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.
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Sign in nowI am a great believer in technology but tech alone is not the answer. I believe the biggest barrier to reinventing healthcare is the current payment system. Nothing new happens unless someone (insurance) pays for it. Perhaps some disruptive technologies can make some healthcare services so cheap that patients/consumers will avoid insurance and drive a new tech-enabled care model.
I will throw out some ideas for improving US healthcare:
1. Allow patients to contract directly for pirmary care with their PCPs, either fee for service or retainer-like relationship, allowing patients to make their own value decisions. This would help by removing 30% of the overhead, fostering innovation, self-care, telecare, and remote monitoring;
2. Rebuild primary care in the US so that we have 70% PCPs and 30% specialists by:
3. Paying PCP’s 30% more;
4. Eliminating “Pay for Documentation”, which is currently required by insurance companies and Medicare, and;
5. Subsidizing primary care education so there is less need for docs to enter high paying specialties
6. Reduce insurance in order to encourage more private pay to create the economic stimulus for invention of better technologies and care models, e.g greater, not less, emphasis on health savings accounts or similar.
thank you. I agree with all of this except the ‘pay PCPs 30% more’. not sure its necessary and if we want to cut costs when 58% of our costs are labor, it doesn’t make sense to raise labor costs.
Thank you for this post.
Personally, I would like to be enlightened about the drawbacks of direct primary care (monthly fee payable to doctor, low-premium/cheap health insurance for patient, extremely convenient office visits) powered by a connected EMR like Hello Health’s that enables billing for all the “customer support” services that patients are accustomed to from retail giants.
This really feels like “the answer” to me.
the Hello Health model is a very innovative one. it is possible that this sort of model will indeed be the one that pulls it all together. While consumers seem comfortable paying for health/wellness/fitness, they are tepid re: paying for care when they are sick. If the Hello Health folks can convince patients/consumers to cross that barrier, they may be on to something.
I’d argue that the Personal Health Record is going to evolve into a disruptive technology. The logical trajectory of the PHR concept will marry deterministic rules engines running automated executable chronic care clinical pathways. PHR’s which are today, largely passive data repositories, will become data driven, personalized, longitudinal care management platforms. The PHR will become disruptive when an American Well-like organization makes the leap that the PHR has the established relationship with the patient (supplanting the doctor patient relationship). With the PHR as the hub, call centers and retail health providers (armed with deterministic clinical decision support tools) will disrupt the traditional primary care model.
In a constantly rationalizing market, payers will continue to seek out lower cost alternatives.
This is a very interesting perspective. Thanks
I agree – I thought Christensen’s OTHER great insight was that rules-based disruptive technologies would be market-driven, not top down mandates like Meaningful Use.
[...] For some analysts, like John Moore at Chilmark Research, the feeling is that “mHealth” is stuck in neutral. But this perspective is often colored by the framework of mHealth being mostly about health apps and mobile tools in healthcare settings and in population health management, and about smartphone health apps for consumers. The healthcare status quo is precisely what many are trying to disrupt, hence it will be those who can succeed at the peripheries, in novel ways, which may effect changes in the current business and reimbursement models. Necessarily, these innovations are going to see sporadic success, at least initially. Dr. Joe Kvedar, Director of the Center for Connected Health in Boston, echoes this same sentiment in his recent blog post “Is disruption of mainstream healthcare the answer to our crisis?”. [...]
The blog was very useful, I agree with all the points mentioned here in this blog. I hope the health crisis will be solved with some innovation ideas. I think if people stick to a balanced diet there will not be any health problem. As they say “Prevention is better than cure”… anyway thank you for sharing this with everyone.
Thanks for your thoughts. Solving this puzzle will be a team sport, so let us know what you are thinking from time to time!
Actually, we DO know what patients want, we just don’t pay attention to it. Although patients do not want to die, they certainly don’t want to suffer, receive ineffective non-beneficial treatment or cause serious financial strain for their family. When 344 seriously ill patients were asked to rank their most important desires near the end of life, the top three were (1) freedom from pain, (2) peace with God, and (3) presence of family.
Other important goals were having finances in order, feeling that life was meaningful, resolving conflicts and dying at home.1 Interviews of 126 patients living in a nursing home when asked the same question indicated they wanted (1) good pain and symptom control, (2) to avoid inappropriate prolongation of the dying process, and (3) to achieve a sense of control.2
1 Steinhauser KE, Christakis NA, et al. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000; 284: 2476-2482.
2 Singer P, Martin D, Kelner M. Quality end-of-life care: patients’ perspectives. JAMA. 1999; 281(2):163-168.
[...] of Partners Healthcare Dr. Joseph Kvedar, who was also on the CES panel, recently wrote a blog post about what patients really want in their health care [...]
Dr. Kvedar, this technology would prove invaluable to people in developing countries, most of which do not have the means to install advanced computers and/or buy smartphones as well. However, connecting people with tuberculosis, for example, to increase compliance, or providing monitoring to women with problematic pregnancies would do so much for public health. Is there a chance that the Center for Connected Health is planning international expansion?
I appreciate your position of what the patient doesn’t know they need. Innovation that is creating a paradigm shift often has to ping the fence with ideas to hone in on the game changing interface – ala Apple/Walkman/Braun.. The world of devices is accustomed to this, the world of workflow change less so, but we have now seen a major trend in consumer behavior shift. What is interesting as we explore novel interactive and participatory models of healthcare is motivation is our greatest hurdle – that of the doctor to seek efficiency and that of the patient to bring short and long term benefit. Revenue generating short term benefit solutions adopt quicker, but healthcare and preventative care is fraught with those issues that are cost (revenue) preventing and have long term gains. We need to continue to push and create experiences that are a delight for the consumer, their perspective is useful more in are we solving a pain point – less so of: Is this what you want.
this is a useful view. I’ll hold off further until your reaction to ‘part II” which will come out next monday
its a fine line. if we don’t ask patients (consumers, customers) what they want, we risk developing irrelevant solutions and appearing arrogant. But if we develop ONLY on what the tell us they want, we’ll miss the ‘Apple’ moments.
we do some work in the developing world, supporting twice a month email clinics in Cambodia
Health care solutions focused on the concept of disruptive innovations have focused on creating new cost layers of service and incentives that ultimately provide lower quality care yet increased costs to the system. We need to stop amplifying the problem and the system needs to pay attention to streamlining access and delivery. Only by cooperation between the healthcare providers and innovation companies can we break dams that hold us at bay and work around legacy systems. mHealth adoption by compelled doctors noted by Dr. Reddy of Apollo is a product of their milieu as much as their capability with the technology and its impact to the outcome of their patient. The good news is there is currently an enormous focus on innovating in healthcare – change for the positive is imminent!
I’m looking forward to reading Part II. In the meantime, if you’re looking for a really disruptive technology that gives new meaning to “what the patient wants,” check out the new advance directives service called MyDirectives.com at http://www.mydirectives.com. Already being used in the US and abroad, and very consumer-oriented. Like no other advance medical directives service out there.
this is particularly interesting to me as i share the same view as you.until we develop patient centered initiatives, that actually take the patients into account when designing the game plan, we are not being truly successful. as more health programs get introduced each year and developments take place the change management strategy adapted by governments and policy developers seems to be incentives to the doctors, subsidizing technology for purchase and all other means by which a particular service or program is adapted quickly by the health professionals. there are very few strategies that are designed around patient uptake of a service .i think what patients want is more information, education and awareness about things they can demand from their GP’s or specialists, how can remote health help them better rather than travelling long distances or simply put how can an iPad help them connect to an ophthalmologist in the city, when they are unable to drive because of an eye infection.
Thanks for your insights. On Monday, 1/23, I’ll publish part two and would love your thoughts on that as well.
Joe – thanks for crystallizing a key challenge in healthcare innovation (as you often do) but I want to take issue slightly – meant to spur dialogue so will state more extremely.
Innovation in industries either need to provide value to the current purchasers or (2) disrupt it in such a way that new purchasing models arise.
In healthcare – consumers/patients – represent a small fraction of the purchasers of healthcare. Providers – doctors and hospitals – and the payors buy most of the services so naturally commercially successful innovations will point to them. Consumers may increase their purchasing with HSAs and exchanges, but to-date out-of-pocket spend does not drive the healthcare market.
We all know countless startups / innovative new divisions of larger companies that have tried out-of-the-box, wow the consumer solutions – and many truly are disruptive but time after time consumers have not paid for these things.
So I am not sure how relevant a reference Apple disruptions for consumer focused innovation in healthcare. The paraphrasing of Steve Jobs would be more like “I don’t really bother to listen to doctors or hospital administrators or payor quality people when I design products/solutions, cause they do not know what they truly want.”
I agree we need to energize the consumer – put them at the center of their care – and have them demand better solutions, but until they are actually part of the industry – in terms of making purchase decisions – they will not be central in our innovations.
Look forward to continuing the dialogue and of course the leadership of the center in driving consumer engagement.
Adam
interesting thoughts. your premise is sound. the reason we don’t have a patient friendly system is because they wield no purchasing power….Let me know what you think of part II, due out tomorrow
What do Patients Want? Great Question. I wonder if there are any places or systems patients are full partners in designing their health care or where its “Members” already have a system that is desinged around their needs? Ah ha there is!
It sounds like you are writing about some future state vs exploring what we currently have in some systems like Group Health and the missing secret ingredient is simply payment reform. Group Health is a “co-op” started in 1947 that has over 600,000 “members’ not patients and not consumer but people who own their health care system that is be default patient centered.
What does this look like in practice? An EMR that was rolled out with a patient portal from the beginning of go-live, 24/7 access to your clinical records as well as your care team, a mobile app that gives you nearly real time access to both labs and radiology results and lets you make appts on the fly. http://ghc.org/mobile/ . New clinics that are being designed without waiting rooms because they take the members workflow into consideration http://www.djc.com/news/co/12030534.html and of course all of the primary care clinics across the state have shifted to the medical home model http://www.ghc.org/news/20100429-cnnMedicalHome.jhtml
What about wellness? Not only do members have access to cutting edge research into wellness and of course fill out a health profile but GHC provides an online wellness application – Limeade for all of its employees. The same app being used by REI for its employees. GHC also sponsors one of the largest bike events (Seattle to Porltand) each year. et.
