My dad was a wonderful guy who could fill the room with his personality. He grew up during the Great Depression and was a World War II veteran. I was thinking of him recently while considering how much health care delivery has changed in the last 100 years.
When asked about his health, my dad would always say, “I feel great. I don’t have any aches or pains.” This is telling. His generation equated pain with the need to seek care from an expert. After all, he grew up before Penicillin was discovered. During that time, given what we knew about health and disease and what we could offer for treatment, it makes sense that people sought the care of a physician when they ‘weren’t feeling well.’
We’re now in an era where chronic illness management and prevention accounts for 70% of health care costs. Of the forces responsible for illness — bad luck, bad genes and lifestyle — lifestyle is the predominant cause of chronic illness.
Our public health officials understand this important change, but consumers by and large still do not. They still mostly seek care when there is some symptom or acute need. This is problematic because so much lifestyle-driven illness is silent for years (hypertension, pre-diabetes, obesity) and only generates symptoms when things are pretty far along.
The other interesting aspect of my father’s adage is the denial underneath it. He was really saying, at some level, “If I don’t have any symptoms, I’d just as soon avoid the doctor so I won’t get any bad news.” This psychology too is quite prevalent among consumers today, adding to the challenge of raising awareness of lifestyle-driven illness. It is easy and human nature, to live in denial.
Another childhood memory I have is how kind my mom was whenever I was under the weather. She gave us extra love, as if that would help the illness improve more rapidly. Given that most childhood illnesses are viral infections, I suspect her added affection didn’t change the course of any illness, but she made it tolerable to be sick.
We all want to be cared for. This enables a child-like approach to the health care system. It is common for patients to come to see us joking about non-compliance and begging, “Don’t yell at me.” Likewise, they boast about their doctors, implying that they can put all of their worries aside: “She’ll make sure I am ok. I trust her.”
This triad of not thinking about health until symptoms arise, not wanting to hear bad news and abdicating responsibility for care to a health care provider accounts for a big part of why it is so difficult for physicians to get folks’ attention before they get sick.
Connected health can help us counteract these challenges. The vast array of sensors now available and their attendant feedback loops make it hard to ignore when we’re not on track with our health. Even if we don’t feel symptoms, we can be reminded several times per day of how we’re doing with respect to a given health parameter. When these data are shared with a health care provider, it becomes more difficult for individuals to ‘abdicate responsibility,’ something we’ve called the sentinel effect. When patients know their objective health data is being shared with a provider, they naturally up their game to appear to be compliant and interested in their health. No one wants to look like a slacker in front of their doctor.
But we still have challenges when it comes to denial and individuals abdicating responsibility for their health. This is magnified because we live in a libertarian society. It is our right to ignore our health if we choose to; and because our politicians want to offer us ‘coverage,’ we can still get our bills paid in the face of unhealthy lifestyle and behaviors.
What tools do we have to deal with this challenge?
- Incentives/rewards. We can offer individuals rewards for achieving health goals. Our connected health sensors can be the source of objective data to automate decision-making around those goals.
- Penalties. As a colleague recently said to me, “There is a continuum. You start with encouraging your workforce not to smoke and offering them rewards for not smoking. Next, you give them notice that those who continue to smoke will pay a higher insurance premium. Finally, you institute a policy to not hire smokers.”
Should we follow this approach with other lifestyle/habits such as physical activity and diet? Does it seem to invasive? What do you think?
Have you ever thought about how we evolved and the implications for health care? For millennia, we sought the help of a physician when we sensed something awry in our daily sensations. Sometimes this is as subtle as ‘I just don’t feel right,’ but sometimes it is as dramatic as an athletic injury or a tooth ache. Those latter circumstances are strong motivators to seek health care services because of the associated pain. Somewhere along the evolutionary road, we developed a nervous system with pain receptors, vital sensors that can help prevent injury. These benefits are most obvious in people with various forms of neuropathy. It is common for them to develop serious burns that they aren’t aware of; pressure ulcers, etc.
By contrast, we did not develop sensations for some equally serious health-related phenomena. For instance, the elevation of blood pressure is virtually undetectable until it gets to acute-crisis levels (hence the term ‘the silent killer’). Most folks can tolerate a blood glucose level of 150 to 200 (normal is around 100) or even higher without having much in the way of symptoms. This is why so many cases of type II diabetes go undetected years before they are picked up because of some other downstream symptom.
