Monthly Archives: November 2013

entrepreneurship, healthcare, rapid learning health systems

Is a Health Coach Better Than an Overworked Doctor?

Going back to first principles to examine what really matters in a therapeutic relationship and discovering its the relationship. That a health coach previously working at Dunkin’ Donuts might be more effective than a Harvard trained doctor might be difficult to compute, but makes complete sense.

Iora Health seem to be limit testing this idea.

 

Is a Health Coach Better Than an Overworked Doctor?

Iora Health CEO Rushika Fernandopulle at the WIRED Data | Life Conference in New York City. Photo: Christopher Farber.
Suzanne Koven was walking in the rain when she slipped, fell and fractured her right shoulder. It took surgery and months of physical therapy to heal. 

“The recovery was miserable,” she said. But it came with a silver lining.

Koven is a primary care doctor at Massachusetts General Hospital, and the hospital insisted that for her first three weeks back she had to take twice as long to do her job. Suddenly, she had the luxury to actually spend time with her patients, to talk with them about what was wrong and how she could help.

“It was the happiest time in my career,” she said. “It completely transformed the nature of the interaction [with patients].”

That wouldn’t last. When her three weeks were up, Koven had to rejoin a system that rewards quantity over quality. She was back to seeing 20 patients a day.

But just a mile away from her office, at Iora Health’s main offices in Cambridge, Rushika Fernandopulle was busy brewing just the kind of medicine that inspired Koven to go into primary care more than 20 years earlier — a practice that, at its core, is about building relationships. At Iora Health’s clinics, teams of doctors, nurses and health coaches work together to take care of patients holistically, bundling together mental health services, peer support groups and nutrition counseling with more traditional primary care services like physical exams.

This model builds on a team-based approach to medicine known as patient-centered care, itself part of a larger movement to cut costs and improve health by upping the quality of primary care. The idea behind it is if people’s baseline health is better, the system will have to spend less money paying for expensive emergency procedures later.

What’s key to our model is to build a team around the patient — Rushika Fernandopulle

 

Large healthcare outfits, university systems and Silicon Valley upstarts have tried this approach with varying results before. But Iora wants to take this concept a step further by actively going after the most expensive, high-risk patients, spending more time and resources on each one, and investing in building in-house data analytics and IT tools. Along the way, the company is killing the standard model, in which doctors are paid for each service they provide, and redefining what a health provider is.

“What’s key to our model is to build a team around the patient” in a data-centric way, said Fernandopulle at the WIRED Data|Life conference in New York City yesterday. They take data from hospitals, pharmacy benefits companies and patients to monitor how patients are doing and to identify what patients to treat in the first place.

So far, he says, this approach has met impressive results. The company has been able to reduce emergency room visits by 48 percent and hospitalizations by 41 percent, resulting in an overall 15 percent reduction in healthcare costs in pilot studies at its four practices in New Hampshire, Nevada, New York and Massachusetts. Plus, the physicians in his clinics tend to be happier.

It’s the type of effect that Koven noticed during her three-week stint working at half her normal pace. She doesn’t have hard data to back this up, but she noticed that it took her patients roughly 15 minutes to start confiding in her. During a normal 15 minute visit, the patient would never get to that point. More open communication, she says, also made her less likely to order unnecessary expensive tests and medications.

At Iora, that’s standard partly because of the way the payment system works.

A provider pays a lump sum of money, usually between $150 and $200 a month, for each patient instead of forking over money per service. Then it’s up to the team to decide how to best treat the communities they serve. The system only works if the clinic keeps patients healthy. It behooves Iora to figure out exactly what’s wrong and tailor treatment to its patient population.

Sometimes that means cutting back on medications or the number of specialists patients see. It can also involve phone calls, text messages, video conferencing through Skype, or group sessions like Diabetes Clubs during which patients socialize and teach themselves how to best manage their disease.

To do this in a data-driven way, the team surveys patients for feedback and uses that information to tweak how care is delivered. It actively collects blood pressure, blood sugar and prescription refilling data to make sure patients are sticking to their health plan. If they don’t refill a prescription, for example, the system creates a task for a health coach to follow up with the patient.

