The healthcare community has been abuzz the last couple weeks over the Apple Watch’s ability (or not) to detect irregular heartbeats in attempt to predict atrial fibrillation. Enthusiasts, naysayers, survivors, Eric Topol, and everyone else in between have been giving their assessment of the results of 400,000+ person study done in conjunction with Stanford University. Some praised the results, others obsessed on the chance of false positives causing unnecessary alarm in apparently healthy young adults. I’m guessing where someone’s opinion fell is pretty much where it started out.
That said, the new Apple Watch, Version 4 is not a FitBit. This is not about adoption of a new-fangled gizmo that after a month will end up in the top drawer of your nightstand next to the (no offense to the FitBit). This is the next generation of that smart device that never leaves your side, or your wrist. I’m not trying to be an Apple commercial … rather just acknowledging a bellweather fact of a societal shift in how we view health and what it means to take care of it.
This is a serious entry into a market by the largest, richest example of capitalism the Western world has ever seen; one whose iconic founder’s last corporate directive was to disrupt healthcare in a way he successfully did to computing, telecommunications, music, retail and essentially culture as we now know it. And it’s one that its current leader has fully taken to heart.
In an excellent piece on digital health usage among young people, Susannah Fox, former Chief Technology Officer of the U.S. Department of Health and Human Services, found these teens (14 to 17-year-olds) and young adults (18 to 22-year-olds) making extensive use of a wide range of digital resources to access health information, tools, peer support, and providers online (Digital Health Practices Among Teens and Young Adults: Key Findings):
- Nearly nine out of ten (87%) teens and young adults say they have gone online for health information: the top five topics searched are fitness (63%), nutrition (52%), stress (44%), anxiety (42%), and depression (39%).
- Nearly two-thirds (64%) say they have used mobile apps related to health, including for fitness, sleep, meditation, and medication reminders.
- The majority (61%) say they have read, listened to, or watched other people share about their health experiences online, whether in podcasts, TED talks, or YouTube videos.
- About four in ten (39%) say they have gone online to try to find people with health conditions similar to their own, using methods such as participating in online forums or closed social media groups on specific issues, doing hashtag searches on social media, or following people with similar health conditions.
- One in five (20%) young people report having connected with health providers online, through tools like online messaging, apps, texting, and video chat.
To the old guard firmly ensconced in their white coats and stethoscope technology conceived 100 years ago … ignore at your peril. Retirement may best be had earlier than later.
The world is increasingly becoming one whose inhabitants have never been without a smart phone – a computer in their hand. Texting and social media isn’t something they take breaks from – anymore than eating or breathing. And that’s not just your teenage kids … it’s becoming everyone. Imagine your life without a car. It’s no different.
The healthcare industry in the traditional sense can longer be debating whether they should acknowledge these gizmos in their patients hands anymore than we can debate that climate change is real. Denial only shows an allergy to change and says little of the context and everything of the person. Physicians and providers will very soon need to put forth all available resources in integrating these digital tools into the process of their patient’s care. If they resist … well, I’ll say it again: it’ll be at their own peril.
Consumers of Health
We can’t just limit our attention to that of cardio health technology though. The Apple Watch and its siblings competing for our attention and our dollars represent much more. They are an emblem of the empowerment to take control of our health. Being constantly reminded of your health status transcends the once a year check up by putting it front and center on demand. The level of our potential awareness is omnipresent. And with this elevation will come modification of our behavior; maybe not always overtly, but at least covertly. Consumers of cheeseburgers can now be consumers of health. And with that will come changes in what the marketplace offers. For example, McDonald’s just announced they’ve removed artificial ingredients from their seven classic burgers, including the Quarter Pounder and the Big Mac. While no bastion of healthy eating, McDonald’s actions show a recognition that health plays a role, an increasingly larger one, in the decision-making of their patrons. These same people will also demand the same empowered recognition from their physician and health provider. And with each day their voices will grow louder. Patient collaboration improves self-efficacy. If patients think what they are doing is going to help their outcome … they’re much more likely to do it. And the act of “doing” is power in itself.