When you get into the realm of preventative care, it is even more curious. Though current evidence overwhelmingly supports daily cardiovascular exercise, most of us feel a very strong pull toward the easy chair or the sofa. Likewise, we can overeat slightly or overtly for years and ‘suddenly’ notice that we’ve gained 10 lbs. There is no symptom of high cholesterol, though we now know it to be a precursor of serious cardiac disease. Somehow our knowledge of pathophysiology seems to be ahead of our evolutionary development.
These latter challenges have become the bane of health care policy makers. We can’t get people to pay attention to diet, exercise and other preventative tasks because there is no symptom associated with unhealthy behavior — until it’s often too late. In fact in many cases, it seems that the unhealthy behaviors are in themselves psychologically rewarding so we are really swimming upstream here.
Enter the modern era of wearables and sensors. Sensor technology is going through a sort of Moore’s law type period, with personal health technologies experiencing exponential improvements. The technology is becoming cheaper, smaller, easier to power, etc. The most mainstream example of how this can affect health care are the systems that combine continuous glucose monitoring with insulin pumps in type I diabetes (so-called artificial pancreas).
The sensor industry is exploding with interesting innovations. Boston-based MC10 can put sensors and associated electronics into a flexible substrate allowing for devices the size and thickness of a postage stamp to be employed in vital sign sensing.
OMsignal is weaving sensors into fabrics enabling a t-shirt that can sense all manner of vital signs.
With all of the attention to nano technologies, it is not farfetched to imagine sensing of phenomena such as the level of cholesterol in the blood.
Are there examples of products on the market today that bring this vision to life? I can think of three. The Muse, by InteraXon, is a wearable EEG device that enables biofeedback and enhanced mindfulness training.
BioBeats senses your heartbeat and uses software algorithms to create music that relieves stress.
HeartMath uses a wearable sensor to give you biofeedback on your heart rate and improves focus, mindfulness and stress response.
So what if high blood pressure was like a broken arm? Think how health care delivery and prevention would change. With the evolution of new sensors, we will be finding out in our lifetimes. Imagine, with me, how this is going to change health and wellness in the future.
The 2014 Connected Health Symposium (our 11th) promises to be a feast for those hungry for knowledge on the subject. This year we have content focused on connected health at scale, the patient voice, new ways of sensing health and the latest policy updates – just to name a few of the topics we’ll cover during this two-day event.
We continue our rich history of outstanding keynoters delivering TED-style talks on the main stage. Don’t miss Eric Dishman. There is no one who tells the story of how connected health can make a difference in a more genuine manner.
Nir Eyal is both giving a workshop on October 22 and speaking on October 23. His recent book Hooked: How to Build Habit Forming Products has made lots of news. He’ll tell us how to make healthy behaviors habit forming.
Additional examples of some of our thought provoking panels include, The Evolution of the Patient, Pioneers at the Intersection of Primary and Behavioral Health, and Lessons Learned from Large Scale Telehealth Interventions.
There will be a themed section on Sensing Aspects of Health That are Normally Silent, which includes a performance by the design firm Sensoree highlighting their innovative clothing that changes color according to the wearer’s mood.
Top it off with book signings and networking breaks. Day one is a can’t miss day.
Day two kicks off with two great speakers: Robin Farmanfarmaian and Clive Thompson. Following that are some terrific panels including one on International Perspectives on Scaling Connected Health. Our themed section for day two is on Patient Voice, and includes both a thoughtful keynote (Sarah Krug) and panel on the topic, as well as a rendition by the comedy group Damaged Care giving us a lighter take on the topic.
Once again, we have more book signings and networking on day two.
I have the honor of closing the conference with my talk asking the question: Will 2015 be mHealth’s Coming Out Party?
Year after year, attendees give us great feedback on the Symposium. It has become a signature event for Partners HealthCare, for the Center for Connected Health and an event which promotes industry growth and cohesion.
It’s a can’t-miss event and I look forward to seeing you there.
I saw another exciting news story on a mobile health intervention the other day. I honestly don’t remember the company or product, but what stuck with me was the declaration of success based on 10 patients using the product for three months. Success was touted in terms of cost reduction and resource utilization reduction in a before/after analysis. This inspired me to collect some thoughts on some of the challenges around evaluating success in mHealth.
mHealth represents the collision of two interesting worlds — mobile, which changes on what seems to be a daily basis, and health care, which changes infrequently, only after significant deliberation and usually much empirical analysis. In the tech (mobile) world, companies are talking about creating a minimally viable product (MVP), getting it out in the market, assessing adoption through metrics such as downloads and customer feedback, and iterating accordingly. This would seem to make sense in the consumer world where the goal is to sell a game, an information app or productivity app. If people use it and are willing to pay, that proves its utility, right?
