Reverse Innovation & The Cost Crisis of American Healthcare

The realization that the American health care system must simultaneously decrease per-capita cost and increase quality has created the opportunity for the United States to learn from low and middle-income countries. “Reverse innovation” describes the process whereby an inexpensive innovation is used first in countries with limited infrastructure and resources and then spreads to industrialized nations like the United States.

The traditional model of innovation has involved the creation of high end products by companies in industrialized nations and the spread of these products to the developing world by adapting them to function in low and middle-income countries. Reverse innovation reverses the direction of spread with the United States borrowing new ideas and products designed for less wealthy countries in order to deliver health care more efficiently. (1)

Resource challenged low and middle-income countries are different from the United States in at least six ways that can serve as catalysts for such reverse innovation: 1) affordability, 2) leapfrog technologies, 3) service ecosystems, 4) robust systems, 5) new applications, and 6) the absence of intermediaries. (2,3)

These nations can’t afford expensive goods so they have to find inexpensive materials or manufacturing options. They also lack 20th century infrastructure and so they have leapfrogged to newer technologies such as mobile phones or solar energy instead of landlines and petroleum based energy sources. Service ecosystems develop in developing countries because entrepreneurs have to rely on others for help by creating new partnerships like video-game cafés where gamers test new products. Emerging markets require products that work in rugged conditions, and 
customers in poor countries have few product choices, providing market openings for add-ons that update and extend the lives of existing merchandise. (2) Intermediaries such as venture capitalists, universities, and regulators are also often underdeveloped in poorer countries. (3)

An example of how an absence of intermediaries can spur innovation is the Medtronic approach to chronic disease management in nations without adequate medical school capacity to train specialists in heart disease. Sixty nine percent of deaths in such nations are due to chronic disease, but the building of medical training programs takes decades. Medtronic designed a low-cost, pill-sized pacemaker inside a stent that can be put into the heart instead of the invasive intercardiac leads used in the US to electrically synchronize the heart. Remote sensors in the pill-sized pacemaker transmit signals via any smartphone to a cloud-computing infrastructure. Although this new technology was developed for India that has one billion citizens but only 100 electrophysiologists, Medtronic intends to market this low-cost pacemaker in the United States and Europe. (3)

General Electric has embraced reverse technology as a way to survive in an era where economic growth is slowed in the United States and Europe, but growing rapidly in India and China. GE developed a $1,000 handheld electrocardiogram device for rural India and a $15,000 PC-based portable ultrasound machine for rural China. These devices are much more affordable and rugged than their American counterparts, and they are now being sold in the United States. (1)

General Electric has also partnered with Embrace to distribute a low-tech infant warming device that consists of a sleeping bag, a sealed pouch of wax, and a heater. In contrast to traditional incubators that cost $20,000, this new device costs $200 and will help warm the 20 million low birth weight and premature babies born around the world. (4)

OneBreath is a rugged, low-cost ventilator that was designed for use in developing countries that experience large influenza pandemics. By measuring and controlling airflow with software rather than hardware, OneBreath was able to reduce the cost of ventilators from $40,000 (with $180 replacement tubes) to $800 (with 50 cent replacement tubes). (5)

Procter & Gamble is now marketing a honey-based cold remedy created for Mexico in the United States and Europe, and the Center for International Rehabilitation has developed low cost prosthetic and orthotic devices that can be used in rural areas where highly-trained specialists are not available. (6) JaipurKnee has developed a $20 high performance prosthetic knee joint for amputees in India who cannot afford the $100,000 titanium knee joints routinely used in the United States. (5)

The Stanford University BioDesign Program has developed a $20 device for delivering fluids or intravenous drugs into the bone marrow when vascular access is unavailable. The device was invented in India, but it could be used in rural America as well. (7)

The United States is now faced with the challenge of decreasing per-capita cost and increasing quality. Many believe that the high cost of American health care is the major reason that the United States is facing a large federal deficit problem that is hampering the ability of American companies to compete in a global economy. Some believe that the high cost of American medicine also is a major factor in causing and prolonging the current recession. The high cost of health insurance is a problem for employers who then do not give salary increases to their employees. The employees borrow money in order to continue to support their lifestyle. Stagnant employee wages have been cited as a reason for Americans defaulting on their mortgages and car payments, which resulted in the current recession that started in 2008.

