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10 Articles in Volume 16, Issue #5
A Review of Skeletal Muscle Relaxants for Pain Management
Applying Kinesiology as a Multi-Prong Approach to Pain Management
Arachnoiditis: Diagnosis and Treatment
Bench to Bedside: Clinical Tips from APS Poster Presentations
Conversation With David Williams, PhD, President of the American Pain Society
Letters to the Editor: Prince Fentanyl Overdose, High-Dose Opioids, Mystery Care
Los Angeles Times Versus Purdue Pharma: Is 12-Hour Dosing of OxyContin Appropriate?
My Experience With OxyContin 12-Hour Dosing
Technology: Changing the Delivery of Healthcare
The Neuroscience of Pain

Technology: Changing the Delivery of Healthcare

From smartphones, Fitbits, and implantable glucose monitors, technology is now a part of our lives. Learn more about how you can incorporate these technologies into your practice.

The Affordable Care Act (ACA), and the broad initiative known as healthcare reform, seeks to ensure quality healthcare to all Americans while reducing or stabilizing costs. But the effort requires more than a simple mandate or new legislation that changes the way we conduct the business of healthcare. It also requires that patients assume greater personal responsibility for their health. Now, a surge in new technology development is helping them do just that.

The New Healthcare Model

Healthcare reform has brought profound changes in both healthcare delivery and the economic incentives for providers. One of the most important changes has been the gradual phasing out of the fee-for-service model, in which providers are paid for each visit and procedure. The problem with that model, experts say, is that it incentivizes the wrong behavior, reimbursing providers for service intensity rather than effectiveness. It encourages medical professionals to administer more tests, see patients more often, and perform more procedures, which is often economically wasteful and, as studies show, does not result in healthier individuals.  

Indeed, the fee-for-service model means the provider is rewarded the sicker an individual becomes and the more care that is required. When provider payments are tethered to optimal patient outcomes, on the other hand, patient and provider interests are aligned and costs come down.

Healthcare reform also changes incentives for patients. The ACA makes healthcare insurance coverage mandatory. To reduce the costs of coverage, many plans provide discounts and other financial incentives for those who take more responsibility for their health. Preventive services, for example, are often provided at no or minimal charge.

Another profound change has been the level of interest patients are taking in their own care—and in the cost of that care. No longer are these individuals just patients. They have also become consumers. And, as such, they have begun to expect more from their healthcare providers.

The Rise of the Patient as Consumer

With healthcare reform we have entered a new era of patient-centric care and consumerism. The future of healthcare is in many ways tied to patient satisfaction.

Patients increasingly search for “value” in healthcare purchases—that optimal balance between quality and cost. The availability of electronic data makes it easier for prospective patients to “shop” for services using hospital rankings, physician grades, and other quality metrics.

Healthcare consumers and consumer advocacy groups are also demanding more transparency with regard to costs for medical tests and procedures. A recent poll estimated that 55% of Americans feel that providing more information to patients about the price of physician visits, tests, and treatments should be a top priority for the federal government.1

It has become evident that patients are willing to become more involved in their personal healthcare—at least from a financial perspective—but are they also willing to take an active role in improving their own health? Are they ready to share decision making with physicians, learn more about self-management, make healthier choices, make important lifestyle changes, and become less reliant on drugs or surgery while placing more emphasis on prevention?

Increasing patient involvement is desirable for 2 important reasons. First, awareness of one’s health status helps individuals make better and more cost-effective choices. Second, according to research, higher patient engagement levels result in greater compliance and, ultimately, healthier individuals.2 Highly engaged patients feel more in control and accept greater responsibility for their health.

There are many approaches aimed at increasing patient involvement, but we will focus on technology and “high touch” methods, currently in use by healthcare systems across the country. High-touch methods are an intervention or activity having high interpersonal value or connectivity (ie, a more personal way to engage another individual). These technologies enable patients to become engaged partners in their own care as well as the principal generators of data through such devices as wearable activity monitors, medical devices powered by microelectromechanical technology, or MEMS, and electronic communication with their healthcare provider.  

