My Talk with the Future

I had a talk with the Future this morning. It wasn’t a surprise; I had set up the meeting. What surprised me was that the Future had accepted. I was sitting there thinking about what the Future would be like to talk to  & wondering why it was late, when my office door opened & there it was, a Timbuk2 messenger bag over one shoulder & a cup of coffee from Cosi in one hand.

“Sorry, I didn’t check my calendar this morning like I usually do, so I didn’t know until just now what time our meeting was.” It unslung the bag, sat in my other chair & fished out a paper calendar & a notebook. It must have seen my expression because its next words were: “I used to carry around a Laptop, tablet & a smart phone, but I gave them to my friends a while ago.”

“How come”, I asked.

“Well, in the first place, it was just too much to carry around. I used the laptop to write & do simulations, the tablet to keep track of blogs, media & social media, & the phone for, you know, a phone plus healthcare apps, music apps, stuff like that. It was just too inconvenient. Then there was all the app incompatibility, like with my calendar… I had Outlook first for my calendar, but that wouldn’t synch with anything, so I moved to Google for everything, but that wouldn’t synch with Outlook. Then I tried Tempo & Calendar5, but they rarely seemed to synch all of my events & meetings, and then I wrote an iCal app, but could never get it to synch with Outlook or the calendar on my Android phone, so…  & that was just for my calendar. You get the picture. Now when I’m in the Present, I just put things down in pencil in my calendar & erase them when I need to.”

What about a smart phone, though,” I asked. “You must use a smart phone.”

“Yeah, I had an iPhone, but it bricked itself when I updated to IOS7, so I got a Samsung Galaxy, but some of the apps I was using weren’t available. It was way cool, but not as convenient as the iPhone. After a while, I felt like I just wanted a phone, so I went back to my flip phone. I’m the Future, so I have other ways of staying connected. Of course, this is just when I’m in the present. In the future, things are different”

OK, I thought, this will be interesting. “So what about in the future” I asked smiling a little at the leading question.

 “Well, I thought you’d never ask,” said the Future. “But you should tell me, you being a technology futurist & all.”

“The thing about being a technology futurist,” I said, “is that you have two ways to look at the future – trends predicted from the lens of the past & imagination informed by what you think is possible & interesting. You might not even see the utility in something interesting. Ken Olsen, my boss’ boss at the Digital Equipment Corporation, famously said “I see no reason for anyone to have a computer in their home.” Of course, he was talking about VAX computers, but missed the PC revolution already underway.”

“So this means that you want to ask me about the future,” said the Future. “OK – three questions, but if I think they’re not insightful, I’ll cut you off.”

“That’s fair, so question 1… back to connectivity. The trend today seems to be toward wearables Google Glass & a whole variety of what appear to be clever visualization & presentation devices, most of which are cloud-connected. Will these actually take over from smaller current devices?”

“What do you think?” the Future asked.

“You’re going to make me work for this… OK, I think hybrid devices will evolve so that you have some sort of small hub that connects you to virtual storage & computing power as well as to a variety of presentation devices some of them wearable, but some not. This will take time as we’re currently stuck with the tension between laptops (& even desktops) versus smartphones & tablets, but even there we seem to be moving back towards laptops with 13 inch “tablets”, attached keyboards…”

“Well,” the Future said as it got up & started pacing, “Can’t stay still too long… & I can’t actually show you anything… this being the Present & all, but… you’re not so very wrong. Several different types of devices will evolve into hubs. Smart phones & tablets won’t, but things like Wi-Fi hotspots & other communications & media controllers will, & before you ask smart phones & tablets are too specialized to evolve like this. Laptops don’t go away, they are just assimilated & evolved… Some people realize this now, but in 5-8 years most people will realize that they need a device that is able not only to run apps or do voice & text communications, but that they still actually need access to compute cycles & much larger amounts of storage than the cloud currently provides. Everyone will need terabytes of storage for media, local & remote compute cycles, many types of presentation devices &…”

“Wait – what about search algorithms, storage, bandwidth constraints,”

“Not so fast, I need a biobreak & a couple of Frescas, then we can talk about some of that other stuff.”

