Tuesday, November 14, 2017

Patients Are a Design Problem

When I say "patients are a design problem," I don't mean that the people who happen to be patients are a design problem.  They may well be, but that's an issue you'll have to take up with Darwin or your favorite deity (or, all-too-soon, perhaps a CRISPR editor...).

No, I mean that making people into patients is a design problem.  And it's a big one.
Over the last twenty years, there has been much discussion and debate about whether patients are, or should be, actually "consumers."  But I've never met a doctor or other health care professional who thinks of the people they treat as "consumers," or, in fact, as anything other than patients.

The term "patient," referring to people getting medical treatment, has been in use for hundreds of years.  It is not a coincidence that it is related to being "patient," that is, suffering without complaint.  No wonder medical professionals like to use it.

There have been many calls to change the word -- see, for example, Pat Mastors or Julie Neuberger -- but what we have is deeper than a semantic problem.  Changing the word we use to describe people caught in the health care system doesn't change the dynamics of that system.  A new word would not change how such people are treated or have come to act.

This is a design problem.
Consider the following:

1.  Physician Respect: We treat physicians as something special.  We hear about how difficult it is to get into medical school, how tough the process of being trained as a physician is, how hard they work, and how much they need to know.  We watch them perform miracles routinely on television, and expect our own physicians to have the empathy of Dr. Welby (some of you may have to ask your parents), the encyclopedic knowledge and keen intuition of Dr. House, and the technical prowess of Dr. Shepherd (some of you may have to ask your wife or girlfriend).  That white coat is no longer needed and may, in fact, be counterproductive, but serves to remind of us the deference the health care system believes physicians are due.
2.  Patient experience: It's hard to get appointments.  The appointment time is often just a vague indicator of when we'll actually see our doctor.  We may have to put on an embarrassing gown and get up on an uncomfortable table.  We may have services done to us that we don't really understand and which not uncommonly are unpleasant, to say the least.   We may be asked to fast unnecessarily for hours before blood work or procedures.  We often are unsure about what is going to happen next, or when. It is not a patient-centered system.
3.  Medicalization:  We talk about the health care system, but we really mean the medical care system.  We almost never include, or pay for, the other things that impact our health, like diet, exercise, and environment.  Instead, we seek our health care providers for our health issues and advice, to the point where some physicians now give out "prescriptions" for exercise.
4.  Better, Soon: We've seen remarkable strides in what medical care can achieve, such as antibiotics, polio vaccines, organ transplants, joint replacements, pacemakers, chemotherapy, and advanced types of imaging, to name a few.  We have become a nation of pill-poppers.  When something is wrong with us, we expect to be able to get it fixed, and we expect that to happen quickly.
5.  Confusion reigns: Nothing about health care seems easy.  It's hard to pick a physician, or a health plan.  The terminology makes no pretense at being understandable to anyone not a health care professional.  The bills are practically indecipherable, especially since the pricing behind them is intentionally opaque.  If you need multiple doctors, tests, or procedures -- which you almost certainly will -- you'll have to navigate the maze around getting them.  No one, lay or professional, claims to understand the "system."
6.  Responsibility: We've delegated responsibility for our health to our health care professionals, especially our doctors.  It is more established than ever that regular exercise, moderate eating, and a balanced life would do more to improve our health than any regime of medical treatments.  Yet we continue to expect that the results of our increasingly poor habits will be "fixed."

These are why we are "patients."  These are why we are expected to be patient.

There are constant calls to reform, even disrupt, the health care system.  There are new entrants, new models, new technologies, and plenty of new money.  As I wrote a few years ago, though, most innovations in health care seek not to disrupt the health care system, but to get their share of the spending.

new article by Clayton Christensen and colleagues points out:
more than $200 billion has been poured into health care venture capital, mostly in biotech, pharma, and devices where advances typically make health care more sophisticated — and expensive. Less than 1% of those investments have focused on helping consumers to play a more active role in managing their own health, an area ripe for disruptive approaches.
Their article highlights Iora Health, while, in another series of articles about disruption, Robert Pearl, M.D., is keen on CareMore, Forward, and Health City.  But none, in my opinion, go far enough.  None redesigns the "system."  None really tilts our system away from medical care system and towards empowering people to take charge of their own health.

We will always need physicians (although not always human ones!), and many other health care professionals.  That's a good thing.  They have knowledge and skills that can help us.  They deserve our respect.

But we should design our health care system around us, not them.

Make the "system" simpler.  Focus it around our health, not our care.  Expect us to have responsibility for our own health -- but ensure we have the tools we need to manage it.  Spend money to prevent health issues, not address them once they've happened.

It won't be easy.  We don't know how to motivate people to be more responsible about their heath, to the point we're excited about digital pills that track whether we take them.  Nifty technology, but I wish we invested more in the underlying problem(s).  Let's make Professor's Christensen's 1% more like 90%.

If patients are a design problem, then maybe people can come up with a design solution.

Tuesday, November 7, 2017

Bjork, Blockchain -- and Healthcare

Healthcare should pay more attention to Bjork.

To be fair, I think everyone should pay more attention to Bjork.  I've loved her since she was in the Sugarcubes.  Her voice is astonishing, her music is always interesting and often magical, and when she sings she commits more fully than any other singer.  If her fashion sense is sometimes out there, well, we expect some eccentricities from our geniuses (and, oh-by-the-way, that infamous swan dress is now honored in a museum). 

But all that aside, health care should be paying attention to how Bjork embraces new technology.  That now includes blockchain.