There is something to this line of thinking. Empiric market success is in some ways the ultimate success, at least for those who want to make a big difference in how humanity benefits from technology.
But does this work in health care? I’m not so sure. As clinicians, we’re trained to turn our noses up at this sort of measure of success. But maybe we’re the ones who are wrong. Let me use the 10-patients-for-three-months example to illustrate some issues.
- Selection bias. Virtually all pilots and trials of any sort suffer from this to some extent. These days, it seems that patient/consumer engagement is the holy grail and we all must realize that people who show up to enroll in any sort of study are already engaged to an extent. What about the people who are great candidates for an intervention (conventional wisdom says the disengaged are sicker and more costly) but are too unmotivated even to show up to enroll? Does anyone know how to handle this one?
- Regression to the mean. This is a pesky and annoying one — and a favorite of folks trained in public health — but unfortunately it is a real phenomenon. This is the stake in the heart of virtually all before/after studies. If you follow a group of people, particularly sick ones, a certain percentage of them will get better over time no matter what you do. The more sick the starting sample, the more dramatic the effect. This is why some sort of comparison group is so helpful and why before/after studies are weak.
- Small sample size bias. This one can go either way, meaning you can exaggerate an effect or miss one. If you want to run a proper study, find someone who has training in clinical trial design to estimate the size of the effect of your intervention, and thus the size of the sample you need, to show its efficacy. Lots of technical jargon here (power calculations, type I error, type II error, etc.), enough to make your head spin. But bottom line, you can’t really say much about the generalizability of data based on 10 patients.
- Novelty effect. I made that up, and there is probably a more acceptable scientific term for it. But what I’m referring to is, when you take that same group of people that was motivated enough to enroll in a study and apply an intervention to them, the newness will drive adoption for a while. We see this all of the time in our studies at the Center for Connected Health. The novelty always wears off over time. In fact, I’d say the state-of-the-art in understanding the impact of connected health is one of cautious optimism because we haven’t yet done long term studies to show if our interventions have lasting effects over time. There is room for argument here, I guess, but three months is awfully short.
Why is health care tech different than finding the MVP in the rapidly-changing, market-responsive world of mobile tech? One reason may be that we’re dealing with health and sickness which are qualitatively different than sending a friend the latest snapshot from vacation. It is cliché to say it, but lives are at stake. So we’re more careful and more demanding of evidence. Is this holding us up from the changes that need to occur in our broken health care non-system? Possibly.
It is true that a well designed trial with proper sample size is expensive and takes time. Technologies change faster than we can evaluate them.
One thing we’ve done at CCH is design studies that use a large matched data set from our electronic record as a comparator. This speeds things up a bit, eliminating the need to enroll, randomize and follow a control group. Results are acceptable to all but the most extreme purists.
What ideas do you have on this dilemma?
I’ve been toiling in the field of connected health for 20 years now, watching for signs of adoption that will move us into the steep part of the curve. I have to wonder, with announcements from several huge consumer companies recently, if that time is coming.
By now you’ve heard about Apple’s HealthKit announcement (my thoughts on this detailed here), which involved not only Apple, but Mayo Clinic and Epic.
Samsung is not sitting still, having released increasingly sophisticated versions of their S Health app.
Rumor has it that Samsung will also be coming out soon with the next version of their Galaxy Smartphone accompanied by a developers’ toolkit for health apps. Google will be launching Google Fit.
Some of this exuberance (is it rational?) also involves excitement around wearables, and the intersection of mHealth and wearables is an area of particular interest. To wit, Microsoft is rumored to be introducing a smartwatch this fall, amid lots of interest at Google, Apple and Samsung in the role of the smartwatch in mHealth.
OK, you get the picture. Any analyst worth her salt has got to be predicting a break-out year for mHealth. The mHealth market is said to have been $1.95B in 2012, growing to $49B by 2020; the wearables market is predicted to be $12B by 2018, of which 60% will be health tracking. We just coined a new term, the Internet of (Healthy) Things to describe this convergence.
What’s not to like here? Well, I’m not sure, but there are some reasons to be cautious. Better still, there are some things we must get right as we steward this amazing opportunity to harness a game-changing technology (mobile) and apply it to the laudable goal of improving the health of our citizens.
