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The Tower of Babel and Consumer Confusion

June 18, 2015


I was fortunate to be invited to speak at the recent AHIP (America’s Health Insurance Plans) conference in Nashville. This is an annual gathering of health insurers and it was my first time attending. My experience there, and a few recent news items, got me thinking about about how health care is evolving and whether we once again will ignore Santayana’s admonition, “Those who cannot learn from the past are doomed to repeat it.”

As we continue our journey to change provider reimbursement to a “Pay for Value” system, the lines between health insurers and health care providers are blurring. Physician/hospital systems, like Partners HealthCare, where I work, are taking on risk for populations of patients through contracts with the Federal government and local payers. According to Secretary of Health & Human Services, Sylvia Burwell, this trend is going to continue. She stated recently that HHS set a goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018. Since the whole insurance industry is based on risk, we inevitably have to start thinking more like insurers if we’re going to be taking on risk.

So I cleared my calendar and attended as many content sessions as I could at the AHIP conference, in hopes that I’d soak up knowledge on how these companies approach their craft.

Sadly, I didn’t learn much. Not because I didn’t listen and not because the speakers were less than talented. I walked away feeling like I hadn’t learned anything because I felt I had gone to a foreign land and was listening to talks in a foreign tongue. I simply couldn’t decipher the health plan lingo.

This worries me because it’s time for these two sectors of the industry to collaborate more. If we can’t understand one another though, it will indeed feel like the Tower of Babel.

Tower of Babel

 

At the highest level, it seems like we should be natural collaborators, as we bring very complimentary skills to the shared goal of building a health care system. As providers, we excel at understanding physiology, pathophysiology diagnosis and therapy. In most cases, we have strong relationships with the end users of the services offered, our patients, which often includes a high degree of trust. When someone’s doctor recommends a course of action, most people at least take it seriously and many often follow that path.

Payers, on the other hand, have always been challenged connecting with their members (you see, we are all a member, a consumer and a patient – all in different contexts – an example of the babbling). Payers excel at understanding risk and setting premium costs, something we as providers have no feel for. But if we’re going to take on risk, we’ll have to learn. Can these former negotiating foes come together to help improve your health? The current landscape does not lead to enthusiasm.

I’ll use some telehealth implementations as examples. Several national payers are adopting virtual visits as a tool for their members. For me, this is a dream come true! BUT, most payers are doing so in collaboration with one of the major vendors in the space and creating shadow physician networks to offer the service to their MEMBERS. When that member’s primary care doctor eventually sees them in the office, she will be puzzled that her PATIENT had an encounter via their health plan that she did not know about.

Walgreens just rolled out a virtual visit program as well. This could create even more confusion, as it brings in a new entrant — the pharmacy — into the battleground for that relationship. Will EMR interoperability solve this confusion? It certainly helps, but I’m also concerned about mixed messaging to the consumer/patient/member. It seems like we’re all fighting for your attention, which may lead to conflicting messages.

This reminds me of a time, about 25 years ago, when this new thing called disease management sprung up. Payers were frustrated by the cost of managing patients (members) with chronic illness. They got no help from providers, so they took matters into their own hands, hiring call centers staffed with nurses to contact patients/members with tips on how to manage their illness, and often sent generic brochures about high blood pressure and other conditions. Payers may have influenced the care of some patients/members, but no one was ever able to prove that this was an effective strategy.

There were numerous stories about patients receiving conflicting advice from these ‘disease managers’ compared to their own doctor’s advice, leaving patients confused. Doctors would get faxes from these same disease management companies and (perhaps arrogantly) throw them in the waste basket without reading them. As a result, the disease management industry collapsed in the middle to latter half of the last decade.

In the meantime, we now have workplace wellness programs, virtual visits offered by your health plan, retail clinics, virtual visits offered by pharmacies and — dare we forget — advice your doctor gives you, which should be more in tune with prevention now that providers are taking on risk.

See what I mean by a Tower of Babel? How do we fix it?

