Emotional Contagion - You're Bringing Me Down Man!

We've all come across people who are described as "fun suckers" or alternatively "light up the room" whenever they are present. These are both extreme examples of how a person's mood can influence others around them. Away from the extremes we are still very much influenced by the emotions of those around us; family , friends and work colleagues. As well as influencing how we feel our social networks can also influence what we do and the lifestyle behaviors we choose. Research from the Department of Healthcare Policy at Harvard published a few years ago showed that a person's chance of becoming obese in any given time frame increased by 57% if he or she had a friend who became obese during that same period. Their research showed this to be a very consistent effect across the network and held true for other lifestyle related behaviors such as smoking and heavy alcohol consumption.

This research paper, just published in PLOS One, by researchers at UC San Diego looked at Facebook status update data between January 2009 and March 2012 to determine whether status updates by users had a discernible affect on the emotions of their friends who were not in the same city as them. There's some pretty high end math in the paper, but putting that aside they showed that rainfall directly influenced the emotional content of the status messages of individuals and that this in turn affected the emotional content of the status messages of their friends in other cities not experiencing rainfall. The researchers used the Linguistic Inquiry and Word Count (LIWC) software to assess the positivity and negativity of messages posted.  

This is fascinating stuff, and shows that we don't have to be in the same physical location as someone to potentially influence how they feel (or indeed be influenced by how they feel). The question arises whether this affect through a digital social network is confined just to emotion or whether, like in physical social networks, it also extends to influencing others' actions and choices?

As many of us spend increasing proportions of our waking hours communicating by digital means, and possibly less time than we used to in face-to-face interactions, this is certainly an area that warrants further investigation. In addition it bodes well for digital social networks as a catalyst for positive health behavior change in society.  

As an addendum, when I run this blog post through the free version of the LIWC software I get a count of 1.27 positive emotions to 0.51 negative emotions. So all in all pretty happy!  

Image form : http://facebookgallery101.tumblr.com/

Getting Your Wellness On

One of the little known, or at least little discussed, elements of the Patient Protection and Affordable Care Act (ACA) was establishing the annual wellness visit as a fully covered benefit for all Medicare beneficiaries. Since January 2011 CMS covers an initial welcome to Medicare wellness visit and then an ongoing annual wellness visit (AWV), and reimburses appropriate healthcare professionals for conducting the visit.

Prior to the patient attending the AWV they are required to complete a health risk assessment (HRA) questionnaire that specifically covers a variety of lifestyle and medical risk factors that are known to contribute to future disease and ill health. HRAs have been used to inform and assess workplace health promotion initiatives for decades, however they are relatively under-utilized in the provider setting and it is not clear exactly why this is.

A research study published in 2006 showed that Medicare enrollees who completed an HRA had between $101 and $648 per year lower healthcare costs compared with those that did not. In addition, Dee Edington and colleagues showed that by using an HRA it is relatively straightforward to segment the population into groups according to risk , which closely correlates with future care utilization and costs.

The great thing about the modern internet and mobile technology is that, even compared to a few years ago, it is possible to deliver so much more personalized and relevant information and recommendations than previously. As well as making people think more deeply about their health and lifestyle an HRA is a great vehicle by which to deliver actionable and relevant information to people.

Imagine getting everyone attending a medical facility to complete an HRA prior to their visit and having a summary of their data available to the provider of care to view at the time of the visit? Even if the provider were to spend just a few seconds giving lifestyle recommendations during the consultation we know that such a "brief intervention" has profound effects on motivating individuals to make changes. Couple this with the output from the HRA containing real and actionable recommendations for the patient; for example the telephone number to call for the quit smoking service or the person to contact at the local YMCA for beginners activity classes, and you have a very powerful instrument of change.

Well...this is exactly what we've been doing with a number of our clients across the US and also the UK. The initial results we are seeing are extremely promising. With one integrated delivery organization that we have been working with since 2012 we have seen 67% of respondents stating they had made lifestyle changes based on the information contained in their HRA report. In addition, 77% of respondents stated that they found the information about local services and resources relevant and useful and almost 20% of them actually made contact with one of the recommended institutions.

With increasing emphasis being placed on managing outcomes and costs in defined populations this is a "no brainer" in terms of engaging patients in a dialog about their health and making them active participants in improving it.

Smart and smarter. The battle for the "smartest" watch

Following on from a blog post I wrote at the beginning of January the media attention around smart watches seems to have reached fever pitch. Thanks to @Paul_Sonnier's Digital Health Group on LinkedIn I came across this article about how Samsung are already launching their second generation smart watch. From what I can gather it does pretty much what the original Samsung Gear did, but has been redesigned to be more ergonomically sound.

