The Rise of Contextual Medicine

While the theme that stuck out for many attendees at HIMSS13 was “patient engagement,” the related term that sticks in the mind of this remote viewer of HIMSS13 is “context.”

I had a contextual view of HIMSS13 through interviews performed on site via a streaming Internet connection (enabled by the great work of Pat Salber, Gregg Masters and Nate DiNiro) through HIBC.tv. The conference happened in a context that I, the viewer, largely defined. I was able to see interviews from the conference in my office, and I could mix my viewing with other information, stories and my own narrative.

Viewing events in this manner hints at the future of  ”contextual medicine.” To understand this potential future, let’s take a look at how observers are describing similar shifts.

Shifting Contexts In The Digital World

John Hagel, Co-Chairman of Deloitte Center for the Edge describes the shift from content (articles and video, other consumed digital information) to the “context trajectory” that goes from experience to stories to narratives. An engagement trajectory might follow a similar path. Hagel states in a post about finding persistent context:

“In our digital world, content providers progressively chunk up their offerings to provide more choice and easier access. Music is now available by the track rather than packaged onto a CD. Sure, we will continue to watch movies and TV programs on our digital devices, but increasingly we consume video in bite-sized chunks – the preferred length of a YouTube video is two to five minutes. As for text, it has been progressively deconstructed from books to articles to blog postings to 140-character tweets. As this occurs, value moves from content to context.

In a context-driven world, the viewer defines the experience and his level of engagement much like I did with HIBC.tv. The content is foundational, but the viewer then decides how it is delivered and when, and with what other content. The viewer defines how the experience is architected to fit her own story and level of engagement.

System Architectures Define the Context of Music and Medicine

We can look to music as an example as to how context can affect content. A shift in context has been happening more or less continuously for centuries as the distribution methods for musical content have shifted, having a profound affect on what kinds of music work and which don’t in different contexts. I suspect medicine will also change as its cultural and physical contexts shift.

In “How Music Works,” former Talking Heads singer David Byrne “explores how profoundly music is shaped by its time and place, and he explains how the advent of recording technology in the 20th century forever changed our relationship to playing, performing, and listening to music…. Byrne sees music as part of a larger, almost Darwinian pattern of adaptations and responses to its cultural and physical context,” according to the publishers.

In Byrne’s own words: “How music works, or doesn’t work, is determined not just by what it is in isolation…but in large part by what surrounds it…How it’s performed, how it’s sold and distributed, how it’s recorded, who performs it, whom you hear it with…these are the things that determine not only if a piece of music works…but what it is.”

There’s a great TED talk by Byrne that summarizes the concepts in the book, well worth watching and thinking about how changing architectures of healthcare might shift the industry.

You could replace “music” in the above passage with “a medication” or “healthcare” or “conferences” or many various forms of content that is distributed in ways that are traditionally associated with a location. Then, take a look at this post about Dr. Rafael Grossmann’s thoughts on the use of Google Glass and think about how the architecture and context of health information might be changing.

In the post, Dr. Grossman, a pioneer in the use of mobile technologies in trauma surgery, describes the use of next generation mobile in a physician’s workflow. (Workflow is often used to describe the context in which information is used in medicine.) How might the architecture of medicine change how medicine is practiced?

Limited Context of Medicine Slowly Changing, For Now

Despite what might be coming — and health today exists in just a few different contexts — we have limited access to the power of information outside of the limited context offered in healthcare, for example:

  • Physicians interview patients to find out what’s wrong, but patients are demonstrably unreliable in describing what’s wrong in 10 minutes or less. They also forget what the doctor’s told them by the time they get to the parking lot.
  • We do routine screening tests to see markers that may or may not be good predictors of a disease state, like PSA and mammograms, often causing additional unwarranted harm to patients.
  • We take blood pressure or a measurement in a clinic and extrapolate these same measures to other times and to other places.
  • We train medical students in large lecture halls devoid of much human interaction.
  • We prescribe medication for large populations that will be only effective for a small portion of the population.

The list could be almost endless, and that’s the problem — we haven’t much considered context in medicine. It limits the economies of scale. It’s complicated. Therefore, how medicine actually works, how medicine is influenced over temporal, physical and social contexts is still largely a mystery. We’re unsure of how stable many measures are over time and place.

As Nora Belcher, executive director of the Texas e-Health Alliance, said recently at a Dell Services Think Tank on healthcare: “Whether data is good or bad is based largely on its context.” Yet, up until recently, we largely ignored the context of data in healthcare.

Still, some accountable care providers are starting to uncover how well digital and contextual medicine will work.

According to a recent article by Jonathan Cohn in The Atlantic on next generation medicine:

“One such institution is the Group Health Cooperative of Puget Sound, a nonprofit, multi-specialty group practice. Matt Handley, the medical director for quality and informatics, says that about two-thirds of Group Health’s patients now use some form of electronic communication, and that these methods account for about half of all ‘touches’ between patients and the group’s doctors or nurses. ‘They set up their own appointments. …They don’t need to call somebody and ask when I’m free,’ Handley says. ‘They send messages to doctors; look up lab tests and radiology results; and order refills. …The fascinating thing is that people of all ages are using it. …I have people in their 90s who secure-message me.’ “

Rearchitecting Medicine Around Patient And Physician Experience, Context and Narrative

The context of medicine, the very architecture of how it is practiced, is changing. How will new healthcare experiences be architected?