Perhaps their biggest challenge remains branding since some people consider large systems to be impersonal (aka the public health model) but their clinics look more like medical spas now.
This all sounds great but what about cost and outcomes? GHC was the only health care insurance (they are an integrated system) that kept their rates for medicare flat last year and they consistently rank in the top tier of quality metrics (according to the PSHA community checkup).
FYI – I don’t even work for them.but did during their EHR implementation and serve on multiple committess (PHSA) and boards (HIMSS- WA)) with people who currently do.
So the only thing you missed was the business case that drives patient centered design
thanks so much for this perspective. I don’t have personal experience with GHC, but everything you say I’ve heard from others. However, they may be unique or unusual. We need to encourage others to emulate.
[...] of Partners Healthcare Dr. Joseph Kvedar, who was also on the CES panel, recently wrote a blog post about what patients really want in their health care products. “Consider with me how we as [...]
In 2010, we went through a large exercise at the Washington Health Foundation to develop a set of design principles you could use to create a truly person-centered health system. That work led us to focus on a number of key issues identified in your list of the things patients want. One of the big ones for us (name because we believe that context and semantics have a powerful – if often invisible – influence) is that individuals (especially in non-acute care settings) ultimately want to be treated as people – not as patients. Many of the statements in your list reflect this need to be treated as people… perhaps with the slight exception of transparency (which is quite different from making something understandable and indicates a traditional power dynamic that the rest of your post pushes against).
Here’s the list of principles we came up with an a short post about our process and the event that resulted from the project:
-Embeds feedback loops that empower people to interact with the system as partners and individuals, not just patients (Feedback)
-Requires shared responsibility to select among a bounded set of trustworthy options, so that people’s outcomes and experiences meet their expectations (Affordance/Constraints)
-Allows people to easily understand the relationship between parts of the health system and the value that they are seeking from it (Mapping)
-Connects people and provides them with the tools to relate to others openly and freely, in ways that build from their communication needs (Networked)
-Re-shapes diverse knowledge into frameworks that people can use to improve their health and make sound personal health care decisions (Enhancement)
-Responds to the changing demands and health needs of people by providing flexible services that can adapt to emerging trends (Accessibility)
http://h3p0.tumblr.com/post/4697128446/make-it-about-people
thanks so much for your thoughtful input. i must now digest it!
Great post. Perhaps the simplest way for physicians to answer this question is to ask the patient. I don’t intend my response to be flippant…it’s just that we patients are seldom asked.
Here are some additions I would make to your list from a patient’s perspective:
- Trust – we want to know that you are acting in our best interest and not the interests of a hospital, health plan, or big pharma – We want you to learn how to run your practices in a more productive fashion in order that you have the time to talk with us.
- We want you to demonstrate a little empathy now and again when appropriate- We want you to do a better job providing the recommended preventive services – if we are only receiving 50% of recommended preventive services…please tell me which 50% you are not giving me.
- Please stop telling me you don’t have time or are not reimbursed enough to talk to me – it kinda cheapens the advice you do give
- Ask me my beliefs and opinions about my health before you callously tell me to do something that runs counter to my beliefs..can you say intentional non-adherence
- Invite me to get involved in the visit by asking questions even though you may not really mean it
I think you get the idea. I research and write extensively about the challenges associated with physician-patient communication – an area often taken for granted by clinicians and patients.
Steve Wilkins, MPH
http://www.healthecommunications.wordpress.com
.
Great post and responses! I think healthcare needs to be more flexible in how and where care is provided, to be the most responsive to patient needs. Patient portals are great and should be available in all practices. Home monitoring should be encouraged and data collected and reviewed by docs to better see health trends in patients. Patients need to be respected as the owner of their health and as the expert on their own health/illness experience. If the healthcare system has options, other than just the traditional doctor visit, for patient/doctor interaction, more of us may engage in health and wellbeing.
People want not just to thrive, not just survive. This is not solely the province of the healthcare system, although we’d agree that it has a major role in supporting individuals toward realizing this vision of their lives, even if they struggle with chronic illness.
My company is taking is thus focusing on seniors not just as patients but as individuals who have a hierarchy of needs (keying off a 2006 paper that came out of MIT’s AgeLab near you in Boston). Health needs are part of the foundational tier, but so are other services ranging from transportation to Meals on Wheels. So we use social networking and social commerce to strengthen their connection to local care coordination and in turn to local medical and non-medical service providers. We then try to help people move up the ziggurat of needs by linking them to local activities — ranging from the garden club to volunteer and employment opportunities — and other seniors in their communities. Turns out that people over 50 link them to their communities (care coordination, medical and non-medical service providers, local activities ranging from the garden club to volunteer opportunities) and other seniors. Turns out that sites like Match.com have been focusing on the 50+ demographic in part because those young whippersnappers have been moving to Facebook. Of course, older folks are also following them, with Facebook membership among folks over 55 skyrocketing by 1,400 percent between 2009 and 2010.
This is not an ad for my company — but we’ve talked to a couple of healthcare organizations, including a large hospital-based pioneer ACO — that think our platform could have a role in what they’re doing. We’re trying to treat patients as consumers, and not in the sense that they want to go shopping (a la consumer-directed healthcare per se) but in terms of engagement.
Having gone through the medical system quite intensively a few years ago, here is what I find most frustrating about patient care: in my experience, most doctors treat patients like the blind men and the elephant. (“It’s a tree trunk! no, no, it’s a hose! no, no, it’s a dagger….” ) First and foremost, I want to be treated as a WHOLE patient, not as a brain, or kidney, or stomach, or thyroid, or uterus, or malignancy, shuttled off to various specialists who seem to forget that I am a whole person. I think the dependence on specialists has certainly helped in expanding treatment options for many diseases, but at the expense of ignoring systemic interaction and overall, wholistic patient health and well-being. My experience is that specialists have a tendency to “medicalize” and treat any symptom that’s on their respective checklist immediately and minimize or ignore anything that isn’t, whereas a generalist is more likely to adopt a risk/benefit, wholistic approach. As a patient, I also hate to be treated as a statistic. It is fine to quote me the prognosis stats and the risks of various treatment options, but from my INDIVIDUAL perspective, my response to and side effects from treatment is usually either 0% or 100%. It’s only when grouped with a lot of other patients that the statistics become relevant; most doctors I’ve dealt with don’t seem to appreciate the individual perspective of a patient. My best treatment has come from doctors who have had their own health issues that have forced them to go through the same system that I go through. I know some medical schools are adopting requirements for students to spend time as patients in the system, and I think this is great and should also be a regular part of continuing education for physicians. Perhaps have docs shadow one of their patients through the system for one week every five years. Just a suggestion. And let’s not even start on the Byzantine record keeping and lack of coordination among various arms of the system that is infinitely frustrating and can really detract from a patient’s focus on getting well.
Rather, people want to thrive, not just survive!
At the risk of sounding repetitive on my comment to Part I, I think that your article above misses one very important piece of the healthcare demography, which is the older patient nearing the end of life. So much of what healthcare technology innovation focuses on today involves people that are not older, retired individuals. I’ll use my mother as an example. She just turned 65, and she has been suffering with MS for over 30 years. She is currently receiving treatment from what I would consider to be one of the top hospitals in the nation, and of course they have a patient portal. Does my mother use it from time to time to ask for prescription renewals? Yes. Does she use it to communicate with her doctors? No, she asks me to communicate with them because it confuses her. Has she ever once looked at the results of lab tests and MRIs that are available on the patient portal? No – again, it confuses her. Does she use it to make appointments? No, she makes those in person when she’s in the doctor’s office or clinic receiving an infusion. Could she live without a patient portal? Absolutely.
All of this to say that “insiders” in healthcare innovations seem to singularly focus on (and talk incessantly about) all of the wonderful things that will result from increased patient data that can be aggregated and shared among physicians and healthcare systems and pharmaceutical companies. I have no doubt that what they are saying is true, but the question is, do patients really want this? I would say they don’t care, because they don’t understand any of it. To them, it is a medical/healthcare system problem that confuses them instead of bringing clarity to their daily lives. When someone comes up with a solution that is understandable and simple, they’ll adopt it.
Which brings me back to my original comment on your Part I. What do patients really want? I agree with what you say in Part II (with the exception of your last bullet point under “fitness and wellness,” for the reasons discussed above – most people aren’t collecting that data on themselves and don’t care), but you’re missing the last chapter of life in your analysis (so, similar to your comment on Dr. Detsky’s article, your article isn’t off-point, it’s just incomplete). At the end of life, patients almost always want the same thing (which was discussed at length in the two articles I cited for you): (1) they don’t want to suffer or be in pain, (2) they don’t want to prolong the dying process, and (3) they want to be with family and have a sense of control.
Studies show that approximately 2.5 million people die in the United States each year, and of those, approximately 2.1 million are over the age of 65 and Medicare recipients. Other studies show that, if asked, approximately 75 to 98% of those 2.1 million people would tell doctors that they don’t want extraordinary measures used to keep them alive – to prolong the dying process – and they would like to die at home surrounded by their friends and family. As I’ve stated previously, we KNOW what those patients want, because they’ve told us. The real question is, what are healthcare “innovators” doing to give those patients what they want?
Thanks again for your articles, which really are very good. I look forward to your thoughts!
Joe, thanks so much for laying out this vision. I think you are pretty much right on, except that you are missing an important element. Consumers, i.e., patients, want information that tells them which physicians or hospitals do the best job of guiding them through the system, coordinating care, and achieving optimal results. We know that there is huge variation in these variables when comparing providers, but most of the data are locked up in clinical registries and EHRs that are inaccessible to anyone other than the providers themselves. So, I would like to add to your list of what patients really want information about alternative treatments and providers that would help them to make better choices. I know that some will say that no one other than a very sophisticated subset of the population is asking for this today, but that is because the general public is largely ignorant about the amount of variation in care and what it might mean for their health and well-being.
