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Context is Everything

February 6, 2012

A few weeks ago, I had the opportunity to talk with an innovative company about a new product.  I make it a policy not to endorse any particular company or product on this blog, so this is not an endorsement.  Rather it is a fascinating story that tells us lots about human nature and gives us clues on how we should design healthcare programs, apps, etc. as we move into the world of patient engagement and accountability.  And we are moving there. Whether your focus is achieving meaningful use of your EMR (increasingly we’re going to be graded on how we engage our patients in this regard), the journey to becoming an Accountable Care Organization (as we enter an environment where we’re compensated for quality and efficiency, patient engagement becomes key) or simply that you realize that we don’t have enough healthcare providers to take care of all those folks who need it (in this case, patient engagement becomes a tool to give patients the opportunity to be their own providers, taking work off of our beleaguered primary care workforce), patient engagement is all the rage.

Right out of the gate, we health care providers have a big hill to climb.  We are the ones who remind you that you are sick. Who wants to be engaged with that?  Once patients get into the mindset of being sick, the context becomes pain, suffering, inconvenience, depression, time out of work, rehabilitation, and on and on. It’s no wonder that patients don’t engage much (other than the occasional masochist among us).  And the conversation immediately gravitates to whether insurance will pay or not. We’ve observed patients in our connected health programs who are happy to go to the sporting goods store to fork over their own money for a heart rate monitor so they can watch their heart rate during a work out, but baulk at paying for a blood pressure monitor to be part of a hypertension program.  After all, fitness is your own business, but when we’re talking about sickness your insurer owes you….

A little while back, some airports introduced those whole body scanners – the ones where you stand with your hands over your head and the machine takes an image of your body to rule out the presence of weapons, explosives, etc. Given all of the threats from shoe bombers to liquid bombers that have made it through traditional metal detectors, I thought this was a good idea.  More monitoring to insure my safety is a good thing.  But the outcry from the libertarians and the privacy crowd was deafening.  It was newsworthy for weeks.  All kinds of concerns about TSA agents peaking at one’s body profile, etc.

So imagine my surprise when I talked on the phone the other day with folks from Unique solutions.  They use the exact same technology in the shopping mall to allow consumers to create a clothing size template that is unique to them.  Armed with that scan information, you can go to certain merchants to buy highly customized clothing of a fit that is unique to you.  When I heard about this, I wondered how widespread it is, but right after the phone call I saw one of these in a mall near my home.  Consumers are flocking, apparently.  No complaints from the privacy crowd on this one.  Who’d a thunk it?  Essentially the same scan.  Same risks best I can tell (couldn’t an errant employee view your scan?). But no outcry.

This is fascinating.  There are two angles to think about here. One is the psychology and the other is the health application for this technology.

I’m motivated to think about how many ways we can re-invent how we engage patients about their illness.  By way of analogy, I’d say that we as healthcare providers are like the TSA with the airport scanners.  The alternative therapy, fitness industry is like the mall-based solution.  Two ways of viewing the same challenge. What this tells me is that we have to think hard about how we communicate with patients and develop ways to be less serious, less dour and more hopeful. I don’t mean to say healthcare should become a joke, but there is a long way between comedy and the way we talk to our patients now.

The applications for this technology in health are interesting to ponder.  Overweight is not one uniform problem.  Abdominal fat has more dire health consequences than other types of fat.  There are other examples of where body habitus can help predict health outcomes.  People who engage in serious exercise programs can add muscle mass as they lose fat, obscuring the value of BMI as a reporting tool.  I could imagine a new metric beyond BMI which would use one’s unique body scan as a tool to predict future health state and to track response to weight loss or diet initiatives.  Add a wireless weight scale and a smart pedometer and things start to look very interesting.

Tell me what you think about this.  Why do people raise a fuss about a technology in one location but embrace it as hip when presented in a different context. Does that give us clues as to how we should design our communication tools and patient engagement initiatives?  Do you see health care applications for this type of scanner? Let me know.

24 Comments leave one →
  1. Josh Fotheringham permalink
    February 6, 2012 5:21 pm

    When I go to the airport, I am required to go through security screens (using the new body scan technology or otherwise). When the technology is used for custom fit clothing, the tool is voluntarily used. In general, people don’t respond as well to tasks that are forced vs those that are optional. Additionally, users of the mall-based technology have more to gain (personally) than non-offenders who are required to be scanned at the airport. Shoppers may end up with great fitting clothes (albeit at a higher price) while the airport technology is essentially slowing users down. In many cases, passengers could be simultaneously rushing to catch a plane!