…

“OK – two more questions…”

“Search,” I say, “I think search is key. This is what we found out at Documentum. You can store & retrieve terabytes or petabytes (I’m not so sure about zetabytes), but you have to be able to articulate what you are looking for in a way that is relatively unambiguous & the system has to be able to then effectively search a large volume of data in finite time, retrieve what you want & present it in a way that is understandable (or at least potentially understandable). That’s minimally three hard problems that may require new ways of initiating queries, new or very improved ways of representing many disparate types of information from structured alphanumeric to images & everything in between; not to mention how to present all this stuff…”

“Stop, stop,” said the Future… “All true, but… search is the human facing key, you can’t accomplish anything without it, but representation is the system key. Hadoop & its competitors today continue to develop & soon there is no type of information that cannot be stored & then searched. Column & noSQL databases become storage utilities that can deal with zetabytes of information routinely & most people have at least multiple terabytes of storage for their “stuff”: photos, videos, documents… everything in their life. The cloud is moot, because except in very extreme security cases, everything is in the “cloud”, & again Amazon, Google etc. have given up this business as a commodity that is run in common. People are not aware of the need for acquisition or management of storage or computing resources because they are just there…”

“Isn’t data & personal privacy an issue?” I ask.

“Sure, but at the point where information sharing & large scale analysis has basically cured many current diseases, close to eliminated eFraud & identity theft, created a transparent financial system & allowed the flowering of millions of individual entrepreneurial efforts, people are less concerned with the privacy issues.”

“This is like 200 years from now, no?”

“Actually not that far from now. Once these changes start, It’s both hard to stop them & opinion begins to favor them… OK, have to go, lot’s of things happening…”

“Will I see you again? There’s a lot more to talk about. What happens to social media? How does app development & programming evolve? Is what we call AI important or just something we made up? Can we…”

“Too much to talk about now, & sure, we can sit down again, just make another appointment”

The Future smiled, picked up his messenger bag & his half finished Fresca & walked out into the corridor. I walked to the door & looked up & down the hall, but only saw the present.

Stay tuned for my next posts:

•         a path to productive analytics for under-resourced healthcare organizations
•         the evolution & implications of search for how we interact & work

Clinical Workflow & other Arcane Rituals...

In my last two posts, I’ve been writing about the problem of re-engaging patients in collaborating with their providers in order to make their healthcare decisions. Patients do not seem very motivated to use current tools (PHRs, patient portals, private social media) to affect this collaboration, & they are already overwhelmingly using public social media (Facebook, YouTube, Twitter, etc.) to share very intimate details of their personal health information. I proposed that the integration of public social information into the workflows of providers & healthcare organizations might be an effective way of encouraging or eliciting this collaboration. What does this mean? & is it feasible?

First several short, but relatively interesting (I hope) digressions. What is it that we mean by workflow? This is one of those things that everyone understands but that no one can define, design or optimize effectively. Wikipedia defines workflow as “…a sequence of connected steps where each step follows without delay or gap and ends just before the subsequent step may begin.[1]” Workflows can be abstract (models) or concrete (task or process steps). In the case of a clinical or other medical workflow, it is the sequence of tasks that a provider or other medical professional carries out in order to provide care for a patient. These steps may include information gathering &/or treatment tasks. Until recently, most clinical workflows had been developed & modified historically by provider actions & by the efforts of medical professional associations. More recently, workflows have been provided (at least in part) by the use of EHR systems that have implied workflows associated with their use. Many providers in the U.S. have gone through major changes in clinical workflows as they have adapted to the use of EHRs in order to qualify for meaningful use incentives offered by the Centers for Medicare & Medicaid (CMS). This adaptation may make it harder to get providers to accommodate to additional workflow changes.

Second, what is collaboration? Again Wikipedia defines collaboration as: “…working with each other to do a task and to achieve shared goals. It is a recursive process where two or more people or organizations work together to realize shared goals.[2]” The criteria for achieving collaboration have been deeply researched. Eisenhardt[3] has described the criteria necessary for actual collaboration as:   

•     Having a shared goal structure, or explicitly agreeing to disagree on goals,
•         Having a similar reward structure so that one party to the collaboration does not benefit more than the other, &
•     No substantial asymmetry in knowledge or information between parties.

