In January 2015, Stanford Medicine launched ClickWell Care, a new type of Primary Care clinic which leverages technology to allow patients to virtually connect with their own Stanford primary care clinicians and wellness coaches via video or phone visits.  Patients use the MyHealth mobile app to schedule and conduct a video visit and share home health device data with the care team. Through this model, patients can choose to receive all of their primary care including integrated wellness coaching virtually, unless the physician indicates the need to come into the clinic for vaccinations, pap smears, procedures, or other physical exam needs.

“Initially we created this virtual model for our ACO. We knew that 18-30 year olds were not interacting with primary care and were choosing to go to the Emergency Department or urgent care for their needs. During focus groups with this patient population, we learned they were so busy and didn’t have time to come into the office but really valued the relationship with their doctor. They wanted to receive care from their doctor but it wasn’t available in a way that was convenient to them.  We knew that we needed to use technology to help support this relationship and not replace it”, explains Sumbul Desai, Medical Director ClickWell Care and Vice Chair of Strategy and Innovation in the Department of Medicine at Stanford University School of Medicine.

ClickWell clinicians and coaches support healthy patients and the ‘rising risk’ (e.g. up to 2 conditions), who are employees of Stanford University, Stanford Adult and Children’s Hospitals. With this highly educated, tech savvy patient population, there is a tremendous opportunity to leverage mobile tools to enhance the patient experience.

Patients see a doctor for primary care visits and engage with a wellness coach on health goals (i.e. weight loss, stress, activity, and nutrition) and to receive support for chronic conditions (i.e. diabetes, hypertension and hyperlipidemia).  “The average age of a ClickWell patient is 36 years old.  However, we have a growing group of 40-65 year olds, part of the ‘rising risk’ population, who prefer to do the majority of their visits virtually. These patients feel comfortable interacting by phone or video because they have a better understanding of the healthcare system and their health goals than our younger patients”, Desai shares.

The ClickWell Care program is designed to give patients complete control over how they want to access and interact with their doctor/coach and convenience of extended hours. Although patients have the option of scheduling a face to face appointment, they are incentivized to participate in a “no fee” virtual phone or video visit. Patients simply log into the MyHealth portal for their virtual appointment. 

To date in the ClickWell program, there have been 2,142 visits; 43% conducted in-person, 32% through phone visits and 25% via video visits. ClickWell staff have seen 1,223 patients. Although 30% of new patients start off with a virtual visit, most prefer to meet their doctor first in-person. After an initial face to face visit, 60% opt to see their doctor virtually for their return visits via phone or video.

MyHealth Mobile AppAll patient information from the virtual visit is transmitted to the Epic EMR and is accessible through the MyHealth portal. Patients can ask follow up questions through the portal.  When patients need to have blood work done, they are directed to the lab without having to come into the doctor’s office, and lab results are incorporated into the EMR with portal access. “Stanford was the first to use Epic’s integrated telemedicine service because we wanted this visit information available to patients in the portal and clinicians in their daily workflow”, confirms Lauren Cheung, Physician, ClickWell Care, and Medical Director, Strategic Innovations at Stanford University School of Medicine.

“One myth about telemedicine is that many patients choose to do video visits over phone visits. The truth is that it is an extra effort for the patient to participate in a video visit since the patient needs to be in front of a computer or mobile screen versus the phone visit which can be done while walking around”,  Cheung adds.

“Back in 2013, we rolled out video visits as part of our primary care practice but we didn’t see a strong uptake. When we conceived the ClickWell Care program, we knew that we needed to introduce wellness coaching to provide a complete overall healthcare experience and deliver a higher level of healthcare service to our patients”, describes Desai.

Strong collaboration with IT and Operations have been pivotal in implementing this new care model. Through this collaboration, ClickWell has been able to leverage the new MyHealth app developed internally and has worked closely with IT to improve the platform and video visit capabilities to provide an excellent patient experience.

As part of the ClickWell Care program, the MyHealth mobile app helps strengthen care collaboration. The doctor/coach prescribes the health tracking app to the patient as a way to monitor key measures which may include steps, weight and blood pressure. The patient uses the MyHealth app to upload tracking data from Withings, Fitbit and Apple HealthKit to the EMR, sharing health status between visits. “When I see a patient with blood pressure trending higher, I ask the patient to schedule an online visit so that we can discuss how to address this through diet or medication changes”, Cheung explains.

