This white paper will describe the Doctella platform as a means to facilitate patient engagement in the healthcare process, and briefly summarize some of the rationale behind the development of the product. The white paper will also explain how the Doctella “Smartlist” has been designed to assist healthcare providers in improving clinical outcomes, improving patient experience, and meeting important performance measures, which can help in the transition from fee for service reimbursement models to value-based reimbursement models that are becoming more prevalent among public and private payers. The architecture and content of Doctella Smartlists have been designed to help providers meet the complex reporting requirements put forth by the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission, improve processes and outcomes through patient engagement, decrease readmission rates by alerting patients and family members about important tasks to complete and early signs/symptoms of potential complications, and improve patient experience by facilitating open communication between patients and providers. As metrics and reporting requirements evolve over time, the Doctella platform is uniquely positioned to adapt to these changes, which will be illustrated by providing examples of new features currently under development.
What is Doctella?
The Doctella platform enables patients and their families to prepare for and engage in their own healthcare by linking information-rich checklists of questions and answers, mobile alerts and reminders concerning required actions and task completion, and real-time patient monitoring using the Doctella “Smartlist”. (www.doctella.com) Doctella’s mobile, web, and print platform hosts these Smartlists, and the platform allows for secure, HIPAA-compliant delivery of health information to patients via e-mail or text messaging. Delivery of Smartlists can be accomplished in “one-click” from a provider’s computer or mobile phone. Information can also be delivered to the patient through the electronic medical record. Doctella’s security architecture is unique in that it allows the patient to control the security “keys” to his or her own information. In this way, patients themselves determine how and with whom their protected health information is shared.
Through our content license with Johns Hopkins, Doctella Smartlists include evidence-informed questions (with answers) that a patient should ask his or her physician about upcoming surgical procedures, prescribed medications, and/or chronic medical conditions. The Smartlist also includes a series of alerts and reminders specific to each procedure, medication or condition. The Doctella user interface has been designed to facilitate effective delivery of information to the patient. The information is perceived as being sent directly from the patient’s own physician, and it is delivered in a “chat”-based, short answer format.
In conjunction with clinical experts, Doctella has developed Smartlist “templates” of questions, answers, alerts and reminders, which individual healthcare providers can readily edit in order to customize the information to their own practice patterns. This helps to minimize the initial time commitment necessary for a provider to get up and running with Doctella. Healthcare providers also have the opportunity to gain full transparency into the degree of a patient’s engagement through a provider “dashboard” that tracks which informational questions a patient has viewed, and monitors which alerts and reminders a patient has completed. If desired by the healthcare provider, the dashboard also allows patients to transmit important clinical information to the provider’s office such as vital signs, weight, pictures of healing wounds, activity level before or after surgery, blood glucose levels and range of motion after joint replacement.
Doctella to Improve Outcomes and Increase Patient Engagement
The Doctella Smartlist is essentially a clinical checklist that is designed for distribution to patients. Checklists are known to be important tools for decreasing preventable medical errors and improving patient safety. The use of clinical checklists decreases catheter-associated bloodstream infections in intensive care unit patients. 1 In the operating room, checklists reduce surgical complications and improve processes geared toward patient safety. 2,3 The use of surgical checklists decreases 30-day surgical morbidity, 3 inpatient post-surgical complications 2 and surgical death rates. 2 4,5 Demonstration of these benefits correlates with the degree of checklist compliance. 5 The use of checklists has gained wide acceptance, and there is a consensus among hospital personnel that checklist use provides important patient safety benefits. 5
An important mechanism by which checklist use improves patient safety is by enhancing team communication, cooperation and cohesion. 6 This can be particularly important as it relates to patients and their families, since they are the only members of the healthcare team who are present during the entire continuum of care, starting with the recognition of signs and symptoms, progressing onwards to diagnosis, medical care, and finally post-treatment recovery and hopefully a return to health and wellness. Whereas checklist use in the operating room and the intensive care unit enables team members other than physicians to speak-up regarding patient safety issues, checklist use with patients and families can engage and activate these previously unrecognized members of the healthcare team, providing an important extra set of eyes and ears to identify potential safety hazards. Patient activation in this manner can empower patients and family members to voice any concerns related to the safe delivery of their own healthcare.
