What do Patients Really Want? Part I
I recently wrote about an innovator’s dilemma of sorts – or call it a paradox – in healthcare. The paradox is that as we look to innovate in healthcare, the very authority figures we must turn to for fact-checking our innovative ideas are conflicted and highly motivated to support the status quo. I’m talking about physicians of course.
In a fee-for-service world, physicians are both the fountain of relevant knowledge and the source of all revenue. So we have built our workflows, systems and processes around their comfort and success. As physicians succeed, so does the rest of the healthcare juggernaut. I know other industries fall victim to these kind of MC Escher-like business models, but it seems particularly acute in healthcare.
My belief is that this paradox makes our industry highly susceptible to under-imagining what real innovation could look like. We have some pretty deep blinders on, it seems. One of my favorite Steve Jobs legends is that when asked about the consumer research that led to the development of the iPad, he quipped, “We don’t expect consumers to be able to tell us what they don’t realize they need.” [I am paraphrasing, but this is reasonably accurate.]
As we trot out our prized innovators in healthcare, we don’t seem to hear that kind of talk. We hear about improved ‘door to balloon time’ in the care of acute MI, about using Lean to improve hospital work flow and supply chain management, about programs to encourage more generic drug prescribing and about decision support systems that help doctors avoid wrong dosing or prescribing medications that negatively interact with one another. Indeed these are innovations, but they are all innovations that Christensen would classically call incremental.
At the Center for Connected Health we purport to be patient-centered in our approach. I think we do a decent job at this. But try as we might, it’s hard to get at two things. One is a true patient perspective that is imaginative, articulate and consistent.
I’m making a pitch to our Symposium organizers that this year we devote a good deal of space on the program to drawing out the patient perspective from multiple angles. We’ll see how persuasive I am.
The second challenge is finding patient advocates who do not feel intimidated in front of an audience. We also have trouble finding advocates that are ‘pure’, i.e., folks simply disguised as patient advocates but really championing a different cause. I have to give thanks to the tireless work of folks like Dave DeBronkart and Sarah Krug who are tireless advocates and my friends at the Society for Participatory Medicine. But we need more like them.
In the meantime, consider with me how we as innovators should best create the programs, technologies and services that chronically ill patients don’t know they want or need yet. How do we develop devices to motivate and monitor activity for the fitness buffs who think they are content with a good pair of running shoes and a gym membership? How important is the patient perspective in the development of connected health programs and services?
In my next post, I’ll share with you my impressions of an article that appeared in JAMA last month about patient perspective.
Is disruption of mainstream healthcare the answer to our crisis?
I’ve been a fan of Clayton Christensen’s work. The idea of disruptive innovations really resonates with me and provides a powerful framework for understanding how innovations are adopted (or not) by various businesses. As I think about our healthcare dilemma (escalating costs, misuse of limited resources, shrinking access to care and, in general, creating a drain on our country’s economic health and competitiveness in a precarious global fiscal environment), I think about the construct of disruptive innovation quite a bit.
There has been a lot of hand-wringing and discussion about how to fix this problem. There is even a new series of buzzwords entering our lexicon (ACO, patient-centered medical home, bundled payments, shared savings, bending the cost curve – this is an incomplete list). This last one amuses me – bending the cost curve. Try as we might, those of us in organized healthcare can’t come up with ways to really cut costs. We proudly talk about strategies that may keep costs from going up as quickly. The goal of keeping medical inflation at the same rate as general inflation is often mentioned. The trouble is, we’re starting out spending so much more than any of our developed world comparators. Yet, can we claim that the quality of care we deliver is as good as other nations that spend considerably less? So is ‘bending’ the cost curve really enough?