As the article appears on a site called 9 to 5 Mac it's hardly surprising that the majority of the discussion is around when Apple are going to launch their smart watch. This article from a few days ago is quite fascinating, suggesting that Apple's new smart watch (note no-one is saying that Apple won't go down this route) is going to have way more health data functionality that just movement sensing.

As mentioned previously, although valuable, there has to be more to wearable devices that purely movement tracking to make them truly useful health management adjuncts for the masses. Jawbone, Nike and Fitbit have all done great jobs of taking the humble pedometer and transforming it into a piece of tech that can be integrated seamlessly into daily life (albeit with a slight bump in the road for the Fitbit Force), but this surely is just a first step.

For most of us our wristwatch is the only item we wear every day. It therefore makes sense to use it as the conduit to capture health related data. It doesn't seem beyond the realms of possibility to have a wristwatch continuously monitor heart rate, body temperature and movement throughout the day. Add to this an inference on how much sleep one is getting at night time (I say "inference" as all of the sleep monitoring apps and devices rely on interpreting movement, or lack of movement, at night time to crudely quantify sleep duration and quality) and you have a data stream that would be extremely useful in monitoring individuals with a number of chronic diseases.

Take for example someone with COPD (chronic obstructive pulmonary disease), a condition affecting 6.8% of US adults. Individuals with COPD are prone to "exacerbations" where a simple viral respiratory infection can lead to severe shortness of breath, copious mucus production and sometimes a super-imposed bacterial infection. If left unchecked an exacerbation can be life threatening and invariably requires hospital admission, however, if caught early and treated with antibiotics and steroids hospitalization can often be avoided. Now imagine someone with COPD wearing a smartwatch continuously transmitting data back to their provider. Their heart rate will increase a day or two before they start to feel unwell, their temperature may also increase. In addition, as the infection starts to take hold they'll probably feel more breathless and so won't be moving around as much as they normally do. The combination of these three data streams should be enough to identify an exacerbation at an early stage. With this early identification comes the ability to treat and the real possibility of avoiding a hospital admission. Now that to anyone's mind has to be a victory for health tech!

Prevalence of COPD in the United States. Image from CDC website: http://www.cdc.gov/features/copdadults/copdadults_a600px.jpg

 

    

Electronic patient portals – panacea or passé?

Sitting on an 11 hour flight from London to Los Angeles I finally got round to reading this paper which was published at the tail end of 2013 in the Annals of Internal Medicine; Electronic patient portals; evidence on health outcomes, satisfaction, efficiency and attitudes. If you remember the publication was met with quite a few news stories stating we need to move on as patient portals don’t work and have no impact on satisfaction or outcomes. However, when you actually delve into the meat of the paper (something I think few commentators are inclined to do) this is actually not what was found. The researchers from the VA and UCLA trawled through a vast number of published research articles from the last twenty-three years and found quite a mixed bag of outcomes. Certainly utilization of some patient portals did appear to generate improved outcomes, both in terms of better disease management and a need for fewer face-to-face visits, although some didn’t. One of the main issues the researchers’ encountered was the fact that there was usually a paucity of information around the context of how the portals were implemented and publicized. The conclusion from the study was not that patient portals don’t work, rather we need to better understand what elements are needed in terms of functionality and how best to implement them. Only then can we better understand how to use them and ultimately quantify what impact they can have on patient care.

With so many areas of our lives digitized these days I am frequently amazed at how slow we have been in healthcare to adopt similar strategies to streamlining medical practice. After all, these days you can sit at your computer and shop for groceries, access your bank accounts to transfer money or send checks, and even purchase an exotic foreign vacation. But the chances are you won’t be able to access your medical record, communicate with your provider or book an office visit. This will change; I am convinced of that fact. Already EHR vendors are including patient portal functionality in their solutions. In many cases these are quite rudimentary and only allow for a limited scope of interactivity, but it’ a start. Undoubtedly the new patient portals need to be “tethered” to the EHR, however I don’t think they necessarily need to be part of the same software suite. My reasoning is simple, EHRs are designed with a very specific task in mind; they are optimized so that data from individual patients can be written, stored and retrieved when necessary. This is very different functionality to what a patient portal needs and to this end this is why I think innovation and practical usability will happen quicker if separate organizations create this functionality and then plug this in to the broader EHR ecosystem.

