Health Experiences
Peter Heywood wrote this on January 21, 2015 / no comments

Landor Creative Champs_MINT02Patient engagement remains one of the most prevalent ideas bandied about in healthcare today. It and “patient-centered” are two phrases I’d like to expunge from the lexicon.

Don’t get me wrong. Patient engagement and patient-centered care are imperatives for healthcare. More than enough has been written about the transactional and unresponsive nature of healthcare, and a good dose of consumer-centricity is needed in a sector which tends to treat the patient as fuel, not a customer.

Let’s focus on patient engagement today.

As the theory goes, people who are more engaged in their care will ask better questions, take some responsibility for their actions and see better outcomes. Engaged patients who are trending to Type 2 Diabetes, for example, will better adhere to the regimen prescribed by their doctors. They may download apps or buy devices that help then manage diet, monitor blood sugar or exercise more. And, it is hoped, they will never progress to diabetes, saving them and the system a lifetime and the costs of managing the disease.

The same logic and expected outcomes can be applied to people who already have chronic diseases or those who simply (simply!) want to stay healthy.

So where’s my problem with this? The issue is not about being engaged, but about taking ownership.

My personal view is that “patient engagement” has been appropriated by those who want to window-dress the delivery of care. They use the phrase to describe “features” bolted on to existing systems to make them appear friendlier, while not doing the heavy lifting required to truly change processes and attitudes to put the patient in charge.

One example of this is the “patient portal.” Meaningful Use required certified EHRs to include a patient portal, and portals have also appeared on hospital web sites (Cleveland Clinic MyChart), payer web sites (United’s MyUHC) and, of course, the myriad dashboards that accompany all of the health and wellness apps out there.

Yet these dashboards, in particular those associated with physicians and hospitals, present the providers’ view of what they think the patient needs to see. It’s like the providers are “rewarding” the patient with a glimpse into their own records, as opposed to giving them control. With due regard for the challenges of information security, none present a consolidated and useful view of the consumer’s relationship to all of healthcare. None are managed by the consumer.

There was an interesting recent post by Brian Manning (@bcmanning) at http://briancmanning.com/2015/01/15/mint-com-for-healthcare/. Responding to a tweet by Vince Kuraitis who was grumbling about the multiple portals he and his wife have to manage (“patient enragement, not engagement”!), Manning suggested that consumers are looking for healthcare equivalent of Mint.com.

The idea itself is a nice one. Mint lets you bring your financial information from multiple providers into one easy-to-use dashboard. The information becomes yours. You’re more than engaged, you’ve got control (or at least know where you’re out of control).

It raises the next question, however. Who might be behind a Health Mint?

One of the business drivers behind the creation of a patient portal is that it will become the default destination for the consumer for all things healthcare. Imagine the revenue opportunities of all those eyeballs! Of all those people using my portal for life-central issues!

I’m not convinced. I don’t think consumers are going to give pride of place, or the “daily relevance” to a portal because it helps them quantify themselves, or has some version of their health record. But – and taking a page from Mint – they might do so for a site that helps them manage their health finances.

The world of healthcare payments is becoming a bewildering place for consumers. Well, it was always been bewildering but outside of the consumer’s purview, Now – with public and private exchanges, new levels of plans, high-deductible plans, HSAs, co-pays, incentives and more – consumers need help not only selecting the right plan but also managing their personal outlay. One of the reasons why healthcare costs appear to be leveling off is that the consumer is assuming a greater and greater burden for the costs of care, off the books of the payers. By choice or not, the consumer is becoming engaged in – is owning – her healthcare spend.

There are many sites now that help consumers and employers select the right plans (CastLight, Maxwell Health, Benefitter). There are also sites that provide price information and ratings (see what Blue Cross Blue Shield of North Carolina is doing to open up opaque pricing on that front).

But no one – yet – has pulled it all together and enabled the consumer to manage the entire healthcare spend, like a Health Mint. Someone will, and the interesting thing is that such a site will also become the place for your fitness dashboards, your health record, your ratings dashboard and more. It will (sorry, fitness dashboards) be the aggregator.

Imagine, for instance, how monitor-based evidence on progress on your fitness fed into your Health Mint dashboard could start to affect your payments. Or how your Health Mint could recommend wellness services to purchase with your HSA because your plan and available funds permit it. Or how it could match a recommended disease management plan with the most cost-effective insurance, local health services and self-monitoring devices, all with the peace of mind that you can afford it

Sure, the integration will be a challenge, but consumers aren’t going to flock to a dozen different sites to manage their health – they’re going to want to go to a single place, one they feel they have control over. So keep an eye on the sites that connect consumers’ physical and mental health to their financial health. They’re going to earn the right to be the dashboard.