Different Chronic Illnesses Demand Different Connected Health Strategies

May 18, 2015


In the seven or so years I’ve been blogging, I’ve only written a few posts that prompted controversy in the comments section. Looking back, I notice that these posts have involved chronic illness management, motivation, adherence and/or engagement. In fact, a commentator recently felt my writing was that of an old-fashioned doctor who believes that paternalistic messaging is key to engaging patients in an effort to improve their health. I’m paraphrasing but you can read the post and commentary here for more context. This spirit prompted me to reflect on my writing and intent. I believe sincerely that our work at Partners Connected Health is patient-centered in every way, so why the disconnect?

One possibility is that when I write about chronic illness, I am largely focusing on those conditions that are silent in nature (e.g., hypertension, diabetes, high cholesterol, obesity). We made a decision some years ago to build the case for connected health around the management of these illnesses because:

  1. They are costly. By some estimates these chronic diseases account for 70% of U.S. health care costs.
  2. They have a significant lifestyle component. This backdrop seems an ideal canvas for connected health interventions because they involve motivational psychology, self-tracking and engagement with health messages. These chronic illnesses pose a unique challenge in that the lifestyle choices that accelerate them are for the most part pleasurable (another piece of cheese cake? spending Sunday afternoon on the couch watching football, smoking more cigarettes and drinking more beer.) In contrast, the reward for healthy behavior is abstract and distant (a few more minutes of life sometime down the road or an avoided heart attack or stroke). This combination of lack of symptoms and the uphill battle around lifestyle improvement makes these illnesses uniquely challenging.
  3. They are mostly amenable to tracking some objective bit of information about you (e.g. your blood pressure, blood glucose or activity level) in order to make you more aware and, hopefully improve your lifestyle in order to improve your health.

20100811 - Wednesday, August 11, 2010, Fairhaven, MA, USA – LIGHTCHASER PHOTOGRAPHY – Images of a Mass General Hospital diabetes patient in his own home using an advanced home monitoring system for the Partners HealthCare Center for Connected Health's 2010 Progress Report, Forward Currents.   ( lightchaser photography 2010 © image by j. kiely jr. )

Focused on these illnesses and the attendant challenges, we developed programs for home blood pressure monitoring, home glucose monitoring and various activity challenges (nothing on cholesterol just yet). By iteration, trial and error, we’ve become comfortable with the psychology around these illnesses and how it affects both our ability to manage patients and the patient’s ability to improve these conditions.

Because these conditions are silent and because most people would rather not be reminded that they have an illness, we found that a strong engagement platform is needed to get people’s attention. We also found that we need to create tools that nudge people to adopt and sustain a healthy lifestyle rather than ignore our natural tendencies to ignore these silent conditions and engage in unhealthy behaviors.

Blood pressure Remote Monitoring_Kvedar_Partners Connected Health

Over the years, this has led me to make some (apparently) controversial statements, such as: “We can’t just give people what they want.” This bold statement was made in the context of this conundrum of the tendency to ignore silent illness and engage in unhealthy lifestyle choices. I was also putting this in the context of mobile app development, where people seem to conflate the success of apps like WhatsApp and Snapchat with the potential success of mobile health apps. Once a commentator called me out on this. I see how it appears arrogant taken out of that context. The challenge remains however, that with our libertarian culture in the U.S. and minimal individual accountability for either health care costs or preventative health, we need some sort of tools to get folks to engage in healthier lifestyle choices. It’s a societal imperative if we’re going to tackle these chronic illnesses that account for 70% of health care costs.

If we don’t intervene, I think we all agree that the incidence of diabetes and other chronic, expensive illnesses will bankrupt our country in the coming years.

