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Brent I. Fox, Pharm.D., Ph.D and Joshua C. Hollingsworth, Pharm.D., Ph.D.

Today’s pharmacists have seen wave after wave of technological innovations touted as the next greatest tool to improve [fill in the blank]. Whether the target pain point was a workflow bottleneck, reimbursement inefficiency, or patient care practice that was not up to expectations, innovations have promised to address a myriad of issues in the pharmacy. How many innovations that did not live up to expectations can you think of in 10 seconds? ComputerTalk readers with a few decades of practice experience can likely generate a list of 10 to 15 innovations in this time frame. These same readers can also likely identify innovations explored in this column that did not live up to expectations.

One of the most-hyped innovations today is digital health, which has been defined as “the cultural transformation of how disruptive technologies that provide digital and objective data accessible to both caregivers and patients leads to an equal level doctor-patient relationship with shared decision-making and the democratization of care.” (See the September 2017 issue of the online journal mHealth for the article titled “Digital health is a cultural transformation of traditional healthcare.”) We have previously addressed digital health in this column. As pharmacists, we know that our colleagues are sometimes skeptical when faced with new innovations like digital health. We acknowledge that this skepticism is often rooted in experiences with failed innovations. The good news (or is it bad news?) is that your physician colleagues have similar scars that they can share from their experiences with new innovations. As an example, while electronic health records (EHRs) are essentially commonplace in today’s hospitals and physician clinics, the previous decade’s effort of implementing EHRs caused considerable turmoil for the end users, especially those in small to medium-sized community practices. Even successful innovations can be painful.

Turning our attention to digital health, the American Medical Association (AMA) created a guide to help medical practices of all sizes and specialties navigate digital health technology implementation. Formally known as the Digital Health Implementation Playbook (available at www.ama-assn.org/amaone/ama-digital-health-implementation-playbook), the guide was developed through consultation with physicians and thought leaders representing the gamut of medical practices. Digital health is an umbrella term that includes mobile health, telehealth, wearables, and other technologies. Arguably, one of the most well-known digital health areas is individuals’ use of wearables (sensors, trackers, etc.) to monitor a variety of parameters throughout their day (and night), often focused on chronic disease or wellness. While the Playbook provides general strategies and tactics applicable to all digital health technologies, remote patient monitoring serves as a use case relevant to today’s patients.

The Playbook was written for physicians and their practices. However, many of the principles are relevant to pharmacists, pharmacy, and pharmacy vendors. The playbook theme is used throughout the guide, with 12 steps divided into four sections: warmup, pre-game, game time, and post-game (Table 1). We will highlight several of the relevant steps here.

 

While the first step (identifying a need) may seem obvious, developing a clear understanding of the end goal is crucial to digital health implementation success. Specifically, implementing a technology simply because of the gee-whiz factor usually does not end well. The decision in this first step is essentially a question of, what are my wants versus my needs? Identification of needs begins by collecting feedback from staff members who know the operations. Patients can serve as a key source of information as well. Does your practice have a specific patient population who would be interested in a specific digital health innovation? Conversations with patients are critical at this step.

Involving Your System Vendor

Conversations with pharmacy management system (PMS) vendors are also important in the first step. To optimally use digital health data, it should be integrated in the PMS to ensure the pharmacist has a complete view of the patient’s health. Vendor collaborators are key to overcoming the technical hurdles to integrate these data. Accordingly, vendors should be consulted to help prioritize the list of needs identified in step 1. The pharmacist’s number-one priority may not match the vendor’s development road map. These discrepancies must be addressed.

Stephen Covey, author of the popular book The 7 Habits of Highly Effective People, says, “begin with the end in mind.”  This is a variation on step 3, which is the process of defining the conditions for success in digital health implementation. The focus here is the outcomes of the innovation. Many are familiar with the triple aim of healthcare: improved patient outcomes, enhanced patient experience, and reduced costs to the system. Recently, caregiver satisfaction has been suggested as a fourth aim. In this context, caregivers are trained professionals, family members, and anyone who provides care for another person. Regardless of the desired outcome, a clearly measurable endpoint is a necessity, because subsequent steps are built around the desired outcome.

If pressed to pick the most important steps in the guide’s plan for digital health implementation, we would certainly include step 7 in our top three. Pharmacy practice is highly workflow dependent. At a minimum, workflow alterations can negatively impact efficiency. In the worst-case scenario, workflow alternations can lead to patient harm. While we acknowledge that redundancies and existing technologies can address negative impacts from workflow alterations, we also know that workflow is critical to pharmacy operations. In the case of remote patient monitoring, patients play an even greater and more direct role in the pharmacy’s workflow because they are generating and sharing data with the pharmacy. On the pharmacy side, new workflow must be defined in terms of when, how, and by whom data are reviewed. Additionally, critical values that trigger intervention must be defined. And workflow should be developed for alerting other providers, and include the context under which they are notified.

Ultimately, digital health innovations allow patients to be more engaged in their care. This is represented in step 9, patient partnership. An advisable approach is to begin with patients likely to be successful in the rollout. This will require talking with patients to identify those who are inclined to digital health technologies, or identify patients with a family member who can help with the technology. Beginning with motivated patients will allow staff and patients to implement and revise training materials, including providing patients with what-if scenarios specific to their conditions. Motivated patients can also help determine the impact of the innovation’s complexity on patient uptake. As complexity increases, the need for changes in the patient’s behavior also increases. This can impact patient engagement. Methods for identifying, communicating, and enrolling patients can also be tested with an initial group of motivated patients. Full-scale implementation, evaluation, and scaling are the final three steps.

Readers know that implementation of any new technology is not as simple as depicted here. Readers also know that their patients’ desires and capabilities to engage in their own care are changing. We encourage readers who are considering incorporating digital health in their practices to head over to the URL we have provided and download the Playbook. It is freely available and includes numerous checklists, worksheets, and other guidance documents. We also encourage readers to contact us with their questions or comments. CT

Brent I. Fox, Pharm.D., Ph.D., is an associate professor in the Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, and Joshua C. Hollingsworth, Pharm.D., Ph.D., is an assistant professor, Pharmacology and Biomedical Sciences, Edward Via College of Osteopathic Medicine, Auburn Campus, Auburn University.
The authors can be reached at foxbren@auburn.edu and jhollingsworth@auburn.vcom.edu.