Archive for category Health inSight

On #DataPrivacy Day

Introduction

On Data Privacy Day, I thought it might be helpful to write a little bit regarding the nature of privacy in the healthcare world. Many people know that there are laws like HIPAA that are in place to protect patients from their personal health information being breached. And while there are stories regularly about breaches, the amount of effort that goes into protecting health information is immense. Maybe by providing some insight into that world you, as a reader or one of our clients, might gain a greater sense of confidence or understand ways in which you can also protect yourself.

It’s more than just privacy

In order to manage the private information of all of our clients across the United States, MINES employs the use of an electronic health record system that stores and protects access to information, even from within our own company. We use layers of access and control as well as tracking our own users within the system. This also means that we have to employ some pretty strict control mechanisms within the system to ensure that security of data is maintained.

But, there are many times when we need to exchange information with other groups on your behalf. An example of this is providing an authorization to the provider that they are pre-approved to receive payment for services. To do so, many providers elect to receive this information via email, in which case the provider is sent a notification email where they are prompted to log into a secure website where that information can be accessed. We have structured our agreements with these providers to protect that information as best we can from the very beginning.

Part of the key to good data privacy policy that MINES employs is to only ask for information that is needed to provision services. For most of our clients, especially on the Employee Assistance side of our services, we ask for the last four digits of your social security number. This is used to help verify identity for later discussions with you. But the reason we don’t ask for your full social security number is because it creates a situation where we are storing information that isn’t critical to our needs to serve you.

Identity and security

As mentioned above, a critical element to protecting your privacy is tied to identity. Without going too deep into how this is handled across the healthcare industry, identifying an individual is usually done at MINES by their date of birth and last four digits of their social security number. From there, all internal work is handled by using a unique identifier, called a Patient ID. This allows us to be able to reference information from the central patient database without using your name, or other personally-identifiable information; decreasing the likelihood of erroneously sharing your data.

A note on confidentiality

Your information is never shared with your employer except in the case of Work Performance Referral in which case you will be asked to complete a letter explicitly allowing us to communicate with your employer regarding your progress. Your information is also confidential from disclosure to other employees at your company or anyone else for that matter without your permission. For example, even your spouse or family member cannot receive information about you from our staff without your permission. The exception to this is when information that we receive poses a threat to others, in which case we may be legally required to act.

Ways you can protect yourself

This isn’t meant to be alarmist, or to suggest that you shouldn’t provide as much information as you can with MINES. We implement a lot of control to make sure that the information that you provide to us is protected. However, below are a few things that you can do to help protect yourself.

Email

If you elect to receive email from us – for example, to communicate about an upcoming session, or request additional information – you should know that email alone is not secure. While most information that would be sent isn’t highly sensitive, it’s certainly something to be aware of. Regarding corporate email, specifically, most information that flows through corporate email servers is logged, stored, and likely accessible to IT professionals on some level at your organization.

Request a copy of the privacy notice

All providers should have this readily accessible to clients. By reading through the privacy notice, you can get a sense for how information about you can be used and what recourse you have in the case of a breach or needing a copy of your record on file with the provider. If you’d like to see our privacy policy, you can find that on our website, here.

Voicemail

As mentioned above, regarding the confidentiality of your information, when you call into MINES to receive access to services, the staff will ask if it is okay to leave voicemail. By providing a voice mailbox that is accessible only to you, we can make sure that your information is not being shared with other parties.

What’s on the horizon for us

In an effort to continue to meet the needs of privacy in an ever-more-connected world, MINES is engaged in a number of initiatives that will further protect and ease information exchange to simplify how we work with you. Soon, you will be able to create an online account with us where your history with MINES can be accessed. You and your provider will be able to use this platform to communicate with each other in a secured environment. You will be able to create your own account with us without calling in, so that if you want to request services but are concerned about someone overhearing the call, you can do so silently. And perhaps most exciting from my perspective, you will be able to create and access your account using a Facebook or Twitter account, allowing you to quickly authenticate your identity without pesky usernames and passwords!

We take security very seriously at MINES. We want you to have peace of mind when sharing information with us. If at any point in time you have questions, concerns, or suggestions regarding how we handle privacy and security, we welcome your insight. You can email or call us during regular business hours at info@minesandassociates.com or 800.873.7138.

To your health,

Ryan Lucas
Chief Information Officer
Security Officer
MINES & Associates

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HEALTH INSITE: #POKEMONGO AND HEALTH

Intro

I know there are a TON of articles and posts that have surfaced in these 6 days since PokemonGO was released in the United States. The sheer volume of discussion around this just-short-of-a-phenomenon app is certainly surprising in many ways, though another very popular app that just recently was eclipsed in downloads, Tinder, also got a ton of press at the beginning – mostly for the questionable intentions of its users. In this case, you might be able to make a case for the questionable intent of the creators, but I’ll stay away from either of those as the crux of this post and use it as a jumping off point for what I see as valuable technology for the future of health intervention.

What is PokemonGO

pokemongo3

From NianticLabs.com

Loosely based on “Ingress,” PokemonGO is a marriage between Google spin-off Niantic and Nintendo’s Pokemon company. Both companies have, on their own, somewhat of a cult following at this point. While the platform that enabled Pokemon to flourish, Nintendo, has wider reception, both at this point, are not particularly popular on their own. I was actually never a big fan of either. There may have been Pokemon Pogs when I was growing up, but aside from that, I’m not intimately familiar with either. But this combination of geolocation technology and fantasy are not new at all. In fact, if you check out ARGNet, you will find a number of times when games have moved beyond their stated fantasy world and brought them into the real world. Even Cards Against Humanity’s 12 Days of Holiday Bullshit involved very real things IRL (In Real Life) that helped to solve a massive puzzle by contributing members.

But why is it so dang popular!?!