One reason we have so much trouble is that so much of our costs are tied up in labor (56% according to one recent study). As someone recently quipped, “in healthcare, a dollar saved is a dollar of someone’s wages lost” – or at least 56 cents of wage lost. Also, as classically described by Christensen in The Innovators Dilemma, most of our decisions are made either by physicians or in consultation with physicians. So many times over the years, I’ve witnessed interesting ideas brought forth and dismissed out of hand by physician leaders. “Our patients would never go for that….”or ”That would not work clinically,” etc. Of course clinical judgment plays an important role in healthcare delivery and the perspective that a physician brings is valuable. But when we’re talking about efforts to really manage costs, we have a conflict of interest. Can decision-making physicians really look objectively at solutions that are presented which might result in less demand for our services and may affect our income? After all, we’re only human.
Last week, I was privileged to be on a plenary panel at the 3d annual mHealth Summit in Washington. My predecessor on the panel is the President of Apollo Hospitals in India. He gave an impassioned speech (effective too, laced with humor and using his booming voice and stage presence) declaring that mHealth would go nowhere unless doctors were compelled to adopt it.
Our Center stands on the border between two very different worlds.
In one world, our healthcare delivery system is facing the hurdles alluded to above. Partners, the delivery system we work for does its best to move 7000 physicians and a large hospital system to a new reimbursement model and, consequently, a new care model. It’s going slowly, but we’re viewed as leaders and we’ve done amazing things to try to get us there.
In our industry, there is more talk than ever about the potential of connected health, but not too much implementation just yet. In fact, the predominant strategy floating around involves hiring more staffing for better care coordination and improved quality. Wait, didn’t I say that 56% of costs are labor? So we’re adding more labor?
In the other world our Center lives in, consumers are moving to take charge of their own health, adopting connected health as either a personal fitness aid, or as part of an employee benefit offering (e.g., the work that Healthrageous is doing). This too is in its early stages, but as I watch it unfold, I’m struck by the possibility that the health care cost crisis may be solved by innovation that occurs outside of the traditional healthcare delivery system.
One example that is interesting is retail clinics. They are flourishing now. They are taking business away from our primary care physicians. No one notices because they are all so busy, but as retail clinics grow, at some point we’ll notice. Another trend to follow is how Walmart re-invents primary care. It’s early and speculative, but I’ll bet a week’s pay that this model will include some component of home monitoring and surely lots of opportunity for patient/consumer self-care.
At our Connected Health Symposium last month, we held a lunch for several companies who are ‘non-traditional’ entrants into connected health. We had participation from a beverage company, a consumer products company, and a large retailer to name a few. Why are they all interested in connected health? I’m just learning, but I’m sure if they smell a business opportunity it is unlikely to involve mainstream healthcare.
So keep an eye peeled for something to happen. Some routine service that you think you must see your doctor for will be delivered online or in some much more convenient way. God knows, today’s mainstream healthcare delivery is about as consumer unfriendly as you can get. So once something that competes and is convenient, a true sea change should be upon us.
What do you think? Can you conceive some truly disruptive concepts that will take business away from mainstream healthcare delivery and still deliver quality care?
Cutting Through The Clutter of Connected Health Innovation
I had the pleasure of speaking this last week at the Future Forward meeting in Wellesley. This is one of a series of meetings that brings together the Boston innovation and entrepreneurial community to hear about trends and opportunities. My talk was on how technology is maturing to achieve consumer engagement in health and resultant behavior change.
In preparation for the meeting, I reflected back on the days when my colleague Doug McClure, now CTO at Healthreageous, and I envisioned what would be needed to bring connected health mainstream. One area that has been troublesome has been the ease with which we can extract data from various home-monitoring sensors (blood pressure cuffs, pedometers, glucometers and the like) and get it into the cloud for analysis and utility. At this point a variety of strategies exist, from plugging a device into your computer (via USB port) to the wireless home hub, to embedded mobile chips in the sensors themselves. This cacophony suggests an integration nightmare. Long before we founded Healthrageous, Doug and I thought device connectivity would give us an edge.
Fast forward 5 years and its hard to find a sensor that does not have some sort of wireless connectivity. Many of them have connectivity integrated through a smartphone or home hub directly to the company’s website.
Device connectivity has largely been conquered. So is that the market? Well, there are countless sensors that you can buy and easily start tracking your own physiologic info and learning from the experience. It is this phenomenon that was the genesis of the Quantified Self movement, now with meet-ups in many cities world wide. It seems like selling products to this burgeoning market of self-tracking zealots might make sense.
