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Your reporter from this conference is Donna Cusano
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Thurs 22 October: Morning
Apologies for the delay in posting this. Unlike yesterday when I could retreat to my room and write, the need to check out from the hotel room and end of day running for the Acela back to NYC meant writing on the train (no WiFi on Acela – why?) and (finally) at home. Drink your morning coffee and read on….it may have been like drinking from a fire hose, but it was worth every drop…DC
The first morning keynote extended the ‘Overhauling Healthcare’ theme with a ‘disruptive’ and I believe significant presentation by Jason Hwang, MD, Executive Director of the Innosight Institute. How Disruptive Innovation Will Change Healthcare was researched for and drawn from his book, The Innovator’s Prescription, co-authored with Clayton Christensen and Jerome Grossman, MD. Disruptive innovations are breakthroughs in technology that, in their adoption, upset existing business models and force decentralization of distribution or usage. Examples: computer mainframe to mini-computer to PC (PC and now smart phones being the disrupters), the transistor, and online e-commerce in travel purchasing (on the last, from personal experience, being in the wrong side of disruption is a painful place to be). Dr. Huang’s point was that it is often futile to cram new technologies into old business models. The current centralized medical center is the old business model and rapidly becoming non-viable, much like Digital Computer.
What is driving decentralization in healthcare? Technologies that enhance the ability of technicians and non-physician clinicians to perform procedures, move care into the home and provide information directly to individuals and social networks. The former medical center becomes a ‘solution shop’ – the home of highly specialized expertise for diagnosis, even with the physicians themselves becoming more generalists. The ‘value added’ process (procedures following diagnosis) and follow up care will include more technicians and nurses doing routine, skilled procedures, with physicians taking a smaller role. Consumer information? Facilitated networks will distribute information through provider and patient communities. It’s all still evolving, no one is there yet, and the new ‘value network’ needed to gain traction is still undefined. At the end of this presentation I did understand one thing; if you wake up some mornings wondering what you’ve gotten yourself into, be reassured that you have lots of company.
Take all this disruption in our semi-free markets, empower the consumer and he or she will make rational decisions for their personal health, right? Peter Ubel, MD says, “I don’t think so”. His keynote presentation, Irrational Decisions and the Limits of Free Market Medicine (drawn from his book Free Market Madness, www.peterubel.com), examined how we as individuals and even medical professionals may make our decisions quite irrationally. Negative factors are our perception of risk, how the information is presented, perception of consequences and emotions. To him free markets have their limits, freedom and well-being are to be balanced. How? Ubel suggested negative incentives (e.g. taxes) on unhealthy behaviors (high fat or calorie food) and to subsidize healthy food and behaviors (fitness centers). We returned to this topic later in Drilling Down.
These were wrapped up with a panel moderated by Robert Hanscom, JD of CRICO/Risk Management Foundation; panelists were John Glaser, PhD, John Halamka, MD of CareGroup Health System, Peter Neupert of Microsoft and Jim Tosone of Pfizer Healthcare Informatics. The bulk of the discussion was on disruptive innovation, with Dr. Glaser focusing on the complexity of issues that result, such as accountability of both institutions and patients, plus the adoption rate of PHRs, but that second and third order effects are not predictable at this point. A differing view was held by Mr. Tosone, stating that disease management models were proving to be very difficult in terms of scale and business model. Decision support systems (DSS) were a ‘hot button’: Dr. Halamka projected that DSS would help patients make decisions and Dr. Glaser predicting that some high-value aspects of care would be pushed to trained clinicians (non-physicians) with DSS as a guide, but he was also sanguine on DSS’ limitations (e.g. not radiology). Neupert’s dash of realism was on what it will take to get to personalized medicine– the great investment in IT and support needed, he could not see happening right now.
On Ubel’s topic, it was a rational discussion on how much irrationalism there was out there and setting limits. Dr. Halamka believed that a clear set of probabilities would help patients make rational decisions; Dr. Glaser advocated DSS to set the boundaries in clinical decisions; and Mr. Tosone proposed a book sequel called “Mandated Madness” detailing the irrational decisions made by legislators and policy makers.
