Donna Marbury

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Have pain? For many years, the answer has been to take a pill. But the opioid epidemic has shown the limitations - dangers - of sticking to just pharmacological approaches to one of the most common, fearsome health problems that people have, especially when the pain settles in as a chronic problem. Clinicians and entrepreneurs - and some patients - have a growing interest in nonpill approaches to pain treatment that use device technologies.    

Multiple virtual reality (VR) solutions now available have been effective in helping patients cope with acute pain. VR can be so absorbing that it takes people’s minds off their pain. For instance, VR applications can help women manage labor pains and even help with the sharp pain caused by removing a bandage. But chronic pain is complex and VR applications to help with it are still very much under development. 

“Acute pain has been proved many times over to be treated very well through VR via distraction therapy,” says Sandra Marshall, a senior associate at the consulting firm Booz Allen Hamilton, who focuses on VR and other augmented reality technologies. “I’ll be curious to see where chronic pain goes in the VR space. It’s a newer application for VR technology, and, as chronic pain manifests itself differently in everyone, what might work for one individual might not work for the next,” she says. 

Marshall says at-home mindfulness, meditation and breathing treatments coupled with VR in the office could help patients with pain. “There is a difference between a wellness app and a clinically prescribed pain management application. If people want to get a wellness app, they can easily get one and use that in the comfort of their home,” she says. “But if they want to use a clinical app specific to treating chronic pain, then it has to be prescribed and monitored by their doctor. Chronic pain therapy can be used both in a clinical setting and at home through a prescription service. That being said, acute pain management is more often used in just a clinical setting.”

For now, Marshall says, practitioners should implement VR in a pain management plan on a case-by-case basis. The devices are getting smaller, although most models are still about the size of a snorkeling mask, and they’re becoming more affordable. VR headsets on Amazon are priced as low as $35. Treating pain with VR “really has to be tailored to the patient, and we are still exploring what types of therapies we can offer in the form of VR treatment that will best help individuals suffering from chronic pain,” says Marshall. She also notes that gathering and analyzing data about chronic pain will help with the development of VR techniques.

Spinal cord stimulators are devices that involve placing electrodes between the spinal cord and the vertebrae in the epidural space. Why they relieve pain isn’t completely understood, but researchers believe that the electrical impulses modulate dysregulated pain pathways. The impulses may also dilate blood vessels, thereby relieving ischemic pain. In this country, the most common indication is for chronic pain after failed back surgery. In Europe, practitioners use spinal stimulators to treat peripheral vascular disease. Yet studies of the efficacy of spinal cord stimulators have produced mixed results. Calculations of how many patients suffer complications vary greatly, from small minority to as many as 40%. Lead migration, when the electrodes move out of place, is one of the most common complications.

Medtronic, Boston Scientific and other large medical device companies offer spinal stimulators. One of the newest is Abbott’s Proclaim XR recharge-free device, which the FDA approved in September 2019. A key selling point is that it works at low doses, so the battery can go without recharging for 10 years, according to Abbott.  

“Our device has a lot of unique aspects to it that are very patient centric,” notes Allen Burton, M.D., medical director for neuromodulation at Abbott. The stimulator works with Bluetooth and Apple iOS, allowing patients to fine-tune the settings within limits set by the physician. “The device controls patients’ pain and brings their symptoms down to a very tolerable level. The patient goes on about their life, and they don’t have to spend a lot of time making those subtle adjustments with the device,” he says.

Burton says the Proclaim XR is for patients with chronic pain who are stuck in a “chronic care cycle where they’re having a terrible quality of life and consuming lots of healthcare resources.” He adds, “We have studied and found that psychologically, it is very advantageous for chronically ill patients to get control of their chronic symptoms but not have constant reminders that they have a chronic illness. We’ve really taken time to engineer this in a very patient-centered way to achieve those goals.”

The vagus nerve, the longest cranial nerve, travels down the body from the brainstem to the pharynx, larynx, trachea, heart and the entire gastrointestinal tract. But it also has two branches that go out to the auricle, or the external part of the ear.

Transcutaneous auricular vagus nerve stimulators take advantage of this structure and the access it provides to the vagus nerve. They work by stimulating the vagus nerve with electrodes placed on the auricle. The first auricular nerve stimulator to get the go ahead from the FDA was approved for acupuncture-like treatment in 2014. 