ClickWell Lessons Learned

The Stanford Medicine team has gained insight into ClickWell Care program usage, the telehealth platform and mobile app to bring the most value to primary care patients and providers. They understand that it is not about the technology but instead about how the technology is put into the care model through a program.

Patients have shared many positive comments about the ClickWell Care program:

“Video visits allowed me to continue with pressing work concerns, instead of taking time off work to travel to a clinic. Video visits allowed me to chat with a Doctor late in the evening, and appointments were very easy to get.  I felt that my virtual care was more personalized and provided a better experience.”

“I have not had many medical issues until recently. It is such a relief being able to ask questions and get answers quickly. My wellness appointments have me watching my diet and exercise regimen. Everything is done efficiently. I cannot say enough about the whole team that has been watching over me.”

“My experience with the ClickWell Clinic has been extremely informative and remarkably efficient. The flexibility they offer works perfect for people with busy schedules, without sacrificing the quality of care. The model of the Clinic makes other forms of healthcare communication feel outdated.”  

“I have never had better communication and quicker responses than I have since becoming part of this program. I travel a lot and therefore keeping up via phone calls is not that practical. Being able to send messages electronically and to have an appointment via video chat is ideal.”

Doctors and wellness coaches have provided mostly positive feedback as well:

“Overall my experience with virtual visits in the clinic has been very positive. Compared to my previous experience with only in-person visits, it seems like the virtual option may make wellness patients more likely to continue with follow-ups. The integration with the doctors is also helpful in learning more about the patients and providing well-rounded care. It is a unique experience to be able to discuss treatments so closely with the patient’s doctors and in such a timely manner.”

“The integration of clinical care with wellness coaching has been phenomenal. I couldn’t imagine going back to health coaching without it. I am able to provide more targeted, individualized, and thorough care to my patients since I have full access to their medical records, provider notes, and work directly with their primary care physicians. Working directly alongside physicians has helped me to expand my knowledge on chronic disease management, stay up to date on clinical guidelines and recommendations.”

“As a provider, the technologies we use in this clinic allow us to quickly connect with our patients and address concerns for our patients proactively. The extended hours also allow for expanded patient access, as well as a flexible schedule for providers who staff the clinic who may desire alternative hours outside of the usual 9-5 business day.” 

“Through our discussions with patients, we have also heard some suggestions for change. In the beginning, we were contacting patients to convince them to switch from in person to virtual visits. This frustrated some patients and most wanted to stay with the modality that they had initially chosen”, Desai shares. 

Future ClickWell Care

As with other healthcare systems across the country, Stanford Medicine sees what is happening with the retail pharmacies increasing care access to patients. However, they believe this only fragments care because the visits are outside of the patient/doctor relationship. ClickWell Care is designed to be “longitudinal” and not episodic.

In 2016, Stanford Medicine is looking to extend into specialty care. “We are interested in integrating preventative cardiology for our patients since care entails discussing and improving risk factors for cardiovascular disease, which can be done virtually. Preventative cardiology patients would also benefit from wellness coaching to improve their risk factors for disease.

We also want to expand the use of connected health devices. Currently, very few patients upload and share their data with our care team. We are planning to incorporate this health tracking into a program for a  patient population (e.g. specific chronic conditions) and integrate this information into clinical workflow to ensure that these patients receive excellent care. With our Precision Health initiative, we are not just interested in treating illness but rather finding tools to deliver a personalized health and wellness experience to ensure the best outcomes”, Desai concludes.

Dr. Milani with longtime patient Andres Rubiano, pilots Apple WatchDuring the last eighteen months, the Ochsner Health System has moved into new territory, meeting consumers where they are, from their OBar, a retail genius format to patient hypertension pilots with the Apple Watch to drive behavior change. 

As an innovative healthcare organization, Ochsner, a large Louisiana- based health network with 12 hospitals, 40 clinicians and an a 1,000+ Physician Group Practice, is committed to helping consumers use mobile and wearable connected health tools for self- management and care collaboration

It all started back in late 2013 when Dr. Richard Milani, now Chief Clinical Transformation Officer and Vice Chair of Cardiology at Ochsner, observed what was going on nationally, a tremendous growth of mobile phone and smart apps. “At the time, I noticed that a lot of people didn’t know much about the health apps and wearables or were fearful about how to use them. My background is in preventive medicine”, explains Dr. Milani. “I saw a powerful opportunity for Ochsner to empower consumers to use mobile technology to enhance their health, opening the door to favorable behavior change.”

