OWN YOUR BILLBOARD

What would you do if a truck pulled into your yard, a crew erected a billboard in front of your living room window, and ads were beamed at you at all hours?  Or what if you hired a plumber to fix a pipe and, while he was in your house, he took an inventory of your belongings and sold it to ad companies resulting in yet more nuisance calls to sell you stuff.  I bet you would tell them to get lost and never do business with them again. 

So why do you allow this to happen on your computing devices?  Your device screen is a billboard, controlled by others, to sell you stuff that they predict you will buy as derived from spying on your Internet clicks through their insertion of cookies into your operating system.  I guess you didn't “get the memo” that in exchange for free Internet content and apps you agreed to a constant barrage of ads and legions of spies infiltrating your computer.  What’s next, GPS tracking of our car journeys, cookies on our smart TVs, face recognition in stores?  Well, er, yes!  There appears to be no end in sight to advertisers’ intent and ability to get more information about you to sell you more stuff.  

There needs to be an advertising industry smackdown.  Clearly the industry will not restrain itself and government will not act. It's up to us to shut them down.   And we have the tools to do so.

According to Forbes magazine, online ad spending will exceed $135 billion in 2015.  This is in addition to the $150 billion spent on conventional ads.  It is clear that digital commerce companies like Google, Facebook, and even newspapers like the New York Times are really not in the business of search, social exchange or news.  They are advertising companies.  Google’s ad revenues in 2014 were $60 billion, accounting for 89% of company revenues.  Search, email, and maps and all the rest are just means to the end of extracting personal information from you to fine tune ad promotions to increase the clicking and purchase conversion rate.  Facebook is designed specifically for people to “share” their intimate details with friends…and with advertisers.  The New York Times allowed 26 trackers, such as Doubeclick, Optimizely, and google analytics, into my computer when I clicked on a news article.  How much money did they make by selling me off?  Maybe I forgot to read the fine print in the terms and conditions that they can auction me off at will.

Pervasive ads are distracting, suck up your computer’s cpu and batteries, and condone breaking and entering and theft of personal information.  Why can’t digital companies make money the old-fashioned way?   You know, by creating valuable products and services that people will pay for directly. 

Here’s what to do.  Get an ad blocker, such as AdBlock, to kill the ads. Your screen will be so much cleaner…and you will own your billboard!  Get a tracker buster such as Ghosterly to stop the cookies from infiltrating your computer when you click on content.  And get a browser tracking buster, such as Disconnect, to stop browsers from gathering data on your searches.   Check it out…these apps work well.  It is one big step you can take to preserve your privacy within this overbearing surveillance society we live in.  And, if enough of us to so, it will send a resounding message to advertisers to actually listen to customers and change the way they do digital business. 

Alien Intelligence Has Landed

The aliens are coming and they can help us.  With the information explosion, our human RAM is overloaded and bogged down.  We need an external drive and complementary, sophisticated software to make sense of it all and guide us toward a healthier future.  Indeed, researchers at the University of California at Berkeley have given birth to robots that can learn to screw the cap on a bottle, even figuring out the need to apply a subtle backward twist to find the thread before turning it the right way.  This may seem like a minor task but the underlying, pioneering technologies will migrate to worthwhile applications in health and healthcare.

In health care, the increasing volume of data produced from scientific reports, medical records, and personal information has far outstretched human capacities to digest and make sense of it and to act upon it.   Help is on the way in the form of artificial intelligence (AI). Artificial is a strange term for what it has to offer. It may be produced in a seemingly nonhuman way, but rather than being artificial, it is quite genuine, albeit different in some ways. In fact, its greatest contribution may be what Kevin Kelly from Wired Magazine calls “alien” intelligence.

The promise of AI has been touted for decades. Twenty years ago, I was part of a team at GTE Labs that developed an AI system that analyzed health insurance claims data and provided an automated analysis of “multiple dimensions to determine the most interesting deviations of specific quantitative measures relative to norms and previous values...and generated simple recommendations for correcting detected problems.” Our reason for developing the system was that each time I wanted a report on health claims data, I paid a consulting firm tens of thousands of dollars. It seemed that this could be automated through good logic and code for routine analysis and reporting. It did a nice job and reduced consultant expenses.