What to people want? We want to move our care along to the next step, and/or to know we are on the right path to achieving our goals.
As a family physician, I have enjoyed use of secure email communication with my patients for over 10 years. It’s been a great channel to stay in touch with my patients. We have found it a great patient and provider satisfier.
The issue in care is what information do we need to make a decision? Is it history, exam, lab/imaging studies? 90% of clinical decisions are based on history, much of which can be obtained via email. It’s particularly great for quick questions, status updates, and ‘do I need to see you’ questions.
I’ve kept many a COPDer/CHFer out of the hospital with email.
Through email, I’ve identified reasons for testing, that eliminated a visit with me, but directed patients promptly to specialist care. And, have brought people into the office earlier to see me, getting started on reassurance or treatment earlier.
When we were considering an interruption of email service in anticipation of an electronic medical record conversion, our patients and clinicians said a resounding , “NO WAY!”
Getting people the right care, the right person, at the right time to help them achieve their goals, requires multiple channels of communication: phone and email are great enhancements to what can happen in the office.
Email is a great channel for key information to care givers, helping to move care to the next step.
Paulanne Balch, MD
Family Practice
Kaiser Permanente
Dr. Kvedar,
Our many problems with healthcare, it appears, stem from the “industry” having gone ahead of ourselves. Three sets of contradictions manifest themselves, particularly in the US, but also increasingly elsewhere in the world:
1. Innovation and technology versus the compulsive “need” to use them in a service setting, raising costs all around;
2. Specialization versus general practice or family medicine, that have manifested themselves in glorifying the former and altering incentives at the supply level; and
3. Indirect payment mechanisms (employer insurance) versus purchase as consumers, resulting in inability of consumers of healthcare to appreciate expense and according importance to consumption patterns and how behaviors could alter them.
New and evolving technology could help, but only if underlying structures are disrupted and incentives created to recast these contradictions. What can be done? For one, it might help if direct out-of-pocket expense is encouraged with appropriate tax incentives for both consumers and providers of preventive or primary care. This would also require means to foster competition in the retail marketplace for such out-of-pocket services. For another, de-incentivize consumption of high expense care that is not life threatening. This could include dis-incentives to practitioners and providers that direct patients to such forms of care (including endless tests). Some of these are already being done, but these are piecemeal without an all-encompassing strategic perspective. Somehow, we need to get back to basics – that of prevention being better than cure.
In General
* We always want two options and we always want NO to be one of them
brief and to the point. thanks
thanks so much for taking the time to bring your perspective forward. I agree completely
Dear Suneel: I so much appreciate you taking the time to make my blog a better place to visit by adding your experience and wisdom.
thanks for your thoughts
Love this. just ask…powerful!!
indeed its a complicated industry, unnecessarily so. I hope some smart person figures out how to successfully simplify it.
Portals are a big step forward, indeed.
Thanks for your comments, Chris. its an honor to have you as a reader!
thanks so much. terrific stuff
treatment
Reblogged this on lava kafle kathmandu nepal and commented:
patients needs
Adoption of technology will take a concerted effort by many. Hope several associations can co-operate. Is CCH following the legislation in Energy and Commerce related to FDA approval of innovative technology, and promoting adoption of technology in healthcare? Timing seems pretty good because FDA re-authorization every 4 years. Hearings begin next month. Have suggested American Telemedicine Assn. comment. Thanks.
Although I am not a physician, I work in healthcare technology. I think the list above is great and reflects a lot of what I want. But the list is still a bit biased from my point of view since I spend my days thinking about how technology can improve healthcare. I think a key question is what do people, who do not work in healthcare in any manner, want?
I recently had a conversation with friends (who do not work in healthcare at all) about why Google Health failed and why people didn’t use what seemed like a good idea. When I try and think about what I would want as a patient and speaking as someone who is not a physician. I want incentives. In general we don’t think about health, until we’re sick. But there is so much benefit to preventive care (i.e. staying out of the hospital, losing weight, healthy diet), but still relatively little incentive to live healthy or maintain our health. I think there is still a huge need for incentives to bridge the gap between our everyday lives when we do not think about our health and when we’re sick and all of the sudden health our greatest concern.
As we blog about this today I am a healthy man who has taken measures to improve my health through diet, I can show through lab tests how my cholesterol has improved as an example. but I receive no benefit (for example a lowered premium) compared to someone who has gained 20 lbs. and who has developed high blood pressure. This is one common viewpoint I hear from friends and family.
Technology can improve healthcare. But there is still a point that technology’s impact on healthcare is limited by the very model it’s trying to improve. It’s a big picture issue but if providers, payers, and most importantly patients can create incentives that say, to everyday people who have a million other things on their mind that, if you take some time occasionally to think about your health and improve it you’ll receive benefits for doing so. If every year I could show my insurer that my health has improved or maintained and I received a small decrease in my premium I’d be a lot more incentivized to use a Personal Health Record.
Incentives are indeed a big part of success.
Great post and I think that you have got it right here. My big question is do people want to avoid being patients? Are they looking for ways to enhance their well being, thereby avoiding being patients in the first place.
This is a great question. On the surface, obviously, yes. Who wants to be sick? But when presented with long-term consequences of the risk of poor health, people still choose near-term behaviors that are unhealthy.
I think everyone wants to avoid complications and to be as healthy as possible
We at NXThealth are planning the Patient Room 20//20 and its mission is patient empowerment. We feel also the patient will be the one being in charge of this care process and are striving to have the tools available for that to happen. It is a challenge indeed but stay tune to our progress! Tom Jennings, NXThealth.
wonderful article and great participants. Such a privilege to have been here, thanks.
Thought-provoking post. Clearly written from a perspective where ‘someone else’ but not the individual patient pays for their care.
I also want the best *car* that will drive without problems for my entire life – if someone else pays.
If I pay myself, any patient will always look at cost – vs – preference.
Healthcare need is unlimited if cost is not a factor for the patient, assuming we are discussing routine care, not catastrophic care.
It should be at the top of your list.
Earlier ChrisWasden commented,”Chronic Disease consumes 75% of all health care dollars in nearly every country.” This is from my perspective as a patient with chronic kidney disease. Chronic diseases are for the most part incurable, they can only be managed and who has to be the primary manager? The patient of course!! My nephrologist can tell me what I need to do but unless I control my blood pressure, weight, exercise regularly and restrict my sodium and protein intake(in other words eat a proper diet) my creatinine will gradually increase until I reach the point of kidney failure and go on dialysis or die.(I will opt for the latter because in my opinion dialysis is “living death”). For three years I have maintained a level creatinine rate and protected my remaining kidney function at 30%. during those three years I have periodically charted my blood pressure, pulse, weight, O2 and submitted that information to my nephrologist who does not have
EMR and does not use Email. I have talked to him on the phone on two occasions in three years! The point is that while I appreciate his competence and guidance, I am the one that is doing the managing of my chronic condition not him! This is true for most chronic condition patients. The doctor needs to remain connected with the patient. It is just not good enough to prescribe treatment and to not see or hear from the patient for “two months”. In the interim the doctor has no clue as to what or how the patient is doing and absolutely zero control over the patient’s adherrence to the prescribed medication schedule or what if any side effects might have been encountered, the patient’s weight, blood pressure, pulse, temp, respiration rate, O2, sleep quality, diet that is being consumed, pain, etc. Only the patient has management responsibility for their vital signs, reporting side effects, how they feel and doing the things they need to do to manage their chronic disease(s). Obviously there needs to be way for the patient to communicate with the physician whether it is via a patient portal to the EMR or Email. That ongoing communication can permit the physician to intervene, if necessary, and may prevent heart attacks, strokes, and hospitalizations for asthmatic attacks.
The people at Stanford University developed a six week Chronic Disease Self Management course which instructs on how to cope with chronic disease, how to communicate with their doctors and to follow their instructions and to do all of the right things in managing a chronic condition. Every person with chronic disease could benefit from taking this FREE course but here we haven’t been able to even get the doctors to endorse this program!! They are apparently fearful that somehow this is encroaching on their medical practice to help patients self-manage their chronic conditions even though that is what they have to do anyway and the more help they can get they better are the outcomes for the patients and the doctors.
please let me know how it goes.
thank you. you are right. the post was written from the perspective of our current system. the thought was that people still want the same things. in an environment where they are responsible for payment, they may make more choices sacrificing what they want, but their wants should not change.
Good luck with your struggle. Great to know about the Stanford course. thanks for passing it on.
I think one area which concerns both wellness clients and chronic illness clients is cost: neither wants to know or pay the actual cost (however it is calculated) of care, and both groups want to know price of services, and want clinicians and providers to be transparent in putting it forth.
Both groups of clients are currently insulated from cost and price. The only clients who see it are those who go to retail clinics (coming soon to Walmart, already in place at Walgreen’s, and many others); to clinicians with retail practices (many plastic surgeons, dermatologists, some allergists and bariatric surgeons); and to some alternative practitioners.
My own patients call my office with the question of cost more often than nearly all others, because they expect that insurance hasn’t caught up to the one-on-one, time-intensive approach we take.
And my own experience in trying to find out the price of a screening colonscopy was really revealing: it was very hard to discover, because I had to comparison shop without a guide; trace bills and potential bills from more than one provider (lab, provider, surgicenter); and more. There’s a business here!
I think Intuit was trying to do that — Quicken Health? That was supposed to empower people to manage their health care finances in much the same way Quicken and Turbotax empowered us with your general finances. What kind of physician are you? If you’re in internal medicine, is there some kind of delimited menu of services that you would offer to a preponderance of your patients, with prices laid out in menu-like fashion?
Is there any data for the last claim? Wants do change, IMO, when there are unlimited choices.
Think of an eatery’s buffet line: the order in which items appear, their actual appearance and the size of your plate all influence your choices.
Health care (on an outpatient, wellness-basis especially) can resemble that buffet: with many test and treatments possible, once they become known, patients and clinicians both “want” more of them.