With her latest album, Utopia, due to be released later this month, Bjork is teaming with blockchain company Blackpool to use blockchain and, more specifically, crypocurrency to try some new things.  As reported by Musically, fans can:

  • Pre-order the album using several different kinds of cryptocurrencies, such as Bitcoin or Audiocoin, along with more conventional forms of payment.
  • Earn 100 Audiocoins -- worth $0.19 currently -- just for pre-ordering.  The digital coins will be deposited into a e-wallet, and can be exchanged for other cryptocurrencies, converted into "fiat currencies (like dollars), or kept for future use.
  • Receive additional Audiocoins by interacting with Bjork and her music, such as attendance at concerts or perhaps promotion on social media.  
  • Use their Audiocoins to buy additional Bjork music or related materials.  
It wasn't explicitly spelled out but presumably the fan participation will be tracked using blockchain.

Bjork and Blackpool will develop more details about how fans can earn and use their cryptocurrency over the next couple years, but it certainly is a unique approach.  As The Next Web put it, "at the moment it just kinda sounds like a hybrid between a CVS pharmacy rewards card and a fan club. That’s not necessarily a bad thing."

Blackpool CEO Kevin Bacon told Musically:  
You could create blockchain-enabled digital treasure hunts, although what we don’t want to do is turn this into Pokémon Go! But why not reward your fans for engaging with what you do, and reward them in a meaningful way?

Keep in mind this isn't the first time Bjork has creatively used technology in conjunction with her music:
  • She made a critically acclaimed video ("All Is Full of Love") featuring robots -- in 1998.  
  • In 2011, Biophilia came as a standard audio version but also featured a collection of apps that transformed the audio experience.  MoMA included the app as the first downloadable app in their permanent collection, noting: "With Biophilia however, Björk truly innovated the way people experience music by letting them participate in performing and making the music and visuals, rather than just listening passively."  There is now also a Biophilia Education Project to help inspire creativity in children.
  • A subsequent album, Vulnicura, led to a virtual reality (VR)-based exhibit also expanded the musical experience.  It has appeared in major museums around the world.
Bjork may be not just a genius with her music but also in using technology to change how we experience it.

I have previously written on why and how bitcoin, blockchain, and even smart contracts might be used in health care, but to pretend that I actually understand any of them would be overstating the case, to say the least.  Fortunately, more knowledgeable people in the field are increasingly coming up with applications for it, as a recent synopsis in HealthIT Analytics illustrated.

Let's think, though, about how Bjork's latest experiment could be translated into health care.  Imagine, for example, a direct primary care practice (DPC) that:
  • Allows/encourages patients to pay for their services using crypocurrency;
  • Uses a smart contract to establish the mutual obligations, the agreed-upon measurements for "success," and the mechanisms for performance-based rewards/penalties;
  • Tracks patients' behaviors (preventive visits, exercise, etc.), readings (vitals, labs, etc.), and records (diagnoses, treatments, etc.) using blockchain (a blockchain EHR!);
  • Allows patients to earn additional cryptocurrency for meeting desired health goals and/or activities.    

I used DPC as the example because the fixed monthly fees may be easier to work with than fee-for-service, but there is no reason a similar approach couldn't be used for health plans, health clubs, or even fee-for-service providers.  

Bjork's blockchain-based :"CVS rewards card/fan club" that rewards fans for a variety of desired types of involvement is particularly intriguing.  Applying the concept to health care would help recognize that most things impacting patients' health happen outside of health care settings, and could create ongoing, visible, positive incentives for patients. 

Not just DPC; Fitbit and Apple Watch: are you paying attention?

We're not going to transform the entire health care system into blockchain immediately, nor should we.  There are still too many unknowns.  However, experimenting with it within a moderately closed environment like a DPC practice might be a great place to start. 

Blackpool's Kevin Bacon has a great perspective on blockchain:

There’s a lot of talk about whether crypto and blockchain is a bubble. I don’t see it as a bubble: I see it as a burst of energy. I think you’ll see a lot of activity, a lot of things will disappear or get left to rot, but the important things will stay and grow. 
I think blockchain and crypto will be like the dotcom boom and bust in the late 1990s. We’ll see enormous adoption over the next couple of years, then some kind of bubble burst, but then a long-term change.
Blockchain won't solve the health care mess we find ourselves in, especially in the U.S.  There are too many fundamental issues that we need to address.  What it may do, though, is give us a new set of tools to help solve it.  We need to see that boom and bust that Mr. Bacon refers to, and see what uses are left standing.

I'm looking forward to hearing more about what Bjork does with her new initiative, and I hope some health care organization takes note.

Meanwhile, I can't wait to see how Bjork will use what Fast Company says may be the next iteration of the Internet itself -- Dispersed Computing.   But that's a topic for another post...

Tuesday, October 31, 2017

Strange Bedfellows

Strange days in health care: Amazon appears to be getting into the pharmacy business, CVS wants to buy Aetna, and Uber is bidding on Doctors on Demand.

OK, I made up that last one, but it doesn't seem so far-fetched anymore, does it?

Health care is seeing some strange bedfellows these days, and I, for one, hope we see more.  I'm going to list some of the intriguing combination I'd like to see, but first let's start with what's actually going on.


CNBC and others have been reporting on Amazon's interest in pharmacy for several months, and just last week the St. Louis Post-Gazette reported they'd acquired wholesale pharmacy licenses in several states (a move that may mean less than it suggests).  Pharmacy stocks immediately took a tumble (as had happened to grocery store stocks when they announced their acquisition of Whole Foods earlier this year).  

No sector wants to see Amazon enter its space, as Amazon is known for low margins and excellent customer service.  Health care is an appealing target, with pharmacy considered one of Amazon's most natural first targets, given high prices and convoluted supply chain.