American health care organizations are facing decreased revenues due to decreased volume of hospitalizations and office visits by unemployed workers, Medicare cuts contained in the Affordable Care Act, and cuts resulting from the budget deficit ceiling compromise passed by Congress that will result in January 2012 with either a $1.5 trillion or a $1.2 trillion decrease in federal spending. At a time when it clear that health care providers will be receiving less revenue, it would be wise to adopt inexpensive innovations that have been created for less developed countries. Reverse innovation may be one way that American medicine can decrease per-capita costs and increase quality at the same time.

References:

1. http://hbr.org/2009/10/how-ge-is-disrupting-itself/ar/1

2. http://www.businessweek.com/innovate/next/archives/2009/04/5_tips_for_tric.html

3. http://blogs.hbr.org/govindarajan/2011/05/patient-care-in-the-cloud.html

4. http://www.genewscenter.com/Press-Releases/GE-Healthcare-Partners-with-Embrace-to-Help-Address-Infant-Mortality-in-Rural-India-Through-Affordable-Infant-Warmer-2d80.aspx

5. http://blogs.hbr.org/govindarajan/2011/09/how-to-build-a-reverse-innovat.html

6. https://www.iconsinmed.org/content.cfm?id=595E75&searchIT=1

7. http://biodesign.stanford.edu/bdn/india/BiotechNews2010_story1.pdf




Avatars, Computers, and Robots Are Coming to Primary Care

Within in five years primary care providers will begin being replaced by sociable humanoid robots, avatars, and computer programs. Within ten years you will no longer hear any complaints about medical students choosing specialty residencies over family practice because the role of the physician will be completely redefined to complement a rules based approach to the diagnosis and treatment of many diseases. This transformation is inevitable because of demographics, economics, and progress in artificial intelligence, but the academic leaders of medical education and health policy are largely ignorant and unprepared for this massive disruption.

It is hard to understand this change because it requires us to challenge the conventional wisdom that we need more doctors and that a trusting relationship can only be had between two human beings. It will also require us to understand the implications of the evolving relationship between human beings and technology, and how disruptive innovations change industries.

Many do not see this future because they fear it. Samuel Stenes, MD spoke for many physicians when he posted the following comment on a blog I wrote about this subject: “You are truly out there. People do not want that cow waste, but the profession has been sufficiently depreciated that anarchy care will rule.” (1)

Philosopher Roger Scruton makes a similar eloquent argument about trusting relationships requiring two human beings:

In real life, friendship involves risk. The reward is great: help in times of need, joy in times of celebration. But the cost is also great: self-sacrifice, accountability, the risk of embarrassment and anger, the effort of winning another’s trust. Hence I can become friends with you only by seeking your company. I must attend to your business... When I relate to you through the screen there is a marked shift in emphasis. Now I have my finger on the button. At any moment I can turn you off...Of course I may stay glued to the screen. Nevertheless, it is a screen that I am glued to, not the person behind it.” (2)

Professor Andy Clark of Edinburgh University works in the “embodied cognition” and “extended mind” fields of philosophy, and he has an entirely different take on this issue. Citing studies that show that research subjects who are prevented from using hand gestures perform poorly on tests of mental ability, he concludes that some of the activities that enable us to think and create trusting relationships occur outside of our body and brain. “Evolution and learning don’t give a jot what resources are used to solve a problem. There is no more reason, from the perspective of evolution or learning, to favor the use of brain-only cognitive strategy than there is to favor the use of canny (but messy, complex, hard-to-understand) combinations of brain, body, and world.” (3)

The health care problem that the United States needs to solve is how to increase the quality and decrease the per-capita cost in an era of aging Baby Boomers, inadequate numbers of primary care providers, and a struggling economy that cannot support spending 18% of its GDP on health care. The messy, complex, hard to understand solution is that sociable humanoid robots and computer programs will replace human providers in diagnosing and treating some diseases.

Clayton M. Christensen, Jerome H. Grossman, MD, and Jason Hwang, MD in The Innovator’s Prescription provide a framework for understanding how disruptive technologies are making the current business models for diagnosing and treating chronic disease obsolete. They divide chronic diseases into two types: intuitive chronic diseases and rules-based chronic diseases. Intuitive chronics diseases such as lupus, back pain, and schizophrenia lack clarity in diagnosis and treatment and so at the present time still require a human physician working in a multidisciplinary solution shop such as a tertiary care hospital. Rules-based chronic diseases such as Type II diabetes, GERD, and heart failure are well enough understood scientifically that a computer following an evidence-based medicine protocol can diagnose and treat the patient.