To accommodate this new paradigm, healthcare providers will have put forth resources, both financial and attitudinal, to accommodate the movement of patient health data; or as they call it in the industry, interoperability. This interoperability must extend from within the confines of their clinic walls to other providers (often competing ones) to the personal data gathered by the health consumers themselves. In their new empowered state, patients and consumers will want access to their health information no matter where and how it’s gathered. And if the healthcare provider wants to maintain market share, they will have to oblige. The OpenNotes movement is making strides raising awareness and organizing patients to demand their providers give them access to the notes physicians take during and after their visits. At last count over 26 million consumers are represented by healthcare providers who subscribe to this process … and this number will only increase exponentially. Just yesterday, I was involved in a Twitter thread on the realism of recording patient/physician office visits.
Even with this data flying in all directions – a true health collaboration runs the risk of being siloed in the domain of only the technical assessment of the physical body. We are much more than that. We are an accumulation of our experiences; our environments, and the actions and reactions we make in those environment. We are products of how we grew up, our education level, the work we’ve done, where we’ve done it – and maybe most of all who we’ve done it all with. This is our narrative, or as I call, an Engagement Narrative. The idea for this came from many inspirational discussions I have had with the patient engagement leader, Jan Oldenburg – as she puts her interpretation of it to use in real life. This narrative must be taken into account when looking at our health and well-being – and what we should do about it going forward in our lives.
The Ivory Tower Must Go
The days of the patriarchal middle age white male in a white coat standing in front of you as sit on a hard exam table in an open back gown, stripped of all power and dignity, are fast becoming a relic only to be seen late at night on second tier cable television. Today’s physicians are not different from the people we see everyday. Many are just as tuned into technology as their most informed patients. They’re health consumers and patrons of Apple and Amazon just like us. They reflect the population. Women and ethnic minorities represent an increasing portion of the demographics making up the industry (though not nearly enough).
It’s not just that our physician demographics have changed; so have the societal conditions around us. Our population is aging and with it is the increasing role played by caregivers. With the prospect of Trump-induced knee-jerk governmental austerity measures looming daily – our mental health is constantly being put to test. Health happens outside the clinic walls more than it does within them … and someone has to be there to assist. In most cases this role is played by spouses, adult children, grandchildren and other family members. But we can’t discount the part played by other stakeholders outside immediate family. Friends and neighbors should be considered an active part of the support solution. This will be even more the case with the government trending towards abdication rather than responsibility. These components of a changing technical and sociological health landscape are demanding a new vision … a new paradigm.
A Collaborative Health Paradigm.
We must create a national movement of empowerment, one of New Power, revolving around health and well-being that transcends our current definition of “healthcare.” The traditional position of fee-for-service reimbursement is coming to an end – though not nearly fast enough. In its place I hope will be compensation models that reward healthcare providers for their role in elevating the health and well-being of not only their patients, but also the communities they operate in. And this new role will require collaboration from parties beyond the constraints of “healthcare” itself.
The Health Consumer as a collaborator
If we, as health consumers and patients, don’t look to ourselves as being the main source of health – the actions of our healthcare providers don’t really matter. Past are the times when your physician was the only source of good health. And gone are times your annual checkup is the only times you even think about your health … if you even do that.
The first step in taking control of your health is creating an Engagement Narrative. The Engagement Narrative is much more than just your story though. It’s an exercise in self-awareness. The very act of writing something down makes it real, something you can refer to and build on. Creating the Engagement Narrative also gives you an unprecedented opportunity to involve those close to you to shed light and become more involved in your life. This collaboration will provide more insight and commitment than if you just composed it yourself. And with it carries accountability. Not only are you writing down where you’re at and where you want to go … it’s being shared with your closest confidants. There’s no escaping now. Whether you like it or not – you have a team behind you.
Even with an enhanced physician relationship brought on by your Engagement Narrative, your path to health involves much more. Inspirations for well-being comes from everywhere. Just your normal day-to-day comings and goings give you a multitude of opportunities to better yourself through simple engagements – however insignificant those engagements may seem. Participating in a local clean up effort gets you off the couch and gives you an opportunity to meet new people; taking you out of your comfort zone and building synaptic connections. Deciding to walk to the store rather than … well not, can start a habit that literally can change your life.
Your positive actions will also have an effect on others – contributing to their health and collectively that of the community. A simple compliment in line at the grocery store can not only make a person’s day; it may cascade into the validation of a decision they made (say a new hair style) that empowers them to carry themselves with confidence before an important meeting or job interview. No act of kindness is too small. No engagement is insignificant.
