The Challenge with Compliance

With 50% of consumers not taking medication as prescribed, medication compliance is a big problem

Pharmaceutical companies, pharmacies and healthcare systems are looking for solutions to improve compliance to therapies.  Meanwhile, healthcare consumers are looking to better understand their conditions, track aspects of their health and become informed partners in their care.   

With healthcare consumers connecting with their pharmacist more often than their family doctor, doesn't it makes sense to build solutions between pharmacists and patients to improve medication compliance?

Pharmaceutical companies are seeking solutions by partnering with the start-up world and providing investments for digital health solutions.   Most recently Leo Pharmaceuticals announced a $65M project for digital health innovations, joining the ranks of Pfizer, Bayer and J&J (and others) who are reaching out to the start-up community. 

Community pharmacy has also invested in innovative partnerships.  Pharmacy giants such as CVS and Walgreen’s are leading the way in providing digital solutions to help their prescription customers manage their medications.   In a recent interview CVS Chief Digital Officer, Brian Tilzer articulated the company’s vision to create a “connected” health experience that makes it radically easier for people to save time and money.  CVS is looking to play a major part in helping its pharmacy patients better manage their chronic conditions, by arming them with everything they need to manage their medications.

But compliance is not just a patient problem.

In the rush to create solutions, it's important for digital health companies to be mindful of regulatory compliance.  The resource intensity and time spent on ensuring compliance should be seen as both an investment and a critical success factor to finding sustainable digital health solutions.

The opportunities for improving health are exciting but, as Fast Company’s Christina Farr recently wrote, “the "move fast, break things" mentality that is fundamental to the success of consumer-tech companies doesn't fly in health care”.  

Digital Health: Patients at the Centre, Patience to Market

No one can say that we were not told.  In fact, the prediction was announced in the New York Times over a year ago.  Larry Page predicted that if we data mined health data we would probably save 100,000 lives in a year.  It appears that mental health patients will be first in line to test the theory of using data mining to save lives. 

Last week Google announced that it hired Tom Insel, long seated Director of the National Institute of Mental Health.   When asked about what his role will be with Google, Mr. Insel confessed he does not know but is excited for the opportunity to work with Google.   “Mental health is something they’ve (Google) decided will be their next area of focus in the life sciences – they’ve already done exciting work in cancer, heart disease and diabetes. As I said before, I think this technology will have an enormous impact on people with mental illness.”

Forbes Magazine  recently announced that the first digital pill, Proteus, will begin FDA review. “Proteus Digital Health reported on September 9 that the FDA will be reviewing its unique “chip within a pill” device for the depression and schizophrenia medication, Abilify, to hopefully gain approval as the world’s first digital medication.”  Renowned Bioethics scholar Arthur Caplan describes the ethical challenges this week in an editorial Would You Take a Digital Pill?  “Once you swallow the pill, a message can be sent back to whoever is registered to get it — doctor, pharmacist, nurse, probation officer or all of the above. If you aren't taking your psychiatric medicine pill the way you are supposed to, it's possible a whole lot of people will know.” 

While these announcements are distinct it isn’t difficult to see the overlap.  Google turns its incredible data mining power towards mental health, hiring one of the leading Mental Health authorities to, well we don’t know what he is going to do yet but I bet it will be high profile.  In the same week a widely prescribed medication for mental health patients with a digital sensor goes to the FDA for review. 

Saving 100,000 lives is an honourable goal and I applaud the efforts.  But there’s no doubt that it may come at a loss of privacy and patients need to be at the centre of the discussion as we move forward.  We have come a long way from the injustices imposed on individuals like Henrietta Lacks and vulnerable populations of orphans, slaves and homeless persons all in the name of health research.   Health QR is dedicated to never losing sight of their sacrifices as we work to empower health care consumers with access to their personal health information.  Let’s all enter the realm of digital healthcare cautiously.  

A Star System for Hospitals – Helping Patients Make Informed Decisions

Warning!  