But computers are not that smart and patients will never accept such an arrangement. The first objection does not stand up to scrutiny when one thinks about the implications of the four year Watson/Jeopardy! Project at IBM. Columbia University Professor Herbert Chase, MD believes computers will replace physicians as expert diagnosticians (4) by utilizing the same methods that defeated human Jeopardy champions: taking a question about a patient’s symptoms, analyzing the question, generating a differential diagnosis, collecting and evaluating the entire medical literature on the subject, and coming up with a diagnosis with a measurable level of confidence. David Ferrucci the leader of the IBM Watson project explains how Watson can do this in a 20 minute video (5), and Stephen Baker’s book Final Jeopardy: Man Vs. Machine and the Quest to Know Everything is a fascinating description of the development of Watson by a twenty person team at IBM.

United Hospital in Saint Paul, Minnesota is already taking a similar approach by using Isabel to search the medical literature in real time to generate a differential diagnosis for the hospitalized patient based on the patient’s symptoms and medical history. “Isabel is like a medical Google. It doesn’t think but it searches and sorts and shows you what it’s found,” says Scott Tongen, medical director for quality at United. Tongen notes that such a system can help with the number one reason for mistakes in diagnosis: early closure on a diagnosis with confirmation bias preventing the physician from considering alternative causes for the patient’s illness. (4)

Studies are starting to appear that document improvements in diagnosis with the use of computer technology. Computers outperformed radiologists in diagnosing Alzheimer’s Disease; Face identification software did better at diagnosing acromegaly than endocrinologists; a 2010 British Medical Journal study of a pediatric computer-aided diagnosis tool revealed a higher rate of accurate diagnosis of urinary tract infections, pneumonia, and bacteremia compared to the performance of emergency room physicians. (4)

The Watson approach to improving diagnosis by searching the entire medical literature is not the only way computers will change clinical practice. Dr. Joseph C. Kvedar of Partners HealthCare’s Center for Connected Health has developed the concept of emotional automation, and he believes that humans can and will develop trusting relationships with sociable humanoid robots (6). Kvedar notes that humans have a tendency to anthropomorphize objects such as pet rocks and tomagotchis, and Sherry Turkle of MIT has famously observed that smartphones and tablet computers have transformed our relationship with technology. “It is different now that we carry our second self with us. We think with the objects we love and we love the objects we think with. (7)” Kvedar believes that Karen the virtual wellness coach/avatar who motivates human patients to exercise more than a control group and hospital patients who preferred a robot discharge planner to a human one are examples of humans learning to trust technology in a healthcare setting. The robot was favored because it was not in a hurry and did not talk down to the patients being processed for release from the hospital. (6)

Technology is also beginning to change clinical practice when therapists use digital worlds with autonomous, virtual human avatars to help patients work through problems with social anxiety, drinking, gambling, post-traumatic stress (8), and agoraphobia. Therapists can discuss the patient’s feelings when the virtual bartender asks the patient’s avatar if he wants to order another drink. Different coping mechanisms can be practiced in real time in virtual situations that are experienced as real. In one study, people with social anxiety disorder confessed more of their personal flaws, fears, and fantasies to virtual avatars programmed to be socially sensitive than to live real therapists. (9) B.J. Fogg of Stanford has written extensively about what he calls “captology:” computers as persuasive technology, and his thinking needs to be integrated into clinical practice. (10)

Nick Yee has described the Proteus Effect where video game or digital world avatars change how we behave in virtual environments and in real life. Subjects given more attractive or taller avatars disclosed more personal information and bargained more aggressively than unattractive, shorter avatars. Yee has shown that the subject’s perception of his or her own attractiveness persists outside of the game or virtual world to affect participation in real life online dating. Yee writes that providing users with “fit, athletic avatars in exergames may encourage longer and more engaged exercise sessions than if they were provided with normal-looking avatars or avatars modeled from their own bodies. (11)”

