AI-Driven Interactive Patient Engagement: Interview with TeleHealth’s Richard Bootes

October 19, 2018

The virtual health coach is a breakthrough in a rapidly growing industry to improve healthcare by better engaging with patients and families, using AI and machine learning to determine ideal times for teaching important information. iCare Navigator draws data from electronic medical records and uses machine learning to build relationships with patients and family members.

The iCare Navigator system responds in real-time based on how engaged the patient is at any given moment and makes workflow decisions based on the patient’s engagement level. Workflows and processes for engagement and education respond to system triggers based on data-driven measurements in order to optimize patient engagement.

Richard Bootes, a pioneer in interactive patient engagement, led the development of iCare Navigator. Bootes’ goal in developing iCare Navigator was to create the first interactive patient care system that combines empathy, game theory, and family involvement to help patients be more receptive to changing their health behavior. The cloud-based system is integrated with electronic medical records and other clinical systems to follow the patient through the entire continuum of care, from pre-admission to post-acute and at home during recovery.

We spoke with Mr. Bootes to learn more about the technology his firm has developed.


Alice Ferng, Medgadget: Tell me about yourself – what is your background, and how have you been involved with this novel product?

Richard Bootes, VP of Product Development at TeleHealth Services: I have served as the vice president of technology at TeleHealth Services since 1996 and led the development of iCare Navigator as the healthcare industry’s first and only interactive patient engagement and education system for hospitals driven by artificial intelligence. iCare Navigator is the first interactive patient care technology platform to use an avatar as an adaptive and empathetic virtual health coach with an artificial intelligence engine to engage patients in new data-driven workflows through the entire continuum of care.

Previously, I led the creation of the TIGR patient engagement and education system. TeleHealth Services was the first company to develop digital technology for patient education video-on-demand through interactive voice response technology. The standard practice advanced from VHS tapes on rolling TV carts with scheduled viewing times to digital on-demand education in multiple languages. The leap to iCare Navigator is even greater for the industry to truly engage with patients and families in unique ways that improve health and treatment outcomes.


Medgadget: Why do you think market penetration has been so difficult with these types of technologies? How has your company been able to overcome those barriers?

Mr. Bootes: Patients in a hospital are naturally filled with anxiety, fear and loneliness. Often, being hospitalized is a life changing event. It is really the worst time to try to educate someone about their health, but it is also the best time because caregivers have a captive audience.

Today, conventional interactive patient engagement systems integrate a library of condition-specific educational videos with smart TVs, Internet-based software platforms, interactive applications and mobile devices. TeleHealth Services is the largest provider of these interactive patient engagement systems to hospitals with more than 430 systems installed. But I knew something was still missing. Too many hospitals (8 out of 10) are still using paper handouts for education at discharge with little thought given to patient and family health literacy, education levels, or cultural and language barriers.

With hundreds of millions of dollars invested in electronic medical records (EMRs), the healthcare industry has focused on data-driven solutions but is still seeking new methods to engage patients with meaningful digital strategies that improve outcomes. Conventional patient engagement systems have typically focused on displaying information at the hospital bedside, but that alone is not authentic patient engagement. Displaying information on patient televisions can be like Bloomberg TV for healthcare. I believe that the inability to truly connect with the patient is why no company has fully penetrated the market.


Medgadget: Who conceptualized this novel product and what was the inspiration behind it?

Mr. Bootes: I’ve been in the interactive patient engagement business for two decades and I knew we were still missing something for authentic and lasting patient engagement. After researching patient behavior and the science behind behavioral change, I had insightful discussions with hospital clients. Then I proceeded from a framework of understanding that each patient is unique. We need to learn about each patient and understand how to motivate them to take an active role in managing their health. I also learned about the importance of recognizing that simple is better and storytelling is critical.

I studied the research by Dr. Brian Jack, professor and chair of the Department of Family Medicine at Boston University School of Medicine. His research, and his role now as a strategic clinical advisor, influenced the development for iCare Navigator. Dr. Jack used an avatar-like coach to deliver his award-winning discharge methodology, called Project RED (Re-Engineered Discharge). This research has been widely recognized and honored.

Project RED was designed to improve the health of patients and lower costs to hospitals by reducing readmissions through better patient engagement and education. The amount of time doctors and nurses spend with patients prior to discharge teaching them how to care for themselves with medication and at-home care information is typically four to six minutes. Half of the patients have problems with new medications after the first two days. Research demonstrated that 19.6 percent of Medicare patients have adverse events that lead to readmissions and, thus, high healthcare costs. Reducing readmissions from 20 percent to 15 percent will save $35 billion over four years, according to the Centers for Medicare and Medicaid Services.

A clinical study demonstrated that Project RED lowered the rate of readmissions in the month after discharge by 30 percent. The avatar ‘humanized’ the Project RED clinical discharge processes. Surveys conducted during Dr. Jack’s research revealed that twice as many patients preferred interactions with the avatar than doctors and nurses who always seem to be in a rush. I knew we could effectively do the same for other education processes during the entire patient journey, which you could say was the inspiration behind iCare Navigator.