Fernandopulle recounted the story of “Mr. Edwin,” a patient with end-stage renal disease and anxiety. His panic attacks sometimes prevented him from getting the dialysis that was keeping him alive, which resulted in 17 emergency room visits and $280,000 in healthcare costs.

His health coach asked him what calmed him down and he said listening to music. She used Iora’s discretionary budget to buy him a $45 iPod onto which the health coach loaded merengue music, Mr. Edwin’s favorite. Mr. Edwin took his merengue music with him to dialysis, and, Fernandopulle says, that quelled his anxiety and prevented expensive ER visits. This would have never happened in a traditional healthcare setting, he said.

Because that hinges on having a good rapport with patients, the company puts a premium on social skills. A background in health isn’t even necessary to get hired as a health coach. For example, before joining the company, some of Iora’s best health coaches worked as cashiers at Target and Dunkin’ Donuts, possibly the last place a traditional healthcare system would look for talent.

“It’s one of the most innovative models out there. What they’re doing is trying to start to think outside the traditional confines of who can provide care,” said Ashish Jha, a professor of health policy at the Harvard School of Public Health. “You don’t need to go to medical school to be a great health coach, to connect with people and motivate them. Those skills exist much more broadly.”

But, he says, that’s not an approach the healthcare establishment is necessarily ready to adopt in its entirety. The concept of building practices around team-oriented care might be scalable, but a strong leader is critical to make this model successful. “It would take a very special, very large healthcare provider to tolerate this approach. The idea that you’re going to get a health coach from Dunkin’ Donuts just seems hard to tolerate.”

Then, there’s the question of whether small companies like Iora can really make a dent in the country’s $2.7 trillion healthcare bill. There are hundreds of experiments and pilots around the country trying to redefine primary care, and it’s still unclear what will work, says Kevin Tabb, the CEO of Beth Israel Deaconess Medical Center in Boston. ”It’s not clear that a small company has the resources to really develop sophisticated systems on their own. Google couldn’t pull it off.”

I don’t think of talking with patients and getting to know more about them as some warm and fluffy add-on. It’s what medicine is — Suzanne Koven

 

Still, Tabb says, if one or several of these works out, it could still have a big impact.

And it wouldn’t have to be as scalable as you might think. “Five percent of the sickest patients are responsible for more than 50 percent of the healthcare spend,” Tabb said. “It may be that we only need to provide intensive care to a small percentage of the population.” What Tabb means by “intensive care” is not the intensive care unit of a hospital, but the type of personalized, regular care experimental primary care practices like Iora provide.

What all this says to Koven is that healthcare is very much a service industry. And what sets a good service apart is the ability to listen to customers well and to make them feel like what they say matters. That builds trust.

“Primary care — or my idealized version of primary care — actually allows for much more of that storytelling,” Koven said. “I don’t think of talking with patients and getting to know more about them as some warm and fluffy add-on. To me, it’s what medicine is.”

And that’s the type of medicine Iora Health is trying to kickstart.

Source: http://www.wired.com/wiredscience/2013/11/wired-data-life-iora-health/#!

entrepreneurship, meaning, policy, politics

Bill Gates: Here’s My Plan to Improve Our World — And How You Can Help

From: http://www.wired.com/business/2013/11/bill-gates-wired-essay/all/

Bill Gates: Here’s My Plan to Improve Our World —
And How You Can Help

  • BY BILL GATES
  • 11.12.13
  • 6:30 AM

I am a little obsessed with fertilizer. I mean I’m fascinated with its role, not with using it. I go to meetings where it’s a serious topic of conversation. I read books about its benefits and the problems with overusing it. It’s the kind of topic I have to remind myself not to talk about too much at cocktail parties, since most people don’t find it as interesting as I do.

But like anyone with a mild obsession, I think mine is entirely justified. Two out of every five people on Earth today owe their lives to the higher crop outputs that fertilizer has made possible. It helped fuel the Green Revolution, an explosion of agricultural productivity that lifted hundreds of millions of people around the world out of poverty.