First the words of caution. My friend Nancy used to tell me she hated to be the skunk at the picnic, and those words ring true here. But allow me a couple of comments contrary to all of the enthusiasm. As noted previously, if HealthKit is just another place to store health-related data — moving from a web application to a mobile phone — do we really think consumers are going to jump for joy? Santayana said, “Those who do not learn from history are doomed to repeat it.” Did we learn the lessons from Google’s failed PHR? From Microsoft’s HealthVault? If you build it, they do not necessarily come. For health, it has to be more compelling than that.
Here are some facts that remind us of the challenge:
- Although one out of ten U.S. adults over the age of 18 owns an activity tracker, within six months, one-third stops using it.
- More than 80% of health apps (like Lose It! or MyFitnessPal) that are downloaded are abandoned within two weeks.
- Also of note, Aetna discontinued CarePass last week, seemingly because their members weren’t enthralled by it.
Most app development is based on the adage, “Give the people what they want.” Snapchat, Instagram, Tinder, etc., are all designed to meet a basic human need in a very simple way. The challenge in health care is that, though we know what patients/consumers need to do to improve their health, most of them don’t want to hear about it. That makes building ‘sticky’ health apps and devices much tougher than a messaging or photo sharing app.
Today, most health care app development is still confusing education with inspiration. They are not equivalent! I’ve told the story before about how we check our smartphones 150 times per day. But in a blood pressure monitoring study at the Center for Connected Health, we had difficulty getting patients to push one button once a day to participate in a program their doctor enthusiastically recommended for them.
What, then, do we do to take full advantage of the opportunity that Samsung, Apple, Google and others are providing us? The answer, simple and yet elusive, is: Focus on Engagement
Over these 20 years, I’ve seen technologies come and go, trends take hold and others fade away. We are learning a great deal about how to empower patients to self-manage their health, and what to do with all of this patient-generated data. The common denominator, the one critical element we must get right, is how to ‘sell’ health to consumers and keep them coming back for more. I say it’s got to be personal, motivational and ubiquitous. What do you say?
I heard the other day that by 2017, 50% of the pharmacy spend in the U.S. will be on specialty pharmacy. It seems this is driven by two phenomena. The first is the growing crop of new molecules that are in the class ‘biologics’ – developed via biotechnology and which are complex to manufacture, require special handling and care coordination. They are incredibly expensive but have given us new hope for such conditions as Hepatitis C and a variety of cancers. These are classified as specialty pharmacy drugs. The second phenomenon is that just about everything else will be generics. Specialty drugs in this one burgeoning expense class seem to be taking over the pharmaceutical industry, and bucking the trend in health care — to succeed by being more efficient. This brings to mind two opportunities for connected health. One is surrounding these expensive therapeutics with connected health applications in order to improve outcomes and reduce costs. The second is that connected health interventions, because of their demonstrated improvements in adherence, can improve the care experience, patient satisfaction and quality of life, and themselves prove to be therapeutic.
I am not going to speak to the first opportunity, but we are working on a real-life example of this at CCH now. We are under non-disclosure with the research sponsor, but I promise you it will be an exciting result when we can publicly discuss it.
The latter opportunity is intriguing and a bit of a sleeper. Traditionally, the introduction of new technologies into health care has been assumed by knee-jerk reaction to add costs. Yet, we’ve accumulated evidence to the contrary. I have two stories to demonstrate this.
The first example is a clinical research program we have under way with adolescents who have asthma. We’ve created a private Facebook group for them to be part of, and that’s about it really. No fancy bells and whistles. Just old-fashioned social networking. This is a study in progress, but to date we’ve already seen a positive effect, as measured by an instrument called the Asthma Control Test (ACT). Typically, the success rate of teenagers filling out this survey is 18%. Although the results are still preliminary, it appears that just putting kids in a Facebook group increased their participation to 80%. More importantly, the improvement in the score on the ACT measuring how well these teens are controlling their asthma also appears to be significantly improved, compared to the use of a new inhaler, it seems that Facebook can be more therapeutic than a drug. I’m being provocative here, but you get the idea.
The second example is in type II diabetes, using connected health to improve activity. We randomized patients with type II diabetes into two groups, one received an activity tracker and nothing more versus a second group that received a tracker plus were sent automated motivational messages every day.
The messages were algorithm-driven; they were not sent by a person. The algorithm took into account several variables, including self-reported information on how motivated the individual was to increase activity, data from the activity tracker, weather data, and some electronic records data. This intervention was conducted over six months. Interim data suggests that patients receiving the automated messages had a significant drop in HbA1c, more robust than the effects of Metformin, one of those generic drugs referenced above. Once again, we see the potential of connected health to be more therapeutic than a drug. This result is even more impressive when you take into account the fact that the messages were machine generated.