Interestingly, many of the commentators who have challenged me on this language have been folks with chronic illnesses but of a different type – the type that are debilitating because of symptoms. Whether it be chronic migraine, fibromyalgia, arthritis, inflammatory bowel disease or any other debilitating illness, they pose a very different set of challenges:

  1. The associated symptoms make sufferers aware of their condition, all day every day. No tracking required at least as a tool to raise awareness.
  2. Lifestyle alterations usually have minimal effect on improving these illnesses.
  3. The individual’s motivation to get better is usually not in question.

With that context, it’s easy to conclude that these illnesses are quite different and that connected health tools to help address them require a different set of design principles.

I can also see where sufferers of this set of illnesses might have been offended at some of my comments in past blogs. For this misunderstanding, I apologize.Cancer_Pain_Management_Center_for_Connected_Health

But here’s the good news. Our research team recently built and tested, in collaboration with the palliative care group at Massachusetts General Hospital (MGH), an app to help patients manage chronic pain associated with cancer. We are just crunching the numbers now, so I don’t have much concrete detail to share, but I can say that the study enrollees found it engaging and helpful and their need for interaction with their doctor’s staff went down precipitously.

We’re on our way to thinking about how to support folks with debilitating, symptomatic chronic illness. Here’s hoping we can help. As much of a challenge it is to steer folks with silent ‘killers’ to improved lifestyle choices, it may be a bigger challenge to help those with chronic symptomatic debilitating illnesses to feel better.

Pay Me or Charge Me? How Best to Engage Me?

April 24, 2015


A couple of years ago, my clinical practice (Dermatology Associates at Massachusetts General Hospital) began sending patients a bill when they did not show up for an appointment.  Dentists do this with some frequency, but it’s unusual for a physician practice to do it.  Our reasoning was that we have many folks who insist they need to be seen right away and, despite a large, busy practice (we see more than 1,000 patients each week), we still have a long wait time for appointments.  Our practice used to overbook slightly (like the airlines) and count on a few no-shows.  Every now and then, everyone would show up for their scheduled appointments and we’d have to deal with understandable patient frustration at the long wait times in the office.

Since implementing the ‘bill for no-show’ policy, our no-show rate has decreased.  This is an illustration of the well-studied psychological concept that if you give something away it has no value.  People, it seems, were routinely making appointments with dermatologists all over town and taking the one where they got in quickest, not bothering to cancel the rest. Since we began informing patients of the consequence of not showing up, we’ve had more engagement around keeping appointments versus canceling.

In contrast, there is a famous project from the city of Ashville, NC, where a large, self-insured employer made history by implementing a system that waived co-pays for medications for certain chronic diseases. The poster child for success was type II diabetes.  So, it seems we have a case here of giving something for free and improving engagement.

Finally there are a few studies (among them research done at Partners Connected Health) showing that compensating patients with a small financial incentive can improve adherence.

All this makes my head spin.  The conventional wisdom seems to vary from asking people to pay to keep them engaged (‘skin in the game’), to giving something away to remove a barrier, to paying people for achieving a behavioral goal…. Is one of these based on better evidence than the rest?

Calendar: Medical Exam Reminder/ Doctor Appointment

Maybe there are other variables.  In the first example, the patient was motivated enough to call an office to make an appointment.  Presumably there was some anxiety or physical symptom of concern.  In this case, the patient already has skin in the game in that she wants to get a question answered or a problem solved.  This is important, especially as we deal with chronic illness. So much of early stage chronic illness is asymptomatic. In fact, the habits that lead to chronic illness (smoking, excess calorie intake, etc.) all have reward systems of their own.   When you are already motivated to achieve an outcome, we can probably expect that you would be willing to make a financial commitment as well (copay, missed appointment fee, etc.).

cHealth Blog_Kvedar_copay

The Asheville project was multifaceted and the biggest part of that intervention featured high-touch pharmacist involvement with patients. Maybe we could say that, in the case where you have a recurring, engaging interaction with a provider, the idea of waiving co-pays makes sense.  Our research shows that interaction with a care provider is a powerful stimulus to improve adherence. In that context, it may make sense to give medication away because the pharmacist is ever-present to remind the patient to take it.   In this case, the waived co-pay may indeed be perceived as a gift and a motivator rather than a communication that the medication has no value.

cHealth Blog_Kvedar_reward

The last example is most vexing to me.  I believe the preponderance of behavioral research shows that financial incentives are weak long-term motivators.  They get your attention early on, but over time they become expected and if taken away can have a significant negative ‘boomerang’ effect.