These days I get to spend a lot of time trying to advance innovation that improves people’s lives in the same way that fertilizer did. Let me reiterate this: A full 40 percent of Earth’s population is alive today because, in 1909, a German chemist named Fritz Haber figured out how to make synthetic ammonia. Another example: Polio cases are down more than 99 percent in the past 25 years, not because the disease is going away on its own but because Albert Sabin and Jonas Salk invented polio vaccines and the world rolled out a massive effort to deliver them.

Thanks to inventions like these, life has steadily gotten better. It can be easy to conclude otherwise—as I write this essay, more than 100,000 people have died in a civil war in Syria, and big problems like climate change are bearing down on us with no simple solution in sight. But if you take the long view, by almost any measure of progress we are living in history’s greatest era. Wars are becoming less frequent. Life expectancy has more than doubled in the past century. More children than ever are going to primary school. The world is better than it has ever been.

But it is still not as good as we wish. If we want to accelerate progress, we need to actively pursue the same kind of breakthroughs achieved by Haber, Sabin, and Salk. It’s a simple fact: Innovation makes the world better—and more innovation equals faster progress. That belief drives the work my wife, Melinda, and I are doing through our foundation.

WE WENT ON A SAFARI TO SEE WILD ANIMALS BUT ENDED UP GETTING OUR FIRST SUSTAINED LOOK AT EXTREME POVERTY. WE WERE SHOCKED.

Of course, not all innovation is the same. We want to give our wealth back to society in a way that has the most impact, and so we look for opportunities to invest for the largest returns. That means tackling the world’s biggest problems and funding the most likely solutions. That’s an even greater challenge than it sounds. I don’t have a magic formula for prioritizing the world’s problems. You could make a good case for poverty, disease, hunger, war, poor education, bad governance, political instability, weak trade, or mistreatment of women. Melinda and I have focused on poverty and disease globally, and on education in the US. We picked those issues by starting with an idea we learned from our parents: Everyone’s life has equal value. If you begin with that premise, you quickly see where the world acts as though some lives aren’t worth as much as others. That’s where you can make the greatest difference, where every dollar you spend is liable to have the greatest impact.

I have known since my early thirties that I was going to give my wealth back to society. The success of Microsoft provided me with an enormous fortune, and I felt responsible for using it in a thoughtful way. I had read a lot about how governments underinvest in basic scientific research. I thought, that’s a big mistake. If we don’t give scientists the room to deepen our fundamental understanding of the world, we won’t provide a basis for the next generation of innovations. I figured, therefore, that I could help the most by creating an institute where the best minds would come to do research.

There’s no single lightbulb moment when I changed my mind about that, but I tend to trace it back to a trip Melinda and I took to Africa in 1993. We went on a safari to see wild animals but ended up getting our first sustained look at extreme poverty. I remember peering out a car window at a long line of women walking down the road with big jerricans of water on their heads. How far away do these women live? we wondered. Who’s watching their children while they’re away?

That was the beginning of our education in the problems of the world’s poorest people. In 1996 my father sent us a New York Times article about the million children who were dying every year from rotavirus, a disease that doesn’t kill kids in rich countries. A friend gave me a copy of a World Development Report from the World Bank that spelled out in detail the problems with childhood diseases.

Melinda and I were shocked that more wasn’t being done. Although rich-world governments were quietly giving aid, few foundations were doing much. Corporations weren’t working on vaccines or drugs for diseases that affected primarily the poor. Newspapers didn’t write a lot about these children’s deaths.

This realization led me to rethink some of my assumptions about how the world improves. I am a devout fan of capitalism. It is the best system ever devised for making self-interest serve the wider interest. This system is responsible for many of the great advances that have improved the lives of billions—from airplanes to air-conditioning to computers.

But capitalism alone can’t address the needs of the very poor. This means market-driven innovation can actually widen the gap between rich and poor. I saw firsthand just how wide that gap was when I visited a slum in Durban, South Africa, in 2009. Seeing the open-pit latrine there was a humbling reminder of just how much I take modern plumbing for granted. Meanwhile, 2.5 billion people worldwide don’t have access to proper sanitation, a problem that contributes to the deaths of 1.5 million children a year.

