The Merck Social Health Hack – New Ideas, Diversity, and More

photoOver the weekend, I dropped in on the Merck Social Health Hack. Some of the things I heard at the event underscored a lot of the major things I see going on in the digital health space right now.

1) Diversity

The event attracted participants from across the health care spectrum. 2 out of 3 people in one of the final teams were health economists designing a gamification app to support patients through the Hepatitis C care pathway. The winning concept came from a group with experience in branding and marketing. The solution focused on tapping into NYC’s design and film community to produce short videos that re-brand diabetes. These collaborations represent the exact type of cross-industry partnerships necessary for building patient-centered solutions. It was exciting to see.

2) We sure want an app/tool to measure our food intake

Over the past couple of weeks, I have been hearing a lot about the need for apps and tools that passively capture our dietary intake. The Meal Snap app can determine the nutritional facts of your food just from a simple photo. Will people get into the habit of snapping photos of their food? It’s becoming increasingly clear that whoever designs the most user-friendly app/tool for measuring food intake will have a lot of people from industry knocking on their door.

3) There is no such thing as frictionless clinical integration

One participant started his pitch with a bold statement: “we have designed a solution with frictionless clinical integration.” During the judging, NY Presbyterian Hospital’s, Jonathan Gordon, reminded the team that this claim is basically impossible. As excitement over blue button and the consumer health movement continues to brew, it is important to remember that integrating digital health solutions into the clinical workflow is a MAJOR task.

All in all, the event was an exciting display of where we are headed. Validic, a technology platform for accessing data from mobile health devices, wearable, in-home devices and patient healthcare apps, offered up their API and Merck provided mentorship, a beautiful space, and food. Clearly, newcomers and industry leaders are zeroing in on the potential of a completely integrated and consumer-driven digital health future.

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Why WebMD is Paying Attention to Innovations in Consumer Health

As part of the Mobile Health Seminar that I am taking at Cornell Tech, Professor Deborah Estrin has arranged to have a series of speakers come to discuss their work. This week, we were joined by Nick Alterbrando, Vice President of Professional Product Innovation at WebMD.

Nick started with an overview of why we have seen little to no progress in the evolution of a consumer healthcare economy. He then brought up two major initiatives that could open up the health care market to consumer driven innovations:

1) Direct Project
Launched in 2010 in conjunction with the eHealth Exchange, the Direct Project outlines a, “simple, secure, scalable, standards-based way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the Internet.” To those who do not find this to be particularly groundbreaking, Nick reminded us that in healthcare, the fax machine is still considered the dominant mode for secure communication.

2) Blue Button Plus
Blue Button Plus defines the xml protocol for health records and gives consumers the ability to request their health record in machine and/or human-readable format.

So, what do these two things mean exactly? Essentially, while the information stored within a medical record has always technically belonged to the patient, this is the first time where the industry is establishing standards and protocol for consumers to access their personal health information online. In Nick’s words, we may be moving towards a world where I can call my doctor’s office and say:

“I would like to have my EHR in XML format, please send it to my Direct address.”

While we are still a ways away from this, it will be interesting to see how the two initiatives listed above and Meaningful Use specifications push the health care industry towards more consumer-friendly products and services.

Health Care Consumerism: Patients Still Lack Agency at the Point of Care

Something we have been hearing a lot of lately is how this is the moment for the healthcare consumer (see, Bloomberg Review video, MedCity Article, Forbes article on trends to be excited about).  Basically, people are noting that EMR’s and patient portals, the proliferation of health and wellness related mobile apps, and greater transparency across the system, will all lead to a new age of health care where patients have the information and tools to savvily navigate a streamlined healthcare delivery system oiled by customer reviews, online tools, and digital gadgets. Think Yelp and MenuPages meets healthcare.

While all of the trends listed above are exciting leaps forward, not enough attention is being paid to the patient’s needs at the point of care. Research on patient activation and shared or participatory decision making all points to the following:

Empowered patients who actively participate in decisions about their health and treatment options are more likely to be compliant with their medications, make less risky and more cost effective decisions, and are more confident in the management of their health outcomes.