Peter Heywood wrote this on October 01, 2014 / no comments

“The definition of health needs to expand to include life”Flickr_BrokenBridgeMED_EvaTheWeaver611546983_e06981c11c

Alexandra Drane, founder of the health experience and behavior change company, Eliza, made this comment while chairing the Unmentionables panel at the recent Health 2.0 Fall Conference. There were many interesting technologies at the conference, and equally many compelling speakers, but her comment stood out for me. It’s not its clarity that compels, but really, the fact that she needed to say it.

I hadn’t been to Health 2.0 in some years. It was a lot of fun in its early days (it still is) but back then there was a tremendous amount of hype around solutions that didn’t actually exist, work or ultimately failed to deliver (hello, Google Health). That has certainly changed, as the range of in-the-market monitoring, digital therapy and analytics apps and platforms so clearly demonstrated.

But a significant gulf still remains between the promise of all of these new advances (which in most cases are based on real patient empowerment) and the traditional world of healthcare.

This was Jane Sarasohn-Khan’s observation. She’s a health economist and great blogger who asked Dr Jacob Reider of the ONCHIT about the gap and what can be done about it.

Dr Reider didn’t have a convincing answer, because he and the ONC are as challenged by the gap as so many of the innovators we saw at Health 2.0. There are the usual suspects – the system’s (and doctors’) reluctance to embrace any new technologies, the lack of compensation for their adoption, the complexity and lack of interoperability of so many competing platforms and apps. The first is a red herring, the other two have some validity but I think there’s a deeper reason, captured by Alexandra Drane’s comment. The traditional healthcare system is not yet ready to give up on its old role as a sick care system that fixes problems, to transform to one whose defining purpose is keeping people well.

Even with the vastly increased amounts of data, greater use of clinical technologies and the rise of risk-sharing and value based care, the culture – the mindset – of much of healthcare is still in the “we fix problems” state. This is reflected in the reluctance of providers to truly involve patients in decision-making or share all the information necessary for the patient to make an informed decision. It’s embodied in payment regimes that still attach value to the provider’s work and little to that done by the patient herself, even as we move to outcomes-based care. And most of all, in the traditional healthcare systems reluctance to embrace those actions that help us live well, to Alexandra Drane’s point.

There are, of course, many exceptions to this, organizations truly searching for a new relationship with patients and using these new tools in collaboration with patients to help with life, not just sickness. Bernard Tyson, CEO of Kaiser Permanente, spoke about his company’s involvement in “irrigating” the food deserts in so many urban areas. Nick Macchione, Director of the Health and Human Services Agency of San Diego County, had amazing stories of tackling childhood health through everything from school lunch programs to transformed policing. There is a commendable number of other organizations and providers taking similar paths.

But the culture of traditional healthcare mostly looks askance at the tracking, digital therapy and communication tools that form such a big part of Health 2.0. Ultimately, our relationship to our own health and our understanding of how we can live better have to evolve dramatically to achieve the costs and outcomes changes in healthcare that are imperatives. The ideas we see at Health 2.0 will form a large part of that evolution. But, as long as the healthcare system sees these as superficial or part of a lesser, consumer-driven parallel system, the gap will remain and the change so much harder to achieve. In other words, as long as their view of health does not include life.

Peter Heywood wrote this on August 25, 2014 / no comments

whats-nextFor the most part, our interactions with the healthcare system are not by choice. Of course, we are generally interested in staying healthy, and some of us work hard to ensure we stay well and avoid the healthcare system in the first place. But we don’t choose to engage with healthcare the way we do with a restaurant, or a retailer, or a bank. For the most part, circumstances have driven us there.

But when we do have to interact with the system – our physicians, hospitals, specialists, even at the pharmacy – we would all like to have an experience with the same customer focus and respect that we encounter at more typical consumer businesses. It’s not always the case, however.

For me, it doesn’t ring true when you hear so many in healthcare speaking of their patient-first focus. In spite of the fact that some indeed do provide a true patient-centric experience, healthcare mostly still seems to be thought about and delivered in a way that reflects what I once heard a bank president say: “Sometimes it seems as though we regard our customers as a necessary inconvenience.” Population Health Management, anyone? Accountable Care? Accountable to the payers, actually.