Flash forward to realize that there is reason to believe that the long “AI winter” is nearly over and its capabilities are stronger and much more relevant. Eric Topol, in his new book, The Patient Will See You Now: The Future of Medicine is in Your Hands, states that “Computers will replace physicians for many diagnostic tasks.” Similarly, Alan Greene, chief medical officer of Scanadu, a start-up that is building a diagnostic device based on AI, says “At the rate AI technology is improving, a kid born today will rarely need to see a doctor to get a diagnosis by the time they are an adult.”   And Michael Ford, in his new book, Rise of the Robots:  Technology and the Threat of a Jobless Future, predicts that many high skilled jobs will be taken over by AI robots.  For example, he says that radiology will be a job performed by machines as computers are rapidly getting better at analyzing images.

The fact is that prominent technology companies like Google and Facebook have gone way beyond their standard search function to embed it with AI for intelligent search.  And according to Kelly, AI has attracted more than $17 billion in investments since 2009 and the “business plans of the next 10,000 startups are easy to forecast: Take X and add AI.”  The reasons for the breakthrough in AI are mostly due to converging advances in computing, including cheap parallel computation for immense computing power, big data fueling natural language engines making AI smarter, and better algorithms for deep learning.

On the one hand, AI will automate routine tasks better than the ubiquitous smart chips in everything from vacuum cleaners to dishwashers. In health care, this will include mining information stored in the EHR to provide real-time clinical support or mining the literature and the experiences of many providers and patients to recommend potential treatment options to physicians, as is being pioneered with applications from Modernizing Medicine. IBM has demonstrated the capabilities of AI for machines to outwit humans as with Deep Blue for winning chess or Watson for winning Jeopardy!  Ford also suggests that wearable medical devices are already monitoring “just about any kind of biometric data that can be collected in an I.C.U.”  McNeill, in his book Using Person-Centered Health Analytics to Live Longer, asserts that AI can offer significant functionality to finally engage people with personal digital health devices.

On the other hand, AI’s most useful feature may be decidedly unhuman. It will not just automate and accelerate what our brains usually do. It will think differently. This is partly because artificial intelligence learns from all the data and the decisions it makes. It will add wisdom because it will look at the world differently and offer new perspectives, thereby becoming irresistible and keeping us interested in learning more about how we do important things in our life, like living a long and healthy life.

I’ll Have a SOPrDiMoCa

SOPrDiMoCa is not a popular travel destination in Italy, nor is it a seasonal coffee from Starbucks. It is an acronym for Self- Oriented Prevention, Diagnosis, Monitoring, and Care.

SOPrDiMoCa tools help people assess their own risk factors; sort out symptoms and learn what to do next; monitor a wide variety of signs, symptoms, and life events; and adjust their own care. All of these tasks can be done effectively and safely in real time and in one’s own home, and they can save time and cost less than going to a doctor’s office. According to Christensen, Grossman, and Hwang in their book, The Innovator’s Prescription:  A Disruptive Solution for Health Care, “Following the diagnosis and treatment by physicians, in many instances physicians can’t add much additional value beyond teaching patients broad categories of do’s and don’ts. Patients and their families typically must distill from their own experience algorithms of diet and activity that minimize the severity of their symptoms. Patients with these behavior–intensive diseases can generally formulate better algorithms of care through trial and error than their physicians can.”

The trend away from professionalism and centralization and toward simplicity, convenience, and a consumer-focused market is, according to Christensen et al, a natural progression during the “second and third waves of growth” of all industries.  For example, people are questioning why some of the things done in doctors’ offices have to be done there. Alternatively, they go to box stores like Walmart and health stores like CVS Health to receive “retail” clinic care for common ailments. In most cases, it is equivalent, quicker, more convenient, and cheaper. And while they are in these stores, they see a growing list of high-quality products that they can use to test and take care of themselves in aisle 7, SOPrDiMoCa.

