Sunday, June 26, 2011

Not Everything in Health & Wellness Can Be Reduced to a Single Number

"To measure is to know." Lord Kelvin

"If you can not measure it, you can not improve it." Lord Kelvin


“Asking science to explain life and vital matters is equivalent to asking a grammarian to explain poetry.” Nassim Nicholas Taleb

“Technology is at its best when it is invisible.” Nassim Nicholas Taleb

How can technology help us live healthier lives? Why did Google Health fail? Why are Klout and Twitter Grader publicly issuing a number to me by name about how influential I am? What do Lord Kelvin and Nassim Nicholas Taleb have to teach us?

I was taught in medical school and pathology residency that health was defined as absence of disease; this definition pleased me because not much important could happen to the patient until I peered into my microscope and rendered a diagnosis. I looked up to Virchow and Rokitansky who were the most important and influential physicians in the most advanced medical centers in the 19th century.

In the mid-20th century the World Health Organization (WHO) famously stated: “Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or injury.”

“The dialogue between Asclepios, the god of medicine, and Hygieia, the goddess of health – the external intervention and the well-lived life – goes back to the beginning. Only in the twentieth century did the triumph of ‘scientific’ modes of inquiry in medicine (as in most walks of life) result in the eclipse of Hygieia. Knowledge has increasingly become defined in terms of that (and only that) which emerges from the application of reductionist methods of investigation.” (

The WHO rejection of the “absence of disease” definition of health has been warmly embraced by some and largely ignored by many more. After all if the WHO definition means that our wellness is affected by all human activities, what should the Department of Health and Human Services focus on and budget for? The WHO definition of health has “been honoured in repetition, but rarely in application.”


At one time I thought Google Health would become the Personal Health Record (PHR) that would allow individual patients to keep track of their medical and daily activity data and apply the WHO definition of health to their own life; I blogged about PHRs because I hoped they would solve the enormous problem of hospital based IT systems not communicating with each other.


I still remember the excitement when Google CEO Eric Schmidt described Google Health for the first time at HIMSS 2008, and I played around with it. I found it easy to use and understand, but I never really used it for my own health and wellness purposes. The Wall Street Journal had a similar experience: “We signed up for Google Health…and a bunch of other personal health records for a story, but never quite felt compelled to actually use them.” (

Google Health failed because

· Patients are not that interested in entering their data into a PHR

· Google underestimated the complexity of health care

· Most consumer health data is not in a structured, machine computable format

· As an untethered PHR, professionals distrusted the accuracy of the data

· Google did not work with or engage physicians in the effort.

· It did not coordinate with technology developers.

The best analyses of the sad ending of Google Health can be found here (, here (, and here (

Because I am no longer protecting the narrow interests of pathology, the WHO definition of health continues to ring true. Since all human activity affects health and wellness and since we have such poor memories, how does one better understand one’s own body and mood? The personal informatics ( and quantified self movements ( are true descendants of Lord Kelvin; they believe that scientific, objective, quantified measurements can lead to behavior change that can promote wellness and health. Dr. Joseph Kvedar changed his attitude about yard work when the data from his Bodymedia armband convinced him that he burned more calories doing gardening than bicycling ( Shaun Rance used the anonymous website to reduce his drinking after his father received a diagnosis of end-stage liver disease. Jon Cousins built Moodscope, a self-tracking system to manage his bipolar affective disorder; he even shares his personal mood data with a few friends. His self-tracking metrics are supplemented by human sympathy made possible by his online connections and community. (

While much that is written about self-tracking celebrates the potential of measurement to help the individual with sleep, exercise, sex, food, weight loss, mood, alertness, productivity, and spiritual well being, there is a dark side to the movement. Alexandra Carmichael, one of the founders of CureTogether where patients conduct research on diseases, wrote about why she stopped monitoring 40 measurements about herself: “Each day my self-worth was tied to the data. One pound heavier this morning? You’re fat. Skipped a day of running? You’re lazy. It felt being back in school. Less than 100 percent on an exam? You’re dumb.” (

Google Health failed largely because consumers did not see the value of a PHR and because it was time-consuming to input data. Gary Wolf thinks four things have changed that make self-tracking easier and more acceptable:

· Electronic sensors got smaller and better

· People carry smartphones that are powerful computers

· Social media made it normal to share everything

· The development of the cloud

Other researchers believe that technology may support health and wellness not by having individuals self-track, but by monitoring our social networks. This approach has been called the social contagion theory of disease, and much can be learned without the individual doing anything except carrying around his smartphone. (

By analyzing the famous Framingham Heart Study, Nicholas A. Christakis and James H. Fowler were able to map 5,124 subjects for a connection web of 53,228 ties between families, friends, and co-workers. Obesity appears to spread among friends like a virus. “When a Framingham resident became obese, his or her friends were 57% more likely to become obese too.” “A Framingham resident was roughly 20% more likely to become obese if the friend of a friend became obese.” “You may not know him personally, but your friend’s husband’s co-worker can make you fat. And your sister’s boyfriend can make you thin.”

