Notes & Links: October 29, 2013


Making Health Addictive
Joseph Kvedar writing on HealthWorks Collective is presents the premiss that people’s addictive relationship with their smartphone can be leveraged to improve health. Kvedar admits right up front “…is there any way health can really be addictive?  Probably not.” What he wants to present is the “juxtaposition of motivational health messaging with some other additive behavior, specifically checking your smartphone.”

Next comes the science of checking our phones 100 times a day (I’ll raise my hand) and how that is addictive and it releases dopamine associated with ingestion of addictive substances. Yup we get off on our phones looking for emails, stock news, weather reports, news, cat videos, etc. So far still good.

Why are smartphones so additive? All the apps, video, social networks, and just plain curiosity. Kvedar makes the following statement.

Many have talked about the transformational possibilities of mobile health including:  the opportunity to use an always on, always connected device to message you in-the-moment about health; to capture health-related information about you via the camera and through connected sensors; and, of course, the ability to display relevant information in context.  All of these are exciting, but if we can exploit the addictive quality of smartphones, it will be the most important characteristic of mobile health as we move forward.

Here are his strategies for doing the above:

1. Make it about life: Learn what the person wants from life his/her aspiration and tie health related messages to those aspirations.

2. Make it personal: Put it in the context of the phone user in relevant ways. Personalized medicine

3. Reinforce Social Connections. We all want connections to others and especially around health problems or questions we are seeking to solve. They are very powerful tools and as Kvedar notes not just for friends and family but for accountability and adherence to care and wellness plans.

Here are the tactics that are offered:

1. Subliminal Messaging. “Imagine if every time you checked your phone, an unobtrusive brief message appeared on YOUR health issue and how to improve it.”

2. Use Unpredictable Rewards. ” B.F. Skinner proved that operant conditioning is more effective when the stimulus and reward are tied only some of the time.”

3. Use Sentinel Effect. “This effect of having an authority figure look in on your life is a really powerful tool that can be used to effectively promote good health through mobility.”

Kvedar ends with reference to this in the Boston Globe

What’s going on here? We’re witnessing the death throes of advertising’s “Mad Men” era, and the birth of the Mr. Spock era. Mad Men were all about coming up with clever ideas for ads, treating clients to steak-and-martini dinners, and putting TV spots on the most popular shows. You didn’t know exactly who saw your ad when it ran on “Bonanza,” or what impact it had on sales, but you knew it reached a lot of people.

Mr. Spock is all about making logic-driven decisions based on data collected about consumers and the context surrounding the ad. Who is clicking, and is that click leading to a transaction? Is this ad worth what we’re paying?

I agree with his premiss we should leverage the smartphone we are all addicted to in order to maximize the technology that will drive outcomes and improved patient care. I agree that for this to work we need to determine what the patient wants or needs. Where I split hairs is around how we do that? Using surrogate markers of sites visited or other behaviors on the phone or even the computer is not accurate and may not directly address the problem the patient wants to solve. What needs to be done are for patients to say I need to understand this about myself and my health. I want to opt in and I want to opt in with a trusted partner or partners.

The problem here is that will we ever reach a critical mass of patients who will drive community outcomes? Will we be able to go beyond those who are active healthcare participants and move to the next demographic those who have a minor interest? This is similar to getting the young invincible’s to sign up for ACA. How can we apply all these ideas to successful marketing?

Overcoming Fragmentation in Health Care
John Noseworthy writing on the Harvard Business Review Blog Network addresses the reality that the quality of healthcare in America is fragmented which drives ‘unsustainable health care spending.’

Noseworthy points to the fact healthcare is in the throws of consolidation through mergers and acquisitions and that is at the root of fragmentation because the larger and more complex a system becomes the greater its fragmentation and cost.