Accessing health care may cause the following: 

• Death - Medical mistakes are the fifth leading cause of death in the US
• Harm - As many as 25% of all patients are harmed by medical mistakes
• Injury - 3-17% of patients will experience an injury as a result of their care
• Unnecessary Procedures - Approximately one quarter of all medications and medical procedures may not be necessary
• Unnecessary Risk - Many patients who are candidates for minimally invasive surgery are never told of their options and instead have more extensive surgery with greater risks

According to two highly regarded health care experts in the United States, we should all be better informed advocates for our health care.  In fact, an empowered patient is seen by both learned professionals as a key driver to improving quality and avoiding being one of the statistics above.

Wouldn't it be great if we could research the quality of our hospital before we go in for elective surgery, in the same way we check out a hotel or restaurant before we go there.  What about a ‘star-system’ for hospitals?  Secret shoppers/patients?  Anonymous critics?

In his book, Unaccountable, Marty Makary, MD chronicles what hospitals won’t tell you and how transparency can revolutionize health care.  He shares a great deal of frightening anecdotal evidence from his years as a resident and is a vocal advocate for ‘sunlight being the best disinfectant’.  

Dr. Makary makes a compelling argument for hospitals publishing a range of quality indicators including:

• Bouncebacks (readmissions to hospital)
• Complication rates (e.g. what is the post-surgical infection rate)
• Never events (e.g. having surgical equipment left inside of you or operations done on the wrong part of your body – should NEVER happen)
• Safety culture scores (% of hospital staff who would want to have surgery at the hospital they work at – yes there are surveys out there that capture that) and;
• Hospital volumes (how many surgeries does the hospital do in a year – practice makes perfect). 

Dr. Makary promotes ‘open notes’ as one solution to the quality crisis in health care.   “Being able to review your doctor’s notes in writing might be even better, particularly if you could add your own comments, perhaps via the web.  Transparency plus collaboration puts patient and doctor literally on the same page so people no longer have to wonder what their doctor is thinking or whether it radically diverges from what they understood.”

Donald Berwick played the role of critic in his book, Promising Care How We Can Rescue Health Care by Improving It.  Donald is past president and CEO of the Institute for Healthcare Improvement (IHI) and is a well-recognized expert on healthcare quality internationally (currently running for Governor of Massachusetts).  In his recent book in the chapter ‘My Right Knee’, he tells the story of his own experience with the healthcare system when he required knee surgery.  If you only read one chapter of this book, read that one (although the entire book is excellent).

Donald puts into print what all of us would like when we are faced with surgery, an agreement with the surgeon on what he/she will/will not do.  This was what Donald (international expert on health care quality) wanted from his surgeon:

-        No needless death – don’t kill me

-        No needless pain – don’t hurt me

o   Don’t do stuff that won’t help me

o   Don’t repeat things that have already been done

o   Don’t leave me worse off than when I arrived

-        No helplessness – don’t make me more vulnerable

-        No unwanted waiting – my time is as important as yours

-        No waste – give me effective, efficient, necessary care

In one of his IHI keynote addresses published in his book, Donald spoke of his personal experience as a patient and in so, provided a solution to reducing health care quality risks.  “The two most important ways to prevent helplessness are to share information with me and to give me choices.  First, keep me posted.  That’ll begin with my medical record.  No one can touch my knee who won’t give me my medical record to read anytime I want it, no questions asked, and no delays.  Better yet, let me keep my record with me, and I’ll let you use it anytime you want.”

These are two great books that everyone should read.  I accidentally read them back to back and was impressed by the common elements that these two experts shared.  While they often present polar opposite perspectives of the same problem, (one glass half full, one glass half empty) both are right.  After reading Makary’s book I would be afraid to enter a US hospital but after reading Berwick’s book, I’m reassured that quality abounds in the system.  One shining a spotlight on the problems one focusing on the solutions, both recognizing the importance of patients advocating for quality health care. 

Your Health.  Your Health Information.  Manage it Well.  

Healthcare Reform - Your money and your life

Two interesting healthcare questions have emerged in the healthcare debate recently that are important as we step into 2014. Forbes magazine (@PaulHsieh) asks “Is it your doctor’s job to save money for ‘the system'?” and the Atlantic (@MeghanMcCarthy_) “Should doctors be paid if they don’t keep people healthy?” I will address Meghan in another blog, Paul provided too much fodder to cover them both in one. 

Is it your doctor’s job to save money for ‘the system’?