The IB-Stim device is a version of a transcutaneous auricular vagus nerve stimulator for the treatment of pain from irritable bowel syndrome. The FDA approved it last year for use in patients 11 to 18 years old. Innovative Health Solutions, a device company headquartered in Versailles, Indiana, markets IB-Stim and a similar device, sold as NSS-2 Bridge, for treating the symptoms of opioid withdrawal. 

Katja K. Kovacic, M.D., a pediatric gastroenterologist at Children’s Hospital of Wisconsin in Milwaukee, says patients wear the IB-Stim device for five days straight, day and night, and then take it off for two days before seeing their doctor the following week for evaluation. She adds that depending on individual needs, a patient can use the device on this schedule for several months. Transcutaneous auricular vagus nerve stimulators are an attractive choice for younger people because many parents, as well as the patients themselves, don’t want to involve strong pain medications, observes Kovacic. Practitioners have so far treated more than 500 patients with the device, according to Kovacic.   

Donna Marbury is a writer in Columbus, Ohio. 

Articles

The opioid epidemic has led doctors and patients to look for other ways to control pain, and they’re turning to technology for answers.

New Tech Delivers Needed Options for Treating Pain

In the past five years, HHS’ Office of Civil Rights (OCR) has increased enforcement of Health Insurance Portability and Accountability Act (HIPAA) violations, according to the 

. In 2015, there were only six HIPAA penalties, compared with 11 in 2018. Not only have enforcements increased, but fines and settlement amounts are also on the rise. In 2018, more than $28 million in penalties was paid to OCR. The mean penalty amount for 2018 was $2.6 million. Anthem settled for $16 million for failure to respond to breaches that had occurred since 2015 and for lacking technical controls to prevent unauthorized electronic personal health information (PHI) access.

Because OCR enforcement continues to grow, costing healthcare organizations in both dollars and damage to their brands, it is important that health systems stay proactive when deploying technology that keeps PHI and other healthcare data safe. As the healthcare industry becomes more connected, through providers and payers, PHI and other data are transferred between more vendors, says Tim Eades, CEO of VArmour, an applications security company in Los Altos, California. “As health insurance carriers begin or mature within their ‘digital’ journey - think digital health ID cards held in digital wallets or mobile healthcare policy apps - the potential for PHI and personally identifiable information exposure increases,” Eades says.

But with interoperability, there’s a greater risk involved, with data becoming increasingly accessible, says Rich Temple, vice president and CIO of Deborah Heart and Lung Center in Brown Mills, New Jersey. “Ironically, the push for interoperability, and the goal to bring to a provider a patient’s entire medical history across many different arenas of care, poses some serious challenges in the HIPAA realm,” Temple says. “As the flow of PHI increases in the three V’s - volume, velocity and variety - more opportunities open up for that sacred information to be compromised, either by hackers or even by, ostensibly, well-meaning providers who may be using the patient’s data for use cases that go beyond what HIPAA allows.”

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Ultimately, healthcare executives must stay on the hunt for technologies that can keep data protected, because threats from hackers continue to grow and be more sophisticated every day, says David Williams, general manager of the healthcare provider division of Conduent, a healthcare technology company in Florham Park, New Jersey. “Whether you’re talking about a national level or international level, the ability to hack healthcare data is fairly alarming.”

With the explosive growth of cloud-based technology, especially with many healthcare organizations using third- and fourth-party vendors, the fact that EHR systems are being moved to or connected with cloud-based platforms is a concern. Cloud-based applications can help with data security because the major providers have capabilities that can be used to enable strong security overall, says Eades. “However,” he adds, “if any system is brought from a non-cloud space to full cloud - lift and shift - or a fully on-premise platform is suddenly connected to the cloud, data security - and overall security - can be threatened if the naturally exponential relationships cloud introduced aren’t managed correctly.” 

Although cloud-service vendors can stay abreast of security issues, often faster than their clients, working with a third-party also has its risks, says Temple. “The challenge is that the healthcare organization is now dependent on yet another party, or business associate, to maintain HIPAA standards, and any breach on the part of the business associate will come back to bite the provider, even if the provider themselves didn’t do anything wrong,” Temple says. 

Being able to visualize or map data flow is critical to applying appropriate protection technologies, says Eades. “Healthcare platforms must have the means to map network and systems topologies against data flow. As in the EHR to cloud/cloud-connected example, it’s critical that hybrid cloud and multi-cloud environments are considered as well.”

