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Patient engagement and design in the art of medicine

Patient engagement is controversial for many physicians because it interferes with the traditional values that arise from the several hundred-year old guild of medicine. Per the NEJM Catalyst Insights Council, patient engagement is characterized as patients interested in participating in choices about their health care, taking ownership of those choices, and having an active role in improving their outcomes. Given the current epidemiology of chronic diseases, it is not surprising that many patients have low levels of engagement as well as health literacy. As someone who is preoccupied with the diagnosis and treatment of diseases, it is difficult for me to view any problem solving from the patient’s lens; yet, I know through the literature and intuitively that how patients feel impacts their outcomes. The following are a few of the things I have learned and will work on as I improve my ability to deliver care:

  • Time = effectiveness Opinions of clinicians and leaders in patient care have determined that increased patient time with a health care team lends to increased engagement. A basic concept in human dynamics is that the mere exposure to someone over time is enough to start an unlikely relationship. Tack onto that high quality communication and understanding nuances of healthcare literacy, and you have a more engaged patient. In modern medicine, this would be accomplished through a multidisciplinary team effort. This task is challenging given the constraints of our current healthcare system. Could I increase time with patients through mobile technology? If there was an automated way for me or another care team provider to connect with patients via text or a quick phone call at specific intervals, I would be able to increase exposure and augment time.
  • Shared decision making is key Another finding of the NEJM Catalyst is that shared decision making is one of the most effective strategies in improving engagement. We learn about this academically through the interpretative model (as opposed to paternalistic, etc.) of provider-patient relations; but this is also just common sense. I like to think this gives patients a sense of control, a sense of choice in a matter, where frankly, a lot make be out of your control. We are also better able to accept the consequences of the decisions we make, rather than the ones that are placed upon us. One of the reasons that UNICEF has been effective in helping children around the world is from the core guiding principle that children inherently have rights. American political views are reflected in the current model of access, but I would like to practice medicine with the belief that patients have inherent rights. It is a slippery slope because patients’ actions can be counterproductive to their health – but my preference is still to protect patient autonomy.
  • Technology alone cannot solve the problem The concept of remote monitoring with wireless devices doesn’t appear to improve chronic disease management or outcomes. Technology alone cannot solve a dilemma in a people’s “business”. I would opt to use adaptive technologies that improve my relationship and sense of connectedness to the patient over technology that would offer mostly education or content to the patient. The idea of people taking ownership for a difficult problem is non-trivial. It requires motivation at a level that is primarily internal. How do you access that in people? In the self-help world, the most effective motivational coaches tend to elicit a hyper-emotional state in people along with placing a high premium on discipline. I think it’s logical to work on building a relationship, connecting, allowing a safe space for vulnerability, and witnessing the struggle to achieve begin from that foundation. While patient engagement is primarily a patient responsibility, I think providers have a responsibility to elicit patient activation as this directly affects outcomes.
  • Design-thinking can help When Indra Nooyi became the CEO of Pepsi, one of her top priorities was to explore her staff’s beliefs on the concept of design. She asked business executives to take photographs of anything that they believed constituted design. After such an abstract request, she noticed that not only did people not care to complete the assignment, that some had even hired professional photographers to complete the task. My interpretation of this story is that she believes that there is an artistic aspect in the most unsuspecting of transactions. According to IDEO, human-centered-design is about building a deep empathy with the people you are designing for. In the process of being inspired, ideating, and implementing, a design researcher explores the texture and what matters most to a person before execution of a solution. How is this any different from delivering empathetic, tailored care to a patient? What we do well in medicine, some of the time, is already done at a higher level of sophistication in the real world outside of our clinics and hospitals. While design-centric thinking may lead to innovations in healthcare, for the provider I think the greatest advantage is that you amplify the relationship you have with the patient and increase overall engagement.

Whether it’s the creation of something that didn’t exist before or making decisions that are influenced by intuition, everyone is at one level involved in artwork. Improving patient engagement particularly with design-centric thinking would bring more value and meaning to the art of medicine, a skill I look forward to building throughout my career.

Posted in: Behavior Change, Healthcare transformation, patient engagement

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Exposure at a digital health startup

Physicians typically endure years of training by being put in a pressure cooker with no safety valve. They persist through sheer brute force and discipline within a highly regulated, high barrier to entry industry. The high stakes culture of medicine often lends to emotional immaturity and an inability to relate to most of the world around. Ironic and sad, given that one of the core principles in patient care is to demonstrate empathy towards the human condition. The information asymmetry that exists between patient and provider further puts more onus on the physician to have character and compassion. In addition to being out of touch with reality, physicians also grapple with the changing times. Technological advancements and accessibility of information through technology has influenced the way physicians learn and practice medicine. Physicians who are uncomfortable with technology tend to find it harder to keep up with the latest innovations and research that affects patient care.

