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?

Tuesday, September 12, 2017

The World Is Not (Going To Be) Flat

Too many of us have come to believe that the world is flat.  No, I'm not talking about the Flat Earth Society or the random celebrities who purport to believe it is (although both are troubling).  I'm talking about the rest of us, who increasingly see the world through the prism of our various screens, be they smartphones, computer screens, or TVs.  Americans admit to almost 11 hours of screen time daily, and one has to suspect that is understated.

That's going to change.  Soon.  And digital cinema camera maker RED may be showing us how with its new Hydrogen One smartphone.

In a partnership with Leia Inc., an HP spin-off, RED announced the Hydrogen One, which it claims is "the world's first lightfield "holographic" smartphone."  It is expected to be on the market in the first half of 2018, and will retail for $1,200 ($1,600 for the titanium version).  

Their press release says: "The Hydrogen program will feature stunning holographic content and 3D sound for movie viewing, interactive gaming, social messaging and mixed reality."  That's all very nice, but it is the holographic display that has people's attention (well, that and the price).

RED's background has been in cameras, aiming to "build the world's best cameras," which began with 2007's RED ONE, a breakthrough 4D digital camera (they now claim products with "8k resolution").  Leia has similarly grand ambitions, stating that:
Our proprietary Diffractive Lightfield Backlighting (DLB™) solution adds nanostructures to a conventional display and gives them almost magical properties while preserving their standard imaging capabilities.
Got that?  A 2015 Leia video helps illustrate their display:
OK, so it's not quite like the holograms we expect from science fiction television shows and movies, and content is going to be an issue for some time, but it is at least a break from the flat screens we're used to, even with 3D renderings in 2D.  And they're not alone.

Apple, for example, has filed a patent application for "interactive three-dimensional display system," according to CB Insights.  Holus has a Kickstarter campaign for its "interactive tabletop holographic display." while Holoxica claims "several generations of holographic technologies, which span from static images to motion video displays with interaction."

There are published papers in Nature and Optics Express that promise, respectively, "Holographic displays generate realistic 3D images that can be viewed without the need for any visual aids" and a "360-degree tabletop electronic holographic display."

Writing for NPR last month, Glenn McDonald asserted that for true holographic displays, we're not quite there yet, but "we're getting awfully close, though."  He cites a laser display from the University of Rochester and a laser-plasma approach from Aerial Burton as examples.  Other versions are still, he believes, more like optical illusions of "genuine" holograms.

If we only think we're seeing a hologram, does it really matter, as long as we do see them?

The point is, holographic displays are not only feasible with existing technology, but are starting to be commercialized.  RED may have gotten a jump on the market, and may be early in what the experience can yet deliver, but its state-of-the-art will not remain the state-of-the-art very long, nor will they be the only ones.

There will be some fast followers, and they will, indeed, follow fast.

It won't just be about smartphones.  Anything that uses a screen could be augmented, or replaced, by a holographic image.  I've written before about the coming world of "ubiquitous computing," where your device could be just about anything and your display show up anywhere you desire.

You may not care about a holographic display of text, for example, but you might about images, especially if they are interactive.

Entertainment and gaming, of course, are two industries where holographic displays should find early uptake.  Health care, on the other hand, is rarely a fast follower of new technology, but the industry needs to be thinking about the possibilities.

Health care is about people, but it is full of words and data.  Your medical chart is full of words you don't know, drugs you can't even pronounce, numbers that have no obvious meaning.  Health educators do their best to come up with illustrations, simplified explanations, videos, and visual aids, but most of us have health literacy levels well below our general literacy.

Even health professionals struggle to take in all the information, and that problem will grow exponentially as that data does, such as through sensors in wearables and elsewhere.  We need more pictures, and some of those pictures should be holograms.

Picture a hospital room, with the poor patient hooked up to various monitors (all beeping away constantly).  A doctor or nurse coming into the room has to look at the screens and try to make sense of what they are saying about the patient's health.  They may be very good at it, from years of practice, but perhaps it doesn't have to be so hard.

A holographic display -- perhaps of the patient, or trend lines -- could help more easily illustrate problem areas or indicators that are trending in the wrong direction.  It doesn't have to be holographic, of course; it's just that we are visual beings.  A holographic image might make the situation more real and the comprehension faster.

I long for the EHR that is based on holographic displays, allowing the clinician to not only visualize a patient's history and current status but also interactively annotate them.  The display could also be much easier for the patient to view and understand, as well as allowing for on-the-spot visualization of any diagnoses or proposed treatments.

If, as the saying goes, a picture is worth a thousand words, then a holographic display might be worth ten thousand words of medical jargon.

Augmented reality (AR) and virtual reality (VR) are equally exciting, but, to the extent that they require us to view them through devices, may have different uses.  At some point, though, the three technologies may, for all practical purposes, merge into a unified "hand-free" interactive experience.

So, kudos to RED and Leia for showing us the way forward with smartphones.  The future of holographic displays can't come fast enough.