The availability of home testing tools is expanding quickly. For example, OPTUM, a subsidiary of UnitedHealthcare, provides an At-Home Kit for members for biometrics. “This easy, self-administered test offers remote employees, spouses and new hires a private way to ‘self-screen, leveraging step-by-step instructions and a screening kit delivered directly to their doorstep.”  The Public Health Foundation of India deploys an android-based mobile system called the Swasthya Slate, which can perform 33 tests, including blood pressure, glucose, hemoglobin, and ECG. It can also test for pregnancy, dengue, and malaria. It retails for Rs 25,000 (or about $400) and has been tested and approved for use by community health workers.  A proponent says, “When we get sick, we won’t need to go—in high temperature and in severe pain—to our doctors’ offices, only to wait in line with patients who have other diseases that we may catch. Our doctors will come to us over the Internet.”  SimulConsult is a diagnostic tool that ingests the complete body of research literature for certain disorders.  The tool prompts doctors to enter information about the patient’s condition. It then generates hypotheses with associated probabilities about what the patient may have.  With a little more translation and technology to make it simpler, it could become a tool for people to use.

People have already adopted a more self-reliant role in other aspects of their lives. They use data and tools, make their own decisions, and prefer to “do-it-yourself” instead of relying on professionals to do their finances (e.g., online banking, electronic tax preparation and filing), travel (e.g., navigating directions, using online travel services), education (e.g., online coursework and degrees), shopping (e.g., buying online), and more. In these areas, technological advances have equipped and enabled people to take on these functions and have “changed cultural expectations regarding what people can learn, know, and do.”  The notion that people will not use data and tools to take a more active and decisive role in their lives has been debunked.

From Slick and Click...to Tick and Stick

Despite the tens of thousands health apps, it is clear that digital health developers are not winning over consumers.   A killer app has not swept the market. Even the commanding iPhone 6 and IOS8 and the Apple Watch may not carry HealthKit in its bountiful wake to ignite consumers’ interest in a digital health revolution.

Thus far, digital health technology for consumers has been slick and focused on making people click.  It is premised on the belief that the great successes with functions and apps delivered through smartphones can spill over into health. But, what people like to do on smartphones is mostly entertainment and social communications: Technology developers:

• Miscalculate that the technology, such as the-data-platform, is a “big deal” and will interest consumers as much as it does techie developers.
• Presume that the click mentality for revenue production derived from advertising and will work in health.
• Perpetuate uni-focused apps, like hailing an Uber cab, buying a product on Amazon, or making an airline reservation, will also work in health. 

These conventions are constraining and not an easy transplant for the health market. Apps perpetuate the characterization of people as extremely distractible, only capable of handling one simple function at a time, and not willing to pay for digital services while accepting the hidden costs of marketing intrusion.

When it comes to changing people’s behavior, technology has to understand what makes people tick and how to make them stick. The big draw of activity sensors seems to be that it lets people know when they reach 10,000 steps with its beeps and this insight can be shared with friends and family.  But, is this simple model really enough to hook people on a sustained program of activity for health? I think not.  Technology can offer so much more. 

Your Health Plan Will See You Now

My father is 92 years old and lives in a very nice retirement community.  He received a call from his health insurance plan, Tufts Medicare Advantage, inviting him to have a free in-home doctor visit.  He was told that the doctor would do a complete evaluation and make recommendations to improve his care.  He was a bit puzzled and flattered.  He remembered having a doctor visit many decades ago and was nostalgic about doing so again.  He was urged to accept the invitation quickly as “doctors are in the area now” and “this is a limited time offer.”  The doctor spent an hour with him and told him he was in great health but should consider taking testosterone for his fatigue.

All of this seemed rather suspicious to me.  I called Tufts and they referred me to CenseoHealth, a firm that contracts with Tufts to provide doctor visits.  I got the same script about doctors in the neighborhood, how it would improve his care, and act now.  I asked if the information gathered would be used for any other purpose but to improve his care and was assured that it would not.  I asked my father to request a copy of the report.  He has not received it.