While checklists are the means by which Doctella increases patient engagement and activation, patient engagement and activation is the means by which Doctella can be leveraged to assist providers in the transition from fee for service to value-based reimbursement. Patient engagement is an important focus of the Affordable Care Act, and initiatives are in place to encourage shared decision-making and patient self-management. 7 Studies show that patients are ready and willing to engage in their healthcare in order to help prevent unnecessary medical errors. 8 Patient engagement is an important tool in decreasing such errors and improving patient satisfaction. 9,10 For example, greater patient and family engagement in healthcare activities can increase hand hygiene compliance of healthcare professionals by up to 94% and significantly decrease medication errors by as much as 50%. 11,12 Improvements in patient-reported experience through better physician-patient communication, sufficient explanation, and increased patient involvement can also lead to better patient-reported outcomes and lower patient-reported complication rates after elective surgery by as much as 30%. 13 Greene and colleagues recently demonstrated that higher levels of patient activation, as measured using a validated patient activation instrument, are significantly associated with better clinical indicators, healthier behaviors, avoidance of hospital admission and emergency department visits, and overall lower costs of healthcare. 7 Patient activation demonstrated a “dose-response” relationship with these outcomes. 7 Moreover, changes in patient activation scores were also shown to be significantly associated with changes in health outcomes and changes in cost of medical care in the expected directions. 7
Doctella’s Business Opportunity: Assist Providers with Transition to Value-Based Reimbursement
Despite the obvious desirability of increased patient engagement/activation and the mounting evidence of its association with improved clinical outcomes, we recognized that a strong business case and concrete return on investment was necessary for already overwhelmed healthcare providers to adopt a new digital technology. As a result, the various constituent parts of the Doctella platform and Smartlist were developed to address the complex performance measurements upon which providers are being judged and reimbursed. This places Doctella in alignment with the new and evolving incentives of healthcare providers to improve clinical outcomes, improve patient experience and decrease cost of healthcare. With advances in digital technology and a general acceptance of this technology for use in healthcare delivery, Doctella is positioned as a potentially important tool for providers as they transition to value-based payment models.
Doctella Smartlist Content
Questions embedded in Doctella Smartlists specifically map to CMS and Joint Commission reporting measures (a related White Paper addressing this mapping in more detail can be furnished by Doctella on request) . Patients are prompted to ask their providers about important, reportable topics, which can reinforce provider compliance with these metrics. For example, each Doctella surgery Smartlist includes questions regarding the necessity of venous thromboembolism (VTE) prophylaxis, and the patient is prompted to ask his or her healthcare provider whether or not such prophylaxis has been prescribed and delivered. Smartlists also contain questions addressing appropriate antibiotic use, vaccination, and the use of other medications such as statins and aspirin. Doctella Smartlist content can also help patients play an active role in improving outcomes and decreasing hospital acquired conditions by prompting them to ask about urinary catheter removal to decrease catheter-associated urinary tract infections, ambulation to decrease the risk of deep venous thrombosis and pressure sores, the continued need for a central venous catheter, and the possibility of discontinuing antibiotics to decrease the risk of clostridium difficile infection. Questions are also focused on pain management, which is one of the measured components of patient experience through the HCAHPS survey. 14
Doctella Alerts and Reminders
With Doctella, customized alerts and reminders about important tasks can be delivered in a timely fashion to a patient’s mobile phone or computer. These alerts and reminders can be shared with family members and other caregivers who are assisting the patient during the healthcare episode. These alerts and reminders are an important mechanism to improve patient safety, increase compliance with prescribed treatment regimens, and increase patient vigilance, all of which ultimately can have a positive effect on patient outcomes and decrease the occurrence of adverse events.
Alerts and reminders about preoperative task completion can improve safety for surgical patients. Reminding patients to stop certain medications such as anticoagulants, perform appropriate skin cleansing before joint replacement or bariatric surgery, complete a bowel preparation before colon surgery, continue beta-blockers or diabetes medications, and not to eat or drink anything for several hours prior to surgery can help avoid potential surgical complications. Such alerts and reminders can also contribute to decreasing the risk of hospital acquired infections and surgical site infections. Patients can also be reminded to stop smoking prior to surgery and to remain physically active prior to surgery.
