Behavior Change

Archive for Behavior Change

The Known Citizen: A History of Privacy in Modern America

Although the “P” in HIPAA stands for portability, the question of privacy and data protection is a big topic in healthcare. While at the same time we need to protect all personal health information for patients, individual patients have the right to share that data how they wish. New legislation on data interoperability seeks to break down silos and data blocking to enable patients and providers to have access to data to improve care. With this as the current situation in 2019, those interested in privacy should not miss Sarah Igo’s excellent history of privacy and policy “The Known Citizen.” We recommend this book to all data and privacy nerds. While not focused on healthcare, it provides a great primer on the evolution of privacy and technology’s ability to outpace our understanding and desires both to be known and to be forgotten.

The book kicks off with the advent of photography and the debate at the time about whether people own their likeness. (At the time they didn’t, and people found their pictures on boxes in the grocery store.) It details the evolution of thought, law, and popular sentiment in privacy, including the first ideas that patients have a right to privacy, championed by nurse Dorothy Smith in 1969, and institutionalized in the Patient Bill of Rights in 1973. The premise is that while the loss of privacy is required in the doctor/patient relationship and to deliver care, this doesn’t mean that all aspects of privacy should be ignored. “Arranging for privacy”: curtains, confidentiality, (robes that close at the back?), can created a zone of privacy around the patient and help preserve the individual’s dignity. Smith felt that this was the duty of the nurse, although now we see it as the responsibility of everyone in healthcare from the receptionist to IT.

Healthcare privacy is also touched on in the social determinants of health, and whether people receiving public aid should have their entire lives under the microscope, and again, in the introduction of internal review boards and ethics committees for medical research to protect patient/subjects from harm, but also from disclosure of private information without their full cooperation or understanding of its use.

While you may know Betty Ford for her disclosure of addiction and subsequent support of treatment, she is also responsible for destigmatizing breast cancer and showing that open discussion, and especially by prominent figures can drive public health agendas. After Ford disclosed her breast cancer and mastectomy in the media, there was a noticeable uptick in mammograms, and over 5,000 calls of support to the White House.

While healthcare is a small part of this book, the learnings from society at large, and the race between technology, sentiment, and legislation have great lessons to apply in healthcare. And interestingly much of the discussion we are having today about being known, has been going on for over hundred years, and the
“big data” discussions for at least 50 years. Finally, this book has the added bonus of a really interesting bon mot for your next cocktail or mocktail party: the first reality TV show was broadcast in 1973, on PBS of all broadcasters!

Posted in: Behavior Change, big data, Clinical Research, Data Protection, Health Regulations, Healthcare Legislation, Healthcare Policy, Healthcare Research, Healthcare Technology

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HIMSS WA Innovation Summit

I had the opportunity to attend the Washington HIMSS Innovation Summit, where leaders from Virginia Mason, Providence, Overlake, Seattle Children’s, UW Medicine, Vera Whole Health and Confluence spoke about innovation in their organizations. A lot of great themes and takeaways. These are the ones that stood out most to me.

Technology Adoption

Several panelists mentioned they have problems with their health systems adopting new technologies. Executives tend to bring in new technologies, get pilots kicked off, but struggle in the system-wide adoption. A lot of times new technologies are implemented and expected to work immediately. The reality is that no matter what Health Systems are implementing, they need to invest resources. Physicians and end users need to be engaged early on to really take ownership of the new technology. A well-defined change management process is also key to ensuring a successful adoption. Lastly, even though organizations are piloting the new technology, call it Phase 1 vs Pilot. Pilots imply a short-term project with and end date. Phase 1 makes the technology more real and gets people thinking about what Phase 2 and 3 look like.

Return on Investment

One of the panelists challenged any technology vendor to show him a technology that has ROI. He said his organization does over $200M in uncompensated care per year so he must evaluate new technologies against cost of patient care, which is a valid point. This brought up an interesting discussion about what health systems consider to be a ROI. Not all technologies will give Health Systems dollar-for-dollar return. Some technologies will. ROI can be a blend of hard and soft cost, so it’s important to spend time thoroughly defining a business case and make sure that success metrics align with the overall mission of the Health System.

Patients

I was surprised at how much of the discussion was focused around clinician-facing vs patient-facing technologies. I agree better tools and algorithms for clinicians will directly influence the quality of care that patients receive. Virginia Mason panelists did a great job bringing everything back to the patients. Patients should be the center and they should have access to all their data, regardless of where it comes from, in one place. They should have one seamless app and experience for all their healthcare needs. We at Wellpepper could not agree more!

Key Takeaways

When evaluating and implementing new technologies:

  • Define a realistic business case and what financial and non-financial ROI looks like
  • Ensure alignment to Health System’s mission and goals
  • Don’t assume that new technologies can just be plugged in and solve all problems
  • Allocate resources and engage providers and end users from the beginning
  • Treat it as a multi-year, phased journey; call it Phase 1 instead of a Pilot
  • Have a solid change management process
  • Keep patients’ experience and needs at the top of mind

Posted in: Adherence, Behavior Change, Healthcare costs, Healthcare Disruption, Healthcare Technology, Healthcare transformation, HIMSS, patient engagement, Patient Satisfaction, patient-generated data, Return on Investment, Uncategorized, Using Wellpepper

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You Are Here: Voice Assistants In Healthcare

“We’re at the beginning of the end of the first phase of voice” said James Poulter, CEO of Vixen Labs.

The beginning of the end of the first phase might be optimistic for voice, but that did not dampen the enthusiasm at the second annual Voice.Summit in New Jersey this week. Another speaker likened voice to being at the same stage of technology as the release of the first iPhone. If you remember, at that time everyone else had feature phones, and Android didn’t exist. Voice Summit Keynote

Not surprisingly, this year’s summit reminded me a bit of the early days of mobile development: more talk about how than why, more developer content than business content, and just an inkling that we really don’t know what we don’t know about where voice will go. One of the great things about this conference is that it’s a cross-industry event, so was a specific healthcare track, with topics ranging from best-practices for designing voice care plans to ethical considerations of voice, AI, and bots in healthcare, there was also the opportunity to learn from other industries, and also directly from the key technology leaders in the space.

The following are some highlights, learnings, and implications for healthcare as well.

Amazon Alexa

Dave Isbitski, Alexa Developer Evangelist, kicked off the summit with a couple of announcements for Alexa, skill connections which enable one skill to invoke another skill, for example if you want to print content from a skill you can call another skill designed for printing, like the HP skill. While this is currently limited to named skills, it has huge value in healthcare where every skill shouldn’t have to recreate medication lists or a full lexicon of disease education, and it would be better to call on a proven authority like Mayo Clinic or WebMD to get more information.

Dave also announced Dialog Flow, which uses neural networks to develop skills with less coding, and less manual tagging, although admittedly we’re realistically still in the turn>multi-turn phase rather than full machine-learning and AI. This is probably okay for healthcare: let’s focus on getting patient feedback on structured conversations, like triage surveys, before trying to design a system that is completely responsive to any healthcare need.

Another announcement, the ability to have one skill that uses two languages, rather than installing a separate skill for each language would also be beneficial in healthcare to provide patient instructions, especially to family members who may have different “first” languages.

