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“Deep Support” in Patient and
Population Health
Bradford W. Hesse
Chief, HCIRB, Behavioral Research Program
2
Excerpts from 21st Century Life
Mobile
Banking
Global
Positioning
E-Ticketing
Daily
Weather
Apps
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
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
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.
6
Temptation to Automate Rather than Informate Dangerous
An over-reliance on autonomous systems.
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
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
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.
10
Consider the case of FedEx …
11
Core mission is to be accountable to every customer …
12
Using power of communications (20th Century) …
13
Using power of communications (21st Century) …
14
Promising deep support through connected accountability
15
Case Study: Cancer
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
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
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
19
Dr.Kevin B.Johnson
Filmmaker
“No Matter Where”
20
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
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
“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
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.
25
Building the National
Health Information
Infrastructure
26
Healthcare Declares a Crisis in Connectivity
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
By 2016, over 95% of Medicare/Medicaid-eligible hospitals had
achieved meaningful us of certified Health IT.
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
30
75% of Patients Encouraged to Use Online Record Complied
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
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
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.
34
Example 2: Screening
Kaiser uses integrated EHRs to track, prompt, and personalize
Nirav ShahVP & COO,
Kaiser So Cal
35
Nirav ShahVP & COO,
Kaiser So Cal
Example 2: Screening
Significant increases noted
36
Nirav ShahVP & COO,
Kaiser So Cal
Example 2: Screening
Population Management
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
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
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
40
Example 4: Life Long Support
41
A Cautionary Tale
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.
43
American Medical Association’s Checklist
44
21st Century Cures Act: $4.8 Billion over 10 Years
Source: https://www.fda.gov
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
21st Century Cures: Data Flow & Communication
• Trusted Exchange Network
• API without Special Effort
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
48
13 health
systems
Apple Health Care
21st Century Cures: Private Sector Investment
49
Samsung Home
Health Solutions
21st Century Cures: Private Sector Investment
More competition in this space
50
21st Century Cures: Private Sector Investment
June 21, 2018
51
Public Health in the Digital Age: Opportunities & Challenges
SOPHE Executive Summit, Washington DC June 5-6, 2018
52
The Road Ahead
53
Extreme Poverty, 1820-2015 Life Expectancy, 1771-2015
Child Mortality, 1751-2015 Homicide Deaths 1300-2015
Reason for Optimism
Steven Pinker, Ted talk
https://www.ted.com/talks/steven_pinker_is_the_world_getting_better_or_worse_a_look_at_the_numbers
54
A Supernova of Opportunity
55
What if?
56
We could enable a communications
“safety net” to ensure that we left no
patient behind.
57
We could help clinical teams work
together more efficiently, reduce
burden, and protect the joy of
medicine.
58
We could provide unyielding communication support
for a patient over a lifetime.
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
We could achieve a true learning healthcare system to
accelerate knowledge, and improve practice.
61
We could apply industry-level engagement techniques to
help individuals and communities improve their health.
62
We could move healing from here … to here.
63
Mahalo

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Hesse hopkins 6.20.2018

  • 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.
  • 6. 6 Temptation to Automate Rather than Informate Dangerous An over-reliance on autonomous systems.
  • 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.
  • 10. 10 Consider the case of FedEx …
  • 11. 11 Core mission is to be accountable to every customer …
  • 12. 12 Using power of communications (20th Century) …
  • 13. 13 Using power of communications (21st Century) …
  • 14. 14 Promising deep support through connected accountability
  • 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
  • 20. 20
  • 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.
  • 25. 25 Building the National Health Information Infrastructure
  • 26. 26 Healthcare Declares a Crisis in Connectivity
  • 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
  • 30. 30 75% of Patients Encouraged to Use Online Record Complied
  • 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.
  • 34. 34 Example 2: Screening Kaiser uses integrated EHRs to track, prompt, and personalize Nirav ShahVP & COO, Kaiser So Cal
  • 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
  • 40. 40 Example 4: Life Long Support
  • 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.
  • 44. 44 21st Century Cures Act: $4.8 Billion over 10 Years Source: https://www.fda.gov
  • 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
  • 48. 48 13 health systems Apple Health Care 21st Century Cures: Private Sector Investment
  • 49. 49 Samsung Home Health Solutions 21st Century Cures: Private Sector Investment More competition in this space
  • 50. 50 21st Century Cures: Private Sector Investment June 21, 2018
  • 51. 51 Public Health in the Digital Age: Opportunities & Challenges SOPHE Executive Summit, Washington DC June 5-6, 2018
  • 53. 53 Extreme Poverty, 1820-2015 Life Expectancy, 1771-2015 Child Mortality, 1751-2015 Homicide Deaths 1300-2015 Reason for Optimism Steven Pinker, Ted talk https://www.ted.com/talks/steven_pinker_is_the_world_getting_better_or_worse_a_look_at_the_numbers
  • 54. 54 A Supernova of Opportunity
  • 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.
  • 62. 62 We could move healing from here … to here.