When patients take advantage of these technological advances, they are more likely to follow treatment plans, reducing pain and other disease symptoms and possibly preventing other illnesses. Medical providers also benefit from improved patient relationships and reductions in costs.

Engagement Is Motivational

With the advent of email, texting, patient portals, and activity/medical trackers, the connection between patients and their physicians has changed profoundly. These technologies, which were initially only reluctantly adopted by the medical profession, have now become commonplace. Healthcare providers use them to monitor conditions and modify patient behavior, preventing illness or hospital readmissions, controlling or reversing chronic disease, and directing patients to appropriate treatment before their condition worsens.3

Electronic messaging can be an especially effective adjunct to face-to-face intervention in weight management and smoking cessation programs. Evidence suggests that an extra 3 minutes of talking to a patient makes a significant difference in cessation likelihood.4

An ongoing impact analysis at the Mayo Clinic is examining the use of text messaging to extend provider outreach. The analysis found that “smoking quit rates for the text messaging intervention groups were 36% higher compared to the control group quit rates. Results suggest that SMS text messaging may be a promising way to improve smoking cessation outcomes.”5

Smoking cessation is a high-priority program because of the proven downstream benefits that make this a highly cost-effective intervention.6 In addition to text messaging, mobile apps that sense when someone is entering a high-risk environment such as a bar, where others will be smoking and temptation may be greater, are also available.

Sensor Technologies to Aid Diagnosis, Patient Compliance

Disease management programs are benefiting from MEMS—miniature biocompatible biosensors that can be inserted subcutaneously, providing round-the-clock data to patients and their providers. This technology is currently in virtually all smartphones and new applications are evolving in healthcare. MEMS technology is designed to detect levels of hormones, blood, lymph, and other fluids to help monitor diseases and treatment effects. Patients with cancer, cardiovascular disease, stroke, or diabetes, for example, can be remotely monitored, easily and accurately, using this technology.

If the data indicate abnormalities, alerts are sent to both patient and provider. MEMS can even provide 3D motion sensors that can identify when someone is falling, instantly transmitting a signal to a medical office to alert the provider. They are also being used to detect colon cancer by interfacing with an image sensor to show an area such as the small intestine. Some believe MEMS could even allow earlier detection of serious diseases, helping patients get care sooner.7

From a patient engagement standpoint, MEMS technology resembles the wildly popular interactive technology used in wearable monitors like the Fitbit (Figure 1). These devices keep track of the user’s activity and some basic but important data, including heart rate, breathing rate, steps per day, and calories burned. Activity monitors can sync to a laptop, tablet, or smartphone, allowing users to access their data anywhere.

Both wearable devices and over-the-counter activity monitors make individuals the primary generators of their own health data, revolutionizing the way this information is collected.

Fitbits and other wearable medical devices are especially effective in encouraging patients to take control of their health and engage in healthy behaviors. Because they provide instant feedback of steps taken, for example, users often report that the devices motivate them to exercise more.  

Wearable medical devices, such as microchips, implantable glucose monitors, or CardioMEMS implantable devices that measure cardiac output, can monitor conditions such as diabetes and heart disease. Early detection of a worsening condition helps avoid the cost of delayed medical interventions as well as the negative impact that disease progression or increased pain has on a patient’s quality of life. Consider, for example, traditional glucometers used for monitoring blood sugar, which rely on manual data uploads to a PC. New devices automatically upload data to a cloud-based analytics platform. Data can be passed to a diabetes care team for evaluation and actionable resolution.

Portable devices can also help avert tragedy when, for example, an individual suffers an accident and cannot communicate. In this instance, an ultra-portable wristband device that can securely store a patient’s entire medical record can be plugged into a USB port and provide critical data to first responders.  