I chose to do a rotation at a digital health startup because of the fear of being disconnected and clueless. Plus there are a few other beliefs of mine that I wanted to more fully explore during my time at Wellpepper:

  • Understanding patients in the aggregate is important. Understanding what patients want, feel, and expect is not just an interesting data set, but is essential for me in providing optimal care. While a physician still deals with a patient one on one and the experience is influenced by patient characteristics, knowing the context in where the patient is coming from provides the best chance for an optimal encounter.
  • Technology that enhances the patient-physician relationship is a top priority. The physicians I have respected the most have tier 1 communication skills and relationships with their patients. A good relationship can literally bend the physics of the situation (e.g. that’s why doctors who have good bedside manner don’t get sued).
  • Technology that promotes value based care is the current landscape. It is no longer around the corner. Every stakeholder in healthcare is interested in improvement of care from an outcomes and cost perspective. Current practices in medicine are rapidly adapting in order to keep up.
  • Betting against yourself is a great strategy for growth. Based on the culture of medicine, it has always been more important for me to implement care that is standardized and in service of saving a patient’s life rather than considering how he/she feels. Something as simple as a patient having to give five histories within the same hospital admission is normal to me and also has value due to the difficulties in eliciting accurate information. But what if I considered that a patient doesn’t want to hear the same question repeatedly and that ultimately effects his/her perception of care? What if their lives were saved but they didn’t believe that anyone truly cared for them in the hospitalization? Would this be a meaningful experience, or a shallow one sided win? Challenging the way I think, the way I was indoctrinated into thinking and behaving, is something I look forward to in this process.

In summary, I chose to do a rotation at Wellpepper because I have a growth mindset. I want to consciously be a part of the most exciting time in medicine, where the hard work of innovative and creative minds improve patient lives.

Posted in: Behavior Change, Healthcare motivation, patient engagement, Patient Satisfaction

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Patients As Designers Of Their Own Health

Seattle’s grassroots healthcare community continues to gain traction with a new meetup for patient-centered design. Last week’s meeting was generously sponsored by MCG a subsidiary of Hearst Publications who are quite active in the healthcare world with content and education. The panel discussion featured Dana Lewis, a patient-maker who is active in the open source movement for diabetes care and built her own artificial pancreas, Christina Berry-White from the digital health group at Seattle Children’s, and Amy London, Innovation Specialist at Virginia Mason. The group talked about how to effectively get feedback from patients, and how patient hackers like Dana can take poor design into their own hands build tools they need, and ultimately influence large healthcare companies, in this case device manufacturers.

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Dana, Christina, and Amy, photo credit Alina Serebryany

The panel had great advice for understanding and developing products and improving processes for patients, as well as for soliciting feedback from patients. Here are a few of my takeaways.

Tips for developing products and process

  • Understand patient’s goals and desires. Often the goals of the hospital or health system are not the same as the patient’s. After meeting with a group of patient advocates one Virginia Mason surgeon realized that the only outcome that really mattered was whether the patient had a positive experience.
  • Let patients customize their views and experiences. Amy talked about a particular chart where she wanted to see the graph rising to show increasing blood sugar and another user she talked to wanted to see the graph lowering to show insulin lowering and a need for intervention. Amy was confused by this view but created her open source artificial pancreas interface to enables people to choose their own view, and the result was that people who had diabetes looked at it the same way Amy did and parent-caregivers of diabetic children wanted the second view. Which brings us to the next point–
  • Differentiate between users. Patients often have different requirements than their caregivers, whether that’s parents caring for a child or teen, or adult children caring for a parent. As well, the clinical workflow shouldn’t dictate the patient experience.
  • Get feedback early. Amy mentioned meeting with a device manufacturer who showed her an almost ready for release glucometer that was intended to fit in the pocket. She quipped “you obviously didn’t test this with women’s pockets.”

Tips for collecting feedback

  • Build it into the product. Christina from Children’s mentioned that when they switched from reams of paper to an iPad-based tool for patient on-boarding forms the physicians wanted to stop using it because it did not immediately integrate with the EMR. Luckily the tool had a feature to survey users on whether they preferred using it to paper, and the answer from parents was overwhelmingly yes. The digital health team showed these results to the physicians, and the tool stayed in place.
  • Be creative when soliciting feedback. Children’s knew from experience that parents and patients were reluctant to give them negative feedback after a lifesaving experience like an organ transplant, so they used techniques that are often used in brand market research: analogies. For example, they asked teens to describe a digital tool as a car, and found out that their tool was like a pick-up truck to them: useful but utilitarian.
  • Use patients to collect feedback. Patients are also often intimidated to provide direct feedback to healthcare professionals as they see them as authority figures. At Virginia Mason patients who have already had a successful joint replacement visit post-surgical patients to find out how they are doing, and talk about their own experiences. Patients are a lot more candid with each other, and Virginia Mason was able to benefit from understanding the questions they asked the peer ambassadors and incorporate that information into formal programs.
  • Ask the questions at the right time. If you want to understand post-operative experiences ask within a few weeks of the actual experience, not 6 months later.
  • Be aware of selection bias. Patients who volunteer for focus groups are often those who have the time and money to be able to do so. Your feedback may be skewed towards retired patients, and those who are not hourly workers. Consider how you will cast a wide net.

