PEACEHEALTH, Whatcom County, WA
Life occurs in the large spaces,
Between visits
Between organizations
Between EMRs
Which organizations and technology will support people in between?
2. Ecosystems
for
Supported Behavior
Change
The Holy Grail?
Questions & Speculations
Marc Pierson, MD
PEACEHEALTH
Whatcom County, WA
3. Speculations
about:
“ DISRUPTING our minds before
INNOVATING?
“ Community health ecosystems?
“ Networks„relationships?
“ Flourishing together?
“ Supporting technologies?
4. Why the growing
interest in behavior
change?
“ Payment for outcomes,
especially population health
outcomes.
5. Who is “we”?
Where is “home”?
“ For the sake of what?
“ Who is in this together?
“ The problem space is larger than our
organizations. It is at least the size of
our communities.
--Read from introduction to John
McKnight’s THE CARELESS SOCIETY,
Community and it’s Counterfeit
6. BETWEEN
Life occurs in the large spaces
“ Between visits
“ Between organizations
“ Between EMRs
Which organizations and technology will support
people in between?
7. PERSON’S HOME
“ Where almost all decisions and actions occur
“ Where medications are taken or not
“ Where diets and exercise occur or not
“ Needs information and decision support
9. Why Behavior Change Matters
This chart shows the determinants of health and
their contribution to premature death.
10. 114 yrs of
MISSION, VISION, VALUES
“ MISSION ELEMENTS
” …Personal and Community Health
“ VALUE ELEMENTS
” Respect, Stewardship, Collaboration, &
Social Justice
“ VISION
” 1990 Seamless care across the whole
community
” 2006 Every patient will have safe, evidence
based, compassionate care, every touch,
11. PeaceHealth/Whatcom
Background
“ Accountable Care Community 1993-1997
“ RWJF / IHI Pursuing Perfection 2001-
2006
“ Direct input from patients =>
✴Navigator Coaches
✴Shared Care Plan (like a “FaceBook
for Health”)
- MS HealthVault, WA Health Record
Banks, CMS Transitions of Care
“ Accountable Care Community--2010...
14. Root Cause /
Solution?
“ Positive Health outcomes <= High
Patient Activation Measure <=
Positivity Ratio >3:1
“ HOW to flourish (how to <
Negative emotions and > Positive
emotions)
“ Science of feelings and emotions-
- “Broaden and Build”, Barbara
Fredrickson.
15. Care Networks?
“ Who cares? Really? Who really
cares? -- John McKnight
“ The “Health Family”?
“ The “Health Neighborhood”?
16. Disruptive
Innovation?
“ Three disruptive
business cases
“ Third is likely
the most
important and
most disruptive:
NETWORK MODEL
17.
18. BEHAVIOR --
Skinner
and/or
Barbara
Fredrickson?
“ Mechanics and gadgets?
and / or
“ Approaches and tools for socially
constructed Meaning--CARE?
Who will choose go jump into who’s
Skinnerian box?
19. FEAR & ANXIETY
“ Are inevitable and useful
“ Kill creativity
“ Narrow choices
“ Limit problem solving
“ Add to illness burden
20. Patient Activation
Measure (PAM)
“ Predicts health outcomes and
costs
“ Person’s perceived ability to
address their own health issues
“ 4 levels
21. Human Flourishing
“ Measurable
“ Understood
“ Actionable
“ Core to “activation”
22. Broaden & Build
“ Positive emotions open our
minds.
“ Positive thinkers literally see
more of the world around them
and are more likely to find
innovative solutions to
problems.
23. Leverage Points?
“ Patient Activation Measure
“ Measured positivity ratio with
interventions / actions
“ Work place
“ Neighborhoods
“ Friends (‘health family‛)
“ Self
24. Pivotal Roles?
“ Health care professionals?
“ Educators?
“ Ministers?
“ Employers?
“ Community organizers?
“ ‚Health family‛?
“ All together?
25. Community?
“ Not “population” -- a number, an
abstraction
“ Rather people in Community
working together for their
shared
- Health
- Wellbeing
26. Connection?
“ More than e-connectivity
“ More than proximity
“ Flourishing together
27. Positivity Ratio >
3:1
“ Individuals?
“ Families?
“ Work units?
“ Organizations?
“ Neighborhoods?
28. Innovation
“ Context matters, specific:
Ecosystem?
- Hospitals, Providers, Payers,
Employers
- Citizens/Actors/Patients --
“health families”
- Schools, churches, associations
- Technologies in place
“ How to introduce inventions and
get adoption within a complex
health ecosystem
29. Ecosystem
Technology?
“ Support flourishing
“ “Affectors”
“ Sense makers, meaning makers
“ Awareness of how we are doing
“ Real time measures & feedback
“ Reminders
“ Meaningful connections &
coordination
30. ECOSYSTEM ECHNOLOGY:
“ Shared Care Plan
Congral’s Coordination Suite
“ Calendar with SMS & E-mail
Alerts
“ Care Manager Dashboard
“ Transition Coordinator„driving
calendar
“ Direct Coordinator„driving
calendar
“ Integration with MS HealthVault
& MS Community Connect
platforms
31. The Coordination, Rules,
Seamless (plugin-like) insertion Analytics and Messages are
of SCP platform into any EMR or implemented via platform's
HIE solution to improve public API
coordination of care
Mobile Mobile Apps
Apps Coordination Rules,
Analytics, Messages
Patien Secure Messaging Using NHIN
Direct Provid
ts ers
EMR
DEVICES 1 - N
CLAIMS DATA
DEVICES 1 - N
CDR LABS
DEVICES HV N
1-
DEVICES 1 - N
Ecosystem
IMAGING
Applications
PHARMACY
32. Calendar, Rules , Messaging 33
& Alerts
Choose pre-set rules or
alerts or build your own to
better manage the health of
you and your family