For the purposes of this blog, I am focusing on the concept of a patient as an active participant at the point of care. From my own personal experience, it seems that “doctor knows best” remains the dominant paradigm. Instead of having a conversation about treatment options, the pros and cons of alternatives, variations in costs and side affects, I am more often than not prescribed a medication or treatment option and sent about my day. If I feel like knowing more about the medication (that I have already agreed to take), I usually conduct research after the appointment.

To get a general idea of other people’s experiences, I had some of my classmates fill out a survey about their own habits when prescribed a medication. (Note this is an extremely biased sample and in no way to be regarded as serious academic research). Of the 46 students who responded, about 75% of them said that they felt comfortable talking to their doctor about treatment options (no big surprise there, these are graduate students). When asked to give the medication a score from 1-10 in terms of how much they knew about it at the point of agreeing to take it, the average score was a 5. When I asked students if they would want to know more about a medication before agreeing to take it, the overwhelming response was something like this: “yes it would be great to have time to research more at the appointment but I would feel awkward looking things up on my phone in front of my doctor.”

This perceived lack of influence at the point of care is extremely troublesome. At a time where we are seeing a boom in clinical decision support tools for physicians, there seems to be no genuine attempt to provide patients with actionable information at the point of care. Furthermore, even if a tool were to be created, it appears that paternalistic models of medicine are so entrenched in our society, that most would feel far too uncomfortable to impose a shared-decision making model onto their physician.

So what does this all mean? Even as we drive towards patient-centered care and have more tools hit the market to help health care consumers, there is an entrenched imbalance when it comes to the patient-provider relationship. Something we often hear referred to as information asymmetries. The affects of information asymmetries are well documented in the health economics literature and until we start to chip away at this through entirely new models of care that look to patients to be active, not just before and after appointments but DURING appointments, progress towards consumer driven health care may be slower than we expect.

Designing for Behavior Change

Over the Fall, I took Steve Dean’s DIY Health Course at ITP. The course focused on designing a self-care system with a specific focus on the the sensor and self-tracking revolution. Check out the syllabus with a lot of worthwhile reads.

One of my favorite days of class focused on the mechanics of designing for behavior change. In this session we focused on the following formula:

B = MAT

Behavior = Motivation x Ability x Trigger

One of the most important pieces of the equation is the timing of the trigger. (Think Facebook sending you an email telling you that you’ve been tagged in a photo. A trigger that will most likely get you to visit the site).

A second important thing to remember when designing for behavior change is that the most successful programs get you to do one well defined task one time. It is much easier to design a system to get Sally to do “15 jumping jacks at 3 PM on Tuesday” than it is to get Sally to “exercise more”.

Lastly, we discussed how difficult it is to design a system that influences behavior change through motivation. Because of the difficulty with motivation, it is easier to design a system that focuses on ability. Let’s say I have a friend who wants to do 30 minutes a day on the elliptical. She is more likely to succeed at this, if I put an elliptical machine in her living room (ability). She is less likely to succeed at this if I send her a motivational text message every day encouraging her to go to the gym (motivation).

To be successful, digital health tools designed for patients need to take the mechanics of behavior change into account. We are creatures of habit and getting people to change behavior, particularly with regards to their health, is no small feat. Hospital administrators and clinicians looking to implement patient centered care models can also take some of these ideas into account when thinking through the touch points of new care models.

NHS England and the Case for Open Data

As part of my work with The GovLab, I am supporting the development of a research agenda and evaluation framework to inform NHS England’s Open Data strategy. As a first step in the process, we took a look at the objectives behind their open data initiatives. An excerpt from an early report I wrote detailing these objectives is below:

NHS England collects large quantities of data from health care providers. The NHS is now starting to release more data to health care professionals and the public to improve health outcomes, the patient experience, and efficiency in the health care system. Its goal is to promote a culture of transparency and participation that NHS believes will help achieve the following six objectives[1]:

1. Accountability

a. Theory: Opening comparative data on health outcomes will ensure that physicians and hospitals are held accountable for unwarranted variation (for example, in the use of certain medical procedures) shown in the data.