The challenge is, it appears to be about 10% of the population. Lots and lots of devices chasing a small and finite population…..
Then there is the deluge of smartphone apps. More than 10,000 of them last count. So are apps the answer? Well not exactly. It seems that 26% of the time apps are opened zero or one time. Further, 75% of the time folks stop opening them at about the 10th try. That is kind of discouraging. It seems that apps alone are not the answer.
Maybe there is some way to marry these two concepts. We know that data=self entry is a particularly weak strategy as it is subject to social desirability bias as a confounder. We all want to look good and healthy so we’re prone to report those readings that support this and somehow not report those readings that do not.
Healthrageous has taken the path of focusing on dynamic personalization. With all of the data being collected about you, they are able to craft a uniquely motivational program of messaging for you. And it’s working. Their early results show positive improvement in both blood pressure and activity monitoring.
Likewise Runkeeper is doing some interesting integrations with devices as is Gravity Eight.
These are just a few of the companies that now take advantage of the near ubiquitous tracking data that can be derived from consumer-level sensors, but seek to surround those data with strategies to draw the consumer in and create the opportunity for sustained behavior change.
The tools are: social networking, incentives, games/contests, and automated coaching.
So if you are in the business of recommending investments or partnerships in the rapidly changing/growing space of connected health, the data is coming in.
Companies that figure out how to present objective data to consumers in a compelling way, combined with motivational coaching, social networks and gaming will succeed. Not all of these tools will be necessary. But the trick will be finding out which one suits each individual. Those entrants that have a highly customizable platform and an ability to sense what you as the consumer will respond to, will be the winners.
Self-Quantification as a Driver of Behavior Change
I was privileged two weeks ago to keynote at the 8th Annual Connected Health Symposium. In the event you were not able to join us, the video is available for viewing here, and below is a summary of my remarks.
In 17 years of swimming in the waters of connected health, the single biggest insight I’ve gained is that individuals, when given objective information about their health, have the capacity to change their behavior. I never dreamt how engaged and committed patients could be in managing their own health. I know it sounds silly, but it’s a side effect of training as a health professional. We undervalue the opportunity to engage patients in self-care.
The most useful construct for thinking about this phenomenon is the idea of feedback loops. When you are driving down the road and spot one of those digital displays showing your speed as a flashing yellow light (compared to the speed limit), do you slow down? Most folks do. That is odd since you are looking at redundant information – your speed is on your speedometer and you know the speed limit. Somehow the juxtaposition of the two and the flashing are effective tools to change your behavior. That is a terrific illustration of the power of feedback in connected health.
Feedback loops have four important components (this is covered in more detail by my friend Thomas Goetz in a recent issue of Wired): evidence, relevance, consequences, and action. In our experience, with connected health, it boils down to three things: active reflection, the sentinel effect, and the ability to take action. Let me unpack each of those.
Active Reflection
I’ve been impressed by the insights that can come from reflecting on objective health information. I wear a BodyMedia armband, which calculates activity level and caloric output among other things.
I like to cycle for exercise. Last time I checked, an hour of cycling around town burns about 275 kCal. This time of year, I’m forced to spend weekend time on another activity I like less well, leaf raking. I used to really resent the time I’d spend raking leaves because I thought I should be cycling in order to get exercise. Imagine my surprise when I checked the caloric expenditure for yard work and found it to be ~ 400 kCal. I realized my own ‘go to the gym equivalent’ in yard work and I don’t hate it so much any more. Our patients with diabetes, hypertension and congestive heart failure talk about insights like these every day. Eat a salty food today and gain a pound or two of fluid tomorrow. Drink too much tonight and see your blood pressure go up tomorrow. Karen Federico, a nurse with Partners Health at Home, tells the story exceptionally well in this video.