OBar, Retail Genuis Bar with Apps & Devices  

After more than nine months of planning, Ochsner launched their OBar in early 2014 at the new Ochsner Center for Primary Care and Wellness. The OBar is located in the lobby to attract people walking by as well as patients. The retail store is welcoming with digital tablets loaded with vetted mobile apps to support consumer health, “non-clinical” genius types to answer questions, provide guidance and sell discounted devices (i.e. Activity Tracker, wireless scale, blood pressure cuff and glucometer). “We created this retail setting to show people how to make themselves healthier on their own, independent of their health system. We also felt that as a health system, we could show you which health apps were good and can help you get the app loaded on your phone to begin using it.”

Doctor gives patient RX for App, directs to OBar Ochsner wanted to go further, tying the OBar into their primary care services. Dr. Milani and his team created a prescription pad for their PCP offices, which lists the types of available apps and devices. The doctor simply checks off, hands the patient a prescription pad sheet and directs him downstairs to the OBar. Since this extension into primary care, clinicians have heard back from their patients about how the apps and devices have helped them make better health choices around activity, diet and their disease. Patient feedback has motivated these clinicians to tell others about the OBar.

Dr. Milani went on to explain that the OBar initiative is not designed to be a profit center. As a non-profit, Ochsner is most interested in helping people stay healthy and has invested in a retail format as a way to be sticky to attract and keep consumers coming back. As with any retail store, visitors walk in and out which makes it challenging to capture and measure the value that consumers have gained from using these apps and devices. Through anecdotes, however, Ochsner has heard about the weight loss, the knowledge about “buying the right foods” and the ability to better “understand my disease”, which has helped many consumers visiting the OBar.

Apple HealthKit & Epic Integration for Connected Health

Ochsner was the first hospital to integrate the Apple HealthKit with their Epic system. This integration powers their Connected Health programs. While the patient is still in the hospital, she is given a tablet to answer a detailed questionnaire. Hypertensive patients, for example, are asked sodium consumption, medication adherence and affordability, social situations, depression, physical activity, BMI, sleep, Health literacy, Patient activation and more. Ochsner believes that patients respond more truthfully to the tablet.

“We are phenotyping patients based on their specific disease and psycho- social measures that are fed into algorithms to personalize the care plan and decision support tools”, Dr. Milani explains. “Ochsner started with Heart Failure in early 2014, with a program for CHF patients to avoid readmissions through weight monitoring. In February 2015, we launched our Hypertension Digital Medicine Program, monitoring blood pressure and heart rate. “With the HealthKit/Epic integration, we are able to use the patient’s unique responses to the survey combined with the monitoring data to tailor the intervention to the individual”, adds Dr. Milani. Ochsner care providers monitor the dashboard to determine which patients are the priority today and to see the task check list for action.

The national data reflects that currently, only 50% of individuals diagnosed with hypertension (high blood pressure) have their blood pressure under control, or at goal.  Lack of achieving goal blood pressure means that these individuals have significantly higher rates of stroke, heart disease and kidney failure. Ochsner has enrolled only patients that have failed to meet control blood pressure goals, and using this integrative approach, has achieved more than 60% control rates within 2 months.

Dr. Milani and his team wanted the patient to see his progress in the program and designed an insightful report, which visually displays results and progress, quantifies risk and describes how the patient can reduce that risk. This program report is available in the patient portal and is also mailed monthly to the patient. “We decided to mail the report because we wanted the patient to have the opportunity to share the report with their family and to have the discussion about how they are doing in controlling their blood pressure in order to strengthen every day support”, admits Dr. Milani.

In addition to the program report, program participants receive ongoing mobile texts for motivation and encouragement.

Ochsner closely tracks, monitors and has presented very positive patient outcomes of their Integrated & Connected Health programs. One interesting insight that Dr. Milani has shared is that these participants are more successful in the beginning when they have the OBar support. “A Hypertensive patient can go to our OBar, get the program app downloaded on her phone and a demonstration about how to use the devices. This is especially important with older patients who may not feel comfortable getting set up over the phone. We realize the importance of providing this face to face technology support for our Connected Health program and are adding OBars to our other regions”, confirms Dr. Milani. Ochsner is planning to launch three more retail OBars by the end of the year.