Simply put: it’s fun to play. In Jane McGonigal’s book Reality is Broken and in her TED talk Gaming can make a better world, she covers why gaming can be so much fun and how it can be used for more than just checking out from reality. For those that don’t know what makes a game, there are 4 rules for game-making:

  1. It has to be fun
  2. There are rules
  3. There has to be feedback
  4. It has to be voluntary

And PokemonGO handles these splendidly. If you are able to suspend seriousness and simply play the game, you get the cute characters of Pokemon as if they are in your own world. And then you have to interact with them. There are rules and while you don’t necessarily know them as a newbie, you pick them up rather quickly because there is a lot of feedback as you fail. And voluntary? At over 50Mb to download, significant battery management, dedication of time to the task, and a VERY serious draw on device memory, you’re making a conscious decision to volunteer your time to the goal “gotta catch ’em all.”

How does it work?

Relying on Niantic’s successful incorporation of layering fantasy graphics on Google’s mapping technology, your movement within the real world is translated to the world of PokemonGO. With real world locations acting as stops, real world walking moving you toward Pokemon, and real world feedback as you navigate around obstacles to find these critters, the technology is immersive while being a bit of a “screen suck.” You swipe and click the screen throughout the game to engage different activities (preferably once you’ve stopped moving!) and try to level up through the game.

A word on design

Despite the fact that there are no real instructions on how to use the game, it is incredibly easy to use and intuit as to the next thing you need to do in the game. In the case that you get jammed up, you can always talk to a friend about what they have experienced. And that conversation results in extended conversations about what you’ve seen, done, and enjoyed; even sharing what your highs and lows have been.

Laying the fantasy world on top of the real world allows for the interaction between real and false worlds to transcend the experience of the individual. While it is not necessarily a new technology, it certainly hasn’t been used to this level across a population of people. Look no further than the people walking around parks to see how pervasive this game has become.

Security

Besides the clear security issues that one might expect with an app that logs one’s location, we’ve seen articles that highlight a number of, sometimes false, security concerns that may or not may reveal private details about someone. For example, Instagram’s geotagging feature might reveal that the user is nowhere near home; meanwhile, there have been users that have been vandalized by their Uber driver because they were recently driven to the airport.

While there is only one clear security issue derived by the PokemonGO app, other than the iOS opening that created access to Niantic for the complete control of the users’ Google account (which was quickly remedied within the first five days of operation) PokemonGO does not have the hallmarks of issues, inherent to the app, that many others have had. The one condition to this that I would offer is the use of Lures at Pokestops, which allow for control over the fantasy world for other players as well. This is intended to allow you to attract Pokemon and potentially meet other people, but as you can imagine, that might cause a problem if someone wanted to maliciously use that tech to lure users more than Pokemon. You can’t see other users. You can’t lure those users (unless it’s discovered that incense works beyond the user – which, as of yet, it hasn’t). And until you can hack the database, which, as far as I, know never happened with Niantic, the users are relatively safe.

Health hazard or opportunity

So what are the real opportunities or hazards for this app. Truth is that we’ll likely see more and more stories about the extreme situations like a robbing in O’Fallon, IL that used the technology to target individuals (disproved in this case but could have been a Lure) and a young woman finding a dead body near a stream near her home. But truth is that this has created an engaged population, regardless of age, that is regularly walking through areas that they don’t regularly. And is that bad? We live in a country that is SO LARGE that we don’t inhabit more than 90% of the mass, and yet we have SO many opportunities for exploration for a nation of explorers.

Maybe it is. There are maybe some places that we don’t go and that’s okay. But for the large majority of people playing this game, it seems that it runs through the normal course of daily activity, or just slightly more.

What can it potentially do?

Gamification

Without going too deep into what the values of using gamification are here (feel free to read more here), it is certainly becoming more commonplace to bring this theory into regular technology for deeper interaction with users. The reason that gamification can be such a powerful tool in the capture of behavior change is that it seemingly separates the activity’s goal from the activity’s work by creating an intervening level of excitement with the user. This is done by initiating what is known in psychology as Flow.

figure1

From Gamasutra.com, link below

Flow is the state where the skill meets the difficulty that the user is presented with in a maximally optimal position to engage.

Augmented Reality

One of the best arguments for, and against, augmented reality that I’ve seen is nicely packaged in the form of this short film:

While there are many opportunities that augmented reality potentially brings to the table with regard to the mundane (paying your tab at a restaurant, preparing food, even exercising like PokemonGO has been credited with) there are also potential dangers to these augmentations. With regard to PokemonGO in its current version there’s certainly no actual human interface except through the handheld device. While it can influence behavior by incenting the user to do one thing or another, it cannot override human decision making. Yet.

But let’s set aside the potential for danger for a moment to consider how immersive PokemonGO has become for its users and how another user interface might have a significantly decreased reliance on the “phone” to play the game might actually allow for it to become more of a background activity, rather than what one is actively doing. In PokemonGO, the user is staring at a screen trying to find where the leaves are moving and that’s partly because of the limited amount of time most devices can actively “play” the game. But if, say with a device like Google Glass, you could be hunting Pokemon all day long? What if, rather than having to seek out Pokemon in a thirty minute “hunt,” you were hunting all day? Tracking steps all day to incubate eggs? Regularly checking into PokeStops and learning about those locations?

There are certainly risks, and those need to be mitigated. But there’s definitely a lot more opportunity too.

Teams

When you are strong enough to actually do battle at a gym, you pick one of three teams to join. These have their own internal meanings to the game and once you’ve joined a team, you can rely on those other team members for support in controlling gyms and help with training your Pokemon.