Governments don’t do enough to drive innovation either. Although aid from the rich world saves a lot of lives, governments habitually underinvest in research and development, especially for the poor. For one thing, they’re averse to risk, given the eagerness of political opponents to exploit failures, so they have a hard time giving money to a bunch of innovators with the knowledge that many of them will fail.

By the late 1990s, I had dropped the idea of starting an institute for basic research. Instead I began seeking out other areas where business and government underinvest. Together Melinda and I found a few areas that cried out for philanthropy—in particular for what I have called catalytic philanthropy.

I have been sharing my idea of catalytic philanthropy for a while now. It works a lot like the private markets: You invest for big returns. But there’s a big difference. In philanthropy, the investor doesn’t need to get any of the benefit. We take a double-pronged approach: (1) Narrow the gap so that advances for the rich world reach the poor world faster, and (2) turn more of the world’s IQ toward devising solutions to problems that only people in the poor world face. Of course, this comes with its own challenges. You’re working in a global economy worth tens of trillions of dollars, so any philanthropic effort is relatively small. If you want to have a big impact, you need a leverage point—a way to put in a dollar of funding or an hour of effort and benefit society by a hundred or a thousand times as much.

One way you can find that leverage point is to look for a problem that markets and governments aren’t paying much attention to. That’s what Melinda and I did when we saw how little notice global health got in the mid-1990s. Children were dying of measles for lack of a vaccine that cost less than 25 cents, which meant there was a big opportunity to save a lot of lives relatively cheaply. The same was true of malaria. When we made our first big grant for malaria research, it nearly doubled the amount of money spent on the disease worldwide—not because our grant was so big, but because malaria research was so underfunded.

But you don’t necessarily need to find a problem that’s been missed. You can also discover a strategy that has been overlooked. Take our foundation’s work in education. Government spends huge sums on schools. The state of California alone budgets roughly $68 billion annually for K-12, more than 100 times what our foundation spends in the entire United States. How could we have an impact on an area where the government spends so much?

We looked for a new approach. To me one of the great tragedies of our education system is that teachers get so little help identifying and learning from those who are most effective. As we talked with instructors about what they needed, it became clear that a smart application of technology could make a big difference. Teachers should be able to watch videos of the best educators in action. And if they want, they should be able to record themselves in the classroom and then review the video with a coach. This was an approach that others had missed. So now we’re working with teachers and several school districts around the country to set up systems that give teachers the feedback and support they deserve.

The goal in much of what we do is to provide seed funding for various ideas. Some will fail. We fill a function that government cannot—making a lot of risky bets with the expectation that at least a few of them will succeed. At that point, governments and other backers can help scale up the successful ones, a much more comfortable role for them.

We work to draw in not just governments but also businesses, because that’s where most innovation comes from. I’ve heard some people describe the economy of the future as “post-corporatist and post-capitalist”—one in which large corporations crumble and all innovation happens from the bottom up. What nonsense. People who say things like that never have a convincing explanation for who will make drugs or low-cost carbon-free energy. Catalytic philanthropy doesn’t replace businesses. It helps more of their innovations benefit the poor.

Look at what happened to agriculture in the 20th century. For decades, scientists worked to develop hardier crops. But those advances mostly benefited the rich world, leaving the poor behind. Then in the middle of the century, the Rockefeller and Ford foundations stepped in. They funded Norman Borlaug’s research on new strains of high-yielding wheat, which sparked the Green Revolution. (As Borlaug said, fertilizer was the fuel that powered the forward thrust of the Green Revolution, but these new crops were the catalysts that sparked it.) No private company had any interest in funding Borlaug. There was no profit in it. But today all the people who have escaped poverty represent a huge market opportunity—and now companies are flocking to serve them.

Or take a more recent example: the advent of Big Data. It’s indisputable that the availability of massive amounts of information will revolutionize US health care, manufac­turing, retail, and more. But it can also benefit the poorest 2 billion. Right now researchers are using satellite images to study soil health and help poor farmers plan their harvests more efficiently. We need a lot more of this kind of innovation. Otherwise, Big Data will be a big wasted opportunity to reduce inequity.

