As primary care physicians and leaders of Wellframe, a mobile health company working with payers and physicians groups to extend care between visits for patients with complex comorbidities, Drs Panch and Goodman discuss their experiences building a mobile application used by elderly patients to communicate with clinicians and manage chronic disease.
Symbiotically, the medical delivery system has grown around us to not just treat our ailments, but to help us make sense of our experiences with illness. The clinical consultation is, therefore, not only the fundamental unit of information exchange between a patient and clinician; it also serves as the forum for a patient to recruit their doctor in helping them make sense of what is happening and to find an ally for their healthcare journey. If successful, a therapeutic bond forms that can bridge the temporal chasms between consultations and make each individual exchange more effective. In contrast, many health apps and patientfacing technology products have been designed to work in parallel with or in place of the patient-clinician relationship. However, we believe that it is the clinician’s skills in empathy, sense making (forming and testing hypotheses from poorly structured and incomplete data), and communication that enable relationships, and that these uniquely human skills should be amplified, rather than replaced, by technology.
We have also become convinced that these supportive “between-visit” relationships are of particular importance to older patients. With aging, comes a longer list of medical problems that have a lower probability of cure. Therefore, this need for ongoing management, rather than definitive solutions, dramatically increases the demand by seniors for both healthcare resources and the continuing patient—physician relationship to make sense of their situation. With an aging population and rapidly rising levels of effectively incurable cardiometabolic diseases, the need for these sense-making relationships that underpin care rises exponentially. Thus, we are faced with a situation in which the demand for the human beings involved in care delivery is growing unsustainably in parallel with costs.
Enter stage left, technology: robots, telemedicine, mobile devices, and, more recently, artificial intelligence have each had their time in the limelight. But can these technologies meaningfully influence those patients that need them most? Understandably, many have raised concerns that the answer in elderly populations will be “No,” given the lack of access to or familiarity with enabling technologies—namely, mobile devices (smartphones and tablets) and the Internet—among the elderly. In many studies, data have borne out these concerns. But our experiences have shown that there are ways to design technology with seniors in mind that mitigate many of these challenges.
WELLFRAME’S EXPERIENCE BUILDING TECHNOLOGY FOR SENIORS
Although new technologies, such as smartphone apps, may be second nature to younger members of the population, seniors notoriously find these advances more difficult to use and they blame themselves for these difficulties. In multiple focus groups with seniors, in the early stages of designing the Wellframe app, we observed that older users underestimated their abilities (“I am just not good at these kind of things”) and blamed themselves for technology failures (“I must have done something wrong, but I just could not get it to open”.)
Younger users, in contrast, were more likely to give feedback that the app was poorly designed if they struggled, rather than assuming that the issue was caused by a deficiency in their own ability or knowledge. These factors, alongside well-known limitations in vision and manual dexterity in the elderly, explain much of the reticence among some seniors to try new technologies and the propensity with others to stop using them quickly.
We also received qualitative feedback that the fact that the app was enabling more frequent interaction with a clinician, rather than only teaching self-management or tracking, was of huge value in the elderly population. Alhough we haven’t formally studied the reasons that underpin this observation, we believe this likely has to do with the increased complexity of illness and the higher risk of social isolation/less robust social support systems that affect many of the elderly patients we work with.
THE WELLFRAME EXPERIENCE
• Age distribution. The median age of a Wellframe user is 54 years, with 22% over age 65. The average age for patients older than 65 is 70 years, with a median age of 69. The average age for users under age 65 is 47.5 years, with a median age of 51 (FIGURE 1).
• Technology access. As expected, the share of patients with smartphones declines with increasing age, going from 30% to 50% in those under age 65 (depending on the site) to between 5% and 30% in those over age 65, based on clinician reports at partner sites. We believe the differences in penetration between partner sites reflects varying socioeconomic circumstances and is consistent with published analyses1.
• Engagement. Rates of engagement with our app (in terms of daily and weekly active patients) among those older than age 65 is equivalent to and, in some groups, greater than adults aged 25 to 65, but less than the very young (ages 16 to 25) (TABLE). Of note, all of the young people in the Wellframe sample are in community-based rehabilitation programs for the treatment of severe and persistent mental illness.