One thing that is currently lacking in this first version of the game is the ability to bring in one’s pre-existing social network. Because you must log into the game with your Gmail account or a Pokemon.com account, the audience is potentially limited when it comes to mining the available social network data that might be available with, say, a Facebook login. Then you could invite your friends to join your team in the search for Pokemon. You could actually provide each other with tactical and strategic support in quests as well as provide emotional and physical support in reaching goals. Our social networks are significant in our health decisions, and forcing users into only having the option of the three team options in the game – which are highly contrived and not very useful on their own, so far as I can tell – there are additional opportunities for increasing the effectiveness of the platform for health behavior generation.

Socio-environmental disturbance

One thing that is for sure: there are a lot of people I’ve watched over the past few days playing this game. Will it last? I’m not sure. But watching two people who are running around a park together while staring at their phone certainly acts as a pattern interrupt for me. I’ve watched as someone stared at their phone and walked around corners, and down streets, trying to engage the PokemonGO world largely oblivious to their surroundings except for what is represented on the screen. And when you see someone doing that, it definitely has a similar impact to the way that we all responded when Bluetooth headsets and wireless earphones became popular for holding mobile phone calls in the public.

Yes, it’s a pattern interrupt. And yes, it was extremely annoying when phone calls made it out into the general public, seemingly creating dialogue that only existed in the speaker’s head. But that has become so normalized now, I can’t imagine there won’t be a possibility of a similar normalization of that activity. And once normal, adoption will likely go up, not down.

Why is this important?

BmsB9w6 - ImgurThese are not the Pokemon you seek

While the PokemonGO craze has blown away the expectations of the game-makers, and frankly any Ingress user is probably also doing the, “I was geocaching before it was cool” thing right now, this does start a discussion about how we can better leverage the technology that is already available to us to change our behaviors in small, although ultimately significant, ways.

Just the beginning…

…but an important one. Critical events like this are rare in helping to shape how we want our world to look. Each of us has the capacity to impact the way that we want to engage with our communities and our technology. What do you want your world to look like? Or, more precisely, what do you want which of your worlds to look like?

To our health,

Ryan Lucas
To stay ahead on topics related to this, follow me on Twitter @dz45tr

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Health inSite: Healthcare is not just about the people who work in HealthIT, it’s about everyone…

This posting was originally published by one of our associates on xchangehealth.wordpress.com

Special thanks to the many influences that have contributed, directly or indirectly, to my questions leading into this #HITsm chat: @leonardkish@ochotex @avantgame @gzicherm@connected_book @paullikeme @robertamines@kellymcgonigal @joepine @hankgreen

Intro

I’ll be moderating the #HITsm chat on August 28th at 10am MDT and wanted to put together a couple of thoughts related to the topic before going into the chat. Maybe you’ll find these useful. Also, feel free to join us if you are interested in the topic. The more the merrier! Toward that end, let’s have a discussion about what we, in #HealthIT can do to make sure that we’re meeting the needs of those who are our end-users.

Considerations should include #EHR & #App design from #Payer, #Provider, #Patient, and #Peer per this posting on #4PHealth.

It’s the convergence of all four P’s (Provider, Payer, Patient, and that Patient’s Peers) that will allow for greater healthcare reach. When the Payer and the Provider are able to engage the Patient’s Peers, then true health generation is possible and the benefits of one’s social network can then be fully leveraged.

People:Person Design

We have historically looked at healthcare (and by extension, #HealthIT) as though it exists outside the “natural” world, or as though health is outside the realm of our social experience. Yet, we know that health is not divergent from our health reality or our everyday lives.

Healthy behavior is not dependent on what payment models, medical technology, or other innovations come about in the healthcare debate.  We know that your friend’s friend has a great impact on what you do – and vice versa.

How do we reconverge these two realities knowing that what we do in our daily lives result in healthcare outcomes? Framed differently, how do we leverage the way we make decisions every day in considering how #HealthIT is designed?

Our health is not our own. We are bound to others, near and far, and by each decision and every sharing of those decisions, we birth our health.

#HITsm T1: Knowing that #health is dependent on daily life, how do we design #HealthIT in consideration of the larger, social world?

Cognitive Bias, Iterative Decision-making, Behavioral Economics, Game-Theory

Considering the depth of our knowledge related to cognitive bias, are we considerate of this branch of psychology in design? Knowing what we know about iterative decision-making (that decisions have to be made in sequence, often after new or different information) how do we prepare adaptive #HealthIT that responds to new information as it becomes available, like it does for Human Beings? For details on Cognitive Bias and Decision-making, see here and here. For Game Theory (including iterative decision-making), see here.  

So what does a salutogenic framework look like?  Mindfulness, resilience, focus on daily health-promoting activities that increase our ability to get healthier, rather than fend off illness.  Of course, a fee-for-service model doesn’t bode well with this concept, so unless you’re enrolled in a highly visionary health promotion healthcare system, you’re probably on your own – for now.  

Antonovsky’s explanation of Salutogenesis was well depicted by a river.  His concern with the current model of health (Pathogenesis) is that it’s generally believed that we are healthy from the beginning but that because of environmental / circumstantial events, we become sick.  Antonovsky expressed this as a river, where all healthy people stand on the bank, safe from the raging river’s flow.  Once one stepped into the river – got sick – then something needed to be done.  Salutogenesis, however, sees all people already in the river; but at different distances from the mouth.

There are some obvious benefits to these advances in Health IT, but one of the things that may not be fully clear yet is the application of Watson to understanding more about human behavior. While Watson can absolutely tell a clinician the likelihood of a set of symptoms’ association with a given disease, I’ll bet Watson can’t tell you how the patients’ family impacts their overall wellbeing through behavior reinforcement. If Watson knew who the patients’ workout buddy was, Watson might be able to help identify with a high confidence whether that workout buddy was a statistically-sound partner in the overall health management of the patient. Further, Watson would be able to weigh in on the evaluation of treatment adherence based on real-time data pouring into the health record for the given individual.  This is the game state evaluation of the health of the individual in a real and meaningful way.  With this, a total and complete understanding of the long-term treatment of chronic conditions (and even more important to the salutogenic framework that I’ve discussed previously in this blog series, total health production) through the understanding of actual human behavior devoid of the clinical separation from reality is the “social human” version of epigenetics that will become more useful in the coming years.  This is where the data comes to life.