Apple Watch for Patient Pilot

Dr. Milani views the Apple Watch as a behavioral change tool. As a foundation, this is a wearable, with many non-health features which captures the consumer’s attention and motivates consumer engagement. It takes the consumer’s focus off the phone and onto the wrist to communicate time as well as personal and professional messages.

Ochsner is designing a study to understand the potential for changing the consumer’s behavior around health. They will be enrolling hundreds of hypertensive patients with the goal of increasing physician activity and improving medication adherence.

Dr. Milani mentioned two of the health related Apple Watch apps which he plans to incorporate to help patients achieve the pilot goals. “There is a WebMD app which is a great medication reminder. It taps you on your wrist and shows you the picture of the pill that you need to take at that time. This is important because 50% of patients with chronic disease do not take their medications as prescribed. The second built-in app is for physical activity which can be used to set goals. It will tap me and remind me to stand up every 50 minutes. I can also see how I am doing against my activity goals”, shares Dr. Milani.

For the Apple Watch pilot, Ochsner will compare the outcomes and behavior change for patients in their Hypertension Digital Medicine Program with a subset of patients who also have the Apple Watch medication and activity reminders and tracking. Throughout the pilot, Dr. Milani and his team will be closely monitoring whether and how these apps impact positive patient behavior change. 

You cannot turn on the television or look at a newspaper today without being reminded of the obesity epidemic facing our nation. According to a CDC study, over 37% of U.S. adults are obese, while about 70% are overweight.

 Obesity has been associated with certain chronic conditions such as diabetes (type 2), cardiovascular disease and stroke. Last summer, American Medical Association classified Obesity as a disease, and the National Heart, Lung and Blood Institute recently published guidelines recommending that primary care physicians provide obesity counseling to all patients with Body Mass Index over 25 (which classifies them as overweight).

Many Americans try to lose weight but do not have the tools or professional guidance to be successful. Most physicians don’t have the training or tools to provide a comprehensive weight management program in their practice, and sometimes refer patients to commercial programs that are not clinically supervised.

RediClinic has stepped in to help. “We have developed a medically supervised program which is not just about weight loss but about health management”, explains Danielle Barrera, Chief Operating Officer at RediClinic. “When we developed this program in 2009, we noticed that many programs on the market were missing critical elements of a successful weight management program, and did not incorporate healthcare professionals, who are well positioned to have a significant impact on their patients’ lifestyle and health decisions.”

According to IDC’s Connected Health 2014 Predictions, “Retail Clinics Will Disrupt the U.S. Healthcare System”. Most people think about Retail Clinics as a place for getting flu vaccinations or addressing acute problems such as strep throat or ear infections. Retail Clinics are bringing more services to the community and some are now offering preventive services (i.e. physical exams) and chronic disease monitoring.  

Over the past two years, RediClinic has been offering a weight management program called Weigh Forward. Shoppers walk into one of their 30 locations inside grocery stores to sign up for the 10- week program. During the initial visit, the clinician does lab work to establish a base line to monitor progress in key health measures.  Throughout the program, the clinician provides guidance and teaches life skills not only to lose weight, but keep it off.

“Our program is a ‘Connected Health’ model. Participants use the MyWeighForward  platform to access educational information, track food and physical activity, and receive online coaching and social support between visits to the clinic. During weekly visits to RediClinic, the clinician reviews the participant’s program information (i.e. goals, lab work, tracking information and eCoaching activity) to deliver personalized guidance.”

RediClinic’s Weigh Forward program incorporates four key components which are reinforced both in- person and online through the program’s technology platform – myWeighForward.com: 

RediClinics Patient Portal on MyWeighForward Platform

1. Medical. Initial medical assessment with a comprehensive set of lab work, regular biometric monitoring and measurement, and weekly counseling by healthcare professionals.

2. Behavior Modification. Proprietary assessment tool developed at Yale's Prevention Research Center by Dr. David Katz (WeighForward’s Medical Director) to identify and address individual barriers to success and readiness to change, to create a personalized weight loss plan.   