    I believe this same logic can apply to health technologies (per your post). If users are obligated (or heavily suggested by insurers, doctors, etc.) to use a technology, they may often feel that there is less for them to gain and more for them to lose. This may be a result of having more ‘bad’ information or simply another reason why they may be charged for another point of care. On the other hand, if these technologies are voluntarily used, the same information may be perceived as beneficial since the patient now has more information than before – which ultimately can help them better manage their own care.

    From the technology point of view, the results may be the same. However, the perception of their value differs greatly depending on the required vs voluntary state of usage. The answer may be that we need to find more ways to incent rather than require technology use.

  2. February 6, 2012 5:27 pm

    Yes, indeed. how you present something matters so much. thanks for your thoughts.

  3. February 7, 2012 2:30 am

    An article entitled: “Research Reveals Key Differences in the Way Men and Women Use Online Health Improvement Programs” in Managed Care Outlook Volume 24, No.1 January 1, 2011 addresses the approach and certainly they show it can make some difference.

    But I agree with Dr. Kvedar that “context is everything.” I just tweeted something about that a couple of days ago…bubble wrap was really invented as wall paper and velcro…well, it continues to be adapted to new ideas all the time…I think every parent is grateful not for the genius that invented velcro but the genius who replaced their toddler’s shoelaces with it.

    Context is what limits us from engagement. Context is everything because as the doctor, the health educator, etc. we are limited by our own context as much as the patient is limited by theirs.

    In this video: http://youtu.be/BsrvW3iQdJY – it looks like its all about the words (the approach), its also really about connection with another person’s reality, their story, their senses. As humans we want to mitigate risk, we are motivated to overcome our innate sensibilities by connection with meaning.

    When we view engagement, we view it from our world and engagement becomes a pull or push to join us on the better side of it,…our side, but context provides opportunities to connect and contextual engagement produces meaningful change.

    Could the body scanner be used to monitor the escalation of arthritis or scoliosis?

    You can view some of the links I mention here – https://twitter.com/#!/GottaBNimble

    • February 7, 2012 8:48 pm

      wonderful thoughts and love the link to the video

    • February 9, 2012 2:09 pm

      I don’t know where to begin here, so I’ll just dive in. Chris your video and commentary completely resonates with a venture I’ve had the fortunate opportunity to participate in. It started as a simple book project sharing the “secrets/lessons” of masters-age athletes who have been successful at being physically fit, whether they started late in life, rehabbed from injury or other ailment or maintained fitness for most of their life. After filming interviews & action footage with these people, who we call Forever Athletes, we knew their presence & words shared via video would be monumentally more powerful vs. text alone. This gave way to producing eBooks featuring their stories & related videos. Again the idea was/and still is to share their experiences for the benefit of other adults to get started and sustain a journey of physical fitness and increased quality of life!

      In reference to your specific comment, Chris, “…its also really about connection with another person’s reality, their story, their senses. As humans we want to mitigate risk, we are motivated to overcome our innate sensibilities by connection with meaning.”, you’ve summed up our intentions with the videos we’re producing. Providing a context of the motivation for being physically fit, through the real-life stories of those we’ve interviewed, we hope to trigger that motivational piece for those who need it most…to trigger something beyond that which a medical clinic can provide…something that relates to soul of our humanity and quality of life.

      Myself and team-members working on the videos, are very open to feedback regarding our intent. More specifically, what are the thoughts around inspirational video-messaging serving as the motivational piece to create behavior change in the obese/overweight population?? Could a physician-prescribed “treatment” involving a series of videos over time, be useful towards providing the context needed for patients to respond favorably?

      Sample of the general video content we’ve begun producing: http://www.foreverathletes.com/wp-content/generic1/index.html

      Sample story (eBook with videos): http://www.foreverathletes.com/wp-content/cheriestory/index.html

      Thanks for your feedback.

      -Jessica
      jseyfert@foreverathletes.com

      • February 9, 2012 7:42 pm

        Jessica,

        I’m so honored to be asked my opinion. I love the concept and your approach. I think its important to realize that the video link I provided works because it motivates the person in that moment to dig into his pockets and give a blind man some change. I don’t think that video would make that person continue to go back and give the blind man their change forever.