The Sentinel Effect
This is important. About 10% of the population can achieve behavior change on active reflection alone, but the rest of us need some other motivators. For many the idea that someone (particularly their healthcare provider) is going to see their data and hold them accountable to it, is powerful motivation to be more adherent to the program. As one of our heart failure patients, George, puts it, “I can’t fudge because I can’t eat fudge!” He hastens to add that he feels comforted knowing that, “trained professionals are looking at my information on a daily basis and available to take care of me at a moment’s notice.” Here is a link to a video of George telling this story. The sentinel effect is powerful. It’s what makes connected health – in the context of healthcare provider management of chronic illness – so powerful.
The Ability To Take Action
Of course feedback loops would be useless without empowering individuals to change their behavior based on the insights they gain from pondering their health data. We measure our success in this regard by looking at healthcare outcomes in the populations of patients participating in our programs. Here are three brief examples. A glowing pill bottle that reminds patients to take their medication and records that the medication was taken increased medication adherence by 68%, compared to a control group. Diabetics engaged in active home glucose monitoring and sharing those results with their provider, via the Internet, showed a combined 1.5% drop in HbA1C. During a six-month home monitoring program, patients with high blood pressure who monitored their blood pressure and received automated coaching feedback had a significantly lower blood pressure than those in a control group. It’s clear that feedback can lead to clinically meaningful behavior change. One of our pharmacists, Amy Bilodeau, does a nice job of explaining how this works with her patients in a linked video.
Our Patients Are Our Largest Untapped Resource
Chronic illness is on the rise. The baby boomers are entering their high maintenance healthcare years. We’re in a debt crisis and we MUST bring down the costs of healthcare. Our profession has reacted by pushing electronic records, the patient centered medical home, and accountable care. All of these are worthwhile, but I’ve yet to see a concerted effort to bring patients into the process.
Start tracking something (blood pressure, steps, weight). Engage a coach and make some commitments. Share your insights with your doctor and move the conversation forward.
Advances in Connected Health From the MIT Media Lab Featured at the 2011 Connected Health Symposium
I’ve always been a fan of the accomplishments of the folks at the MIT Media Lab. Their accomplishments have been legion, and just a few admirable highlights are: their ability to continually attract large industrial sponsorships; their open IP model; their collective ability to look 10-15 years out and capture those innovations that will be mainstream at that point; and not least their efforts to add technologies that will aid in the repair of our broken health care delivery system.
I’m excited to say we have a big Media Lab focus at this year’s Symposium. Two of their current giants, Sandy Pentland and Rosalind Picard, will be speaking as well as a Media Lab graduate, Tim Bickmore, who is doing amazing things with his program at Northeastern.
These three have something in common that excites me. They are exploring the boundaries of technology in its ability to substitute for humans in the caring process.
Sandy has been prolific in commercializing his work, first by founding Cogito, a company whose goal is to pick up your mood state based on a 10 second voice print. Subsequently, he launched Ginger.io, which is founded on the basis that all of those electronic bread crumbs you leave behind each day (GPS data, who you text, who you call, where you spend money and what you spend it on, etc.) can be analyzed to come up with a unique health behavior print that can aid in both public health applications and in encouraging you to improve your own health. I recruited Sandy to be on the Scientific Advisory Board of our Center’s spin out, Healthrageous, because I value his perspective on this topic of disparate data collection and analysis.
Roz has been working for years (she was Tim Bickmore’s adviser) on ‘affective computing.’ She is also a founder of Affectiva, a company whose technology can objectively assess your emotional reaction to stimuli via a wrist sensor and face-recognition technology.
Tim’s team continues to impress with their implementation of Relational Agents, software agents that are designed to exhibit relationship-building behaviors. His most recent achievement is showing that, strategically used, these software agents can participate in health care delivery and that patients prefer them to doctors and nurses.
So how do they all fit together? As the demand for health care services (largely driven by lifestyle-related chronic illnesses) skyrockets, we don’t have enough providers to meet the need and it doesn’t make sense to try to train or import them. We’re also trying to control costs, 60-70% of which are related to human resources, so adding more will not solve that problem. We MUST adopt solutions that increase self-care and spread providers across larger groups of patients. However, for a number of cogent reasons, we can’t abandon our roots as a caring profession to pull this off.