Following hospitalization, Doctella’s alerts and reminders continue to have a positive effect on outcomes by encouraging patient compliance with prescribed discharge treatment regimens. Patients and their caregivers can be reminded to take medications as prescribed, perform necessary wound care, participate in rehabilitation programs, perform exercises aimed at improving functional outcomes, and keep necessary follow-up appointments. Adherence to these instructions, which at times can be overwhelming for newly discharged patients, can lead to better functional outcomes, decrease the risk of treatment-related complications, decrease the risk of infection, and improve patient vigilance towards identifying developing problems. This level of compliance and vigilance can potentially decrease hospital readmission rates and improve overall patient satisfaction with care by effectively and simply communicating what needs to be done after hospital discharge. Preliminary data support this hypothesis by demonstrating that implementation of the Doctella platform can decrease emergency room visits/hospital readmissions after outpatient Ear, Nose and Throat surgery by nearly 60%. 15
The above features were designed to engage and activate patients in their own healthcare with the goal of improving patient safety and the overall outcome of care. However, delivery of information and alerts/reminders does not guarantee that patients will interact with the material or complete the tasks prescribed. As a result, the Doctella Smartlist includes a monitoring feature that allows healthcare providers to gain full transparency into how a patient interacts with the platform after he or she leaves the office or hospital. The Doctella monitoring “dashboard” enables healthcare providers and their support staff to see exactly which questions and answers patients have viewed, and determine precisely which alerts and reminders patients have acknowledged and completed. This helps providers to “close the loop” by determining how engaged and activated patients are in their own healthcare. This also allows providers to intervene early if important tasks are not completed. For example, if a patient does not acknowledge timely completion of a bowel preparation prior to surgery, the provider is notified by an alert through the Doctella dashboard and the patient can be contacted before it is too late to safely complete the task. Preliminary data suggest that Doctella implementation can lead to a substantial decrease in surgery cancellations, approaching 60%. 15 In addition, monitoring can allow providers to identify and intervene when patients are not taking medications appropriately or not completing prescribed exercises or rehabilitation. Such monitoring and intervention can only lead to improved patient safety and better outcomes.
Patient Activation with Doctella to Improve Patient Experience
Engaged, activated patients experience a better quality of healthcare and have greater trust in their healthcare providers. 16 This leads to higher patient satisfaction and a better patient experience. 16 Patient experience is a major component of the value-based purchasing program. 17 Through its ability to activate patients, Doctella expects to have a positive impact on this performance measure.
The Doctella Smartlist provides the mechanism by which patients become active members of the healthcare team, empowering them to speak-up and ask questions. This can be expected to improve communication between patients and healthcare providers. Better communication between these parties is expected to improve HCAHPS measures related to nurse and physician communication as well as responsiveness of the hospital staff. 17 Specific questions related to medication use should improve the HCAHPS domain scores related to communication about medications, and questions addressing options for pain medications are targeted to the pain management domain of HCAHPS. 17 Specific sections of Doctella Smartlists address post-discharge care and provide information about recovery at home, which should promote a dialogue between patient and provider about care following hospitalization and thereby address the discharge information domain of HCAHPS. 17 It is further anticipated that activating the patient will improve overall patient experience and satisfaction, thereby improving the patient’s overall rating of the hospital and increasing the likelihood of recommending the hospital to family, friends and acquaintances.
Doctella Platform Evolution and Adaptability
Because the focus of performance measurement, provider reporting and value-based purchasing continues to evolve, the Doctella platform has been designed to be adaptable to the future needs of providers and patients. New features currently under development broaden the capabilities of the platform with the goals of decreasing readmission rates following hospitalization and helping providers manage new reimbursement models such as bundled payments. The Doctella platform currently offers the ability for two-way transfer of information between patient and provider. While we have found that most providers do not want yet another method for e-mail exchange with patients, we did find that many providers want to receive specific, targeted information that is relevant to patient management in the pre-operative period or after hospital discharge. The Doctella platform will allow patients to transfer this specific information to providers, including the number of steps taken each day before surgery (prehabilitation), vital signs, pictures of healing wounds, and joint range of motion measurements. Such information can potentially alert providers to developing problems, allowing them to intervene at an early time point to avoid costly emergency room visits and hospital readmissions. In addition, if rehabilitation after surgery is progressing well as evidenced by improving activity levels or joint range of motion, physical therapy and rehabilitation can be discontinued appropriately (thereby saving money) without compromising outcomes. Transmitting such information also keeps patients and family actively engaged during the post-hospitalization period. This type of platform capability can be very helpful for providers managing bundled payment models, such as for joint replacement surgery.