As I suggest below, our current system does in fact include people who are responsible for payment: about 12% of my hospital’s current revenue comes from self-paying patients. I think that number will increase going forward.
I’m an internist, and specialize in nutrition (http://drjohnlapuma.com/about) and weight management.
Quicken Health is selling the admin/CMS back-end to physicians, to replace or complement current office processes but it doesn’t solve (or try to solve) the problem I indicated.
Yes, I think an internist could offer a menu of services, and that would help a lot for those who need the transparency of pricing–either those with self-pay, or with high co-pays (our hospital’s insurance plan just raised their co-pay to $50 for an office visit), or those who are just curious.
Urgent care centers also do this, from time to time, but retail clinics (and retail clinics onsite for employers) are offering a high-value proposition: see this MIT analysis of CVS’ MinuteClinic vs. the Cleveland Clinic: http://bit.ly/wHnbT2
1thanks for the added rich dialogue
I practiced in a rural town in South Dakota for 15 yrs. The farmers there are self-pay or high-high deductible. So to answer the question, what did the consumers want? Answer: to get out of pain. They often sacrificed their long-term health in order to get the cheapest way out of pain today. They avoided diagnostic tests in favor of playing the odds of a disease.
Sometimes, I think a national healthcare plan, even a bad one, would be better than what we have now. 50 million uninsured people letting their wallet decide their treatment plan is not healthcare; that’s disease mitigation.
Dr. White – well said! Your poignant message describes a healthcare crisis very well. Thank you for sharing this.
Hi Dr Kvedar,
My name is Liz and I am the community manager of I Had Cancer (ihadcancer.com) – an international social support network for everyone who has/had cancer or is supporting someone through the disease. Our community is well over 5000 members strong from 65+ different countries; we launched 5 months ago. I wanted inquire whether you would be willing to feature us, based on the subjects you cover, I thought it would be a good fit.
Our service focuses on creating real, organic connections between people in similar situations. Our community search filters are intuitive and very easy to use. You can search for others by type of cancer, type of user (supporter, survivor and fighter), age, year of diagnosis, gender and location and a number of other interesting features that help facilitate communication between users (check out Dear Cancer – a soap box for cancer).
We hope that by allowing members to easily connect, share experiences and information, the acquired knowledge will turn them into medical self-advocates. Our founder, Mailet Lopez (33 years old at the time) survived breast cancer due to a chance encounter with a stranger – I would love to put you in contact with her. I encourage you to check out the site for yourself to really understand what our site does and how it works.
We have gotten some wonderful press recently abroad and aim to generate it across the US. http://www.thesun.co.uk/sol/homepage/woman/health/health/3868932/Social-network-for-cancer-survivors.html.
Looking forward to hearing from you. If you choose not to feature us, please forward this email to someone who might be interested or please provide me with their contact information. Thanks.
Best of health and wealth to you,
-Liz@ihadcancer.com
thanks for letting me know about your organization
I agree you have the general idea of what a patient wants, sir. You obviously have a whale of experience, and we can learn much from you.
What patients also want is trust. I’ve worked in ER and I’ve practiced in chronic health care. They can get trust from acute as well as chronic care. I agree a chronic care setting has its added advantage of prolonged patients’ evaluation. We, as doctors, must learn to read our patients. It’s called body language. If we do it well, the rapport is instantaneous. It’s chemistry. The bond, along with a sincere smile, initiates the healing process.
Patients want to get well. They don’t want to live forever. They want to live quality, healthy and productive lives. And when they do, we do.
Well spoken. thanks
When I go to the airport, I am required to go through security screens (using the new body scan technology or otherwise). When the technology is used for custom fit clothing, the tool is voluntarily used. In general, people don’t respond as well to tasks that are forced vs those that are optional. Additionally, users of the mall-based technology have more to gain (personally) than non-offenders who are required to be scanned at the airport. Shoppers may end up with great fitting clothes (albeit at a higher price) while the airport technology is essentially slowing users down. In many cases, passengers could be simultaneously rushing to catch a plane!
I believe this same logic can apply to health technologies (per your post). If users are obligated (or heavily suggested by insurers, doctors, etc.) to use a technology, they may often feel that there is less for them to gain and more for them to lose. This may be a result of having more ‘bad’ information or simply another reason why they may be charged for another point of care. On the other hand, if these technologies are voluntarily used, the same information may be perceived as beneficial since the patient now has more information than before – which ultimately can help them better manage their own care.
From the technology point of view, the results may be the same. However, the perception of their value differs greatly depending on the required vs voluntary state of usage. The answer may be that we need to find more ways to incent rather than require technology use.
Yes, indeed. how you present something matters so much. thanks for your thoughts.
An article entitled: “Research Reveals Key Differences in the Way Men and Women Use Online Health Improvement Programs” in Managed Care Outlook Volume 24, No.1 January 1, 2011 addresses the approach and certainly they show it can make some difference.
But I agree with Dr. Kvedar that “context is everything.” I just tweeted something about that a couple of days ago…bubble wrap was really invented as wall paper and velcro…well, it continues to be adapted to new ideas all the time…I think every parent is grateful not for the genius that invented velcro but the genius who replaced their toddler’s shoelaces with it.
Context is what limits us from engagement. Context is everything because as the doctor, the health educator, etc. we are limited by our own context as much as the patient is limited by theirs.
In this video: http://youtu.be/BsrvW3iQdJY – it looks like its all about the words (the approach), its also really about connection with another person’s reality, their story, their senses. As humans we want to mitigate risk, we are motivated to overcome our innate sensibilities by connection with meaning.
When we view engagement, we view it from our world and engagement becomes a pull or push to join us on the better side of it,…our side, but context provides opportunities to connect and contextual engagement produces meaningful change.
Could the body scanner be used to monitor the escalation of arthritis or scoliosis?
You can view some of the links I mention here – https://twitter.com/#!/GottaBNimble
The key element here is more “choice” than “context”. Nobody is being compelled to use a scanner to buy clothes. Compulsion tends to put people into a negative and resistant frame of mind, making them want to assert their freedom of choice above their own self interest on occasion – I see this regularly in the field of medication compliance “Don’t tell me what to do!”
Any parent of adolescent children is familiar with the syndrome. Often the most effective way to steer behavior is to move from compulsion to freedom of choice. Giving free choice is one of the most effective ways to show respect, and showing respect is often rewarded.
Treating problems like obesity has more to do with psychology than either technology or dietary/fitness regimens. For many socio-economic groups the choice to be fat is one of the few ways they have to assert themselves. Every fat person is well aware that it is not good health wise, and that they can generally do something about it. The more people tell them that they “must” do something about it, the less likely these people are to change their ways. We don’t really need to worry about supporting the guys who go to the gym – except perhaps to protect them against the consequences of too much exercise.
I have been recently dealing with context and its application in development of health care standards, a lot at work. Its a tricky issue, one I haven’t really completely understood.
I agree things change with the context they are presented or developed in. Coming from a country that is constantly under terrorist attacks, I think the more security checks, body scanners, sniffer dogs, etc. the better. (context) But I think context is not everything!! Personal experiences, lifestyle, education and personal choices also matter.
For e.g.- a family who has lost a loved one to cancer is bound to be more careful about regular check-ups, follow ups and in general living healthy (personal experience) or some adopt an altogether different approach where they stop caring and just start living (choice). The rich who have their own aircraft’s don’t care about how tight airport security is, but they have body guards and personal security to protect them from potential danger (lifestyle). A science student wouldn’t necessarily risk have unprotected sex, having learnt the transmission mechanism and life threatening diseases (education).
The point I am trying to make is, there are other factors that influence decision making other than the context in which they are presented. So adoption of blood glucose meters versus heart rate monitors is an individuals choice,I know some people who use both the devices in totally different contexts, as they are just more aware and conscious.
My 2 cents!
By context, I do mean everything that you mention and more. It isn’t just the context in which they are presented but everything is incorporated into the context of how we present information and how we connect to it. The reason mobile is important is because it is now almost everywhere you are, enabling you to connect to that context whatever it may be and where it is coming from and help drive your choices where they will go if you do connect with it.
If we are talking about behavior change how do you connect with the person who chooses to be fat so that they choose to exercise and be health conscious about what they eat? I agree with you, it is psychology, but studies show that rewards work in some cases and not in others to motivate choice.
You are fortunate if there is a straight path, however, some need to progress in smaller steps. They can’t make the leap you want them to, enabling them to succeed is the progression of their context.
wonderful thoughts and love the link to the video
two very thought provoking comments
fair enough. perhaps the title Context is EVERYTHING is too simplistic.
So much here depends on your point of view and where you are coming from. As a patient i really take exception to the idea that it is the doctor reminding me that I am sick – I have never been reminded that I am sick – it has always been a matter of my making an appointment because I am sick. And ninety nine times out of a hundred all I get is a prescription to “make me better”. And this is an approach that has been fostered by the medical profession so often discouraging the patient from educating himself – patients are regularly told not to learn from the internet as it is full of misinformation!! I was diagnosed in 1993 with the early stages of emphysema – but was never given any help as to how to live with the disease or with its consequences. In my lifetime (I am now 70 y.o.) I can only remember one doctor making any attempt to encourage and help me to quit smoking, just wish that I had been able to succeed, but this was way before any pharmaceutical aids to quitting. I finally quit when I came to realize that I had to quit or die, and then I had to ask for help. And not a single one, to this day, has advised me as to exercise.
As regards the body scanners I agree with those that have pointed out that forcing someone to be scanned is very different to volunteering or even paying for it, but remember also that there is no evidence that those same people that protest at airports are the same people that go for a scan at the mall. I personally doubt that the airport protesters will get scanned voluntarily at the mall.
I think that it is time for the medical profession to take the time to educate and advise the patient about how to care for his health problems – not as ‘superior beings’ but as caring teachers.
I had a conversation with a neighbor the other day, we both love history and our ramblings went from the beautiful architecture he’d seen over the holidays in the UK to the Industrial Revolution. Caught up in admiring the architecture, many don’t think of what enabled such beauty. A lot of that history might involve colonization and taking of resources from others, which we’ve learned about, but compartmentalized elsewhere in our minds while admiring what’s directly in front of us.