Will patients embrace technology or refuse to form trusting relationships with sociable humanoid robots? I don’t know, but the rapid adoption of smartphones and initial studies indicate some may welcome technological solutions to common problems. A qualitative Beth Israel Deaconess Medical Center study utilized focus groups in Boston, Portland, Tampa, and Denver, and the subjects fully expect that computers will be increasingly used in health care and substitute for face-to-face physician encounters. “Patients know how busy their doctors are and they want to reserve us for what they really need us for – treating serious illness...They may be more than happy to rely on computer protocols and ‘faceless doctors’ to help them manage garden-variety medical problems,” says senior author Tom Delbanco, MD. Stephen Downs of the Robert Wood Johnson Foundation commented on the study, “Year after year, people have seen information technology transform one industry after another and, more to the point, transform their everyday experiences. This is the age of the iPhone, Facebook and Google Maps, yet health care feels very much the same. This study suggests that people are ready for change – they want a modern health care experience.” (12)

During Man-Made Minds: Living With Thinking Machines at the World Science Festival in New York City, Eric Horvitz of Microsoft showed a tape of a medical kiosk avatar interviewing a mother and her child who has diarrhea. After asking several questions, the avatar decides the child is not sick enough for immediate attention and makes a clinic appointment for the child for later in the week. The moderator of the panel of artificial intelligence experts got a big laugh from the audience when she noted that the avatar was much more compassionate in relating to the child and his mother than human triage nurses she has encountered as a mother taking her child to New York City Hospital emergency rooms. Anyone who is not familiar with recent advances in artificial intelligence needs to acquaint himself or herself with Horvitz’s avatar assistant on a computer screen outside his Microsoft office. Because this computer program has been learning about Horvitz for over 10 years, she can predict that he will not attend a meeting on his schedule for 4:00 PM and she can offer that time slot to a colleague who she recognizes by name and who needs to meet with Horvitz. It is perhaps relevant that all four artificial intelligence expert panelists predict that robots will be built that will be hard to tell apart from real human beings. (13)

It would be wise for health policy and academic health care experts to educate themselves about recent developments in artificial intelligence and computer technology; the implications for health care delivery are enormous and may change projections about cost, workforce requirements, and the training of health care professionals.

References:

1. http://thehealthcareblog.com/blog/2010/12/16/will-avatars-robots-and-video-games-replace-doctors/

2. http://technology.timesonline.co.uk/tol/news/tech_and_web/the_web/article5139532.ece

3. http://opinionator.blogs.nytimes.com/2010/12/12/out-of-our-brains/

4. http://www.acphospitalist.org/archives/2011/08/diagnosis.htm

5. http://www.youtube.com/watch?v=3G2H3DZ8rNc

6. http://www.youtube.com/watch?v=7DQGNQRVhjI

7. http://www.nytimes.com/2010/12/03/technology/personaltech/03TOUCH.html

8. http://bits.blogs.nytimes.com/2009/10/22/a-virtual-clinic-to-treat-the-stresses-of-war/

9. http://www.nytimes.com/2010/11/23/science/23avatar.html

10. B.J. Fogg, Persuasive Technology: Using Computers to Change What We Think and Do. San Francisco: Morgan Kaufmann Publishers, 2003.

11. http://www.healthgamesresearch.org/our-publications/research-briefs/the-proteus-effect

12. http://www.rwjf.org/pioneer/product.jsp?id=42849

13. http://kentbottles.blogspot.com/2011/06/ai-experts-on-robots-and-living-with.html

The Department of Human Nature: The Pervasive Sins of Doctors and Others

The essence of professionalism is to be constantly striving to take better care of our patients. “The aspiration to do better, coupled with commitment and a sense of personal responsibility will drive knowledge seeking” and empathy and compassion for those who are our patients. http://www.amazon.com/Educating-Physicians-Jossey-Bass-Foundation-Advancement/dp/047045797X/ref=sr_1_1?s=books&ie=UTF8&qid=1311109510&sr=1-1

And yet we know that during medical school students become less compassionate and less altruistic; the largest drops in empathy have been documented between the beginning and the end of the first year and between the beginning and end of the third year of education. http://www.amazon.com/Educating-Physicians-Jossey-Bass-Foundation-Advancement/dp/047045797X/ref=sr_1_1?s=books&ie=UTF8&qid=1311109510&sr=1-1

And we also know that there have been recent revelations of numerous occasions where practicing physicians have failed to live up to the ideal. The Wall Street Journal documented spine surgeons who did large numbers of spine surgery and received large payments from a medical device manufacturer. (http://online.wsj.com/article/SB10001424052748703395204576024023361023138.html) Pro Publica has shown that faculty at prestigious medical schools have failed to comply with university conflict of interest policies (http://www.propublica.org/article/medical-schools-policies-on-faculty-and-drug-company-speaking-circuit/single) A Maryland cardiologist has had his medical license revoked and his hospital had to pay back Medicare millions of dollars because of allegedly inserting stents in patients who did not need them. (http://articles.baltimoresun.com/2011-07-13/health/ms-md-midei-license-revoked-20110713_1_midei-unneeded-stents-stent-business)

How can we support our fellow physicians and medical students so that we all strive to become the best caregivers we can possibly be? Is the problem with living up to the ideal a specific problem within medicine or is it a more general problem of human nature and the current cultural environment?