I noted in a previous post that it irritates healthcare providers when you (unfavorably) compare the healthcare experience with those in other sectors. We’re doing important work, they say. We don’t need the glitz and window dressing of a great store, coffee shop or online retailer.

I take the point (although healthcare environments that were more carefully designed and maintained would be a nice bonus) but their reactions still ignore the fact that successful patient centric care means engaging patients on their terms, addressing their issues.

My guess is that patients would be satisfied – delighted even – if healthcare became really, really good at answering the one question they all have:

“What’s next?”

People get stressed over the poor access to care because they’re unable to find out what to do next, and nurse-run clinics continue to grow in popularity because they provide an answer faster. Consumers flock to medical sites for the same reason, or because they didn’t get the clear direction at their doctor’s office, even if they got in. Patients and their families are frustrated by the opaque procedures at a hospital because no-one has told them what the next step they need to take is.

  • “What should I do when I get home?”
  • “Who do I meet with after this?”
  • “What are the side effects of this medicine?”
  • “Should I be bringing my kid in?”
  • “What’s next?”

Recently, McKinsey released a European survey on consumers’ willingness to adopt digital health technologies. “Most people want the same thing: assistance with routine tasks and navigating the often-complex healthcare system.” They don’t want anything complex. They want technologies that help them take the next step. I suspect the results could be ported easily to an American context.

Imagine, then, how everything from apps to the physician’s communications with patients to the information you receive while in a hospital was designed with a single-minded focus on answering “what’s next?”  The principles of a “what’s next?” solution are actually pretty easy to describe, if tough to execute:

  • A “what’s next?” solution should be simple, clear and results-oriented.
  • It may seem obvious, but a “what’s next?” solution should be personal. What do I need to do? What are you going to do with me?
  • A “what’s next?” solution should allow for engagement through a series of small steps and wins. Answering “what’s next?” is not describing the entire illness or care cycle pushed back to the patient, but simply the next step.
  • A “what’s next’ solution should always include a feedback loop. Engaged healthcare consumers have engaged providers, and the power of any innovation is diminished if a provider is not part of the equation.
  • Finally, a “what’s next” solution should be accessible and not transitory. Often when patients or families are informed about a condition, the stress means not everything is heard and the next step recommendations and instructions should be accessible for later review.

Patient-facing health technologies are getting more and more complex as well as more comprehensive. I’m not completely convinced that the majority of consumers want all this information, and certainly not the responsibility of knitting it all together. As the sophistication of the wearables, analytics, decision support and dashboards increases, and the experience becomes more intuitive, maybe we will have the ability to get simple answers to next steps from our technology and our providers. And done, well, consumers will flock to such solutions because they’ve made it simple to find out “What’s next?”

Peter Heywood wrote this on July 18, 2014 / no comments

Relationship Map

In July, the New York Times published a piece by Dr Aaron Carroll in its Upshot column. Dr Carroll is a professor of pediatrics at the Indiana University School of Medicine, and I suspect in his position he would be quite open to new ideas and aware of how innovative change actually unfolds.

So I was disappointed by his article http://nyti.ms/1jYFwoK suggesting that the Affordable Care Act was not going to deliver on its promise of achieving the Triple Aim. In it, he picks up on the old retailer bromide: “Price. Quality. Service. Pick two” by noting that if quality is going to increase, then costs may rise, or if access is going to get better, it will be at the expense of quality.

One of the examples he cites has to do with newly-insured consumers in Massachusetts using expensive hospital ERs more, because now they have coverage and, well, the ER is convenient. In the same vein, the incidence of invasive surgery increased by 9% in Mass because, again, people now had access to it.

He does slide in a reference to the fact that the ACA may reduce overall spending because of “other changes to the health care system” but doesn’t really dig into that point. Yet these “other changes” may well be the most important observation he makes, if somewhat dismissively, in his post.

I agree that the consumer facing side of the ACA is primarily about providing access, although you could argue that it’s really about encouraging people to access the system because now they’re covered. And if all that the ACA, and healthcare reform in general did was to open the doors of an existing system to more people, then, yes, the ACA will fail in its mission. Kind of like building high speed onramps to an existing narrow two lane road.

This is similar to the many articles written about how the first ACOs haven’t delivered on their promise, or the challenges of integrating EHRs into practice. Guess what? The first iterations didn’t work. Gee, that’s never happened in innovation before.