We talked about our children and their schooling and that brought up the Industrial Revolution. Our school system came about during this time as folks left farms for factories and assembly lines. Assembly lines are efficient by compartmentalization.
A medical professional is educated in this fashion as well. Kids are competing to go to the best colleges to proudly become doctors. When they graduate, they will have spent more years in institutions that came about from the concepts of efficiency from the Industrial Revolution…to take in mass amounts of data by compartmentalizing it, than the patients they often see.
Psychologically, there’s also a benefit in leveraging it, particularly for med students in dealing with the pressure and anxiety of studies or dealing with too many patients and too little time. Navy Seals actually use compartmentalization as part of their technique in enabling more of their recruits to get through Hell Week…to master the mental challenges associated with the grueling physical tasks they have to endure by compartmentalizing. http://www.foxnews.com/health/2011/05/03/navy-seals-exhibit-ultimate-mental-toughness/
I hope most doctors and teachers go into their profession because they care about their students and patients, but despite their best intentions, they are limited by their context, what they have learned and where they have come from as well as the system they deal with.
My grandmother was a smoker and died of lung cancer. When she was 11, doctors told everyone that smoking was good for you so she lit up with everyone else.
My mother’s generation didn’t breastfeed their children because doctors told them that formula was better for their babies.
My son’s teacher said he had trouble with the writing assignment, “The Holiday Tradition we celebrated over Winter Break.” I asked what she did to help him, she replied, “I show him his vocabulary tests because he always gets 100%.”
There is the controversy over the goals and objectives in No Child Left Behind, that what is measured forces the teachers to teach to (pass) test rather than teaching to learn. But teaching to learn is the same to me as enabling you to engage in behavior change.
A young child doesn’t initially share, we are ruled by our instincts not to, but eventually a child learns that sharing gives greater rewards.
By the very fact that you are reading or responding to this blog, you are sharing and that is participatory medicine. http://youtu.be/NBmvBS9D6HU
Its folks like Dr. Kvedar who are thinking outside of the box and the momentum that we all create by sharing that is going to shift the paradigm that technology changes are creating.
A blog on the history of Doctors (they left out the Industrial Revolution) – http://blog.soliant.com/careers-in-healthcare/the-history-of-physicians-doctors/
I’m glad you quit, I know change is hard.
One big difference between the TSA scan & the mall scan that I haven’t seen mentioned is the plain fact that the person being scanned receives the data from the scan at the mall and is able to use the data to make better choices. TSA scans, like most data collected by our health care providers, are not made available to travelers and patients, although we have definitely made progress in making patients’ records available to them. However, data from those records aren’t provided in ways that have immediate value to patients, in most cases. Furthermore, to use the device analogy, patients don’t have access to data from medical devices that aren’t sold over-the-counter. Hugo Campos, who has an implanted cardioverter defibrillator, is on a campaign to change that. See his recent TEDx Cambridge talk:
http://www.tedxcambridge.com/thrive/hugo-campos/
A friend forwarded me this blog post as I’ve been part of team, we call Forever Athletes, focusing energy to build something where we can all benefit from the experiences of those who have been successful. Yes, we’re certainly not the first to emulate the learning approaching of modeling after successful examples, but is it a popular method to empower active, healthy living?? I suppose the jury is still out. But what we do know is that there are a plenty of tools for tracking exercise, nutrition, sleep, etc. If more people aren’t motivated to use them, what good are they??
After the last 1.5 years of filming interviews with various adults who regularly participate in some type of sport or physical activity, very quickly, common themes rose to the top. We interpreted the themes as “lessons” that the general population could implement to become more healthy. And so, we started created videos to share the stories of the people we’ve interviewed, but in a way that hopefully “teaches” the lessons through actual application. Videos samples here: http://www.foreverathletes.com/wp-content/generic1/index.html
The thought is, if we can get the support of doctors to “prescribe” a series of videos to their patients, based on the patients’ needs, and have a means for following up with that patient, there may be a good chance of real behavior change. Using these videos as a primary “treatment”, we would hope to put the patient back at the center of the treatment and provide hope for real change, where change is needed.
Any thoughts on this??
thanks for your perspective. Even though you say your doctor doesn’t remind you that you are sick, you say you only seek his help when you are sick. this reinforces my point. i don’t know too many folks who visit the MD because its fun
very well articulated
It is ALWAYS my body that reminds me I am sick! I need and get no reminding from my doctor – what I get from my doctor are solutions! This is no big hill to climb for him as I am already engaged. His hill is to find the solution for my problems – and thankfully when I lived in the US I was never turned down by health insurance companies. My employer self-insured, and I suspect that his solution was to ‘unemploy’ me a little earlier than normal retirement. Now that I am back in Canada neither I nor my doctor has to worry about that sort of problem!
I don’t know where to begin here, so I’ll just dive in. Chris your video and commentary completely resonates with a venture I’ve had the fortunate opportunity to participate in. It started as a simple book project sharing the “secrets/lessons” of masters-age athletes who have been successful at being physically fit, whether they started late in life, rehabbed from injury or other ailment or maintained fitness for most of their life. After filming interviews & action footage with these people, who we call Forever Athletes, we knew their presence & words shared via video would be monumentally more powerful vs. text alone. This gave way to producing eBooks featuring their stories & related videos. Again the idea was/and still is to share their experiences for the benefit of other adults to get started and sustain a journey of physical fitness and increased quality of life!
In reference to your specific comment, Chris, “…its also really about connection with another person’s reality, their story, their senses. As humans we want to mitigate risk, we are motivated to overcome our innate sensibilities by connection with meaning.”, you’ve summed up our intentions with the videos we’re producing. Providing a context of the motivation for being physically fit, through the real-life stories of those we’ve interviewed, we hope to trigger that motivational piece for those who need it most…to trigger something beyond that which a medical clinic can provide…something that relates to soul of our humanity and quality of life.
Myself and team-members working on the videos, are very open to feedback regarding our intent. More specifically, what are the thoughts around inspirational video-messaging serving as the motivational piece to create behavior change in the obese/overweight population?? Could a physician-prescribed “treatment” involving a series of videos over time, be useful towards providing the context needed for patients to respond favorably?
Sample of the general video content we’ve begun producing: http://www.foreverathletes.com/wp-content/generic1/index.html
Sample story (eBook with videos): http://www.foreverathletes.com/wp-content/cheriestory/index.html
Thanks for your feedback.
-Jessica
jseyfert@foreverathletes.com
Jessica,
I’m so honored to be asked my opinion. I love the concept and your approach. I think its important to realize that the video link I provided works because it motivates the person in that moment to dig into his pockets and give a blind man some change. I don’t think that video would make that person continue to go back and give the blind man their change forever.
I think these videos are great in initiating motivation to start your journey but you risk losing that enthusiasm pretty quickly with what is shown. These “forever athletes” talk about their long road and the baby steps they took to get to where they are, but then you show them doing some amazing things like pole vaulting & weight lifting. Often at the gym I see newly motivated people start running on the treadmill or take a fitness class that is above their ability level, they don’t come back after that day, instead they are walking backwards down the stairs at home due to the soreness they feel and swearing they won’t ever do that again.
The journey is in-between, where they started and becoming a “forever-athlete.” The connections needs to happen there or you lose the enthusiasm that motivated them to try in the first place.
The connection points from something like text or other communication channel tied into your efforts is extremely important because its the interaction with your message that changes the context and meaning of the message to that individual that make the change happen.
The Marshmallow Study demonstrates the importance of self-discipline in lifelong success. Offer a group of 4-year-olds one marshmallow, but tell them if they wait for your return after running an errand, they’ll get two. You disappear for 15-20 minutes. The theory was, children who could wait demonstrated their ability to delay gratification and control impulse, which later showed they were more successful and healthier in life.
How do you take the 4-year old one marshmallow eater and get them to override impulse for reward? The video is like the artist on the street. In 30 minutes s/he has created something before your eyes and you say, “how much for that?” and s/he replies, “$20,000.” “Are you crazy?,” you say, “it only took you 30 minutes to make that!” and they reply, “30 minutes, plus 20 years.”
In this example, connecting meaningful improvements to get to the final product took 20 years…what connections are you providing in that journey from start to end result.
Great points, Chris! Would you be available to talk further on the phone? It seems as though you have quite the informed opinion on motivational content along the spectrum of sustaining behavior change.
I definitely hear you on the issue of connecting from start to finish. I should have prefaced the video samples with the fact that we’ve only started the video production using our extensive library of footage. The videos in the ‘Getting Started Series’ eBook are certainly not intended to be the comprehensive unit to promote real behavior change. Rather, it’s more of an overview of the the primary topics that would constitute a series of videos. Each of the videos within the topic would be created & ordered along the Transtheoretical Model of Behavior Change. Does that makes sense?
Ultimately, we’ve just begun the video-creation process after almost a couple years of gathering video & textual interviews. The challenge is determining whether or not this type of video-messaging can actually prove effective towards behavior change, as well as identifying potential partners that supplement the videos with some form of counseling effort (virtual or in-person).
Feel free to shoot me an email and we can set up a day/time to chat further!
jseyfert@foreverathletes.com
-Jessica
I am late to this conversation, but I can’t help but more briefly sum up what I want as a physican who is now a patient; way overstated for dramatic effect, but probably universal.
1) “Hey doc, I’m an American, give me a pill, not all this eating, exercising, and life style advice.”
and
2) “I just want some control of my life back. I am not used to not being in control.”
i like the simplicity of it
I agree with Janice. In the Mall Scan example, the data collected is gathered from the consumer who can “use the data to make better choices”.
For Healthcare, think about how data can be captured and shared with the consumer in a way that delivers ongoing value:
> Comparison- With benchmarking information, how do I compare with others like me (e.g. using profile information?) During visits with our Pediatric doctor, we hear about how my child is growing physically, mentally and socially compared with others their age and gender.