3. Diet & Nutrition. Online educational information on food choices, weekly meal plans with 500+ recipes, and access to a diet/nutrition e-coach.

4. Physical Activity. Customized activity plan based on preferences and abilities, access to fitness videos and the capability to collaborate with a fitness e-coach.

Consumer Experience with the Weigh Forward Program

Deborah Hastings signed up for RediClinic's 10- week Weigh Forward program to start shedding 60 pounds. Deborah's daughter is getting married in six months and Deborah wants to get around without pain in her knees and to fit into a new dress for this special event.

During her first appointment, she meets with a clinician for a comprehensive evaluation to discuss her health and weight loss goals and determine her overall health status and readiness for change. She learns that her cholesterol and blood pressure are both high and that she is at risk for Metabolic Syndrome.

She uses the MyWeighForward.com portal to follow a meal plan suggested by the clinician and dietician eCoach, view exercise videos, and to track both her food and physical activity.  

Patient prepares for visit with clinician at RediClinic

Deborah is preparing for week #5 visit which is teaching her that it “takes a village” to help her achieve her goals, and she needs support from family, friends and office co-workers. She inputs her Visit objective, completes her checklist of specific tasks and selects a "Barriers to Bust", how to deal with family when they are sabotaging her diet. This barrier is posted on her Visit Plan which she will review with the clinician during her RediClinic visit. While Deborah finishes her homework, her clinician reaches out to the eCoach that Deborah has been working with to discuss nutrition concerns. Within the private clinical portal on the Weigh Forward platform, they discuss strategies for Deborah. During the upcoming visit, Deborah will work with the clinician on the barrier she has selected and will consider suggestions from her eCoach. 

Deborah has taken advantage of the social community capabilities on the Weigh Forward platform. She created a profile with demographic information and indicated how much program information to share with other participants. Deborah has decided to share the “Busting the Barrier” badges that she has earned each week. Deborah searched to find others like her and has connected with over a dozen new friends. She has also found an online group with her same barriers and is looking to gain some new real life strategies to address them.

During her week #9 visit, her clinician will take a blood sample to compare key biometric markers to those measured at the beginning of the program. She will be able to view these measures and see her progress in reducing her cholesterol and Metabolic risk in her MyWeighForward program account .

With several months before her daughter’s big event, Deborah is motivated to extend the program. She is planning on paying for the "Boost Maintenance Program with ongoing access to MyWeighForward with e-coaching as needed, monthly clinician visits and weekly in-clinic visits for "body composition analysis/biometrics".  

Connected Health Program Engagement & Results

Although the Weigh Forward Program was launched in 2011, it wasn’t until RediClinic moved to the new MyWeighForward Platform powered by Wellness Layers in October 2013 that they were able to offer enhanced functionality and support for patients and clinicians including: 

• Personalized Consumer Experience & Outcome: Participants create their own mini- electronic health record which collects program information, preferences, visit planning, tracking data, social engagement and progress through health measures. Program participants have the convenience of seeing different clinicians within the same clinic based on appointment availability or in a different location since all RediClinic clinicians have access to the participant’s program information to deliver a consistently high quality and personalized experience.
• Social Engagement: WeighForward participants use the platform 24x7 for ongoing emotional and educational support through their weight loss journey.
• Clinician Support and Collaboration: Clinicians have their own portal, giving them access to information to support and consistently deliver the program and to privately and securely collaborate on care. RediClinic's Clinician Portal on MyWeighForward Platform
• Care Continuum: Participants can access a Program Summary with their program health measures to send to their own doctors. “If the patient has secure messaging with their physician, they can share this information to include in their EMR”, adds Barrera.

“Our results have been very positive. On average, our patients are losing 1- 2 lbs per week which is considered to be a healthy rate of weight loss, and are significantly improving their cardio-metabolic risk factors. In many cases our patients have moved from pre-hypertensive and hypertensive to normal and pre-diabetic to normal”, exclaims Barrera.

Comments from Program Participants 

What I liked about the online part of the program was that it gave me homework to do to keep me accountable and focused.

I had been the 'queen of couch potatoes.' The best things about the program were the accountability each week, recipes and shopping list, and incredible support from the staff

Dr. David Katz's lesson on Trial by Aisle taught me to check ingredients lists for hidden sugars and salts, and to pick the shorter lists. The best thing about the program was it provided me with information to change my unhealthy lifestyle into a healthy lifestyle.