Change is not an event. It’s a process. Systems often try to apply innovations to existing structures or processes, Often the early results are less than satisfactory and it takes time for the full potential and scope for change to make itself evident. For instance, when television first appeared, it was essentially radio with cameras. It took a decade or more before the rudiments of an entirely new entertainment system finally appeared. Or when electricity first appeared in factories. It took a generation before the far more efficient linear assembly line innovation arose. Before that, people arrayed machinery around a central power plant, just like when (and as if) they were steam powered.

Back to access and the ACA. What can happen to the health care system when the impact of more access and more portable coverage is truly absorbed? I believe innovations will in fact let us choose access, lower costs and quality. A new system (and a pretty disruptive one to the established order) will, I am sure, evolve that is not confounded by Dr Carroll’s “trade-offs” but instead operates by new rules, expectations and behaviors. Some of these changes might include:

  1. Consumers understanding that “going to the doctor’s” means visiting a place, not a person. Not every visit or interaction requires a consult with a physician, although consumers (and in fact physicians) have so far been trained to view all of the ancillary staff as simply reactive support for the doctor, not experts in their own areas.
  2. Supporting that, pressure for a regulatory move to give skilled specialists (nurses, pharmacists, physical medicine providers and more) greater scope in managing or leading a patient’s care plan.
  3. The continued acceptance and rise of alternative care destinations, such as retail clinics, to address issues of convenience.
  4. The evolution of Accountable Care (the regulation driven initiatives) into accountable care, true outcomes based care practiced as the norm throughout the system, with the attendant care plans and evidence-based actions that obviate unnecessary interventions.
  5. The evolution of new technologies that far better utilize the potential of all the data out there than the glorified filing cabinets that are most of today’s EHRs, to give access to true evidence-based protocols.
  6. The equal rise of consumer technologies that simply and coherently link health actions, behavior change and provider communication so that consumers really start to take charge of their health.

The only thing you can really predict about the future is that it won’t look like you imagined it. Thus you can be critical but not make unalloyed declarations that something’s a failure this early in the game. We’ve only just started down the path of massive change in a system that, Lord knows, needs it. You can’t be Pollyanna-ish about the future – pitfalls, barriers and failures will be there, of course, but the ACA is not really about access. It’s about unleashing creativity by revealing entirely new needs. And the impact of that will take time and many wrong turns to realize.

Peter Heywood wrote this on June 23, 2014 / no comments

healthkit launchAlmost a decade ago, when Apple launched the iPhone, one of the world’s best known branding experts, Al Ries, wrote about the perpetual failure of convergence and the challenge Apple was facing. In a nutshell, he didn’t believe that consumers would gravitate to something that could do everything. This fuzzy positioning, he believed, would mean that it effectively did nothing.

Although Ries had plenty of past evidence from other companies and products to back up his argument, he was most definitely proven wrong with Apple. With the way paved by the iPod, the iPhone, as part of an ecosystem that included an OS music, media content, thousands of apps and stores (digital and bricks and mortar) to flog it all in, disrupted our perception of what a “phone” could be and do. It truly converged things we never thought of as being together before. The iPhone itself (although not the iOS) is the market leader for smartphone in the US but beyond that, it has defined the category. It’s what everything is compared to.

So what to make of the non-product announcement at Apple’s Worldwide Developers Conference on June 2nd. Plenty of news about Swift, a new and friendlier programming language, a new iOS, and a much more open set of APIs all bundled around a Kit brand name. Is Apple out of product ideas and making a fast move into content development?

Of interest, of course, is a piece of ‘Kit’ called HealthKit. It’s Apple’s entry into the Digital mHealth API market, whose vendors are all seeking to be the aggregator of consumer and provider health data, mostly from monitors but also from technologies like EMRs. It’s a pretty crowded market, including massive companies like Qualcomm (QualcommLife) and Aetna (CarePass) and smaller concerns like Jawbone (Up) and HealthTap. [See @Paul_Sonnier’s great and growing list of APIs at http://storyofdigitalhealth.com/api/ – thanks, Paul]

It’s also by all reports not a very successful market. While there are huge numbers of monitors and health and fitness apps on the iTunes and Google Play stores, the sustained use of such tools by consumers is low. Many reasons are given for this – the multiplicity of devices and/or apps you need to get a full health and wellness picture. The hassle of downloading results. The absence of timely and valuable feedback from the information we gather. And maybe, the fact that for most of us, this constant measurement and evidence lays bare our lack of success in hitting healthy targets.