Medgadget: Tell me more about the technology itself. How is AI incorporated and how is it effectively used to encourage patients to interact with the system long-term? Have you been able to study the use of your technology by patients after they are discharged from the hospital to see if they continue to interact with the system over time?

Mr. Bootes: iCare Navigator provides a virtual personal health coach who comes to life in the form of an avatar on a TV screen or mobile device to guide the patient along their healthcare journey.

iCare Navigator determines patient engagement, measuring responsiveness, mood, receptiveness, adaptation and activation levels through the AI engine, the heart of the iCare Navigator solution. As a patient interacts with iCare Navigator, the AI engine continues to measure the level of engagement. The system responds in real-time based on how engaged the patient is at any given moment and makes workflow decisions based on the patient’s engagement level. Workflows and processes for engagement and education will respond to system triggers based on these data-driven measurements to optimize patient engagement.

The patient’s user interface (tablet, bedside screen or in-room TV) is designed to be more personalized and responsive to patient preferences and adaptive to the patient’s level of engagement, including identifying ideal learning times. Patients have options when selecting their personal health coach based on variable demographics, ethnicities and linguistic backgrounds. The personalhealth coach continuously “learns” patient preferences during interactions that are uniquely tailored for each patient and continually evolve. Discussions are guided by the patient’s EMR and data analytics created through interactions with the patient.

iCare Navigator is unique in that our system differentiates between a patient’s participation and engagement levels. For example, while a patient may appear participative by interacting with health-agnostic functions of the system, such as watching television, at the same time they may demonstrate a low level of engagement toward their health condition. In such patient situations, iCare Navigator leverages a patient’s overall participation to introduce motivational-type activities designed to increase their interest and engagement in their health.

The relationship with the patient extends beyond the walls of the hospital, often through integration with a hospital’s patient portal so patients at home can manage their health education using the same portal they’re directed to use for scheduling and provider communication.

Medgadget: A lot of patient care systems are arguably “interactive”, though interaction can be described by something as simple as a patient self-selecting options in a standard web browser. How does your system go beyond this level of basic interaction between a patient and digital system?

Mr. Bootes: iCare Navigator changes the game in patient engagement and education, bringing a personalized delivery of healthcare information that combines audio, video and imagery to make a personalized relationship between our virtual health coach and patients. Engaging patients begins with understanding their uniqueness and motivation. We know simple is better, and we know to engage in storytelling. We also know patients do better when the family is involved. iCare Navigator uses a personal health coach (avatar) along with demographic information from the EMR, with queues based on patient interaction, empathy, and game theory to develop a relationship and experience that educates patients in ways that are uniquely best for each patient. A Personal Care Network can also be established with the system for family and friends to send short, motivational messages to patients as they progress and complete stages of their care they progress and complete stages of their care plan.

Responsive, adaptive personal health coaches can better prepare and motivate patients to take more responsibility for their own care. Data has demonstrated that patients actually prefer interacting with their virtual personal health coach instead of nurses and doctors who, understandably, always seems to be in a hurry. The virtual health coach is a breakthrough in a rapidly growing industry to improve healthcare by truly engaging empathetically with patients and families, using AI and machine learning to determine ideal times for teaching.

We focus on “patient activation,” meaning patients have the knowledge, skills and confidence to manage their health. iCare Navigator is more simple and intuitive than conventional products on the market today. It is designed not only to appeal to tech savvy patients, but also for seniors over 65 years old and engaging family members of all ages in the care of their loved one. The personal health coaches interact with patients, continuously learning their preferences. Virtual discussions are uniquely tailored for each patient and continually evolve, guided by the patient’s electronic medical record and data analytics created over time through interactions with the patient.

The personal health coaches guide patients through health education plans, relaxation therapy and clinical support services. Encouragement is built-in with gamification strategies that reward progress in the patient’s care plan. iCare Navigator helps the patient develop a personal care network with family members to motivate patients in adopting healthier behaviors.

We worked with Healthwise (a health education content provider) to integrate microlearning content delivered by the personal health coaches including audio discussion scripts and educational videos. Microlearning is an emerging strategy for teaching and learning, providing educational content in small, very specific bursts of information. Instead of 10-plus minute videos in many conventional patient engagement and education systems, microlearning content is broken into 30-second to two-minute segments.

Combining modern microlearning strategies with artificial intelligence and virtual personal health coaches to dynamically determine when and how to best deliver information is a leap forward for the industry. Learning becomes more of a conversation and a compassionate approach that will improve retention, reduce readmissions and foster long-term positive health results through behavioral change.


Medgadget: What studies have you performed to validate this system?

Mr. Bootes: Much of the experience that we’ve created centers on the studies of avatar and patient engagement done in Project RED.  The results of Project RED indicate that a patient is more likely to retain information when engaged with an avatar as opposed to their nurse or a clinician.  They feel that the avatar is more patient and that they have more freedom in expressing their curiosity, confusion, or frustration.

