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Emotional Automation: Bonding with Technology to Improve Health

October 26, 2010

During a keynote panel discussion at the Connected Health Symposium last week, I proposed a new idea that challenges the need for face-to-face doctor patient interactions to deliver quality care. Here’s a synopsis of my remarks:

As we take stock of the opportunities the Patient Protection and Affordable Care Act (PPACA) provides, we can look to the experience in Massachusetts for some suggestion of how things may turn out.  Recall Santayana’s admonition:  Those who do not remember the past are condemned to repeat it.  In 2006, Massachusetts passed universal healthcare, leading the nation with a bold vision for universal access.  By early 2008, local headlines noted that there are not enough primary care doctors to care for our citizens and later that year, the same news outlets were headlining how the new system was costing more than estimated, resulting in immense strain on the state budget.  As we look at the situation in the U.S., there is nothing to suggest that these same roadblocks will not present themselves in due time.

Workforce statistics show that both physicians and nurses are in short supply at present.  It is estimated that we will be over 100,000 physicians short by 2025.  The growth in chronic illness is showing no decline, however, and the post World War II generation is just beginning to enter their high-maintenance health care years.  Twenty-four million U.S. citizens have diabetes, and the incidence is growing at 8% per year.  One in three adults have hypertension and one in 10 over 65 have congestive heart failure (CHF).  Our current care and payment models dictate that care can only take place when two people meet in the same location at the same time.  The supply and demand mismatch calls out for a new way.

The concept of time and place independent care is not a new one. Visionaries have been studying, piloting and demonstrating new care models for decades. In our own CHF telemonitoring program at Partners Healthcare, we have cared for more than 3,000 patients with CHF using in-home monitoring of weight, blood pressure, heart rate and oximetry.  Using this approach, we have seen readmissions drop by 44% and we are able to care for a daily census of 250 patients with 3-4 nurses.  Considering that those same nurses, in a certified homecare agency model, would be caring for 4-6 patients daily, the impact of telemonitoring on extending the reach of providers to larger populations of patients becomes evident.

I used to think that the key roadblock to moving this vision forward was payment reform.  In the last several years,  particularly with the passage of the PPACA, new payment models are at the tip of administrators’ and policy makers’ tongues (bundled payments, shared savings, full-bore capitation), but the provider response is light on including connected health as part of the solution.  Instead, the predominant models employ a team-based approach, surrounding a primary care provider with a lineup of nurses, care managers, pharmacists, etc., in a promise to deliver truly patient-centered care.  I’ve made the case, two paragraphs earlier, that this is not a sustainable plan, due to the supply and demand mismatch.

I now think that the primary roadblock is a psychological one.  Providers, and to a lesser extent consumers, intuitively believe that quality care means meeting one’s doctor face to face.  The main reason for this belief, by both parties, is that a trusting, caring relationship with a provider is thought of as a cornerstone of effective care.  While it it undoubtedly true that trust is critical for an effective relationship and that effective relationships with providers lead to improved care (the likely best explanation for the placebo effect), I want to call into question the assertion that these relationships have to be human-to-human or face-to-face.

Consider for a moment your experiences with objects such as pet rocks, Tamogatchis, automobile navigation systems and mobile devices.  It is not uncommon in any of these circumstances to assign a name to these objects and develop true bonding relationships with them.  Clifford Nass has written extensively about this in his recent book, The Man Who Lied to His Laptop.  While we often joke about these relationships, they are real and as Nass’ work shows, meaningful.

In our own case, at The Center for Connected Health, a computerized relational agent was effective at coaching individuals to stick to their activity regimen.  Thus we can safely say that bonding with technology can lead to improved health.  In another instance, a similar relational agent was used for discharge planning and patients preferred the agent to a health care provider, because she did not talk down to them, was not in a hurry and allowed them to ask the same question multiple times.

Lets call this phenomenon Emotional Automation.  Lets start a dialogue about it.  Is it far fetched to think that we could parse provider work flow into those actions that truly require a real-time interaction with a provider and delegate others to technology?  Can we set up systems that are extensions of our providers that will allow patients to feel cared for by their doctor but be interacting with a piece of software or a robot?  How many examples can you come up with?  What are the pros and cons of this approach?

18 Comments leave one →
  1. October 26, 2010 3:22 pm

    “Can we set up systems that are extensions of our providers that will allow patients to feel cared for by their doctor but be interacting with a piece of software”

    Prof John Bachman has made a report on interactive patient interview questionnaires being used achieve this at the Mayo Clinic:

    Watch some great videos here:

    • October 26, 2010 4:50 pm

      thanks for the great links. will review with interest!!