Lots of great advice at this event, much of which we already incorporate into our processes and products at Wellpepper, although I definitely got some new ideas and it’s great to see the community coming together to share best practices. My only disappointment with the event was that with a title of Patients as Designers, I expected to see more patients on the panel. While there was a last minute cancellation of a patient-maker, it would have been amazing to have Children’s and Virginia Mason bring one of their patient-designers to be on the panel. Maybe next time?

Posted in: Healthcare Disruption, Healthcare Research, Healthcare Technology, Healthcare transformation, Lean Healthcare, Research, Seattle

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Infographic: Factors Related to Adherence

Just as no two patients are identical, the factors that affect adherence vary dramatically from patient to patient, and also importantly what type of treatment plan they are adhering to. Adherence to medication is often affected by medication itself: side-effects, contraindications, timing, and the way it is applied. Adherence to a physical rehabilitation program is affected by the function of the patient, very often by the level of pain they feel, and sometimes by the patients own belief in their abilities. Adherence to diet is affected by so many factors including, access to appropriate food and social pressure. Even with these differences, though there are a number of common factors that affect patient adherence, both negatively and positively.

The 2008 study “Factors affecting therapeutic compliance: A review from the patient’s perspective” provides a comprehensive review of research on the subject, and presents this view of the factors.

AdherenceFactors

As a provider, there are some areas that you can influence, and some that are data points that might help inform how you approach the patient. You probably can’t impact their socio-economic situation, but you can understand how it might impact their treatment. For example, how big of a factor is cost or transportation in their ability to adhere to a program? Trying to save money often results in patients trying to take fewer pills than prescribed. We spoke with one arthritis researcher who prescribed swimming for her patients, however, for many of them the cost of a gym membership and transportation to the pool was prohibitive.

When putting together a treatment plan for a patient, it’s good to keep all of these factors in mind, working with the patient to come up with a plan in which they are most likely to succeed. Tailoring the plan to the patient lifestyle, rather than the other way around.

Posted in: Behavior Change, Healthcare motivation, Managing Chronic Disease, Uncategorized

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Resolve to Create Better Resolutions!

Tis the season to regret all the cookies, chocolate, and rich foods you ate over the last few weeks and start the New Year off right! Resolution time is here. Do you make them? Do you think they work? Do you incorporate behavioral change methods in your resolutions? Simply deciding to do something new or stop doing something old without making corresponding changes in your ability to do so will not have the impact you’re looking for.

There are three key factors that facilitate behavior change:

  1. You have to have the capability to change.
  2. You have to have the motivation or desire to change.
  3. You have to have the opportunity to change.

If these three conditions exist, you can change. So let’s say your goal for 2014 is to sit less. However, you have a job where you sit at a computer all day, and while you know that sitting is not good for you, you like your job and quite frankly your family and mortgage like your job too. You might be motivated to sit less but unless your employer supports you in this desire for example by helping you install a standing or treadmill desk, or removing all the chairs from the conference rooms, you might not have the capability to change. Or let’s say you want to walk to work but your office is 20 miles from your home in an industrial park off a freeway. Again you might have the motivation, but not the opportunity unless you are able to change jobs.

Picture of cocktail

Cocktail source: Steamykitchen.com

One year I decided that I had become old before my time (in my pajamas by 9 on a Friday, if you must know), and I made three resolutions:

  1. Drink more cocktails
  2. See more films
  3. Go to more art galleries.

Now, you’re thinking, these don’t sound like good New Year’s resolutions, but according to the factors that facilitate behavior change, I was on the right track. I had disposable income, single friends, and lived in a large metropolitan area with plenty of theatres and art galleries. Friends were more than happy to help me keep these resolutions, and I got out of my hermit-like funk and was inspired by connecting with people, the vibrancy of the city, and by art.

If you need some help designing your resolutions, first off use the simple framework. Are you capable? Are you motivated? Do you have the opportunity to make the change? If any of these is no, consider whether these factors can change. This video by behavior change expert, BJ Fogg can also help you break it down to something that is manageable.