Given these criteria, it is clear that the interaction, even decision making interactions, between provider & patient &/or caregiver is not & cannot be a collaboration. Even if they share the goal of a positive clinical outcome, they have very different contexts for that goal; the reward structure is similarly skewed, as is the symmetry of knowledge & information. What can happen is shared decision making[4] that is the patient & provider making decisions together with the resources & understanding that they have each developed. There has been much research on shared decision- making (SDM)[5] that has focused on building a consensus between provider & patient on a preferred treatment plan & its implementation. Notice that this is different than collaboration. What is needed, then, is a workflow that facilitates shared decision-making between providers & patients & their caregivers.

OK – how can this workflow be developed so that it engages both the provider & the patient. As I have already written, the integration of public social media for information sharing, community building & communications will be important as will gamification of the provider/patient relationship & the use of healthcare apps on smartphones & other devices. The easiest, & perhaps most painless way to do this for providers is to let the EHR vendors do it. This, of course begs several questions: what does this provide for the patient? How can the quality & efficacy of the vendors’ efforts be ensured? Even, how can the vendors be motivated to do this? My initial answers to these questions are: nothing, with difficulty & with difficulty – sorry about that. Many EHR vendors are moving in these directions, but their motivation to provide patient functionality via their products, except for that required by meaningful use criteria will be low. Many healthcare organizations are providing PHRs for patients to contribute information to their personal healthcare information, but providers have low motivation to use this “data”. There are companies now providing private social media capabilities for healthcare organizations, but it is just that – private. These private networks have trouble gaining traction with patients with the possible exception of directly messaging their provider (although many of the private networks &/or healthcare organizations using them do not permit this).

The real solution is to re-engineer clinical workflows so that there are (at least) alternatives task paths that include import or evaluation of data from public social networks, including chat & tweet streams, images, direct messages, video etc. Such streams could be displayed as is or extracted so that data might be available for import into other applications. Re-engineer you say… Yes, that re-engineering. About five years ago I did a set of work on comparisons of productivity measurements in ambulatory healthcare & two benchmark industries: auto & information. Ambulatory healthcare had relative good productivity based on measurements[6] such as value added to GDP from overall revenue & value added to GDP through Full-Timed Employee (FTE) wages. Ambulatory healthcare measurements were generally than Auto (1998-2005) & a bit lower than Information Industries[7]. Other productivity measurements are more focused on how organizations are structured & managed (Total Factor Productivity, TFP) or on the effect of multiple factors (Multi-Factor Productivity, MFP)[8] such as research & development investment, economies of scale, managerial effectiveness, etc. Ambulatory Healthcare had negative trends in MFP & TFP during the 1998-2005 timeframe while both Auto & Information had highly positive trends. It is thought that these results reflect the very large investment made in the benchmark industries in process optimization & workflow re-engineering. These efforts, with the exception of adaption to EHR adoption, have yet to be made in healthcare, & it could be argued that optimizing clinical & other healthcare workflows could result in much larger gains in productivity subsequently resulting in positive trends in outcomes.

A provider working through the EHR workflow could get to the history page (clinical history including diagnosis from past encounters, clinical data for selected measures etc.) or other relevant page & be presented with an alternative page that incorporated data from the patient’s PHR, selected (relevant) data from tweet & post streams, patient supplied images & video as well as potential symptom descriptions from social media streams. This additional data could provide valuable information not elicited by the normal EHR workflow. A good deal of work would have to be done to determine the most effective & productive way to provide this data as part of the workflow, so projects to explore this should be started now.

Patient portals could be redesigned with what we have learned about effective shared decision- making. This would make these portals much more interesting to patients (as well as to providers). Such portals could still provide access to patient data, provider messaging, but could also serve as workspaces for shared decision making with their own workflows, information sharing, game elements etc. The combination of information from public social media available in the clinical workflow (engaging providers with data not usually available) & a patient portal that was a shared decision-making workspace for the patient & provider could be a breakthrough combination.