Think of it another way. To get the most out of our providers we will need to look beyond the traditional office visit. Expecting patients to meet one-on-one in a physical location creates a true bottleneck for health care delivery. However, using today’s technology, while I can get a near continuous read of your weight, blood pressure, blood glucose, activity level and some data on your sleep, I can’t put those physiologic measurements in any kind of emotional context. That is arguably one of the most important aspects of what the doctor does in the office exam. Systems like Cogito and Affectiva are the beginning of providing the emotional sensing to enable the doctor to get a full picture of your physical and emotional state, in a time and place independent manner.
The other side of the office visit is caring for the patient. There are myriad of data showing that a patient that feels cared for will do better and that the strength of the patient-provider relationship is important in health outcomes. So how do we extend our providers across greater numbers of patients while preserving that caring bond? Undoubtedly it will be a challenge. But Bickmore’s work showing that patients prefer relational agents in certain care settings is an encouraging first step to getting us there.
As I said, the Media Lab is leading the way in creating these technologies and showing their early phase potential. We at the Center for Connected Health are pleased to have a strong showing from their faculty at this year’s Symposium.
Quality and Efficiency at the 2011 Connected Health Symposium
We are incredibly excited this year to be hearing from both Brent James and Atul Gawande at our annual Connected Health Symposium. They each point out the importance of quality, safety and efficiency in achieving the vision of a health care system that can meet the care requirements of our nation while keeping costs in check. Let me say a word or two about each and then share about why we recruited them and how they fit into connected health.
Brent James is Chief Quality Officer at Intermountain Healthcare based in Salt Lake City. He is known nationwide for his relentless focus on quality, measurement and outcomes. His organization is the envy of health care leaders far and wide, as they’ve been able to deliver high quality, standardized (do I dare use that charged word?) care and achieve success — by all measures — doing it. Brent was featured in a wonderful New York Times Magazine piece in November 2009. He is on record advocating for improved efficiency of care delivery, for measuring our effectiveness and for reporting these data to patients, payers and regulators. He is also on record advocating for shared decision making and for wholesale payment reform.
Atul Gawande needs no introduction to most of you. He has been a prolific writer for the New Yorker and published three New York Times bestselling books. He has a wonderful way of telling stories about his training and work as a surgeon, about his experiences with patients and about how we, as professions, can do better. He too is passionate about quality improvement. He has taken the simple idea of checklists and made that into a movement in healthcare, using time-outs, lists, and processes to prepare for events that have a high degree of potential patient safety risk (surgery being the prototype).
We are excited that both of these giants will be sharing their thoughts with us.
Why did we recruit them and how do they fit in to the connected health ecosystem?
Both share a passion for patient-centric care, as we do, believing that it is fundamentally better care and will conserve dollars. Both are advocates for health information technology and connected health is a subset of that domain.
The best way to contextualize these two speakers, though, is to think about how a connected patient population would impact their respective visions. Imagine a world where we are all equipped with ‘wear and forget’ sensors continuously streaming wireless information about one’s health. This forms a powerful set of information to analyze and on which to base quality and performance decisions.
A good example of this is our Diabetes Connect program. Patients who are having challenges controlling their A1c or are starting insulin therapy upload blood glucose readings to our database using a wireless home hub. We share that information back with them in a way that is contextually relevant; we also provide it to a diabetic nurse in dashboard format so decisions can be made just-in-time about care plan modifications.
We’ve shown that increasing engagement from both patients (as measured by frequency of blood glucose upload) and care provider (as measured by frequency of logging into the Diabetes Connect website) lead to improved A1c (up to a 1.5% drop when both parties are engaged).
Imagine, for example, if Dr. James’ vision of quality and measurement was enhanced by these sorts of data streaming in about all of Intermountain’s patients.
The opportunities to analyze, segment, intervene and measure the effect of interventions are enormous. We believe this will be a reality in the not-to-distant future. In fact, based on the success of programs like Diabetes Connect, our organization, and others, is moving steadily in this direction.
