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In 1853 when Giuseppe Donati invented the classical wind instrument he called the “ocarina” in his workshop in the village of Budrio, Italy, people tended to know the daily activities of their neighbors. When someone in your neighborhood played the ocarina in his or her home late at night, not only could you hear it, but you also might have recognized the player and the tune. Maybe you would join in on your own instrument.

You would probably have much less of an awareness of the world beyond the vicinity of Budrio, not much past the big city of Bologna. But you knew your neighbors: Their stories, their experiences, their music, their relationships, and their gossip all had a place in your brain.

In the next century people would gain an ever-expanding awareness of the world beyond their local community through the virtual experiences of mass media. Starting with motion pictures, then television, 24-hour news channels, and the Internet, the world would become a lot smaller. We now live in a state of continuous awareness of the entire world. At the same time, we have become less aware of and connected to the people in our own local communities.

There has been much written lately about brain training and brain plasticity, and how we are entering the brain fitness age. If our experiences with the world can change the wiring of our brains, then how is our immersion into the constant stimulation of digital media affecting us? Is our continuous experience with the larger world through digital media impairing our ability to socially connect with our neighbors?

The brain maps of our ancestors just a century ago probably included many more connections for the social network of our local community. Some of that map has probably been superseded and replaced by our current awareness of and pseudo-relationships with the celebrities of the mass media. Too many of us know all about the daily activities, relationships, and gossip of Paris Hilton and Britney Spears, but do not even remember the names of our neighbors.

The Ocarina application for the iPhone from Smule is a deeply compelling example of how a new generation of social media technology could be the start of a new kind of community experience. The social media experience surely will change our brains, and I believe in a highly positive direction. Learning to play the ocarina on the iphone gives us yet another chance to learn new skills, which keeps our brains fit and growing. The brain training impact of individual practice is trivial, however, compared to the deep impact of connecting us to a new global community.

We might not know our geographical neighbors, but more than ever we can find and connect with our creative, intellectual and spiritual neighbors, anywhere in the world. And from our home late at night, we can hear them playing a new tune. And we can join them.

For a decade now, just about every service industry has taken for granted the benefits of information technology: Increased productivity, faster and better service, and access to services from home. All actionable information is recorded and shared electronically so that ever smarter information systems can help us anticipate and prevent problems. Whether it is retail, financial services, or even fast food, productivity in everything has gone through the roof.

Every service industry except health care, that is.

I stumbled across a presentation that I gave on the topic in 2004 together with Harris Miller, then president of the Information Technology Association of America. The ITAA had just released its chronic care improvement paper describing how Medicare could save money and save lives while stimulating an emerging health care information technology industry by adopting approaches that we have come to expect from every other service business.

Since 2004, the technology industry has responded to the opportunity to improve health care: Microsoft and Google are breaking the impasse in the electronic medical records field by providing connected online personal health records for free. Global technology giants have entered the home health market: Bosch acquired Health Hero Network, Honeywell acquired HomMed, and Intel launched into telehealth with its Intel Health Guide for home health monitoring, each aiming to bring connected health to the homes of seniors in need of chronic care.

The real barriers to advancing and modernizing health care still remain, however. It has not been a lack of technology, innovation, or insight from the information technology industry. Instead, the culprit has been a lack of imagination and initiative on the part of governments to develop, refine, and improve with policy changes aimed at rewarding the proactive management and prevention of chronic disease.

We know a better model of care and better service for the money is possible with smarter information-based approaches. With a new administration in Washington and a fresh infusion of imagination, determination, and energy into government following the recent elections, maybe we can start to turn health care from a net drain on the economy into a model for the world.

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America’s core fiscal challenge, according to the Congressional Budget Office, is health care. In 2011, the first of 80 million baby boomers will hit Medicare. In the twenty years to follow, the Medicare rolls will nearly double. Future obligations based on current policies leave our country technically bankrupt, and something has to give.