Since 2009, more than 189 million healthcare records have been stolen or exposed in over 2,500 breaches, according to the 

. The number of breaches in the past decade amounts to nearly 60% of the U.S. population possibly being affected.  

As more connected devices become available for patients, Temple says, providers have to stay alert when they interact with a health system’s data network. Medical devices themselves, such as balloon pumps and patient monitors, and the growing array of healthcare devices classified as the “internet of things,” are alluring targets for criminals, notes Temple. Having technologies that are monitoring data and how it’s being used can be one of the best ways to catch a possible HIPAA violation early and take steps to fix it, Williams says. “Health systems should have technology to identify a threat, monitoring on a daily basis, if not hourly,” Williams adds. 

Building in redundancy is also important if a primary system gets compromised through a malware attack. “We go well beyond the standard anti-virus, anti-malware that most organizations have deployed. We have robust backup regimens so in the event of an attack, we are as well positioned as we possibly can be to recover a legitimate dataset,” Temple says. “We are continuing to enhance our security toolset to monitor packets crossing our firewall and our endpoint assets for irregular activity. We even have some redundancy in our monitoring to make sure we have that extra layer of protection.”

Although increased technological advances can keep healthcare organization in compliance with HIPAA, ultimately educating staff on data safety is a first barrier, says Temple. A 2019 analysis by Bloomberg Law found that the fifth most common cause of data breaches in healthcare is from staff having inappropriate access to team members’ or patients’ information. Though the intent of the staff’s inappropriate access wasn’t always clear, the analysis found that some employees had looked up patients’ or other staff members’ data out of goodwill, such as to send a sympathy card. However, many staff breaches are due to mistakes, carelessness, and ignorance of HIPAA laws, the Bloomberg analysis found. 

Because of the real risk in human error, Temple also suggests endpoint and perimeter protections that can monitor for unusual behavior on the network and alert key players to that behavior. “A big technology gap is the human beings who work at healthcare organizations,” says Temple, noting that bad actors gain access to systems through phishing emails. We constantly have to keep our people vigilant to not click or open things [when] they are not absolutely certain of the legitimacy of the source.”

Technology that provides encryption, two-factor authentication, secure messaging portals and automatic log offs can help when human error leaves PHI vulnerable, says Michelle Garvey Brennfleck, associate and healthcare attorney at Buchanan Ingersoll and Rooney, a Pittsburgh law firm and lobbying group.

 “Technology that is as close to fool-proof as possible may limit vulnerabilities and associated risk.” Brennfleck adds. “This is particularly important in the HIPAA space where one negligent or bad actor can create high dollar exposure.” 

Donna Marbury is a writer in Columbus, Ohio.

When deploying technology that keeps personal health information and other healthcare data safe, health systems stay proactive.

Technologies That Keep Your Health System HIPAA Compliant

Personalized services are already a huge part of retail and financial sectors. Being able to reach patients with direct services using technology is even more critical as the need for chronic care continues to grow.

“Personalized approaches are so important because each individual’s health and well-being is highly complex,” says Yoona Kim, CEO and co-founder, 

a healthcare technology company located in San Francisco, that combines data science with clinical expertise via artificial intelligence (AI).

Many healthcare organizations are using technology as a way to add value to services. “We want our technology experiences to enhance human connection, not replace it,” says Nikki Caputo, senior director of experience and innovation, UCHealth.

, a nonprofit network of 12 acute care hospitals and more than 150 clinics throughout Colorado, Wyoming, and Nebraska, using voice-enabled technology started with a comprehensive AI strategy.

“Two years ago, we began to operationalize our conversational AI strategy. Voice has always been a piece of that. More importantly, it's about giving people choices to access information,” Caputo says.

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In summer 2019, UCHealth began utilizing the Livi skill on Amazon Alexa smart speakers, as a virtual assistant for patients and their caregivers. Users are able to ask questions about health conditions and location information for practitioners or specific doctors.

“You can ask Livi to find the nearest urgent care and she'll tell you the closest location and follow up with a text message that includes contact information and driving directions,” Caputo says.

Caputo says that there are several use cases for voice-enacted technology and that the organization is cognizant of possible challenges.

