The cHealth Blog

I’m usually a touch overcommitted.  There are so many exciting things to be part of now that the connected health marketplace is blossoming.  However, that makes it hard at times for me to practice what I preach.  Although our Center is not specifically about prevention, we tend to get involved because of our interest in connected health in the fitness market and in the Quantified Self.

By far and away, the biggest proliferation of connected health devices has been in the activity monitoring space, so I am inevitably trying, testing, wearing two or three of them at any given time.  And they remind me every day how active or inactive I am. 10,000 steps a day is a nice benchmark – most days I get to 5000. 7000 is high.  10,000 is rare.  Stated another way, I’m at a plateau in my quest for a healthier lifestyle.  How can I get there?  Do I have to give up some of the exciting work-related things that keep me a touch overcommitted?

When I first started monitoring my activity, it became quickly apparent to me just how inactive I am on an average day in the office.  Meeting after meeting means lots of time in a chair.  I just learned of a study from Australian researchers published two years ago that found that spending more than four hours a day in front of a computer or television was associated with a doubling of serious heart problems, even among people who exercised regularly.  Stated more dramatically, if you sit for more than 4 hours per day, your risk of heart attack is roughly equivalent to someone who smokes.  My own Body Media armband data from a recent Sunday illustrates this principle.  I was catching up on computer work in the morning and went out to do yard work in the afternoon.   The vertical axis is kilocalories and the horizontal axis time.

You can see just how low the calorie burn is during the first part of the graph (period of inactivity) compared to the second part.  When we sit for long periods of time, our body tells our metabolic machinery to make more fat for storage and this contributes to obesity, diabetes, hypertension and risk of heart attack.

So what is the solution?

I’m calling it “small frequent activities.”  You can use your activity monitoring data to help you with this.  If you are tracking steps, set a reminder on your phone or computer to check your step count a few times/day.  Find some activities that you can do which enable you to get in 10 minutes of walking or at least standing.  Fit those into your schedule in a way that is not disruptive.  Use your step count as a tool to measure success.

This is not to excuse you from setting a work out goal and a longer-term activity goal.  Think of daily step count as a batting average and these 10-minute excursions as individual at bats. Both are important to achieving success.  But if you work out for 30 minutes per day, and walk an additional 3000 steps, your heart attack risk will be lower if you spread those 3000 steps out in small, frequent activity increments.

Can the same logic be applied to calories taken in?  I don’t believe research has been published to confirm it, but intuitively it makes sense.  In fact, recently in the New York Times, Claudia Dreifus wrote about a mathematician, Carson Chow, who has built a mathematical model to explain why our country has put on so much weight over the last 20 years.  One of the things Chow notes in his model is that, “if you eat 100 calories fewer a day, in three years you will, on average, lose 10 pounds — if you don’t cheat.”  In one way, this sounds like useless advice because most of us vary our caloric intake on a given day by way more than 100 calories (there are 100 calories in 8 ounces of soda).  But there is something empowering about these data.  Dr. Chow has created a simulator that you can access to see how small changes in your diet or activity make a difference long term.

The insight here is to make small adjustments and stick to them. Climb a few flights of stairs each day and don’t put that teaspoon of sugar on your berries in the morning.  Take a conference call while walking around your office.  Sustained over time these adjustments lead to better health and they are not so overwhelming as the New Year’s resolution of going to the gym or the diet that drops 30 lbs in two months only to see it creep back on over time.

I guess the baseball analogy holds well again.  Hitters make adjustments in the middle of the game according to what the pitcher is throwing. They tend to get more hits the second time through the order. And if they do that consistently, their batting average rises.

I was chatting with a friend the other day about  how to get people’s attention in this information-overload age, and we decided that the use of buzz words was a critical component of success.  So I decided to test this catchy title and see if it leads to any more reader traffic than I usually get.

Really, I’m not messing with you.  There is something to the idea of buzz word use in our search engine optimized world, but as I reflected on these three technology trends, I thought it worth pausing for a moment to reflect on just how game-changing each is for those of us in the connected health space.

Wireless/Mobile

Of all the top-of-the-hype-cycle buzz words in health care right now, mobile tops the list.  And while we probably can’t cure cancer, reverse aging and find the true meaning of life with mobile technology, it really has revolutionized the world of healthcare.

The key features that are so exciting are the miniaturized computing capabilities in mobile devices combined with their always on, always connected state.  Those of us who grew up espousing the vision of telehealth now have no excuse (from a technology perspective anyway).  We can videoconference from our iPads over 4G networks, or use our smartphones as data-collection hubs for remotely monitored sensor data about our patients.  We can message our patients in the moment when it’s most needed.  With mobile technology, we have the infrastructure to deliver on the promise of connected health: using objective information derived from patients to provide insights that lead to improved self-care, as well as the opportunity to deliver care in the moment or continuously.  Both of these strategies have been shown to improve quality and lower costs, particularly when applied to chronic illnesses such as diabetes, hypertension and congestive heart failure.

