helped me by guiding me in every way possible – giving me tips on my diet and adjusting my medication on the fly. They are a good support team.”

Staff:

“I love the Ochsner Digital Medicine program. As a physician, I love having the Digital Medicine team helping me because it’s like having other coaches on the team.”  Dr. Victoria Smith

Ochsner’s Digital Medicine Program is available to employees across their health system. 

“The Ochsner Digital Medicine program is one of the most important components of healthcare for our (employees). If I can offer better benefits and possibly reduce healthcare costs, why wouldn’t I? We have had employees sign up for the hypertension and Type 2 diabetes programs and have seen many positive results in a short period of time. The program lets your employees know how much they mean to you by investing in them”, Chief of Administration, Chris Kaufmann

It all started with a simple question one day, and grew into a trusted health relationship a few short months later. Sarah was very busy at work that crisp fall morning and had only a few minutes to log in and ask about her daughter’s diabetes medication. Sarah was comforted by the response and a bit intrigued when her Health Assistant Harriet introduced herself and explained that she is a resource to help her and her family with any of her health questions or concerns. They began a conversation about her daughter’s condition and a trusted relationship began.

Later that week Harriet made a follow up call to see if Sarah was able to pick up her daughter’s medication and asked how everything was going. Sarah mentioned that she finally got her daughter’s pills and confided that she was completely overwhelmed. Sarah shared that she was recently diagnosed with breast cancer and that her husband was often unavailable as he traveled constantly for work. She explained that she had a hard time getting to her treatments. After their call, Harriet explored and evaluated resources, and scheduled transportation to help Sarah get to her next appointment. Harriet put the appointment confirmation into Sarah’s patient portal and set up a reminder, including date and time, about the ride to her next treatment.

This may sound like fiction in the current healthcare environment, where services are siloed and patients are burdened with making their own decisions around healthcare – often complex and costly. Sarah is relieved to have this service today. She first learned from her employer about the Accolade platform and health advisor service last summer. It wasn’t until she reached out with a simple question to her health assistant that Sarah experienced the true value of having a healthcare advisor on her side.

A 2016 Harris Poll reveals that 84% of working families placed a value on having a single, trusted resource to help support their healthcare needs. Busy families have limited time and resources so they appreciate having one place to go to help them understand their options and sort through their healthcare decisions. 

Personalized Patient Experience

With the Accolade Health Assistant as the single point of contact for her family, Sarah is able to reach out to Harriet for guidance all along her and her family’s healthcare journeys.  Accolade integrates high tech and high touch to deliver a superior patient experience with lower healthcare costs. 

Accolade Health Assistant Harriet accesses the Accolade platform to interact with and personalize her support for Sarah:

Preferred Communication: Harriet engages with Sarah and her family based on their communication preferences. Sarah likes phone calls and email through the Accolade online portal. Sarah’s husband Sam prefers secure text messages since he can send quick messages and follow up later during his business trips.  

Personalized & Proactive Experience: Harriet’s interactions with Sarah are driven by rich patient profile information, which contains contextual information, social determinants of health and service utilization. Sarah and her family’s profiles are updated with data collected over time and more than 150 data feeds integrated into the Accolade platform. The HIPAA-certified approach creates profiles that are continuously analyzed through sophisticated algorithms and health assistant reviews, which allow for personalized conversations around individual health needs, care gaps and obstacles.

A recent Accolade platform trigger prompts Harriet to reach out to Sarah’s husband Sam when she notices that he is still refilling this pain medication many weeks after his knee surgery.  Harriet sent a text to Sam to inquire about his knee surgery. After a text exchange, Harriett suggested that he see his doctor to discuss his persistent pain.

Patient Education & Connected Health: Sarah and her family can access educational information and recommended health apps. Before Sarah’s husband knee operation, Health Assistant Harriet texted Sam with a link to a video and suggested questions to prepare for his surgery and provider discussion. 

When Harriett spoke with Sarah about her daughter’s diabetes appointment and care plan, Harriet informed Sarah about the Livongo mobile diabetes application available through her employer’s health plan. Together, they review the Livongo app, which can help Sarah and her daughter better track and manage her diabetes. With Accolade and Livongo, Sarah is able to share information from the mobile app with her daughter’s doctor, giving him insight into her problems with controlling her A1C levels.

Continuous Connection to Clinical Resources and Support:  Harriett asked Sarah if she would like to speak with an oncology nurse to help prepare her for her upcoming oncologist appointment. Margaret, an Accolade Clinical Health Assistant and RN, joined them on the line and offered empathetic support by asking more about Sarah’s diagnosis, where she was in her care plan with her doctor, whether she had a support network and what was planned for her next appointment. Margaret provided Sarah with questions to ask her oncologist and recommended a follow-up discussion.

Intelligent Engagement: Harriet and her Health Assistant team are continuously alerted by the Accolade platform. On an ongoing basis Accolade gathers, aggregates and models de-identified data to trigger alerts and guide Health Assistants in further personalizing their interactions with their clients.  Health Assistants are prompted to ask questions about health behaviors and emerging symptoms, applying specialized training and skillset. 

Patient Experience Success Measures:

Paul Csigi, Director of Benefits at Philadelphia- based Temple University Health System (TUHS), rolled out the Accolade solution in 2015 and has over 7,000 employees on the platform today.  “So much of healthcare is getting people to the right place at the right time. Accolade has created an experience where our employees build a relationship with an assistant that gives them what they need, when they need it. Accolade takes a single problem that the patient has called in about and creates a relationship to support the family on an ongoing basis. With all of the information about our employees, Accolade addresses the whole person, connects the patient with clinical resources, and continues to reach out. This helps treat our employees sooner, which is less expensive for our organization.”

In addition to financial measures, TUHS monitors qualitative feedback from employees. With the Accolade platform outreach (phone or online), TUHS is able to capture the patient’s experience engaging with their Accolade Health Assistant:

“I'd like to thank Temple for the Accolade program. We have been going through some really tough times…..my health assistants have been a big support and a big help to my family in helping to guide us to the right doctors to help with family issues and illnesses. I really appreciate this program. Without it, I'd really be lost.”

With two years of the Accolade solution under their belt, Paul Csigi and his team are considering new ways to support TUHS employees. “I have an employee population with diabetes and heart disease. I am interested in learning more about Accolade’s partnerships to bring patient data into the platform to support these populations.”  Csigi sees the benefit of bringing in data from patient devices and smart applications. Integrating this data with the patient’s medical record gives new insights to Accolade Health Assistants, empowering them to deliver even better support and drive improved outcomes.

OMADA HEALTH CONSUMER VIEW

OMADA HEALTH COACH VIEWTeammates and their coach collaborate via the Omada Health platform. The coach monitors progress and gives real-time feedback via private messaging, group discussion board, text messaging or by phone. Teammates use food and activity trackers to capture high level daily eating, drinking and movement and engage in “healthy competition” messaging with other group members. Cohorts keep them motivated and accountable. Teammates can see the cohort member’s progress towards the weight goal displayed on the group dashboard by a green circle around their profile picture. Only the coach can view each teammate’s detailed progress page with tracked weight, food and activity information.