People often ask me, “What can I do? How can I help?”

Rich-world governments need to maintain or even increase foreign aid, which has saved millions of lives and helped many more people lift themselves out of poverty. It helps when policymakers hear from voters, especially in tough economic times, when they’re looking for ways to cut budgets. I hope people let their representatives know that aid works and that they care about saving lives. Bono’s group ONE.org is a great channel for getting your voice heard.

Companies—especially those in the technology sector—can dedicate a percentage of their top innovators’ time to issues that could help people who’ve been left out of the global economy or deprived of opportunity here in the US. If you write great code or are an expert in genomics or know how to develop new seeds, I’d encourage you to learn more about the problems of the poorest and see how you can help.

At heart I’m an optimist. Technology is helping us overcome our biggest challenges. Just as important, it’s also bringing the world closer together. Today we can sit at our desks and see people thousands of miles away in real time. I think this helps explain the growing interest young people today have in global health and poverty. It’s getting harder and harder for those of us in the rich world to ignore poverty and suffering, even if it’s happening half a planet away.

Technology is unlocking the innate compassion we have for our fellow human beings. In the end, that combination—the advances of science together with our emerging global conscience—may be the most powerful tool we have for improving the world.

healthy habits

Social app puts bad habits to good use

Interesting, generalised, socially-mediated swear jar… another interesting addition to the habit-breaking arsenal…

Social app puts bad habits to good use

Social Rehub collects money every time users swear, or commit any other bad habit decided by their friends.

 

Bad habits are not only detrimental to the people that are chained to them, but can also be annoying for others. Acting as a digital swear jar, a new app from Romania — Social Rehub — collects money every time users blaspheme, or commit any other bad habit decided by their friends.
Multiple users can set up their own group of friends or colleagues who participate in the tip jar. Each individual can then be assigned a bad habit their friends get annoyed by — whether it’s swearing, smoking, biting fingernails or being late. Every time a friend catches a user transgressing, their tally goes up and they must pay the amount set by the group. The app also enables friends to snap a photo of the incident as proof. The collected money can then either be used to fund group nights out or sent to charity.
healthy habits, words

oleaginous

Simon Chapman (Medical Observer, 5 November, 2013):

“Big Tobacco is not investing in e-cigarettes to wean itself off cigarette sales,” he says.

“Its recent oleaginous rhetoric about them saving lives is utter duplicity. As with other forms of smokeless tobacco, Big Tobacco wants smokers to use e-cigarettes as well as cigarettes, not instead of them.

“Urged on by myopic health professionals who seem to have lost any population health focus they might have had, this may become one of the biggest blunders of modern public health.”

oleaginous
adjective
  1. 1.
    rich in, covered with, or producing oil; oily.
    “fabrics would quickly become filthy in this oleaginous kingdom”
  2. 2.
    exaggeratedly and distastefully complimentary; obsequious.
    “candidates made oleaginous speeches praising government policies”
cool, data saving lives, meaning, musings, quotes & aphorisms

“The best minds of my generation are thinking about how to make people click ads… That sucks.” Jeff Hammerbacher

“After a couple years at Facebook, Jeff Hammerbacher grew restless. He figured that much of the groundbreaking computer science had been done. Something else gnawed at him. Hammerbacher looked around Silicon Valley at companies like his own, Google (GOOG), and Twitter, and saw his peers wasting their talents. “The best minds of my generation are thinking about how to make people click ads,” he says. “That sucks.” (…)

“Any generation of smart people will be drawn to where the money is, and right now it’s the ad generation,” says Steve Perlman, a Silicon Valley entrepreneur who once sold WebTV to Microsoft for $425 million and is now running OnLive, an online video game service. ” (…)

Hammerbacher: “If instead of pointing their incredible infrastructure at making people click on ads,” he likes to ask, “they pointed it at great unsolved problems in science, how would the world be different today?”

— Jeff Hammerbacher, founder and the Chief Scientist of Cloudera, one of Facebook’s first 100 employees, cited in Ashlee Vance, This Tech Bubble Is Different, Bloomberg BusinessWeek, April 14, 2011