> Perspective- How am I changing from one point of time until another. During the annual doctor’s visits, we walk out knowing our latest weight and height (yes some people are getting shorter) but are not shown key data points over time.
> Insight for Action- What does this information really mean? Is a certain percentage of weight gain at 50 years old normal?
We will engage more consumers in their health by leveraging data in a way that creates value for them.
Very well stated and organized, Sherri. thanks
It’s the human factors that one has to address. The context is totally different. At the airport it’s just one more obstacle to getting onto the plane, thus delaying one’s primary goal. The other use of the same technology is for one’s sought after personal benefit. As to fitting clothing, it’s probably less personally invasive than the old way where a relative stranger touched many of your body areas while taking the required measurements.
Yes, the airport scanner may save one’s life, however, it’s not viewed in that way. Education may help, but airport screening is always an impersonal thing in my mind making it difficult to change from I’m being invaded to I’m being saved.
You’ve got to be kidding me-it’s so tarsnpaertnly clear now!
Thanks Paul for your thoughtful comments.
A lot of research has been done on achieving behavioral change and when you are really serious you have to raise prices or legislate – think of cigarette smoking, alcohol consumption, seat-belts.
So while it is a nice idea to think of reimbursing wellness coaches, financial and legal measures are likely to work better.
On genetic screening we need to think very carefully how to introduce this. Screening is quite a controversial topic with e.g. evidence that screening for breast and prostate cancer has done more harm than good on occasion. If the industry gets off on the wrong foot it will take years to repair the damage.
These are useful thoughts. I am in the process of preparing a post on the psychology of all of this and would welcome your thoughts at that time. The legislative angle is an interesting one. It took us ~ 50 years to get smoking down to about 20% of the population. If we wait that long for obesity and diabetes, the battle will be lost. Perhaps a combination of gov’t policy initiatives and individual motivators.
Regarding your comments about screening: I did not have so much screening in mind as using genetic information as a tool to micro segment the population. I think these are different goals.
Your idea to focus on chronic diseases is great – I nearly said two or three, but that is not focus!
I think to win trust it has to be a balanced view – so not everyone is likely to get diabetes when they don’t exercise but some will. Are you one of the at-risk category? If so …
My Auntie Hilda ( a real person) lived well into her nineties on a pack of untipped cigarettes and a third of a bottle of scotch a day. She never took exercise. I guess we all know of these cases and this is why blanket statements don’t work to convince us individually of our personal risk. Likewise my father and grandfather were both significantly overweight and lived to a ripe old age – my father is still going strong at 89, loves a fried breakfast and eats fries as often as he can.
People do believe in science and so with genetics/genomics/proteomics we have an opportunity to make a new attempt to convince people to change – but it has to be balanced and perceived as fair. Government propaganda over the last 50 years is discredited because it is patently not true in our own experience and is regularly corrected because the experts got it wrong. We need to get it right this time.
I’m not sure what to make of this post. You seem to admit at the outset that you are not typical (“I haven’t played Angry Birds or Farmville”), but then use yourself as the typical case (“Lets go back to me as an example”). So is this opinion?
I would hope that most people would agree that it’s great to be able to design customizable solutions, but are you saying that social-network-based solutions are not a good idea, because you don’t think they work for everyone (i.e., you, with your “plain-spoken character” values you grew up with – which most of the country would also say they grew up with)?
I agree with the assessment that this is (in many ways) the beginning of a journey – where the only objective is better health (not a fixed desitnation).
Ernst & Young released a pretty compelling report on this just this week. In effect, they say that everyone in the healthcare industry (payer, provider, pharma etc…) is now in the behavior change business. I couldn’t agree more – and I wrote as much on my blog too:
http://www.forbes.com/sites/danmunro/2012/03/12/ernst-young-outline-new-vision-of-patient-centric-healthcare/
This is helpful feedback. My point was that there is no one size fits all solution, and that the next phase of development will be systems that sense one’s motivational make up and respond accordingly.
Thanks for the link and reference to the E & Y report, which I had not seen
I completely agree that engagement mechanisms need to be tailored to the individual –> each person is unique, is motivated by different things, and has different obstacles to overcome. One additional point – The measurement of success of such wellness/connected health programs should include, not just the % of people engaged, but also the length of time engagement is maintained. Many of us start exercise programs, diets, etc., and achieve positive outcomes in the short term (i.e. 6 wks, 6 mos., 1 year). However, many of these gains are lost over time (i.e. 2-5 years). Sustainable behavior change over the long term is the ultimate goal.
Indeed, decay is a well recognized challenge with all behavior change methods. The feedback loops that are embedded in the connected health design tend to help combat this.
Framing is critically important in developing innovative approaches. How do you decide when a program has been ineffective and a patient needs genetic testing? A low-impact behavior change will lead to large segments of the population going for genetic testing.
Genetic testing may differentiate individuals who are at high-risk or at very low-risk. Low risk patients, such as the example provided by Chris Johnson, can indulge as they please. How would health care practitioners counsel these very low risk patients? Eat, drink and be merry, because your longevity genes will protect you against cancer and heart disease at young ages.
On the other hand, genetic dispositions to addictions and gambling disorders are important to know about, which are often suggested by family history. Genetic testing will help family members make more informed decisions about whether to be a teetotaler, or not.
I have reservations about the frame “personalized prevention” because it builds on personalized medicine, which is based predominantly on a positivistic, reductionist and mechanistic worldview of disease, as opposed to ecological, holistic and emergent worldview of health. To make this paradigm shift, we need to expand our worldview of disease to embrace ontological and complexity worldviews about health.
No doubt, medications for treating obesity will be developed to re-adjust the satiety thermostat. But this is secondary prevention. What is a more powerful determinant of risk behaviors? The biomedical or psychosocial genome. Health is more of a social construct than a psychological or biomedical construct. What about individualized prevention? But this individualistic frame does not explicitly address the socio-psychological dynamics of health behaviors. What about socio-psychological prevention? This term implies that the social determinants of health behaviors are more powerful than individual determinants at population-based levels.
Health care systems clearly lack the capacities to scale up health coaching for all, and we clearly need catalytic innovations, in addition to macro-level changes in public policies. What about family and peer health coaching programs, for patients and led by patients, developed under the stewardship of intersectoral leadership and action?
I just read part 1 and was responding when I thought I should post in part 2 to keep up with the dialogue…
The 40% predisposed towards diabetes/obesity who can follow the connected program protocol are successful doing what they should to change their behavior because they receive the educational information prescribed by their doc or other authority.
However, while some predisposed to the disease might buy into interventions that may be generalized so they never become chronic conditions, others require more personalized help to reconnect mind-body with context.
And the longer one becomes habituated, further silo’d and sick, the harder and more personalized intervention may need to be to change as the disconnect between mind and body becomes more ingrained.
If you are genetically predisposed, you are compromised and the methodology provided to everyone else is only a band-aide prevention to a systemic issue. You are completely vulnerable to following your genetic predisposition at any given contextual trigger point and once you are mired in that quicksand, how do you get out?
Studies like these – http://holykaw.alltop.com/ai-gets-a-boost-from-baby-brainpower
reveal as young children, we are able to take information in through our senses and act on it appropriately. Connections help to us to derive meaning and extrapolate our thoughts further from there.
However, as we become educated, many of us fall through the cracks, losing our connection within ourselves and the ability to change our behavior meaningfully. In an effort to be efficient, education focuses from the neck up, while health seems to focus on the symptoms from the neck down. There are many reasons why that is…we have more information with the same amount of hours to learn, our model stems from industrialization & efficiently run factories, etc…but what it’s creating are silos of specialty and the loss of our individual natural capacity to self-regulate and adapt our behavior given all the contextual information.
This is where your genetic screening comes in but another study I found fascinating is from Professors Marcel Just & Tom Mitchell at Carnegie Mellon who have done fMRI studies showing the link between read/spoken words in brain activated areas, then putting others through the fMRI, & putting the areas of the brain activation scanned into their machine algorithm, the computer can determine which word was spoken/read to that other individual. This was also done with people in different languages. http://www.ccbi.cmu.edu/reprints/brain_imaging-H264.mov
To me, what this shows is that undamaged brains have the same functional abilities but context and experience can vary, so it’s the collective context derived through various connection points and experience engagement enables.
When it comes to teaching that leverages rote memorization, you can have increased self-control based on the correct response (teach to the test) for that special 10% & a more generalized program for the other 30% that need a little help but to have true self-control through engagement (critical/lateral thinking) required by that 60% to get over their challenge will require real data driven metrics and patient-centered engagement in my opinion. Connection between the mind-body and context needs to occur in an internal feedback loop of joint attention, perspectives, so higher-ordered thinking enabling self-control through engagement with others can be leveraged.
Play, language, and engagement within ourselves and externally with others in intersecting feedback loops enables us to understand the meaning, context and experience of others and extrapolate our own thoughts and learning from there but unless we connect to it ourselves, we might feel we can’t change our behavior.
Then I think data metrics for these individuals isn’t only about the quantity and duration of exercise, it must include monitoring engagement data through various connection points as well.
It would be wonderful to find a cost effective solution to genetic screening.
Genetic testing appeals but its costs are worrisome | Healthcare Finance News http://bit.ly/wDDIW6
thanks for such a thoughtful and educational comment
the price continues to come down and by many estimates will be in the $200 range in a few years there is hope
thanks so much for your thoughtful comment, Rick. I agree Health care systems can’t seem to get it done, so I’m placing a bet that an industry will spring up around traditional healthcare
I wonder Joe. I think it very difficult for traditional healthcare to innovate in this way – for one thing traditional healthcare lacks humility. When we go to traditional healthcare for help we know we will meet a succession of people who think they know better than we do – this is not a comfortable position from which to engage. And objectively, traditional healthcare has been wrong so often in my lifetime that the patronizing superiority smacks of arrogance.
Perhaps a more humble approach will work better. “We don’t really know, so your opinion is perhaps better than ours. Where are you facts?”. At least then people may be stimulated to find out.
Joe, reread your post. Perhaps we are saying the same.
