“To change behavior, mobile health applications need to go beyond self- tracking, providing tips or access to an online community. Such applications need to address disconnects between long-term intentions and moment-to-moment choices. The most effective tools will creatively instantiate well-evidenced behavior-change principles with data mining, social networking, location awareness, and other capabilities of mobile technologies.”

- Margaret Morris PhD, Senior Researcher, Intel

The idea is to improve patient engagement and outcomes by using games and the idea of competing, earning rewards, and solving challenges to improve health.  I think this is especially relevant with all the chronic diseases and obesity challenges in kids, but there are gamers of all ages.  Certainly, Wii and other technologies that respond to movement and integrate into social media help enable this.

Keas is certainly one company whose name I’ve heard a few times in this space for healthcare.  But, I think lots of people are talking about this and trying to figure it out.  A simple Google search pulls up lots of discussion on the topic.

With the upcoming Facebook IPO and their success working with Zynga on gaming, it makes me wonder if they’ll make any movement in this space.  They’ve generally stayed out of the healthcare space other than exercise and diet, but with their recent effort around organ donation, one could speculate about what they could do with all the money they’re raising.

Gabe Zichermann, the author of Game-Based Marketing, speaks of balancing the fun and frivolity of gamification with the task of making life easier for cancer patients. He says, “I don’t presume to think that we can make having cancer into a purely fun experience. But, we have data to show that when we give cancer patients gamified experiences to help them manage their drug prescriptions and manage chemotherapy, they improve their emotional state and also their adherence to their protocol.”

We all know rates were getting cut in Medicare so this shifted some of that pain to make companies focus on what matters in terms of quality and outcomes.

Now, the GAO has put out a report that questions whether the expansion of the Star program to include 3 Star plans was a good idea.  (see Gorman’s comments here)  I think this is a fair question.  Should we reward mediocrity?  I think there are ways to do this.

1. You could pay 3 and 3.5 star programs but only if they show improvement year-over-year.
2. You could lower the payments or only reimburse them for investments made (i.e., no profit).
3. You could do it for one year then move the line up to 3.5 stars and then move it to 4 stars to give plans some time to implement, learn, and improve.

Right now, very few plans earn 5 stars, but dropping it to include 3-star plans makes almost 90% of plans get bonuses.  Maybe this is a case for some time of GE program where the top 10% get the biggest bonus; the bottom 10% have to stop offering a program; and the remaining funds get divided up based on some time of rating system.

The key here is not to throw the baby out with the bathwater.  The framework is good.  It’s taking time to understand the program, implement changes, and see an impact.  But, let’s not reward people that can’t continue to innovate and improve and do it in a way that rewards members based on outcomes and satisfaction.

My favorite point from talking to him was…

Cancer is a process not an event. Communication is critical.

In his presentation, he talked about several things:

• The $227B total cancer cost in the US (2007).
• The personalization of risk assessments and interventions.
• The services of MD Anderson.
  • Mortality reductions
  • Wellness education
  • Vaccinations and chemoprevention
• The US Preventative Services Task Force.
• The work that they’re doing direct with an employer (Shell).
• The CEO Cancer Gold Standard.
• The impact of aspirin on all-cause mortality.

So, after his formal presentation, we talked about several things.