        I think these videos are great in initiating motivation to start your journey but you risk losing that enthusiasm pretty quickly with what is shown. These “forever athletes” talk about their long road and the baby steps they took to get to where they are, but then you show them doing some amazing things like pole vaulting & weight lifting. Often at the gym I see newly motivated people start running on the treadmill or take a fitness class that is above their ability level, they don’t come back after that day, instead they are walking backwards down the stairs at home due to the soreness they feel and swearing they won’t ever do that again.

        The journey is in-between, where they started and becoming a “forever-athlete.” The connections needs to happen there or you lose the enthusiasm that motivated them to try in the first place.

        The connection points from something like text or other communication channel tied into your efforts is extremely important because its the interaction with your message that changes the context and meaning of the message to that individual that make the change happen.

        The Marshmallow Study demonstrates the importance of self-discipline in lifelong success. Offer a group of 4-year-olds one marshmallow, but tell them if they wait for your return after running an errand, they’ll get two. You disappear for 15-20 minutes. The theory was, children who could wait demonstrated their ability to delay gratification and control impulse, which later showed they were more successful and healthier in life.

        How do you take the 4-year old one marshmallow eater and get them to override impulse for reward? The video is like the artist on the street. In 30 minutes s/he has created something before your eyes and you say, “how much for that?” and s/he replies, “$20,000.” “Are you crazy?,” you say, “it only took you 30 minutes to make that!” and they reply, “30 minutes, plus 20 years.”

        In this example, connecting meaningful improvements to get to the final product took 20 years…what connections are you providing in that journey from start to end result.

      • February 10, 2012 10:40 am

        Great points, Chris! Would you be available to talk further on the phone? It seems as though you have quite the informed opinion on motivational content along the spectrum of sustaining behavior change.

        I definitely hear you on the issue of connecting from start to finish. I should have prefaced the video samples with the fact that we’ve only started the video production using our extensive library of footage. The videos in the ‘Getting Started Series’ eBook are certainly not intended to be the comprehensive unit to promote real behavior change. Rather, it’s more of an overview of the the primary topics that would constitute a series of videos. Each of the videos within the topic would be created & ordered along the Transtheoretical Model of Behavior Change. Does that makes sense?

        Ultimately, we’ve just begun the video-creation process after almost a couple years of gathering video & textual interviews. The challenge is determining whether or not this type of video-messaging can actually prove effective towards behavior change, as well as identifying potential partners that supplement the videos with some form of counseling effort (virtual or in-person).

        Feel free to shoot me an email and we can set up a day/time to chat further!

        jseyfert@foreverathletes.com

        -Jessica

  4. February 7, 2012 6:40 am

    The key element here is more “choice” than “context”. Nobody is being compelled to use a scanner to buy clothes. Compulsion tends to put people into a negative and resistant frame of mind, making them want to assert their freedom of choice above their own self interest on occasion – I see this regularly in the field of medication compliance “Don’t tell me what to do!”

    Any parent of adolescent children is familiar with the syndrome. Often the most effective way to steer behavior is to move from compulsion to freedom of choice. Giving free choice is one of the most effective ways to show respect, and showing respect is often rewarded.

    Treating problems like obesity has more to do with psychology than either technology or dietary/fitness regimens. For many socio-economic groups the choice to be fat is one of the few ways they have to assert themselves. Every fat person is well aware that it is not good health wise, and that they can generally do something about it. The more people tell them that they “must” do something about it, the less likely these people are to change their ways. We don’t really need to worry about supporting the guys who go to the gym – except perhaps to protect them against the consequences of too much exercise.

    • February 7, 2012 11:28 am

      If we are talking about behavior change how do you connect with the person who chooses to be fat so that they choose to exercise and be health conscious about what they eat? I agree with you, it is psychology, but studies show that rewards work in some cases and not in others to motivate choice.

      You are fortunate if there is a straight path, however, some need to progress in smaller steps. They can’t make the leap you want them to, enabling them to succeed is the progression of their context.