Almost as if in response to the Amazon rumors, CVS surprised almost everyone with their bid to acquire Aetna.  A drugstore getting into the health insurance business -- what sense does that make? 

More than one might think.  CVS is already a large PBM (pharmacy benefit manager), including for Aetna, and owns SilverScript, one of the largest Part D plans.  They should understand this business, and they would increase their potential engagement with tens of millions of people.

CVS has apparently been preparing for this for some time, having also reportedly talked to Anthem and UnitedHealth before agreeing to the Aetna acquisition.  It's a bold move, and could end up the largest health deal to date, at an estimated $66b price tag. 

At this point, intra-industry health care mergers, like last year's Aetna-Humana or Anthem-Cigna mergers -- both of which ultimately failed -- seem positively old-fashioned.

With tongue only slightly in cheek, here, in alphabetical order of acquirer, are some potential, perhaps unexpected mergers/acquisitions that might make sense:

  1. Alphabet-WebMD: Private equity firm KKR is in the process of acquiring WebMD, in a deal worth some $2.8b, but Alphabet's Google would make a better home.  After all, health is one of the leading search topics on Google, and WebMD is one of the top destinations for those searches.  Google could figure out what to do with that content and further monetize those searches.
  2. Amazon-Medibid: Amazon can certainly shake up the pharmacy world, but how about if they get into medical tourism instead/in addition to?  Not just for overseas medical tourism, which is booming, but interstate, intra-state, even intra-city "tourism" as well.  Amazon could create a market by having providers list fixed prices for bundled services, then letting consumers compare and "buy" those services on Amazon's marketplace.  There are not many companies in this space, but MediBid would be a start. 
  3. Apple-Medtronic: Apple makes great consumer devices, focusing on delighting the users.  Medtronic is a leader in consumer devices too, only with focus on medical and often not visible to (or delighting) consumers.  With medical devices becoming more IoT, and with more focus on DIY health and patient satisfaction, Apple could raise the bar in medical devices significantly -- and further lock in their developing health ecosystem.  Their interest in primary care may have to wait.
  4. Disney-Humana: Humana has long prided itself on being member-focused.  They recently announced a partnership with Oscar Health to boost their consumer focus, but nothing would make the leap to improving the member experience than by joining up with the guru of all customer experience, Disney.  Why would Disney want to get into health?  Well, maybe because there's a lot more money in health than in vacations.  
  5. Facebook-PatientsLikeMe: Perhaps not a blockbuster deal, but Facebook's acquisition of PatientsLikeMe, one of the leading health "social networks," would further solidify Facebook's reach -- and give them access to much more data.
  6. Microsoft-Practice Fusion: Microsoft has tried hard to be a leader in health, just like it has struggled to be a leader in anything other than PC operating systems.  One thing it is good at -- although still not the leader -- are cloud services, so why not buy Practice Fusion, which touts itself as the largest cloud-based EHR platform?   Better yet, snap up both it and athenahealth., another leading cloud-based EHR.  Both athenahealth and Practice Fusion are reportedly struggling.
  7. Uber-Doctors on Demand: That opening sentence may not have been so far-fetched after all.  People have speculated about who would be the "Uber of health care," and Uber itself is trying with Uber Health.  Matching up patients with on-demand telehealth providers would seem within Uber's sweet spot, with Doctors on Demand on of the leaders in that space.  And if they could figure out how to add house calls, such as through Heal, they might really be onto something.
  8. UnitedHealth-Epic: UnitedHealth has long seen itself as a health company, especially through its Optum lines of business.  They love data and analytics, and Epic's data would be a treasure trove.  Moreover, Epic has connections with huge numbers of doctors, hospitals, and other health care providers, which could strengthen United's ties to them.  And who knows: United's health information exchange expertise might even spur Epic's much criticized interoperability.
  9. Walmart-Cardinal Health: Walmart is one of the best consumer retailers, while most consumers have never heard of Cardinal Health.  But most hospitals and other health care institutions have, relying on them to supply medical supplies and pharmaceuticals.  Walmart has low prices in large part because it is superb at supply chain and logistics, so it is a natural fit.
  10. Walmart-Centene: If Walmart wants to stick to retail, it could do worse than to scoop up Centene, one of the leading Medicaid managed plans (and now exchange plans too).  Walmart has long been known for appealing to lower income customers (although they have been trying to broaden), so Centene's Medicaid and near-Medicaid populations would make sense.  The insurance could help push even more business to Walmart's huge pharmacy business, vision centers and retail clinics.
Surprised (or amused) by any of the above?  I sure hope so.

I'm tired of the (very dangerous) vertical and horizontal consolidation we continue to see in health care.  I want to see more surprises. 

Some of these suggestions may seem unlikely, but I'm more worried that they are not surprising enough.

Tuesday, October 24, 2017

AI Docs Won't Be Like Human Docs. Good



The 21st century is going to be a world of artificial intelligence (AI), whether we’re ready for it or not. And we’re probably not, especially not when it comes to health care.

Let's start with two tweets:
Chrissy Farr: "My favorite Friday quote: @Farzad_MD citing a peer at Mass General: "Any doctor that can be replaced by a computer should be.""
Trisha Greenhalgh: "I predict the very last doctor to be replaced by a robot will be the GP.  Almost none of our work is algorithmic."
These sentiments are widely shared by physicians. They view what they do as uniquely human, and are pretty proud of it — although some now allow that AI might be able to augment them. Someday.

However, feeling that their job is not likely to be replaced by AI (or other automation) is not unique to physicians. Consider the following from a Pew Research Center survey:
In other words: too bad for those fast food workers or those overpaid software engineers, my job is safe. And not just this year or next year, but for the rest of my life. There likely is some wishful thinking going on here, and that may apply to physicians as well.

