July 5 NEJM published an article titled ‘Automated Hovering in Health Care- Watching Over the 5000 Hours’.
The primary premise presented is that the US is ‘a reactive, visit-based model’ where patients are seen when they become ill, are hospitalized, and as outpatients. Besides being expensive and not driving proactive improvements in health it fails to address the 5000 hours per year that all of us spend outside of those healthcare encounters. It is during those 5000 hours where we engage in healthy or not behavior.
The importance of those 5000 hours is being addressed with various initiatives focused on employers and employee wellness programs, medication adherence, transitional care, and identifying the highest needs patients. These programs engage personal hovering, which make them expensive and difficult to scale up. A multi-center telemonitoring trial with heart failure patients showed no effect on outcomes of rehospitalization and death.
The authors presented three developments where automated hovering offered promise. The first is payments for outcomes as well as non-reimbursement for preventable readmissions. The second is the application of behavioral economics and the human desire to want better health and know what needs to be done to achieve it by applying motivation and financial incentives. And finally new technologies such as cell phones, wireless, and the Internet offer new ways to hover during those 5000 hours at a lower cost.
A study using a home-based pill dispenser connected to a lottery system offering a chance to win prize money reduced the rate of incorrect doses from 22% to about 3% in patients taking warfarin. Another study randomly assigned difficult to control patients with diabetes to receive standard care or mentorship from another patient who was successful in managing their glucose levels. After 6 months glycated hemoglobin levels were greater than a full percentage point lower then those in the control group.
The authors conclude by identifying targets fro automated hovering. Those include conditions whose management is dependent on individual patient’s behavior, medication adherence in hearth failure patients, management of diet, exercise or weight. Key to this success is how to make hovering heard over the din of social media, TV, and those things competing for out attention.
The ground work has been laid: behavioral economists, clinicians, educators, and patient groups will be gathered and studies initiated. These are complex studies. Any outcomes from these studies may not be anything that can be easily executed at the bedside or following an office visit. There may be one or two small things the HCP and the patient can do while waiting for these studies to be completed and initiatives to become part of our healthcare landscape.
Perhaps the HCP and the patient can establish something like shared decision making but in the realm of shared knowledge exchange where both the HCP and the patient agree to exchange information about health related topics specific to the patient. These can be as simple as short text messages regarding glucose monitoring or exercise or articles on a topic specific to the patient. This can all be established prior to the office visit via a tablet and confirmed during the visit. The principle is that at the visit the patient is more aware and interested in health and healthcare: leverage it. No point in loosing an opportunity to establish a conduit for communications, a way for both parties to open up those 5000 hours to each other in simple non annoying nanny state fashion. You can’t change behavior without having both parties sharing the need and desire to listen and learn. Engagement is a small simple step in communications between patient and HCP that begins perhaps a long term relationship.