brown2020

Yesterday, I built a contraption that turned my already hideous treadmill into something even more aesthetically questionable: a home office. I am typing this blog post on my MacBook as I walk on the treadmill at 3.5 miles per hour.

Treadmill Laptop Computer Stand

Like millions of people around the world, this New Years I again resolved to exercise more. After a bunch of failed attempts in prior years, this year would be different. I decided to word my New Years Resolution a little differently as well:

Find a sustainable exercise pattern that works for me, together with the tools to support it.

Emphasis on sustainable, as in beyond the first quarter. I also said I would find a pattern that works for me by the end of the year. That way I don’t need to feel like a failure even if I have not found the right thing for me when summer rolls around. There still will be plenty of time to keep looking.

This year I also told a few friends about my goal, which implicitly makes me feel more accountable. Actually, I did that before, and no one really cares about someone else’s exercise goal. What’s new this year is that I wrote this blog post, shared it on Facebook and Twitter, and now the whole world can see my New Years Resolution, and my laptop treadmill contraption, if they happen to stumble across this site. More importantly, I changed the context for exercise.

The first principle of behavior change is that our behavior is highly context-dependent. Our behavior at the office is different than at home. Our behavior at home is different than at the ball game. Our behavior at the ball game is different depending on whether our team is winning or losing. When it comes to behavior, context is everything.

In my 2010 exercise experiment, I am changing the context of my morning email routine so that the default behavior, the path of least resistance, encourages something healthier.

By nature, we are lazy. And even if we don’t think we are, the laziness assumption is always a better strategy when designing new tools and processes. We seem to be obeying one of the most fundamental laws of physics, to find an equilibrium point that minimizes energy consumption.

For a lot of us, this laziness equilibrium point is on the couch with chips and drink in hand watching American Idol, which, this time of year is on TWO nights a week.

Since it looks and feels kind of stupid to stand on my treadmill and type on my laptop with the treadmill turned off, I turn on the treadmill and walk. Next thing you know, I have walked five miles, answered all of my emails, reviewed a new contract, checked in on Facebook, written a couple of tweets, and completed this blog post.

Maybe this year my resolution to exercise more is actually going to work! If I only can convince my wife that my new treadmill office contraption is as aesthetically pleasing as it feels…

April 20, 2009, Page 9

In “Wrong Prescription,” Dr. Scott Haig correctly suggests that digital medical records are no silver bullet for the costly, inefficient U.S. health system, but for the wrong reasons [TIME, April 6, 2009].

Information technology (IT) improves efficiency with the rules of the game currently in play. If the rules reward treating disease complications but discourage management and prevention, IT will help health-care businesses churn out more complications per hour.

The fundamental flaw in our current system is that despite decades of debate, no one has an adequate stake in preventing those costly complications in the first place.

Steve Brown — Published in TIME

This presentation accompanied a talk I gave recently to a group of health care executives at an ABL Roundtable event in San Francisco. I was asked to discuss the meaning, importance and potential application of social media in health care.

Social media is often defined as “people having a conversation online.” In contrast to mass media produced by a few, social media is generated by grass roots efforts of millions of people. It has become the largest and most interesting use of the web.

Despite the fact that health care is one of the most information intensive fields, the health care industry notoriously lags behind every other industry in its adaptation of information technology. To get our initial bearings, we decided to kick off the discussion by asking the audience to describe their own personal use of social media.

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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

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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.

Last week I spoke at the On Lok Lifeways Conference on October 22, 2008 in San Francisco, entitled “Sustainable Long Term Care: Ethics, Technology and International Perspectives.” The organizers asked me to draw insights from my experience in developing new models for chronic care as the founder and former CEO of Health Hero Network, and to compare that to what I had learned while traveling in Rwanda with Partners in Health last year. Here is my presentation.

In the most innovative models of care on both continents, health care providers have discovered that delivering better care with fewer resources can be possible with a proactive approach to supporting and monitoring patients at home rather than waiting for the inevitable complications of neglect. On both continents, healthcare providers have discovered that technology can be a useful tool to improve the effectiveness of care providers and to increase rather than replace personal touch.

In the United States, our healthcare system too often still penalizes rather than rewards prevention, especially in the largest fee-for-service system, Medicare. When it comes to innovation in disease management and prevention, we claim that we “can’t afford it,” while in a much poorer country in the heart of Africa, the government and the health system are working together to embrace innovation in home and community-based care because they can’t afford not to do it.

We have something to learn from innovations arising in places like Rwanda, where necessity truly is the mother of invention. Learning from such innovations can help us expose some of our own false dichotomies that too often have become an excuse to stifle innovation.

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Emerging infectious diseases that start with a fever or a rash can pose a risk to public health because they might not be recognized at the early stages when containment or treatment is possible. After September 11, our fears were stoked by anthrax. Then came SARS, and we still wait anxiously for bird flu.

A patent recently issued to Health Hero Network describes a simple but powerful idea that addresses the pandemic challenge by enabling near-real-time syndromic surveillance that can be adapted on the fly. Easy-to-navigate survey devices collect data from hospital waiting rooms, school nurses, and other points of care. The survey script can be changed and updated remotely by public health authorities based on the latest information. The devices report data to central computers that look for any unusual patterns and then alert public health authorities immediately so that they can investigate further.