Still, 79% of respondents believed that within 20 years doctors will rely on computers to diagnose and treat most diseases. The real question is the extent to which a human doctor will still be involved. 

This is hard for physicians to accept. Caroline Poplin, MD, JD, FACP, argues “Medicine is Not Manufacturing.” She laments that: “Even as Western medicine has become more scientific over the centuries, the central role of the physician-patient relationship, with the interest of the patient being paramount, has remained the same — until recently.”

In recent years, she believes, health care has become more of a business, and concludes that the the unique thing about medicine is its soul, “the essential element that has given patients comfort and relief for thousands of years and does so even today.” 

Take that, computers. 
The fact is, like it or not, that health care is a business, in which lots of people and organizations make a lot of money. It’s hard to walk into a hospital, or a surgery center, or even a doctor’s office, and not see that they are manufacturing operations. 

They’re often not very efficient, mind you, and as much as they say they are all about the patient, that is often hard to believe.  

That is not to say that there are not very empathetic, caring people in health care — many of them physicians — but let’s not confuse that with the practice of medicine. Not anymore. 

When physicians had little idea of underlying disease states and even less ability to do anything about them, that confident bedside manner helped many patients, but as we apply more science to diagnosing and treating patients, we should need it less.

What is it, exactly, that we’re trying to preserve? Physicians treat patients based on their experience with previous patients, the training they got, the research they remember, the imperfect and intermittent data they have, and their vaunted intuition. Those are a lot of variables, potentially leaving wide gaps in what they can bring to bear upon the care for a specific patient.

Human doctors do the best they can, in most cases, but they do make mistakes, they do order care that is unnecessary at best and inappropriate or dangerous at worst, and they don’t always agree with other doctors about patients. 

An AI, on the other hand, can bring to bear analysis of huge datasets, the depth and breadth of all existing research, and an infallible memory. Plus, it doesn’t have bad days, isn’t going to be tired, and doesn’t go on vacations.

It might even develop a bedside manner

The odds are that your human doctor is almost certainly not the “best” in the world, if we could ever figure out who that was, but the best AI doc could treat an unlimited number of patients.  

One of the most interesting recent AI developments comes from a game. Google’s Deepmind program AlphaGo Zero learned the fiendish difficult game Go — in three days, without any human instruction. It didn’t look at games played by humans, it didn’t have human Go experts programming it, it didn’t even play humans.
Instead, it was fed the rules, then played itself. Endlessly. Millions of games. It made stupid mistakes initially, but when all was said and done after the three days it was at a level no human ever has been. It learned many of the intricate strategies that humans have figured out over the centuries, as well as ones that Go experts called “amazing, strange, alien.”

“They’re how I imagine games from far in the future,” Shi Yue, a top Go player from China said, or, more colorfully, which Go enthusiast Jonathan Hop describes as “Go from an alternate dimension.”
Imagine this for health care.

We’ll start with more data. A lot more data. Not just finally breaking down all those ridiculous silos, but from more ongoing monitoring through wearables and other devices, helping establish our base health and giving more early warning of when things are getting off track.

AI will come up with ways of diagnosing and treating that we’ve already discovered — along with ones that are “from far in the future.” That’s a good thing, and we should welcome it.
Dr. Bryan Vartabedian, for one, thinks that AI will force doctors to rethink what they do. Computers make information widely available, imaging more precise, pattern recognition more possible. He points out:
The end result is a paradox: We want the precision and specificity of the machine yet we want to believe that we can still do it all with our hands and eyes and ears.
We probably can’t. So we need to start redefining what the human doctor of the 21st century will do.
Dr. Vartabedian thinks the key question may boil down to “What can a human do that a machine can’t?” That is a question whose answer will be continually evolving — as will the role of physicians.

In a separate article, Dr. Vartabedian hints at an answer:
My work is about translation and connection… I help them negotiate the transition between life with a chronic condition and the healthy development that can create some semblance of a normal life… It’s a far cry from the work of a scientist. And I’m good with that.
The goal of AI in health care isn’t to get rid of human doctors, but it shouldn’t be to preserve them either. The goal should be to do what is best for patients, for us.

There will be a role for physicians in the future. Probably. But there will also be one for AI. It won’t be the same as human doctors, and that’s OK. 

Monday, October 16, 2017

Elon, Do We Have a Disaster for You!

One of the most interesting twists resulting from Hurricane Maria striking Puerto Rico was Elon Musk's offer that Tesla could help Puerto Rico solve its energy crisis, with a long-term, 21st century fix.  After all, its electrical grid was devastated, with almost all the power wiped out.  It didn't help that even prior to this disaster its system was antiquated and badly in need of repairs.

It is telling that we don't have similar offers to rebuild the Puerto Rico's health care system, which is similarly devastated.  Or, for that matter, our system, which is its own kind of disaster.
Mr. Musk was asked on Twitter if Tesla could help Puerto Rico using solar and battery power, and he responded in the affirmative, saying it had done so on smaller islands but faced no scalablity issues.  Next thing we knew the Governor of Puerto Rico and he were talking.  Now Tesla is starting to deliver their battery systems to the island, so we'll see.

The appeal is obvious.  The island has a perfect climate for solar power.  Rebuilding the power plants and power lines is a daunting task, especially for an island that is essentially bankrupt.  Solar is renewable, oil and coal are not.  And, being a tropical island, Maria is not the last strong storm that will strike Puerto Rico, so future outages are inevitable.  Solar/battery at least decentralizes the grid, lessening how wildspread such outages might be.