Hsieh opens with the scary anti-socialist interpretation of publicly funded healthcare (Medicare in Canada and Obamacare for you guys to the south) with dire predictions that your government will decide what health care you may receive.  I think, Paul, the AMA (American Medical Association), will have something to say about that if even a faint whiff of government control seeps in (which it never will).  Canadian Medicare was created to provide all citizens access to reasonable care.  If you compare our two great nations, we have higher taxes in Canada (get used to it) but we don’t have crippling insurance fees and we have a much more accountable system, lower per capita spending and better health outcomes.  Canada is far from a perfect system but the American model, under any level of scrutiny, is worse.  Let’s address your four (4) points and highlight some questionable assumptions:

1. Doctors will be increasingly expected to save money “for the system” – good grief, I hope so and you should too.  ‘The system’ is going to be funded through your tax money and if doctors in the US continue to over serve and over bill their patients in the new system (lots of great articles in this New York Times Series ‘Paying Till it Hurts’) then yup, you guys will be in big trouble.  So, you need to put some safeguards in place; standardize the pricing for services; adopt a reasonable standard of care for patients.  ‘Appropriate Use Criteria’ is not evil but doctors bilking insurance companies for thousands of dollars for unnecessary tests (creating an increasingly illness focused, paranoid population) is certainly unethical.  If you can’t trust your doctor to put your best medical interests first, time to find a new doctor.  As a Canadian, it wouldn’t even cross my mind that my doctor wouldn’t put my best interests first.  What the hell is wrong with your doctors that you (a doctor) would even suggest that your colleagues would put government interests ahead of patient care?  And why aren’t they protesting outside the Forbes offices for an apology that you would even suggest such a thing? 

2. This will further fuel the nanny state – individual freedoms will be restricted if they are too costly to society.  This is Paul’s reference point: “As writer Steve Schweitzberger observed: “If Michael Moore has a toothache, it is not my responsibility to pay for his dentistry. If it were, then I would have the right to tell him not to eat sweets. I don’t want that kind of government-paid medical policy. Do you?””  @Forbes, do you guys not fact check?  Steve Schweitzberger wrote a Letter to the Editor of the Rocky Mountain News in 2007 that doesn’t make him a writer.  And, the letter was in response to Michael Moores documentary on Columbine and gun policy in the US.  Mr. Schweitzberger’s daughter escaped the gun fire and is an advocate of more liberal gun laws so citizens can protect themselves which makes him a perfectly credible (albeit biased) reference for an article on gun control but healthcare??  Shame on you Paul for misleading your readers with 7 year-old quotes from gun-rights advocates, couldn’t you find a relevant quote from, gee, someone who is actually talking about legitimate impacts of Obamacare?  Don’t make up fear mongers, there are plenty out there and it stains your credibility. 

3. Health benefits will become increasingly politicized – we agree.  We experience the same in Canada with each province controlling the ‘menu’ of insured services and some level of differentiation between jurisdictions.  While you highlight a few variances (and there will be more), what constitutes ‘essential health benefits’ can be identified and put in place, that is the meat of it.  Lobbyists will abound and policies will be impacted – report on that it’s an important debate, it just hasn’t happened yet.

4. Sooner or later, government spending Other People’s Money means the government taking your money – agreed.  Your taxes will go up.  Paul likens access healthcare to cell phone coverage implying that a free market approach to healthcare makes for healthy competition and lower costs.  Paul, you do realize that Americans have the highest per capita healthcare costs in the world (and some of the poorest health outcomes)?  The Organisation for Economic Co-operation and Development (OECD) reports on health spending and health outcomes globally (they kind of rule the evidence in this space).  “In 2011, the United States continued to outspend all other OECD countries by a wide margin, with the equivalent of USD $8,508 for each person.  This level of health spending is two-and-a-half times the average of all OECD countries and 50% higher than Norway and Switzerland, which were the next biggest spending countries.”  And if that isn’t bad enough, the health indicators used to measure outcomes globally show the US performing below the OECD average in most areas.  Here’s a few snippets:

a.       Life expectancy at birth OECD average = 80.1  US = 78.7 (best is Switzerland = 82.8)

b.      Life expectancy 65+ OECD average = 20.9 yrs US – 20.4 (best is France = 23.8 yrs)

c.       Mortality Ischemic Heart Disease OECD average = 122/100,000 pop. US = 122 (best is Japan 39/100,000)

There is a lot more evidence out there Paul that proves that your adored free-market model is broken, but you have to stop covering your eyes and look up.  The healthcare systems that are producing results for their citizens are blended private public models.  If I were an American I would be asking why my outrageous healthcare costs are not giving better results and why a doctor, who is a contributing writer to Forbes, is not shouting from the rooftops about that!    