    • February 7, 2012 8:50 pm

      two very thought provoking comments

  5. Nivedita permalink
    February 7, 2012 7:11 am

    I have been recently dealing with context and its application in development of health care standards, a lot at work. Its a tricky issue, one I haven’t really completely understood.
    I agree things change with the context they are presented or developed in. Coming from a country that is constantly under terrorist attacks, I think the more security checks, body scanners, sniffer dogs, etc. the better. (context) But I think context is not everything!! Personal experiences, lifestyle, education and personal choices also matter.
    For e.g.- a family who has lost a loved one to cancer is bound to be more careful about regular check-ups, follow ups and in general living healthy (personal experience) or some adopt an altogether different approach where they stop caring and just start living (choice). The rich who have their own aircraft’s don’t care about how tight airport security is, but they have body guards and personal security to protect them from potential danger (lifestyle). A science student wouldn’t necessarily risk have unprotected sex, having learnt the transmission mechanism and life threatening diseases (education).
    The point I am trying to make is, there are other factors that influence decision making other than the context in which they are presented. So adoption of blood glucose meters versus heart rate monitors is an individuals choice,I know some people who use both the devices in totally different contexts, as they are just more aware and conscious.
    My 2 cents!

    • February 7, 2012 8:51 pm

      fair enough. perhaps the title Context is EVERYTHING is too simplistic.

  6. February 7, 2012 10:39 am

    By context, I do mean everything that you mention and more. It isn’t just the context in which they are presented but everything is incorporated into the context of how we present information and how we connect to it. The reason mobile is important is because it is now almost everywhere you are, enabling you to connect to that context whatever it may be and where it is coming from and help drive your choices where they will go if you do connect with it.

  7. Chris Wigley permalink
    February 7, 2012 10:30 pm

    So much here depends on your point of view and where you are coming from. As a patient i really take exception to the idea that it is the doctor reminding me that I am sick – I have never been reminded that I am sick – it has always been a matter of my making an appointment because I am sick. And ninety nine times out of a hundred all I get is a prescription to “make me better”. And this is an approach that has been fostered by the medical profession so often discouraging the patient from educating himself – patients are regularly told not to learn from the internet as it is full of misinformation!! I was diagnosed in 1993 with the early stages of emphysema – but was never given any help as to how to live with the disease or with its consequences. In my lifetime (I am now 70 y.o.) I can only remember one doctor making any attempt to encourage and help me to quit smoking, just wish that I had been able to succeed, but this was way before any pharmaceutical aids to quitting. I finally quit when I came to realize that I had to quit or die, and then I had to ask for help. And not a single one, to this day, has advised me as to exercise.

    As regards the body scanners I agree with those that have pointed out that forcing someone to be scanned is very different to volunteering or even paying for it, but remember also that there is no evidence that those same people that protest at airports are the same people that go for a scan at the mall. I personally doubt that the airport protesters will get scanned voluntarily at the mall.

    I think that it is time for the medical profession to take the time to educate and advise the patient about how to care for his health problems – not as ‘superior beings’ but as caring teachers.

    • February 8, 2012 1:52 am

      I had a conversation with a neighbor the other day, we both love history and our ramblings went from the beautiful architecture he’d seen over the holidays in the UK to the Industrial Revolution. Caught up in admiring the architecture, many don’t think of what enabled such beauty. A lot of that history might involve colonization and taking of resources from others, which we’ve learned about, but compartmentalized elsewhere in our minds while admiring what’s directly in front of us.

      We talked about our children and their schooling and that brought up the Industrial Revolution. Our school system came about during this time as folks left farms for factories and assembly lines. Assembly lines are efficient by compartmentalization.

      A medical professional is educated in this fashion as well. Kids are competing to go to the best colleges to proudly become doctors. When they graduate, they will have spent more years in institutions that came about from the concepts of efficiency from the Industrial Revolution…to take in mass amounts of data by compartmentalizing it, than the patients they often see.

      Psychologically, there’s also a benefit in leveraging it, particularly for med students in dealing with the pressure and anxiety of studies or dealing with too many patients and too little time. Navy Seals actually use compartmentalization as part of their technique in enabling more of their recruits to get through Hell Week…to master the mental challenges associated with the grueling physical tasks they have to endure by compartmentalizing. http://www.foxnews.com/health/2011/05/03/navy-seals-exhibit-ultimate-mental-toughness/

      I hope most doctors and teachers go into their profession because they care about their students and patients, but despite their best intentions, they are limited by their context, what they have learned and where they have come from as well as the system they deal with.

      My grandmother was a smoker and died of lung cancer. When she was 11, doctors told everyone that smoking was good for you so she lit up with everyone else.