The next area is what to include in the patient portal. Research has shown that giving patients access to their medical records improves engagement and self-efficacy. Indeed, the BlueButton movement is a great example of how opening up the data stream can result in some very innovative and valuable applications. My personal feeling is that the patient portal needs to be centered around specific task, in a similar fashion to doing online banking or booking a flight on Expedia. You go to the portal to perform a specific transaction (unless of course you’re my wife who will spend hours browsing vacation spots she will never visit!). In the case of the patient portal this may well be completing a health assessment as a prelude to an annual wellness visit, the creating an advance care directive or simply requesting a prescription refill or an office appointment. Whatever the task it needs to be simple and intuitive to complete and ideally accessibly from mobile devices as well as standard “home based” computers.

Without a doubt the digital age is finally creeping up behind us in healthcare. Some will try and ignore it for as long as practicably possible, although I believe that those of us who embrace it will see real improvements in their relationships with their patients, and importantly their outcomes too.

Example of provider's dashbard of their patient's health assessments results just prior to co-creating an annual wellness plan with them. 

It's Time to Practise Better Medicine

This article from @KathyKrostof on CBS got me thinking this week. Although as physicians we're no strangers to the art of complaining, it does appear that things are really getting strained out there on the front line. Talking to friends and colleagues from many different disciplines much of the frustration seems to stem from not being able to practise the sort of medicine we want to, and indeed signed up for when we first entered medical school. Too little time with our patients, over burdensome paperwork, a disjointed system where half the time we are in the dark as to what's happening with our patients outside of the office. I know I have to frequently spend significant amounts of time trying to piece together what's been happening with patients who see other specialists in different institutions; usually by wading through a disorderly pile of faxes or letters. This isn't medicine as it should be, this is fire fighting and disaster aversion. I am constantly amazed at how backward we have been, and to some extent continue to be, in how we practice medicine and deliver care.

This blog posting by @GertiTechBlog speaks volumes about the challenges faced by many of us, especially those working in primary care. And it is my feeling that the reason many physicians are feeling unhappy at the moment is not because they've fallen out of love with the practise of medicine, rather it is increasingly frustrating trying to do a good job.

Technology has transformed many aspects of our lives. It is sometimes hard to remember that we used to have to go to a travel agency to book a flight or a vacation, or go to a book store to buy something to read. Many of us now have complete control of our finances and bank accounts via the Internet and hardly ever have to visit a branch. Yet the practice of medicine has hardly changed during the time that this revolution has occurred in other areas of our lives. Why is this?

Part of the problem is undoubtedly the fact that as providers of care we have been extremely reticent to adopt new ways of doing things, preferring the status quo of the way its always been done. It wasn't a desire to practise better medicine that drove the uptake of electronic health records, it was the huge amounts of Federal incentives that made it happen. It really is very curious that it should take what is ostensibly a "bribe" from the government to do something positive, rather than taking it upon ourselves to enhance how we practise. Of course there is the debate that EHRs have not actually made the practise of medicine more efficient, cost effective or better...but that's a topic for another discussion!

Perhaps if we spent a little time looking at how other industries have developed and utilized technology over the past decade we could get some ideas on how we could improve what we do. I really do believe that the intelligent use of technology in our day-to-day interactions with patients and colleagues has the potential to improve how we feel about our jobs and also enhance our patients' satisfaction with the care we provide.

It's no secret that most major vendors of products and services have highly sophisticated customer retention and loyalty programs. They want to stay close to their customers, recommend other services that may interest them and find out what they think about what they've received to date. Now this is not a direct analogy with delivering medical care, but there are probably some aspects that still hold true. How difficult would it be for us to inquire from our patients how they are doing, what they thought of their last healthcare interaction and whether they were on track to reach the goals agreed on their last visit? Using traditional face-to-face interaction would probably prove quite difficult (or at least time consuming) for this, however, this is where technology can help and it is where the likes of Amazon, Expedia and Hilton, to name but a few, have excelled in driving loyalty and trust.

We need to think differently about how we deliver healthcare in the second decade of the twenty-first century. Storing information in an EHR is just the beginning, there are so many other ways we can interact and influence our patients in a positive fashion. Those of us who grasp this challenge, I believe, will drive better outcomes and greater value; two facets that are going to be integral to the future of healthcare.

nGage Health's patient timeline where all interactions with the healthcare system are graphically displayed for ease of review by both patient and provider.