Such devices monitor the daily fluctuations of individual patients but can be scaled to an entire population, which is undoubtedly the plan for many healthcare systems. Population health management will rely on remote monitoring of key critical components of chronic diseases to achieve better care coordination and patient compliance. Imagine a communication system designed to provide instantaneous parameter monitoring and virtually immediate feedback in the form of a message such as “your blood sugar is a little low—how about an orange juice,” along with instant messaging from the patient’s diabetes coordinator. A system called Livongo is already in place at 7 hospitals in the Mount Sinai Health System in New York City (Figure 2).

Win-Win: The Patient Portal

Patient portals are secure websites created by healthcare groups, insurance companies, or employers that allow patients to communicate with their physicians or other providers, access test results and other medical information, and arrange appointments. Many portals also notify users of overdue vaccinations or regular preventive health screenings. When combined with other wellness services such as health coaching, risk assessments, and biometric screens, portals are useful in both educating patients and motivating them to take better care of their health.

Activity trackers such as the Fitbit can also be synched with some portals to provide additional information and incentives to improve health. In fact, to encourage employees to stay healthy (and reduce healthcare costs), some employers are keeping track of activity levels and reimbursing those who have performed especially well with insurance premium reductions, vacation days, or other incentives.

Virtual Simulation Technology and Pain Management

Advances in computer processing power are making possible new medical interventions such as virtual simulation devices (VSD). Doctors at the Walter Reed National Military Medical Center are now using neural imprint to reduce pain incurred in debridement sessions, a typically excruciating procedure that burn victims must undergo to aid healing. The technology uses a headset to create a virtual world, indistinguishable from the real world, in the mind of the patient. For burn patients, for example, VSD creates an environment of ice and snow, cancelling out signals from the skin, central nervous system, and brain that indicate heat and searing pain.

Tackling pain has been proven to improve quality of life as well as reduce healthcare costs. Virtual reality technology is being used at Walter Reed to reduce pain caused by a variety of conditions, including cancer, fibromyalgia, phantom limb discomfort, and chronic pain.8

Technology to Improve Research and Data Collection

The ever-growing pressure to collect healthcare data is driven largely by insurance reform and regulatory mandates aimed at reducing costs. Insurance companies increasingly rely on scientific evidence about patient outcomes to make coverage decisions,  placing this evidence-based paradigm at the forefront of cost containment. Now, greater computer processing power aids research by allowing scientists to generate, store, and manage larger amounts of data than ever before.

Data derived from large sample sizes often reveal small but clinically significant results, but researchers using computers that lack the necessary processing power have been unable to instill confidence in their findings. Processors capable of handling larger amounts of data promote more accurate conclusions and greater credibility.

Greater computer processing power also allows large sample sizes and data sets to be mined for important trends and relationships between key variables, generating actionable data and reducing costs of additional trials. “Big data” analysis heralds a new era of clinical research, which may lead to better treatments and patient outcomes as well as a reduction in healthcare costs. It is the current thinking for data scientists that big data exploration (mining) will yield valuable insights that will, amongst other advantages, allow us to more strategically select the most important variables to bring into an expensive and time-consuming trial. Continued progress will require personnel with expertise in both research science and information technology.

Using Healthcare Data In the Real World: Rehabilitation Medicine

Healthcare reform is changing the way clinicians deliver care, requiring both greater engagement with their patients and compliance with new regulatory mandates and insurance reforms that determine how they will be paid for their services.

The use of outcome measures has always been central to the field of rehabilitation medicine, given the field’s lengthy history and its practitioners’ extensive experience in using such data. In fact, patient reported outcomes (PROs) originated with this field and have become a critical part of the rehabilitation care process over the last 30 years.

As a result of their focus on patient outcomes, rehabilitation professionals have become adept in using function-based instruments that measure patient progress. Many other healthcare providers are newcomers to these measurements and may be struggling to adapt to the shift in service provision paradigms, from a hospital-centric to a patient-centric focus. The use of outcome measures in general clinical medicine is a more recent phenomenon that has been met with mixed enthusiasm by some, and reluctance by others, as many providers feel overwhelmed with current levels of mandatory clinical and regulatory documentation.