At the Connected Health Symposium, we’ll have the opportunity to discuss the challenges of improving quality care, patient safety and efficiency with such thought leaders as Drs. James and Gawande who are, right now, putting technology to work – and making it work for providers and patients.
Over the next several weeks, I will be authoring a series of posts on some of the keynote speakers slated to present at the 2011 Connected Health Symposium. This year, the Symposium is unparalleled and we’re trying a multimedia approach to get the word out, stimulate dialogue and debate and prepare people to take in the amazing content that will be available.
First up, psychology and connected health.
We are delighted that Cliff Nass, author of “The Man Who Lied To His Laptop” is speaking at the Symposium. At first glance, you might wonder what the connection is between a psychologist who uses computers to tease out the basics of psychology and connected health.
I was first attracted to Cliff’s book about a year ago. I’ve been very interested in the role that computers can play in substituting for humans in providing the emotional aspects of care. This can be an off-putting concept to some, but we are at a cross roads with respect to the demand for medical services and the supply of providers. We don’t have enough healthcare providers to go around, especially if we continue to demand that a face-to-face encounter between patient and provider is required to move a treatment plan forward. So when I saw this book title and the review in The New York Times, I was intrigued.
The book is both entertaining and informative. It reads like a guide to success with such pearls of advice such as:
Praise others (but not yourself) freely, frequently, and at any time, regardless of accuracy.
Clear personalities are better than ambiguous personalities, even if they do not match that of the person with whom you are interacting.
Traditional team-building exercises don’t build teams because they support neither identification nor interdependence.
Your persuasiveness comes down to whether people perceive you as expert (are you worth listening to?) and trustworthy (should you be listened to?).
Being labeled an “expert” or a “specialist” grants you all the persuasive power that actual experts have.
All of these and many other truths are convincingly laid out using a common experimental framework. Namely, Nass and his students use computers as emotional agents, but ones that are absolutely controllable (in a scientific sense) so they can tease out the psychological variables that lead to the conclusions above.
This all makes for great reading. But once again, you may ask, what is the relevance to connected health?
To me the relevance is in the part of the story that Nass tells early on and then dismisses.
Have you heard the story of the border guard who watches a young man with a bicycle cross the border day after day? Each day the guard stops the boy and searches him because he is suspicious that the boy is smuggling. After years of this charade, the guard, in frustration, finally asks the boy, “Alright, I can’t stand it…what ARE you smuggling?” to which the boy smugly answers, “bicycles.”
The relevance to connected health is right under our nose.
It is amazing that Nass and his colleagues can draw study subjects into innumerable scenarios using computers as agents of behavior change. Here is a brief excerpt describing some of them:
“I’ve had to put participants in my experiments through many struggles and travails: answering difficult math problems amid the pressure of stereotypically superior competitors (in the form of avatars), dealing with a nagging passenger and frustrating roads on a drive (in a driving simulator that talks), enduring false praise and criticism (from a game-playing computer)….”
Study subjects found all of these gimmicks convincing, or at least their behavior was altered. This is the hidden gem.
So, here is the connection to connected health. What Nass’ experiments show is that the applications for using computers to bond with our patients and alter their behaviors are enormous.
I look forward to Cliff’s keynote and hope he will spend some time on this connection.
A related presentation will come from keynoter Tim Bickmore whose relational agents have repeatedly been shown to be a potent tool for behavior change. Among the experiments I’m sure Tim will talk about is our collaboration using Karen the Virtual Coach. Patients who had a virtual ‘meeting’ with Karen three times per week did significantly better in achieving their activity goals than controls. Likewise, Tim has some impressive data showing that using a relational agent for hospital discharge is preferred to having discharge planning done by a human.
These presentations create a theme around how we can use technology to provide care to our patients, make them feel cared for, and allocate our human resources to serve more patients at any given time, attacking that supply and demand mismatch. There will also be some debate and commentary on this area and my own talk, “Quantification as a Tool for Behavior Change”. All in all, the topic of computers as agents of behavior change will be well covered.
