Three Health App Lessons from the James Bond Movie "Spectre" - Shaking and Stirring Health Care

The Population Health Blog took time out of its busy schedule to check out the latest James Bond movie. While posting anything that refers to a months-old movie is inconsistent with standards of modern social media, Spectre has some important lessons. 

 

The PHB begs its readers' forgiveness as it is filters out the improbable car chases, dubious gadgetry and staged fisticuffs and examines the underlying health app technology insights. 

 

Without revealing too much of the plot, Mr. Bond continues to recklessly expose himself and others to STDs while battling a global conspiracy that is led by a cryptic master criminal.  The bad guys want to exploit the weaknesses that come with combining the intelligence data of the world's democracies. 

 

And what are three cinematic health app teaching moments?

 

Health Information Technology vs. People is a Classic False Choice: In Spectre, British Intelligence seems ready to invest in a global big-data initiative and jettison the "Double O" programme; Whitehall apparently fails to realize combining both would be greater than either alone.  Think Deep Blue "versus" Kasparov, or Dr. Watson "versus" Dr. House. Yet, Bond prevails precisely because Ms. Moneypenny is his 24-7 data muse.  Smart health app designers understand that the best apps are the ones that synergistically enhance, not replace, what doctors and patients bring to their care planning.

 

For example: Asynchronous two-way HIPAA-compliant communication that allows consumer concerns to be mutually addressed in partnership with a nurse-provider before the emergency room becomes the best option.

 

Health Information Technology Needs Good People: No Bond movie is complete without legions of pistol-wielding bad guys who can't hit the side of data warehouse, which is why Bond prevails. Think putting an Acela locomotive on decades-old train tracks under AMTRAK's ossified management. The health technology insight here is that any health app that perpetuates health workers' can't-shoot-straight business-as-usual will enable incremental, not transformative change.

 

For example: During a recent health plan launch involving the medSolis app, the PHB had the pleasure of working with expert professionals who knew the purpose of the program (er, programme) initiative was to enable informed patient decision-making.  In response, we also began to alter long-standing health plan policy and procedure.  

 

All Things Equals No Outcomes: Other than pooling the intelligence data, none of spy-administrators seem to be able to articulate the purpose of their joint data initiative. While cleverly branded and all-purpose apps strive to "be" the intended outcome, truly successful health apps will be those that can be purposed for a defined population and prospectively aimed at a limited set of clinical, financial and patient-centered outcomes.

 

For example: Once the generic coding/architecture is set, a winning app's content, channel and outcomes can be tailored for, say, a precisely defined group of high risk persons with diabetes.  And, to borrow from the concept of "parallel processing," the app should also be able to be altered to simultaneously serve a parallel population that is prone to rehospitalization (outcome: reduce avoidable readmits), or who would benefit from weight loss (outcome: reduce BMI).

 

Conclusion: Health concerns aside, perhaps nothing signals Bond's adaptability better than his willingness to forego his long-standing "shaken, not stirred" workflow in favor of quaffing a "dirty" martini with the sultry Dr. Madeleine Swann.  Even the Bond franchise is not immune from the adage that "change happens."

 

The same should be true for traditional health care as it continues to import an emerging ecosystem of health apps.  Delivery systems, hospitals, clinics, ACOs and networks that understand that will win.

 

And "Cheers!" to that, Dr. Swann.

 

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The Latest Health Wonk Review is Up!

The latest Health Wonk Review is available at the Workers Comp Insider.  This one is a holiday-laced compendium of health policy musings on everything from Obamacare to sleep deprived trainees.

 

Enjoy!

The Latest Health Wonk Review is Up!

Contrary to simplistic nostrums of the advocates for or the detractors against Obamacare, the truth is that health reform continues to be a messy tangle of science, policy and economics.  If you like things simple, continue to bask in the echo-chambers in mainstream and social media, and keep your browser away from this link.

Peggy Salvatore of the Health System Ed blog is hosting the Health Wonk Review.

The Limits of Financial Incentives for Docs

"It is written: Man shall not live by bread alone."
Luke 4:4

No matter what you think of the source of that quote, the idea that there may be limits to "aligning incentives" has some merit. In healthcare settings, physicians seem to be  supportive of being fairly compensated for their work, but also seem to be quite skeptical about the use of "carrot and stick" style economic rewards to influence clinical practice.

Case in point is this interesting paper describing the results of a randomized clinical trial that used blood cholesterol-level control to assess the relative merits of a) rewarding just the patients vs. b) rewarding just the doctors vs. c) rewarding both patients and doctors vs. d) usual practice, or a control group.

The study took place in three marquee institutions, involving 340 primary care physicians who were already taking care of 1503 adult patients with 1) elevated cholesterol levels who 2) either had coronary artery disease or were at high risk for coronary artery disease.

About half of the patients were already on cholesterol-lowering pills.

The purpose of the study was to determine if real money could be used to increase the rate and level of prescribing a statin drug aimed at achieving levels of cholesterol control that were consistent with national guidelines.

The 358 patients in the first group (a above) were cared for by 58 physicians; these patients rewarded by participation in a daily lottery system that gave $10 or $100 if the right number was hit and a wireless-enabled pill bottle indicated that it had been opened.

The 64 docs in the second group (b above) caring for 433 patients with no incentives were rewarded with $256 for each patient per quarter who successfully lowered their cholesterol to target levels. 

In the third group (c above) 346 patients got $5 or $50 if they hit the lottery, while their 58 physicians got $512 per patient at target.

A fourth comparison group of patients and physicians served as the control group with no economic incentives.

All patients received their statin drugs in a radio-enabled pill bottle that signaled each time the container was opened.. This allowed researchers to track medical usage.

The results?

12 months later, compared to the control group, the only patients that lowered their cholesterol in a statistically significant manner were the ones in the third "shared incentives" group.  What's more, while the drop was greater than would expected through chance alone, the absolute change was relatively small and wouldn't be expected to result in a big change in the likelihood of a future heart attack.  Last but not least, while the shared incentives group opened their pill bottles more frequently, the average level of medication compliance for all groups was less than 50%.

The authors correctly point out that the usual care control group of patients (N=366) being cared for by their control physicians (N=58) were exposed to the wireless-enabled pill bottles and that the lowering of their cholesterol levels made the three intervention groups look bad by comparison. 

The Population Health Blog's take? 

While notions of "pay for performance," "value, not volume," and "skin in the game" are attractive notions to policymakers and health leaders, their top-down impact at the one-on-one doctor-patient level defies linear economic logic. The PHB suspects that the physicians caring for these patients had already talked to their patients about starting or increasing the cholesterol medicines and that that quality care had already occurred independent of any fancy monetary incentives.  In other words, they were already doing their best. 

On an unrelated note, simply monitoring medication compliance with the radio-controlled pill bottle seemed to have an outsized impact on the study.  The PHB wonders if that can't be used to help patients who are already trying to do their best.

This study should give pause to anyone who thinks that physicians can be manipulated with more money.  They live by more than bread alone.

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