Maybe it is a marketing stunt on Mr. Musk's part -- if so, you have to give him credit for it -- but the idea has merit.  A disaster like Maria is a once-in-a-lifetime opportunity to try bold new ideas instead of blithely rebuilding what was there before (let's hope Houston does the same with its zoning and floodplain issues).

Meanwhile, Kaiser Health News reports on the toll Maria has taken on the island's health system and residents' health, both now and for some time to come.  Relief workers are doing the best they can, but there's no easy fix for the underlying problems the system was already facing, like high prevalence of chronic conditions, funding shortfalls, and an ongoing brain drain of health professionals, all exacerbated now by lack of clean water, adequate supplies, and shelter.

Still, even Elon Musk isn't bold enough to offer to rebuild their health care system, much less ours.

Sometimes disasters do make us rethink our health care system.  Katrina, for example, has often been credited with creating the impetus for electronic health records (EHRs), since it destroyed countless paper records, wrecking havoc on care for thousands of patients.

But we didn't pay enough attention to even that very visible crisis.  We do have a lot more EHRs now, but less than 30% of hospitals self-report being interoperable, and half of physicians' time is supposedly spent on their documentation efforts.

The records themselves remain largely physician-centered and exclusively medical, although Epic, the nation's largest EHR vendor, is finally saying they will move to a "comprehensive health record" (CHR).  "Because healthcare is now focusing on keeping people well rather than reacting to illness, we are focusing on factors outside the traditional walls, Epic's CEO told HealthIT News.  Rivals say they are doing the same.

I'm glad that in 2017 EHRs vendors are finally realizing there is health outside a medical facility.

It shouldn't take a hurricane -- or an earthquake, or a bickering Congress -- to realize that we have an in-progress disaster with our health care system.  Sure, health care hiring is booming and hospital/medical construction is everywhere, but those are signs of the disaster, not of the robustness of the system.

We spend way too much on medical care, we get too much unnecessary care, we are subject to too many medical errors (including deaths), and we suffer from too many lifestyle diseases, such obesity and diabetes.  Our longevity is embarrassing -- and declining.

We give tax breaks to "non-profit" hospitals regardless of how they use those breaks, and to employer health plans, which end up disproportionately benefiting the middle and upper class.

We finally managed to give health coverage to millions of previously uninsured Americans, but now those gains are under attack, while half of the poor and near-poor remain uninsured.

We bounce from one new dietary finding and/or fad to another, while eating too many processed foods and not nearly enough healthy foods.  Meanwhile, few of us get enough exercise, and we spend too much time on our various screens.  Our social networks are increasingly online rather than in-person.

There is not nearly enough "health" in our health care system, just ever-more "medical."

If all that isn't a disaster, I don't know what is.

Let's say we were starting from scratch.  Let's reset what our health care system could be.  Let's say we didn't have all these hospitals, hadn't trained any physicians, hadn't deployed any medical devices or used any prescription drugs, although we could start with the knowledge of what each of those could accomplish.

Would we remake the system as it is, or would we design something new?

In a previous post I enumerated several things about our health care system I was dying to redesign, and in another I gave some specifics about how a re-engineered system might work.  Even those, though, didn't start from entirely scratch, still focusing more on the medical than on the broader health perspective.

We should be spending more on our health needs -- broadly defined -- than on our medical care.  We should be more worried about if people are going to the park than if they are going to the doctor's office.  And when we do get medical care, we should make sure it is care that has solid evidence of working, rather than too often accepting care that might work.

Elon Musk has his hands full saving humanity, not to mention helping Puerto Rico, so we probably can't count on him to offer to reinvent our health care system too.  So who will it be?

Tuesday, October 10, 2017

Let's Hope This Bores You

I think I know what is wrong with health care: not enough people are bored. 

These are stressful times for health care.  There's a never-ending stream of innovation, constant pressures about costs, concerns about the quality of care, conflicting research findings, ongoing uncertainty about how we should finance what coverage for which people, and new business models and organizational structures. 

There's too much to take in, and everyone in health care is working too hard, too long.  Honestly, who has time to be bored?

But that's a problem. 

We usually think of being bored as a bad thing.  You don't often find people saying they're looking to be bored.  You don't find many activities that bill themselves as being boring.  In our always connected, 24/7 culture, being bored is seen as some kind of a failure: isn't there another notification on your phone, another email you could read, another update you could post, another task on the to-do list that you could try to cross off? 

But being bored, as it turns out, is closely connected to being creative.  Psychology Scott Barry Kaufman writes:   "In recent years, neuroscientists have discovered that we tend to get our best ideas when our attention is not fully engaged in our immediate environment or the task at hand."  He was writing about executives needing more alone time, but the point is to distract the brain in order to allow those creative juices to flow.

Earlier this year Wired reported on two studies relating to boredom.  One found that subjects who had just been doing boring tasks like copying numbers from a phone book did better on creative thinking tests than a control group.  The second found that subjects who had to watch a dull screensaver did better on an associative word test. 

"Boredom becomes a seeking state," said one of the lead researchers.  Another of the researchers worries that: "We try to extinguish every moment of boredom in our lives with mobile devices," thus eliminating "useful, productive monotony." 

Similar, a 2014 study found that bored people are more likely to have "divergent thinking styles...Thus, boredom may encourage people to approach rewards and spark associative thought." 

We're even so scared that our children will become bored that we hyper-schedule them, give them interactive devices, and structure their free time.  Dr. Helen Street says: "A child’s school life is more structured than ever and from an earlier age than ever before....As a result we are seeing a massive creativity deficit in kids."

Imagine what is happening to even-busier adults.

Albert Einstein famously spent several years as a patent clerk, reviewing ideas far removed from the spectacular physics that he was developing at the same time.  He was busy but not so busy that his mind couldn't break free of conventional ways of thinking. 