We are certainly of same mind. I can’t say how effectively I communicated it, but I completely agree? If you have a chance, please read
http://chealthblog.connected-health.org/2011/12/13/is-disruption-of-mainstream-healthcare-the-answer-to-our-crisis/
I think this will confirm for you that we are on the same page.
Thanks for the link. You summarize the situation well. Should I live in Boston I would be very motivated to join your team in Partners.
In my recent engagements here I see conflicts between the main cost driver (labor) and the need for patients to take more responsibility. It seems to be going in the wrong direction. On the labor front our psychiatric hospitals are replacing trained nurses with “bouncers” and pushing more psychotic patients onto the streets (different budget), while with the elderly computer solutions are being pushed with no understanding of how to present these to the constituency so they are often rejected. Doctors do realize the risk of e.g. diabetes but are left to themselves to prescribe a regimen that might reduce risk. We have some success with medication compliance via pharmacies but this is mostly patient/family driven.
I think the new solutions will emerge painfully bottom up – consumer driven. Likely outside current healthcare establishment and insurance systems. The positive I see is that the professionals almost all buy into the goals – they just do not see how to get the job done. I do not buy into the economic motivation for delaying change – doctors and specialists are not on the whole worried about their personal economic picture. The new possibilities have to be effective and patients need to drive. Doctors have to be convinced that it makes sense for better therapy, not for their wallet.
Longer post than I intended. Sorry for that.
you have given a well detailed information about personalized prevention. I hope that many people will benefit from this and actually get the genetic tests.
Dr. K., In your post, you wrote that you respond to authority and comply when reminded. Throughout our lives, we encounter authority figures beginning with our parents, then teachers, and later employers. We are rewarded when we comply with these authority figures or at least avoid punishment for not doing so. In the healthcare field, the clinician is that authority figure, yet patients struggle to comply with the instructions they are given to improve their health, even when they have access to care and health insurance. My dissertation research informed me that people are willing to change their behavior, if their behavior resulted in a great deal of distress. In other words, we have to experience a great deal of grief before we are willing to consider changing our behavior. So, a visit to the emergency department (a source of financial and emotional grief) should be enough to encourage a person to change his/her health related behavior-yet this is not always the case. As a result, I am starting to believe that our health decisions are sitting on a balance scale. On one end of the scale are the benefits we receive from keeping the status quo, which may be numerous. Only if we are overwhelmed with the negative consequences of maintaining our behavior that the opposite end of the scale drops and we can no longer justify our behavior. At this point, it is not that someone has told us that we have to change; we are confronted with the reality that our situation will only worsen if we do not change. Of course, this is not the case for everyone, but change is truly difficult, and we resist it as much as we can. I believe the programs we develop to engage people in new health behaviors may consider this metaphorical scale and approach people based on how the scale is tipping. If the scale is tipping in favor of maintaining the status quo, it may be harder for people to succeed in changing their health behavior, even when provided with the best supportive technology. With these individuals, our strategies may focus on helping them identify the factors that will tip the scale in the opposite direction, allowing them to see the need for change; thus enhancing their ability to benefit from these technologies. On the other hand, if the scale has dropped heavily on the grief side, we may focus more on providing access to low cost, tailored health related tools that are easy to use and adjust to the person’s changing needs over time.
Thank you, Shanta, for your thoughtful comments. It’s a pleasure to have you reading and responding to the blog
I and a few other colleagues in the US have been pioneering the field of persuasive technology, a set of computing tools that can alter human behavior and we have designed and implemented several technologies for healthy lifestyle and wellbeing. I am glad to see your group as well as E&Y finally saying that the time has come to focus on prevention through behavior change. But for those of us who have been engaged on this for a while, I agree that no one solution will work. Moreover we have recently published models in which we are changing our framing from persuasion to empowerment. When can users feel empowered? When the message is experientially rewarding, cognitively convincing but above all is aligned with his/her the long-term goals. To know that one has to enter into motivational interviewing techniques through which one can guage the goals and then design custom-tailored interventions. Also since the next generation is IT-savvy, it is important that we develop these solutions and bring them to where they are: SMS texting for younger folks, blogs and facebook for working adults and perhaps newsletter or websites for the senior older population. The key is to provide actionable message that they can act on.
References:
1. Samir. Chatterjee, Mike Csikszentmihalyi, J. Nakamura, David Drew, Kevin Patrick, From “Persuasion to Empowerment: A Layered Model, Metrics and Measurement” in Proc. Int’l Conf. on Persuasive Technology (Persuasive 2010), Copenhagen, Denmark, June 7-9, 2010.
2. Samir Chatterjee, and Alan Price, “”Healthy Living with Persuasive Technologies: Framework, Issues, and Challenges”, Journal of the American Medical Informatics Association (JAMIA), 2009; 16: 171-178. PrePrint published December 11 2008.
Thanks for the comments, and especially for the references.
[...] 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. [...]
[...] 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 [...]
[...] 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 [...]
Kind of like teaching humanoids thousands of years ago that there’s fat in theose bones and this s how you get it. Most young emulate their local experience, let’s make i better.
indeed. thanks
Activity is so important! Check out this great video by Dr. Mike Evans that puts the importance of exercise in a totally new perspective: http://www.youtube.com/watch?v=aUaInS6HIGo
My response is delayed since I just got to read your blog post, but this topic about engagement in healthcare is fascinating and complex and one I am wrestling with myself at my startup.
I agree fully with Sygriffin’s post that people have to experience “a great deal of grief before…willing to consider changing behaviors” and the idea of a metaphorical scale says it quite simply and clearly. This brings to mind a notion in management (actually, marketing) that is a very useful construct in healthcare – though I’ve never actually seen it being discussed anywhere (I had a post elsewhere on the subject some time ago). That is one of “high involvement” vs “low-involvement”. High involvement goods are those that people care about deeply and spend much time and effort studying, understanding, and internalizing. These products or services, oftentimes, are not terribly important to our lives in the larger scheme of things – such as following the performance of the RedSox or evaluating the New iPad or the iPhone 4S (even as one has the earlier versions) or the latest LCD television or the merits of the latest Toyota Prius.
In contrast, healthcare is low-involvement: even as we may be told, quite bluntly that we are susceptible to something that could cause future problems, we ignore it at our peril. People only become “highly involved” in their health when, to quote Sygriffin, “they experience a great deal of grief” or are “overwhelmed with the negative consequences of maintaining our behavior”. By that time, it is usually too late in terms of the overall toll it has taken on the person and their loved ones.
What connected health, in association with pathbreaking psychology research, has to discover is how to make health endemically high involvement – rather like an iPhone, a Nintendo Wii, playing the daytime trader, or spending time in Las Vegas. In fact, all of these could inform our thinking on what makes people highly involved in certain areas – may be there is some genetic disposition or brain mapping that predisposes us to highly involved behavior in some and not in others.
There is an ironic consequence here – some people are born to be fat. Perhaps we can move further as a species by accepting that.
Today young people have an ideal for their bodies. It is the slim variant – nothing needs to change. However I wonder what is happening with the people who fail to be slim?
When I went to China twenty odd years ago being fat was an aspiration. Now the aspiration is towards slim so we need to swim with that current. Still, it seems, some people will continue to be fat however much they try.
I agree with Joe that we have a lot to gain by informing people of their metabolism when we can do so reliably. Equally we should improve our understanding for people who are genetically inclined to be overweight – the costs of the frustrated fatties who cannot help themselves extend beyond healthcare.
This is a great video. thanks for sharing it.
I appreciate your comments
This is a nice way to simplify a complex topic. I like that. Always looking for ways to simplify the communication.
Fascinating genotypes. Are there a group of genes that are affected? Is Leptin gene involved in the genotypes you list? Thanks, Vandana Bhide, MD (Mayo Clinic)
I’ve attached the reference. it was an editorial from 2007.
Bouchard C, The biological predisposition to obesity: beyond the thrifty genotype scenario. International Journal of Obesity (2007) 31, 1337–1339
(somehow this didn’t get sent from yesterday)
Thanks so much for sharing blog, link & video. I love that you are partnering with Boston Public Schools!
I was fortunate to hear Phil McKinney, former VP/CTO of HP speak at Startupism2012 today. “Ask a question, for example, what is half of 13? But don’t stop at the first answer, everyone has the same answer, move on to the next answer, there is more than one answer. Discoverability is key to innovation.”
After his Keynote, I was able to ask him about health, education, and technology before he was mobbed. He has been asked by the U.S. Education Dept to help them innovate, for example, this link gives you an idea of his focus: HOW to create killer innovations –
http://philmckinney.com/archives/2011/05/ideas-generated-killer-innovation-workshop-education.html
But as the crowd surged forward, I stepped away, not because I was less passionate than others, but because I felt I was already past the first answer. I hold Phil in the highest esteem but he doesn’t have the same experience/context I have…for example, he home-schooled his children, I’ve kept mine in school but changed around which school to ensure the environment was the one I thought best to enable their success, in being forced to stay at school, I’ve had to research every school I felt realistic enough to commute to and that challenge defines my perspective. I’ve read somewhere that nationally 10% of children attend private schools, where I live over 30% attend private.
I agree that genotype screening is a good thing, but when is early intervention early enough? In the 1960′s Todd Risley and Betty Hart went into preschools to provided early intervention but their initial positive momentum declined after a certain point, undeterred, they assessed children from 7-9 mos old…http://www.evidencebasedmummy.com/?p=6
No, this wasn’t a study on obesity, but I do feel there is a connection between mind and body that we tend to ignore. I agree with speaker/authors Dr. John Ratey: “Spark: The Revolutionary New Science of Exercise and the Brain” and Dr. Daniel Amen: “Change Your Brain, Change Your Body: Use Your Brain to Get and Keep the Body You Have Always Wanted,” that there is a connection between mind and body, health and well-being.
I hear many argue that electronics and technology are to blame for the increases in ADHD. Phil mentioned today was Autism Awareness Day and we talked about the new U.S. statistic that 1 in 88, 1 in 54 boys have autism costing $137 billion per year – http://www.wpxi.com/news/lifestyles/health/autism-hits-1-88-us-kids-1-54-boys/nLgZN/.