All of these are important to think through.  As health care providers take on risk for population health, we’re actively considering these matters.

One of the earliest forms of physician payments for achieving desired financial or clinical outcomes is ‘pay for performance.’  In this setting, the physician receives a bonus payment if you reach certain quality or efficiency targets.  Some of my more savvy colleagues have asked, wryly, over the years, “Why don’t we have pay for performance for our patients?”  What they are pointing out, of course, is the irony of being held accountable for health outcomes — many lifestyle related — for a population of individuals where you have no control over their lifestyle.

As we move in the direction of taking more risk, we are seriously considering how to incentivize patients to adhere to their care plans. This is a topic area where I have some instincts, but confess to not having the evidence to make a case for any of these tactics:

Charge patients to insure skin in the game?

Give them medicine and services for free?

Pay them to be adherent?

I’ll bet many of you know the obvious answer. Let us know.

Patient Engagement: Overused Sound Bite or Transformative Opportunity?

March 31, 2015


Criteria for Stage 3 of meaningful use of EHRs were released recently and there is lots of controversy, as would have been predicted. One set of recommendations that is raising eyebrows is around patient engagement.

The recommendations include three measures of engagement, and providers would have to report on all three of them, but successfully meet thresholds on two.

  1. Following on the Stage 2 measure of getting patients to view, download, and transmit their personal health data, the Office of the National Coordinator (ONC) has proposed an increase from five to 25 percent.
  2. The second measure requires that more than 35 percent of all patients seen by the provider or discharged from the hospital receive a secure message using the electronic health record’s (EHR) electronic messaging function or in response to a secure message sent by the patient (or the patient’s authorized representative).
  3. The third measure calls for more than 15 percent of patients to contribute patient-generated health data or data from a non-clinical setting, to the EHR.

This is all a mouthful, and it’s striking and a bit misguided from two perspectives. First, this requires health care providers to present material to or interact with patients electronically in the name of patient engagement. But it is really mostly about shoveling uninspiring material at our patients that is redolent of highly technical jargon with minimal context, with the belief that it is somehow good for patients to be engaged in this way. The intent is admirable, but the execution flawed. In addition, it is not surprising that many providers have had challenges meeting the Stage 2 requirement that five percent of patients download their medical records. It seems akin to saying that this week’s book club selection is the text for advanced graduate study of quantum mechanics — and then wondering why no one shows up for the meeting.

Some define engagement in terms of how many times consumers or patients interact with informational websites or portals. Both insurers and providers do this. Once again, there is puzzlement over why consumers would choose to spend more time on sites such as BuzzFeed, Facebook and Yahoo, rather than intently study their health benefits or review their lab tests.

At Partners HealthCare Connected Health, our first generation interest in engagement came when we saw, reproducibly, that people who interact with connected health programs have consistently better health outcomes.

cHealth Blog_patient engagement_mobilePartners HealthCare Center for Connected Health's 2010 Progress Report, Forward Currents

This brings up two salient points: The first is how finely we can measure engagement using connected health. If it’s a glucose monitoring program, the system knows how often you measure your glucose, how often you upload your data, how often you interact with the website and how long you are there each time. If it’s one of our mobile apps, we know whether you respond to messages, open the app, which screens you visit, etc. Each time we’ve studied it, we have shown that the more people engage, the better their health outcomes. This is a pretty good argument for the power of engagement.

The second point is how we can segment people according to their level of engagement and then offer them different solutions. Not everyone likes a stern coaching voice. Some people respond to a monetary incentive, some a competition, etc. If you are not engaging with what we offer you, we can sense it and should offer you something else.

