A Smart, Small, Familial Approach to Population Health

This is a feature story from our June 2018 issue. Our bimonthly print magazines are available for free at this link.

Andy Dunn, MD, says the features that make Wyoming beautiful also cause healthcare issues. But the state has a high-tech solution.

“I’ve seen a patient who had maggots in his face,” Andy Dunn, MD, says at the end of a long Monday.

He didn’t see that patient that particular day, mind you. He has simply seen the unfortunate situation before. Dunn is a family practice physician and the chief of staff at the Wyoming Medical Center in Casper, the second-biggest city in a state that is anything but cosmopolitan. He’s the medical director for 2 primary care centers, 2 associated urgent care centers, and the continuing education unit, an observation-and-training arm of the hospital.

Dunn played baseball in college and briefly in the minor leagues. You can tell because he litters his dialogue with coach-speak like “stay after it.” He takes what he calls a Norman Rockwell approach to medicine, referencing the artist’s painting of a doctor listening to the “heartbeat” of a young girl’s doll. Dunn is upbeat and energetic. Even when talking about the maggots.

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“The guy was a rancher, and he had maggots in his face for weeks and just wouldn’t come to the doctor,” he says. “Finally, his family made him, and I can’t even describe it. I thought someone was playing a trick on me. His skin was waxy and looked like waves. Grossest thing I’ve ever seen. I just took tweezers and was trying to pull all these maggots out. I know I didn’t get all the maggots before he went to hospice. It was amazing.”

Dunn tells the maggot story not for shock value. Rather, it’s an example of a challenge facing healthcare professionals in the state of Wyoming. He describes this “cowboy mentality,” which essentially means that citizens just don’t want to go to the doctor. That’s a problem for population health because it can be hard to track and maintain in a populace too busy or disinterested to see a physician. An even bigger challenge for population health, however, is that there isn’t much of a population in Wyoming to begin with.

Wyoming is the 10th-largest state by size and the smallest by population. The US Census Bureau estimated in July 2017 that the state was inhabited by 579,315 people, down from 585,501 in July 2016. That sparse population, spread out over a vast land area, creates a unique circumstance for the effective application of population health studies. It might be true that Wyoming has a rancher or cowboy mentality that discourages going to the doctor. But even for those who want to go, doing so can be a difficult proposition.

“It’s very sparse out here,” Dunn says. “Communication is a lot harder than you think it should be. When you spread out the population, it’s really hard to get consistent preventive screenings. Primary care is like you’re the ringmaster of a 3-ring circus or are trying to herd cats. We have triple-bypass patients who live 2 to 3 hours away. They have to travel back for follow-up appointments or face complications.”

Distance and time have always been concerns in Wyoming healthcare. In the modern biotech era, however, the Wyoming Department of Health is developing new tools to mitigate those concerns.

James Bush, MD, is the Medicaid medical director at the Wyoming Department of Health. He first got the idea to modernize how Wyoming citizens track their own healthcare at a community theater, of all places. He was playing R. H. Macy in a production of Miracle on 34th Street when he noticed how attached some of his young costars were to their phones.

“People would come offstage and start immediately looking and playing with apps. Then they’d go back onstage. They couldn’t be away from their app for half a minute. Basically, I have been of the opinion that kids or younger people these days live and die on these apps,” Bush says.

The Wyoming Department of Health had long maintained several websites and would send out periodic surveys to citizens on a mailing list to help build a fuller population health program. Bush had his doubts that those efforts were having the desired effects, so he sought a partner who could help develop a healthcare app for the state of Wyoming.

He decided to focus on a simple, easy-to-measure goal first: prenatal development. He passed that idea along to one of the department’s recruitment vendors, who came back with a Bay Area start-up called Wildflower.

Wildflower CEO Leah Sparks started her career at McKesson Corporation in San Francisco, California. She worked as part of the company’s corporate strategy group before realizing that her real passion lay in building start-ups.

“I first started thinking about the company a few years ago when I was pregnant with my first child,” she says. “We actually incorporated when I was 6 months pregnant. It struck me when my husband and I were starting a family that this was a great opportunity to crack open the healthcare engagement conundrum.”