To that end, our focus has been on changing the patient education experience from presenting a list of items that the patient must complete to guiding them through the learning process with the help of a virtual companion.  As a result, patients choose to engage with their education out of curiosity rather than obligation.  We have seen this effect at Carle Foundation Hospital where patients using the iCare Navigator system are more likely to complete educational assignments during their stay. Surveys showed more patients had a sense of control over their experience and indicated a higher level of satisfaction about their stay in the hospital.

We’ve also changed our approach to education by using smaller and more concise information about topics related to a patient’s healthcare journey.  In the past, our typical assignments would include 15-20 minute videos that covered everything about a specific condition or procedure.  Our new approach involves using shorter video clips in addition to articles, websites, and dialogs with the personal health coach.  Topics are split up so that each stage of the journey can be completed in no more than a few minutes.  And the patient has the choice of which topics that they wish to cover and in what order.  This allows patients to consume and retain the information at their own pace without overwhelming them with information.

In addition, iCare Navigator’s business analytics tools help hospitals gain valuable insight to benchmark success, evaluate initiatives and better serve the patient population. This includes access to relevant, real-time data; aggregate and enterprise-level reports to view on screen or export; track hospital performance on targeted outcomes for improvement and accountability; and improve analysis and organization agility with outcomes management.


Medgadget: What type of data is used for empathy and game theory? How is that incorporated into the system?

Mr. Bootes: Project RED showed us that you can connect with a patient by asking them simple questions like “How are you feeling?” or “Are you a Red Sox fan?” These questions make the patient feel that the system is more of a companion that’s listening to their responses rather than a tool that’s demanding their participation. So we are expanding on that.  We’re using imagery and color that evoke emotional responses to learn what a patient connects with.  We believe that allowing the patient a variety of ways to respond to questions gives them more opportunities to feel that they can adequately express themselves.

We know that empathy is more than just asking a question and offering a suggestion. It’s about acknowledging a person’s state of mind and demonstrating that we understand where they are emotionally.  If the virtual health coach is going to succeed at being a companion to their healthcare journey, it needs to be able to show the patient that it is on their level.

For example, if a patient says that they’re not feeling well today, the virtual health coach responds that it understands that being in a hospital can be especially tough.  It reminds the patient that they are surrounded by people that care about them and who are dedicated to helping them feel better.  The health coach encourages patients to feel safer and reminds them that they’re going to get through this together.

Our virtual health coach connects with patients through dialogs between iCare Navigator and the patient.  In addition, we use metrics provided by the EMR and other sources to learn about general patient behavior based on similar encounters with patients who share the same age, diagnoses, and other key identifiers.  This helps us build demographic profiles that help us better approach patients who are in similar situations.

However, we realize that every patient is unique and iCare Navigator tailors the experience to their needs. By directly engaging the patient with questions about how they are feeling and remembering their feedback to the system, the system is able to better respond to a patient’s emotional needs.  This allows the system to acknowledge the patient’s state of mind and offer emotional support in real-time.

iCare Navigator uses game theory to incentivize patients to remain engaged in their healthcare journey to achieve positive outcomes.  Patients achieve goals set by their care team either by completing real-world tasks or by completing educational assignments within the iCare Navigator system.  Goals can be as simple as drink water throughout the day or as complex as completing a set of assignments that deal with their condition or diagnosis.

The system puts this information in front of the patient at all times to remind patients where they are in their healthcare journey.  The virtual health coach shows interest in helping you reach higher levels and achieving your goals so that by the time you complete them you can both celebrate your achievements.  These rewards take the form of badges, virtual knick-knacks, or perhaps even physical rewards such as a discount coupon to the hospital gift shop

The goal of using game theory is two-fold. First, we want to keep the patient engaged in their healthcare. Second, we want to remind the patient that they are making progress and offer encouragement no matter how small it may seem.


Medgadget: How does this system get trained to improve over time? What are the next steps for the iCare Navigator? What about for the company?

Mr. Bootes: The system improves as more data on user interactions is captured and analyzed in the cloud. The ability to draw insight from larger and more diverse data sets is core to our approach for modelling AI. In our case, the data is all about how patients choose to interact with the system and which interactions provide the best results.  This allows the system to create better paths for engaging patients and ultimately providing them with the best approaches to improve their health.

The next steps for iCare Navigator are continuing to gather larger data sets and applying them to additional opportunities for patient engagement.  The next step forward in AI is understanding how human emotion can affect the decisions we make.  This means knowing which questions to ask of patients, how to respond to those answers, and how best to use that feedback to create more opportunities for positive outcomes.

We are continuing to work on even better integration with systems to improve clinical workflows not only to streamline the effectiveness of clinicians in teaching patients, but also alleviate burdens in their busy schedules.  We continue to focus on working directly with clinicians to understand what their goals are for achieving better health outcomes.

We also want to begin expanding iCare Navigator beyond the boundaries of the hospital into the overall continuum of care.  This means providing iCare Navigator to patients at home, in outpatient clinics and in acute care settings.  We are working with content providers in developing curricula that can be administered over several weeks before or after a medical encounter.  We are working on issues with these providers to extend better support beyond the walls of the hospital setting.

TeleHealth Services website…

Link to press release on the launch of iCare Navigator…

Link to Project RED website

Frank’s source:


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