      My mother’s generation didn’t breastfeed their children because doctors told them that formula was better for their babies.

      My son’s teacher said he had trouble with the writing assignment, “The Holiday Tradition we celebrated over Winter Break.” I asked what she did to help him, she replied, “I show him his vocabulary tests because he always gets 100%.”

      There is the controversy over the goals and objectives in No Child Left Behind, that what is measured forces the teachers to teach to (pass) test rather than teaching to learn. But teaching to learn is the same to me as enabling you to engage in behavior change.

      A young child doesn’t initially share, we are ruled by our instincts not to, but eventually a child learns that sharing gives greater rewards.

      By the very fact that you are reading or responding to this blog, you are sharing and that is participatory medicine. http://youtu.be/NBmvBS9D6HU

      Its folks like Dr. Kvedar who are thinking outside of the box and the momentum that we all create by sharing that is going to shift the paradigm that technology changes are creating.

      A blog on the history of Doctors (they left out the Industrial Revolution) – http://blog.soliant.com/careers-in-healthcare/the-history-of-physicians-doctors/

      I’m glad you quit, I know change is hard.

    • February 8, 2012 8:15 pm

      thanks for your perspective. Even though you say your doctor doesn’t remind you that you are sick, you say you only seek his help when you are sick. this reinforces my point. i don’t know too many folks who visit the MD because its fun

      • Chris Wigley permalink
        February 8, 2012 9:03 pm

        It is ALWAYS my body that reminds me I am sick! I need and get no reminding from my doctor – what I get from my doctor are solutions! This is no big hill to climb for him as I am already engaged. His hill is to find the solution for my problems – and thankfully when I lived in the US I was never turned down by health insurance companies. My employer self-insured, and I suspect that his solution was to ‘unemploy’ me a little earlier than normal retirement. Now that I am back in Canada neither I nor my doctor has to worry about that sort of problem!

  8. February 8, 2012 9:16 am

    One big difference between the TSA scan & the mall scan that I haven’t seen mentioned is the plain fact that the person being scanned receives the data from the scan at the mall and is able to use the data to make better choices. TSA scans, like most data collected by our health care providers, are not made available to travelers and patients, although we have definitely made progress in making patients’ records available to them. However, data from those records aren’t provided in ways that have immediate value to patients, in most cases. Furthermore, to use the device analogy, patients don’t have access to data from medical devices that aren’t sold over-the-counter. Hugo Campos, who has an implanted cardioverter defibrillator, is on a campaign to change that. See his recent TEDx Cambridge talk:
    http://www.tedxcambridge.com/thrive/hugo-campos/

  9. February 8, 2012 8:16 pm

    very well articulated

  10. February 13, 2012 8:48 am

    I agree with Janice. In the Mall Scan example, the data collected is gathered from the consumer who can “use the data to make better choices”.

    For Healthcare, think about how data can be captured and shared with the consumer in a way that delivers ongoing value:

    > Comparison- With benchmarking information, how do I compare with others like me (e.g. using profile information?) During visits with our Pediatric doctor, we hear about how my child is growing physically, mentally and socially compared with others their age and gender.
    > Perspective- How am I changing from one point of time until another. During the annual doctor’s visits, we walk out knowing our latest weight and height (yes some people are getting shorter) but are not shown key data points over time.
    > Insight for Action- What does this information really mean? Is a certain percentage of weight gain at 50 years old normal?

    We will engage more consumers in their health by leveraging data in a way that creates value for them.

  11. Jim Hutchinson permalink
    February 13, 2012 9:33 am

    It’s the human factors that one has to address. The context is totally different. At the airport it’s just one more obstacle to getting onto the plane, thus delaying one’s primary goal. The other use of the same technology is for one’s sought after personal benefit. As to fitting clothing, it’s probably less personally invasive than the old way where a relative stranger touched many of your body areas while taking the required measurements.

    Yes, the airport scanner may save one’s life, however, it’s not viewed in that way. Education may help, but airport screening is always an impersonal thing in my mind making it difficult to change from I’m being invaded to I’m being saved.

  12. July 11, 2013 11:50 am

    You actually make it seem so easy with your presentation but I find this matter
    to be really something which I think I would never understand.
    It seems too complex and extremely broad for me.
    I am looking forward for your next post, I will try to get the hang of it!

    • July 11, 2013 3:51 pm

      thanks for the feedback. keep letting me know if posts are clear of confusing.

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