b. Example: An analysis of open data on the prescriptions written by every family doctor in England showed large variations in regional patterns for prescribing branded drugs vs. generic equivalents (35% of cholesterol-lowering drugs prescribed by doctors in Shropshire were branded vs. 8% in Hardwick). [2]

2. Choice

a. Theory: Open data on patient experience and health outcomes will allow patients to seek out the services that best meet their individual health care needs. Furthermore, increased access to health data will allow patients to choose between providers and treatments, both of which will drive patient satisfaction and quality improvements.

b. Example: Comparative data has enabled informed consumer choice in other sectors such as insurance and housing in the UK, and should also help empower consumers if made available in the health sector.[1] Furthermore, research suggests that under certain circumstances patients prefer shared decision making approaches to care .[3]

3. Efficiency

a. Theory: Connected information for integrated care as well as electronic records will accelerate data-sharing practices and reduce unnecessary duplications in care.[4]

b. Example: Since implementing the VistA electronic medical records system in 1999, the United States Veterans Health Administration has increased in productivity by nearly 6 % per year. The system’s features include clinical decision support and data management features both supported by real-time data that flows across the enterprises.[5]

4. Outcomes

a. Theory: Publishing “outcomes data” drives competition between health-care professionals, which can drive quality improvements and innovation.[6] Opening health data to analysts and researchers improves both the quality and consistency of evaluation.

b. Example: Since NHS heart surgeons began publishing comparable data on clinical outcomes nine years ago, there have been 1,000 fewer deaths in heart surgery units each year.[7] In 2010, following a change in policy that made hospitals financially responsible for certain readmissions that occurred within 30 days of discharge, the Nuffield Trust developed a successful algorithm for predicting people at risk of readmission.[8] This type of predictive modeling can help hospitals target and support at-risk populations.

5. Customer Services

a. Theory: Improving patient access to data and providing convenient customer-oriented services such as online appointment booking and prescription refills will enable the NHS to achieve world class customer service and improve efficiency.

b. Example: With improved online tools, the number of adults banking online rose by 175% from 2001-2006 (for people over the age of 55 this number rose by 350%).[9]

6. Economic Growth

a. Theory: Currently, some data can be difficult to request and expensive. If more data is collected and distributed, the UK will build on its standing as a center for research and innovation. Having all the data in one place will mean analyses can be done at the population level – making the UK an attractive place for health research as well as health innovation.

b. Example: On June 26, 2013, NHS England hosted a free event for health technology entrepreneurs to discuss funding sources as well as future events and networking opportunities. [10]

Citations:

1.The Future is Open: Making NHS England the best customer service in the world. October 2012 http://www.bcs.org/upload/pdf/tkelsey-101012.pdf

2. Open data and health care, Beggar thy neighbor,” The Economist, December 8, 2012. http://www.economist.com/news/britain/21567980-how-scrutiny-freely-available-data-might-save-nhs-money-beggar-thy-neighbour

3.Frosch, Dominick L., and Robert M. Kaplan. “Shared decision making in clinical medicine: past research and future directions.” American journal of preventive medicine 17, no. 4 (1999): 285-294. The Power of Information: Putting us all in control of the health and care information we need.

4.The Power of Information: Putting us all in control of the health and care information we need. Department of Health, May 21, 2012. pg 18.

5. Evans, Dwight C., W. Paul Nichol, and Jonathan B. Perlin. “Effect of the implementation of an enterprise-wide Electronic Health Record on productivity in the Veterans Health Administration.” Health Economics, Policy and Law 1, no. 02 (2006): 163-169.

6. Putting Patients First.

7.Kelsey, Tim. “Transparency in the NHS not only saves lives – it is a fundamental human right,” The Gaurdian. March 12, 2012

8. Billings, John Blunt, Ian, Steventon, Adam. “Development of a predictive model to identify inpatients at risk of re-admission within 30 days of discharge (PARR-30),” Nuffield Trust. At: http://bmjopen.bmj.com/content/2/4/e001667.full

9.“Online Banking Boom for Over 55s,” BBC News, August 24, 2007.