Samsung

Samsung has jumped into the voice fray with a voice assistant called Bixby, which is designed to be a developer platform for people to insert voice into any type of device. Microsoft has this strategy with Cortana, the difference is that Samsung themselves ship televisions and refrigerators that can be voice-enabled. Samsung is also in the “voice and” category with screens being key part of their delivery. This has some really interesting implications for healthcare if you think about the television as the focal point of the living room. Health reminders and actions delivered there could have great impact. We’re working on a mobile version of the MIND diet, which would have huge impact if delivered through voice and visual reminders on the refridgerator door. The challenges with these modalities though are that it may take generations for the technology to become ubiquitous, versus the $39 Echo Dot. Samsung sees a world where your voice assistant knows you across all your devices, which would definitely be helpful in maintaining health context.

Microsoft

Voice as an ingredient, and part of an iOT and AI strategy was echoed by Microsoft. No surprise since Cortana doesn’t have a body or even a hockey puck. This strategy could be very interesting in healthcare if you think about the talking EPI pen. Why wouldn’t all devices and complex equipment have voice prompts for both patients and providers? There was also a meetup group at the conference demonstrating voice running on an ARM chip, which could be very interesting for the cheaper medical devices.

Designers and Developers

The tradeshow floor was full of mostly developer tools for building, testing, and securing voice applications, and the rallying cry in sessions was for the platform providers (Amazon, Google, Apple, Samsung, Microsoft) to standardize on their approach to voice, if not for the developers, then for the end-users. One of the key areas for some standardization is in the lack of standard interface, just as the APIs from platform vendors use different terminology, there’s no standard interface or reusable components aside from the idea of a wake word, to help users navigate. Mobile had the same problem in the early days, and still does to some extent, something that was solved with on-boarding experiences and tours built into apps, something voice has yet to do, but if done consistently could really improve usability.

“Complexity and ecosystem lock-in are threats to ubiquity and frictionless experience. Let’s not build an ecosystem that locks that in.” James Poulter, CEO of Vixen Labs

There was also an admonition to not build apps for the sake of building apps, but to focus on user need, and understand that what users want most of all is convenience, and that they will use the most convenient interface for the task (web, mobile, TV, phone, voice).

What does this mean in healthcare? Context is very important. Make sure your users know exactly what your skill can and can’t do so they don’t expect the full canon of medical knowledge from your one skill. At Wellpepper, we are firmly in the “Voice and” category, (and yet I still get invited to speak at these events): our voice interactions are a subset of the patient’s care plan, and just as they don’t expect the mobile app to do more than deliver the care plan prescribed by their physicians, the same holds true for the voice experiences for Wellpepper interactive care plans.

Ethics

Ethics in designWhile I didn’t hear anyone talking specifically about the ethical issues of both the eavesdropping scandals, and the need for humans to manually tag voice snippets in order to improve machine learning, I did attend a great session by Brooke Hawkins on ethics and design implications in healthcare. Issues tackled included considerations for disclosure of the exact conditions for the efficacy of an app, whether A/B testing on patients can even be done, and understanding the implications of focusing on specific measures in a care plan. On this last one, she suggested that care plans that include weight, like our Sugarpod diabetes care plan

Brand

Along the same lines of not building voice apps for the sake of it, there was also a lot of talk of how your brand is reflected in your app. Not all healthcare systems think of their brand impact, although they should, and the voice skill is an extension of that. Interestingly David Ciccarelli from Voices.com which has voice talent, mentioned that most developers use the standard Alexa voice. It’s not surprising, as it’s expensive to have someone record every possible response for your application, although it’s interesting to think about a world where your healthcare app is speaking in the voice of your own doctor. Given what we’ve seen with the correlation between adherence and healthcare provider engagement, this could give a huge boost to patient outcomes. The technology is not that far off to synthesis voice from other recordings, so it wouldn’t require that your doctor record everything. Or perhaps it would make more sense to have a specific doctor be the voice of all of your apps, which might be more credible than Alexa dispensing healthcare information. Ciccarelli provided a nice matrix of when to use synthetic voice and when to use real humans that applies well in healthcare.

Users

There’s no question that voice spans all ages. Dave Isbitski opened the conference by saying that his kids and his parents were equally excited by voice applications. Speakers at on the Best Practices for Developing Voice Care Plans panel (myself included) were developing specialized care plans for children, seniors, and everyone else. While there are definite generational differences in usage patterns for voice assistant, and there is also a “voice-first” generation coming. One speaker mentioned how his child who had Alexa from birth knew the limitations of the device, and didn’t ask more than Alexa was capable to deliver, however a 6-year-old family friend who didn’t have that experience wanted to ask things like “do you know my teacher.”  In our testing we found similar differences between generations as well, with seniors more likely to try to have a conversation, and younger people sticking to the script of the care plan a bit more. I heard one developer say that they track slang used by end user to determine age and adjust the interactions accordingly.

Wrapping It Up For Healthcare

We’ve written before about the use cases for voice in healthcare, and there are many, from documenting clinic visits, transcribing physician notes, to medication adherence, education, and patient care plans, as well, voice biomarkers, which my fellow panelists called a huge pool of untapped diagnostic data. If we’re at the early days of voice apps, we’re also at the early days of voice data. There’s a ton to be discovered, and the research, especially in healthcare, is just starting.

Our expectations for voice are high. Let’s hope it delivers.

If you’re interested in learning more about voice in healthcare here are some great resources:

Posted in: Adherence, alexa, Behavior Change, big data, Healthcare Technology

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Summer Reading: “Get Well Soon: History’s Worst Plagues and the Heroes Who Fought Them”

Summer Reading: Get Well Soon: History’s Worst Plagues and the Heroes Who Fought Them, by Jennifer Wright

At Wellpepper, we’re huge proponents of evidence, and have worked for years with researchers from Boston University and Harvard University to prove that the things that seem like common sense, like providing help outside the clinic in a digital format, will truly improve patient outcomes. Given today’s focus on evidence-based medicine, and even the sometimes dismissal of common sense if there’s no randomized control trial (even chicken soup is subject to peer review), it’s amazing to remember that we once knew so little about what makes us sick, or the difference between correlation and causation.

If you don’t think you’re interested in plagues, think again. This book is a rollicking journey through a history of plagues that is both funny, sarcastic, and tragic. It reminds us that things that seem obvious today might not have been in the past, and that we’re never that far from mass hysteria when we don’t understand the root cause of a new healthcare epidemic.

While there is a chapter dedicated to each historical epidemic, Wright does not talk about the AIDs epidemic of the 1980s. She believes that history needs to be shared by the ones who were there, while her job is to amplify the voices of history so that we stop making the same mistakes. By uncovering how society, medical professionals, or government either did or didn’t cope with a particular epidemic, Wright offers valuable lessons for today.

For example, when exploring leprosy (which by the way, was a required medical test to get a Russian visa when I moved there in 2008 with Microsoft: spoiler alert, I don’t have it), Wright says:

“Diseases don’t ruin lives just because they rot off noses. They destroy people if the rest of society isolates them and treats them as undeserving of help and respect.”

When people blame others for their diseases, or treat them differently, we are not acting better than our ancestors.