Wildflower received an investment through Rock Health, an accelerator, which put out a press release announcing its portfolio companies. Before Sparks knew it, Bush was calling from Wyoming, far from Silicon Valley and all its start-up glory, saying, “I think you can help with this.”

“A Medicaid population in the middle of the country was going to be our first client,” Sparks says. “It was awesome.”

The first app the pair developed was called Due Date Plus. It was designed to help women track their pregnancies from conception through birth. With the app, the Wyoming Department of Health was able to track 2000 pregnancies to completion, about as many pregnancies as Wyoming’s Medicaid population has in a year.

The department conducted a study that indicated that women who used the app went to more prenatal visits and had fewer low-birth-weight infants. For the cost of $110,000 for the launch of the app, Bush and his team estimated, the state averted $330,000 in costs it would have incurred from low-birth-weight deliveries.

Still, both Bush and Sparks saw pregnancy as just the beginning.

“When we first started, we knew we wanted to do more than pregnancy,” Sparks says. “By really listening to our clients in Wyoming, we heard that we wanted to continue to engage the family after the baby was born. That was what led us to extend the platform so you could move seamlessly from taking care of a baby to a toddler to an adolescent and beyond.”

Wildflower developed a new app that helped patients track their health from birth all the way through adulthood and on into eldercare. Bush envisioned it as an “owner’s manual” for healthcare. In a way, it was meant to be a lifelong companion.

The app, called Family Health by Wildflower, launched in December 2016. Users can download it for Android and iOS devices and then enter a Wyoming zip code to get going. The app then calibrates the information displayed for the user’s location. The main page features easily navigable icons for healthcare milestones, a weight tracker, a vaccination tracker, and information about all the publically available healthcare options around them.

“Leah actually went beyond my suggestions, and now the app covers from conception to death,” Bush says. “Every one of those milestones is in there. Every immunization is in there. Once you get into the teens, they get into sexual topics, drugs, tobacco use. Bullying is in there. Then as you get into your 20s and 30s, the topics are more appropriate for those ages. You have your adult immunizations in there.”

The Wyoming Department of Health orders and receives reports on the apps and which features are most popular. As of April 2018, the app had 111 active users. The most popular features were Highlights, Milestones, and Symptoms & Issues.

Bush says he doesn’t like spending public money on programs that don’t have easily definable concepts of success. For Due Date Plus, the definition of success was clear. There was a definite time period and a definite desired outcome: fewer low-birth-weight children. But because Family Health by Wildflower is designed to last the entirety of a patient’s life span, “success” becomes a bit harder to pin down.

For now, Bush and the Wyoming Department of Health will be focusing on increased early and periodic screening, diagnostic, and treatment (EPSDT)

well-child visits.

“When you’re talking about multiple generations, multiple years, it becomes a little harder,” Bush says. “Our primary focus right now is EPSDT. Is the number of well-child checks going to go up now? Are we able to track any other health outcomes or access to programs? Each of the public health programs is now thinking about how [they can] find success.”

There are still outstanding issues and oversights within Wyoming’s healthcare system. Blue Cross Blue Shield of Wyoming is the only private insurer offering plans in the state’s exchange this year. Wyoming has not accepted federal Medicaid expansion for 2018, and around 10% of the population is uninsured. Premiums are higher there than in most of the rest of the country, but the Affordable Care Act’s income-based premium subsidies keep coverage reasonable for most enrollees.

Still, the unique issue of managing care in a big state with a small population is something that can be mitigated by a simple piece of technology. And Bush believes Family Health by Wildflower will help.

“Our department of health is very forward-looking, and we understand that we can use technology to overcome some of our physical limitations,” he says.

Dr. Dunn is equally optimistic.

“I can’t believe this is Wyoming. It’s really cool. We also get a lot of new parents who aren’t super compliant with their well-child checks. To show them the growth chart and the development milestones—that’s a big thing. Having the ability to say, ‘Hey, use this app. We’re going to communicate this way because we want to check on you, and this is much easier.’ Maybe even with the caveat, ‘You won’t need to see me as often.’” Even if that’s the case, Wyoming will be seeing plenty of these patients, if only through the data points that tell the medical story of a person and a population.

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