New Ideas About Human Behavior in Economics and Medicine, Peter Orszag, Director of the CBO, October 16, 2008

The current economic crisis emerged because as a nation we have been consuming more than we have been producing, and borrowing the difference. Poorly thought through banking regulations made credit too easy, and millions of Americans borrowed against their homes to finance consumption. Because economic growth depended on the “American Consumer”, policymakers rationalized, denied, and delayed addressing the problem. Home prices rose, borrowing rose, people used rising home prices to service debt and to consume. The resulting credit bubble burst, as every credit bubble does, deflating the assets of millions and costing millions more their jobs, their homes, and their security.

Beyond the housing credit bubble, a bigger fiscal challenge looms: Productivity in our economy is fundamentally shifting due to the demographics of an aging population. As baby boomers retire, our economy shifts further in the direction of producing less while consuming more, especially in health care. It is possible that technology will improve productivity, and people may postpone retirement. On the other hand, health care costs may rise faster than projected because of the epidemic of obesity and resulting chronic illness. In any case, there is little doubt that current spending trend is not sustainable.

When the next economic crisis hits, we will look back and see that despite clear warning and plenty of hard data, policymakers had delayed, denied, rationalized and obfuscated any meaningful reform to our currently ill-thought out health policies that already fuel over $2 trillion a year in health care spending.

At an institutional level, incentives must be changed to encourage more efficient models of chronic care. Half of health spending is the result of chronic illness. Complications can be prevented through better monitoring, management and prevention, yet we are painfully slow to implement policy changes that could accelerate innovation and adoption. At an individual level, baby boomers need accelerated innovation in technologies, products, and services that help them keep physically and mentally fit in order to stay productive longer in a highly competitive global information-based economy.

It is a law of nature that anything unsustainable must and will change. The only question is whether or not we will make the changes proactively and thoughtfully, or the changes will be imposed on us painfully and in a crisis. Recent CBO reports contain a glimmer of hope: Because a substantial part of health care spending is driven by human behavior, these are not fixed costs. How doctors practice medicine, or how patents communicate with doctors, and how we live our lives are all major factors in the future trend of health spending.

Many of the same factors that can reduce health care spending, like healthy lifestyle choices and continuous learning that promotes brain fitness, also enable us to be more productive in the global economy. The next financial tsunami is not inevitable but perhaps we can do something about it.

Phineas Gage

Growing up, I learned about Phineas Gage, the railroad construction foreman who survived an incredible accident in 1848 that shot a large iron rod through his brain, destroying the frontal lobes. Although Gage survived for another decade, his personality changed profoundly. The brain science books I read in the late 1980’s still used the over century-old example to introduce the idea that every function had a special location in the brain, and everything was hard-wired for life once you finished childhood. It turns out the hard-wired model of the brain was dead wrong, and academic opinion and dogma had led research down the wrong path for over 100 years.

Dr. Michael Merzenich, founder of Posit Science and one of the world’s leading brain scientists helped disprove the old “what you have is what you get” brain theories. In the 1980’s, Merzenich’s team developed the cochlear implant, a device that stimulates nerves in the inner ear with electrical signals that correspond to sound. With the “bionic ear”, people with profound deafness have learned to process the electrical signals and hear again. Merzenich went on to show that the brain can adapt and change based on all sorts of sensory input. How neurons wire together not only changes based on our experience with the world, but also based on our own thoughts. Posit Science applies this new knowledge of brain plasticity to brain training and brain fitness products that improve memory and processing speed to treat age-related cognitive decline.

I asked Dr. Merzenich: If I were to read just one book about the state of the art in brain science and better understand the background for Posit’s brain fitness research, what would it be? He gave me a copy of “The Brain that Changes Itself” by Norman Doidge, M.D. With compelling cases studies ranging from recovery from brain injury and stroke to overcoming learning and physical disabilities, Doidge details the radical advances in the science of brain plasticity of the past couple of decades. Now that we can measure brain activity even down to the firing of individual neurons, we can see without a doubt that the substance of our thoughts changes the wiring of our brain. The experience of the world around us—what we sense, what we do, what we concentrate on—can change the brain even into old age.

Dispelling the myth that we only stand to lose our minds over time is great news, especially to baby boomers worried about memory loss and cognitive decline as they get older. My English teacher in 7th grade used to say—to much teasing—that the brain is just like a muscle: You need to exercise it every day. It turns out she was right. The other side of brain plasticity, however, is that our brains can get set in their ways by the same principles of brain plasticity: Neurons that fire together wire together.