  2. October 26, 2010 9:58 pm

    Re: “Visionaries have been studying, piloting and demonstrating new care models for decades. ”

    Health Buddy (remote patient monitoring system allowing clinical team to monitor pats where small, friendly “Health Buddy” device placed in pat’s home) – now owned by Bosch North America – has been deployed since 2001 in the USA and since 2004 in the Netherlands – so case studies of patient acceptance and satisfaction exist. All the big guys copied the idea – Intel, Phillips, etc.

  3. October 28, 2010 4:47 pm

    ‘Emotional Automation’ reminds me of the great Veteran’s Administration study of 2008:

    Click to access VA%20CCS%20Outcomes%20Dec_2008_Darkins.pdf

    Particularly notable beyond the cost savings and improvement in outcomes were the patient satisfaction scores: “Satisfaction surveys were administered every 3 months to CCHT
    patients via the home telehealth devices. There was an 86% mean satisfaction score from 42,460 surveys submitted.”

    You would probably agree that they were this satisfied because they knew that someone (through use of the device) was monitoring their well-being. Moving forward, appropriately configured software tailored to individuals can certainly extend this fairly rudimentary monitoring into a true emotionally automated and smart buddy. – Best, Laurie

    • October 28, 2010 4:51 pm

      Yes, their experience is quite consistent with ours. Patients feel more connected in these settings and that gives them comfort. I agree that some of this interactivity can be automated. In fact several successful companies are using interactive voice response to communicate with these folks about their weight, vital signs, etc. The journey has started.

  4. October 30, 2010 8:33 am

    The key is the patient experience and we have many models in other industries to demonstrate both success and failure. Let’s not think of health care as different in that regard. Everyone who has been stuck in a frustrating loop in a voice response system (“press 1 if you need …”) is familiar with loathing the technology designed for efficiency.

    On the other hand, everyone who has spoken to a service provider who could quickly get the information required, analyze the problem, and execute a solution loves it. The trick is to separate the data collection from the data analysis. Design the tech to gather data and identify key markers – and to do so with as little patient burden as possible – and people will value its benefits.

    In the home care world, we are working with remote monitoring systems to get more data, more quickly, at lower expense – and without interfering with client privacy or independence – so that we can be sure humans are on site whenever needed, but not when they are adding little value. When this occurs with the client’s consent, this provides high value and increases their satisfaction with the experience.

    • October 31, 2010 12:34 pm

      I think what you are saying is that we should use the technology to maximally extend the reach of our providers and to that I absolutely agree

  5. Fariba Rahbary permalink
    November 1, 2010 11:30 am

    Dr. Kvedar,

    Let me start by saying that on a daily basis, I look forward to reading Thoughts On The Business of Life on I like to share with you today’s thought which is very relevant to your blog:

    “However far modern science and technics have fallen short of their inherent possibilities, they have taught mankind at least one lesson: Nothing is impossible.” Lewis Mumford

    “Emotional automation” is an interesting concept that I have not thought about before reading your blog. It may not be an immediate answer to the current challenges we face in our health care system but that should not stop us from exploring it further for the benefit of the future generation – why not?

    The only roadblock I see are the mediocre minds whose only answer to the current challenges in the health care system are intimidation, immediate dismissal of any new concept, and complaining without really taking the time to offer any tangible solutions. Of course there are always those who see innovation in health care as a threat to their current practice and are hesitant to move out of their comfort zone.

    Looking at the bigger picture, the issue is not so much picking one system/model of care versus another or necessarily focusing on one aspect of technology such as “emotional automation”. The real issue is how we can embrace the innovative use of current and evolving technology in any setting (existing models, or new innovative models of practice) to improve the quality of care we deliver to our patients and to improve the efficiency with which we deliver such care in a holistic manner in collaboration with other health care professionals and providers when needed.

    We should keep an open mind and embrace all models of care that work and that show proven benefits. The presence of different care models should not be mutually exclusive even within the context of a universal health care system. For example, a team-based approach (e.g. real-time primary care team approach in physicians/nurse practitioner led clinic settings) may work very well in some settings and in some geographic areas and therefore should be endorsed and expanded whenever possible, keeping an open mind that this is not the only model that may work. In other areas, the medical home models, solo-practices, or a connected health system may work quite well for the community. We should constantly challenge ourselves to learn how we can leverage the new and evolving technology to improve our efficiency so that we can provide better care for our patients in any of these settings.