Yet the big players keep on charging at the consumer-directed health market. Google shut down its Google Health offering in 2013 because of lack of interest yet it has responded to Apple’s HealthKit with its own aggregator, Google Fit. opening up its APIs by encouraging even more feature and experience-laden apps and integrated devices on Android. Others will follow suit, but may possibly discover their best way forward is to integrate with the new Apple iOS or Android, because it’s now easier.

Two related questions then.

The first is about Apple’s motives. The company has made a lot of money selling digital information, but it still is at heart a product company, creating its ecosystem to move more phones and tablets. Certainly, there is nothing in Apple’s business model that suggests it will participate or benefit directly from the lowered healthcare costs believed to be enabled by consumer-directed health, unlike, say Aetna and CarePass. Nor does it have the motivation of Google, the world’s largest advertising agency to ultimately leverage everything in Fit for the data it can sell or repurpose. In spite of the absence of new product at the WWDC this year, HealthKit really does seem to be a precursor to launching new devices, such as wearables, branded by Apple and, one assumes, by third-party vendors.

Related, the second question is about the potential impact of Apple’s involvement on consumer behavior. Will the combination of Apple’s new-found openness and history of making convergence work lead to a transformation of the consumer-directed health market? Will Apple be able to pull off what others have struggled with and actually get consumers to sustain use of health-monitoring devices and apps (aka patient engagement)?

Apple caught management and marketing leaders like Al Ries (not to mention competitors) out a decade ago with the iPhone. Now we’re faced with a broadly analogous situation in healthcare. Many devices. Design as, if not an afterthought, the step-child to technologies. Many standards and integration that’s anything but seamless.

You can be sure that Apple is going to address these, but once the gloss wears off of Apple’s sure-to-be-announced products, it will be interesting to see if it all sticks. Here’s hoping it does.

 

Peter Heywood wrote this on May 26, 2014 / no comments

Pressure is constantly being checked. Energy consumed can be assessed over time and on real time. The time to the next check-up is always on view. If there’s trending to a serious condition, the monitors will let you know. And the information is easily shareable and actionable with care givers, not only at the regular location but across the country.

A picture of a healthier future of empowered healthcare consumers? No, actually, it’s my car, today.

tire_pressure_monitorIsn’t it ironic that the modern consumer has become used, expects even, that her car will have all the sensors inside to not only track mileage and fuel consumption but also, in many makes, to anticipate issues from a flat tire and impending low oil pressure to engine failure. And all cars remind you when it’s time to take them in for, er, preventive care.

And at least with my car, the history is gathered up in the key fob (an ECR, the Electronic Car Record) and readable by any garage with the right computer, whether a dealership or independent. Anyone with the fob can tell when my car last had its oil changed and what services were done including warranty claims.

People in healthcare really dislike it when the sectors’ weaknesses are exposed through analogies drawn to other sectors, such as service standards in retail or in this case, remote monitoring and data transfer in automobiles. And, to a large degree, I understand. Modern cars, as complex as they are, are dead simple compared to people, and when our cars become too expensive to fix, we simply go get another one, not an acceptable strategy for people or healthcare!

Yet it speaks to how technology, once embedded, starts to change our behavior and our expectations. It wasn’t so long ago that, regular oil changes apart, you basically fixed something on your car when it broke, the only preventive monitoring was really when the mechanic would pop the hood, listen for “that strange noise” and maybe take something apart, and your service records were greasy pieces of paper jammed in the glovebox or basement files.

Our cars are spectacularly better built than they were three or four decades ago, but we are able and conditioned to take better care of them too. We pay for it, of course – all of the monitoring, record keeping and data transfer abilities are buried in the price of our cars, but we ignore these capabilities at our peril. It could be argued that we take better care of our cars, certainly from the perspective of prevention, than we do of ourselves.

What about us, then? Will we change our own relationships to our bodies when we have the tools to do so? Will we become focused on preventive maintenance of ourselves, with tools that help us watch our sugar intake the same way our cars help us watch our tires?