Finally, get help! Studies show that even if friends of your friends are obese, you have a greater chance of being overweight. The same is true with positive behavior. As a long time “left-coast” dweller, I can attest to the positive transformation that happens when people move here and are surrounded by those with an active lifestyle. Get some friends together who are working towards the same goal. Start a walking group at work. Employee wellness was one of the hot topics of 2013, and while some of the promise of employer-organized wellness programs have not come to fruition, there are simple things that employees and employers can do to facilitate change. We loved these examples from the BUPA HQ in London. If any employee has the motivation, the company facilitates the opportunity.

Eat more fruit!

Eat more fruit!

Take the stairs!

Take the stairs!

Psst. Over here!

Psst. Over here!

Best in 2014 from all of us at Wellpepper for a healthy and happy year!

Posted in: Behavior Change, Healthcare motivation

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Breaking the Barriers to Exercise

Last Friday, May 3rd I attended the IDEA Personal Trainer Institute Conference in Seattle.  IDEA is a conference for personal trainers to come together and get comprehensive, in-depth training from some of the top fitness professionals in the world. Sessions ranged from full-on workout sessions (TRX, Kettle Bell training) to lectures on motivating clients, and running a successful fitness business.  I had the opportunity to attend a session presented by Rodney Corn from PTA Global entitled “Breaking the Barriers to Exercise” in which he discussed how to motivate non-exercisers to get active.

1gf4g Rodney started off the session by asking: “What do you consider exercise?” Now in a room full of personal trainers you can imagine that there were visions of some pretty intense and vigorous exercise. To be fair, the morning sessions looked something like the video you see on the left.  He then asked the room to go through a series of movements. He had us pick up a medicine ball and carry it to the other end of the conference room. Then he had us roll an exercise ball to the other end of the conference room. Pretty easy and non-strenuous movements.  “Was this exercise?” From the expressions of the majority of the people in the room I would say most thought NO.

Exercise is movement.  It is generally defined as movement that is planned, structured, and repetitive for the purpose of conditioning any part of the body. The industry’s  standard for exercise is a minimum of 150 minutes of moderate exercise or 75 minutes of intense exercise per week.  For increased benefits the recommendation is 300 minutes of moderate exercise or 150 minutes of intense exercise per week.

In the following video Dr. Joan Vernikos, looks to simplify the idea of exercise stating:

“The key to lifelong health is more than just traditional gym exercise. The answer is to rediscover a lifestyle of constant, natural, low intensity, non-exercise movement that uses the gravity vector throughout the day.”

So if exercise is so simple, then why aren’t more people doing it? The situation today is pretty dire:

  •  1.6 billion people are overweight or obese in the world
  • 60% of people worldwide don’t get sufficient exercise
  • 70% of the US population is overweight or obese
  • Less than 20% of people get the recommended amount of physical activity
  • 25% of US population does ZERO physical activity

There are more fitness facilities, personal trainers and education than ever, yet there is also less participation in exercise and more disease than ever before. What are the barriers to exercise? Why are so many people remaining inactive? Rodney suggested there are two major obstacles: Pre-existing level of activity and the suggested time required to exercise.

Dr. Roy Sugarman, Neuropsychologist states: “People need the reward of micro-goal successes to avoid ambivalence about the big goals”.   So breaking down daily activities into smaller, shorter bouts and intervals would be much easier for the sedentary populace to digest. Protocols for non-exercisers and beginners should be just 5 to 10 minutes in length. It has been scientifically proven even short intervals (5-10 min) of activity can have a physical and mental benefit.

At this point of the lecture you could hear the collective sigh of the trainers in the room.  Really? Only 5-10 minutes? Personal trainers are used to pushing people to their limits. They turn even the average Joe into an athlete. How can 10 minutes be enough? Rodney hammered home the point by saying:

“People are more likely to change when they have a sense of control, can manage the process and see some quick micro results.”

Trainers should match exercises and programs specifically to the client by knowing their personality, behavior patterns and motivation. They should ensure that the program gives the client a sense of control and that the length of exercise is short enough to facilitate change. The fact is, the more often you can get someone to do an activity, the more likely you are able to help them establish a new habit. If the program is overwhelming for an individual, they just won’t do the exercises. Training programs need to be appealing, nonthreatening and most of all – achievable.

The fitness industry is not designed to meet the needs of the sedentary population because the fitness industry’s idea of exercise is too high. The reality is that any movement is exercise and for some just doing simple movements around the house is where they need to start. As Dr Joan Vernikos says: “Sitting kills, movement heals”. Helping someone get in the habit of performing even the simplest of movements can move them towards a more healthy and active lifestyle.

At Wellpepper, we motivate behavior change by giving clients detailed instructions, reminders, and motivational prompts to remember to do their exercises. Many professionals we have worked with recognize that when it comes to motivation, sometimes less is more.  However, some have asked how many exercises can you prescribe to clients with Wellpepper? The answer is as many as you like,  but the trick is to find that magic amount for the end customer. What will drive them to change?

Posted in: Exercise Physiology, Healthcare motivation

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