Virtual health assistants: A prescription for retail pharmacies
The aging population, financial stress and the Patient Protection and Affordable Care Act has forced the entire medical delivery system into a game of musical chairs. The music has started, and each component of the healthcare delivery system is aggressively looking to have a chair.
All of the national and regional retail pharmacy chains have invested enormous capital in developing strategies to enhance their position in this increasingly fluid and uncertain environment. They have consolidated to leverage size, set up full-fledged primary care clinics to address some of the glaring gaps in the medical delivery system — for example, Walgreens’ Take Care Clinics recently announced it began offering chronic care services, while CVS Caremark’s MinuteClinic made a similar announcement about a year ago — and have invested in huge data analytics programs to increase efficiencies, improve buying power, drive therapy adherence and improve revenues. The stubborn irony is that despite these gargantuan efforts to ultimately better address the needs of the patient, we still face the long-standing probability that the patient will indeed be the component left without a chair.
Data from a recent study based on medical and pharmacy claims of 1.2 million members conducted by Prime Therapeutics and Blue Cross Blue Shield of Minnesota revealed that there were considerable savings for people adherent to statins. Unfortunately, it also reported that 54% of the patients that should be on a statin are nonadherent.
The report did not go into the reason for nonadherence, nor did it need to. Numerous studies have made it abundantly clear that there is no single reason for nonadherence, and that most of the reasons are behavior-based. There are hundreds of programs being offered by health plans, pharmacies, drug companies and employers that attempt to address the issue of nonadherence by encouraging and facilitating behavior change, particularly for patients with chronic diseases. The themes of these programs are common: improve long-term medication possession ratios and show a related improvement in hemoglobin A1c, blood pressure or reduced hospital admissions. But these programs share an inherent problem; the high cost of human resources needed to make the programs effective also means there are severe limitations to how many patients they can influence.
A retail pharmacy prescripition for this challenge is the virtual health assistant, or VHA. VHAs are predicted to burst onto the radar screens of the entire industry and completely transform a pharmacy’s ability to engage, empower and inspire patients to better health.
Much more than a simple app or website widget, VHAs have been proven to engage patients by encouraging a trusted relationship that, in turn, gives healthcare entities a stronger platform from which to influence behavior and adherence. Armed with the ability to sustain this engagement over the long term, VHAs can provide retail pharmacies with an extraordinarily clear window into the underlying reasons each individual patient is nonadherent and enable the use of sophisticated big-data-driven behavioral economics models to tailor interventions to the unique circumstances of each individual patient.
The fuel for this transformation will be the coalescence of raw computer processing power, smart device ubiquity, improved voice recognition technology, artificial intelligence, cloud computing and the emergence of sophisticated natural language processing, or NLP. Of these, NLP is the key component that enables the conversational interface required to engage the patient. Put simply, NLP can quite literally change the music to ensure that the patient has the best possible opportunity to have a chair before, during and after the music stops.
Without a relationship, there is no influence
Current technology-driven strategies to improve adherence include smart device apps, medication text reminder systems, smart medication bottles, auto-ship policies, low co-pay levels, interactive voice response outreach and other tactical efforts to assist patients. A VHA provides a more strategic option because of its ability to enable all of the above and do more. Dr. Timothy Bickmore has been studying these agents and calls them “relational agents” because he has determined that people actually develop a trusted relationship with avatars due to their ability to make an emotional, social and visual connection with patients. This unique human-like connection leads to what Bickmore has characterized as a “therapeutic alliance.” Thus, VHAs offer patients an “x factor” that no technology before it has ever been able to add to the equation.
This “x factor” affords VHAs with the opportunity to inspire patients to meaningful and sustained behavior change. When you consider the 24/7 proactive connection a smart device enables to VHAs, they can extend the relationship with patients of the friendly, trusted neighborhood pharmacist.
This should not surprise us. Most toddlers have their favorite inanimate object that they cling to for support. How many children cry when this same object is not around to help them fall asleep? In actuality, this attachment to non-human objects goes well beyond just toddlers. Later in life, pets and “things” become very important to us. In fact, a recent survey shows that 55% of people would give up caffeine and 70% would give up alcohol before giving up smartphones.
Once the therapeutic alliance is established, the VHA is positioned to change behavior. Of course, behavioral change is something that psychologists have studied for centuries. One contemporary, BJ Fogg has created a model that is one easy way to look at behavior change. The Fogg Behavior Model (FBM) is B=MAT where B=Behavior, M=Motivation, A=Ability and T=Trigger. Behavioral change involves these three basic elements.