It’s interesting reading the savings that some of the early ACOs are realizing in their new value-based care initiatives. $3m here, $5m there. Not chump change and it all adds up, but still just a dent in a $8bn a day sector. The real change will occur when consumers start to change their health habits to such an extent that their need for the healthcare system plummets. The quantified self is still some way off, as the average person’s ability to adopt monitors is still far from seamless or invisible and the cost high for all but the diehards, but the technology to track, transmit and advise is advancing rapidly. When awareness and prevention becomes as easy as my car makes its preventive care today, then maybe we’ll start to see the behavioral shifts that will truly affect costs and outcomes. And maybe my car will tell me when I should be walking instead…

Peter Heywood wrote this on April 14, 2014 / no comments

RobotJust over five years ago, Clayton Christensen, Harvard Business School professor and innovation guru, published a book on healthcare and change called “The Innovator’s Prescription.” Based on my conversations with many, many people in healthcare, it was widely read but with the continuing dialogue about the role of data, evidence-based AI systems and the dehumanization of healthcare through computers, you wonder how much the book’s lessons were absorbed.

Christensen made his name with the publication in 1997 of the Innovator’s Dilemma, where he introduced the concept of ‘disruptive innovation.” With this, he described how even the best run companies could be (and have been) sideswiped) by innovations that come out of left field, change the rules and eat the incumbent’s lunch. All interesting, well-researched and arguably a lot like so many other books on management that have appeared since Tom Peters and Jim Collins  blew open this field 25 years ago (not to forget the godfather of such books, Peter Drucker). Christensen and his team followed this with other titles, such as the Innovator’s Solution, the Innovator’s DNA and others, all reasonably interesting but that felt a little bit like they were over-mining this vein.

Then came The Innovator’s Prescription.

Now, maybe it’s because I spend too much time in healthcare, but I found the book irresistible. Unusually, I read it cover-to-cover twice, and (having read the original) the observations in The Innovator’s Prescription seemed so much more apt when focused on healthcare examples. In particular, he spends considerable time on the need for each “tier’ of healthcare expertise (techs, nurses, doctors etc) to continue to add value to its work and rise up “the value chain” as technology disrupts jobs and assumes the work in the rote and repeatable processes. He notes that equivalent changes have radically altered roles in other sectors and healthcare is ripe for such disruption. Well worth reading.

I thought of it when reading a terrific post (http://qz.com/193919/most-of-what-your-doctor-does-a-robot-can-do-better/ from a young MD resident and inventor named Gina Siddiqui (@gina_wrote).

Straight out of Christensen, she notes: “My medical education focuses on recognizing pathologies under tight deadlines: efficiency and specialized pattern recognition. I’m hard pressed to make a case for my edge over a robot in these domains. And if I have no edge, I would be doing my patients a disservice to guard my job.”

Exactly. But rather than moaning about the loss of humanity in healthcare, about the wise doctor’s insights being over-run by impersonal, evidence based protocols, about doctors becoming nothing more than algorithm jockeys, she offers a much more optimistic challenge to providers.

As Gina Siddiqui again notes “After the Deep Blue supercomputer beat the world champion Garry Kasparov in 1997, something interesting happened. Humans didn’t stop playing chess. Instead, “advanced chess” was born, whereby humans and computers teamed up. Some of those teams won against the otherwise unbeatable supercomputers.”

Technology is not going away. The amassing of Big Data and evidence-based insights is not going away. And the genial bedside doctor disappeared a long time ago, as much as people pull this image out when resisting the onset of technology actually providing care. The healthcare system needs more people like Ms Siddiqui who embrace technology not because of its functionality (something that let’s me do my job faster), but because – as Christensen said – they see the means to team up with IT to change the rules (something that let’s me reinvent my job) and become better, more human providers, not the robots the fear mongers predict.

 

Peter Heywood wrote this on March 06, 2014 / no comments

Have you ever been to HIMSS? Were you there this year?

I have been in the past, but not this year, and maybe (partly so I could observe first hand the tremendous commoditization of messages) I should have gone. One fellow I know whose company genuinely does offer engagement and population solutions said that it seemed everyone was slapping some sort of population health and patient engagement message on their offerings, no matter how tenuous the connection.

big-dataIt’s easy to take potshots at some vendors’ search for relevance in a changing market, but the shift to data and technology driven care is only gathering momentum, and there are in reality far more enabling technologies targeting population health than just two years ago. Although what they’re really enabling is the creation of data. Lots of it.

In the context of “the Internet of things” and Big Data the amount of data produced by healthcare is still small. IBM, for instance, reckons that overall 2.5 billion gigabytes of data were generated every day in 2012, and that’s two years ago. But this is only relative – between the information generated by clinical records, revenue cycle management, remote health and fitness monitors, e-prescribing and more, there is still a vast amount of data being generated in the sector, by institutions, providers and consumers themselves.

But in a time when we are moving to true patient-centered care (aka care that the patient has some control over), who is all this data really for?

