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Innovation for Medically Vulnerable Populations

This 5-part blog series is about designing evidence-based patient-facing digital health interventions for vulnerable populations that are efficacious, scalable, and cost-effective. Think it’s a tall order? IT IS! But it’s not impossible. We have some insights we’d love to share with you. These insights come from our combined 20 years of experience designing, testing, and disseminating effective digital health interventions in medically vulnerable populations.

Medically vulnerable patients and consumers are at highest risk for many adverse health outcomes. This is not news. These consumers are more likely to have low incomes and to be racial/ethnic minorities. They are also more likely, across the US and indeed the world, to live in areas with significant transportation barriers, often in rural or semi-rural areas. These factors mean these patients also face higher barriers to healthcare access and behavior change programs due to:

• Low health literacy, costing the US economy $106 to $238 BILLION each year
• High rates of being un-insured or under-insured (20% of people earning less than $30,000 are uninsured compared to 11% of Americans overall. 23% of people who had insurance during all of 2014 were underinsured, meaning they had coverage but the costs of using that coverage was so high that they are at risk of avoiding care they need or going in medical debt to receive care.)
• Low levels of formal education (An additional four years of education lowers five year mortality by 1.8 percentage points)

Medically vulnerable patients are our highest risk patients whom, due to a confluence of factors, have higher rates of disease and a harder time managing health conditions, both infectious and noncommunicable.

For years, these populations were disconnected from technology. Living and working in low-income, sometimes rural areas, these populations lacked Internet access and by and large did not have computers at home. Today, however, technology may be the key to engaging people, and connecting them to information, resources and clinical care. According to recent Pew data (2014 and 2015), some of the most significant changes in phone and internet adoption patterns are taking place among African Americans, those with relatively low household incomes and those living in rural areas.

For example, college-educated, higher-income Blacks are just as likely as their white counterparts to use the internet and to have broadband at home. Blacks and whites are equally likely to own a cell phone. Over 90% of black adults own cell phones, and 56% own a smartphone of some kind. Blacks and whites are also about as likely as each other to network socially, with similar rates across income levels of social media utilization. As for text messaging, daily rates of use go up as you move down income levels:

This all translates into a great opportunity for innovation in these communities. Your patients are using technology in their everyday lives and we know you want to care for them. We can meet medically vulnerable, historically disconnected populations where they are using evidence-based principles and practices. We can deliver efficacious, scalable interventions to change behavior and improve health outcomes at increasingly lower cost.

In this series, we’ll explain how to design and implement an effective digital health intervention for medically vulnerable populations. We’ll go through each step of the innovation life cycle: problem understanding and hypothesis formation; experiment design; testing and evaluation; and scaling your solution (if it works). Through each of these steps we’ll share different considerations, provide examples, and guide you through the process of developing evidence-based innovation.

In this series, we will:

1. Outline steps and methodologies for innovation in resource-constrained settings including strategies to best address patient safety concerns (eg. informed consent, ethical considerations related to not offering standard of care, perceptions about research among many vulnerable populations)
2. Emphasize how to innovate with a dual emphasis on health outcomes and scalability, paramount in resource-constrained settings because investment is lower and need is higher
3. Explore appropriate technologies and design in these settings
4. Provide examples of what has worked and hasn’t worked and give suggestions for decision making when designing or choosing a digital health solution.
5. Foster greater investment and collaboration in advancing research and scaling effective interventions

There are different solutions out there for different problems, preferences, budget, communities and settings. This series is meant to give an introduction to each. In one community, patients might be struggling with taking their hypertension medications; another might be interested in digital health strategies to prevent teen pregnancy or improve breast cancer screening rates.

We know that cost considerations can be a major barrier for digital health innovation. One of the goals of this series is to provide tips and hints to help keep startup and scale-related costs down. We’ll discuss what kinds of costs need to be estimated: development (up-front) costs, maintenance costs, as well as tips for how to stay ahead of the technology trends. We will also address ways to minimize additional burden on clinic and health system staff when trying to implement and evaluate a potential technology-based solution.

We recognize the barriers to access that patients in these communities face every day — not just to care, but to safe spaces to exercise and play, to grocery stores with fresh fruits and vegetables, and to affordable medications. While technology is not a panacea, it can help improve patient-provider communication, keep patients engaged in behavior change, and ultimately make an impact on the health of those at highest risk.

Well-designed technology solutions can provide ancillary support, skills training, and feedback to patients. When easily accessible, it can help patients navigate confusing health systems and monitor their conditions outside the clinic, reducing readmission rates to EDs and easing the patient volume at overloaded clinics. Building and adding to the evidence base for smart, well-designed, cost-effective digital health innovations in medically vulnerable populations has the potential to revolutionize federal reimbursement models, thereby generating alternative funding streams for such innovations. Best of all, well-designed, efficacious interventions help patients achieve health.

Can’t wait to move this conversation forward! Share your experiences, thoughts and questions on Twitter with the hashtag #safetynettech.

Erica Levine is the Programs Director at the Duke Global Digital Health Science Center. She has over 8 years of experience translating evidence-based behavior change interventions for delivery on various technology platforms (SMS, IVR, web). She was leveraging technology for health in medically vulnerable populations way before it was cool. She has worked on projects in rural North Carolina, Boston, and Beijing.

Vanessa Mason is the co-founder of P2Health, an initiative that supports innovation that fosters the protection of population health and promotion of disease prevention and founder and CEO of Riveted Partners, a consultancy that sparks behavior change through accelerating data-driven innovation. She has over a decade of experience in healthcare innovation and consumer engagement in both the United States and developing countries. Her experience in global health has shaped the way that she sees the role of technology and design in health for vulnerable populations: innovate and integrate rather than break and disrupt.