This social contagion process seems to also work for drinking, smoking, loneliness, and happiness. Christakis and Fowler believe that “these behaviors spread partly through the subconscious signals that we pick up from those around us, which serve as cues to what is considered normal behavior.” (

Alex Pentland, director of MIT’s Human Dynamics Laboratory, uses cell phone data to identify the influencers in any social network that are most likely to change other people’s behaviors. Dr. Pentland says, “Just by watching where you spend time, I can say a lot about the music you like, the car you drive, your financial risk, your risk for diabetes…We are trying to understand the molecules of behavior in this really complete way.” (

Although I have never been studied by MIT, I have been assigned a number that supposedly indicates how influential I am. According to Twitter Grader I am ranked 88,837th out of 9,826,593 with a grade of 100 out of 100. Klout states that I am a “pundit” with a score of 69 out of 100. PeerIndex gives me a score of 18. What do these numbers really mean? I have no idea.

“Now you are being assigned a number in a very public way, whether you want it or not,” said Mark W. Schaefer of Rutgers University. More than 2,500 companies are now using klout data, and special offers are just starting to come into my email box. The CEO of Klout of course thinks this is a great idea: “For the first time, we’re all on an even playing field. For the first time, it’s not just how much money you have or what you look like. It’s what you say and how you say it.” Others are not so sure and worry about creating social media caste systems and that such rating systems lack sentiment analysis (negative comments can be as affective as positive comments in raising one’s score). (

So what can we conclude from this dizzying tour of health, wellness, measurement, technology, and life. I think we need both Lord Kelvin and Nassim Nicholas Taleb to guide us. I think it is a mistake to choose the WHO definition over the absence of disease definition of health, as though they are polar opposites. There is a continuum of meanings for the word health. “At one end of that continuum is well-being in the broadest sense, the all-encompassing definition of the WHO, almost a Platonic ideal of the Good. At the other end is the simple absence of negative biological circumstances – disease, pain, disability, or death.” ( I think Google will in the future realize they shut down Google Health too soon. As smartphones and sensors make it easier and easier to automatically input data, people will want a place to store all of their observations of daily living and medical data. Taleb is right; technology is at its best when it is invisible. However, some of the most important things in life are not reducible to a number or a PowerPoint slide with bullet points. Twitter Grader says I am 100 out of 100; Klout 69 out of 100; and PeerIndex 18 out of 100. Not all of these rankings can be accurately measuring my influence to my twitter community and readers of my blog. And let’s not forget what we are learning from social contagion theory; it is not just about the individual. I also think that there may be something to the Keas approach which, as I understand it tries to use game theory to make it more fun to use technology to help us change unhealthy behaviors. Tom Chatfield’s Fun Inc: Why Gaming Will Dominate the Twenty-First Century and Jane McGonigal’s Reality Is Broken: Why Games Make Us Better and How They Can Change the World certainly gave me many ideas about how to create flow for human beings in the service of individual and population health.


  1. Dr. Bottles,
    I can add one more number. If your autonomic nervous system is working well i.e. the sympathetic and parasympathetic are in balance and working together, your internal organs are being driven well and you are not under mental and physical stress. I can give you this number!

  2. Enjoyed reading this. I have to agree, Google seems to have thrown in the towel without really trying very hard and too early.

    As sensors are integrated into devices, the technology may just become more invisible and Google Health would have been a great place to aggregate these data streams.

    The point about "social motivation" is interesting. We are heavily influenced by our peers. How many people who will share their sensitive health info in the cloud where they have concerns about the security of the data and also the motives of the hosting service?

    Bandura wrote the seminal paper on Self-Efficacy and his concepts may be important to keep in mind. For a lot of people collecting data on parameters like Body Weight can actually work negatively. It may be better to track a process measure. I wrote about this here if you are intersted.
    Thanks for the thoughtful post!

  3. Kent... Insightful comments, as usual :-). I agree with your conclusion. I think they will re-tool and re-evaluate based on vast input from patients and physicians alike. Then the #mhealth revolution will make it far easier to transfer records onto the platform and perhaps a pop in the adoption curve will follow.

    Neil... as an aside.. I liked your post too!
    Howard Luks

  4. Great post. My favorite lines:

    "I think Google will in the future realize they shut down Google Health too soon."

    "technology is at its best when it is invisible. "

    I believe those companies/products/services that make health "invisible" will ultimately create a service that people will adopt en masse. This is why I am so excited about what many are doing in the QS space because there are exciting services gaining significant traction that also just happen to include health tracking as a core feature...

  5. Loved this post.

    Favorite- Google Health closed just before self tracking input could be added.

    My 2 cents in this regard is that PHR's gotta come from the ground up rather than a huge institution trying to guess what patients want to use, and missing.

    Maybe it'll be a few mobile apps that manage small chunks of a PHR (med list, for starters, then glucometer and other vital sign metrics). The good ones will percolate to the top of the app store, and eventually they'll congeal with fitbit and others.


  6. Thanks for Kent Bottles,i really nice post and well appreciated..

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