There was an interesting post on health literacy on the MedCity News site on March 4th http://medcitynews.com/2014/03/hcldr/ It asked, “Once we get our data, will we [the consumer] know what to do with it?” Its conclusion, at least today, was no. In fact, it suggested that the flood of data and information is further distancing the patient from his or her care because it’s so hard to access.

Yet I believe bright types, especially those with no vested interest in keeping the information experience complex, will find ways to present the data and associated insights in helpful, accessible ways, because the consumer market will demand it.

Human centered information and user experience design will play an important part in driving success for these new products and services, but equally important will be the necessary shift in provider attitudes towards patient engagement and empowerment.

The FDA and 23andMe imbroglio notwithstanding, the old provider attitude that your health information is, well, not actually yours will crack under the strain of consumer expectations. It is astonishing that, in this day and age, many providers still believe they need to protect consumers from their own information, and designing the data and information experience to be accessible will only exacerbate the “problem.”

So it’s really encouraging to read about a pilot project by the Ohio State University Medical Center called MyChart Bedside, developed in conjunction with Epic. (read about it in MobihealthNews http://bit.ly/1dsXhXA). OSUMC hands each patient in for, say, a procedure, an iPad that has loaded on to it the patient’s record, contextual information about the pre and post-op periods, medication records and information, patient education information and the ability to communicate with the care team.

Epic-MyChart-Bedside-iPadWith only one (compelling) screen shot accompanying the copy, I can only guess that the entire information experience is equally powerful. I have also assumed that the information is rich, evidence-based and meaningful for the patient, not so stripped down as to be pointless. But however the entire execution has actually been handled, the intent is spot on, and you have to commend OSUMC for using information and process design to truly involve the patient in his or her care and care team.

Not surprisingly, patient reaction has been incredibly positive, and the article notes that OSUMC will be rolling the app out more broadly shortly. Be interesting to see what metrics the hospital has established and how the program affects these, but it doesn’t take measurement to understand why patients would be keen.

Big Data and its associated analytics are valuable to health strategy and policy specialists, no question, and better ways to experience the information in ways appropriate to their needs still have to be designed. But there also needs to be a huge push to increase health literacy and involvement for consumers themselves. The experience of information as conceived by OSUMC is an encouraging sign that the healthcare establishment is starting to get just that.

 

 

Peter Heywood wrote this on December 06, 2013 / no comments

How should the healthcare organization evolve?

One of the most important economists in history died in early September, at the remarkable age of 102. Ronald Coase, who won the Nobel Prize for Economics in 1991, taught and contributed to modern economics theory right up to this year. That we could all leave such long and productive lives.

Ronald CoaseCoase made his name in a short essay published in 1937 (if you can imagine) called “The Nature of the Firm.” In it, he proposed the theory of “transaction costs” as the reason why we have companies, rather than just marketplaces or networks of individuals providing specific services. The transaction costs of a network of individuals, such as setting up multitudes of contracts, managing individual vs. collective accountabilities, handling workflows and handoffs, marketing and sales etc, exceed the actual costs of making the final product or delivering a service. Thus, organizations—businesses—are created to internalize these processes and reduce the expenses, at least to the point where their organizational overhead doesn’t overwhelm the potential revenue.

Coase’s theories proposed that firms can grow to an even larger size through mitigating technologies such as the telephone. He never really addressed what happens when collaborative information management and communication technologies actually reduce transaction costs to the point where our conventional view of the firm changes. Will companies disappear or turn into mere aggregators of individual experts? And if they do develop these new and looser structures, what holds them together so that they can deliver effectively on the promise they make to their customers?

It’s interesting thinking of this in the context of healthcare. Healthcare has been, in many respects, the world’s largest cottage industry. In spite of some very large provider and payer companies, healthcare has been mostly defined by individuals and small organizations, very local and each with a unique perspective on the right behavior, patient relationships, protocols and so forth. Of course, it has also been notably inefficient and costly. Coase would claim, I’m sure, that this has much to do with the elevated transaction costs within healthcare’s fragmented structure. In his view, it would be a situation ripe for consolidation.

And so it has become. Hospitals are being purchased by larger health systems, but even more striking is the number of physician practices merging, or being purchased by larger IDNs or hospitals.

Some have argued that the Affordable Care Act and other regulations have accelerated consolidation, and that those in Washington behind health reform have a visceral dislike of the independent provider. Dr Scott Gottlieb of Indiana State wrote an interesting paper on this [http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2343285].