Recognizing the importance of care transitions, the Doctella platform will soon evolve to host a comprehensive discharge instruction module. This module, which can be delivered to the patient and family electronically using Doctella’s web and mobile capabilities, will be based on the Smartlist backbone and include a checklist of questions and answers patients should know about their planned discharge, as well as alerts and reminders for important tasks to complete. The plan is for this module to be entirely configurable for each patient, and contain components specifying hospital diagnoses, tests performed, diet, activity level, bathing/showering, medications, physical therapy/rehabilitation, skilled nursing care and follow-up appointments. Each individual component can be configured to meet the needs of the specific patient and can include voice recordings from the patient’s nurse or physician, videos describing wound care and physical therapy, and pictures to illustrate things such as catheter or drain care. In addition to managing expectations through the educational component of the Doctella Smartlist, and alerting and monitoring patients to complete important healthcare-related tasks through the engagement component of the Smartlist, the discharge instruction module should help to decrease hospital readmissions by effectively managing the transition of care from hospital to home or nursing facility. The Doctella platform will allow patients to share important discharge information with all of their healthcare providers. In this manner, primary care providers who rarely round on their hospitalized patients can be made aware of hospital diagnoses, tests performed, medication changes and other important factors so that care can be better coordinated between hospital-based and non-hospital based providers.
A very recent change to the Doctella platform has been the addition of patient-reported outcomes measures. Submission of patient-reported outcomes data is an important component of the new Comprehensive Care for Joint Replacement Payment model, 18 and it can be anticipated that patient-reported outcomes data will assume a more prominent role in value-based payment models introduced in the future for other disease processes. These measures are easily loaded onto the Doctella platform, and the Smartlist architecture can be used to electronically deliver the questionnaire to patients using either e-mail or mobile texting, remind patients to complete the questionnaire prior to scheduled provider appointments, track patient responses to questions, score the questionnaire based on published algorithms, and even transmit questionnaire results to the patient’s electronic medical record or to central data repositories.
The move from fee for service to value-based reimbursement models provides significant challenges for all healthcare providers. Reporting requirements are complex, and performance measurements are difficult to meet and to follow given the constantly changing regulations. Healthcare providers need digital tools that are designed to assist them in navigating these complexities while helping them to continually improve the quality of care they deliver. Patient engagement and activation is one important focus of the new reimbursement models, and it is one potential means by which quality of care can be improved without requiring new medical treatments, additional personnel, or a significantly increased time commitment from already over-burdened healthcare providers.
The Doctella platform is a digital tool that was developed to increase patient activation with the ultimate goal of improving patient safety, improving healthcare outcomes and hopefully decreasing the cost of medical care. The platform has been designed to assist providers in the transition to value-based reimbursement by focusing on reporting requirements, patient safety processes and important outcomes that are emphasized in new payment models. The Doctella platform is configurable and adaptable to meet the needs of providers and patients as payment models continue to evolve.
- Pronovost P, Needham D, Berenholtz S, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. New England Journal of Medicine 2006;355:2725-32.
- Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. The New England journal of medicine 2009;360:491-9.
- Bliss LA, Ross-Richardson CB, Sanzari LJ, et al. Thirty-Day Outcomes Support Implementation of a Surgical Safety Checklist. Journal of the American College of Surgeons 2012;215:766-76.
- Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010;304:1693-700.
- Patel J, Ahmed K, Guru KA, et al. An overview of the use and implementation of checklists in surgical specialities – A systematic review. International Journal of Surgery 2014;12:1317-23.
- Russ S, Rout S, Sevdalis N, Moorthy K, Darzi A, Vincent C. Do safety checklists improve teamwork and communication in the operating room? A systematic review. Annals of surgery 2013;258:856-71.
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- Black N, Varaganum M, Hutchings A. Relationship between patient reported experience (PREMs) and patient reported outcomes (PROMs) in elective surgery. BMJ quality & safety 2014;23:534-42.
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- Khalid A. Doctella Clinical Experience. Sunnyvale, CA: Patient Doctor Technologies, Inc; 2015. (Proprietary information to be released upon request)
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- Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services. United States Government, 2015. (Accessed June 25, 2016 at https://www.federalregister.gov/articles/2015/11/24/2015-29438/medicare-program-comprehensive-care-for-joint-replacement-payment-model-for-acute-care-hospitals.)