Big Data

This is the newest of our buzz words, but the healthcare implications are huge and exciting.  The term Big Data is a colloquialism referring to the power of collecting and analyzing large data sets.  The companies that provide storage and super-computing services are salivating at the opportunities to bring this technology to healthcare.

Three trends suggest that they are sniffing at a real opportunity:

• The first is the decreasing cost of genetic sequencing (now around $1000 and falling fast) combined with the exciting results we’ve seen when genetic information has been used to target therapeutic interventions in certain cancers.  The era of personalized medicine is near at hand. The computational power and storage needed to make genetic mapping part of an individual’s standard health information (the same way we all know our cholesterol level today) are staggering.  But the precision that genetic data affords will allow us to diagnose, prognosticate and recommend therapeutic interventions as never before.
• The second trend is the rise in consumer connected health and its intersection with the power of wireless.  Personal health measurement devices abound (FitBit, Withings, Zeo, etc.), each making their data easily available via wireless networking.  The tendency is to publish open APIs so the data from these devices can be captured and analyzed, yielding insights into consumer behavior. This is the cornerstone of the improved self-care value proposition of connected health.  This data collection and sharing will enable us to create phenotypic maps that are as unique and precise as the genotypic maps noted above.  Applying these data sets on individual and population levels represents an enormous opportunity for the Big Data folks.
• The third trend is the movement of bundled provider payment or global payments, otherwise known as the movement to Accountable Care.  Providers are waking up to the notion that organizations need to create highly individualized/segmented programs and interventions that enable efficient, but compassionate care and promote patient affinity and loyalty.  Once again, the opportunity here for data storage and analytics is huge.

The Cloud

Of all of our overused buzz words, this one seems to be the most ubiquitous in consumer advertising these days (possibly tied with mobile).  What does the Cloud really mean and what are the implications for healthcare?  Simply put, Cloud computing involves giant banks of connected computers that can handle multiple software applications and data storage at once.  Up until recently, sharing software applications or storing data was inefficient and had several downsides. Then, a few years back, someone developed software that would enable you to spread your application and storage across many networked devices.  This led to much more efficient computing.  All servers are efficient, operating at capacity. If an organization needs more computing power, it’s easy to immediately order more. Lastly if one computer breaks no one really notices because the load is balanced by others.

The implications for healthcare?  Both the power of mobile and the power of Big Data could not be achieved without the added innovation of cloud computing.  Storage of information in the cloud and access on  mobile devices allows for those devices to truly be windows into the world of information (ever notice how ‘dumb’ your iPad seems when it’s not connected to the Internet?).  All of that Big Data is stored in the Cloud.  These three innovations rely on one another for success.

It’s an exciting time.  Although the buzz word Bingo surrounding these three concepts is slightly annoying, the applications for healthcare are truly amazing.  Healthcare needs to be revolutionized and these technologies provide a critical substrate.

Weight loss (or gain) = calories in minus calories out.  Simple, right?  Well actually, not as any person who has gained a few pounds and can’t shed them will attest.  It seems as we grow older, our metabolism slows. There is also good evidence that once we put on weight, our body re-adjusts to ‘defend’ (that’s a word scientists use) that new weight. Stated another way, if you gain 10 pounds, then lose 10, your body goes into a state where various hunger hormones are secreted more often than they’d be in the case of someone who never gained the 10 lbs. Tara Parker-Pope covered this wonderfully in a recent NY Times Magazine article called The Fat Trap.

But actually that’s only true for some of us.  Those of you who were around to witness the amazing performance of Robert DeNiro in Raging Bull (1980) know he gained 50 lbs to play the character of Jake LaMotta in his later life.  After the film, DeNiro lost the weight promptly and easily.  He can be seen as slim and trim playing a priest in True Confessions  (1981) not long after. Even if you look at modern-day pictures of DeNiro (e.g. in Little Fockers 2010), he is no where near as heavy as he was when he played the senior LaMotta 30 years before.

Ok, now are you convinced that it is more complicated than simple calories in vs. calories out?

In Personalized Prevention, Part I, I reviewed the concept of connected health as phenotypic mapping and started a discussion of how one type of data might inform our use of the other.  In Part II, I discussed the psychology of engagement as applied to connected health interventions.  In this post, I want to use obesity as an illustration of how it might practically work.  I am not going to cover the public health story on obesity (how we live in a time of calorie excess and a dearth of opportunities to be active).  I know some of you will have that top of mind and may wonder why its not mentioned.  Yes, we’re all growing a bit more overweight as time goes on due to this trend. In general, we’d all benefit from eating more plants, more colorful foods, less animal-based food, less processed food and finding ways to be more active.  Today, I want to talk though about how the genetics of obesity may be able to help us create segments of the population that may respond differently to connected health interventions. Also, response to connected health interventions may be a trigger to prompt genetic testing.

