Case study: Colonoscopy
After a particularly discouraging day in the endoscopy suite in which six of seven patients had inadequate bowel preparation for colonoscopy, Dr. Atreja dug a little further into Mount Sinai’s endoscopy data. “I realized we were losing one million dollars a year because of no-shows and inadequate bowel preparation,” he said.
A higher success rate could be achieved with bowel preparation if enough staff time is dedicated to repeat phone calls, he conceded. “But you are spending $300,000 just on a brute force solution” of massive staff resources, he said.
In the Mount Sinai example, when all missed opportunities are considered, “you’re looking at 4 to 5 million dollars that we’re leaking because we are not able to engage patients at the right time.”
Gastrointestinal procedures are a major source for revenue leaks, he said. Patients may miss procedures or be late; up to 1 in 4 patients may have poor bowel preparation, and sometimes patients arrive without a plan for a ride home after a procedure that requires sedation.
Other care gaps include the 30%-70% of patients who don’t return at recommended screening intervals, and patients who have positive fecal immunohistochemical testing but don’t receive a colonoscopy. Some patients have colonoscopies ordered, but never scheduled, and still others are never offered any colorectal cancer surveillance testing at all.
It’s no wonder patients are confused, said Dr. Atreja, providing an example of one center’s colonoscopy preparation instructions for split-dose polyethylene glycol bowel preparation. Patients must closely follow a full page of bullet points to be completed at precise time intervals. “One in four patients actually loses the paper by the time they need it before the procedure,” he said. Another 40% don’t look at instructions until it’s too late to prepare adequately or to line up an escort to bring them home post procedure.
This scenario, he said, shows that “it’s not in the science of medicine, but in the practice of medicine, that we are failing. ... So how about we completely change the game and create a real-time digital navigation for the patient?”
The digital alternative to the slip of paper is a real-time patient navigation tool that guides patients through the entire colonoscopy preparation process. “Based on where the patient is at that point in time, and the procedure, and the bowel prep,” the app gives the patient timely and relevant information: what the procedure is like, why bowel preparation is important, and how preparation is correctly performed, explained Dr. Atreja.
A reminder to arrange an escort arrives on the patient’s phone a full 10 days before the procedure, with subsequent nudges. Patients even receive driving and parking directions. The day before the procedure, a last-minute query checks on transportation. “So we’re working with Uber to actually make an ... integration with Uber so they can pick up the patient if they have transportation issues.”
Post procedure, patients are asked about their experiences, and a plan for appropriate patient recall is integrated into the app as well. “The best part is, this has not been designed by anyone [other] than those in the health system. Because we already know the recommended guidelines, we know the best practices.” This, he said, is where the value of digital apps is truly created.
Early evidence gleaned from a dashboard that’s part of the digital health solution from one site using the app shows a 24% improvement in bowel preparation. Importantly, the rate of aborted procedures has been cut in half, and patient satisfaction rates are at 93%.
