Creating the Digital Health Formulary at Froedtert & the Medical College of Wisconsin
A mentor of mine is famous for saying that “the least utilized resource in healthcare is the current or prospective patient and family.” To this point, patient engagement has been a relatively hot topic. To me, patient engagement is not simply following through with an outlined care plan. Engagement is learning, asking questions, sharing decisions, and moving closer to self-management.
We think that the right apps and digital health solutions will play an important role in engaging and empowering patients. As of two years ago, however, there were at least 165,000 mobile health apps available. How do we sift through these? How do we electronically connect these apps with our teams and workflows so that we can partner with patients when needed? What goes into a recommendation?
To take on this problem, we have been building out the Froedtert & Medical College of Wisconsin Digital Formulary, borrowing a familiar concept from pharmaceuticals. Decision points that drive decisions on tool inclusion onto the ‘formulary’ are the track record of evidence supporting their efficacy (and, ideally, the effectiveness and interest in using the tool in the ‘real world’), ease of use, ability to integrate into our electronic systems and workflows, and cost.
To date, we have three live digital solutions that are integrated into Epic for prescribing at the point of care: for mental health (SilverCloud), for diabetes (Glooko), and for medication management, precision titration, and adherence support (Proteus Discover). Information about each of these tools is available on our internal digital care formulary. We have other solutions that as of yet are not integrated into Epic, but will be soon: for expectant moms (BabyScripts) and for patient education, digital check-ins, and patient-reported outcomes around episodes of care such as a joint replacement (GetWellLoop). Education and health coaching apps are under evaluation as well.
Epic’s Digital Care Activity
To help connect our EHR to the various digital prescriptions, we created the Digital Care activity within Epic. Digital care enables us to review their data with the patient, during a visit, without having to log into multiple other websites. If we, or our team members, are working with patients over the phone, via MyChart or a via video visit, everyone can see the latest patient-shared data to help guide decisions.
Digital care also serves as the prescribing portal for our digital formulary. Tools can be recommended for our patients (based on criteria from things like the problem list or visit diagnoses) and easily prescribed via a link to Digital Care. We can also search for tools by name that we know of. We can click an infobutton to show patients a preview of the tool, and then click to order. Some digital services require an ‘order,’ and for those, a final step is to click the sign button in the Meds & Orders section of Epic. Only services where patients use the app to generate data that is reviewed by the Inception Virtual Care Team (VCT) require this final step. The VCT reviews data at a predefined cadence based on the tool, and they will escalate issues to the clinic nursing pool.
The digital care activity works behind the scenes to invite the patient to the service through e-mail and connects the tool directly to Epic. This connection is not possible without ordering through the digital care activity.
Digital Care is powered by Xealth, a company we have partnered with to facilitate connections between our electronic health record and our digital health tools. Xealth enables ordering and monitoring to be done within the workflow of our clinicians. Inception Health is an investor in Xealth.
Moving Towards Patient Self-Management With Clinical Support
Digital prescriptions can accomplish several things that we can’t easily do? today without them. They can help get the right information to the patient on their terms, when they need it, or when it is relevant. They can collect data to highlight important trends for patients, connecting theory with practicality. They can serve as a resource to patients late at night or on weekends when we are traditionally less available. And they can be fun, engaging, and rewarding — if done right!
Increasingly, we hope to provide patients and families with tools that will enable them to be effective in managing and treating medical conditions at home. When patients need some additional support, we can be there to review data with them and provide assistance. For example, our SilverCloud supporters can coach patients on different parts of the app that can be most effective for them, and they recommend new modules based on changing needs. When patients need additional clinical assistance, our clinicians (increasingly pharmacists) can have easy access to the home data to help pick up and collaborate.
Our partnership with Glooko is a highlight. We were the first in the world to have patients use their new FDA-cleared basal insulin titration algorithm.
The Role of the Virtual Care Team
Technology can be hard and frustrating. There can be a lot of friction in getting patients enrolled and supported using technology. We have built our digital care activity in Epic to take the friction out of recommendations, ordering, and monitoring data for clinicians. While we foresee many tools being educational or only used by patients, many will provide data back to clinical care teams. Where practical to do so, the Virtual Care Team will take the lead in troubleshooting issues, reviewing data, and collaborating with patients, and will escalate clinical concerns to us if and when they arise. This way, clinicians can focus on the patient and their data rather than the technology.
Best Practices For Ordering Digital Health Tools
When recommending a tool to a patient, it’s important to do a brief informed agreement with the patient. My approach is to define why we are using the digital tool and what we hope to accomplish, for how long, and how often will we review the data together. For many, it will be at follow up appointments, but patients may have touch points with either the Virtual Care Team or our pharmacists in between. Reminding patients that we do not review data in real time is important, as is educating patients about how to respond to abnormal readings and when to escalate issues to us by calling, as they do today.
Digitally engaging patients (and families) has several foreseeable benefits. We are learning as an organization how to do this work, and do it well. Please send me your experiences with these digital tools or how technology can further your patient care practices.