Wright also puts into perspective why all types of people fall for information that now may seem ridiculous, with this analogy:

“If you were a peasant and someone said, “If you live in a sewer, the bubonic plague won’t kill you,” your reaction likely wouldn’t be, “I am curious to hear the science behind that.” Your response would be, “Point me to the nearest sewer.”

It’s up to medical professionals to understand why someone believes what they believe, and then try to provide alternate evidence, rather than dismiss it out of hand. It doesn’t mean that you can’t debunk the value of living in a sewer, but do it by understanding where the information came from in the first place. (And also don’t forget that the fake healthcare information is much easier to access than medical journals locked behind firewalls.

Stories of the Spanish flu, and government-sanctioned and media campaign to downplay (aka ignore or bury) the seriousness of the illness so as to not divert energy and enthusiasm for the war effort, versus the example of Marcus Aurelius during the Antonine Plague taking care of business by offering government burials and time off to go to funerals, which both kept bodies from piling up and acknowledged there was a serious problem.

Wright admonishes us to choose leaders well.

“When we are electing government officials, it is not stupid to ask yourself, “If a plague broke out, do I think this person could navigate the country through those times, on a spiritual level, but also on a pragmatic one? Would they be able to calmly solve one problem, and then another one, and then the next one? Or would bodies pile up in the streets?”

As we start to repeat the mistakes of the past (measles anyone?)Wright makes sure to remind us that with our natural human instinct to lean away from bad news, we often forget how bad things were. Measles, anyone?

“Polio was effectively eliminated throughout the world. And then people just … kind of forgot all about polio. This seems to be the human response to any disease. People forget diseases ever existed the minute they are no longer being affected by them. Maybe that’s understandable. Maybe if we all thought about all the potential diseases the world is teeming with, and the extent to which we are, every day, dancing on the edge of a volcano, the world would seem too terrifying to walk around in at all. Or we’d just vaccinate our kids.”

If you’re interested in medical history, policy, or historical epidemiology this makes a light summer read. I’m not kidding. Also, the chapter on Spanish flu should be made into a dystopian/future past film. It’s got everything: media and government cover up, bodies in the street, a mystery, and a hero fighting against the status quo.

Posted in: Behavior Change, Clinical Research, Healthcare motivation, Healthcare transformation, population health, Rare disease

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Transforming Health at Montana HIMSS Annual Spring Conference

Possibly the most interesting thing in healthcare technology is the breadth of scope that health tech needs to cover, and the talks at the HIMSS Montana annual spring conference represented that with talks about security, how to find money for projects, consumer engagement, and how to create a state-wide initiative for healthcare IT. Just like the state of Montana, talks covered a lot of territory.

 

 

 

Here’s a small review of what attendees experienced:

Voice Technology

I had the honor of kicking off the HIMSS Montana Chapter “Transforming Healthcare” conference with an introduction to how voice technologies show promise in patient care. There’s still a lot of concern in the industry about what these voice assistants are tracking, and the speaker immediately after me talked about a surgeon using Alexa to play music in the operating room (a non-compliant use as Alexa might be ‘listening’ to the conversation). However, today’s news that Comcast is also getting into the voice healthcare game shows that there is real promise and high stakes. If you’re interested in this topic you might want to check out our white paper on considerations for designing voice interfaces for patient care, or join me at Voice Summit in Newark this fall for a workshop.

Security

Not surprisingly security remains a hot topic in healthcare, probably because of the surface area of devices and IOT devices. While bad actors and hackers remain a constant threat, people and process are as important, and speakers stressed that often breaches are not malicious but when people don’t follow proper process like the backup company driver who left a van full of backup tapes in his driveway overnight where it was broken into.

Interestingly according to Fred Langston, CISSP, CCSK Executive VP of Professional Services CI Security, imaging systems account for almost 50% of security alerts, possibly because the systems involve both hardware and software, and have often been installed for years. EMRs are seen as relatively safe, and other risks come from devices, attached to the hospital network, where manufacturers have stopped upgrading or patching devices, or simply stopped support for them. The reason is that any sort of software or firmware upgrade requires new FDA certification, which may be cost prohibitive on a discontinued product. There are startups trying to solve this problem, however the FDA may also want to reconsider the unintended consequences of their certification program.

Generally, it takes 205 days within a hospital system until a compromised asset is detected. Decreasing this time and the time from the realization of the compromise and fix (known as dwell time), should be the goal of all IT departments. Hiring a security consultant organization may be the best bet for the broad scope of monitoring that needs to happen.

Finding Money for Innovation

Dianna Linder, MPA, FACHE Director of Grants and Program Development, Billings Clinic is a grant-writer who has been successful at finding funding sources for innovative projects. Much like targeting sales, donor targeting involves figuring out the value proposition you can offer to a particular donor. The Billings Clinic has a shark-tank day where everyone comes with their projects to request funding. Projects are stack-ranked and budget is applied. For those that don’t get budget, Linder looks for other sources like grants. She warns that grants are best used for projects that are new experiments and where the headcount is not part of the spend since they cannot ensure someone of a job when the grant money runs out. A great example of a use of grant money was for building an intake facility for mental health, so that people did not languish in the ED. This program used staff that were already at the system and proved successful enough that it became operationalized the following year.

At Wellpepper, we’ve seen a few projects start with grants, like the one that the Schultz Foundation provided to EvergreenHealth to kick off a patient engagement project that has since been operationalized. Grants for research projects like the one with Harvard are also interesting.

Consumer Experience

Ben WanamakerHead, Consumer Technology & Services from Aetna made us promise not to blog or tweet about his session where he shared some results from Aetna’s partnership with Apple’s smart watch. So, go see for yourself how the application uses behavioral economics and design principles to reward people for healthy behavior.

Building a State-Wide Healthcare IT Strategy

Did you know that 10 states have a state-wide healthcare IT strategy? No? Neither did I. These strategies, when aligned with Medicare and Medicaid initiatives can help drive adoption and support for healthcare technology, innovation, and modernization initiatives. The benefits of the roadmaps are to focus on healthier residents, and freeing information. Another important benefit is funding that is matched by the federal government. While this type of program may be out of reach for the average healthcare technology enthusiast, knowing that they exist can offer opportunities to align with larger initiatives.

Posted in: Adherence, Behavior Change, Health Regulations, Healthcare costs, Healthcare Disruption, Healthcare Policy, Healthcare Research, Healthcare Technology, Healthcare transformation, HIMSS, M-health, patient engagement

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Reading for Healthcare Disrupters: In Shock, by Rana Awdish, MD

May 13-15, I’m heading to the Patient Experience Conference at Cleveland Clinic where Dr. Jonathan Bean, our research partner from Harvard Medical School will be presenting the results of a study using Wellpepper to deliver an interactive care plan for people between 65 and 85 who are at risk of adverse events. We’re excited about the positive clinical outcomes he saw, but more importantly, about the ability for technology to deliver empathy in patient care.

in shock book coverThe ultimate in empathy is to “walk a mile in someone’s shoes.” While this is often not physically possible, if you can emotionally understand someone else’s view this is the beginning of empathy. Research shows that reading fiction increases empathy, but I can imagine that non-fiction like Dr Rana Awdish’s compelling and gripping “In Shock” would do the same. Dr Awdish chronicles her near-death experience and subsequent recovery at the hospital where she practices. By becoming a patient with the mind of a doctor, she is able to deeply experience and understand both sides of a situation: the doctor who sees a case, and the patient who is so much more than a collection of symptoms. As a patient she experiences incorrect diagnoses, not being believed or listened to, arrogance, and condescension. As a physician, she struggles with her training to not get involved emotionally involved with patients and to shrug off traumatic events with her newfound understanding that experiencing pain is the only way to really empathize and connect with each other, and the only thing that will enable physicians to truly deliver care.

