The Iron Triangle of mHealth Apps Due Diligence: What CEOs and Boards Need to Know

As the Population Health Blog's medSolis CMO expertise in mHealth expands, it can't help but admire the infectious "can-do" optimism of its "app" programmer-developer colleagues and competitors. Even if healthcare is a morass of dreary economics, regulatory meddling and dysfunctional politics, these entrepreneurs really do believe that "there is an app for that!"

And neither are leaders in hospitals, clinics, provider systems, insurance companies, medical device manufacturing and population health immune from the developers' enthusiasm. "Apps" are being built or bought with the belief that they'll lower costs, create profits, increase quality, promote satisfaction, build brand, secure customer loyalty and generate invitations to White House conferences.

The PHB agrees. Apps can certainly achieve many of these outcomes, and it is looking forward to seeing the Roosevelt Room for itself in the not-too-distant future.

But that doesn't mean that CEOs, Boards and investors shouldn't be wary of how the healthcare "Iron Triangle" should factor into their "app" due diligence.

Old fashioned management experts will recognize the concept. They know that any project involves trade-offs between cost, quality and access. Improve any single dimension and the other two will suffer.  Improving two means having to compromise on the third. 

In other words, there are inevitable trade-offs.

Population health service providers are well acquainted with this. For example, launching a diabetes initiative means balancing the costs of the program, the intensity with which the enrollees will be managed (quality) and outreach with a span of services as well as associated risks that will be addressed (access). Accepting a lower fee per patient may lead to compromises in quality. Insisting on a greater span of managed risks could lead to higher costs or cut-backs in the level of patient counseling.

Which brings the PHB to mHealth. To the PHB, the three iron sides to configuring an app are the same:

Cost: This is not only a function of the nuts and bolts of programming, hosting and updating the app, but includes the additional economic burden of maintaining up-to-date security for the users' personal health information. There's also the added cost of updates.

Quality: This includes dimensions such as symptom control, condition management, promoting patient safety, reducing identifiable risks and measuring outcomes for quality improvement as well as research.

Access: The interface has to be speedy and intuitive, meeting consumerist expectations for ease-of use. That includes connectivity, screen loading, minimal manual inputting and efficient asynchronous communication.

How should CEOs and Boards think about apps? 

They should think about cost, quality and access and understand the inevitable trade offs that underlie the sweet spot of a successful app.

Costs will never go away. But smart app developers are using off-the-shelf, open-source as well as modular programming with (secure and encrypted) web-based hosting. Shortchanging IT support or security risks not only crashes and hacking, but could limit the end-users' ability to manage the continuum of health risks (quality) in a user-friendly and speedy manner (access).

Quality is important but judgment is necessary in understanding the secret sauce that links quality, behavior change and risk. It's possible to "overdo" condition management with a glut of care options, unnecessary attention to every risk, over-engineered branching logic and over dependence on human inputs. 

Access will be what the end-user cares the most about, including ease of use in a pleasing interface. Streamlining this too much, however, could lead to shortcuts that compromise optimum condition management or require additional costly information technology.

Bottom line?

If a company's senior leadership or Board of Directors is grappling with an app-based product launch, they need to understand the inevitable cost-quality-access trade-offs that were made in the course of its design.  If the cost is low compared to benchmarks, ask about the compromises in quality or access that were made.  If the developers claim that the condition management is the highest quality, scrutinize development costs and how access could suffer. 

Accordingly, the best apps on the market will be those that strike the right balance between cost, quality and access.

CMS and Health Reform: More of the Same

Unmentioned.....

Whoa, with breathless media coverage like this (dramatically change! ambitious!) you'd think that the Feds had just announced something important about health reform. 

After reading the CMS press release, a CMS blog post and this article in the New England Journal, the Population Health Blog has concluded that it's more of the same. 

As the PHB understands it, Medicare's January 26 announcement is that it will build on three ongoing reforms:

1. Financial incentives to expand "alternative payment" methodologies to 30% of all reimbursement by 2016 and to 50% by 2018.  These include accountable care organization arrangements, monthly fees to Patient Centered Medical Homes and use of bundled payments.  In addition, 85% of fee-for-service payments that are still in place will be linked to quality by 2015, with an increase to 90% by 2018.

2. Promoting "provider integration." That apparently means a new forum called the Transforming Clinical Practice Initiative, with a first yet-to-be-planned meeting in March of 2015.  In addition, CMS will continue to rely on its Partnership for Patients and the Patient Centered Outcomes Research Institute.

3. Information technology (IT) including more promotion of electronic records, meaningful use, interoperability and universal information technology standards.

[Yawn]

The cynical PHB is not impressed. The Obama Administration was using, is using and will continue to use faux announcements to advance its reforms.  What's more, when it reads the CMS pabulum, it's riddled with the same top-down mainframe rhetoric on realigning care, moving from volume to value, accountability, alternative payment models, serving populations, building a better system, increasing coordination, convening meetings, promoting information technology etc. There are no new details here.

The PHB will share three insights, however:

1. CMS, Ms. Burwell and their White House handlers lost an opportunity to reach out to the Republicans about the sustainable growth rate and leveraging that to build on multiple areas of agreement to jumpstart bipartisan reform.  Doing so could have accelerated the forward momentum of value-quality-cost-based reforms beyond the 2016 elections.

2. That being said, health care providers need to increase their familiarity with the opportunities as well as perils of payment reform as well as the very real barriers to fixed payment schemes.

3. The announcements are a reminder how CMS is still fixated on the EHR, while the real innovation is occurring in handhelds and their associated applications.  The PHB figures that its not about the providers and their desktop electronic records, but about patients and their smart phones. As these devices continue to grow in speed, power and sophistication, providers who figure out how to use the iPlatform to leverage self-care, communication and decision support will thrive.....

With or without Medicare's incentives, promotion or IT policies.

Image from Wikipedia