Stay tuned for:

•         a continuation with some thoughts on shared decision making workplaces, &
•     I still haven’t posted the talk I had with the Future

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[1] http://en.wikipedia.org/wiki/Workflow

[2] http://en.wikipedia.org/wiki/Collaboration

[3] Eisenhardt, K.M. 1989. Agency theory: An assessment and review. Academy of Management Review. 14(1):57-74. January, 1989.

[4] Shared Decision Making (SDM) is an approach where clinicians and patients communicate together using the best available evidence when faced with the task of making decisions, where patients are supported to deliberate about the possible attributes and consequences of options, to arrive at informed preferences in making a determination about the best action and which respects patient autonomy, where this is desired, ethical and legal. http://en.wikipedia.org/wiki/Shared_Decision_Making

[5] c.f. Elwyn G, Tsulukidze M, Edwards A, Légaré F, Newcombe R (2013). "Using a 'talk' model of shared decision making to propose an observation-based measure: Observer option^{5 Item}". Patient Educ Couns. doi:10.1016/j.pec.2013.08.005.

[6] Harper, M.J. et al. 2008. Integrated GDP-Productivity Accounts. American Economiics Association Annual Meeting. San Francisco, CA. 1/2009

[7] Hartzband, D.J. 2008. GDP-Based Productivity of Ambulatory Healthcare: A Comparison with Other Industry Segments. ESD-WP-2008-11. Engineering Systems Division Working Papers Series. Massachusetts Institute of Technology. February 2008.

[8] Bureau of Labor Statistics. Multifactor Productivity Homepage. http://www.bls.gov/mfp/

The Re-Engagement of Patients - 2014 & Beyond - Part 2

In my last post, I reviewed the evidence that patients are less engaged in their healthcare decision-making today than they have been in the past. I also listed a number of ways that this disengagement is being addressed including: patient access to healthcare information & communication with their providers through patient portals, Patient-Centered Medical Home certification, Meaningful Use Stage 2 qualification, etc. I don’t believe that any of these will be particularly successful at creating patient re-engagement, & I suggested that peoples’ surprising preference for using public social media (Facebook, Twitter, YouTube, G+) to share personal health information (PHI) & create communities around diagnosis & shared experience is a trend that has already taken off. The cited pwc study[1] showed that 90% of 18-24 year olds (28 million people[2] 2) would trust healthcare information on public social media sites & that 56% of 45-65 year olds would engage in healthcare activities on public social media sites (that’s 47 million people aged 45-65[3]). Adding in estimates for the rest of the population it appears that somewhere around half of the U.S. population has or would share PHI & engage in healthcare activities on public social media. It seems shortsighted to not plan to utilize this fact as part of healthcare reform. Patient re-engagement specifically could benefit from using this tendency for trusting & using public social media.

There are two other aspects of the effort to use peoples’ engagement with electronic activities to affect patient re-engagement. The first is electronic gaming. According to the Entertainment Software Association, 58% of Americans play electronic games[4]. Games are starting to play an increasingly important role in healthcare, especially in the treatment of chronic or serious conditions[5] & could be incorporated into the interactions of patients, caregivers, providers & community members to provide a new type of engagement. Finally, there are an estimated 6000+ healthcare & fitness apps available for smartphones & other platforms. The FDA reports that approximately 500 million people will be using such apps by 2015[6].

How could these three trends be used to re-engage patients in making their healthcare decisions? The first possibility I can think of is to integrate information & interaction people have with public social media into their healthcare provider’s clinical workflow. I know, there are a lot if issues with this, but if half the population in the U.S. is ready to interact on public social media regarding their healthcare, it seems foolish not to try this integration. There seem to be a number of real impediments that would have to be addressed.

·          The first is that providers (doctors & other healthcare professionals who interact with patients & make clinical decisions about their care) are not at all fond of having their workflows, that is exactly how they interact with patients, changed – especially if they are not initiating the change. Providers are about improving outcomes for patients & many of them feel that they have already made huge changes in adopting electronic health records (EHRs) into their workflows without seeing much measurable improvements in patient outcomes. Now we would be introducing an entirely new (for the vast majority of providers) dimension of interaction, one that is more immediate, & possibly more intense than their current interactions.