Disease outbreaks that look like the flu at the beginning can be hard to detect early because flu-like symptoms are common and are not always reported. The first cases of an outbreak may be spread out over many different clinics, hospitals, and schools in a metropolitan area. Unusual patterns might emerge only when looking at a broader cross section of a region. The other challenge is that we may not know what data is relevant and important at the beginning stages of an outbreak. Where it might have been fever, rash, and working in a mail room for one threat, it might be diarrhea and travel to a specific region or eating a particular food in another threat.

While many efforts have been discussed and may even be underway to facilitate early detection of outbreaks by sifting through electronic medical records and pharmacy data, the most important information might be missed because no one knew to ask the right question. When we do figure out what question to ask, we won’t have time to add fields to medical records or change forms. Our public health authorities need the ability to change the script as soon as they learn new information.

Despite the simplicity of the approach, it is not easy to organize health systems around new ways of doing things. On the other hand, maybe we won’t need to. Public health surveys could be pushed to iPhone users, for example. There just might be enough iPhones out there by now to provide a statistically significant sample size enabling highly sensitive early detection of potential public health emergencies.

More information on Health Hero Network patents.

Gastric bypass surgery is a rapidly growing procedure in which the stomach is reduced from its normal football-size to something between the size of a thumb and a hardboiled egg. In each case, the stomach itself is healthy: the purpose of the surgery is to force the patient to change behaviors that are leading to obesity.

The images above came from a live Webcast of a gastric bypass surgery performed at Tufts-New England Medical Center in Boston by Dr. Scott Shikora, Chief of Bariatric Surgery at Tufts-NEMC, along with bariatric surgeons Dr. Michael Tarnoff and Dr. Julie Kim. Click on the images to watch the complete video on YouTube.

You also can watch Dr. Stan Hoehn perform a minimally invasive gastric bypass at Shawnee Mission Medical Center in Kansas by clicking on the image below.

A Consensus Panel convened by the National Institutes of Health (NIH) indicates bariatric surgery for people with a body mass index (BMI) of 40 or higher, or people with a BMI of 35 or higher with one or more related comorbid conditions such as diabetes, hypertension, and cardiovascular disease.

Bariatric surgery is regarded by leading physicians on the panel as a lifesaving tool that enables, or in fact forces, the patient to change lifestyle and eating habits.

With 100 million Americans struggling with at least one chronic condition, and over 60 million Americans considered to be clinically obese, we can expect a lot of bariatric surgery ahead. Can we really address the issue of obesity by forcing ourselves to change behavior under the knife, or are there other ways to address this epidemic?

Flip through these slides from the CDC to see a dramatic portrayal of the obesity epidemic in the U.S. The map shows the increasing prevalence of obesity over the past 20 years.

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It looks like Health Buddy is getting traction in the Netherlands, thanks to Sananet. Telebegeliding means telehealth coaching, or guidance at a distance using telemedicine technology, in Dutch.

“Telebegeleiding thuis geeft mensen met chronische ziekte meer veiligheid en zelfvertrouwen.”

Today I had the opportunity to participate in Health 2.0 User Generated Healthcare Conference. The one-day conference in San Francisco was fabulously organized by Matthew Holt of The Healthcare Blog and Indu Subaiya of Etude Scientific.

Indu and Matthew managed to assemble a stellar collection of entrepreneurs, movers, shakers, and creators of the next generation of the eHealth field. A full house discussed search engines that learn from personal health records, social networks that support patients, and how the wisdom of crowds is transforming medical knowledge.

We all know that the current way we organize and manage healthcare is dysfunctional and unsustainable. How else could we find a way to spend $2 trillion per year and leave 45 million people uninsured? How else could we spend so much and still have such mediocre outcomes compared to the rest of the world?

There have been many promising ideas proven futile and many vain attempts at healthcare transformation. What is different this time around? Finally the ecosystems are in place, the tools of production are widely accessible and development costs are so low that citizens do not need to wait for the institutions to be the deciders.

We have entered a new phase of rapid innovation and experimentation that is producing a wave of brave new ideas, some of which will be disruptive to current ways of doing things and some of which will be revolutionary. Pay attention to the list below, because you will be seeing these people in headlines for years to come.

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I had the opportunity to visit the district health center in Rwinkwavu, Rwanda, where Dr. Michael Rich explained why the Partners in Health model of care is able to achieve better medication adherence in Rwanda than even our best practices in the United States.

It is not just the fact that Bill Clinton and The Clinton Foundation negotiated a deal on antiretroviral (ARV) drugs. It’s not just the fact that the once complex cocktail regimen of pills can be combined into one generic pill. It is because an army of community health workers visit patients in their villages every day, checking in to make sure everything is OK, and to make sure that everyone is taking their medicine.

Daily support and monitoring at home, working with informal caregivers in the community to surface problems early so that bigger problems can be prevented: That is the key to improving quality of care with limited resources.

Dr. Paul Farmer, as chronicled in the book “Mountains Beyond Mountains” by Tracy Kidder, realized this in Haiti a decade ago, and now the Partners in Health “accompagnateur” system is being rolled out in developing countries around the world. Is there something we might learn from Rwanda?

This is Bill Clinton’s speech from the TED conference in Monterrey, California. He won the TED Prize, and his wish was that the TED community would join with him in supporting Partners in Health to establish a new model of care in Rwanda that could deliver quality care with limited resources.