The document discusses how connected digital tools and data can help augment human capacity in healthcare by providing deep support for patients and populations. It provides examples of how electronic health records, personalized outreach, and remote monitoring have helped improve outcomes for cancer screening, smoking cessation, and symptom management. However, fully realizing the benefits of these technologies will require addressing issues around data integration, communication gaps, and adapting clinical workflows. The goal is to use digital tools to inform and support patients and providers, not replace human relationships and judgment.
1. “Deep Support” in Patient and
Population Health
Bradford W. Hesse
Chief, HCIRB, Behavioral Research Program
2. 2
Excerpts from 21st Century Life
Mobile
Banking
Global
Positioning
E-Ticketing
Daily
Weather
Apps
3. 3
Common Themes
✓ Ubiquitous supports for the tasks and challenges of
daily life in the 21st Century.
✓ These seemingly pervasive and “easy-to-use”
applications are the product of careful data
integration and standards for interoperability.
✓ Interfaces have been carefully designed to support
a broad swath of consumers, across socioeconomic
characteristics and across literacy levels.
✓ Designed to “augment” human intelligence – not to
replace it.
4. 4
Creating Tools to Augment Human Capacity
“The second transformation to the new computing
is the shift from machine-centered automation to
user-centered services and tools. Instead of the
machine doing the job, the goal is to enable you to
do a better job. Automated medical diagnosis
programs that do what doctors do have faded as a
strong research topic; however, rapid access to
extensive lab tests plus patient records for
physicians are expected, and online medical
support groups for patients are thriving.”
- Ben Shneiderman, 2003.
Source: Shneiderman, B. (2002). Leonardo's laptop : human needs and the new computing technologies. Cambridge, Mass.: MIT Press.
5. 5
Tools are “Informating” rather than “Automating”
In the industrial revolution, the goal was to replace
human labor with automation.
In the information revolution, the goal is to
rebalance tasks so that computers can bring new
insights into the “knowledge worker’s” cognitive
awareness. The goal is to augment human
intellect, not replace it.
In the age of the smart machine, computers will
“informate” rather than “automate.”
- Shoshana Zuboff, 1984.
Source: Zuboff, S. (1988). In the age of the smart machine : the future of work and power. New York: Basic Books.
7. 7
Another Failure: Exploiting Transactions not Relationships
Source: Zuboff, S., & Maxmin, J. (2002). The support economy : why corporations are failing individuals and the next episode of capitalism.
New York: Viking.
Business focused on extracting
profit in the short run; to exploit
the transaction.
Business focused on supporting
customer needs in the long run; in
valuing relationship over transaction.
8. 8
Entering into the Support Economy [and Gig Economy]
“Deep support provides for an
ongoing relationship based on
advocacy, mutual respect, trust, and
the acute alignment of interests.”
- Zuboff & Maxmin, 2002.
Source: Zuboff, S., & Maxmin, J. (2002). The support economy : why corporations are failing individuals and the next episode of capitalism.
New York: Viking.
9. 9
Fully connected data technologies allow for personalization
and relationship building … at scale.
Source: Zuboff, S., & Maxmin, J. (2002). The support economy : why corporations are failing individuals and the next episode of capitalism.
New York: Viking.
16. 16
Progress Against Cancer: All Neoplasms
Source: Cancer Trends Progress Report, National Cancer Institute, NIH, DHHS, Bethesda, MD, January 2017,
http://progressreport.cancer.gov. Accessed March 11, 2017.
Nat’l Trends & Progress Report 2017
17. 17
County by County Mortality: All Neoplasms
Source: Mokdad AH, et al. Trends and Patterns of Disparities in Cancer Mortality Among US Counties, 1980-
2014. JAMA. 2017;317(4):388-406. doi:10.1001/jama.2016.20324
18. 18
Percent Change & Age-Adjusted Mortality: 1980-2014
Source: Mokdad AH, et al. Trends and Patterns of Disparities in Cancer Mortality Among US Counties, 1980-
2014. JAMA. 2017;317(4):388-406. doi:10.1001/jama.2016.20324
21. 21
Disconnects in Healthcare Weighing on Population Health
Source: http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2014.pdf
Total number of preventable
medical errors from all sources
exceeds 17 million each year
Joint Commission’s Sentinel
Database reports 70% of all
reported events had communication
as root cause
22. 22
Cracks will widen with projected stress on healthcare.
Source: Fishman, T. C. (2010). Shock of gray : the aging of the world's population and how it pits young against old, child
against parent, worker against boss, company against rival, and nation against nation (1st Scribner hardcover ed.). New York:
Scribner.
23. 23
“I never felt more alone than when my child felt sick in the
middle of the night and I had no way of contacting my
oncology team.”
Source: Madhavan, S., Sanders, A. E., Chou, W. Y., Shuster, A., Boone, K. W., Dente, M. A., Shad, A. T., & Hesse, B. W. (2011).
Pediatric palliative care and eHealth opportunities for patient-centered care. Am J Prev Med, 40(5 Suppl 2), S208-216.