Learning From Rehabilitation Medicine

So what do rehabilitation practitioners know that others don’t? They know that patient engagement is not only critical for better outcomes, but also better for business. Interaction and good communication skills are an essential part of this engagement. Healthcare providers who communicate well and build trust with their patients (often referred to as “clients” in this field) can expect them to become loyal members of their clinic community. And patients who develop a trusting relationship with their healthcare provider, and get the results they want, will return to that provider rather than seek out someone new.

The many new communication tools, such as patient portals, electronic health records (HER), medical mobile devices, mobile apps, encrypted secure emails, and telemedicine, can help facilitate engagement, but they cannot take the place of face-to-face interaction and relationship building.

Rehabilitation Medicine and Community-Based Disease Management Programs

The new emphasis on preventive care that can reduce healthcare costs has made community-based disease management programs popular with employers and insurance companies. Programs for smoking cessation, weight management, chronic pain, stress management, and fitness training all help prevent disease and improve health.

Fitness training in particular benefits from face-to-face interactions that make building a client relationship essential to optimum service delivery. Many rehabilitation centers also employ smart-card technology that allows the physical therapist or personal trainer to capture data generated during workouts, which helps motivate the user. Like the Fitbit and other technology, smart cards help users stick to their training, providing encouragement by showing how much they have done.

Figure 3 shows a kiosk where a client can insert a smart card to log into a secure system. The card is then automatically loaded with a customized exercise program created for the client by the facility’s staff. The exercise program can be modified at any time as the client improves or regresses in strength or endurance levels. Each strength machine has a module containing a slot (Figure 4) into which the client inserts the card. The module reads the card and displays his or her last exercise session on a screen with prompts to begin, rest, and end exercise at predetermined intervals. Smart cards work especially well for seniors, some of whom have difficulty remembering all the details of their program.

Exercise equipment may also contain heart rate sensors that work with wearable telemetry monitors (Figure 5). Staff members can then calculate optimal heart rate levels for training. Some rehabilitation facilities also provide an estimate of joint loads for weights to prevent injuries in clients with orthopedic issues such as joint replacements or cardiac conditions. If a client attempts to exceed training intensity at either the heart rate or joint load level, machines can be programmed to alert staff members.

During their exercise sessions, clients interact with health coaches, staff members, and with each other while using the interactive screen technology to adjust their exercises for an optimal workout. The technology allows clients to make adjustments to their workloads and meet their training goals.

The data gathered by rehabilitation medicine practitioners can benefit both provider and patient. The data include key health-related variables (risk factor or overt disease markers) that directly or indirectly measure an individual’s health status. On the therapy side, patient progress can be tracked using standardized outcome measures for a particular attribute such as strength (dynamometry/manual testing), by disease or condition such as osteoarthritis of the knee, or by functional status. As the need to engage with patients continues to increase, each provider will need to find the most effective ways to involve and empower patients to be their own best healthcare advocates.

Conclusion

There is a growing consensus that patients who are more involved in their healthcare achieve better outcomes at lower costs.9 Other data suggest that those who feel more in control of their medical care also have better medication adherence, which leads to improved outcomes and reduced pain and other symptoms.

Innovative technologies are helping healthcare consumers become more medically responsible patients by allowing them to gather more information about themselves and receive instructions and encouragement from their physicians, increasing the likelihood that they will adhere to a treatment program or effect positive lifestyle changes. Hospital systems and provider groups are quickly adopting these new technologies and facilitating greater patient accountability.

The growing trend in healthcare consumerism is also changing patient expectations. Traditional methods of providing healthcare services face various challenges, including government mandates, new insurance regulations, changing demographics, reimbursement reforms, EHR, coding changes, evidence-driven paradigms, and patient expectations. New technology tools and other cutting-edge innovations will ease these transitions and reduce some of the financial pressures of shrinking provider margins.

Last updated on: April 14, 2017
Continue Reading:
A Review of Skeletal Muscle Relaxants for Pain Management

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