What’s up with that Paul?  Don’t your patients deserve to live longer healthier lives? 

Perhaps you are focused on: Your money – and Your life – at stake.  

Health.  Information.  Managed Well

Carpe Diem – Seize your data for better health

We are living longer in North America.  If you can avoid getting in a car accident or dying from some violent encounter like being shot, you have a better chance of living longer in the US and Canada than any other industrialized country.  This is good news, IF we can live longer in good health but how do we manage that?    

23 and Me founder Anne Wojcicki offers up a compelling case to achieve ‘Healthy at 100’ (23 and Me’s Mission).  In the recent issue of Fast Company she promotes the personal and humanitarian benefits of participating in genome testing.  For $99, 23 and Me offers a fascinating opportunity for individuals who want to understand the impact that their DNA has on their risk for certain illnesses and, as I wrote last December in  The Risks and Benefits of Making Genome Data Open and Free, the genome holds great promise for individuals who want to manage their health. 

The challenge for individuals adventuring down this road is understanding what an increased risk means in the context of many other factors that impact health.  Our health outcomes, including how long we will live are determined as much by our genetic inheritance as our behaviours and many factors outside of our control. There is no certainty in DNA testing, only a quantified level of risk. 

Will DNA testing tell me more than what I already know from the health history contained in my family tree?    My father, a type one diabetic, died in his early sixties.  He lived his life with an understanding of the toll diabetes would have on his everyday life and his life expectancy.  He watched his younger sister succumb to the impacts of her poorly managed diabetes and he lived his life with tightly controlled behaviours that allowed him to travel internationally, run a successful business and live to see six grandchildren come into the world.  He often declared ‘I’m the healthiest man in this house’.  And he was.

My mother, on the other hand, is the antithesis of the Public Health poster child.  She is fond of processed foods, wine and coffee.  She started smoking long before I was born and doesn’t exercise.  She will turn eighty in a few months and other than some calcium supplements and cholesterol medication, she is illness free, active in many social circles, cognitively sharp and very happy. 

In me is a random combination of mom and dad’s genetic legacy combined with behaviours that emerged from growing up with their influences. There was no obvious health history that would have alerted my doctor or me to a melanoma diagnosis that took me by surprise twelve years ago.  But could there have been a warning in my DNA?

According to 23 and Me, one in 71 Americans develops melanoma over a lifetime. Genetics are thought to account for some of the variation in risk of skin cancer, though estimates vary widely.  While there is cancer in my family tree, there isn’t in my immediate family, I was the first and so far the only one who has had a melanoma diagnosis.  If DNA testing had been available 15 years ago, it may have alerted me to an increased risk of melanoma and motivated me to engage in preventative screening. 

What gems of genetic risk assessment are waiting for me and am I ready to hear about them?  I say 'Carpe Dieum', seize the day, the future is unforeseen and one should do all one can today to make one's future better.  One day that may include DNA testing by 23 and Me but not today. 

Your health.  Your information.  Manage it well.  

No Goat's Gonna Save Your Ass

In a recent blog Bridging the Chasm to Healthy Behaviours I wondered about why the evangelists of digital technologies keep proclaiming to be the panacea for healthcare reform.  ‘Apple postulates in their recent campaign, “Will it make life better?”  I respond, “No!”  Making life better is the sole responsibility of the individual.  Technology can play a supportive role in the hands of a motivated individual, as a coach, teacher and guide but technology can’t put the healthy food choices into your grocery cart or take your evening walk - only you can do that.’