Dr. Merzenich described neural connections as like cow paths in a pasture. When cows continually tread the same paths over and over, the paths become ruts and the cows grow ever more fearful of treading anywhere else. Unless someone kicks the cows off the path, the ruts can become deep and permanent. Our thoughts are like the cows. We need to learn something truly new to make sure that our neurons keep growing and strengthening new connections. Merzenich showed that the biggest changes in our brains take place when we engage in “massed practice”, or efforts that demand intense concentration over a period of time. It also helps to be unique, striking, dangerous, or emotional: When the brain sees a new idea or skill as important, the brain goes into building mode and generates millions of new connections.

What struck me most about the book was the extent to which the scientific community had impeded progress in an area so obviously vital to everyone. Rather than looking at examples like Phineas Gage as evidence that the brain can adapt and change, Gage was used as an example of the opposite. For over 100 years, the academic community refused to consider the idea of brain plasticity and refused to support, encourage, publish, or even give a fair hearing to the few scientists who challenged convention. The social network of academia was much like their outdated idea of the hard-wired brain: Set in its ways with the same cows treading the same ruts.

Luckily for us, Dr. Michael Merzenich and his peers defied their academic advisors and department heads and went on to quietly pursue their brain plasticity research. Their breakthroughs and discoveries have spawned a new wave of brain research and brain training innovations that could improve the lives of millions of people for years to come.

Google Sets is an interesting new tool from Google Labs that finds associations between words or phrases and related terms that we might not have thought about. Who could be better able to offer such a tool than Google: More than any other organization on the planet, Google knows what we are thinking. When something is on our minds, chances are that a significant sample of us are typing it into Google. The resulting data puts Google in a unique position not only to identify associations between words, but also to derive insights into human intentions and behavior.

Google Sets Home Health Monitoring Example

For obvious examples, type “Porsche” and “Mercedes” into Google Sets, and the site returns Ferrari, BMW, Audi and Lamborghini, among others. Type in “brain fitness” and Google Sets returns brain health, mind fitness, mental health, stress, cognitive neuroscience, brain training, and more.

For something less obvious, I challenged Google with the name of my old company, Health Hero Network. Google Sets accurately found AMGA, the acronym for the American Medical Group Association, the company’s partner on an important but not very well known Medicare chronic care improvement demonstration project. Google Sets also identified two of the company’s competitors, Viterion Telehealthcare and AMD Telemedicine, but missed the larger rivals Philips Telehealth and Honeywell HomMed as well as Intel Digital Health, the latest entrant into the home health monitoring market. Google Sets also didn’t pick up the fact that Health Hero Network is now part of Robert Bosch GmbH.

Digging deeper, I tested the phrase “home health monitoring”, the field of capturing health information from patients at home and sharing it with caregivers. This niche appeared to have stumped Google Sets. The website returned a number of terms related to nursing, but veered off into some bizarrely unrelated phrases like “buy sexy Halloween shoes” and “wholesale shoes deal”. Maybe Google has discovered a connection between home health monitoring and sexy Halloween shoes that is not yet obvious to the general population. Maybe this blog post is only going to contribute to the weird association in the Google search index. If enough people press the Digg button above to send this link to the web’s largest social bookmarking site, the behavioral anthropologists studying Google search data could see a stream of even more confusing data!

Google Trends Global Warming and Beer Example

Not only is Google in a unique position to know what the world’s online population is thinking, but Google also serves as a collective memory for our thoughts and interests over time. In past blogs and presentations I have used Google Trends to illustrate how our interests change over time, illustrating the rise of sharing on social networks like Facebook, using web analytics to foretell the fates of presidential campaign contenders, and to lament the relative lack of interest in important topics like global warming compared to things like football and beer, as shown above. See my presentations on life sciences innovation, new chronic care models, and telehealth technology for more examples.

Google Labs is currently running an experiment that could extend our collective memory decades into the past with an new search filter called Timeline. For awhile now, Google has been indexing libraries and archives of books, news, and patents from the past. By looking for the date of origin in footnotes, endnotes and any other notable information in its database, Google may soon be able to give us a clearer sense for how our interests have evolved over the past century, not just the past year.