The book can be read as case study of experiences from both sides of the equation as Dr. Awdish struggles to make sense of her experiences, and learn how well-meaning instructions can result in the wrong outcome. For example, Dr Awdish reflects on her medical school and residency training and how it was designed to search for diagnosis not for meaning.

“We weren’t trained to listen. We were trained to ask questions that steered people to a destination”

When she’s taken to emergency and immediately steered to OB despite her protestations that the problem is not the pregnancy it’s something else, she directly experiences the impact of this training.

When Awdish is admitted to the hospital for bed rest during later pregnancy, her room becomes a defacto support group for medical professionals who need somewhere to properly process and sometimes grieve patient outcomes. This community defies their training which was to shrug off the emotions, and it’s during this period that Awdish comes to her hypothesis that switching communication may have the most powerful impact of all.

“This way of questioning, this recommendation built on empathy and a patient-centered narrative has the potential to heal everyone involved.”

Awdish is full of hope that the medical community can change. She’s a frequent lecturer and has won awards for building empathy and communication programs. The book also includes a study guide, and is being included in medical school curriculum.

You can hear Dr Awdish read from her book in this clip, or follow her on twitter @RanaAwdish

If you’re looking for more great reads check out these recommendations from our blog. Or, if podcasts are more your style, we’ve got those too.

Posted in: Behavior Change, Healthcare Disruption, Healthcare Research, physician burnout, Uncategorized

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Simple Patient-Centered Design

At Wellpepper, we work hard to make sure our software is intuitive, including working with external academic researchers on randomized control trials for people who may have cognitive or other disabilities. This is both to make sure our software is easy-to-use for all abilities, and to overcome a frequent bias we hear about older people not being able to use applications, and also to provide valuable feedback. We’ve found from these studies, the results of which will be published shortly in peer-reviewed journals, that software can be designed for long-term adherence, and this adherence to programs can lead to clinically-meaningful patient outcome improvements.

User-centered design relies on three principles, all of which can be practiced easily, but require continual discipline to practice. It’s easy to assume you know how your users or patients will react either based on your own experiences, or based on prior knowledge. There’s really no substitute for direct experience though. When we practice user-centered design, we think about things from three aspects:

Immersion

Place ourselves in the full experience through the eyes of the user. This is possibly the most powerful way to impact user-centered design, but sometimes the most difficult. Virtual reality is proving to be a great way to experience immersion. At the Kaiser Permanente Center For Total Health in Washington, DC, participants experience a virtual reality tour by a homeless man showing where he sleeps and spends his days. It’s very powerful to be right there with him. While this is definitely a deep-dive immersion experience, there are other ways like these physical therapy students who learned what it was like to age through simple simulations like braces, and crutches. Changing the font size on your screens can be a really easy way to see whether your solution is useable by those with less than 20/20 vision. With many technology solutions being built by young teams, immersion can be a very powerful tool for usable and accessible software.

Observation

Carefully watch and examine what people are actually doing. It can be really difficult to do this without jumping in and explaining how to use your solution. An interesting way to get started with observation is to start before you start building a solution: go and visit your end-user’s environment and take notes, video, and pictures.

Understanding what is around them when they are using your solution may give you much greater insight. When possible we try to visit the clinic before a deployment of Wellpepper. Simple things like whether wifi is available, how busy the waiting room is, and who is initiating conversations with patients can help us understand how to better build administrative tools that fit into the clinician’s workflow. Once you’ve started with observing your users where they will use your solution, the next step is to have them test what you’ve built. Again, it doesn’t have to be complicated. Starting with asking them how they think they would use paper wireframes or voice interface testing with Wizard of Oz scenarios can get you early feedback before you become too attached to your creations.

Conversation

Accurately capture conversations and personal stories. The personal stories will give you insight into what’s important to your users, and also uncover things that you can’t possibly know just by looking at usage data. Conversations can help you with this. The great thing about conversations is that they are an easy way to share feedback with team members who can’t be there, and personal stories help your team converge around personas. We’ve found personal stories to be really helpful in thinking about software design, in particular understanding how to capture those personal stories from patients right in the software by letting them set and track progress against their own personal goals.

Doctor’s often talk about how becoming a patient or becoming a care-giver for a loved one changes their experiences of healthcare and makes them better doctors. This is truly user-centered design, but deeply personal experience is not the only way to learn.

To learn more:

Check out the work Bon Ku, MD is doing at Jefferson University Hospital teaching design to physicians.

Visit the Kaiser Permanente Innovation Center.

Learn about our research with Boston University and Harvard to show patient adherence and outcome improvements.

Read these books from physicians who became patients.
In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope, Rana Adwish, MD
When Breath Becomes Air Paul Kalanithi, MD

Posted in: Adherence, Aging, Behavior Change, Clinical Research, Healthcare Technology, Healthcare transformation, patient engagement, Patient Satisfaction, Research

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Voice: The most natural user interface for healthcare

There’s so much promise, and such a natural fit for voice in healthcare that unlike electronic medical records, we should not have to mandate its use. If anything, right now we are being limited by the lack of HIPAA controls rather than end-user demand. If the sessions at the recent Voice Summit, which was focused broadly on voice tech, and the upcoming Voice of Healthcare and Voice Summit at Connected Health conferences are any indication, there are many natural use cases, and a lot of pent-up demand.

With so many concerns about documentation and screens getting between patients and physicians, and the ability to deliver empathy, and to rapidly learn from interactions using natural language processing, and artificial intelligence, voice seems a natural fit and unobtrusive interface that could leapfrog traditional interfaces.

The Healthcare track at Voice Summit showed some of this promise, but also pointed out that we are still early days. Many solutions are pilots or prototypes, and I had the distinct impression that some of today’s HIPAA workarounds would not stand up to a detailed audit. Despite Alexa’s sponsorship of the conference, Google’s strong presence, and both companies push into all things healthcare, both were mum on whether or when their consumer voice devices might be HIPAA compliant. Regardless, healthcare organizations and technology vendors alike are charging forward on new scenarios for healthcare, and you can see by the diversity that if even a few of these end up being the “killer app” it’s a big opportunity.

Patient Care

Rooming: Waiting for a physician to see you in an exam room is often a wasted opportunity. A voice interface in the clinic room, could help further pinpoint why a patient is having a visit or educate pre and post visit on medical issues. Or simply having a voice assistant capture the questions that a patient has during a visit might go a long way to improving the visit.

Inpatient stay: The combination of voice assistants, wifi, and tablets could completely replace expensive and proprietary systems for inpatient patient engagement. We’re already seeing use cases for anonymous interactions with voice devices to order food, check the time, or find out the time of the next physician visit.