So it was encouraging to see Tim O’Reilly (@timoreilly) tweet that this article In 20 Years We’re All Going to Realize This Apple Ad is Nuts  by Mark Wilson, “may well be the most important thing you will read all year”.  I couldn't agree more.  Technology can play a role in health improvement but it can also be a barrier, a distraction from the factors motivating healthy decisions such as fully engaging with your social network, directing discretionary spending to healthy options and even taking the time for a walk in the woods. 

A friend gave me a button recently ‘No goat’s gonna save my ass’ since she knew I wrote under the Fainting Goat pseudonym.  When I searched for the origin of the button I found it was part of a drink responsibly campaign for the Nova Scotia Department of Health.  The Magic Goat video could just as easily depict consumer’s unrealistic expectations that technology will be responsible for improving their health.  There are no short cuts to healthy living and reducing your risks for chronic disease.  But there are lots of distractions and companies willing to sell you a ‘quick fix’.  Messages bombard you from everywhere.  Your best defense is your own rational thinking but you have to take time to distance yourself from the noise and apply it. 

There was a constructive article posted this week How to be a Proactive Patient and, while I prefer the term consumer (we are not all patients but we all consume healthcare services), the advice holds strong for anyone looking for guidance on how to be a more active partner with your healthcare provider.  My top 3 pieces of advice; don’t be afraid to question your doctor; keep your own medical record; and talk to other patients who share your diagnosis.   The article ends with ‘Remember, your body is your business’ - words to hold onto.

This is not rocket science.  Exercise daily, eat fresh (and local) whenever possible and avoid the junk (we all know what it is).  Take time for family, friends and social supports, if you smoke cut down or quit and if you drink do so in moderation.  Understand the connection between your family’s health and your own (be it genetic or learned) and if you have children, acknowledge the role you have in informing their health behaviours.   Don’t blame others for your choices.  Laugh often and watch out for signs of stress.  

A family member, partner or good friend is going to help you reach your goals much more effectively than a piece of technology.  Share your goals and help those you care for reach theirs. 

Now, this Goat is going to abandon the computer and go for a hike.

  

It’s your health.  It’s your health information.  Manage it well.

Embrace your inner Captain Kirk

I recently noticed that there are no overweight or obese people on Star Trek. Why?  They sit most of the day in front of computer panels, have relatively no commute on the ship that is their home/office/recreation space for years on end and they get beamed from their space ship to planets or other ships through a process that requires little or no exertion.  On the other hand they have no access to fast food, no one smokes and no one appears to drink.  Perhaps the Enterprise provides an ideal, evidence-informed environment that contributes to optimal health, free from negative consumption habits.  

If Gene Roddenberry can envision it, we can certainly duplicate it, right?  There are already segments of our population who resemble the crew of the Enterprise; astronauts and military personnel.  We prepare these individuals for the demanding work they do through intense physical training, a controlled environment and instilling an acute awareness of the potential and limits of their body’s abilities. 

But before we get too excited about creating future Captains like James T. Kirk, let take a closer look at how we are building our future space travel.  General Foods (Tang) and Pillsbury (Space Food Snacks) have already contributed to space food development and now a number of companies such as Virgin Galactic  have privatized space travel.  Keeping on this path, our Enterprise will likely be sponsored by Coke and McDonalds and our captain will more likely resemble Rob Ford or Chris Christie as our poor eating habits follow us into space.  How can we expect a future that isn’t commercialized when we are so attached to our unhealthy commercialized habits here on earth?  

We are not all going to be astronauts but we can learn from them. 

As Astronaut Chris Hadfield so eloquently said “Don’t let life randomly kick you into the adult you don’t want to become”.  Focus on those things that you can control.  Accept those things you cannot control.  Set goals.  Identify the person you want to be and don’t lose sight of it.  Control your environment don’t let it control you.  Be intentional. Be aware.

It is exciting that we will soon have access to Star Trek gadgets like the Tricorder in the next few years (if you haven’t heard about the Tricorder X Prize and the $10 million contest, you will soon as the developers rush to bring versions of this device to market).  But it is only a device that will measure how healthy your body is, you have the ultimate control over the choices that will make you healthy.  This is the difference between Captain Kirk and Captain Crunch.   This is about lives well lived.  This is about legacy and mentorship, role models and real life inspiration. 

It’s your health.  It’s your health information.  Manage it well.