Google Medicare Experimental Search Timeline Example

Take note of Google Trends, Google Sets and Google Experimental Search using Timeline from Google Labs to get more insights on just what Google means when the company describes its mission to “organize the world’s information and make it universally accessible and useful.”

EHealth consultant Sananet has been piloting the Health Buddy telemedicine technology in the Netherlands for several years, with encouraging outcomes in diabetes, COPD, and heart failure, as well as benefits for everyone involved in care: patients, doctors, nurses, health insurers and government agencies. Here is what telemedicine technology looks like in the Netherlands, recently posted on YouTube.

Sananet reports the following results from its telemedicine in chronic care pilots:

• 30% reduction in hospitalization for heart failure patients in a telemedicine study from the University of Maastricht.
• Reduction in length of hospital stay for COPD patients from 13 days to 9 days on average in a telemedicine study from the University of Utrecht.
• In diabetes patients with an HbA1c of 8% or higher, a reduction in HbA1c of 1.5% compared to 0.6% in the control group in a study in Almere.

Although many think of telemedicine and telehealth as the remote collection of data from blood pressure monitors, digital weight scales, blood glucose monitors, and respiratory monitoring devices, Sananet achieved all of these results using a telemedicine system focused on educating and supporting patients at home in a simple daily text-message health dialogue about symptoms, behavior and knowledge.

Related posts:

Dutch Ministry of Health Recognizes Health Buddy for Best Practice in Telemedicine

Telebegeleiding met Health Buddy

In Defense of Food

In his book, “In Defense of Food,” Michael Pollan traces the deterioration of the American diet to 1977, when dietary recommendations became political. A well intentioned Senator George McGovern had introduced the “Dietary Recommendations for the United States,” lamenting that the American diet had become full of fatty meats and sugary soft drinks that were causing disease. The report started a firestorm because every food has a powerful lobby. Discussion of actual foods had to be watered down only to mention mere nutrients. It was politically incorrect, for example, to distinguish between beef, chicken or fish. “Now the culprit is an obscure, invisible, tasteless – and politically unconnected – substance that may or may not lurk in them called saturated fat.”

Keeping the topic of nutrition close to and safe for the food lobbies, the 1977 Farm Bill placed our national nutritional authority with the US Department of Agriculture rather than an agency focused on human health. Our government and the massive agricultural subsidies that it doles out could now stop thinking about nutrition in terms of whole foods, which were too politically dangerous, and could shift to a reductionism that parsed food into a limited set of nutrients that could quantified, processed, and manufactured.

With food merely a vehicle for delivering nutrients, the age of manufactured and processed nutrients—Pollan does not call it food—could flourish. And the American obesity epidemic could begin.

Like every good manufacturing process that wins through ever increasing efficiency, our food supply raced toward the cheapest form of calories: Grains that could be mass produced and fertilized out of otherwise increasingly barren soil, to become concentrated and cheap forms of calories like high fructose corn syrup. We also shifted to feeding livestock with the same cheap calories. No more green leaves ever needed to enter our food chain. We always could add back in manufactured vitamins to fortify the products to meet the government recommendations.

But food is much more complex than the limited collection of nutrients that we currently understand. Each blueberry contains dozens and dozens of anti-oxidants balanced by hundreds of generations of natural selection. That’s just not the same as blueberry flavored high fructose corn syrup fortified with the singular chemical entity known as Vitamin C.

The reductionist approach to food as a collection of manufactured nutrients broke the longstanding connection between our food and nature. For eons, the act of preparing and eating food has been the primary and fundamental interface between our physical bodies and the nature that sustains us and of which we are part.

Where did it come from?

When the food chain was short, the foods themselves were complex, and we were reminded with every trip to the market of our connection to the natural world and to the soil from which our food originates. Food was something that we could identify: an apple, a banana, a chicken leg.

Now the manufactured food chain is long, with so many participants from so many places that we have no idea where the ingredients in the box of cereal we had for breakfast really came from. We no longer know what we are eating. It comes from a complex supply chain from around the world, a supply chain optimized by market forces for long shelf life and high margins, not for human health.

Michael Pollan’s advice is to leave behind manufactured processed nutrients and take a step back toward nature: “Eat food, not too much, mostly plants.” Sounds like good advice to me.