Technology for certain has changed us but it has been a systemic evolution of progress towards efficiency. Our brains and bodies are always looking to optimize opportunity. The Bridges’ bodies are more efficient…they need less calories to hold onto fat. I think Risley & Hart were onto something but here’s my thought…just-in-time intervention is important, to keep us on track but it needs to focus on what Dr. Daniel Kahneman termed as System 2 vs System 1 issues. http://nihrecord.od.nih.gov/newsletters/04_13_2004/story02.htm, which I think you may be getting at with emotion sensors.
I truly believe technology has the ability to extend our capabilities and enable us to overcome our natural limitations…it’s looking beyond the first answer, the first system.
I would love to build a fitness program leveraging technology at my kids’ schools…let me know if this is possible! I’m am all about the possibilities ; )
thanks for all of your thoughtful, rich comments and links! I’m a fan of Kahneman too. reading “Thinking Fast and Slow” right now.
Very interesting article. As a physician running medically supervised weight management programs, I see the genetic variations amongst the individuals. Very enlightening to have the genetics validated.
its early going, but I have high hopes that the field will mature and allow for hyper segmentation and very personalized health improvement plans.
Really great post!! As a soon to be resident in the Partners program I also look forward to working with early intervention programs in school systems. There is definitely great area of opportunity in this population segment to involve lightweight and thoughtful technology as it relates to healthy behavior
Loki me up when you get to town (or sooner). Jkvedar@partners.org
Interesting to read the comments. I think we can make a big step forward when we can say “overweight is bad but it is not necessarily your fault. When your genes are against you there are still things you can do to lengthen your life.”
Between my 26+ years of practicing internal medicine, and the last 10 years as Chief Knowledge Officer at the Institute for Clinical Systems Improvement, I’ve had the opportunity to consider the causes and effects of obesity, both from a physiological standpoint, but also from the psychological impact often seen in those who are obese. In fact, I supervised a weight loss clinic for over 7 years, while in practice, and was struck at the time, by the widely different stories, experiences, and frustrations seen in many of those whom I saw.
This post resonates in that it begins to “destigmatize” the condition of obesity, which is commonly seen–through exhortations for “more will power”, “working harder,” “having more pride in your appearance”– and many more which have permeated our environment.
Beginning to understand the genomic considerations, with their concomitant associated neurohormonal and protein differences, much like we need to consider in mental health issues, is critical. Eric Topol, MD, in his recent book, The Creative Destruction of Medicine, has similar questions and issues with the impact of our present knowledge or lack thereof in addressing specific issues. While there are many concerns with the impact of genomic information becoming easily accessible, it may be the one step to the “democratization” of health care for our patients which we need.
Additionally, as we learn more about human behavior, decision making, and the illogical aspect often times seen, the information such as presented by Daniel Kahneman in Thinking: Fast and Slow, as well as many other books, such as Incognito by Daniel Eagleman, Nudge by Thaler and Sunstein, Predictably Irrational and The Upside of Irrationality by Daniel Ariely, How We Decide by Jonah Lehrer, to name a few, should be considered as we battle “system 1 vs. system 2″ issues.
I also see your recognition of the need to move our previously bounded medical thinking into the community, and recognize the relatively small part of our citizen’s lives that we in the health care community can impact, and the need to consider truly different approaches if we are to truly achieve a healthier tomorrow for our citizens. Great piece, and I look forward to reading more.
Thank you for your wisdom and commentary. I am also a fan of Eric’s book and of Kahnemann’s work!!
Great posts. I know it’s early but finding ways to make knowledge from genomics actionable is vital. We are individuals and we deal with our genomes – consciously or not – by making choices in diet, exercise, lifestyle, behavior that ultimately can mitigate or accelerate our risks. It’s tough to change behavior, just look at the success of Weight Watchers. For those with genomic risks for obesity, how many will change their behavior to deal with it?
Having said that, I then think of the population as a whole. You have to be struck by the rapid growth of obesity in just a few decades. Makes me think there’s more to this than just calories and perhaps we’re just eating the wrong things. See Gary Taubes’ “Good Calories, Bad Calories.” To have nearly half the US population at risk for T2D is staggering. It’s particularly concerning because people are so used to T2D, they may not realize how (1) it’s a terrible disease and (2) it’s preventable. We may have individual risks but there seems to have been a change toward the wrong calories (too many carbs?) over time. It’s amusing at one level: I attended a briefing on genomics and obesity last week. The lunch contained chips, sandwich, a large cookie, and an apple. We all might have done better with just the apple.
On the matter of public schools, I realize this is a more complex social issue with many kids lacking access to healthy food alternatives and safe areas to exercise. But why must we allow candy bars to be sold in school vending machines? Why not try testing healthy alternatives? The kids may prefer it!
There is something called the “obeseogenic environment, which is half the built environment (e.g. We have all of these technologies that obviate the need to expend calories) and the social environment which is all of the poor food choices we make. No question it’s easier than ever to be overweight, but it remains a fact that not everyone is or will be over weight.
Joe,
Great meta-analysis of the convergence of digital technologies (genomics inclusive, i.e. A, C, G, T) with consumer health and clinical healthcare. I call it Digital Health, yet another buzz word.
See you in Oct at the Connected Health Symposium.
Best,
Paul Sonnier
Founder, 10,000+ member Digital Health group on LinkedIn
Thanks, Paul. Looking forward to seeing you too!
Joe,
A superb blog and delighted to pass along to help get some naysayers down from their cloudy positions.
Hi Joe, – your ‘buzz-word bingo’ is not really that annoying – it underlines how digital infrastructure investments are hugely important to just about everything else.
Here in the UK the NextGen team have recognised the importance of this cross-sector approach in financing and policy for digital infrastructure – and the need to get more of a demand-side drive to shake up the telecoms/networking industry.
A practical example is NG Connected – the notion that in whatever sector we are all ‘Connect Causes’ and reliant on a vastly better digital infrastructure. http://www.nextgenevents.co.uk/ng-connected
We read all the time about the economic deficit but we would all agree that there are deficits in health, in the environment and in digital infrastructure.
Dealing with the latter seems to many of us to be a prerequisite for making progress in all the others – but isn’t that just what Obama was saying in his inaugural address?
My comment (1st para) back in 2009 refers. http://www.groupe-intellex.com/editorials/18-gi-global/174-obama-connects-health-wealth-broadband-and-sid.html
So, Joe, grieve for the silo-ed souls whose horizons are delimited by their tags – but rejoice that there is a bigger picture for those of us who care to look at things sideways!
Best wishes
David Brunnen
Thanks, David. I very much appreciate the European perspective
Joe- I thought you might find this interesting related to your post.
the app store model for dna apps- (using Amazon Cloud services)
“This open platform will allow these software developers to make apps for scientific customers who want to sort and quantify reams of DNA data”
http://www.imedicalapps.com/2012/05/app-store-dna-sequencing-software-opens-business/
Thanks, Alex. I hope all is well!
As A TPA and health benefit plan payor, I am intersted in finding out this can be done across an employee group population without running afoul of the very strict GINA regulations.
It’s a good question. I’m only slightly familiar with GINA, but if this concept shows its power, I have to believe there is a work around.
Great post Joe!
While buzzwords are annoying at the outset I find solace in the fact that they will become a normal part of our language soon. These 3 emerging trends are a critical part of the digitization of health that will enable a long overdue consumer centered model!
Take care
Paulo
well stated. thanks for your comments!
The only one I find annoying is “the Cloud,” which most people use when they really just mean “remote hosted storage.” Big cliche at our new HIE these days, “the Cloud.”
I like the story David Brunnen shares in his second link, “what got through to Sid and no doubt millions of others was the sense that we are working together – and you’re part of it even if you’re coming up to 102 (years old).”
But buzzwords like “Wireless,” “Big Data,” “Cloud” would only interest those already interested in technology. Whose attention do you want to subscribe to your blog?
Gosh, I don’t know. I remember a Microsoft commercial a year or so back that was shown on primetime TV where the ‘tag line’ was ‘to the cloud..”. Apple certainly wants every day consumers to understand and use iCloud.
I’m not sure its only techies.
Happy Mother’s Day! – jumping on “Mother’s Day” in a similar way as your thought to use these particular “buzzwords,” P&G knocks yet another one out of the park with this beautiful ad – http://www.wimp.com/beautifulad/
I think it’s a great ad & have helped it go viral I’m sure. I love their universal concept of motherhood, global use of culture and languages, but am less sure about the notion that everyone becomes an Olympian for moms to be proud, although I completely see the advantage of using this to gel together a quick video concept.
I’ll admit I was forwarded this video for Mother’s Day, I didn’t drop the words into a search engine, but what they accomplish is similar to what you hope to gain, to capture someone’s attention with what is relevant contextually to them.
In my humble opinion, buzzwords like “Wireless,” “Big Data,” and “Cloud” are relevant to people already engaged there, if like P&G, mothers are the audience, they were wise to use “Mother’s Day” to draw in that audience.
I love your posts as they make me think and I have interest in the intersection of technology, health and engagement. Although I have an interest in technology, I’m not an IT professional so it’s true that buzzwords like these wouldn’t just draw in techies but contextually because they come from you and the Center for Connected Health, you would be of interest to more folks like me, interested in this particular intersection.
Nevertheless, I think if you are looking at everyday consumers, for example candidates for genomic testing due to obesity, these buzzwords might not draw their attention, unless they have an interest in using a Fitbit or other health-technology device already, so they are already somewhat switched on to these buzzwords. I’m less sure that using the buzzwords with people who aren’t already somewhat interested in these topics would actually lead to new attention because these individuals don’t know there is something to gain in being involved.
But then again, there was Sid at 102, who seemed to understand that technology has the power to connect us and liked to tune in and be a participant. ; )
thanks for your lengthy, thoughtful comment. i very much appreciate the feedback. And the kind words.
[...] http://chealthblog.connected-health.org/2012/05/02/wireless-big-data-in-the-cloud [...]