Author Jordan Rosenfeld wrote in Quartz about retraining her mind to be bored, suggesting:

  • Get in the habit of "spacing out;" 
  • Resist the urge for constant communication;
  • Face your feelings, rather than trying to avoid them.  

Certainly many activities in health care are boring, or at least mundane.  Processing claims, coding bills, updating patient records in EHRs -- not anyone's idea of a good time.  But neither are they tasks that allow for much spacing out, for associative thought that can lead to creative ideas.

Instead, we try to force creativity.  We hire consultants to tell us their ideas, we pour over research to see what ideas other people have, we conduct "brainstorming" sessions, we go on retreats with exercises designed to spur teamwork and new ideas. 

It's not impossible that creative ideas come from all that; it's just not very likely.  It's more likely that we just get iterations and variations of existing ideas.     

Creativity can't be forced, but it can be encouraged.  A previous post talked about the value of "wrong thinking" and "dumb ideas."  Another post talked about the importance of failure as the price of success. 

You have to give people the time to think freely and the support when that freedom doesn't always pay off. 

People say that health care is too important to try creative ideas that might be risky.  People's lives are at stake, after all.  We have to be careful what we try, how we try it, on whom we risk it.  Perhaps that is true, but the end result of that kind of caution is a health care system that costs too much, delivers too little, and that makes no one happy. 

So, be willing to be bored.  Make time for it rather than letting every minute get filled.  Be open to flights of fancy that come from some good old associative thinking.  Stop trying to go from point A to point B and think instead about different kinds of destinations, using different modes of transportation.  Spend less time worrying about what has to be done and more time wondering what might be done.

I truly hope you weren't, in fact, bored reading this, but if a good idea or two came while you were, it will have been worth it.

Tuesday, October 3, 2017

Putting Our Health Before Their Dollars

You have to give CVS credit.  In early 2014 they announced that, as a health company, they would stop selling tobacco products in their stores, despite the estimated $2b in sales those represented.  Sure enough, by September of that year those products were gone.  A follow-up study suggested that many of those shoppers didn't just buy them elsewhere but actually reduced their consumption, with a significant number ceasing to buy them at all.  Credit to CVS.

This year CVS is doubling down, beefing up its selection of healthy food options and health-focused products, while moving candy and junk food to the back of the stores. "Pharmacy is the heart of our business and our focus on providing care to patients and customers defines everything we do in our stores," said their Pharmacy President. 

And yet, in those stores, right by those pharmacies, you can still find plenty of dietary supplements, including vitamins. 

This is not to fault CVS, at least not solely.  After all, other retailers with large pharmacy businesses -- e.g., Walmart or Walgreens -- never even stopped selling tobacco products.  Of course, they sell supplements as well.

It is no wonder: supplements are big business.  The industry itself says it is a $37b industry, although estimates range widely.  At least half of Americans take some kind of supplements, with use among people 60 and over even higher

Supplement use is so mainstream that we not only tell our physicians about using them, they are our leading source of trusted information about them.

The question is not whether supplements are mainstream.  The question is whether they should be.

Just last month a police officer died after taking kratom, an herbal supplement.  Kratom is banned in 6 states, and the DEA tried to ban it nationally, citing 15 deaths in three years.  That ban died due to intense lobbying by, believe it or not, the American Kratom Association.

The problem is that the supplement business is not what one would call heavily regulated.  It barely is regulated at all.  The FDA does not approve dietary supplements.  Companies making/selling them are responsible for ensuring their products are safe and that any claims about them are not false or misleading, but the FDA does not verify either safety or effectiveness. 

In theory, the FDA is allowed to inspect manufacturing processes and maintain adverse event reporting, and can take action if problems are discovered, but there is severe doubt about how well it can perform these tasks.  The FDA's Office of Dietary Supplements has a $5 million budget and about two dozen employees, to oversee an estimated 80,000 - 90,000 products on the market. 

It's not a fair fight.  Supplement manufacturers don't have to prove their products are either safe or effective, but to remove a product the FDA has to demonstrate it poses a "significant or unreasonable risk of illness."

This matters.  The U.S. Poison Control Center gets a call every 24 minutes, on average, related to dietary supplement exposures.  One study estimated there were 23,000 ER visits annually, and 2100 hospital admissions, due to supplements.  The number of deaths associated with them remains in dispute, although a rare FDA ban -- of ephedra, in 2004 -- drastically cut the number.  Shamefully, the industry had fought that ban, but ultimately lost in federal court. 

Part of the problem is that we don't really know what is in supplements.  In 2015 the New York State Attorney General's Office found that only 21% of ingredients listed on various store brands were actually in the products.  Another study looked specifically at one specific product -- "red yeast rice" (I am not making that up) -- from 28 manufacturers and found that the key ingredient varied wildly in dosage and wasn't even present in some versions. 

Keep in mind that there really is very little data that supplements -- even vitamins -- actually have a positive effect.  One study found no impact of vitamins or mineral supplements for cancer or heart disease.   Another study focused on antioxidant supplements taken to lessen risk of Alzheimer's or dementia, and similarly found no impacts.  Indeed, multiple studies have found at best no positive impact and sometimes negative impact.

S. Bryn Austin, a professor at Harvard's School of Public Health, pretty much summed up the industry, telling Business Insider:
Consumers should expect nothing from [supplements] because we don't have any clear evidence that they're beneficial, and they should be leery that they could be putting themselves at risk.  Whether it's on the bottle or not, there can be ingredients in there that can do harm.
And yet supplements are discussed one-in-four primary care visits, with at least 79% of physicians admitting that they have recommended them at some point.  Over half of physicians take supplements themselves.  Some physicians are even selling them directly, which has its own host of ethical and legal questions


It really shouldn't be a surprise that we fall for the supplement hype.  We like quick and easy solutions.  We are a nation of fad diets.  We'd rather get vitamins from a pill than from eating a balanced diet.  We'd rather take weight loss supplements than eat less and exercise more. 