#HITsm T2: How do we achieve #patientengagement over time considering that a one-off solution can’t fix #health?

Gamification

A recent post mentioned that Gamification is failing due to a lack of accurately applying the concepts of gamification; in short, supplanting “badges” for increasing levels of difficulty appropriately. If Gamification is going to solve the #engagement problem, why can’t we quite figure this out? Gamification in health, generally, see here.

Whether we admit it or not, it is the promise of the potential emotional pay-off that lures us into working ridiculous hours already. But unlike gaming environments where we are totally immersed, our modern work environments seem contorted — almost criminally — to keep us from feeling blissfully productive. And once we give up hope that epic wins are possible, our careers turn into drudgery.

It takes more than a website to do this – including focus on using the resources available to a company’s natural habitat, the worksite, to engage employees during the 40 hour work week, and more, by creating a story.  As described in the burgeoning world of Alternate Reality Games and Transmedia Storytelling, the ability to tell a cooperative narrative – on and offline – among those with which you work is an opportunity to actively create health, the benchmark of Salutogenesis.  When you have many platforms for engaging in this storytelling, you increase the modes of access to actively engage all employees where they are, rather than forcing them into a platform that they may not be comfortable with, or is not ideal for their way of engaging in their health generating behaviors.

 #HITsm T3: What game mechanics in #HealthIT are currently being used appropriately? Which are not?

Integration with the larger #healthIT world

Specifically looking at the #payer and #provider perspective, how can we ensure that the same #psych principles are being used to ensure adoption of #HealthIT throughout the Healthcare continuum? When we consider #wearables and #IoT, what do we focus on in terms of integration versus simple cataloging?

#HITsm T4: What should be made usable by #enterprise #healthIT to ensure the #Human element does not get lost?

Free-for-all on Design

#HITsm T5: What design considerations have you seen that work well in #HealthIT / #mHealth?

In review:

#HITsm T1: Knowing that #health is dependent on daily life, how do we design #HealthIT in consideration of the larger, social world?

#HITsm T2: How do we achieve #patientengagement over time considering that a one-off solution can’t fix #health?

#HITsm T3: What game mechanics in #HealthIT are currently being used appropriately? Which are not?

#HITsm T4: What should be made usable by #enterprise #healthIT to ensure the #Human element does not get lost?

#HITsm T5: What design considerations have you seen that work well in #HealthIT / #mHealth?

To our health,

Ryan Lucas
Manager, Engagement & Development

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Health inSite: Decisions and Privacy

Originally posted on xchangehealth:

There is a shift in healthcare related to our concept of privacy that is sorely needed – and it’s probably a little different than what you’ve heard from a lot of groups/people around the web.

We need to stop thinking about healthcare as a private thing.

As far as information about us, it’s simply no longer acceptable to consider our lives as private.  Not in a time where we actually understand our social network to such a degree that we can accurately and effectively map our connections in the social network (not like Facebook but friends, family, co-workers, neighbors, and the ‘guy at the gym’) and understand how we consciously and unconsciously make decisions about how we behave.  These behavioral changes manifest in health outcomes and as we move to a healthcare system (rather than a sickcare system) what you do is what you are – or more precisely what you are going to become.  Now, I’m not saying you shouldn’t be protected from abuse or discrimination or anything like that, but functionally, your decisions every single day are going to have an impact on more than just you; you owe some accountability to your social network (and they to you) as to what your decisions are doing every day, because Community is the Key to Health.

You may not know it yet, but what you decided to eat for lunch today (if you ate lunch today – and for some of you that might not even be the case) was decided long before you actually ate your lunch.  Here’s a non-exhaustive list of the ways in which this decision was made before you actually ate it:

Schedule: The structure of your day had an impact on what you ate for lunch.  Did you have a co-occurring meeting and therefore ate a “bagged lunch?” Did you have a meal prepared ahead of time – and if not did you have to throw a lunch together this morning before leaving, or did it force you to “forage” for a lunch?

Environment: Consider how the environment surrounding your lunch impacts your lunch decision. Did you run out for lunch because you needed some fresh air or a break from the office?  Do you have a place where you regularly eat lunch and therefore have a system for preparing for that meal each day – conversely, did that get interrupted for this particular lunch by environmental impacts like bad weather or the space itself was occupied in a way that prevented you from following that regular schedule?

Social Impact: For some, eating lunch is a social activity.  Do you have a regularly scheduled lunch partner? Was that true today?

Resources: Money and time as resources have an impact on the structure of lunch.  How do you use these resources in an intentional way related to your lunch habit? Do you spend money at a restaurant / court / vending machine each day or bring your lunch?  Do you have the resources of time and money to prepare ahead or use those resources to forgo preparing ahead?

And let me tell ya’, this isn’t even the beginning of the ways that this could be further expanded.  Think about all of the ways that a single meal is planned and replicate that process for each decision you make today.  Exercise, nutrition, social activities, occupational activities, mindfulness activities, financial decisions, personal intellectual development, etc. etc. etc.

Now think about this: why did you make those decisions?  Consciously or not, you may have made those decisions because of someone else.  Did your partner pack your lunch and therefore help to make the decision of what you’re eating – or was shopping not prepared in a way to pack that lunch in the preferred way?  How much of your diet is based on someone else’s decision?  Maybe your doctor suggested a change in your diet?  Maybe you or a family member has a dietary restriction that changes your diet on a daily basis.  In the case of a family member’s restriction, maybe your lunch is the time when that restriction doesn’t apply to your personal diet?