Long-term care: Alzheimers and dementia care are cited as the poster child for the benefits of voice in long-term care facilities. Unlike human caregivers, voice assistants never get tired of answering the same questions repeatedly. There are so many times you don’t want Saturday Night Live to predict the future, but with this one they got it right.

Patient Engagement

If we define patient engagement as interactions outside the clinic, then the opportunities today fall into three main categories triage (or eventually diagnosis), education, and self-management.

Triage Skills: Today we see some basic triage skills from organizations like Mayo Clinic, and Boston Children’s Hospital where you can check some basic first aid, or ask common questions about children’s health. While there are approximately 1,000 healthcare skills, most likely there will be a few winners or “go-to” experiences here from leading healthcare organization or trusted publishers like WebMD. (Interestingly, the presenter from WebMD was one of the more skeptical on voice experiences for patients at the Voice Summit, possibly because of the complexity of the information they present through text, video, and images on the Web.)

Health Education: Chunking content into manageable bites is currently being touted as the best practice for education material through voice. However, this is an area where the interactivity that’s possible through voice will be necessary for stickiness. If you think about the best podcasts, they use different techniques to both engage you and also impart knowledge: interviewing, verbatim quotes, sound effects, interjections, and expository material. To get engaging and sticky health education content, publishers will have to think about how to test for knowledge, advance explanations, and interact with the end-users. Since we can only remember 5 things at a time, simply chunking content is not going to be enough to make the delivery of health education through voice stick.

Reminders and Interactive Health Tasks: As we’ve seen from our testing, where voice interfaces may have the most impact for patients is in helping them complete health tasks for example, in medication adherence, simple surveys, or check-ins and reminders of basic information. Given that the voice interface is a natural in the home, checking in with a voice assistance on when to take medication, or tracking meals is an easy way to engage with a care plan. As well, cloud-based interactive voice response systems could call patients with reminders and check-ins.

Clinical Notes

Conquering the pain of charting is possibly the closest term opportunity for voice in healthcare. With every increasing workloads, and the need to capture information digitally for both care and reimbursement, the EMR has been blamed for physician burnout and lack of job satisfaction. Microsoft recently partnered with UPMC to use their Cortana voice assistant to transcribe clinical notes during a patient/provider interaction. Others attacking this space include SayKara, Robin, and incumbent, Nuance Communications. With HIPAA compliance, it’s hard not to imagine Amazon and Google looking at it as well.

Hands-free lookup

Voice really shines as an interface when your hands are not free, like driving, dentistry, or when you need to keep your hands clean. Voice is a natural in settings where touching a screen or device can cause contamination or distraction. Simplifeye is tackling this in dentistry to improve charting, and lookup of x-rays, and we expect this to infiltrate all aspects of healthcare.

You may have seen a recent article on why Alexa is not ready for healthcare primetime. With all of these great examples it’s hard to believe it. It turns out that the criticisms in this article basically highlight the current limitations of voice overall (except for HIPAA compliance of course). However, some of the challenges of discovery, context, and navigation, are why we at Wellpepper believe in not just voice, but a “Voice And” future where voice is a key interface that is helped or helps others like screens or even augmented reality. Voice is powerful, “Voice And” will be even better.

Posted in: Behavior Change, chronic disease, HIPAA, patient engagement, Patient Satisfaction, patient-generated data, Voice

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Voice First or Voice And? Dispatches from Voice Summit

The inaugural Voice Summit was held last week in New Jersey, with the hashtag #voicefirst. At Wellpepper, we’re actually in the “Voice and” camp. We love voice interfaces for their convenience, promotion of empathy and connection, and their natural engagement. However, there are times when voice isn’t the best interface for the task or others when voice plus other interfaces are even better, which is reflected in some of our work with the Alexa Diabetes Challenge, which I spoke about at the conference.

People can only remember 5 things at a time, which is a challenge for delivery of complex instructions, education, or information through voice. Add this to the fact that voice is a “headless” navigation. That is, there are often no cues to figure out where you are going. Most of us are visual creatures, and visual cues together with voice or text often provide a richer experience. And believe it or not, the many of the sessions at this inaugural voice conference also seemed to reinforce this idea, in particular many of the consumer sessions, in addition to the healthcare sessions.

Talks by two very different consumer organizations, Comcast and Lego both showed how early we are in voice design, and how when voice is more seamless and ubiquitous we may see the promise of “voice first” but also how “voice and” is possibly the better path forward.

While when you think of giants of voice, you many immediately think of Amazon and Google, did you know that Comcast processed over 6B voice queries last year? My first thought on attending this session was that it was going to be about using interactive voice response trees before you get to a customer service agent, but Comcast has been quietly infusing voice into their entertainment experiences.

Did you know that your Comcast remote has a “voice” interface? You can talk to your TV to find programs, change the channel, or start a show. This is probably one of the best examples of “voice and.” First, voice search is actually found on a physical device. The Comcast design team had originally created a mobile app for the remote voice experience, but found that downloads were a small fraction of their entire subscriber base, so adding a “voice button” to the remote encouraged more searches. Also remember that when you use voice to search it shows you the results on your television screen. This is a “voice and” experience which wouldn’t make a lot of sense as voice standalone. Imagine searching for a movie to watch, say you’re looking for something starring Harrison Ford, and you’ve got to keep in your mind all the titles over his varied career and then choose one. First it’s a lot to remember, and second isn’t it easier to browse titles when you can see pictures and a description to jog your memory? I spoke briefly with the Comcast presenters about why they chose to put voice on the remote, versus directly in the cable box, and they said that it helped their users find the option, which was a big takeaway from the conference for me, although voice is a natural interface, the end-user still needs guidance. (A nice side benefit of the button on the remote is that it’s not always on and listening.)

Lego was another unlikely consumer company playing in the voice arena. Lego “Duplo Stories” is an Alexa skill that tells stories that children can then build using Duplo blocks. While the video was heartwarming, this session in particular highlighted both opportunities for “Voice And” using augmented reality, and also the current discovery limitations of voice.

In the video, a child playing with Duplo blocks asks his mother to start a story. The mother asks Alexa to play a Duplo story. Think about this: the skill had to be discovered and activated before any of this could take place. How would you learn about the skill without something printed on the box that the Duplo blocks came in? While it’s clever, imagine a new scenario where voice and augmented reality are built right into the blocks: a virtual Duplo minecraft. The child builds something with Duplo, and then a voice and visual interface projects the story on the child’s creation.

It’s still early days, and the potential for “Voice And” is still huge. In fact, a lot of the content at this conference reminded me of the early days of web interfaces. There was lots of talk about taxonomy of information, and “chunking” information into manageable pieces. (I used to teach a course on writing for the web, where we practiced this, which is funny as we now are so accustomed to screens that long-form journalism is making a real comeback.)

Similar to the early days of the web, there seemed to be slightly more focus on publishing than on end-user goals: what does the end-user actually want to accomplish, not what is the end-goal of the content publisher. What’s different though is that while during Web 1.0, the answer to question of whether every business needed a website, was a resounding yes, it’s not clear that everyone needs a voice skill. With 30,000 skills already available for Alexa, and new features coming online weekly, the irony is that the Alexa team sends a weekly newsletter to keep us up to date. So, even Alexa knows it’s a “Voice And” world.