·          Another part of the workflow issue is that clinical workflows are not standardized, even within specific areas of medicine. They are more so now with the use of EHRs that have an implied workflow associated with them, but most EHRs are configured differently for different specialties: primary care, cardiology, behavioral health, etc. This would have to be taken into account in the integration.

·          Second is that providers are very skeptical of patient &/or caregiver provided information, especially in Personal Health Records (PHRs) & online. Part of the issue with PHRs is that they are not a good medium for use of both patients & providers – they must be simple enough for patients to use but not so simple that they are ineffective for providers to use in treatment. This is even truer of information that patients post online as they may have other motives (than provision of information for treatment) such formation of community.

That’s probably enough limitations. It seems as if the benefits outweigh these limitations so that a real effort can be made to overcome them. These benefits include:

•        The possibility of using both public social media interaction & the information posted in social media streams as part of the task flow for the provider/patient relationship, & that this would improve the providers’ ability to react, both clinically & personally.
•        The possibility of having information to work with that a provider would not normally have; such as the patient’s work/life balance, family issues as expressed in social media, patient’s interaction with community of people with similar medical problems (uncovering their opinions of current & past treatment, fears & hopes for treatment, etc.).
•     The possibility of creating a more trusting & therefore more reliable means of facilitating provider-patient communication & interaction.

These are not the only potential benefits, but they do provide the very real possibility of more informed, reliable & productive provider-patient interaction that could result in measurably improved outcomes. This would require education & evolution of attitudes & behaviors on both sides in order to work (& possibly changes in the written HIPAA guidelines or their interpretation & enforcement), but the fact that up to half of the U.S. population may already be using public social media or may be predisposed towards using it for healthcare purposes makes this an easy – although hard to implement & deploy – recommendation.

Two additional aspects of this evolution might make it easier & more palatable; at least for patients. The first of these is gamification. This does not mean that all or most interactions are done in the context of a game. Actual games, for instance, are not very effective at information gathering & transfer. It does mean that principles of game design & play are used to design the interactions. These would include: goal setting (self), leveling, reward structure, meaningful choice & narrative feedback[7]. Using these design principles for patient interaction (through social media) may result in greater engagement by patients, as interaction becomes both more effective & interesting to them.

Another aspect of information gathering & provider-patient interaction is the use of healthcare related apps on smartphones & other devices. If, as the FDA estimates, there will be 500 million users (worldwide) of such apps by 2015, they also should be integrated into clinical workflows in order to take advantage of the information stored in such apps & the interaction style provided by them. Many of these apps are already “gamified” to some extent  & store information in formats that should be easily shared with PHRs & even EHRs. The introduction of such apps, or more likely, the development of such apps for integration into clinical workflows could be a game-changer in terms of patient & provider engagement.

One other thing to take into account is that there are several commercial efforts underway to provide private social media for healthcare organizations, see, for instance WellFx (www.well-fx.com) or PathCare (http://www.pathcare.co/). Many large organizations (Kaiser Permanente, Partners Healthcare, etc.) are also developing & providing their own private social media apps, either as add-ons to their patient portals or as stand-alone applications. I believe that these efforts will not succeed unless they are connected in some way to the public social media that people are already committed to using.

Of course, the only way to really know if the integration of public social media & gamified healthcare apps into providers workflows can be effective is to do it. Pilots will allow the evaluation of the feasibility of such integration & provide vehicles for testing a variety of paths to achieve such integration. Let’s “just do it”.

Look for my next posts:

•         What exactly is workflow integration in healthcare?
•     Exclusive – I talk with the Future!

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[1] Social Media “Likes” Healthcare – From Marketing to Social Business. pwc Health ResearchInstitute. April 2012.

[2] http://www.research2guidance.com/500m-people-will-be-using-healthcare-mobile-applications-in-2015/

[3] http://www.census.gov/population/projections/data/national/2012/summarytables.html

[4] http://www.theesa.com/facts/pdfs/ESA_EF_2013.pdf

[5] http://www.rwjf.org/content/rwjf/en/search-results.html?u=&k=games

[6] http://www.research2guidance.com/500m-people-will-be-using-healthcare-mobile-applications-in-2015/

[7] Reality is Broken, 2011, Jane McGonigal, Penguin Group (USA) Inc., NYC