Lastly consider this: Can you push yourself to make a given decision either by limiting or adding options?  Can you change the options you have available at the point of decision-making with a little bit of foresight?  Try to find one example of a way that you can “pre-decide” by removing the alternative option.  Maybe one of the questions above can be flipped to help you make a “pre-decision” that will help you make a single, healthier decision this week – even if it’s only once.  You might find it’s pretty easy to do and may be a powerful way to change your behavior in a positive way.  And then consider the flip-side of this.  How can you help someone else through a “pre-decision” that helps someone in your social network make a decision that is healthier for them?

Here’s what I’m saying, and to slightly alter a quote from Cloud Atlas:

Our health is not our own. We are bound to others, near and far, and by each decision and every sharing of those decisions, we birth our health.

It’s time for us to stop thinking that we are fully separate members of society that don’t have an impact on others and start being accountable to one another for how the decisions we make impact others – and vice versa.  Yes, even in health.

To our health,

Ryan Lucas
Manager, Engagement & Development
Follow me on twitter: @dz45tr

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Health inSite: Believe your own data!

I was recently reviewing a video by the very impressive Kelly McGonigal (author of the Willpower Instinct – interview video here) as a part of, what appears to be, a new series called “Open Office Hours” and posted to the Stanford University Facebook account.  At 1:26 in the video, she explains that when you are confronted with a piece of research (specifically in this instance related to health) that it’s important to test it for yourself and then makes the statement “believe your own data.”

That is a very powerful statement to make!

Awareness of the opportunities to impact one’s own health and then the wherewithal to actually make a change also necessitates awareness as to the impact that that change is having on you.  And to do that, conveniently, we have  useful tools available to us to help begin tracking and reporting on that data ourselves…but how?

Enter #mHealth

One of the trends that has certainly begun to make its mark on the issue of monitoring and tracking this data is the mobile health (mHealth) industry.  From apps to the actual hardware itself – in the case of the iPhone 5s and its motion sensing capability, but even as early as the simple GPS function being used in running and biking apps – many people are starting to log and catalog this data for themselves.  The difficulty is that sharing this information is usually specific to a particular platform, creating a barrier to actually leveraging the social side of health behavior modification, which we know to be so important at creating success (read pretty much anything I’ve previously written in the Health inSite series).

An early leader

WebMD is leading the way with an in-app storefront for purchasing interoperable medical devices that already work with the 2net platform (Qualcomm’s health cloud services) and will make it easier to stay on top of health and health behavior.  Further, with the avado partnership and connection between Medscape and WebMD, the app should be able to handle end-to-end management of those health behaviors beginning with: identification of information related to a certain health metric or behavior; access to the acquisition of a relevant piece of equipment to “sense” the data related to the health factor; wirelessly transmitting and logging relevant data; and then through co-ownership between the patient and the provider, the ability to monitor that data and make adjustments.  Throw in a little bit of personal social network for those wanting to connect this with their existing support (or in the “friends’ friends make you fat” way, lack of support) to help create the conversation necessary to actually affect our health behavior and our health self-concept.

Dr. McGonigal is right

While it is exciting that we are starting to be able to monitor and track all this cool stuff about ourselves (some have been doing it for decades in larger and smaller ways even before the tech was available to integrate the monitoring with the data management), the important thing is that you have to test it for yourself.  We don’t all respond the same way to every intervention method, and some things work better for others that won’t even begin to help us.  But we cannot know how or what will work until we make the decision that we want to try and then start tracking that data and, most importantly, recognize that we need to believe in (trust) our own data to help us make the decisions that will have the greatest impact in whatever we want to improve while creating our optimally-performing self. This is the art of health based on the science of health.

To our health,

Ryan Lucas
Manager, Engagement & Development

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Health inSite: #4PHealth

Each week I take an hour to join with a few colleagues and thought-leaders around the world on twitter to discuss all kinds of interesting topics related to where healthcare is going, what to expect in the intersection between Health and Technology, and how we might play a role in that changing landscape. These TweetChats are an opportunity to learn, share, and ultimately understand how social media, technology, and the role of various players in the healthcare world might better work together. Often, we turn to the topic of patient engagement. This is focused on what tools, technology, and other needs might help to get patients more involved in their own health. This can come in the form of tracking various metrics (see the Quantified Self movement) to making sure that individuals on medication are staying on top of that treatment to ensure their continued health improvement. While in our last TweetChat, which emphasized Patient Engagement and Experience specifically.  We discussed that it was important for us to focus on what the patient could do, yes, but also what the provider and the payer could do. This is a common picture of the players in the healthcare world. Someone needs the service (patient), someone provides the service (provider), and someone pays for the service (payer). It looks sort of like this:

#P3Health

But that’s not really the whole picture, now is it? The truth is that this is the model of a sick-care system. As I’ve mentioned in blog postings beforehand, in order to keep people as healthy as possible before they need to access the healthcare system, the system must account for one more “P” in this proverbial puzzle (or pie, if you’d like!); one’s Peers:

#P4Health

It’s the convergence of all four P’s (Provider, Payer, Patient, and that Patient’s Peers) that will allow for greater healthcare reach. When the Payer and the Provider are able to engage the Patient’s Peers, then true health generation is possible and the benefits of one’s social network can then be fully leveraged.

With that, I submit a new hashtag for the consideration of a community that continually strives to make the very complicated healthcare system a little simpler as we move towards greater total health and wellbeing of the individuals that have to access this system. #4PHealth represents the four core stakeholders in healthcare that ultimately are responsible for the health of the patient and responsible for keeping that patient out of the hospital, involved and engaged in their total health and wellbeing, and always striving to improve one’s total health picture. When the Patient, Provider, Payer, and Peers come together, total wellbeing is possible.