One way, through digitization and incentives, is a return to house calls, but this time they’ll be virtual, a major shift in context for both patients and physicians. Dr. Lawrence Casalino, an expert in outcomes and effectiveness research at Cornell University, estimates that more than 50% of visits to primary care physicians are unnecessary.

In “The Creative Destruction of Medicine,” Eric Topol states:

“The need for in-person office visits will be substantially reduced over time, along with those to emergency rooms. Those physicians who can emerge as the medical digerati will have a decided advantage — their accurate data on outcomes, quality, and cost will be posted on the Web and automatically updated on a frequent basis. House calls of yesteryear will be making an incredible comeback, but done through the web.”

Topol goes through several reasons for this change, and I’ll agree that some of the factors are:

  • payment reform
  • a renewed focus on patient engagement as a path to meaningful use and quality measures
  • both of which are (slowly) being mediated by ubiquitous connectivity
  • the difficulty in moving patient data from one physician to another

Each are having a role in a re-architecting of the system around patients and better experience and information use for physicians, including the use of decision support and robotics like Watson (it’s no accident that the machine-learning Watson won against the top Jeopardy contestants based on learning about the same information in a variety of contexts. We’ll see if Watson will soon be able to construct narratives for patients.).

We are shifting the time and place of where healthcare will be practiced, how healthcare “content” (drugs, care plans, decisions, educational materials, diagnostics, and even procedures) will be consumed, or how related activities will be performed due to high costs and poor data flow within existing institutions.

The End of the Blockbuster Pharma Era, How Drugs Work (better) in Context

Meanwhile, as the blockbuster business model in pharma dies a slow death, pharma is beginning to find the power of context.

On the day after Novartis CEO Joe Jiminez declared “The Age of the Massive Blockbuster Drug is Over,” Eric Topol mentioned my post as “Patient Engagement as the Blockbuster Drug of the Century” in his HIMSS13 keynote address. If the timing of these two statements doesn’t signal a shift toward contextual medicine, I’m not sure what does.

How is a drug related to context? In two ways similar to the context Byrne describes for music: the physical context of the patient’s body, including genomics, proteomics and interactions with other drugs, but also in the social context of the patient: their community, their financial situation, their ability to remember to take the medication, and their cultural beliefs, among others.

Another way of saying that the Age of the Massive Blockbuster is over is, “Effective new drugs can’t be developed outside of a well-defined patient context.” The old model of a blockbuster drug is founded upon a business model that assumes a single drug will work in a large population, no matter the physical or social context.

Part of the reason is that quality matters not only in terms of payment reform for providers, but, “Under the ACA, ‘new’ drugs that don’t perform significantly better than current options won’t be eligible for reimbursement from insurance companies,” according the the CNN/Money article on Jimenez’s statement. The old model simply won’t work, and the same is true ultimately for any care that doesn’t improve healthcare quality, cost and experience.

Not coincidentally, Novartis is pursuing a more innovative (what I would call context-driven) strategy that successful biotechs have focused on the last two decades: biochemical pathways. Focusing on pathways is like seeing a drug like content, and the disease pathways (the physical context of drugs and targets) are the context within which it is supposed to work.

The idea is that the context of the patient and the disease pathway will improve the efficacy of some drugs. I’m not sure it will make pharma more profitable, but I do believe it could make their products more effective.

The Context Trajectory

In the Hagel post mentioned above, he says that the “context trajectory” moves from experience (and, I’ll say, engagement) to stories to narratives. Narratives differ from stories in that narratives are open-ended and user-generated. Stories are told by others. When given multiple offerings, the viewer can start to deliver/define/follow narratives in which they can place each of their experiences.

To be an engaged patient, one must be engaged in their everyday activities and decisions at home, where our stories take place, not only in the context of the clinic or the hospital. The opportunity for institutions, including healthcare institutions in a quality-driven healthcare world, is to help patients begin to define their own narratives, in new contexts, for better health.

According to the makers of the film “Escape Fire,”:

Hagel:

“Digital technology provides all of us the ability to define and communicate narratives in rich and textured ways. Video and audio tools and platforms supplement conventional text-based forms of communication, and put them in the hands of everyone.”

When we use these tools to construct patient narratives, that’s real engagement, that’s the real blockbuster.

How do we extend payment reform to make context and engagement reimbursable? And, with much of the content and context locked in clinics with monolithic EMRs and document-based systems, how do we get to platforms that allow the context, often in the forms of workflows, to shift? If patient information can’t flow through clinics, will it have to flow around them?

I wrote that patient goals were the “dark matter” of healthcare back in June 2012 after HealthDataPalooza. Following the context trajectory of medicine, patient narratives and health information in context may be the gravitational force that pulls patients toward their goals.

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OK, now try these context and narrative exercises at home or wherever you are:

Check out AthenaHealth CEO Jonathan Bush’s “preview” to the CommonWell announcement (filmed the night before announcement) including his description of HIMSS as a kind of “boat show” and talk of the “death of software,” fascinating now in the context of the things that happened later in the week.