I am worried that the difficulty of becoming and continuing to be a compassionate, master physician is complicated by the mixed messages that we send and receive as we practice in an environment where there is conflict between the ideal culture and the real culture. In medical school this concept has been identified as the informal or hidden curriculum where medical students sadly emulate the unprofessional behavior of physicians and staff, instead of the lofty ideals listed in the catalogue. Everywhere I look in modern society I find a similar tension between what we say our ideals are in pamphlets and guidelines and how we actually get work done and manage our careers.

Billionaire Raj Rajaratnam is a very successful investor who is a graduate of the Wharton Business School at the University of Pennsylvania, one of our best and most prestigious MBA programs. He has also been convicted on several counts of insider trading. According to a profile in The New Yorker, Rajaratnam liked to call himself a “rogue” and encouraged his employees at Galleon to “get an edge” when making investments. The article states that Rajaratnam’s view of human nature was similar to Willie Stark’s in All The King’s Men: “Man is conceived in sin and born in corruption and he passeth from the stink of the didie to the stench of the shroud.” His younger brother Rengan, who graduated from the Stanford University School of Business is quoted as believing, “Everybody is a scumbag.” My impression is that insider trading is rampant among investors on Wall Street. http://www.newyorker.com/reporting/2011/06/27/110627fa_fact_packer?currentPage=2

The culture that Rebekah Brooks encouraged as editor of The News of the World featured cynicism, cut throat internal competition, and gallows humor. Phone hacking and using criminals as sources for exclusive scoops were standard operating procedures. "We used to talk to career criminals all the time. They were our sources," says another former reporter from the paper who also worked for Murdoch's daily tabloid, the Sun. "It was a macho thing: 'My contact is scummier than your contact.' It was a case of: 'Mine's a murderer!'”

“It was a don’t-get-caught culture,’ said the reporter of seven years’ standing. New staff would be given the cold shoulder until they’d proved themselves to be ‘thoroughly disreputable’ so their colleagues could trust them.

It was no place for anyone to pipe up and say: 'This doesn't seem ethical to me.' That would have made you a laughing stock." The News of the World, which was Britain’s most popular Sunday tabloid has been shut down, and at the time of the writing of this blog, the entire Murdoch media empire seems threatened by the phone hacking scandal.

http://www.reuters.com/article/2011/07/16/us-newscorp-notw-brooks-idUSTRE76F0O420110716

At first the Murdoch executives contended that the phone hacking and questionable reporting practices were limited to a single bad apple. Now it is clear that is not the case. We are now being told that the problems are the ethics of the British tabloid press, and that the Murdoch American companies are ethically run. However, David Carr of the New York Times has discovered what appears to be a similar culture at an American Murdoch company. Paul V. Carlucci the executive in charge of News America used to show the sales staff the scene in “The Untouchables” in which Al Capone beats a man to death with a baseball bat. Robert Emmel, a former News America executive who became a whistle-blower, testified in a civil suit with a competitor that Mr. Carlucci was clear about the guiding corporate philosophy.

http://www.nytimes.com/2011/07/18/business/media/for-news-corporation-troubles-that-money-cant-dispel.html

A disturbing and thought-provoking Christian Science Monitor article asks the question is the US a nation of liars? It summarizes the recent court cases of Barry Bonds who was found guilty of giving evasive answers to a grand jury, Casey Anthony who lied to police officers investigating the death of her child, Roger Clemens who was tried for allegedly lying to Congress about his steroid use, Anthony Weiner who resigned from Congress after admitting that he lied about his Twitter photos, and the Atlanta public school teachers who lied about tampering with student tests to make their schools look good.