Future plans: New Business Model, New Technology Platform Capabilities

Today, most program participants walk into to RediClinic. However, RediClinic is now licensing the Weigh Forward program to other healthcare providers. “We’ve had significant interest and many pilot commitments from large healthcare systems and physician groups, as well as companies that operate retail, urgent care and worksite clinics. Everyone is looking for a turn-key weight and lifestyle management solution for their patients because obesity is so pervasive and expensive. Weigh Forward is one of the few comprehensive programs that is designed to be delivered by clinicians with no previous background in weight management,” Barrera adds.

Regardless of where the consumer is seen, in the clinic or in their PCP’s office, RediClinic is extending the capabilities of the WeighForward technology platform. “We are continuing to enhance the social networking capabilities of the platform, will introduce a mobile version later this year, and are beginning to develop modified versions of Weigh Forward that address chronic diseases, since the platform we’ve built is flexible and extensible”, concludes Barrera. 

Health care companies today are following in the footsteps of the retail-oriented, information based financial services industry.

What financial services companies have discovered is that in order to build their business, they must build a personal relationship with the consumer.  They accomplished this by creating a consumer-centric database, monitoring shopping behavior through reporting and analytics, motivating activity through multi-channel communications and launching a loyalty program to reward consumer spending,

I was part of this customer-centric transformation as the Director of Database Marketing at GE Capital, which provides private label credit card programs for Disney and Apple, to name a few marquee brands. My cross- functional team started with the consumer in mind. We envisioned the experience that our retailer customers needed to deliver to their consumer card holders to differentiate themselves in the marketplace and capture a larger mind share and business share.

This is the same path that health care companies are marching down to get ready for new customers.

Consumers Are Coming!  Health Care Companies Invest in Retail Strategies 

In their report on “The Era of the Health care Consumer,”  Accenture describes the shift in responsibility from the employers to the consumers and the resulting health care company investment changes from BTB to BTC. Accenture cites the opportunity to learn from the retail sector, especially the segmentation, profiling, loyalty and cross channel communications.

A few health care organizations are making the needed investments to move closer to the consumer in order to better understand their needs for information and tools to support health management.  Aetna, for example, has partnered with Best Buy to sell wellness programs to consumers within the retail store and deliver their wellness coaching program online. In addition to store fronts, Florida Blue (previously BCBS Florida) has invested in their Guidewell online initiative to build a relationship with consumers beyond their member base.

Most health care companies, however, are still trying to figure out where to begin.

Barriers for Data-Driven Retail Health Care

There are several key barriers that Health care companies must overcome in order to effectively engage these retail consumers. 

• Knowledge about the New Consumer: Health care companies have limited or no information about their newest customer that is either considering their health product/service or has just come onboard. As a result, the interaction can feel less satisfying.  Using best practices from the financial industry, health care organizations can utilize segmentation and profiling to deliver a more personalized experience while gathering knowledge about the consumer through each touch. 

• Knowledge about Consumers' Data Needs: During their recent research, IDC Health Insights learned that “despite large investments meant to extend the organizations’ consumer-centric model, health plans know little about how consumers want to consume information…”.  Financial Services companies remain aligned with their customers by inviting them to participate in their own private branded online research community. The company captures consumer input and feedback on their product road map and new marketing initiatives.

• Knowledge about Proactive & Personalized Communications: Many health care organizations wait for consumers to come to their online marketing destinations including their website and social media and then wait for them to return. Although these companies maybe have tools in place to capture the contact information of interested consumers, they tend to send out the same information to everyone. Financial Services companies segment these target consumers and stream content of interest across their preferred communication channels to bring them back and engage. 

• Knowledge about Developing a Personalized Incentive Program: One way that health care companies can differentiate themselves is with an incentive program that rewards a consumer for healthy lifestyle behaviors that fit her profile. One of the reasons that some credit card loyalty programs (e.g. American Express) are so effective is that they target personalized offers based on each consumer’s spending behavior profile.  

Health care companies can learn from the leaders in the Financial Services industry about how to leverage technology to build a retail consumer relationship through ongoing personalized communications and programs which are aligned with the consumer’s ongoing data needs.