Which leads me to some recent, exciting news. I’ve written before about our site Wellocracy, which is designed to educate consumers about the value of self tracking.

cHealth Blog_patient engagement_Wellocracy

Based on our research related to engagement noted above, we know that if we can hook you on self tracking, your health will improve. Wellocracy was our entry to helping consumers understand and embrace self tracking, and it has been successful. We even have a quiz that helps identify personality types and then offers consumers advice on matching trackers and apps to their individual goals and motivational characteristics.

But what if we could get to know you more and more each time you came to the Wellocracy website. Our vision is that when you come back you’ll feel like you’re visiting with an old friend that can anticipate your wishes, mood and preferences.

This is what we proposed to our friends at the Robert Wood Johnson Foundation and I’m pleased to say they saw eye to eye with us, funding our vision to build an “engagement engine” to support the sustained use of health and activity trackers to help improve health outcomes. This engagement engine will leverage machine learning and other big data analytic tools to convert insights from users into targeted feedback. We’ll develop and test an algorithm, and then test it in a clinical study.

Of course, there are models out there for this. Netflix recommends TV shows and movies for you. Amazon recommends books. Google populates the side panels of your browser with ads it feels are relevant to your interests based on your search habits.

Our engagement engine will work something like that, but it will have to be much more sophisticated. If Google presents an ad I don’t like, I can ignore it. Likewise, when Netflix recommends the Kardashians because that’s what my daughter watches on my account, I can laugh it off. But if we’re going to get to know you well enough to recommend health behaviors or health-related strategies, we can’t get it wrong. If we’re off one time, that could be offensive and you’d never come back.

We’re optimistic that we can employ the latest techniques in “deep learning” to learn enough about you so that we’ll be able to message you in such a personal, relevant way you’ll feel excited to engage with us.

And we know that improved health outcomes correlate with engagement.

How does this all benefit Partners HealthCare? We are a provider organization that is taking on more and more insurance risk. The way we will win in today’s performance-based reimbursement environment is to more efficiently deploy our human resources over larger and larger populations of patients while maintaining the highest levels of patient care. That can’t be accomplished by one-on-one, face-to-face interactions. We have to employ technology to create effective, meaningful, one-to-many relationships. That is our mission at Partners Connected Health.

As an industry, we have to do better than measuring successful engagement based on whether a patient downloads a copy of their medical record. Our engagement engine represents a fundamental building block to get us there.

More Sign Posts on the Road To Connected Health Adoption

March 23, 2015


Just three weeks ago, I wrote about sign posts on the road to connected health adoption. That post was meant to help readers appreciate the subtleties of a changing environment. A turn of phrase by a senior executive or thought leader can easily be missed if you’re not listening carefully. In this case, a senior executive I work with signaled a change in thinking from ‘healthy skeptic’ to ‘fear of missing out (FOMO)’, by making the statement, “We know [connected health] is going to be a big part of care delivery so we had better start our plans to scale it.”

The healthy skeptic demands data incessantly, to the point where you suspect the ‘more data’ requests are really a polite way to say no. When convincing the healthy skeptic, you bring reams of data. You build logical arguments. When approaching the FOMO attitude, it’s more about enabling experience, assuming that the concept is valid and that eventually we’ll get the economics right. Let’s plan more pilots. Let’s learn by doing.

This is such a liberating signal for any innovator — and I’ve been hearing it a lot lately. I got this same signal from a homecare executive recently. In another example, the CEO of a company I advise intimated to me that his potential customers are no longer asking for clinical proof points as part of their due diligence on his product.

As William Gibson said, “The future is here, but it’s not evenly distributed.” As a bit of a reality check, I also received an email from a colleague who oversees innovation at one of the larger health plans. His query to me: “How do you get doctors to adopt remote patient monitoring?” and adding, “We’re not making much progress with this.”

I in no way mean to declare victory and announced my retirement, but this change in the conversation is worth paying attention to.