It is different at the Mayo Clinic

At the foundation of our approach is a knowledge-management system — an electronic archive of Mayo Clinic-vetted knowledge containing evidence-based protocols, order sets, alerts and care process models. This system, which can be made available to physicians in any location, brings safer care, better outcomes, fewer redundancies, and ultimately cost savings for our patients. Ask Mayo Expert, one of the many tools in our system, helps physicians deliver safe, integrated, high-quality care. Through this system, physicians can find answers to clinical questions, connect with Mayo experts, search national guidelines and resources, and find relevant educational materials for patients. This knowledge is updated in real time and made widely available.

Knowledge and access to knowledge is the single most important driver of better patient care. HCP are life long learners and being able to quickly and easily access experts etc. will slow fragmentation and hopefully slow cost expansion. And that is achieved through the following activities

Through this commitment, Mayo Clinic physicians and scientists have contributed more than 400 peer-reviewed papers on quality improvement in the last five years.

Noseworthy ends with this

To transform health care in America into high-quality, patient-centered care that the nation can afford, we must address fragmentation, we must address variable quality, and we need to create a sustainable health-care financial model. Collaboration is key. Mayo Clinic has a long history of innovation focused on improving the value of health care, but we can accomplish much more by working together — integrating and sharing knowledge with one another.

This is mom and apple pie and spot on regarding learning and how it drives change. What was missing for me was the patient component. Clearly Mayo Clinic is patient centric in its care. That is known and proven but I was surprised to see it not referenced or tied to this article. Fragmentation is the the goal of the institution but the patient is at its center and can benefit if not address fragmentation. Just to make sure I didn’t miss a patient reference I searched the article and the only reference to patients was in the comments.

Great blog! First off, please let me commend you on the amazing work that you, your organization and your employees do everyday. The software you reference to address fragmentation on the hospital side sounds fantastic! May I ask how you are addressing fragmentation in the eyes of the patient? We launched a pilot program in Cleveland, OH that used Lay Patient Navigators to decrease fragmentation. By developing key relationships with patients, the lay navigators were able to massively decrease fragmentation and positively impact patient outcomes. It was a very successful program! Not only did it decrease fragmentation and increase both outcomes and patient satisfaction – it also positively contributed to the hospital’s bottom line! Just another way to think about decreasing fragmentation in the eyes of the patient because as we all know – this health care system is incredibly fragmented and confusing! Do you use lay patient navigators?

We should not forget that the patient is at the center of care and they drive our brave new world of patient engagement. 

The legal justification for mandate penalty/open enrollment realignment
Nicholas Bagley a University of Michigan Assistant Professor of Law submitted a quest post to The Incidental Economist. Let me see I can explain this, the Obama administration offered guidance to ease concerns surrounding the imposition of the individual mandate using “hardship exemption”.

Here’s what the administration is worried about. Under the ACA, an individual doesn’t get slapped with the mandate penalty until she’s gone without health insurance for a full three months. That means she’s got to be covered before April 1 rolls around—which is to say, by midnight on March 31. By regulation, a plan that is purchased in the first half of a month takes effect on the first day of the following month (e.g., a plan bought on February 10 takes effect on March 1). For coverage purchased in the second half of the month, the coverage period starts on the first day of the month after that (e.g., a plan bought on February 20 takes effect on April 1). As a result, to get coverage that kicks in before April 1, an individual has to purchase a health plan by mid-February.

Yet the open-enrollment period lasts all the way through to the end of March 31.

Still, the administration is right that the awkward conjunction of the ACA and the coverage-effective dates has created a trap. Pretty much everyone who purchases insurance in the open-enrollment period will assume—reasonably if wrongly—that they’ve done what the mandate requires of them. That shared assumption provides an eminently plausible basis for invoking the hardship exemption: the assumption, by encouraging delayed enrollment, means that loads of people will face a financial penalty they hadn’t anticipated. That penalty, even if it’s assessed after the fact, will reduce their “capability” to afford the health plan that they purchased. Invoking the hardship exemption to deal with that reduction in capability makes sense, especially because the whole point of the exemption is to alleviate affordability concerns.