1. One of the big focus areas for MD Anderson is prevention. As we know from research, many cancers are preventable. And, the promise of personalize medicine and genetic testing is beginning to help us understand these cancers and their treatments even more.
2. The three types of prevention:
   1. Primary – this would include lifestyle changes such as diet and smoking which help prevent the disease
   2. Secondary – this would include screening and detection to help slow the progression of the disease
   3. Tertiary – this would include the focus on the patient (not the tumor) for treatment and helping them with quality of life
3. He talked about how cancer is really 200 different diseases to be understood and managed.
4. He gave a great analogy about how CVD (cardio-vascular disease) evolved and talked about how all the individual risk factors became asymptomatic diseases which have led to all the “know your number” campaigns around lipids and blood pressure.
5. We talked about cancer as a process which led us into the discussion about palliative care and shared decision making. He made another good analogy here about driving a car. We need to understand the value of wearing our seat belt and having insurance, but we have to make the final decision about whether to do that or not.
6. We talked about personalized medicine including genomics and epigenetics. We talked about how this impacts dosing and understanding of the tumor. (Interesting in a conversation with another person in this field this week they were telling me about how tumors and viruses change over time and those implications on genetic test results.) We also talked about SNPs and the complications in getting validation in studies due to sample sizes. We wrapped up this topic with discussions on coordinated registries and work that companies like 23andMe are doing.
7. Our final topic of discussion was around clinical practice algorithms and how evidence-based medicine (EBM) gets implemented. We talked about the use of guidelines and how those allow for monitoring the use of EBM standards. We also talked about the need for integrated EMRs that would allow for benchmarking and linking outcomes to use of guidelines.

This is a fascinating area. Cancer affects most of us either directly or through some family member or friend.

Another chart shows the annual costs by chronic condition which is good data:

 And, from another area of the website, I found this data on US discharge costs interesting:

While absenteeism costs are obvious as in sick days paid out, presenteeism is harder to estimate but can have significant costs.  Presenteeism occurs when people come to work sick and are not productive.

I’m sure there are numerous methodologies out there, but I found this one that seemed simple and gave me some data by condition on both factors.

Did you ever think about the fact that your physician might not be using evidence-based medicine? This is an interesting discussion topic since we know it takes years for research and information to be disseminated throughout the medical community and become the standard of practice.

Scientific knowledge about best care is not applied systematically or expeditiously to clinical practice. It now takes an average of 17 years for new knowledge generated by randomized controlled trails to be incorporated into practice, and even then application is highly uneven. (According to the Institute of Medicine)

Will that change? One would think so. With technology, you can see more and more tools being used by the physician. You can also see more and more companies doing things like claims editing and then using clinical edits to support the process essentially creating the safety net for the physician, the consumer, and the payer. By implementing clinical standards from places like NCCN or using clinical pathways, companies can help physicians to drive better outcomes at lower costs. This is key for us to manage our healthcare costs here in the US and eliminate unwarranted variation.

So, what is evidence-based medicine? (from Wikipedia)

Evidence-based medicine (EBM) or evidence-based practice (EBP) aims to apply the best available evidence gained from the scientific method to clinical decision making. It seeks to assess the strength of evidence of the risks and benefits of treatments (including lack of treatment) and diagnostic tests. This helps clinicians to learn whether or not any treatment will do more good than harm.

Evidence quality can be assessed based on the source type (from meta-analyses and systematic reviews of double-blind, placebo-controlled clinical trials at the top end, down to conventional wisdom at the bottom), as well as other factors including statistical validity, clinical relevance, currency, and peer-review acceptance.

EBM/EBP recognizes that many aspects of health care depend on individual factors such as quality- and value-of-life judgments, which are only partially subject to scientific methods. EBP, however, seeks to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to ensure the best prediction of outcomes in medical treatment, even as debate continues about which outcomes are desirable.

Here’s a few more articles on the topic:

• http://www.physicianspractice.com/display/article/1462168/1586485
• http://www5.aaos.org/OKO/ebp/EBP001/suppPDFs/OKO_EBP001_S23.pdf
• http://www.dartmouth.edu/~biomed/resources.htmld/guides/ebm_resources.shtml
• http://www.usd.edu/library/evidence-based-medicine-model.cfm

So, there is certainly some debate about this becoming “cookie-cutter” and not being personalized to the individual patient, but I think that’s a common misnomer. EBM is a tool to help guide care to the best decisions based on research and data, but it is balanced with the physician-patient relationship and specific needs.

[BTW – Another aspect of this is enabling consumers with information about how to select locations that are low-cost given the variety in pricing which exists. There was an article in the USA Today about this recently.]

Created by: Medical Billing and Coding Certification