Beyond the Ready and Willing: How AI Can Engage the Hard-to-Reach

Years ago, my staff and I pored over handwritten notes and unsigned prescriptions in order to address patients with chronic diseases. For the first time, we were using data to determine patients’ needs and deploying our clinical resources to meet those needs—before the patients suffered complications or sought care themselves. For most physicians today, this is a more familiar and digitized process. But back then this was a first, and we could see a pattern. Some patients were more familiar than others. I came to understand that there was a major obstacle to chronic disease management, namely, that the patients most likely to benefit from primary care were the ones least likely to seek it out.

Digital health management can help us deal with this conundrum of primary care. It means harnessing technology to support and engage people in their everyday lives when they are not patients and outside the four walls and appointed time of care delivery. More patients can be served with the same clinical resources across multiple clinical specialties with a digital health approach. Because many people are capable of self-managing (at least some of the time) their conditions, digital health management makes it easier and more effective to do so by virtually connecting patients and clinicians through digital experiences such as a smartphone app. These patients would otherwise have to be seen through primary care visits, diverting attention and resources from more complex patients.

We know that digital health management helps clinicians reach more patients, more effectively, with the same resources. But how can organizations make sure they offer digital health solutions to the patients who are most likely to benefit? That’s where artificial intelligence comes in.

It seems like everyone is talking about artificial intelligence in health care. Maybe there is some hype. But there has, in fact, been huge, bona fide advances in deep learning, which can produce super-human results in very focused tasks such as image recognition or language translation. These techniques are more A than I: They are loosely influenced by how the brain works, are implemented with computers, and take advantage of huge amounts of data and computational power.

But despite these advances—and what popular culture may tell us—there’s no reason to expect that sentient robots will be replacing clinicians en masse any time soon. Instead, the intersection between these AI techniques and digital health management presents an opportunity to amplify the work of clinicians.

Trishan Panch, MD, MPH

When organizations deliver digital health management solutions, such as mobile apps, to patients they can generate an entirely new data set on patient activity, patient-reported outcomes, and more insights. It can also be combined with data from the health system such as claims data and EMR data. Through machine learning, organizations can then harness that data to prioritize members based on real-time needs, generate intervention alerts, and recommend follow-up actions with their providers.

This technology ultimately creates a positive feedback loop: Because patients receive timely, personalized support, they engage with clinicians more often. This generates more data, which, in turn, gives care teams more insights. Plus, this approach helps the organization as a whole learn which interventions are most effective and where clinical resources can be most effectively deployed.

For clinicians to meet the needs of all the people they are trying to serve, not just those ready and willing to come to the office and be patients, they will need to marry the technology that extends their reach with the powers of data science. That combination can help them focus on those who are most likely to benefit. I see us entering an era when clinicians can finally cast a wider net and give more time and attention to the people who would not otherwise come to see them. This is where AI’s contribution will make a difference by amplifying care for patients with chronic disease.

Trishan Panch, MD, MPH, is the chief medical officer and co-founder of Wellframe, a digital health management provider in Boston.

After 28 years of publishing, our last issue of Manage Care was December 2019.

While sad, we have much gratitude for the many writers, editors, researchers, reviewers, salespeople, and advertisers who kept us going and made Managed Care a standout publication. And not to be forgotten, we thank you for reading our publication and visiting our website.

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