Posted in: Behavior Change, Voice

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Behavioral changes with deliberate patient engagement

Based on the NEJM Catalyst survey regarding the differences between initiating and maintaining behavior change, in-person social support (followed by virtual social support) ranked the highest in sustaining long-term behavioral changes. Members of the council who participated in the survey believed that continued and consistent contact with patients influenced sustainable changes. The combination of human interaction plus digital tools reinforcing the relationship appear to be the best strategy. Even though there has been a gradual shift away from the fee-for-service culture, it still seems impractical for physicians to invest even more time into patient engagement given current constraints of the healthcare system (e.g. clinicians rarely have enough time to get through all the evidence based teaching necessary let alone focus on other factors seemingly non-clinical). Clinicians often give up motivating and influencing their patients, especially after they see marginal gains (or lack thereof) over the course of several years with patients who have chronic illnesses. You have burned out and cynical clinicians on one hand and patients who love inertia on the other. The irony is that if clinicians were to spend more time towards patient engagement, then there would be more impetus for patients to self-manage and be more accountable in their care and outcomes. Research has demonstrated that patient engagement leads to better health outcomes and reduces overall costs. Ultimately, patients being active participants in their healthcare leads to sustainable, long-term behavioral changes. In order to practice medicine effectively, efficiently, and to allow patients to extract the most out of the healthcare services they receive, clinicians should make attempts at patient engagement in a more deliberate manner with different strategies:

  • Model after other human service businesses

One of the reasons that luxury car dealerships, financial planners, and boutique firms across a range of industries are so effective with their clientele is due to their shameless persistence in engaging with their customers. They seem to be very regimented in their follow-up without it appearing overly contrived. What if clinicians could adopt that kind of style with their patients? A combination of phone calls and digital contact seems appropriate – even leaving a voicemail in the evening as follows could signal enough persistence: “I sent you an email asking you if you’ve ever been tested for Thalassemia about a week ago– I think you are iron deficient for other reasons, but I want to make sure we’re covering all our bases for your condition.  If I don’t hear from you this week, I’ll be discussing this with you at your next appointment in 2 weeks.”

  • Blend a style between a motivational coach and psychologist

Motivational coaches who are very effective typically try to leverage emotional vulnerabilities and emotional language in very explicit ways to enforce change. Psychologists tend to non-judgmentally allow clients to form conclusions by themselves. Clinicians are often balancing these two approaches to avoid both paternalism as well as the snail-paced results of motivational interviewing. Language could be blended, with elements of idealism and also allowing for patient autonomy: “The pain of discipline is nothing compared to the pain of regret. You’ve recently had a lapse, but if you stick with the diet that you initially were so good with, what do you think it will do for your diabetes? Can you imagine what life will be like?”

Clinicians are never at risk of overinvesting in communication skills, as this is necessary to strike the right balance in influencing patients over the long-run. They would benefit from practices and processes in other industries where contact is consistent and maintained over a continuum with the assistance of digital technologies.

 

 

Posted in: Behavior Change, patient engagement

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Alexa, Get Well Soon

The unofficial winner of the Super Bowl ad race this year was “Alexa Loses Her Voice”, an ad that shows celebrities subbing for Alexa when she (anthropomorphic being that she is, comes down with a cold). Both USA Today and YouTube are calling it the most watched ad.

Alexa, who won USA TODAY’s 30th Ad Meter?

“Well, um – me.”

Jeff Bezos looks skeptical that his team can replace Alexa as he should be, since their solution of Gordon Ramsay, CardiB, Rebel Wilson, and Anthony Hopkins is both extremely expensive, (Wellppper CTO Mike Van Snellenberg did the math), and breaks the key trust relationship that people have with Alexa.

Voice is a natural interface, and empathy can be quickly established by the types of utterances and engagement. By default, Alexa apologizes when she doesn’t understand something and it feels genuine. Compare that to Gordon Ramsay insulting his poor hapless user—all the guy wants is a bit of help making some comfort food. What he gets is abuse.

Or, the woman who wants Alexa’s help while she’s in her boudoir presumably getting ready for a date with her love. Instead, Anthony Hopkins insinuates that something horrific has happened to her beau possibly involving a pet peacock.

Cardi B insults a young man’s interest in Mars. Let’s hope she has not squashed his spirit of discovery and his desire to ask questions.

Since this is an all-ages blog, we won’t even mention the response Rebel Wilson gives from her bubble bath to the poor gentleman who asked Alexa to set the mood for a party. He and everyone at his party were fully traumatized.

We get it, Alexa is just better at delivering what people are asking for than real people. Especially real people with attitude like these celebrities.

As we found in our research with people with type 2 diabetes, Alexa has a natural ability that these celebrity Alexa impersonators do not. You can see it in this feedback we received from real people trying to manage Type 2 diabetes.

  • “Voice gives the feeling someone cares. Nudges you in the right direction”
  • “Instructions and voice were very calm, and clear, and easy to understand”

Voice is a natural fit to deliver empathy and care. However, since each one of these people is expecting Alexa, and has no visual indicator that anything has changed, the negative experiences will reflect on Alexa and she’ll have to win back their trust.

While the implied message of the ad spot is that Alexa does a better job of delivering on your needs than any of these celebrity experts we’re still feeling a bit traumatized by the abuse they hurled. For the sequel to this commercial, we’d expect to see Jeff firing the team that replaced Alexa with celebrities, and Alexa as a therapist working through the trust issues that her replacements created. She can do it. We believe in her.

Posted in: Behavior Change, Healthcare Disruption, Healthcare Technology, Voice

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The Secrets of Strong CIO and CMIO Relationships

What’s the secret of a strong CIO and CMIO relationship? Many things including the ability to be adaptable, understand organizational priorities, and deadlines, but most importantly to align on shared goals and purpose.

These were some of the takeaways from the insights shared by CIOs and CMIOs of Confluence Health, and EvergreenHealth at the annual Washington State HIMSS Executive dinner. While the conversation was split between how to foster innovation, and how to manage the demands of an EMR rollout (including the resulting backlog of other IT requests), where the relationship really shone was in the implementation of tools for a shared purpose, in this case tracking and control of opioids to help curb the epidemic we’re seeing in this country.

In particular a project at EvergreenHealth to implement e-prescribing of controlled substances, showed the need for strong CMIO and CIO collaboration. The program is designed to decrease fraud and misuse of controlled substances, but it can also improve patient care. Since it involves both technology implementation and clinical guidelines it’s a perfect example of medical and technology collaboration. In Washington State, where we’re based, the Bree Collaborative also has recommended guidelines for prescribing opioids, that while optional are widely adopted across the state.