I have a headache trying to figure this out and understand it. Bagley has some terrific links and information which helps.  But more importantly I believe the ACA is organic and will move forward in fits and starts to what I hope becomes a valid and working healthcare model. What frightens me is the fact that this looks like how sausage is made at its worse. I wonder how much faith we can hold on to while we wait for some positive metrics?

Caregiving My Opinion and Experience

My essay on caregiving was submitted last month to the Mayo Clinic Patient/Caregiver Scholarship 2013. Three great smart writers wii win a chance to go Mayo’s media week for free. I didn’t make the cut. But Mayo being the monolith of healthcare social media scored these results: 

We had a record number of participants, and through the process drew lots of attention to your stories. There were more than 18,000 page views of the essays, more than 1,800 comments and nearly 1,300 likes, and essays were shared on Facebook and Twitter more than 4,500 times.

Well done. They can sure work a social media room. 

Are we born caregivers? Do we surrender to caregiving? Where do we learn to be a caregiver? How do we measure caregiving?

Donna was a creative director. Her sense of type, layout, art, design, color, and copy was nothing short of brilliant. Donna was smart, strong, independent, and extraordinarily creative. She fought for every success and did not tolerate fools gladly. In 1979 that is the woman I fell in love with. In 1983 I married her.

January 2009 Donna was diagnosed with Stage IV NSCLC, told on voice mail at work you have six months to live. On February 6 Donna had a craniotomy. Two months later she began whole brain radiation. And in another two months began the first of three rounds of chemo. July 11, 2011 she was admitted for a thoracentesis. July 18 Donna was transferred to hospice. On August 7, 2011 she died.

I closed my business to become her caregiver. Donna put her disease in my hands; she gave it to me to manage and guide her. It was hard to imagine that I was guiding the strongest and smartest person I know. I read somewhere “Courage is not the absence of fear it is the presence of dignity in the face of fear.” She was dying yet she kept her dignity.

All through our marriage I made big family centric Sunday dinners for the two of us because as a child those meals were non-existent for her. That was caregiving sans the disease. During her illness caregiving accelerated and morphed: teaching her to ride a bike, helping with the nausea, vomiting, severe alopecia, hypertrophic osteopathy, preparing pill packs, and communicating with friends about her disease. Rallying friends to visit her in the hospice.

Toward the end I would come home from my part time job and just sit on the stoop afraid to see the disease the pain. I was broken and scared. But I went upstairs because it was my true job, my one love, my only universe, and our life.

Caregiving is an emotional rip tide dragging us out to sea to partake in our drowning but it frames love like nothing else. We give care to the best of our abilities but do it for all intents and purposes alone. Over time caregiving debilitates us physically and emotionally. Can that be changed?

We are not given a caregivers toolbox. Where do caregivers rally to find hope, help, and healing? With family, friends, colleagues? How do we measure if we are doing it well?

Caregivers acquire vast amounts of healthcare knowledge. They are little knowledge machines filled with hope and pain. My wish, this essay will be used to create caregiver toolbox of help. And other caregivers past, present, and future will find a voice. Our caregiving experiences can help others reflect and grow. And survive the crushing aloneness of our life after the death of a loved one.

The Harmony of Loss Found in the Caregiver Community

There have been many comments to my essay for the Mayo Clinic Patient Caregiver Scholarship contest. I am struck by them all. Struck by the resonate chord and the harmony we share as caregivers. They fill me with hope and understanding. 

What touches me the most is that we share a similar sense of loss while at the same time we have a strength of knowledge and understanding. This comes from our collective sharing of experiences and using that knowledge to move forward to find some peace. Peace that does not come easily while the pain is mitigated by knowing we are not alone.

If you can read the essay and the comments leave one if can but most of all feel the sense of place we share.

Mayo Patient/Caregiver Scholarship

I have to pay more attention to the rules. I didn’t notice that the essay I submitted to Mayo Clinic Patient/Caregiver Scholarship had the following:

All entries will be reviewed for compliance with contest rules, and beginning July 15 those that qualify will be published on this page for public comments and voting.

 So if you would take a look HERE and comment and vote. Only if you feel my essay works. And as they say in Chicago vote early vote often.