What might be driving this change? Many factors, I’m sure.

More signposts_Mobile Tech_Kvedar

There is the ubiquity of mobile technology in general. When all decision makers see the power of the tool in their hand every day (not to mention the addictive nature of the technology), it is much harder to be skeptical.

More signposts_Payment Models_Kvedar

There has also been a lot in the news lately about both connected health and new payment models, the latter being a driver for adoption of the former.

The Secretary of U.S. Health and Human Services (HHS) is on record saying that by 2018, 50% of Medicare payments would be risk-based. Just a few weeks later, she announced a new ACO model that will become available in 2016. The details are sparse, but notably, there will be the opportunity to take more risk, but reap more reward. Also, there will be more opportunities to encourage the use of telehealth. Health leaders know that 2018 is not far away, so we had better get planning now!

The other announcement from the Centers for Medicare and Medicaid (CMS) that will drive telehealth adoption was the new chronic care management code that came out in January 2015. This code allows physicians to bill for 20 minutes per month of non-face-to-face time spent on chronic care management. This is an ideal set up for encouraging population health and remote patient monitoring.

More signposts_Wearables_Kvedar

Yet another recent announcement contributing to FOMO was last week’s flurry of activity from Apple. By now, most folks believe that the Apple Watch will probably not have immediate ‘care of illness’ implications, as it seems more targeted to fitness and health. However, wearables is now a hot concept. This paves the way for thinking around monitoring of vital signs in the home, as well as mobile communication with patients.

More signposts_ResearchKit_Kvedar

And then there is the highly touted Apple ResearchKit. I’m not sure how this will shake out. My colleague Kamal Jethwani astutely noted that the lack of rigor around which individuals can sign up for which studies may significantly add to the burden of data analysis. Another bright commentator noted that patient self-reported data is subject to all kinds of bias. So it’s too early to tell.

But, think for a minute like an executive. You have information coming at you in an avalanche. You are used to reading headlines and instinctively sensing trends. If you read the headlines about ResearchKit (not to mention the brand-name institutions that have already signed on to use it) and didn’t think too hard about it, you’d have to conclude, “This is a big deal. We’d better get on the stick.” Next thing you know, that organization is scrambling to quickly develop a strategy for mobile health and patient engagement.

Suddenly, we are buzzing past all of that skepticism and the endless requests for data, and instead are focusing on how we’d better get moving – faster.

Perhaps these recent events are more than sign posts, but are putting us on the fast track on the road to adoption!

Sign Posts on the Road to Connected Health Adoption

March 2, 2015


Everett Rogers is credited with the seminal text book on adoption, The Diffusion of Innovations. It is required reading for anyone who is interested in how new ideas become integrated into the fabric of life’s activities. I read this text back in the mid 90’s when we started working in telehealth and it influenced my view of adoption. Understanding adoption is an important skill because it enables us to predict the future to some degree; it is a useful tool in developing strategy from pilot to scale; and perhaps most importantly, it enables patience during those times when the thing to do is so obvious to you and no one else seems to get it.

As I’ve traveled the road of adoption for connected health for two decades, I’ve paid attention to the major sign posts — defining moments when the dialogue changes in such a way that the whole organizational strategy changes with it. I’m also privileged to work at an organization that is generally ahead of the adoption curve as it pertains to connected health, so writing about these sign posts should enable others to take advantage of them in corresponding environments around the world.

I generally think of the adoption road as a three lane highway (bear with me lest the analogy gets tortured), with the lanes being provider adoption, consumer/patient adoption and payer adoption.

Connected Health Adoption_Kvedar

Consumers/patients are by far the easiest group to adopt connected health as a model of care. They thrive on the self-empowerment and convenience. Who could argue with improved access to your provider, less travel to the doctor’s office, more flexibility, etc.? The main barriers with consumers/patients are ease-of-use of technology, out-of-pocket costs and privacy/accountability concerns.