We’ve written about this problem before in pain management for total joint replacement. Sadly, an unintended consequence of the pain management question on the HCAHPS survey, is sometimes an overprescribing of prescription pain medication. According to one speaker at the event, 30mg of oxycontin over 7 days is enough to trigger an addiction, and yet often post-surgery up to 30 days of pills are prescribed. We talked to one patient (not a Wellpepper user) who reported taking all of her prescribed pain medication, not because she needed it but because it was prescribed. The first step to solving this problem is with the prescription, and EvergreenHealth’s e-prescription program, combined with locked cabinets in the operating room (the idea is that if you don’t need it immediately, you don’t actually need it), alerts on over prescribing, and programs to substitute suboxone, coupled with behavior health management can all help. As well behavior change happens with the physicians, and a powerful image was the story of a pharmacist who put a bag of unused opioid prescriptions on the table to show that even if they didn’t think so, some physicians may have been over-prescribing.

However there are ways to take it a step further: tracking what the patient actually took outside the clinic, which is why we include a pain medication usage task in many care plans. This activity asks patients some simple questions about their over-the-counter and prescribed pain medication usage, and alerts if the numbers or the length of time is over certain thresholds. It’s in use in care plans that include general pain management, surgical, and neurology (headache management), and provides a view into usage, and the opportunity to reach out and help patients outside the clinic before usage becomes a problem.

We’re strong believers in the ability for patients to record their own outcomes and experiences, and the value of combining this with prescribing and clinical data to close the loop on delivering better care. If you’re interested in learning more, get in touch.

Posted in: Adherence, Behavior Change, Healthcare Legislation, HIPAA, Opioids, Outcomes, patient engagement

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Your Cupcakes Are Not My Goals

This year Google Maps tried out a short-lived motivational technique of showing how many cupcakes you would burn off or ostensibly could eat if you chose to walk to your destination. Not surprisingly this backfired, and they quickly retracted the feature. The reasons ranged from users expressing feelings of shame for not walking, to those with eating disorders saying it would encourage more obsessive behavior. Beyond that, many questioned how Google was even calculating both caloric expenditure and the actual calories in the cupcakes.

Regardless of the myriad of criticisms the experiment illustrated a key point: motivation and goal setting is best left to the individual, and understanding someone’s personal context is extremely important if you want to help them set goals.

One of our most read blog posts of 2017 was a 2015 post on whether setting SMART or MEANINGFUL goals was most effective for patients. I’m not sure why this bubbled to the top this year but the post provides an overview of two thoughtful frameworks for helping patients set goals.

At Wellpepper, we’d like to propose a third methodology: let people figure out what’s important to them. This year we expanded a capability we’ve had since V.1 that enables patients to set their own goals. This is a free-form, 140 character text box where patients write about what’s important to them. Over the years, we’ve had some clinicians express concern about whether patients could set their own goals. Functional goals are best left to the experts, but these are life goals, things that are important to people and why they are even bothering to use this app which helps them through healthcare activities to manage chronic diseases or recover from acute events.

Since we already knew that setting patient-generated goals is motivating, we also got to wondering whether you could track progress in a generic way based on patient-generated goals. After analyzing thousands of patient-generated goals, we figured out that asking a question about the patient’s perception progress on a Likert scale would work, and so this year we expanded the patient goal task type to include tracking.

It looks like this.

In case you’re skeptical that this works, here are a few examples of patient-generated goals.

Spend more time with family.

Get outside more frequently.

Walk more.

Be ready for vacation.

Now ask the question. See, it’s entirely possible for patients to set their own goals, unaided, and track progress against those goals. We’re pretty excited about the possibilities of this for improving motivation, and also for further analysis of patient adherence and outcomes. If you’d like to know more, or see a demo, we’d love to hear from you.

Posted in: Behavior Change, Healthcare motivation, Healthcare Technology, Healthcare transformation, patient engagement, patient-generated data

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May You Live In Interesting Times: Wellpepper’s Most Interesting Blog Posts of 2017

Who would have predicted 2017? As soon as the election results were in, we knew there would be trouble for the Affordable Care Act no one could have predicted the path through repeal with no replacement to claw backs in a tax bill that no one has read. It’s been a crazy ride in healthcare and otherwise. As we look ahead to 2018, we’ve found that a good place to start is by looking back at what was popular in 2017.

Looking back over the past year’s top blog posts, we also believe trends that started in 2017, but will even stronger in 2018. These four themes bubbled up to the top in our most-read blog posts of 2017:

Shift to the cloud

We’ve noticed a much wider spread acceptance of cloud technologies in healthcare, and the big cloud platform vendors have definitely taken an interest in the space. Wellpepper CTO Mike Van Snellenberg’s comprehensive primer on using AWS with HIPAA protected data was one of our most read posts. Since he wrote it, even more AWS services have become HIPAA-eligible.

Using AWS with HIPAA-Protected Data – A Practical Primer

Consumerization of healthcare

Consumer expectations for efficient online interactions have been driven by high-deductible plans and an expectation from consumer technology and industries like retail and banking that customer service should be personalized, interactive, and real-time. These two posts about the consumerization of healthcare were among the most popular.

The Disneyfication or Consumerization of Healthcare

Consumerization Is Not A Bad Word

Value of patient-generated data

In 2017 we saw a real acceptance of patient-generated data. Our customers started asking about putting certain data in the EMR, and our analysis of the data we collect showed interesting trends in patient adherence and predictors of readmission. This was reflected in the large readership of these two blog posts focused on the clinical and business value of collecting and analyzing patient-generated data.

In Defense of Patient-Generated Data

Realizing Value In Patient Engagement

Power of voice technology

Voice technology definitely had a moment this year. Okay Google, and Alexa were asked to play music, turn on lights, and more importantly questions about healthcare. As winners of the Alexa Diabetes Challenge, we saw the power of voice firsthand when testing voice with people newly diagnosed with Type 2 diabetes. The emotional connection to voice is stronger than mobile, and it’s such a natural interaction in people-powered healthcare. Our blog posts on the Alexa Diabetes Challenge, and developing a voice solution were definitely in the top 10 most read.

Introducing Sugarpod by Wellpepper, a comprehensive diabetes care plan

Building a Voice Experience for People with Type 2 Diabetes

Ready When You Are: Voice Interfaces for Patient Engagement

Since these themes are still evolving we think 2018 will present a shift from investigation to action, from consideration to deployment and possibly insights. Machine-learning and AI will probably remain high in the hype cycle, and certainly the trends of horizontal and vertical healthcare mergers will continue. We also expect a big move from one of the large technology companies who have all been increasing their focus in healthcare, which in turn will accelerate the shift to a consumer-focus in healthcare.

There’s a saying “may you live in interesting times.” We expect 2018 to be at least as interesting as 2017. Onwards!

Note: There was one additional post that hit the most popular list. Interestingly, it was a post from 2014 on whether SMART or MEANINGFUL goals are better for patients. We’re not sure why it resurfaced, but based on analysis we’ve done of patient-directed goals, we think there’s a third approach.

Posted in: Behavior Change, Healthcare Disruption, Healthcare motivation, Healthcare Research, Healthcare Technology, Healthcare transformation, HIPAA, patient engagement, patient-generated data, Voice

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Are Women Better Surgeons? Patient-Generated Data Knows The Answer

As empowerers of patients and collectors of patient-generated data, we’re pretty bullish on the ability for this data to show insights. We fully admit to being biased, and view things through a lens of the patient experience and outcomes, which is why we had some ideas about a recent study that showed female surgeons had better outcomes than male surgeons.