This doesn’t have to be limited to the TwitterSphere, though. Take a moment and think about the real-world applications of this for you in your life. What can you be doing to help those in your peer group become healthier? What opportunities are there for you to help generate greater health for yourself and for your friends, family, and coworkers? What can you ask of your peers to help you with to create better health for yourself? The 4P model may not be the easiest thing for us to accomplish in our current healthcare system given the disjointed nature of care models, but you still have the ability to start working on the fourth “P” today. What will your first step be?

To our health,

Ryan Lucas
Supervisor, Marketing
(illustrations assembled myself!)

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Health inSite: Decision Support, Games, and making people healthier

I’m a bit of a trivia nerd. In fact, I play trivia with a group of friends every week. We do alright, and obviously there are good weeks (I mean, we keep going back) and then there are bad weeks. I play team captain for our group. The responsibilities of team captain are to record our progress (each question gets a wager based on our confidence in our answer) and recording the success or failure of each question in a running total, and helping to marshal the resources of the team (points, knowledge bases of the players, ranking answer likelihood, etc.). The final trivia question of the night is a challenge. Each team is given the question that requires four answers in rank order, usually. When turning in one’s response, a point value between 1 and 15 is assigned to the answer. If any part of the question is wrong, the wager is subtracted from the team’s total score. If the answer is 100% correct, the team gains the wagered points. So it’s no surprise that I would be really intrigued by Watson, a supercomputer that was able to best two of Jeopardy’s greatest champions in a tournament back in 2011. Research into Watson is really interesting.

Confidence

Watson was trained to respond only when a certain threshold had been met in the likelihood that Watson was correct in its assumptions. This confidence was determined based on cross-referencing the available answers and identifying the highest scored answer based on a number of algorithms. While Watson is not right 100% of the time, its significant domination of the final score ($77,147 vs. 2nd place’s $24,000) is no small feat for a computer responding to natural language, searching natural language information, and culling a response to an “open-domain” question.

Game State Evaluation

Part of the programming behind Watson required not just an understanding of the likelihood that Watson was right, but also what the potential for gain or loss in relation to the other players might be. Because Jeopardy includes wagering for daily doubles and Final Jeopardy, Watson had to strategically wager in relation to the likelihood not only that it was right, but also what it would mean if the other players were right or wrong. This is well-illustrated by the final wager that Watson placed in response to the final jeopardy question, which was $17,973. This is a statistically-determined wager based on total game state evaluation at the time of this final question using the above variables.

Thinking

While there is plenty of room for argument as to whether or not Watson is thinking, there is absolutely no question as to whether Watson is logical. As I’ve mentioned before in a couple of articles related to the work of Daniel Kahneman, (if you haven’t, make sure to check out Thinking Fast and Slow) human rationality is very rarely very rational. This is due to a number of intervening variables that interrupt our ability to make rational decisions all of the time. These “biases” can be intentionally or unintentionally applied during the decision-making process. While Watson has a number of heuristics, no-doubt, built into its logical processing, it is probably not as likely to respond to cognitive biases such as anchoring, duration neglect, and certainly curse-of-knowledge as seen in its commanding performance in the Jeopardy games.

Decision Support Systems

Watson is now being used in a number of healthcare applications assisting in the support of clinicians as diagnostic support. Watson is not making decisions, but it is able to cull the plethora of information available in the medical field to provide confidence-rated responses to data that is provided regarding a patient. This marks a big step for the advancement of Health IT as we can standardize clinical response to symptoms, and stabilize health information as it is consolidated into big data stores. And because Watson is able to learn as it answers and receives feedback as to success and failure based on those responses, Watson can only get better at diagnostic prediction and likelihood of treatment success or adherence based on the results of those treatments.

What does this mean for making people healthier?

There are some obvious benefits to these advances in Health IT, but one of the things that may not be fully clear yet is the application of Watson to understanding more about human behavior. While Watson can absolutely tell a clinician the likelihood of a set of symptoms’ association with a given disease, I’ll bet Watson can’t tell you how the patients’ family impacts their overall wellbeing through behavior reinforcement. If Watson knew who the patients’ workout buddy was, Watson might be able to help identify with a high confidence whether that workout buddy was a statistically-sound partner in the overall health management of the patient. Further, Watson would be able to weigh in on the evaluation of treatment adherence based on real-time data pouring into the health record for the given individual.  This is the game state evaluation of the health of the individual in a real and meaningful way.  With this, a total and complete understanding of the long-term treatment of chronic conditions (and even more important to the salutogenic framework that I’ve discussed previously in this blog series, total health production) through the understanding of actual human behavior devoid of the clinical separation from reality is the “social human” version of epigenetics that will become more useful in the coming years.  This is where the data comes to life.

To our health,
Ryan Lucas
Supervisor, Marketing
To stay ahead on topics related to this, follow me on Twitter @dz45tr

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Health inSite: Coding changes signal shift in healthcare thinking

I was recently on a call with a partner of ours discussing the changes in coding established by the AMA known as Current Procedural Terminology (CPT) codes as of January 1 of this year.  These are the codes that allow claims to be submitted quickly and easily without needing heavy-to-lift, unstructured data such as clinical notes.  A very common code for psychotherapy previous to this change was CPT code 90806 (Individual Psychotherapy, 45-50 minutes).  The new code that most closely matches is code 90834 (psychotherapy, 45 minutes with patient and/or family).  The reason we were on the call was to deal with an issue that had come up where one group was asking for additional details to help resolve that this code was not being used for family therapy (an expressly excluded benefit under that particular plan).  It was following this call that, wanting clarification and to confirm my suspicions, I began looking into why the coding had changed at all.  I don’t work in claims, and these topics very rarely touch me, so I haven’t stayed 100% on this issue.