Tuesday, September 5, 2017

Health Care's Juicero Problem

Bad news: if you were still hoping to get one of the $400 juicers from Juicero, you may be out of luck.  Juicero announced that they were suspending sales while they seek an acquirer.  They'd already dropped the juicer's price from its initial $700 earlier this year and had hoped to find ways to drop it further, but ran out of time.

I keep thinking: if they'd been a health care company, they not only might still be in business but also would probably be looking to raise their prices.
Juicero once was the darling of investors.  It raised $120 million from a variety of respected funding sources, including Kleiner Perkins, Alphabet and Campbell Soup.  They weren't a juice company, or even an appliance company.  They were a technology company!  They had an Internet-of-Things product!  They had an ongoing base of customers!

Juicero's founder, Doug Evans, saw himself as a visionary, telling Recode: "I'm going to do what Steve Jobs did.  I'm going to take the mainframe computer and create a personal computer.  I'm going to take a mainframe juice press and create a personal juice press."

The market seemed promising.  All those people willing to pay $5 for a cup of Starbucks or $200 for their own Keurig would certainly see the value in their own juicer, especially with Juicero's own, IoT-connected Produce Packs.  Indeed, Juicero claimed to have sold over a million of the Produce Packs alone.

The ridicule started almost as soon as the hype.  $700 -- even $400 -- for a juicer?  Even for Silicon Valley, that was a bit much.  Mr. Evans was replaced as CEO last fall, but their woes continued.  The negative publicity probably reached its nadir in April, when Bloomberg reported people could produce almost as much juice almost as fast just by squeezing the Produce Packs directly.
Moral of the story: if you want to introduce products that have minimal incremental value but at substantially higher prices, you're better off sticking to health care.

Take everyone's favorite target, prescription drugs.  The pharmaceutical industry has learned how to play the system for higher prices, and profits.  They can take existing drugs and tweak them to justify higher prices, or even buy rights to existing drugs and jack up the price, as we saw with Daraprim ($13.50 per tablet to $750) and EpiPens ($57 to over $500).  Former Turing Pharmaceuticals AG CEO Martin Shkreli, who raised the Daraprim price, may be hated for his actions but he's not alone.

Consider this: studies suggest that only about 10% of new drugs are actually clinically superior to existing treatment options.

As Donald W. Light charged in Health Affairs, "Flooding the market with hundreds of minor variations on existing drugs and technically innovative but clinically inconsequential new drugs, appears to be the de facto hidden business model of drug companies."

As with prescription drugs, we regulate medical devices looking for effectiveness but not cost effectiveness -- and we don't even do a very good job evaluating effectiveness in many cases, according to a recent JAMA study.

And, as Elisabeth Rosenthal pointed out in her remarkable An American Sickness, medical device manufacturers have figured out how to game FDA regulation by claiming products were "substantially equivalent" to existing devices; "The surprising result is that today there is generally far less careful scrutiny of new devices than new drugs."

Take robotic surgery, hailed as a technological breakthrough that was the future of surgery.  A robotic surgical system, such as da Vinci, can cost as much as $2 million, but, so far, evidence that they produce better outcomes is woefully scarce.

As Dr. John Santa, medical director at Consumer Reports Health said, "This is a technology that is costing the heathcare system hundreds of millions of dollars and has been marketed as a miracle -- and it's not."

It is, of course, much more expensive.  

Proton beam therapy?  It's one of the latest things in cancer treatment, an alternative to more traditional forms of radiation therapy, and is predicted to be a $3b market within ten years.  The units can easily cost over $100 million to buy and install, cost patients significantly much more than other alternatives, yet -- guess what? -- not produce measurably better results.

The number of proton beam centers is growing rapidly, of course -- especially in the U.S.

But, in our health care system, with its crazy-quilt system of financing and delivering care, we don't need new drugs or fancy new devices to cost us more.  We pay more for pretty much everything than pretty much everyone else.

Last year Vox used 11 charts to illustrate how much more we pay for drugs, imaging, hospital days, child birth, and surgeries than other countries.  Their conclusion, which echoes conclusions reached by numerous other analyses: "Americans spend more for health care largely because of the prices."

We not only don't get a nifty new juicer from all of our health care spending, we don't even get better health outcomes from it   

Health care's "best" Juicero example, though, may be electronic health records (EHRs).  Most agree on their theoretical value to improve care, increase efficiency, and even reduce costs.  But after tens of billions of federal spending and probably at least an equal amount of private spending, we have products that, for the most part, frustrate users, add time to documentation, and don't "talk" to each other or easily lend themselves to the hoped-for Big Data analyses.

Many physicians might, on a bad day, be willing to trade their EHR for a Juicero.

Jonathon S. Skinner, a professor of economics at Dartmouth, pointed out the problem several years ago: "In every industry but one, technology makes things better and cheaper.  Why is it that innovation increases the cost of health care?"

Essentially, he believes, our health care system pays for too many things that are of too little value, because, "unlike many countries, the U.S. pays for nearly any technology (and at nearly any price) without regard to economic value."

So we can make fun of Juicero all we want, but when it comes to overpriced, under-performing services and devices: health care system, heal thyself first.