The study, conducted on data from Ontario, Canada, was a retrospective population analysis of patients of male and female surgeons looking at rates of complications, readmissions, and death. The results of the study showed that patients of female surgeons had a small but statistically significant decrease in 30-day mortality and similar surgical outcomes.

Does this mean that women are technically better surgeons? Probably not. However, there is one sentence that stands out to a possible reason that patients of female surgeons had better outcomes.

A retrospective analysis showed no difference in outcomes by surgeon sex in patients who had emergency surgery, where patients do not usually choose their surgeon.

This would lead us to believe that there is something about the relationship between the patient and the provider that is resulting in better outcomes. We have seen this at Wellpepper, while we haven’t broken our aggregate data down by gender lines, we have seen that within the same clinic, intervention, and patient population, we see significant differences in patient engagement and outcomes between patients being seen by different providers.

Some healthcare professionals are better than others at motivating patients, and the relationship between provider and patient is key for adherence to care plans which improve outcomes. By tracking patient outcomes and adherence by provider, using patient-generated data, we are able to see insights that go beyond what a retroactive study from EMR data can show.

While our treatment plans, and continued analysis of patient outcomes against those treatment plans go much further than simply amplifying the patient-provider relationship, for example with adaptive reminders, manageable and actionable building blocks, and instant feedback, never underestimate the power of the human connection in healthcare.

Posted in: Adherence, Behavior Change, big data, Clinical Research, patient-generated data

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Ready When You Are: Voice Interfaces for Patient Engagement

We started experimenting with voice as a patient interface early this year, and showed a solution with a voice-enabled total-joint care plan to a select group of customers and partners at HIMSS 2017. Recently we were finalists in the Merck-sponsored Alexa Diabetes Challenge, where we built a voice-enabled IOT scale and diabetic foot scanner, and also a voice-powered interactive care plan.

Over the course of the challenge we tested the voice experience with people with Type 2 diabetes. We also installed the scale and scanner in a clinic, and we found that clinicians also wanted to engage with voice. Voice is a natural in the clinical setting: there’s no screen to get in the way of interactions, and people are used to answering questions. Voice is also great in the home.

However, voice isn’t always the best interface which is why we think multimodal care plans including voice, text, mobile, and web can deliver a more comprehensive solution. Since it’s easier for someone to overhear a conversation than look at your smartphone or even computer screen, mobile or web are often better interfaces depending on the person’s location (for example taking public transit), or the task they need to do (for example, reporting status of a bowel movement). We do think that voice has many great healthcare applications, and benefits for certain interactions and populations.

In our testing, we found that both patients and providers really enjoyed the voice interactions and wanted to continue the conversation. They felt very natural, and people used language that they would use with a human. For example, when asked to let the voice-powered scale know when he was ready to have his foot scan, one person responded with:

“Ready when you are.”

This natural user interface presents challenges for developers. It’s hard to model all the possible responses and utterances that a person would use. Our application, would answer to ready, sure, yes, and okay, but the “when you are” caused her some confusion.

Possibly the most important facet of voice is the connection people have with voice is extremely strong, and unlike mobile voice is not yet associated with the need to follow up, check email, or other alerts. (Notifications on voice devices could change this.)

“Voice gives the feeling someone cares. Nudges you in the right direction”

Creating a persona for voice is important, and relying on the personas created by the experts like the Alexa team, is probably the best way for beginners to start.

“Instructions and voice were very calm, and clear, and easy to understand”

Calm is the operative word here. Visual user interfaces can be described as clean, but calm is definitely a personification of the experience.

Voice is often seen as a more ubiquitous experience, possibly because using fewer words, and constantly checking for the correct meaning are best practices, for example “You want me to buy two tickets for Aladdin at 7:00 pm. Is this correct?” We often hear pushback on mobile apps for seniors, but haven’t heard the same for voice. However, during our testing, a senior who was hard-of-hearing told us she couldn’t understand Alexa, and thought that she talked too quickly. While developers can put pauses to set the speed of prompts and responses in conversation, this would mean that the same speed would have used for all users of the skill, which might be too slow for some or two fast for others. Rather than needing to build different skills based on hearing and comprehension speed it would be great if end-users could define this setting so that we can build usable interfaces for everyone.

While this was our first foray into testing voice with care plans, we see a lot of potential to drive a more emotional connection with the care plan, and to better integrate into someone’s day.

People need to manage interactions throughout their day, and integrating into the best experience based on what they need to do and where they are provides a great opportunity to do that, whether that’s voice, SMS, email, web, or mobile. While these consumer voice applications are not yet HIPAA-compliant, like our tester patient said we’ll be “ready when you are.”

Posted in: Behavior Change, Healthcare Technology, Healthcare transformation, patient engagement

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What Motivates You, May Not Motivate Me

At Wellpepper our goal is to empower people to be able to follow their care plans and possibly change their behavior, so we think a lot about how to motivate people. Early on when working with Terry Ellis, Director of the Boston University Center for Neurorehabilitation, wanted to make sure that our messages to patients that may struggle with adherence were positive. She works with people who have Parkinson’s disease, and stressed that while they may improve symptoms they would not “get better.”

Last week I had a similar conversation with an endocrinologist about diabetes care plans. People with chronic diseases are often overwhelmed and may take a defeatist attitude to their health. Feedback and tools need to be non-judgmental and encouraging. Ideas like “compliance” and “adherence” may not be the way to look at it. Sometimes the approach should be “something is better than nothing.” And humans, not just algorithms need to decide what “good” is.

Am I good or great?

Here’s an example, non-healthcare related of algorithmic evaluation gone wrong. Rather than applauding me for being in the top tier of energy efficient homes, the City of Seattle, says I’m merely “good.” There’s no context on my “excellent” neighbors, for example are they in a newly built home compared to my 112 year old one, and no suggestions on what I might want to do to become “excellent. (Is it the 30-year old fridge?) I’m left with a feeling of hopelessness, rather than a resolve to try to get rid of that extra 2KW. Also, what does that even mean? Is 2KW a big deal?

Now imagine you’re struggling with a chronic disease. You’ve done your best, but a poorly tuned algorithm says you’re merely good, not excellent. Well, maybe what you’ve done is your excellent. This is why we enable people to set their own goals and track progress against them, and why care plans need to be personalized for each patient. It’s also why we don’t publish stats on overall adherence. Adherence for me might be 3 out of 5 days. For someone else it might be 7 days a week. It might depend on the care plan or the person.

As part of every care plan in Wellpepper, patients can set their own goals. Sometimes clinicians worry about the patient’s ability to do this. These are not functional goals, they represent what’s important to patients, like family time or events, enjoying life, and so on. We did an analysis of thousands of these patient-entered goals, and determined that it’s possible to track progress against these goals, so we rolled out a new feature that enables patients to do this.

Patient progress against patient-defined goal

Success should be defined by the patient, and outcome goals by clinicians. Motivation and measures need to be appropriate to what the patient is being treated for and their abilities. Personalization, customization, and a patient-centered approach can achieve this. To learn more, get in touch.

Posted in: Behavior Change, chronic disease, Healthcare motivation, Healthcare Technology, Healthcare transformation, Outcomes, patient engagement, patient-generated data

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