24. 24
The “Last Mile” Problem: Communication Capacity as a
“Superdeterminant of Health” (FCC)
Source: Greenberg, A. J., Haney, D., Blake, K. D., Moser, R. P., & Hesse, B. W. (2017). Differences in Access to and Use of
Electronic Personal Health Information Between Rural and Urban Residents in the United States. J Rural Health.
27. 27
Prelude to Healthcare Reform
Meaningful Use
Safety, Quality
Improvement
Privacy, Security
Patient
Engagement
Continuity of
Care
Population
Health
Management
HITECH Act of 2009: Meaningful Use for Health IT
28. 28
By 2016, over 95% of Medicare/Medicaid-eligible hospitals had
achieved meaningful us of certified Health IT.
29. 29
Patient Trends for Interacting with Healthcare System Online
Source: Hesse, B. W., Greenberg, A. J., & Rutten, L. J. F. (2016). The role of Internet resources in clinical
oncology: promises and challenges. Nat Rev Clin Oncol. doi:10.1038/nrclinonc.2016.78
31. 31
Example 1: Prevention
Michael Fiore, MD
UWisconsin
Used EHRs to track smokers and prompt interventions
Source: Morgan G, Fiore M. (2016). Prevention, Information Technology, and Cancer. In B. W. Hesse, D. K.
Ahern & E. B. Beckjord (Eds.), Oncology Informatics (pp. 103-122). Boston, MA: Elsevier.
32. 32
Example 1: Prevention
Michael Fiore, MD
UWisconsin
Evidence is promising, but more RCT’s are needed
Source: Boyle R, Solberg L, Fiore M (2014). Use of electronic health records to support smoking
cessation. Cochrane Database Systematic Review, Dec 30; (12).
“Adding tobacco use as an electronic vital sign collected during a
medical visit appears to increase some of the recommended
clinician actions for treating patients who use tobacco” … not
enough RCT’s to be conclusive, though.
33. 33
Example 1: Prevention
Michael Fiore, MD
UWisconsin
Accelerated decrease in smoking prevalence during 2009-2015 period
Source: Fiore, M. C. (2016). Tobacco Control in the Obama Era - Substantial Progress, Remaining
Challenges. N Engl J Med, 375(15), 1410-1412.
35. 35
Nirav ShahVP & COO,
Kaiser So Cal
Example 2: Screening
Significant increases noted
36. 36
Nirav ShahVP & COO,
Kaiser So Cal
Example 2: Screening
Population Management
37. 37
Source: Rhoads, K. F., Patel, M. I., Ma, Y., & Schmidt, L. A. (2015). How do integrated health care systems address racial and
ethnic disparities in colon cancer? J Clin Oncol, 33(8), 854-860.
Nirav ShahVP & COO,
Kaiser So Cal
Example 2: Screening
Disparities Absent
38. 38
Source: Basch, E., Deal, A. M., Dueck, A. C., Scher, H. I., Kris, M. G., Hudis, C., & Schrag, D. (2017). Overall Survival Results of
a Trial Assessing Patient-Reported Outcomes for Symptom Monitoring During Routine Cancer Treatment. JAMA.
Ethan Basch, MD
U North Carolina
Example 3: Symptom Management
Patient-Reported Outcomes
39. 39
Source: Peterson, S. K. & Patrick, K. Creating a Health Information Technology Infrastructure to Support Comparative
Effectiveness Research in Cancer, in Oncology Informatics, B.W. Hesse, D.K. Ahern, and E.B. Beckjord, Editors. 2016, Elsevier:
Boston, MA. p. 373-386.
Example 3: Symptom Management
50% Decrease in Hospitalizations
42. 42
“We’ve mistakenly treated (the wiring of
healthcare) as a technical problem: simply buy the
computer system, … take off the shrink-wrap, and
flip the switch.
We were wrong – “The wiring of healthcare has
proven to be the Mother of All Adaptive Problems.”
- Robert Wachter, 2015.
45. 45
21st Century Cures Act: Patient Voice
Source: https://www.fda.gov
Health Communication Opportunities
▪ Patient Experience Data (Sec 3001)
▪ Patient-Focused Guidance (Sec 3002)
▪ Report on Patient Experience (Sec 3004)
46. 46
21st Century Cures: Data Flow & Communication
• Trusted Exchange Network
• API without Special Effort
47. 47
Source: Mandl, K. D., & Kohane, I. S. (2016). Time for a Patient-Driven Health Information
Economy? N Engl J Med, 374(3), 205-208.
21st Century Cures: Creating an Ecosystem for Communication
56. 56
We could enable a communications
“safety net” to ensure that we left no
patient behind.
57. 57
We could help clinical teams work
together more efficiently, reduce
burden, and protect the joy of
medicine.
58. 58
We could provide unyielding communication support
for a patient over a lifetime.
59. 59
We could link our public health data systems to improve our
support for population health management.
Source: NCI and Department of Energy Collaboration to Improve Cancer Surveillance.
60. 60
We could achieve a true learning healthcare system to
accelerate knowledge, and improve practice.
61. 61
We could apply industry-level engagement techniques to
help individuals and communities improve their health.