Also check out the live version of the #HITsm chat recorded during HIMSS13.

A contextual view not only allows us to see things from our house, but, as it’s recorded, go back and put it into a storyline or narrative. The AthenaHealth interview looks very different now than it did when it took place the night before the Commonwell announcement.

Or, you could just listen to One in a Lifetime:

leonardMore from Leonard Kish

@leonardkish

Leonard is Principal and Co-Founder at VivaPhi, an agency that solves multi-disciplinary business problems involving data science, software, biomedical science, behavioral science, health care, product design, community development, marketing, consumer engagement and organizational design. He has been quoted in Forbes and other top-tier publications for thought leadership on patient and consumer engagement. In addition to his role at VivaPhi, he is Chair of the Marketing and Communications Group for the Collaborative Health Consortium. Prior to VivaPhi he held the position of Vice President of Operations at Capitis Healthcare International as well as executive positions with several startups. He started his career as a software requirements analyst on Qwest Communication’s highest priority IT project while earning a triad of advanced degrees from the University of Colorado. These included an MBA, a Master’s of Science in Information Systems and a Master’s in Biomedical Sciences (Thesis on System Dynamics in Parkinson’s Disease). Leonard earned a Bachelor’s in Zoology from Miami University in Oxford, Ohio. He’s interested in how systems evolve, and how to help them evolve, in a variety of unique contexts. Connect with Leonard: @leonardkish, LinkedIn and Google+

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11 Responses to The Rise of Contextual Medicine

  1. disqus_6eL0p4skVz March 22, 2013 at 7:52 pm #

    The thought processes that went into this article are very simplistic and jargonistic.

    Let’s get complicated and look at things from the point of the patient AND the physician

    “patient engagement” is much more than facilitating electronic communication. From this rural primary care internist’s point of view engagement is working together with patients to catalyze THE PATIENT to protect themselves from onset of disease, resist the progression of disease, enhace bounce back from progressed disease and protect themselves from complications of disease. This involves working with the patient to focus on the “positive factors” affecting their health while working as a physician to minimize the negative factors of disease:

    The “context” of the patient is whether these factors are in play at any time with each patient concerning each Disease. There is a role for physicians re focusing on “negative factors” and a role for patients to focus on “positive factors” as applicable to the patient. The physician in primary care is responsible for up-to-date knowledge of both the negative and positive factors and to have specific motivational approaches to “engaging the patient” to focus on positive factors as identified by both the physician and patient. An after visit summary needs to accompany the patient upon exit from clinic so the patient “does not forget what the physician said”.

    The HIT community has the responsibility to have clinical reminders available for physician and patient discussion DURING the patient visit.

    This means clinical HIT =

    Comprehensive HIE connected with –

    1) Intelligent extraction of data from the HIT and EMR at the time of the visit

    2) Intelligent recognition of salient events and factors pertinent to the care of the patient

    3) Clinical reminder feedback to the clnician BEFORE the after visit summary is constructed

    4) Assistance in constructing the after visit summary

    5) Assistance in documentation in the EGAD format: E = events and pertinent review of systems; G = Goals of visit as specified by patient and physician for the visit, A= Assessment and Plan structured under each problem and annotated / dated in the annotable Problem List

    D = Documentation – SOAP or ROAP the visit so that reimbursement can be appropriate and timely for the visit with autoSOAPing minimized as much as possible to avoid data cloning

    Onset of Disease

    Risk Factors, if present, increase the probability of onset of disease

    Protective Factors, if present, decrease the probability of onset of disease

    Progression of Disease

    Stress Factors, if present, increase the probability of progression of disease

    Resistance Factors, if present decrease the probability of progression of disease

    Recovery from Progressed Disease

    Antagoinistic Factors, if present, decrease the probability of bounce back from progressed disese

    Resilience Factors, if present, increase the probability of bounce back from progressed disease

    Complication of Disease

    Risk Factors, if present, increase the probability of onset of a complication

    Protective Factors, if present, decrease the probability of onset of a complication

    Let you guess which are “negative factors” and which are “positive factors”.

    Let you surmise how the biopsychosocial model of practicing medicine fits in.

    Let you decide how a physician can keep up to date and can really act on this model of practicing medicine without having to declare bankruptcy.

  2. Leonard Kish March 25, 2013 at 3:34 pm #

    Thanks for your thoughtful comment. I agree with everything you’ve said (aside from the first line, but I do appreciate the feedback), and my definition of engagement largely means influencing the mental space patients occupy, what they spend their time focusing on as a prerequisite to leaning and making better decisions…. “System 2″ in Daniel Kahneman terms. I wouldn’t expect the physician to do all of that, but I would expect the system to be capable of helping to create that focus. http://www.amazon.com/Thinking-Fast-Slow-Daniel-Kahneman/dp/0374275637 And I would expect the physician to be paid more, not less, for doing those things well. We need IT, we need good docs, we need receptive patients, and we need payment reform. All of the above must be present for a model like this to work, it’ll be hard, but it’s not impossible.

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