Isn’t it ironic, however, that this trend to consolidation is occurring at precisely the time when enabling technologies could allow for the formation of “virtual healthcare companies” addressing the issue of transaction costs through shared information, processes and, maybe, brands, and not through outright consolidation? That would allow the continued independence of the centerpiece of transformed healthcare, the primary care physician, while bending the cost curve in the right direction.

And let’s face it, the last round of HMO-driven practice acquisitions twenty years ago was a disaster, for health systems, providers and patients. We need a new approach to address transaction costs, economies of scale and aggregation of population health data that also happens to provide a better experience for providers and patients. The right technologies (we’re not talking about you, EHRs!) provide that approach.

It will be important to keep an eye on evolving Accountable Care Organizations. The first participants have been in the large dominated by institutions, which have backfilled their primary care obligations through acquisitions (the M&ACO?). Once we get through the growing pains, I am optimistic that we’ll see ACOs that are truly collaborative networks, driven by physicians, tied together by technology and a powerful patient-focused brand, lowering their transaction costs while retaining the independence that most physicians crave. I wonder what Coase’s view on these would have been?

 

 

 

 

 

Peter Heywood wrote this on November 21, 2013 / no comments


Staples easy buttonWe’ve all heard and read—a lot—about the Accountable Care Organization, or ACO. An ACO is a collaboration of hospitals, specialists, primary care physicians and other care providers who have entered into a contractual relationship to be responsible for the health of a defined patient population. As generally interpreted, an ACO’s participants receive bonus payments from their payers for maintaining and improving the health of their populations, and in helping patients avoid using the more expensive parts of the system, through better care coordination and preventive care.

Smells like an HMO? Well, there’s one big difference. No patient is required to belong to an ACO, or necessarily use the services of the “medical neighborhood” the ACO has established. Putting aside any other issues within the ACO model, this creates an interesting new challenge for providers­—they’re going to be rewarded for managing the health of people who don’t have to deal with them. In other words, to work as promised, an ACO is going to have to be the most attractive option for healthcare consumers.

Imagine that. A healthcare organization is going to have to be appealing. It’s going to have to put patient (i.e. consumer) needs front and center. This means more than the window dressing of a nice receptionist or well-designed web site, as great as those can be. It means digging into all the processes that impact how the patient is engaged and managed, from scheduling and communication to professional hand-offs, care transitions and billing, and then evolving these to meet and exceed the promise the ACO is making to its “consumers.”

This is what we mean when we talk about designing the patient “healthcare experience.” You bake the components of an inspiring, patient-driven experience right into the delivery of healthcare and the organization of the business. And critically, ACOs are going to have to look well outside of healthcare to see how to genuinely engage the consumer as an individual, and keep them loyal.

The best retailers have been doing this for years, through everything from in-depth analytics of an individual’s buying history to the design of their bricks-and-mortar environments (if they have these). Even if their employees have the right practical skills, they invest in training to ensure the customer experience seamless. They look to their technology, where transactions are accelerated for customers, letting staff devote more time to those parts of the relationship that the consumer values. Next time you go into Starbucks, notice how the barristas complete each others’ tasks without asking, because their training is designed to help them work together to serve the customer, not complete a job assigned just to them. That’s customer experience-based.

It’s not necessarily about nice environments or friendly service either. It’s really about designing all aspects of the experience to align with and support the specific promise of your brand. When you go to Costco, you don’t expect refined design or attentive service (and you don’t get it!), because the promise is about an efficient warehouse full of unexpected cool stuff at great prices, what retailers call the “treasure hunt.” Costco is successful because they know what their brand stands for, and work their systems and unique experience to support that specific promise. Ever notice that the huge checkout lines move faster than at any other store? That’s by design.

Another example is the famous Staples ‘Easy’ button. Brilliant campaign, but the real challenge is making sure that the customer experience is indeed aligned around the easy promise. Is it easy to find products? Easy to locate staff who can answer your questions? Easy to return a product? Easy to shop online?

Often, those in healthcare are irritated by such benchmarks. “We’re doing vital and hard work. We’re not selling printers or lattes!” Yes, healthcare is important stuff, but it doesn’t mean patients (aka customers) leave their sensibilities at the door and accept indifference, poor communication and lack of clarity.

So it will be interesting to see if the various ACOs invest the financial and human resources to understand what their brand should stand for, understand the consequences of the promise and truly transform their workflows to create the experiences that deliver. Old habits are hard to change, even when your business depends on it.