David Callahan, author of The Cheating Culture, states, “Every day there’s new evidence of successful people who have cheated to get ahead, and it creates cynicism.” Douglas Porpora of Drexel University in Philadelphia, comments, “At a certain point, you’re watching all these jerks and you say, ‘What am I, a schmuck?’ A lot of people want to do the right thing, and after a while they say, ‘You know what? I’m going to follow the jerks.’”

http://www.csmonitor.com/USA/Society/2011/0719/Is-US-a-nation-of-liars-Casey-Anthony-isn-t-the-only-one

The problem of unethical behavior in medicine appears to be part of a much larger societal cultural problem. We need to hold each other accountable; we need to speak out when we see wrongdoing; we need to accept constructive criticism from our peers; we need to provide better role models for our medical students and colleagues. We need to be professionals who really do care more about our patients' well-being than our income or status in society.

Another Information Flaneur Blog You Won't Like

I find it hard to predict what tweets will get retweeted and what blogs will elicit comments and dialogue. I really liked my blog post about becoming an information flaneur http://kentbottles.blogspot.com/2011/06/why-i-am-information-flaneur.html, and yet nobody has seen fit to comment on it at all. Two of the blogs that routinely repost my writing decided to turn this one down.

I am still stunned that nobody retweeted my post about the interview with Red Shea about Whitey Bulger:

KentBottles KentBottles

http://ow.ly/5qfII Fascinating interview with Red Shea, former enforcer for Whitey Bulger {he wants to snap Whitey's neck}

Am the only one who is intrigued by this man struggling to speak coherently while being interviewed on CNN about his criminal past and his relationship with the rat who was once his surrogate father? Guess so.

I am not really looking for validation, but I do find it interesting that my approach to life, information seeking, blogging, and tweeting does not resonate with many of my tribe.

And then I heard a NPR story about people walking out of the movie The Tree of Life when the storyline about a family in Texas veers off into the most amazing pictures of life, stars, and nature. When I saw Tree of Life at the Ritz in Philadelphia about 7 people walked out. The NPR story contrasted those who believed this movie to be one of the best of the last decade and those who walked out. http://www.npr.org/blogs/thetwo-way/2011/06/30/137533978/love-it-or-hate-it-few-are-in-between-about-tree-of-life

Those who liked the movie The Tree of Life are more likely to resonate with the concept of an information flaneur than those who require a linear plot to sit through an entire show.

This morning on twitter I stumbled upon a great story about being an information flaneur.

“Glass and his This American Life production team had given themselves a special assignment: to collect the best stories they could stumble upon far off the beaten path of their day-to-day reporting routines. They followed the standard operating procedure of the Atlanta Journal’s ‘Georgia Ramble’ columnist Charles Salter, who researched more than 500 columns in the late 1970s by roving around small towns of the Peach State in a company car.”

The article and the radio shows both document how powerful and surprising this wandering around approach can be. (http://current.org/news/news1112georgiarambler.html)

Maybe there are at least two kinds of people in this world. Those that like to wander around and those that need a coherent, linear story. I guess I fall squarely into the former category. I sort of like being confused most of the time. After all my favorite Jack Welch quote is “If you are not confused, you do not know what is going on.“

Are Mystery Shoppers Such a Bad Idea for Health Care Quality Improvement?

The decision by the Obama administration to employ “mystery shoppers” to pose as patients to see how difficult it is to get an appointment with a physician has sparked criticism from physicians. However, access to primary care physicians is a very real public policy issue that needs to be understood if we are to successfully care for the more than 30 million Americans who receive coverage under the Affordable Care Act. Is the use of “mystery shoppers” a bad idea?

Dr. Raymond Scalettar certainly thinks it is a bad idea. “I don’t like the idea of the government snooping. It’s a pernicious practice – Big Brother tactics, which should be opposed.” (http://www.nytimes.com/2011/06/27/health/policy/27docs.html?ref=health)

Dr. George Petruncio says, “This is not the way to build trust in government. Why should I trust someone who does not correctly identify himself.” (http://www.nytimes.com/2011/06/27/health/policy/27docs.html?ref=health)

Westby Fisher, MD writes in his blog: “When information gathering trumps patient care - particularly fictitious care - we've got a problem. Is this a new quality standard we can expect from our new government health care initiative?