 

After some research, I now understand that the purpose of the visit was to gather information on his “risk score” that could lead to the insurer getting much higher payments from Medicare.  According to a recent investigation by the Center for Public Integrity, Medicare made nearly $70 billion in “improper” payments to Medicare Advantage plans from 2008 through 2013, mostly due to over-billings based on inflated risk scores.  But, my personal concern is not that health plans are gaming the system to increase revenues.  After all, they have been the target of gaming for a long time from providers “upcoding” billing records to get better payments.   It just seems to be part of the culture of health insurance.

My concern is about trust.  My father did not derive any benefit from the visit.  He was deceived about the purpose.  The purpose was to extract information from him so that Tufts could increase their revenues while pretending to do the doctor-thing to improve his health.  He was preyed upon as an elderly person.  This type of deception has no place in health care and especially not from the #1 health plan in the US, as Tufts promotes itself. 

Health insurers need to work on trust.  Let’s face it, it took an act of Congress to force them not to discriminate against the sick by denying coverage for pre-existing conditions.  Health plans come in dead last among major industries when it comes to customer engagement according to Forrester Research.  And a recent Gallop poll found that only 26% of Americans place a lot of trust in health insurance companies to keep their personal information secure. 

Indeed, the use and abuse of personal data is at the cutting edge of gauging the trust factor of companies today.  Health insurers harbor a vast amount of data about us.  They know our diagnoses and medications.  In addition, many buy personal data on what we buy, who we voted for, and where we travel and use it to drive algorithms about whether we are worthy of health management programs, deserve good customer service, and offer a high lifetime value as members worth keeping on.  For example, one company that services health insurers, Predilytics, touts that its use of advanced analytics results in “more accurate identification of risk adjustment opportunities” and that these “high opportunity members generated 25% more coding value than prior models.”

I want my father to live a long and healthy life.  That should be job #1 for those he pays to look after his health.   Decisions about his health should respect his point of view and his privacy and abide by the saying “nothing about me, without me”.  Tufts says on its website, “We strive every day to be a health plan you can brag about to your friends and family.  Do you have ideas on how we may improve your experience?”  Here’s an idea:  Use all the data you have collected on my father to identify ways to make him healthier.  Coordinate with him and his health care providers to make sure it happens.  And, use your precious information resources wisely to make a difference in people’s lives rather than to scrounge for more revenues.  

Protecting the Wealth of Your Health

How much is your life worth?  Of course, it is priceless.  But economists actually monetize it at more than $70 thousand per year of life.  At birth, we are given the gift of life which, for a person born in 2012, amounts to 79 years and a lifetime value of $5.5 million.  For 99.9% of us, it is the most important asset we will ever have. 

Unfortunately, the American way of producing a long and healthy life is failing.  Abundant research indicates that the U.S. ranks 28th out of 34 OECD countries in producing a long life as measured by years of life lost due to premature mortality.  When compared to countries with the lowest premature mortality rates, Americans lose 36 million years of life every year.  The years of life lost have a value of $2.6 trillion which is nearly equivalent to annual health care expenditures of $2.8 trillion.  The fact is that producing a long and healthy life and capitalizing on our lifetime worth is not on any organization’s mission statement but our own.

The health care system is focused on sickness, not health; on services, not outcomes; on medicine, not on prevention or social determinants of health.  Public health program budgets have been slashed and programs tend to focus on the emergent, e.g. one ebola death in the U.S, but not on the important, e.g. over a million deaths attributed to lifestyle behaviors.  Government attempts to improve health through social programs are beaten down with socialist rhetoric and contempt for redistributing wealth.  And, food, alcohol, tobacco and marketing companies seduce us with tasty but very harmful foods, play to our hopes through advertising, and keep us coming back for more by getting us addicted.