Intelligent agents can help motivate and initiate triggers as well as encourage patients by engaging them in active dialogue at the most teachable moments.
In addition to providing technology with which to address the behavioral aspects of medication adherence, VHAs can effectively get retail pharmacies deep into the business of wellness, prevention and disease management. They can gather and track patient-generated health data, monitor and facilitate pharmacovigilance activities, increase health literacy and help patients manage unrealistic expectations.
Once implemented, the tasks and activities a VHA can facilitate become almost endless and include the ability to:
- Proactively and discreetly inquire about sexual dysfunction due to antihypertension drugs and provide possible remedies;
- Score patients using interferons on a depression scale and notify the appropriate healthcare provider when appropriate;
- Provide on-going measurements of disability progression for a patient with multiple sclerosis and suggest the patient discuss treatment adjustments with the pharmacist in real time;
- Provide a periodic pain measure for a rheumatoid arthritis patient so other treatment options can be explored;
- Monitor (e.g., using the GPS capability of a smartphone) physical capabilities and limitations of cardiac and respiratory disease patients;
- Remind and assist HIV patients with complicated medical regimens;
- Help cancer patients understand and tolerate the unavoidable side effects of their treatment and utilize motivational interviewing and virtual coaching techniques to help them “get through it”; and
- Act as coaches to motivate and improve exercise efforts; they can even ask what music a person wants to hear after reminding him or her to take a walk or jog — and find it online to purchase if it is not on the device.
This technology already exists and is being used by a number of large enterprises, including Aetna and the U.S. Army, to accomplish the seemingly mutually exclusive goals of improving customer service while lowering the cost of high value interaction with customers. And as surprising as it may sound, this technology can be integrated into current systems and databases with a relatively low impact on already stretched IT departments.
Those pharmacies that become early adopters of virtual health assistants can gain a significant head start in finding a chair for themselves and for patients when the music suddenly stops.
From the author: I don't disagree... but it is not happening now. My youngest brother died of an avoidable death due to non-adherance to therapy for coronary disease. No pharmacist had ever bothered to call him... I went to his daughter's graduation a few weeks later. I understand that you are probably a pharmacist. I get it. You think that pharmacists can connect with people. Yes they could if there were enough of them and they had the time. (I suggest you read: http://www.nejm.org/doi/full/10.1056/NEJMp1203869) My background was starting 5 HMO and being an NCQA surveyor, president of a health department, and for several years I ran the clinical operations for one of the largest disease management companies in the US. We could get people to goal for diabetes, HBP, CHF, asthma, but it cost a LOT. Average talk times was 30-40 minutes depending on the disease and age of the patient. Pharmacists are not capable of spending that amount of time and still fill prescriptions...nor would they want to. We had an enormous turn over of nurses due to the repetitive nature of the conversations. An agent could do it with ease. We have tried a lot of things to improve adherence over the 41 years since I started medical school... we have techniques that are proven to work. Motivational interviewing, Prochasta's model of behavioral change, etc. But, we do not have the people nor the funding to change the behavior of the nearly 120,000,000 people in the US with diabetes and pre-diabetes... and that is just one condition! Tell me you can scale the people driven solution with existing funding to these 120,000,000 people and I will hand you the reins. But remember, my brother never got a call...
When you consider that nonadherence to medication regimens costs, conservatively, $290 billion per year in avoidable health care costs, the expense of humans working with patients is not the problem. If VHA can manage health behavior change and machines can dispense drugs, why do we need pharmacists? Adherence is complex . Education alone is not enough (if it were, health care professionals wouldn't smoke or be overweight). Identifying factors that affect an individual's problem with medication adherence is only part of the problem. Responding to these in a way that allows the patient to feel understood and cared for is another major component. Patients also must be dealt with in a way that allows them to draw their own informed conclusions about their health without pushing a health care provider's agenda down their throats. VHAs can be a tool but will not replace the complex interactions and caring afforded by human interaction that is needed to affect adherence in a substantial way. Moreover, adherence to medication regimens is only one behavior to be assessed and influenced. Lifestyle changes are also critical. If pharmacists can demonstrate a significant reduction in the $290 billion with better outcomes, the cost of human interactions will not be problematic. If they cannot do this, VHAs and dispensing machines may replace them.