And we fall for placebos of all sorts, mainstream and alternative, while allowing use of prescription drugs and medical devices that are not nearly as safe or effective as we think.  Supplements aren't an outlier; they fit quite nicely into the rest of our health care system. 

Part of me feels that if people want to spend their money on products with no validated efficacy, that's their choice, as long as those products are marketed accurately (which is a big caveat).  If they want to go to GNC, a health food store, even to the junk foods section of a drugstore to buy them, well, it's their money.

Just don't pretend they belong in the pharmacy.

A larger part of me, though, wishes that, rather than embracing supplements due to their popularity, "mainstream medicine" should be even more vigilant about requiring evidence for use of any treatments -- prescriptions, devices, procedures, tests, or supplements.

When CVS -- or other pharmacies, doctors, hospitals, or other health care professionals-- start only selling or recommending treatments that have proven value, then I'll believe they're putting our health above their dollars.

Monday, September 25, 2017

Patients Are Not Consumers...But Who Is?

It has become an article of faith in some health policy circles over the past 20 years that the "solution" for our health care system's woes is to make us better health care consumers -- the so-called consumer-driven movement.

After all, we've known for at least forty years that increased cost-sharing does influence how much health care we consume, so, in theory, higher deductibles and coinsurance, plus better cost/quality information, should give us the right incentives to shop.

Most health care professionals are equally convinced patients aren't, and are never going to be, "consumers" in any meaningful sense.  Health care is too scary, relies on too much specialized information, and is too often "consumed" at times when we are least able to make thoughtful decisions.

So far the evidence that health care shopping works is skimpy, and I've often wondered why.  I've come to realize that it is not just a health care problem.

We're just bad consumers generally.

Oh, no, you might say.  We're a nation of consumers!  We love shopping!  We're the home of the mall, of Walmart, of huge grocery stores, of Amazon!  Shopping is as American as mom and apple pie.

Well, if health care has shown us anything, it is that just because we spend a lot of money on something doesn't mean we're good consumers.

Take one of the most common consumer products over the past thirty years, the personal computer.  Through luck or shrewdness, Microsoft managed to ensure that most of the early computers ran on a Windows operating system, buggy though it was, and we didn't demand better.  It wasn't the best OS available then and it isn't now (although it has improved), yet Windows remains by far the dominant operating system.

Well, then, consider mobile phones, specifically smartphones.  We love our smartphones even more than we ever loved our PCs, and Apple has certainly raised the bar for the entire market with its iPhones.  Here, certainly, is a case where we've acted as good consumers.  

Or maybe not.  Last year Apple made around 80% of all smartphone profits, despite only having around 15% of market share.  That is not a sign consumers are demanding better value.  Apple is now rolling out iPhoneX starting at a cool $1,000, and preorders for it are already depressing orders for other models.

If it is new and flashy, we want it.

Then there is the quintessential America product, the automobile.  Once upon a time, U.S. manufacturers dominated not just the U.S. but the world.  They got cocky, gave us ever more expensive and lower quality cars, and assumed we'd just keep buying them.  They didn't introduce car safety features like seat belts or air bags because we demanded them or because they wanted to improve their vehicles, but because lawsuits and consumer gadflies like Ralph Nader forced them into it.

Higher gas prices in the 1970's gave foreign car manufacturers the chance they needed, and they've been taking market share ever since, to the point when it's fairly even.  We now have better choices, safer vehicles, and -- thanks to the Internet -- virtually all the information anyone could want to shop for the best vehicle.

So what do we buy?  Year-in, year-out, the top three selling models in the U.S. are huge, gas-guzzling, expensive pickup trucks (Ford F-series, Chevy Silverado, and Dodge Ram).  

It's not that so many of us are farmers or construction workers.  We buy them because we like who we think that makes us.  You don't have to watch too many car commercials to realize they're appealing to our desired self-image rather than encouraging us to shop smartly.  And it works.

Most of us don't like our cable companies, but most of us tolerate old technology, subpar customer service, and paying for channels we never watch.  Few people consider flying a fun experience these days, but airlines continue to shrink legroom, tack on ancillary fees, and reduce choices of flights.  Yet we keep flying. 

OK, but surely the success of Walmart and Amazon proves we're good consumers, taking advantage of low prices and comparison shopping?  Don't count on it.  Even at these low-cost merchants, there still are plenty of markups on most items (think Air Jordans really cost $150?).  And Amazon illustrates how prices for the exact product can still vary greatly -- yet some people still pick the higher priced options.

If there is anyplace we might be expected to act as good consumers, it might be at the grocery.  We all shop there, and our lives literally depend on our choices.  Any illusions one might have about how wisely we shop there should be dashed by the cereal aisle, which is filled mostly with overpriced ways to repackage sugar.

So where, exactly, are we acting as good consumers?

The fact of the matter is that we are not rational consumers.  There is a raft of research literature on this point.  Psychologist Peter Noel Murray, Ph.D., calls it "the myth of the rational consumer."  We like to tell ourselves -- and anyone who asks -- that we're making sound, rational purchase decisions, but much of our purchase decisions are driven by influences that we may not even be aware of.

In the end, Dr. Murray says: "It is the consumers’ perceptions of emotional payoffs that cause purchase behavior."

We're aware of how badly we consume health care services because the health care system is so bewildering, and because our encounters and health insurance premiums are so expensive.  If we used more legal services, we'd be talking about the arcane legal pricing structures and how ill-equipped we are to shop for those services.