Intel Health Guide Blood Pressure Monitoring

After over three years of research, development, and market study, Intel announced the launch of the Intel Health Guide, an Intel-branded device for remotely monitoring and managing patients with chronic illness at home. From Intel’s demo one can see that the device is a laptop computer no keyboard and a reversed touch-screen. Patients can connect and upload blood pressure monitors and other medical devices to communicate results with remote health care providers. In addition to vital sign data collection, the health monitoring software also provides patient reminders, surveys, educational content, and other communication tools.

Although Intel appears to be targeting at the same chronic disease management market, the Health Guide from Intel adds features and functions far beyond its predecessor Health Buddy from Health Hero Network, now a division of Robert Bosch. It will be interesting to see whether or the enhanced functionality such as video conferencing and multimedia content will be the key to market adoption.

Intel Health Guide Home Health Monitor

The real barriers to adoption of remote monitoring and other chronic care strategies may be less about functionality than about institutional incentives and business models ingrained in our health care system. The health care market with Medicare in the lead still rewards health care providers far more for treating the complications of chronic illness than it does for proactive management and monitoring aimed at preventing them.

The incentive systems that determine the viability of new models of health care enabled by devices like the Intel Health Guide and the Health Hero Health Network Health Buddy could be about to change, however. With favorable results from the Medicare chronic care improvement demonstration project currently underway from Health Hero Network in Washington and Oregon, Medicare coverage for health care providers to offer home health monitoring services may be around the corner.

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Great design starts with empathy for human needs, and great designers gain their insights by immersing themselves in the world and looking at challenges through the eyes of their users. That is the philosophy of IDEO, one the most innovative and successful design firms in the world.

Yesterday, I had the good fortune to hear a thought provoking presentation on innovation and design thinking by the CEO of IDEO, Tim Brown. Tim described the lengths to which IDEO designers go to understand the point of view of their users and then to generate a stream of prototypes as they experiment and try out ideas. Prototyping is part of the learning process. Insights are more likely to come spending time with extreme users, the youngest and the oldest, and the most challenged.

Here is a presentation by IDEO from the First Conference and Intensive Training on User-Centered Design in May 2008 which conveys the IDEO design process and basic principles of design thinking:

Nowhere is the IDEO approach to human centered design more necessary than in health care, where we spend more resources than any other sector of our economy and yet we still have the greatest unmet needs. While I was CEO of Health Hero Network, we partnered with IDEO to design the first Health Buddy device for home health monitoring. Here is a sketch from the Health Buddy design patent that we received on the in-home appliance that served as the front end for a home health monitoring service:

Health Buddy Design Patent Sketch

Our goal with Health Buddy was to enable people with chronic conditions to effortlessly record health status information at home and share it with remote care providers over the Internet. We hoped to enable caregivers to identify problems early and do a better job of educating and supporting patients at home to prevent more serious problems that would lead to hospitalization.

The first design challenge that I gave IDEO was to enable my grandmother to communicate meaningful information with her nurse over the Internet using just one trembling knuckle. The second challenge was to use design to deliver a friendly, supportive and compassionate interface to remote caregivers so that patients would feel comfortable in sharing information daily about health issues that most people would rather not think about.

The collaboration with IDEO was tremendously successful in creating an better interface to chronic care from the home. The most common response from our users was that they “felt like someone was there for them.” Hospitalizations were reduced, patients adhered to treatment, and caregiver productivity improved. Now if only the design of the economic models of health care could catch up to advances in designing a better chronic care model!

Partners in Health has been improving chronic care in rural communities in Rwanda through an innovative model of care inspired by Paul Farmer. The regional hospital sees its mission as training community members to extend care into the community and monitor patients at home in order to prevent disease complications and the need for hospitalization. The hospital tracks symptoms and medications using electronic medical record (EMR) systems based on open source technologies. Meanwhile, the United States continues to neglect reforming our crisis-oriented health system because “we can’t afford it”, and the cost of chronic care continues to explode as the population ages. With far fewer resources, but with more creativity and courage, innovative leaders in Rwanda are creating new models of care based on prevention because they can’t afford not to. Maybe we can learn something from Rwanda.