Sports physicals critical to promoting children’s health
As summer fun winds down, families make preparations for return to school. For the retail clinician, summertime is back-to-school season. Sports physicals or pre-participation physical evaluation (i.e., PPE) represent an important service in the retail health setting and an important opportunity to impact the child’s health. The required PPE is one of the most common reasons teens seek primary care and may be the only time otherwise healthy teens seek care. While the overarching goal of the PPE is to promote safe sports and physical activities, the PPE provides a real opportunity to evaluate health, promote such vaccines as HPV and meningitis, and provide preventive counseling.
The PPE should be ideally administered when the child is not ill and six to eight weeks prior to beginning the sport or practice season to allow for further evaluation or rehabilitation of any problems that could be discovered at the time of the exam. While the medical history is best taken from an adult parent or caregiver with long-standing knowledge of the child, adolescents should be seen apart from the parent for part of the exam to allow the clinician to inquire about risk-taking behaviors. Retail clinicians should set the stage for this early in the evaluation. In addition to a complete medical history, a standard head-to-toe exam with a brief musculoskeletal assessment is required. The most common conditions warranting further evaluation or referral to a personal care provider or a specialist will be identified during the cardiac and musculoskeletal exam.
Remembering that since the sports physical might be the only time this child or teen interacts with a healthcare provider during the year, the PPE is an excellent opportunity to provide preventive counseling and health guidance for both the patient and parent. With the understanding that time constraints limit the amount and content of counseling, pertinent topics should be individualized and based on the history obtained during the course of the PPE. Topics might include: safety (e.g., seatbelt use and safe driving, helmets and protective equipment); importance of proper rest and hydration, sun protection, steroid avoidance (i.e., tobacco, alcohol and drug use should be addressed at any teen health visit); breast/testicular self-exam; and abstinence or condom use encouraged to prevent pregnancy, HIV transmission and other sexually transmitted infections.
Retail clinicians may refer to the chapter on Sports Physicals in a new industry textbook “Convenient Care Clinics: The Essential Guide to Retail Clinics for Clinicians, Managers, and Educators.”
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Providing accessible, affordable quality care
Happy summer! It was wonderful seeing so many of you in May in Las Vegas at the 6th annual Retail Clinician Education Congress. The event was a tremendous success, thanks to our colleagues at DSN Collaborative Care. We have already started the planning of 2014’s conference. We have received feedback from many of you about the conference and will be incorporating your suggestions into the format and layout of the conference next year. If you have ideas for us, please feel free to reach out to me any time.
The Convenient Care Association was very excited to introduce our first book, “Convenient Care Clinics: The Essential Guide for Clinicians, Managers, and Educators,” published by Springer, at RCEC. This is the first comprehensive book about setting up, operating and practicing in a convenient care clinic. The book addresses all key medical and operational considerations pertaining to running these local retail health clinics that are rapidly proliferating in pharmacies, supermarkets, airports and other locations throughout the United States. Key features of the book include:
- Essential information needed to establish, operate and practice in a convenient care clinic or urgent care clinic;
- Relevant information for practitioners, including NP-DNPs, PAs, clinic managers, CNOs, graduate nurse/PA educators and students;
- Relevant information about the 20 top conditions seen in retail health clinics, including workup and treatment regimens;
- Metrics associated with retail medicine; and
- Philosophy of retail care and parameters of primary services.
The book is available for purchase through Springer Publishing at SpringerPub.com. It is a must-read.
CCA recently has partnered with the National League for Nursing to host a roundtable discussion to examine current employment trends around the country for advanced practice nurses and to brainstorm transformative educational strategies to meet the staffing needs for new models of healthcare delivery. This meeting, held in May, brought together representatives from the retail health industry, national nursing organizations and nursing leaders, and was the first of many conversations around these important issues. Some of the important recommendations that came from the meeting included curriculum development in nursing programs that incorporates the convenient care clinic model, scholarship creation for both nursing students and academic leaders within the convenient care clinic arena, clinical preparation for new graduates and leadership development. CCA will continue to engage with the nursing and physician assistant communities to keep the conversation going about opportunities in the retail clinics for growing the healthcare work force and helping to meet the needs of healthcare reform.
Thanks for all you do to provide accessible, affordable, quality care to millions of Americans in retail-based convenient care clinics across our great nation.
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