So, as I began searching for reasons why the change occurred, I found a couple of interesting things.  The first was the American Psychiatric Association’s crosswalk of CPT codes which confirmed our thinking that the 90834 was intended to replace code 90806.  The second, and more interesting thing I found was a PowerPoint presentation developed by the AMA which explains the coding usage through examples (slides 29-34) and an explanation for the change (slides 18-20).  It’s stated that the reasons for the change are:

  1. The site is no longer relevant to the CPT code to be used.
  2. To match the time-bounding of the codes for other areas of the CPT dictionary.
  3. Psychotherapy may include face-to-face time with family members as long as the patient is present for part of the session.

Slides 29 and 32 provide very instructive examples of a much larger issue that these new codes hope to achieve going forward – they are systems-oriented.  This is a big step!  Effectively, the AMA has recognized that the treatment plan as well as the acuity of a given Behavioral Health issue may either stem from, or may be treated in some way by, the system in which the patient operates.  Now it may only be the family unit so far, but I wonder if this may signal a slight shift in the fee for service (FFS) model that may help erode the need for classifying treatment for the purpose of reimbursement; it may even signal the eventual demise of a FFS model altogether.  In any case, it at least begins to push the reimbursement model toward considering systems-based psychotherapy which relies on support systems like the family to achieve treatment adherence.

Further, inclusion of the family unit in the psychotherapy model is a slight tip of the hat to shared health responsibility.  It doesn’t necessarily follow that we’re moving to a true “your friend’s friends make you fat” approach to health, but by bringing the family into the individual treatment setting means sharing in the health of the patient; some responsibility is shared with that family member to report on successes and failures, and help guide that patient down the path to greater health.  If that relationship were reciprocal, and as we know to some level that might be the case given link influence, then this step into the 90834 might start to have greater effects than was originally anticipated.

To our health,

Ryan Lucas
Supervisor, Marketing

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Health inSite: Placebo, by any other name, is just as effective?

The Placebo App

A review of a year and a half of Health inSite research and how I think one group is probably more on target than some might think.

I’m going to start out by laying out a couple of concepts for review.

Placebos and psychology

A placebo is defined as “a simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient.”  This causes what is called the placebo effect.  A patient is said to have experienced a placebo effect when the intended deception manifests experienced results.  While the research indicates that there is a small range of people that are susceptible to the effect, that range hovers at around 30% of the population.

Rationality

One might ask, “How is it possible that the effects of a non-drug could be experienced as having the results of an actual drug that has the intended, or actual, impact on a patient?”  This is explained as the product of self-fulfilling prophesy, or a form of expectation bias.  If you recall the previous posting on Thinking Fast and Slow, one of the difficulties we face as human beings is both our difficulty in matching up experience and memory, as well as overcoming biases that tint our understanding of rational data.  In a word, we are not always rational beings and sometimes our understanding of an experience or idea is subject to our memory and cognitive constructs that allow us to think fast.  We respond the way that our mind has told our body it expected to experience the event.  The concept, “Where your mind goes, the energy goes,” has been mentioned extensively by my colleague Dr. Mines in his series on Psychology of Performance, beginning with his first posting.

Hysteria (or mass psychogenic illness)

If you happened to miss the events in Le Roy, NY, where 18 people experienced Tourette’s-like symptoms for an extended period of time, there were many that identified the cause of the experience of these individuals as mass psychogenic illness.  Mass psychogenic illness has been largely attributed to situations in which individuals are experiencing similar physical effects (tics, for example) without any clear physical reasons (e.g., environmental toxins, viral or biological triggers, etc.).  Historically, this has been referred to as mass hysteria.  The complexity of the condition has led many to write it off, but the core assumptions of mass psychogenic illness are sound given what we know about social influence.  Oftentimes in mass psychogenic illness, an index case is discovered in which someone’s conversion disorder acts as a catalyst to the development and spread of the illness through the network.

Assuming that this is the way in which mass psychogenic illness works, index cases could be used to induce behavior change in a network towards a positive outcome. In this way, it is not mass psychogenic illness, but mass psychogenic salutogenesis (widespread generation of health through the influence of the mind over the body within the social structure of a network).

CBT and treatment adherence

Critical to adherence to any health maintenance or treatment protocol plan is the ritualizing of new behavior.  In the chemical dependency field, we’ve known this for a long time.  By creating new routines that positively impact our behavior; we are able to more easily overcome the many triggers that previously caused our substance use.

Triggers are defined in the substance abuse field as events, emotions, or thoughts that trigger the addiction response.  They are a major focus in many treatment protocols and are especially important for recognition in the cognitive behavioral therapy (CBT) model.  The goal in CBT is to identify why it is that we respond to thoughts, emotions, and events and then to develop, for ourselves with the help of a therapist, ways to counter the effect of those triggers.  In this way, it’s not the abolition or avoidance of triggers so much as a rational understanding of the trigger and building tools to overcome that trigger’s effect on the coached patient/client.

Network theory, social comparison, and braggadocian behavior

If you’ve read all of the links to other blog postings in the Health inSite category, but missed the posting on braggadocian behavior, the concept is very simply that social media has enabled us to engage in bragging around the things that we are doing and that this activity can influence the way that others perceive us – and we do this to intentionally accomplish that change in perception.  This gives us the ability to influence the way that others behave as they engage in responses which may include trying to match our behavior (wittingly or unwittingly)  or rejection of our behavior as a method of coping with one’s own deficiency in the category of behavior being expressed.  This has a powerful impact on the social network in which agents operate as they can directly and indirectly influence the behaviors of individuals that are proximally or distally connected to them.

In their book ConnectedChristakis and Fowler explore the significant effects that our social network has on our health and health behaviors.  Social networks, of course, are not just websites like Facebook or Twitter, but all forms of interaction that we have with various people in our lives, including our family, friends, co-workers, neighbors, and even the people at the grocery store.  The power of individuals to have an effect across a network based on their location within the network is a clear and well-documented reality.