The question isn't why we're not better health care consumers, but why we ever thought we'd be better at shopping for it than anything else.

That being said, there are people who do try to shop prudently, and would probably do more in health care settings if they had better data and more options.  We may not be actually getting better deals at auto dealers -- their profits don't seem to be suffering much from all our supposed hard bargaining -- but more of us at least can leave there feeling we tried.

We can at least hope for that much, even in health care.

Tuesday, September 19, 2017

Not Just Better Tech, Nicer Tech

We are surrounded by our technology.  We're glued to our smartphones, and when we're not on them we're looking at our tablets, computers, televisions, or gaming systems.  We're turning our cars into mobile technology platforms and our houses into "smart" homes, complete with Internet-of-Things (IoT) connectivity and always-on-call virtual assistants like Amazon's Alexa.  Most of our jobs are increasingly infused with technology, even ones historically considered low-tech.

We're addicted to technology, but we're not all that happy with it, and nowhere is this more evident than in health care.


For example, a recent post-mortem of HITECH, by John Halamka and Micky Tripathi looked at the "miraculous" success of the program in moving health care providers to electronic health records (EHRs).  Still, the authors admitted: "Along the way, however, we lost the hearts and minds of clinicians.".

In their great analogy, "we gave clinicians suboptimal cars, didn't build roads, and then blamed them for not driving."

Indeed, EHR tasks are said to consume half of primary care physician's time, and nearly two-thirds of health care professionals in another survey said the ROI on EHRs has been terrible or poor; only 10% rated it positive.

As Jody Medich warns in Singularity Hub, our interfaces are killing us.  According to Ms. Medich, The "human-machine-interface" (HMI) we've been relying on is all-too-often based on a time when we sat at a desk, looked at a terminal, and did things like math.  It wasn't intended for now, when our computing devices are with us everywhere and expected to be always-on-call, for a variety of everyday tasks and in ways that we can immediately process.

Our cars as mobile technology platforms are a good example: driving at 70 mph, is not the best time to have to look at verbal information on a small screen or at confusing icons.

Ms. Medich believes we are about to go into an era of cognitive or perceptual computing, which "recognizes what is happening around it (and you) and acts accordingly...This means technology will be everywhere, and so will interface."

David Webster, a partner at design firm Ideo, frames the coming technology revolution differently.  He writes: "The key is to design experiences around emotional value rather than rational value."

That may be the problem; our technology has always been written by hyper-rational coders, aiming at "rational" tasks, while much of what we do every day is driven by more emotional reasons.  .

Mr. Webster gives the health-related example of a "smart" scale that chided a woman for gaining a few pounds -- not realizing she was four months pregnant.  Getting such alerts can help motivate people, but they need to be appropriate and in context in order to be effective.

Just ask any health care professional about "alert fatigue."

Mr. Webster goes on to say:
The fundamental role of designers is to use creativity to bridge the gap between rational and emotional—to make new technology engaging and appealing by having it meet humans on their terms. We’ve found the best way to get people to integrate new products or behaviors into their lives is to connect with them emotionally, which encourages adoption.
If there is any sector that needs to think about the emotional, it is health care.

People turn into patients when they enter health care settings.  They turn into patients once they're diagnosed with a health issue.  As patients, they're forced to rely on health care professionals, they're bombarded with unfamiliar jargon, they're often asked uncomfortable questions or put through unpleasant treatments and/or procedures.  They may be scared, worried, angry, uncertain, or even delighted (a new baby!).

Talk about emotional.

Much effort has been put into giving patients access to their heath records, yet Ambra Health reports 31% of consumers can't easily access them, and other research suggests that well below 30% of patients with such access actually access them.  And how many understand them?

Meanwhile, we're also collecting data from other sources, such as wearables.  We're able to track our steps, monitor our blood pressure and heart rate, measure our blood glucose levels.  We can see all those resulting numbers, and get alerts about them.  But more numbers are not what we need.

We're already floundering in data we don't easily understand and we're making it worse.

If health care was strictly rational, placebos wouldn't work and we'd be eager to replace our human doctors with artificial intelligence (AI) ones.  But they do and we aren't.

EHRs shouldn't be data collection vehicles for clinicians, and they shouldn't be primarily data reporting mechanisms for them, or for us.  We are not data and our health can't be reduced to it.

Similarly, it's very clever to create "dashboards" for our various health information from our many devices, but we care less about what the numbers are than what they mean for us.

A previous post argued for the importance of data visualization, pointing out: "Let's face it: most of us are not good with numbers.  Most of us don't think in numbers.  Most of us think in pictures."  Rasu Shrestha, MD, MBA, the UPMC chief innovation officer, gently disagreed, saying that most of us think in stories.

Pictures or stories -- either way, if we want tech to be effective, it has to engage us emotionally, not just rationally.

In a Wall Street Journal opinion piece, Mark P. Mills -- a senior fellow at the Manhattan Institute and engineering professor at Northwestern -- says the cyber age has hardly begun, as we have yet to truly integrate software into hardware "so that it becomes invisible and reliable."

Further, "the U.S. now stands at the equivalent of 1920 for ubiquitous cyberphysical systems," he believes, and "the dominant players of the cyberphysical age have yet to emerge."

Our 1960's/1970's approaches to technology have been very successful, but it is now the 21st century and it is past time for the next era of technology.  Whether that is cognitive computing, emotional design, or cyberphysical -- or a combination of all three -- our technology needs to and is going to act very different.  It needs to "know" us and react to us appropriately.

We are building technology with ever-higher IQs, when what we really need is technology with EQ.

Where better to start than in health care?