Although I am not an expert on genetics, I have studied up on the genetics of obesity as I am giving at talk at BioIT, May 25, at the BIO meeting in Boston.  We are a long way off from having exact obesity genotypes the way we now do for certain cancers and the like.  But the genetics argue that we can distinguish at least 5 genotypes:

• Thrifty genotype: low metabolic rate and insufficient thermogenesis

• Hyperphagic genotype: poor regulation of appetite and satiety and propensity to overfeed

• Sedens genotype: propensity to be physically inactive

• Low lipid oxidation genotype: propensity to be a low lipid oxidizer

• Adipogenesis genotype: ability to expand complement of adipocytes and high lipid storage capacity

Imagine a world where we knew this information before or shortly after birth.  Could you envision someone with either the thrifty genotype or the sedens genotype being targeted for an exercise program involving activity monitoring and customized motivational tools as were discussed in Parts I and II? If we got to these folks when they were young, do you think we’d have the ability to reorient their lifestyle choices for the better?

One example worthy of consideration is the partnership we have with the Boston Public Schools to encourage activity in children from some of our underserved schools.  I blogged on this some time ago.  The 2011 program was such a success that we’ve expanded it this year, and we are just launching the spring 2012 program.  The children who took part last year shared numerous stories about how wearing a smart pedometer, getting weekly feedback and participating in a classroom competition on activity helped them become more aware of how active they are, encouraged them to be more active and even bring the culture of activity into their homes.

When people are on a connected health program,  we can determine at an individual and at a population level who is active and who is not responding to the program. Imagine that we could take those data and compare them with genetic data to elicit finer and finer comparisons.

I am wildly enthusiastic about personalized connected health, about the opportunities to combine genetic and phenotypic data to gain insights about individuals and about personalized prevention.

Today I’m following up to my last post, exploring the question of how and where the consumer perspective fits in the development of connected health.  Recently, I read with great interest a piece in JAMA called “What Patients Really Want From Health Care” by Allan Detsky.  It is a well-written and provocative piece. I don’t know Dr. Detsky but one gets the sense he must be a fine physician, in the tradition of Marcus Welby or the type of doctor I grew up with in Barre, Vermont, who would make house calls and always seemed to know how to make you feel better.

While interesting reading, to me, the piece seems flawed from two perspectives.  First, the article is highly focused on an acute care view.  Dr. Detsky notes that he practices in an inpatient setting and the piece reflects this bias.  Secondly, it is truly difficult to really know what patients want when you are in the role of the doctor.  I can fully say that when I take on the role of patient, I can’t really do so in a pure way, completely divorcing myself from my role as a doctor. I don’t think its possible for a physician to fully embrace the role of patient, possessing the insights into health and disease that years of clinician training and medical practice.  So, despite his best efforts, I don’t think that Dr. Detsky can tell us what patients really want.

It’s not that I think the JAMA article is off-point but rather incomplete.  There is so much more to health care than what goes on in the acute-care/inpatient setting. When we are sick enough to need an inpatient bed, most of us want to be cared for in the most profound way.  This perspective on care doesn’t translate well to the two other domains of health care that I routinely think about – namely health/wellness and chronic illness.

Focusing on health/wellness and chronic illness, I’m going to risk falling into the same trap I’ve criticized Dr. Detsky for: I’m going to take a stab at what I think patients want. However, using the blog format for this communication allows me to take advantage of social media allowing for feedback, especially from those of you who are not doctors!  So, please help me with this.  If we hit a home run, the output from this dialogue will be fodder for our Symposium and for other writing projects I’m involved with.

In the realm of fitness and wellness, I believe:

• We want to live forever in a healthy, painless state.
• We want our health care professionals to take us seriously when we engage them in dialogue around alternative approaches to diet, exercise, nutrition, sleep and longevity.
• We want integration of our fitness/wellness world into our healthcare world. Right now they are silos that don’t talk to each other.
• We want to engage our healthcare professionals in conversations around all of the data we’re collecting about ourselves with consumer-level devices (and not have those data dismissed as unimportant).

In the realm of chronic illness:

• We want low-friction solutions to help us cope.
• We don’t want to be told we’re sick and we don’t want to be treated as sick.
• We don’t want to face the future consequences of our chronic (often symptomless) illnesses.
• We want to feel as if we can dig ourselves out of the chronic illness abyss – to feel hopeful.

In general:

• We want good service.  A person to answer the phone.  A kind voice.  A caring and supportive person.
• We want to be treated with respect.
• We don’t want to spend time in the doctor’s office or hospital.
• We want simple, consumer-friendly processes for accomplishing tasks like scheduling an appointment or refilling a prescription.
• We want access to professional advice (Dr. Detsky and I align on this one).
• We want transparency of process – ‘a play book on how to get things done.’
• We want a way to take charge of coordinating our care without complex, repetitive and obtuse processes.

For centuries, patients have put up with tremendous inconvenience and friction to move themselves through the healthcare system.  They’ve put up with it because the only way to get care is to visit the doctor and the system is constructed to make the doctor’s work life as productive as possible, not to make it easy for patients.  I expect that to change in the coming years.  We’ll see more patient empowerment,  more instances where consumers can make their own health care decisions without  a physician and more opportunities to streamline care delivery making it simpler and more patient-friendly.

What do you think?  Did I get it right? What’s missing? Let me know.