Suspension of disbelief

As I mentioned in an earlier blog posting on the fourth and fifth wall, suspension of disbelief is critical to the effectiveness of theater.  Without the audience allowing suspension of disbelief, a presentation falls flat in its ability to engage the audience emotionally.  Think back to a PowerPoint presentation that was particularly awful because the speaker failed to actively paint a picture that the audience could connect with.  Similarly, engagement strategies are starting to use these concepts to create thick tapestries of story that immerse the audience in the story-line, and even sometimes ask them to co-create the story, as in the case of the Lizzie Bennet Diaries spin-off series, Welcome to Sanditon.

New technology

Recently, an IndieGoGo campaign was started for a new project that would create a placebo app.  You might think to yourself, “How the heck could a placebo app affect someone’s health?”  The app, which leverages the power of mirror neuron activity and the placebo effect by creating positive thought-feelings in the brain, could actually override the systems in the brain that cause us to act irrationally in terms of triggers and cognitive biases by leveraging suspension of disbelief.  Further, the app allows individuals to interact with their social network around their use of the placebo app, creating a unique opportunity for mass psychogenic salutogenesis.  Now all we need are some index cases to start the process toward a tipping point.

It will be interesting to see the resulting data from this project as we would expect that there is a real opportunity for this to be leveraged to significant effect, not only for those directly accessing the placebo app, but also those that end up interacting with those users.  But the rest of the story is still to come.

Whew, that was quite a round-up of research, huh?  Comment or send questions!

For more…

…check out a G+ Hangout from HuffPost on placebos and their effect.

Ryan Lucas
Supervisor, Marketing
To stay ahead on topics related to this, follow me on Twitter @dz45tr

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Health inSite: Breaking the Fifth Wall

A refresher on Alternate Reality Games, Transmedia Storytelling, and Engagement

While I highlighted the opportunities with Alternate Reality Games and Transmedia Storytelling in my last post, I wanted to take a moment to share a recent production that I’ve been looking into that really highlights how this format works: The Lizzie Bennet Diaries. The Lizzie Bennet Diaries (LBD) is a modern retelling of Jane Austen’s Pride and Prejudice.  The characters in the story have their own online presence within various social media outlets and interact with one another through Twitter, Tumblr, YouTube, ThisIsMyJam, Websites, and more (various examples shown).  The characters share their stories with one another through these dynamic media and oftentimes interact with the audience as well.

While this has engaged a pretty significant audience (fandom), what is really incredible is the way in which the audience has begun to participate with one another.  A recent update to the story included new information that Lydia Bennet (Lizzie’s youngest sister in the updated version) has been caught up in a sex tape scandal (remember, this is not meant to be perfectly along the storyline that Jane Austen wrote, but one that resonates with the audience of this retelling).  There was a huge outcry from the audience expressing dismay at this turn of events.  So much so, that that there was discussion the fandom should look for a hacker who would be willing to hack the website on which the video’s seller was collecting interested buyers with a countdown clock.  This created an immediate problem for the producers/writers of the story.  If the site indeed had been taken down, the team would have to develop a way to get around the change in the storyline created by the audience, and at great expense.  In this way, the audience collaborated to solve the problem of the character, rather than maintain their understanding that this was simply part of the story for consumption.

Let’s start with the Fourth Wall

In theater, the Fourth Wall is the theoretical veil between the audience and the stage.  Breaking the Fourth Wall happens when the players on the stage actively communicate directly to the audience.  There are countless examples in which the magic of the story playing on any stage (screen applies here too) is broken in this way, but the practice is increasing with evermore prevalent new media projects.  In my last post, I described Transmedia Storytelling and Alternate Reality Games as a way of telling a story through multiple media streams and its ability to engage an audience in new and immersive ways.  But breaking the Fourth Wall can be used to engage the audience in participating in the story through these methods to expand the value of the experience that the audience has.  For more on the Fourth Wall, check out Wikipedia for a quick overview, or TV Tropes for all kinds of cool information about the idea and the way that the  this device may be used.

Now, to the Fifth Wall

There is another proposed wall which has been less well explored, and often debated as to its name: The Fifth Wall.  The operational definition that I like is the veil that separates members of the audience from one another.  For a long time, the audience has been the passive observer of entertainment with notable exceptions of breaking the Fourth Wall.  But, rarely does a media experience really ask for members of the audience to work with one another.  This concept of the Fifth Wall could have significant implications in the sharing of narrative within an Alternate Reality Game with a true Transmedia Story backbone.  Consider the opportunities of having participants in the audience that can help guide the story cooperatively; sharing goals, pushing one another toward success, battling challenges together.  If your friends’ friends impact your health in positive and negative ways (see previous posts about link influence here), what about engaging a first node relationship more directly to change the perception of the second or third node to ripple back through the network to you.  In this way, the network then begins to course with change and as you make changes that influence others, their responsive changes come back to you.  In this way, helping others get healthier helps you get healthier.

The Walls and their implications within LBD

The surprising situation that happened within the LBD is that while the narrative has been so clearly billed as a story, with many instances of the Fourth Wall being broken (the producers actually have entire blog postings dedicated to talking about the production process as it is occurring), it turns out that the Fifth Wall nearly took down the production.  The audience reverted to a sense of belief as they interacted with one another.  The characters, then, are part of the audience – and the audience part of the characters.  This creates a shared experience where the audience felt that they were responsible for helping solve the problem for the character.

Summary

The investment of the audience in their shared experience (this includes characters, as mentioned above) has huge implications for health programming.  Imagine a story with so much motivation and movement as LBD written to achieve Salutogenesis by creating a shared landscape around health behaviors.  If we know that education, knowledge, and external incentives are not motivations for behavior change, is this the next landscape to try?  We think it is.

To our health,

Ryan Lucas
Marketing

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