Providers take their fiduciary duty to patients quite seriously, so their first concern is about quality. If your innovation changes the way care is delivered, will it risk lapses in quality or possibly result in sub-standard care? This message was loud and clear up until about five years ago. That meant for 15 years, our work was very much focused on gathering the evidence for a model of care delivery supported by connected health. Lots of trials, control groups, papers, P values and the like. I took a page from the pharmaceutical industry and went into any discussion with doctors or nurses armed with reprints from the literature and graphs or charts of evidence from our own system to support each innovation I was promoting.

Then one day, I passed a sign post. I was talking to the primary care leaders at Massachusetts General Hospital about our Blood Pressure Connect and Diabetes Connect programs and started my talk with slides showing recent data on these programs. Two minutes into my presentation, the leader of the group interrupted me saying, “We get it, Joe. These programs work. Now figure out how to get them into our workflow and how to get us paid.”

Connected Health Adoption_Kvedar_2

 

Armed with that input from the front line, we worked diligently on integrating our programs into our core clinical systems (the workflow piece). The reimbursement piece lagged because, though our organization was contemplating sharing risk with our payers, we were really in pilot mode with that type of reimbursement until recently. All we could do was promise our providers that we’d figure out a way to reward them for connected health-driven care, but we could do little more than that.

The next sign post came recently when the Centers for Medicare and Medicaid Services (CMS) announced the new CPT code for chronic care management (see also Five Accelerants to the Adoption of Connected Health). This now gives us a framework to make financial calculations about work units, value, etc. We’re currently working with such a reimbursement framework for internal deployment at Partners HealthCare.

Connected Health Adoption_Kvedar_3

 

The final hurdle in provider adoption is capacity. Certain groups of providers are so busy with face-to-face patient interactions (dermatology is one example, which I know firsthand), all of the above criteria could be met and there will still be little adoption. This is a supply and demand problem. Since I trained in the mid 80’s, the demand for dermatology has been on a logarithmic growth curve and the supply has increased linearly. Thus, even with image sharing by iPhones, etc, we have little adoption of teledermatology. In a market with tight supply, suppliers have the upper hand.

The sign post I past most recently triggered my idea for this post. As Partners HealthCare has taken on more risk (we are a pioneer ACO with about 500,000 lives at risk, have risk-bearing contracts with all local payers and self insure for our 60,000 or so employees), we’ve started looking at how we might incorporate connected health into the fabric of care delivery. The reverse psychology here is that when payers only pay for face-to-face care, there is no financial incentive to adopt connected health. When we take on risk payments centrally and are rewarded for keeping people healthy, the face-to-face barrier is removed.

For the better part of the last three years, we’ve looked at the cost of connected health deployments and spent lots of time on ROI analyses, all for an executive team that are healthy skeptics. Our rigor at this level makes for good fiscal discipline and has forced us to innovate on the supply/operations side. None of that is a bad thing. But in two recent meetings, two different senior executives said something that made my ears perk up. Both suggested that connected health as part of the care delivery process is inevitable. The follow-on comment, in both discussions, was that we had better get as much experience as we can, as fast as we can, so that we don’t get left behind.

Connected Health Adoption_Kvedar_4

That is an amazing leap of faith. It says we’ll get the ROIs right, but we should work on experience and deployment so that we stay ahead of that adoption curve. That is an impetus for a real change in strategy at Partners Connected Health.

Could I have imagined this day twenty years ago? Well, actually yes — or else I would not have undertaken my commitment to connected health with such zeal. What I didn’t appreciate back then was that it would take twenty years. Good thing or I might have moved on to something with more short term gratification. However, understanding Rogers’ book and theory helped give me the patience to continue to move forward and watch for the sign posts.

The Wow of Wearables

February 19, 2015


The hype around wearables is deafening.  I say this from the perspective of someone who saw their application in chronic illness management 15 years ago. Of course, at that time, it was less about wearables and more about sensors in the home, but the concept was the same.