It’s up to us.  Research shows that our own behaviors are far more consequential in determining our healthy longevity than the actions taken by others on our behalf.  Indeed five behaviors of everyday life account for almost two-thirds of the loss of healthy years of life.  These behaviors include eating poorly, smoking tobacco, drinking alcohol, exercising too little, and not taking medications.   

Doctors, governments and a burgeoning self-help industry exhort people to change these behaviors and have achieved a modest degree of success, but there is still a yawning gap as evidenced by the numbers above.   The missing piece is that people have not invested in their health asset for a variety of very understandable reasons.

But, this is changing.  People are breaking free of the medical paternalism that breeds dependence.  More information has been liberated for their use and technologies make it more accessible and sharable.  With the large increase in out-of-pocket financial exposure due to the new generation of health insurance plans with astonishingly high deductibles, people are more vigilant about the value of health care.  And people want convenience, eschew encumbrances, and believe in themselves to do many of the tasks previously owned by professionals in many aspects of their lives. 

They are also being equipped to be more self-reliant.  People are going to box stores like Walmart and health stores like CVS Health to receive “retail” clinic care for common ailments.   It is equivalent, quicker, more convenient, and cheaper.  And while in these stores they see an expanding display of high quality products they can use to take care of themselves.  I call these products SOPrDiMoCa, an acronym that stands for Self-Oriented Prevention, Diagnosis, Monitoring, and Care.  These tools include self-administered diagnostic tests previously controlled by doctors and labs, self-monitoring devices and coaching software to control glucose and blood pressure, smartphone apps and sensors to maintain healthy behaviors, and more.

Technology can play a strong role in bringing about this person-centered health movement by perfecting better analytics designed for people.  The business model has to change, however, from making us click to generate advertising revenues to understanding what makes us tick in order to make behavior change stick.  For example, it can produce wise information to know the individual better than she knows herself thereby providing fresh insights. It can develop “digital hugs” in order to engage the individual emotionally because that is so important for change.  And it can provide ongoing, smart coaching to help people master barriers and achieve goals. 

Investing in our health asset is fundamental to a long and healthy life.  Herophilos, a Greek physician from 335 B.C. said, “When health is absent, wisdom cannot reveal itself, art cannot manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied.”  The surest way to reap the benefits from our birth asset is to stay healthy and manage the five behaviors of everyday life.  Increasingly, people are grabbing the baton, others are welcoming them as true partners in health, and powerful tools are emerging to equip them to be successful.  

Using Person Centered Analytics to Live Longer:  Leveraging Engagement, Behavior Change and Technology for a Healthier Life

By Dwight McNeill, PhD, MPH

Using Person Centered Analytics to Live Longer is about empowering and equipping people to take a more active role in mastering five behaviors of everyday life that cause and perpetuate most chronic illnesses. 

It is three books in one.  It provides:

-A framework for understanding why person-centered health analytics is important by describing five convergent realities:  The American way of producing health is failing, people are the drivers for improving health, converging trends demand a person-centered orientation, everyday behavior changes are the interventions that matter, and analytics provides new insights to catalyze it. 

-A toolkit for people that includes information, tools, and a quick reference guides to links that people can use on their own. 

-An opportunities guidebook for stakeholders to understand person-centered health from the person’s perspective, describes how analytics can contribute, and what actions they can take to support it. 

It is different from other books.  It goes beyond a call for action and provides tools and resources.

It describes a new generation of analytics for health.   It diverges from the usual health care analytics that focus on business intelligence for the two Ps (providers and payers) by zeroing in on the health needs of the forgotten P, people.  It is not about worshiping the art of the possible of information technology; it’s about putting analytics to work to engage people to achieve their health destiny.

The defining elements of person-centered health analytics (pchA) are:     

pc:  The focus on the person in terms of what really matters (healthy years of life) and the means to achieve it (personal behavior change). 

      h:  The focus on health that covers the continuum from wellness to sickness and places a priority on well-being and prevention. 

      A:  The focus on capturing and integrating a wide variety of health data and using connected devices, advanced computing, and social networks. 

It is published by FT Press with a release date of April 2015.  For more information on the author, Dwight McNeill, please see his author page.