“If Alexa can't understand the customer's voice when asking for a doctor's phone number, that's an issue,” Caputo says. “We want to use conversational AI to deliver more personalized experiences to build stronger relationships with our customers. To do that we need to make sure our integrations are fully secure.”

Telehealth is growing faster than any other healthcare option, according to a national study of insurance claims from 2016 to 2017 by 

. The study found that telehealth claims increased by 53%, while claims to urgent care centers increased by 14% and retail clinics by 7%.

Retailers are investing in telehealth to increase engagement by offering more convenient options to patients. Walgreens

 plans to close 160 clinics and increase the reach of its telehealth platform, Walgreens Find Care, focusing on diabetes, chronic obstructive pulmonary disease, and asthma patients.

“We believe that by integrating connected care devices, digital therapeutics and the pharmacy experience, we’ll help individuals better manage their chronic conditions while also lowering the overall cost of care,” said Giovanni Monti, vice president and director of healthcare innovation, Walgreens Boots Alliance, Inc.

Though telehealth options continue to grow, 

 conducted by J.D. Power found that only 10% of healthcare consumers have used it.

“Once providers and payers refine the formula for awareness and adoption, telehealth will change the landscape of how affordable and quality care is delivered,” says Greg Truex, managing director of health intelligence, J.D. Power.

 who need user-friendly medication monitoring has expanded across the health system of more than 800,000 patients.

 platform to continuously monitor patients’ conditions and recommend changes to care plans and medications. During the pilot, 92% of care plan adjustments were implemented by physicians and the health system saw a 40% reduction in hospitalizations.

“Our platform makes use of a sophisticated feedback loop where our data-driven clinical interventions can be continuously improved upon to achieve specific treatment goals for an individual, driving clinical and economic outcomes,” Kim says, adding that a combination of hands-on care from practitioners informed by AI’s personalization will give patients the maximum benefit.

“One of the biggest things we learned was that patients don’t respond to generic interventions or engagement techniques, even if these are aimed at improving their well-being at no additional out-of-pocket cost,” Kim says. “AI can help healthcare organizations understand how and when to best intervene on a patient given their unique circumstances.”

Increasing chronic care needs are incentivizing direct-tech services.

3 Technologies Providing Personalized Healthcare

As value-based care initiatives continue to drive healthcare decisions, it’s no surprise that mobile applications are being used by providers and payers as a way to connect with patients and connect silos within the healthcare community.

But as mobile apps on smartphones are commonplace for many consumers, it can be overwhelming to decipher what apps are the most useful. There are more than 318,000 healthcare mobile apps available to download, according to 

At this point of market saturation, mobile apps in the healthcare space are expected by patients and consumers, says Benjamin Kanter, MD, FCCP, chief medical information officer of Vocera, a healthcare technology company with more than 20 years of experience in developing mobile apps and digital communications, in San Jose, California.

“The real question is how can we improve our clinical and operational efficiency? And you can't do that without a modern communication and collaboration platform,” Kanter says. “I would suggest that executives should not differentiate between the applications that help them communicate from the applications that also help them process, mobilize, and act on data.”

Though many consumer-facing healthcare apps have become more robust in their data collection by using cloud and machine learning technology, executives still have to wade through apps’ capabilities in order to find the ones that are the most effective, says Paul Cerrato, MA, author of 

Realizing the Promise of Precision Medicine.

Mobile Apps Bridge the Patient-Provider Gap

“Physicians and healthcare organizations that are making financial decisions have to find those apps that are really well supported by the evidence, not just conceptually well-supported but in terms of actual experiments to show that these apps work,” Cerrato says.

Static apps that offer just education and information aren’t as useful as those that can help patients with specific health issues, Cerrato says.

“If you have a patient who wants more out of his or her healthcare app, then you have to start thinking about investing in interactive programs,” he adds.

New mobile app technology shouldn’t be a one-off investment but part of an overall digital strategy, says Vincent Martino, chief product officer and co-founder of VisitPay, a mobile patient portal solution.

“The investments health systems need to make in mobile development will depend on how they think about mobile strategy within their larger service offerings,” Martino says. “In our experience, health system leaders should think about mobile no differently than they think about web in terms of importance. In fact, we encourage our clients to rollout their web and mobile strategies concurrently. Any features that are on the web should be mobile-optimized.”