After a short break, we returned to man’s irrationality with Drilling Down on Mad Markets; Gentle Nudges and Behavioral Economics. Michael Barrett, JD of Critical Mass Consulting presented behavioral economics 101 [i.e. the basics] and typical biases such as conformity effect, loss aversion, anchoring and adjustment. The meaning for healthcare lies in pivoting BE for ‘prescription’ and creating ‘choice architects’ who bend the architecture of choice to produce a result, creating a small downside if you choose the other way. In public affairs, other terms used are ‘libertarian paternalism’ and the ‘nudge state’ which arrange the choices in a way to leverage them for the ‘common good’ (Cass Sunstein, 2008 CHS speaker and author of Nudge, now a policy czar in the current administration). For instance, you can limit cafeteria food consumption by not providing trays; encourage more people to use the stairs rather than elevators for extra exercise; unfortunately for fitness, many internal stairs are unsecured, thus unsafe (walk stairs with pepper spray in hand, I assume). (Comment–It all sounds rather benign, but the political process ‘nudges’ morph into ‘mandates’ all too easily.) Robert Schwarzberg, MD of Sensei described that everyone’s daily life has a conflict in values vs. health, and not to be given a choice is often a problem; also be careful in what you wish for, as you can create stigmas (e.g. overweight children singled out in school weigh-ins). Further illustrating the Law of Unintended Consequences was Laurie Orlov: ending gym in grammar schools for additional instructional time has been one more contributor to childhood obesity; living to an older age has meant more need for universal design and assistive technologies.
Thurs 22 October: Afternoon and Final
The final full breakout I attended was also with Laurie Orlov (aka Agent 99) here very firmly in her space – Get (Your House) Smart: Aging in Place, at Home, Aided by Technology. Joined by Charles Hillman of GrandCare Systems, Joe Coughlin, PhD of MIT AgeLab, Tom Ryden of North End Technologies and moderated by Marc Holland of System Research Services, this panel had much to say in their 50 minutes and could have easily filled an additional engaging 15.
This area is where much real-world tech is happening, but adoption has a long way to go.
The ‘smart house’ for Dr. Coughlin is the nexus of innovation, hardware, software and health information. It is not about devices but lifestyle and services, not about making up for health ‘loss’ but ‘gain’. The current business model is now oriented to what Medicare will reimburse (not much) and nothing is right in terms of the technology. Right now it is all about a home for those who are obviously old and frail – the paradox is that if you design a home for them, no one will buy it, including the old and frail.
Mr. Hillman approached the smart house as (Gregory) House – we’ve become masters of acute care, but not very good at assisting independent living and aging ‘responsibly’. Systems should be designed holistically and include 1) physiologic sensing (vital signs), 2) activity monitoring, 3) social connectedness and 4) home controls that light rooms at night, turn on outside lights, etc. The service he developed, GrandCare, has incorporated all four.
The smart home in Ms. Orlov’s view uses technology to more tightly connect the senior to others and to be safe, through communications and engagement, home safety and security, health and wellness and continuous learning and participation in social networks. Older people ARE interested in technology – broadband is being adopted by them in increasing numbers. But it has to be acceptable to the senior and can’t be imposed by family.
Mr. Ryden added robotics to the smart home, especially the development of small robots that can aid in everyday activities (versus the Japanese model of robopets for socialization).
Mr. Hillman pointed out that ADL (activities of daily living) monitoring is growing; currently it is largely a private pay service as LTC insurance and Medicare do not pay for it at present. LTC insurance should be paying for monitoring and other smart home assistive services, as they do for home care.
Homes, especially in this tired market, need something extra to sell and older homes need to upgrade; as Mr. Ryden put it, the ideal for technology would be ‘available at Best Buy’ and reimbursable. But the potential disrupters – home builders and remodelers–seem to avoid the older market except for ‘senior communities.’ Ms. Orlov described attempting to work with builders in her state, Florida, to create a ‘smart home’ demo incorporating universal design and technology in one of those plentiful unsold homes, and amazingly has not succeeded as of yet. (Keep trying, Laurie!)
NORCs – naturally occurring retirement communities – often need upgrading. And alternatives such as ‘intentional communities’ must be explored for the rising single population, especially those in the suburbs and exurbs. If they would realize it, the real disrupters and the new model may be via home builders, retailers and (Dr. Coughlin) utility companies. (In the US utilities are increasing selling ‘value added’ in products and services.)
Current technology is NOT fun, interactive or particularly desired to consumers. If it were, it could be a lot more appealing and useful. So where are the game designers? In fact, as Ms. Orlov pointed out, the terminology – aging – is terrifying; large companies are avoiding it in their messaging and we don’t have good terminology to replace it. Her final note: ‘patients’ are really people, and we should be referring to them that way.
A tip of the hat to Laurie Orlov’s Aging In Place Technology blog and her POV on the Symposium
The last word…
The final general session launched the Journal of Participatory Medicine (online at as of 3:30pm 22 October) and its editorial staff: Jessie Gruman, PhD (co-editor), Gilles Frydman, Alan Greene, MD (deputy editor), Dan Hoch, MD, PhD and Charles W. Smith, MD (co-editor). In their words, “Participatory medicine is a cooperative model of health care that encourages, supports and expects active involvement by all parties (clinicians, patients, caregivers, administrators, payers and communities) in the prevention, management and treatment of disease and disability and the promotion of health.” The journal is open peer review, and articles can be sourced from the medical community, consumers, caregivers, employers, administrators etc. It is one more example of convergence, and appropriately was the last business of this excellent Symposium.
Donna Cusano
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