    I agree with your statement, as we all know and have witnessed, meeting face-to-face does not necessarily translate to an improved quality of care and providing quality care also does not necessarily require meeting face-to-face. I believe that the absolute pre-requisite for delivering quality care is the amount of time you initially take to build a trusting relationship with your patients so that you can interact with them in a meaningful and caring way in the future. Once that initial trust is built, then you can deliver quality care face-to-face, in a team-based environment, or remotely thorough the use of technology, robotics or other innovative technologies if and when needed. In my opinion, this is what patient-centric care is about – initially building a trusting relationship between two human beings (the patient and the provider) in order to understand the patient’s needs, values, beliefs and the preferred style of communication, and then delivering the quality care based on those needs and values. I am truly amazed at the number of studies that fail to take this into consideration when measuring the impact of their intervention on various patient related outcomes.

    Unfortunately, some people are so intimidated by the words “innovation”, “technology”, and “reform” that they totally dismiss the concept and close themselves to even hearing about such ideas. These people just prefer to make presumptions and assume that a model does not work rather than taking the time to understand it, assess it, explore it, and offer solutions to what they think may be roadblocks to implementation. Sometimes this is about resistance to change and progress, sometimes it is about the fear of the unknown, sometimes it is about personal and political agendas, and sometimes it is about putting the financial interest of the practice and business ahead of any initiatives that relate to the health care reform.

    Ultimately, improving the health care system is a shared responsibility among all stakeholders, from the government and professional associations, to medical device manufacturers, the pharmaceutical industry, insurance companies, health care professionals, public health officials, patients, and the public. We all need to hold each other responsible and accountable and one way we could do this is to embrace change while providing tangible solutions to things we see as the roadblocks to change. I see in your c-health blogs and through the Connected Health Community that this is exactly what you are trying to achieve.

    Fortunately, the U.S. is currently blessed with a visionary President (independent of political party affiliation) who among other things is an intellectual, a thinker, and a doer and again fortunately for you, the American Medical Association is a visionary organization that supports innovations in health care.

    We, in Canada, also have great minds, organizations, and dedicated health care providers, journalists, and leaders who are trying to bring about reform by offering solutions other than intimidation and band-aid solutions to our ever increasing sickness care system. Hopefully, as both countries go through reform in our health care systems we can learn from each other’s challenges and share our success stories along the way ….

    I enjoy reading your thought provoking blogs.

    Fariba Rahbary Pharm.D.
    Consultant Pharmacist, Toronto, Ontario, Canada

  6. November 1, 2010 2:11 pm

    Hello Dr. Kvedar,

    I believe “emotional automation” is the true beneficial effort in the use of mobile devices to aid patients. We are actively developing mobiles solutions in this very area at UCSF. The advanced telemedicine group is using AI techniques embedded within patient care mobile solutions to have patients view their mobile device as a “companion”. These solutions support patient behavior intervention (e.g. depression episodes) and behavior modification (e.g. stage 2 diabetes diet). There are a few clinical trials here which relate to the area of “emotional automation”. Very exciting area of research.

    Larry Suarez
    Software Architect Advanced Telemedicine
    UCSF School of Medicine

    • November 1, 2010 9:39 pm

      undoubtedly, mobile is an important component of realizing the vision, because it allows us to communicate just-in-time allowing for in the moment insights.

  7. Terry O'Neal-Cox, MD permalink
    November 8, 2010 9:20 am

    ….. “Once that initial trust is built, then you can deliver quality care face-to-face, in a team-based environment, or remotely thorough the use of technology, robotics or other innovative technologies if and when needed.” ……

    Dr. Kvedar:
    It is certainly a pleasure to share your approach to improving healthcare by means of IT. It is also a pleasure to see that you are facing a difficult task head on, and seeking input from the stakeholders, while presenting the facts, and not attempting to force feed personal opinions.

    I copied the above statement from an earlier comment by Fariba Rahbary. To me, this says it all. I believe that benefit can only be had by employing both F2F and effective technology. The order of use can flip flop. But for CDM (Chronic Disease Management), technology can provide 24/7 monitoring that would definitely yield improved quality of care.

    About “emotional automation”, I believe that this is the wall we hit when trying to implement technology. As providers, we are fully aware of the emotional variability of humans. It is this very factor that is largely responsible for a majority of the chronic diseases. For example, COPD, HTN, DM type II, and obesity are costing a tremendous amount (financially, morbidity, and mortality), but the emotional state of the individuals, in spite of prior knowledge, supersedes their will to avoid factors contributing to these diseases. Emotional factors also contribute to patient non-compliance, regardless of shared information or education, which further exacerbates their condition.

    How can we truly automate the psyche without creating equality in defiance of genetics? or did I misinterpret “emotional automation”?

    • November 8, 2010 1:21 pm

      Very thoughtful. I don’t know about automating the psyche, at lease not all at once. I’d start by sorting out which interactions with your healthcare provider are routine and predictable and see if we could automate those (blood pressure check, discussion of normal lab results, etc.), My concern is that I can’t get much interest from the provider community even for that simple first step.


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