More than 40% of working adults have problems with medical debt-amounting to more than 72 million Americans, according to 

 by The Commonwealth Fund. As high deductible healthcare plans are on the rise, and patients are more financially vested in costs, healthcare organizations have to be more agile in fitting patients’ needs.

“Consumers’ perceptions of the overall healthcare experience are heavily influenced by the level of transparency, control, and convenience provided by the billing experience. A one-size-fits-all billing strategy lacks the flexibility and personalization required to meet people where they are in their lives,” Martino says.

After surveying more than 1,700 patients that use VisitPay, the company found that a number of variables can determine how patients manage their billing obligations and the best way to engage with them.

“People manage their lives through their mobile devices. They schedule appointments, plan their social lives, order products and services, and manage their money through their phones. More consumers are expecting to be able to manage their healthcare needs anywhere, anytime, and on their own terms,” Martino says. “Most industries, including healthcare, are investing considerable resources to reach and engage consumers through mobile devices.”

Martino says ongoing communication about mobile app offerings is important in order to boost and maintain adoption.

“Four years ago, our clients were reporting that 20% of the patients who used our platform to manage their billing did so through their mobile device. Today, that average is 40%,” Martino says. “By comparison, web-based logins average 56% across our health system clients. The gap is quickly closing, and I expect mobile payments to exceed web-based payments within two years.”

Kanter says that mobile apps can be an integral part of an internal communication strategy for practitioners. He estimates that less than 15% of nurses use smartphones as a part of their workday routine.

“If you make communications easier, you're not only improving the tasks of the caregivers, you actually improve the lives of the patients as well,” Kanter says.

He adds that practitioners can choose between providing staff with their own devices or creating a “bring-your-own device” policy where staff can add a secured app to their smartphones. Kanter says each way is affected depending on the company’s culture.

“I think that by making communication easier, it actually makes somebody's job easier,” Kanter says. “It also makes hospitals and healthcare environments safer because when communications are hard to accomplish, they tend not to occur. We know that the majority of healthcare issues are almost invariably traced to a problem in communication.”

Vocera has created a mobile app, Vocera Vina, that helps clinicians make decisions in real time by prioritizing the most urgent information to the top of the inbox and delivering patient context as part of an inbound phone call, so they know what to focus on instantly. That means they get a meaningful picture of a situation quickly, when a patient’s status declines. The app also gives nurses the ability to communicate with others on the care team instantly.

Ultimately, Kanter says, internal apps that can offer real-time triage information is a part of a broader initiative to help healthcare organizations digest data properly.

“When we have mobile apps and software available to us all of the time because of the device in our pocket it isn't really a phone, it's just a mobile computer,” Kanter says. “I don't differentiate any longer between mobile apps and the apps that sit on the computer. The question is, what are we going to do with all this computing power that's available to us in relationship to healthcare?”

The future of voice-activated apps in healthcare

Cerrato says many hospitals are considering voice-activated assistants, such as Amazon Alexa, to enhance internal communications for nurses and other staff. In April 2019, Amazon issued an 

 to create HIPAA-compliant healthcare skills for Alexa, after a trial at Cedars-Sinai Medical Center in Los Angeles. In August 2019, Amazon released 

 with six healthcare providers, including:

Scheduling same-day appointments (Atrium Health)

Post-operation information and appointment management (Boston Children’s Hospital)

Employees managing health goals and wellness incentives (Cigna)

Prescription home delivery status (Express Scripts)

Connecting blood monitoring device and voice-command glucose readings (Livongo)

Helping patients locate nearby urgent care facilities and schedule same-day appointments (Providence St. Joseph Health)

“Hospitals should be thinking about embedding Alexa, Google Assistant, or some of the other mobile assistants into the hospital environment so they can, not only improve the patient experience but also give the clinicians less of a work load,” Cerrato says.

Voice assistants that recognize speech can be used for medical transcription and chart searches during patient appointments. And hospitalized patients can use them to request services and information from on-site staff.

Cerrato adds, “Instead of a patient hitting a call button to request the nurse, he or she can simply ask, ‘Alexa, when am I going to get my next medication?’”

The healthcare industry is investing considerable resources to reach and engage consumers through mobile devices.

Author | Donna Marbury

Articles

New Tech Delivers Needed Options for Treating Pain

Technologies That Keep Your Health System HIPAA Compliant

3 Technologies Providing Personalized Healthcare

Finding the Most Effective Healthcare Apps