These data drive home the point that engagement is powerful and that engaged patients do better. In both cases, those patients who were engaged, measured by either participation in the Facebook group or frequency of opening messages, did even better than the intervention groups as a whole.
Here are two examples, then, where connected health competes with chemical therapeutics in terms of efficacy.
It suggests a future where connected health programs are widespread, either as adjuncts to or substitutes for chemical therapeutics. And, we haven’t yet discussed how connected health strategies can be integrated into clinical trials, or deliver value-added programs to build brand loyalty and patient engagement.
Of course, these days connected health programs are more costly than the chemical therapeutics (the generics anyway), but that cost will plummet over time.
How does this future look to you?
Apple has been making headlines again, which is not unusual for a company that sets trends and moves markets. A week or so ago they announced that iOS 8 would have a built-in app to collect all of your health info in one place. Then there was the announcement of the partnership with Mayo Clinic and Epic Systems. This generated even more headlines. I saw all kinds of opinion pieces published, ranging from predictions that this will be the ‘game changer’ that mHealth has been waiting for, to those who said, “Not so fast. What is really novel here?” I let the dust settle, processed all of this, and came up with the following reflections.
It’s impossible to give an educated opinion because all we’ve seen so far are some hints at what the software will do. We have no idea what the hardware play will be and we don’t yet know all of the planned software capabilities. However, there are some things I believe we can count on.
Apple has an amazing track record of creating superbly designed, intuitive software and beautiful, flawlessly integrated hardware. By contrast, virtually all software created for health care users (providers, patients and administrators) is poorly designed. If Apple offers some breathtaking software and very sexy hardware to help us stay healthier, it could make a difference, or at least point the way for others as the iPod and iPhone did.
Also, hats off to Epic and Mayo Clinic for showing us the way on the integration of patient-generated data into the electronic health record. If the platform gets traction with Mayo clinicians and/or if they can show patient-generated data being used to improve health outcomes or lower cost, this could be a very big deal.
I can’t help but be optimistic. But I also can’t resist playing armchair quarterback and offering some advice as the effort goes from screen shots to reality. With so much opportunity to be transformative, I hope they take up that mantle seriously and don’t repeat the mistakes of recent connected health history. Here is my wish list for Apple as they launch HealthKit.
- Please don’t think that a health data repository on a mobile device will be transformative. Google discontinued its health data repository and Microsoft’s has gotten very little use. We (society, health care experts, providers) have not given consumers/patients enough of a reason to make the effort to store all of their health data on one platform. People don’t feel compelled to take ownership of their health data. The only compelling use case is the traveler who gets ill and that just isn’t enough. Yes, HealthKit will make the collection of health data mobile and most likely passively captured. But overcoming these consumer barriers will not be enough to assure widespread adoption, I fear.
- Please don’t make it just about seeing your doctor’s notes/lab data, etc., on your mobile device. This would be under-imagining the potential of this type of platform. I’m assuming that with the wave of wearables and Apple’s interest in health tracking, we will see heavy integration of patient-generated data. But, assuming is dangerous, so this is my explicit plea to Apple to do lots with patient-generated data, both collected via a device and self-reported.
- Please do employ analytics on all of the data streams to feed insights to users in order to help us to improve our health. This seems obvious, but I worry. At the Center for Connected Health, we have accumulated lots of evidence that personalized engagement messaging is what will make something like HealthKit sticky over the long run. I don’t see evidence that Apple has done this.
Apple does OK at best, while companies like Google, Amazon, Netflix and Facebook live and die on their analytics ability. Other than iTunes, can you think of a software application that Apple created that is superior? Apple excels at many things, but any time they’ve been challenged to use analytics to target messaging and personalization, it has not gone so well. Just look at the example of Ping, Apple’s attempt at a social network, or how iTunes Radio stacks up to Pandora. We know there is no comparison to great machine learning as it pertains to keeping individuals engaged. I don’t see this as a core competency at Apple.
For me, it boils down to this: Will easy-to-use, intuitive, engaging software and beautifully designed hardware be enough to bring people into an environment like HealthKit and keep them there? Or will it take a killer app with analytics to drive personalization to keep people engaged (a la Netflix recommendations, Pandora’s predicting songs for you or Google knowing exactly what your searching for after only three keystrokes).
If you are in the former camp, you predict Apple will be remembered for changing the game in connected health. If you are in the latter camp, you may be seeing HealthKit go the way of Ping or Google’s health data repository.
What’s on your wish list for HealthKit?