• Retention. The share of patients who stay with Wellframe programs beyond 60 days are equivalent regardless of age, as seen in FIGURE 2, further illustrating that those over 65 who use our technology use it as avidly as those under age 65.
Qualitative analysis of users reveals that the principal driver of continuous adherence with the Wellframe technology—enabled programs is the knowledge that the app connects them to a person who they know and trust, and who is available to help them make sense of their journey.
In our experience rolling out our technology products with payers and providers, several big themes have emerged about how to successfully implement technology programs aimed at the elderly:
• Making sense makes sense. A therapeutic relationship not only helps in getting access to information and support in the tasks of diabetes self-care; it also helps patients, especially seniors, make sense of the deeper, more existential questions they face. We believe that a key design imperative for technology aimed at seniors is to help patients and clinicians build therapeutic relationships such that the software experience essentially melts away. The design of technology for seniors, from the feature set to the user interface to the user experience, should help these patients find meaning. A relationship with a clinician is a tried-and-tested way of doing this, and we believe that all technologies designed to be used by seniors in the clinical context should view themselves as communication technologies empowering patients to build therapeutic relationships with clinicians.
Experience has shown that innovations that are not connected to a clinician are only used in the short term. This is typical of most technology initiatives that treat patients as beacons of health data who are willing to take on self-management of their conditions. Such solutions in practice offer little value beyond self-tracking. Our payer and provider customers report that uptake of these tracking solutions is typically less than 10%, and 1-month retention rates less than 1%.
• Change management matters. Although the managed care context naturally serves to encourage alternative models of care delivery, the reality is that the consultation is still the fundamental unit of healthcare delivery and we are all primed to consider healthcare as what happens in consultations. Introducing digital tools, such as Wellframe, into the context of care delivery requires considerable investment in change management at the care-delivery level, enabled by a fundamental commitment to use such technologies to amplify clinical relationships by enabling participants to collaboratively create their positive effect at greater scale and with greater frequency.
We have consistently found that patient adoption follows clinician adoption. Although clinician adoption may be challenging at first, it takes off once the new technology demonstrates value and becomes the default. The initial “pilot mentality” that attracts the early-adopter patients and clinicians alike evolves into a more assured pattern in which clinicians see Wellframe as a default aspect of their care delivery model. This assuredness is implicitly and explicitly communicated to the patients and manifest as greater onboarding conversion rates and improved retention. As you might imagine, comfort and familiarity on the part of the clinicians is critical to being able to convince elderly patients that they will be successful in using a new technology product. As an older patient, if your (likely younger) care manager or doctor is intimidated by the technology, your own confidence will be understandably shaken as well.
• Technology should be people-worthy. It is sad that seniors blame themselves for the faults of technology creators. Muhammad Yunus, the Nobel Prize—winning economist who created a pioneering community-based model of microfinance for the poor, said, “It is not that people are not credit-worthy, but it is that banks are not people-worthy.”2 The same could be said of the legacy of health technology for seniors: it is not that seniors will not use technology, it is that the technology offered to them is often not “peopleworthy.” Thinking about the essential questions that an elderly patient faces, and using technology to help them make sense of their experience, is what makes the difference between creating a solution that can be woven into the fabric of care instead of one that will alienate seniors and ultimately be discarded.Trishan Panch, MD, MPH, is the co-founder, chief medical officer, and head of product at Wellframe, Boston, MA.
Elaine Goodman, MD, MBA, is assistant in medicine at Massachusetts General Hospital and medical director at Wellframe.References
1. Mobile technology fact sheet. Pew Research Center website. http://www.pewinternet.org/fact-sheets/mobile-technology-fact-sheet/. Published December 27, 2013. Accessed April 10, 2016.
2. Black L. Muhammad Yunus: the model social enterprise leader. The Guardian website. http://www.theguardian.com/social-enterprise-network/2012/sep/12/muhammad-yunussocial- enterprise-leader. Published September 12, 2012. Accessed April 17, 2016.