Healthcare providers as a collaborator
My idea of the healthcare provider isn’t a physical clinic at all, but a relationship; beginning with one person, a concierge, who would direct me to who and where I need to go (including transparent options) for specific situations, including prevention advice. Imagine a human health interface. Accompanying this human component would be comprehensive AI functions integrating and managing my care, as well as suggestions to elevate my self-efficacy. All administrative functions would be hidden from me (appointment setting, forms, etc.) – synced with my personal data wherever its origination, and available on the technological communication conduit of my preference. In addition to my technical data, my healthcare provider (physician and any support staff) would refer to the Engagement Narrative I provided them (personal and professional history, etc.). We’re all on board recognizing health is a function of my environment and my interaction with it as much (if not more) than anything happening between the four clinic walls.
Being a healthcare provider, we need you to lobby for our communities to be places that prioritize people and relationships – not cars, parking lots and box stores. We need you to take the money you don’t pay in taxes and invest it in community gardens, farmers markets and street fairs that showcase local art encouraging creative engagement. We need you to lead the way advocating for healthy eating by including cooking and nutrition as an integral part of our treatment. And while you’re at it – include our stakeholders. We need you to be advocates for engagement and “getting out of the house.” Communities that encourage something as simple as allowing dogs in parks will boost their residents’ collective health and well-being. Why not propose that at a city council meeting?
But however substantial your clinic’s direct efforts may be, whether it be setting up a farmers market in your parking lot or organizing mentor groups for current cancer patients – we need you to do more. We need you to use your stage and your megaphone to reach the entire community. We need you to be vocal when you see politicians and government not doing what they should to improve the human condition of our communities. You should be a regular contributor in the OpEd section of the newspaper. You can’t hide behind the nonpartisan label just because you’re afraid of losing a few ideological wayward customers. Losing them is nothing compared to losing your integrity and human decency. And believe it – there are people out there like me, who can write better than I can, who aren’t afraid to call you out on it … publicly.
The community as a collaborator
Our actions and reactions determine our physical, mental and even social health. We our products of how we interact with our environments – as well as choosing what environments to put ourselves in. In the post A Saturday in May … a study in engagement, I chronicled a day of incredible experiences I had entirely due to breaking outside my comfort zone.
We need to use our daily routine as a source of good health and well-being. Everywhere we normally go has the opportunity to nudge you in a healthy direction – we just have to look at it that way and engage. We have to be present and mindful. I call these physical sources of opportunities in your community, Front Porches, named after the front yard gathering spots so often seen in Latino communities that are used for neighborhood discussion and connection to the street. Only in this context, they’re very often small businesses … places we probably already frequent, like the corner grocery store or our habitual morning coffee shop. But it’s not just businesses that can be Front Porches though. It’s anywhere where people gather than can be turned into hubs of social interaction and civic engagement; schools, parks – even our neighbor Bob’s garage with the big screen television. From this engagement we can create home-spun volunteer efforts that mend the social safety net commonly let to fray by our traditional institutions. These efforts can range from to fixing a school playground, to organizing an elderly outreach effort, to even spearheading a high school mentoring program.
Ivan Illich argued that it is not a case of ‘either/or’ (community or institution), so much as a question of, which comes first. He contended that an institutional inversion had taken hold in modern societies, through which the community role becomes that which is left after the institutions and their professional helpers have done what they think they can do better or more expertly. Illich contested this inversion, and argued for its reversal whereby the institutional and professional role should be defined as being that which is left after the community has done what it can and wants to do. (Cormac Russell in “Does Medicine Make Us Sicker?”)
Today … looking forward
Healthcare is changing. Reimbursements are now starting to be tied to community health metrics. No longer is it only about number of procedures and tests. But still – this progress is slow. It needs to be turbo-charged. It needs all parts of the community working together for individual and collective goals. The days of the silos of healthcare and looking at health from only the perspective of medicine are numbered.
We must create a societal “wave” of health and well-being. It will be up to all parties, including healthcare providers, to decide which side of the societal evolution they wish to be on. Profits and revenue can be very fickle … and fleeting. Pleading ignorance or thinking that substantive change is beyond the parlor rooms of their ivory towers isn’t a viable option.
The barbarians are at the gate … and they’re the ones who are paying the rent in those ivory towers.