Over the years, we’ve seen growing signs that wearables were going to be all the rage. In 2005, we adopted the moniker ‘Connected Health’ and the slogan, “Bring health care into the day-to-day lives of our patients,” shortly thereafter.  About 18 months ago, we launched Wellocracy, in an effort to educate consumers about the power of self-tracking as a tool for health improvement.  All of this attention to wearables warms my heart.  In fact, Fitbit (the Kleenex of the industry) is rumored to be going public in the near future.

So when the headline, “Here’s Proof that Pricey Fitness Wearables Really Aren’t Worth It,” came through on the Huffington Post this week, I had to click through and see what was going on.  Low and behold this catchy headline was referring to a study by some friends (and very esteemed colleagues) from the University of Pennsylvania, Mitesh Patel and Kevin Volpp.  Other authors were Meredith Case and Holland Burwick.  Also notable was that the study was published in JAMA.  In this research letter, the authors compared several fitness wearables to smartphone-based apps as tools to track activity.  They asked healthy volunteers to walk either 500 steps or 1,500 steps on a treadmill, and compared step counts on multiple devices as well as on smartphone pedometer apps.  It is worth spending some time reviewing their data tables.

The first take-home for me was that steps counted on the wearable devices and the mobile apps, when walking on a treadmill, are pretty accurate.  I was somewhat chagrined to learn this. I have a treadmill desk and this time of year spend many evenings walking while reading email.  It always seems like I’m walking farther than the Fitbit tells me, but now I know I’m probably just tired at that hour.

Kvedar_treadmill desk

Their main point, however, is that smartphone apps are as accurate as these wearable devices.  This makes sense intuitively, as we’ve known that smartphones have embedded accelerometers, which can be used to track the movement of the phone.  For years, there have been apps that can take this data and, by applying some software algorithms, show activity that the phone has traveled as steps walked by the owner.  I believe they were initially not so accurate. However, a bigger problem in the early days was that these apps drained the phone’s battery because the processor always needed to be on while tracking the accelerometer’s activity. This has been remedied in the most recent generation of mobile phones, as they now have separate processors dedicated to this sort of continuous tracking.

Thus, we have plentiful pedometer apps (a search on the Apple App store produced too many to count). We’ve also solved how to run these apps in the background without disrupting the phone tasks or draining the battery. So, is it time to ask, “do we really need fitness wearables anymore?

I’d frame the question a different way. Is the future of patient-generated data migrating to the mobile phone (the proverbial digital Swiss Army Knife of life) or will it be migrating to the realm of micro-sized wearable seeds, ingestibles, injectables, bandaids and the like?  I was a fellow panelist with tech guru and futurist Nicholas Negroponte, and in an off-handed comment, he said that wearables are just a temporary fad and that the future is in ingestibles.

On the one hand, it’s tempting to think about a world where all of your health-related data are generated on and analyzed by software resident on your mobile device. One big challenge to this vision is that we don’t always have our phones on our person. Some folks carry them in a bag, etc. This latter point calls into question the experiment that our friends at Penn did and, more impressively, that JAMA chose to publish it. The quality of the science is quite high but the applicability is questionable.

Also, there are many other health sensing applications than just pure activity tracking. What about continuous heart rate or blood pressure monitoring. It’s hard to imagine getting those done without some sort of sensor.

Going back to the eye-catching headline from the Huffington Post and channeling Mark Twain, I’d have to say that reports of the death of wearables have been greatly exaggerated. The power of sensor-generated data in personal health and chronic illness management is simply too powerful to ignore.

The last point to be made, however, is that wearables and their attendant feedback loops are relatively weak motivators on their own. In fact, the same group from Penn came out with an opinion piece, also in JAMA one week earlier, thoughtfully talking about this point.  Our Connected Health research team at Partners HealthCare has shown repeatedly that the motivational messaging that puts these feedback loops in context is the true driver of behavior change.

That will no doubt be delivered via your smartphone!

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