Just like scam-artists that phish for unsuspecting people's financial information online, governmental appointment phishing should not be tolerated in any way, shape, or form. It is fraud - plain and simple.” (http://drwes.blogspot.com/2011/06/appointment-phishing.html?utm_source=feedburner&utm_medium=twitter&utm_campaign=Feed%3A+DrWes+%28Dr.+Wes%29&utm_content=Twitter)

Several physicians on twitter retweeted Dr. Fisher’s blog post and indicated they agreed with his analysis.

A mystery shopper is a quality improvement tool that has been used in the retail and hotel industry for decades. In 2004 the health care industry accounted for 2% of mystery shopper revenue, but the use in health care is increasing.

(http://www.ncpa.org/sub/dpd/index.php?Article_ID=10273)

In health care, mystery shoppers have been used to provide feedback on every step in the patient experience: making an appointment, environment of the waiting room, encounter with nurses and office staff, and visit with the physician. There has been an increased interest in mystery shoppers by health care providers since CMS started posting patient satisfaction information on hospitals as part of the Website Hospital Compare. (http://www.boston.com/business/healthcare/articles/2007/06/13/on_sly_workers_rate_hospital_service/)

The use of mystery shoppers has been reported to lead to better patient flow and improved wait times, extension of office hours, improved telephone etiquette, better physician communication with patients, and more time with patients answering questions about surgery.

(http://www.boston.com/business/healthcare/articles/2007/06/13/on_sly_workers_rate_hospital_service/)

(http://www.pjonline.com/pdf/articles/pj_20040515_mysteryshopping.pdf.2004;272:615-617)

(http://www.ama-assn.org/amednews/2006/09/18/bise0918.htm)

The AMA Council on Ethical and Judicial Affairs studied the mystery shopper question and concluded that a sound program would include:

1) The places that unannounced visits will affect should know about the program.

2) The information should be used for improvement and not punitive actions.

3) Mystery shoppers should not be the sole source of data for evaluating clinical performance

4) The program should not adversely affect access to medical care by legitimate patients.

(http://www.ama-assn.org/ama1/pub/upload/mm/38/a08cejoreports.pdf)

I disagree with my colleagues that a properly planned and implemented mystery shopper program is a bad idea for trying to improve health care. For far too long, we in medicine have been too arrogant to learn lessons from other industries that improve quality. I think we need all the help we can get to take better care of patients.

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

Vs.

“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 19^th century.

In the mid-20^th 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.” (http://www.amazon.com/Why-Some-People-Healthy-Others/dp/0202304906/ref=sr_1_1?s=books&ie=UTF8&qid=1309114252&sr=1-1)

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.”

(http://www.amazon.com/Why-Some-People-Healthy-Others/dp/0202304906/ref=sr_1_1?s=books&ie=UTF8&qid=1309114252&sr=1-1)

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.

(http://icsihealthcareblog.wordpress.com/2009/07/17/kent-bottles-thoughts-on-phrs/)

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.” (http://blogs.wsj.com/health/2011/06/24/google-health-r-i-p/)

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 (http://www.readwriteweb.com/archives/google_health_why_its_ending_what_it_means.php), here (http://chilmarkresearch.com/2011/06/24/rip-google-health/), and here (http://www.nytimes.com/2011/06/25/technology/25health.html?ref=health)

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 (http://personalinformatics.org/) and quantified self movements (http://quantifiedself.com/) 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 (http://www.technologyreview.com/blog/themeasuredlife/26918/?ref=rss) Shaun Rance used the anonymous website drinkingdiary.com 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. (http://www.nytimes.com/2010/05/02/magazine/02self-measurement-t.html?scp=1&sq=nytimes+sunday+magazine+quantified+self+wired&st=cse&pagewanted=print)

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.” (http://quantifiedself.com/2010/04/why-i-stopped-tracking/)

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. (http://www.amazon.com/Connected-Surprising-Networks-Friends-Everything/dp/0316036137/ref=sr_1_1?s=books&ie=UTF8&qid=1309114482&sr=1-1)

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.” (http://www.nytimes.com/2009/09/13/magazine/13contagion-t.html?_r=1).

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.” (http://online.wsj.com/article/SB10001424052748704547604576263261679848814.html)

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 88,837^th 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). (http://www.nytimes.com/2011/06/26/sunday-review/26rosenbloom.html?ref=opinion)

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.” (http://www.amazon.com/Why-Some-People-Healthy-Others/dp/0202304906/ref=sr_1_1?s=books&ie=UTF8&qid=1309114252&sr=1-1) 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.