Wearable and Cool

I've spent a lot of the last week reading reviews and watching videos from the Consumer Electronics Show (CES) in Las Vegas. Unfortunately I wasn't able to make it out west, but that didn't actually matter too much with the amount of commentary that was coming out of the show in pretty much real time. This was the first time that I can remember that I really felt like I was immersed in a "real world" event while physically being more than a thousand miles away. Now clearly it's not going to be quite the same as being there in person (canapés and a cocktail on your own isn't that much fun!), but the sheer depth and breadth of the commentary coming out of the event from people who were there was astounding.

It seemed from the outside that healthtech and wearable tech were big items at this years show, with companies big and small previewing their new offerings. This infographic from the organizers seems to confirm this, with these two areas coming in first and fourth in terms of volume of mentions on social media.

As an organization that harnesses data from wearable devices and apps, and makes this data usable for healthcare providers, this is obviously great news for us. It appears that there is growing interest in self-monitoring and quantification and it seems unlikely that the large tech companies would be putting in so much time and effort into creating new and improved devices if they didn't see a real market for them.

Having said this I have got he impression that the majority of the devices are variations on a theme; physical activity, sleep and nutrition.This discussion thread on the Digital Health group on LinkedIn started by @BillVick calls for more diverse offerings. I do tend to agree. Although the data from continuous monitoring of activity and sleep patterns is extremely valuable there are so many other parameters that would augment this data and provide real insight to both the individual and their provider of care.

Of course there is the gray area between what constitutes a medical device and what is a consumer product. Falling foul of the FDA is not something anyone wants to do, especially in the light of the recent 23AndMe episode. However, with the pace of change in the industry seemingly accelerating to "warp speed" I am sure it is not going to be long before a consumer will be able to measure and monitor pretty much any parameter that their physician can. With this I truly believe there will come great opportunities to improve the health of the population, reduce the cost of delivering healthcare and make sure our patients (read clients) are satisfied.

Example of how the nGage Health platform presents data from a population using different devices to track physical activity.  

Health Engine Optimization

I recently read this Wired article on search engine optimization (SEO) and how Google are potentially leveling the playing field by placing more emphasis on the value of the the content on a website. Rather than clever coding and tagging tricks that have traditionally been used to enhance a website's position in a search they are saying that it is the quality and relevance of the content that is going to dictate its position. You can't really say fairer than that you have to admit.

In a way an analogy can be drawn with healthcare and the need to optimize a process that for decades has functioned in a very nontransparent way. You become unwell, visit a doctor, get treated and (hopefully) get better. The process then repeats itself the next time illness strikes. This episodic approach is possibly fine (but not optimal) for relatively minor ailments, but as we age and the likelihood of developing chronic diseases increases, this approach often falls short of delivering quality care. By comparison with other developed countries the United States routinely languishes near the bottom for mortality from most chronic diseases. 

Healthcare reform may go some way to redressing this aberration (how the richest country with the most expensive healthcare system can consistently perform so poorly compared with other industrialized nations), but providers of care also have to critically examine how they deliver care. This I believe is where significant optimization can occur.

There is the dawning of recognition in the medical community that every episode of care does not necessarily need to be conducted in a face-to-face setting, or indeed happen in real time. But counteracting any significant change in how medicine is practiced are the perverse incentives associated with a fee for service model for remunerating providers. This is gradually changing, with greater numbers of physicians being employed by larger systems, opting to practice concierge style medicine, or participating in accountable care organizations. This will eventually mean the fee for service model won't be as big an influencer on behavior as it is today. 

As this change gathers momentum there will be an increasing need to modernize the way medicine is practiced, because provider remuneration will be based on outcomes and patient satisfaction, and not just episodes of care. This I believe is where technology comes in. As I mentioned, not all interactions need to be carried out face-to-face, and in fact some may even be better for not being face-to-face. This is not just telemedicine (although I am sure that it has a significant role to play in the future of healthcare) it's about utilizing technology to create an ongoing connection between provider and patient.

Imagine if providers had a dashboard that would give them access to regular, current data on, for example, diabetic patients' blood sugars, or an asthmatic patients' peak flow readings? They would be able to be proactive in managing these conditions both at the individual level, but also at the population level. The step change from the episodic reactive way of managing patients to one where there is a real opportunity to be proactive and predictive would surely improve outcomes, reduce costs and lead to greater patient satisfaction.  

This is not just a fantasy. It is happening in the here and now. At nGage Health we're creating solutions that allow providers to capture data from their patients (using health assessments and popular apps and devices) and merge that data with salient information from the EHR to generate a real-time population-wide dashboard, and we'd love to tell you more.   

nGage Health's Provider Dashboard for Population Health Management