10. “The NHS is opening up to health technology entrepreneurs – find out how,” NHS England, June 26, 2013. http://www.england.nhs.uk/2013/06/26/tech-entre-event/

Heatlh Datapalooza: Open data fueling innovation in health care

Back in June, I had the pleasure of attending the 4th Annual Health Datapalooza Conference in Washington DC. Here is the text from the recap I wrote for The GovLab:

Earlier this week, entrepreneurs, data scientists, doctors, health IT innovators, and representatives from Washington gathered for the 4th Annual Health Datapalooza Conference in Washington DC. What started 4 years ago as a 45 person gathering, now attracts almost 2000 participants. The two-day event included breakout sessions and app demos that explored innovative ways to leverage the opening of government health data to engage patients, improve clinical outcomes, and (if done right) bend the health cost curve.

The various panels at the Conference highlighted four key drivers toward re-imagining how we provide and govern health care:

1. Cost: Open health data may spur innovations that have the potential to improve the quality of care delivered while reducing costs. In the United States, National Healthcare Expenditure is hovering around $3 trillion. The United States spends more on health per capita than any other country by a sizeable margin and yet ranks poorly in both health and quality of services—innovations that improve quality and drive down costs have an eager market. A potential of the use of open health data includes clinical decision support through technologies that provide advanced analytics at the point of care. For example, Humedica Mindshare helps providers identify high-risk patients and target resources accordingly.

2. Policy: Policy and legislative frameworks are enabling technological changes in how health care is provided and paid for. During Monday’s Plenary, StartUp Health CEO Steve Krein declared the current moment to be “the most important decade in healthcare” and elaborated on some of the forces that have aligned to make this possible, including the Patient Protection and Affordable Care Act (“ACA”) and unprecedented access to data and experts. The ACA’s transformative power was echoed throughout the conference with particular emphasis on how reform-supported payment models catalyzed the institutional restructuring necessary to improve clinical outcomes as well as coordination between caregivers. During The Kojo Nnamdi Show, Health Care in Transition: Fee for Service vs. Pay for Performance recorded on Tuesday, Bob Kocher, Partner at Venrock, underscored the importance of new payment models as drivers of innovation. Kocher, a key architect of the ACA, stated that one of the aspirations of the reform was to “stop paying for all the ingredients and start paying for meals.” He later continued, “we are shifting towards things like accountable care organizations, like patient centered medical homes, like capitation, where doctors are paid a fixed amount and then they can reengineer the system to be more efficient.

3. Open Data: Calls for more transparency from patients and policymakers are accelerating health sector institutional innovation. In her brief keynote, Secretary Sebelius affirmed, “we are a great believer that unlocking our data, turning it over to those of you that know how to formulate that data for policymakers and providers, is the best possible thing to do.” Representatives from the UK shared their commitment to open health data declaring transparency and participation the, “secret sauce for world class patient services.” When asked to elaborate on the potential of transparency in health care, NHS Information Centre Director Mark Davies pointed to an instance where a local community improved uptake of diabetes screening services by 285% in 6 weeks. He commented that the NHS delivered “well-packaged” information and key change-agents were called upon to design solutions. He described the story as a “dramatic illustration of the power of the crowd” and concluded, “the people who are real experts are individual patients and we need to tap into that wisdom and we will be fine…this requires a level of transparency and braveness in terms of opening up data.”

4. Patient Engagement: Improvements in health care rely on engaged patients and communities. The most talked about driver for change throughout the conference was the power of patients. United States Chief Technology Officer Todd Park and others quoted health strategist Leonard Kish’s “patient engagement is the blockbuster drug of the 21st century,” and several exhibitors displayed products designed to help people monitor their health and habits. For instance, both BodyMedia and the Kinsa Smart Thermometer empower patients with real-time data—the former focuses on personal behavior and the latter on illness and community health.

There is clear consensus that greater patient engagement must be a guiding principal for how we move forward with reimagining health care. And yet, the United States has a ways to go when it comes to inspiring the level of engagement necessary to put patients in charge of not just their personal care but also the entire health ecosystem. In addition to restructuring health care delivery models, health care leaders across industries must take on the challenge of designing new methods to capture and evaluate the human experience of health and care. While health data is the bedrock for health innovation, to design a patient-centered health system we must start with the people not the data.