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Internet Turns 25 – Looking Back And Forward

happy birthday

Wow!  The Internet turned 25.  Do you remember when you started using computers and technology?  I can.

I think my first computer was the Commodore 64 which we plugged into our home TV for a monitor and used a tape recorder to store files and access programs.

commodore 64

I can remember when we got 3 Macintosh computers to use at school.

first Mac

I can remember when we got our IBM PC Jr.


After that, computers started being a little more common where we had them in high school for typing, but at the same time, people were using electric typewriters more than computers.  (I can’t believe that they still sell electric typewriters – see Wal-Mart ad.)

I can then remember being at the University of Michigan with massive computer labs of Apple computers.  At that time, I still remember using the Gopher technology that had been developed out of the University of Minnesota and pre-dated today’s Internet and HTML.


This eventually led to all the excitement about physical companies having websites and being able to do amazing things like order pizza online…the rise of e-commerce and eventually the dotcom bubble.

I still smile when I think that one of my first assignments in healthcare was to convince managed care companies to build a website.  I flew all around the country as a consultant with Ernst & Young LLP meeting with teams to convince them of what the Internet could do, why they should build a website, what functionality to put on it, and how to drive members to the website.

And, now, our kids grow up with this as normal.  Everything can be “googled”.  There is no card catalog to look things up or waiting to figure out why someone is late.  Things are instantly available.  (If you’ve never seen the list of what graduates will never remember, here’s a link to their 2017 graduate list.  Always interesting.)

So, I’ll wrap this up with a look at the future from a new report by PEW.  Here’s 15 predictions from their report:

1) Information sharing over the Internet will be so effortlessly interwoven into daily life that it will become invisible, flowing like electricity, often through machine intermediaries.

2) The spread of the Internet will enhance global connectivity that fosters more planetary relationships and less ignorance.

3) The Internet of Things, artificial intelligence, and big data will make people more aware of their world and their own behavior.

4) Augmented reality and wearable devices will be implemented to monitor and give quick feedback on daily life, especially tied to personal health.

5) Political awareness and action will be facilitated and more peaceful change and public uprisings like the Arab Spring will emerge.

6) The spread of the ‘Ubernet’ will diminish the meaning of borders, and new ‘nations’ of those with shared interests may emerge and exist beyond the capacity of current nation-states to control.

7) The Internet will become ‘the Internets’ as access, systems, and principles are renegotiated

8) An Internet-enabled revolution in education will spread more opportunities, with less money spent on real estate and teachers.

9) Dangerous divides between haves and have-nots may expand, resulting in resentment and possible violence.

10) Abuses and abusers will ‘evolve and scale.’ Human nature isn’t changing; there’s laziness, bullying, stalking, stupidity, pornography, dirty tricks, crime, and those who practice them have new capacity to make life miserable for others.

11) Pressured by these changes, governments and corporations will try to assert power — and at times succeed — as they invoke security and cultural norms.

12) People will continue — sometimes grudgingly — to make tradeoffs favoring convenience and perceived immediate gains over privacy; and privacy will be something only the upscale will enjoy.

13) Humans and their current organizations may not respond quickly enough to challenges presented by complex networks.

14) Most people are not yet noticing the profound changes today’s communications networks are already bringing about; these networks will be even more disruptive in the future.

15) Foresight and accurate predictions can make a difference; ‘The best way to predict the future is to invent it.’


Healthcare Gamification

If you believe all the hype about digital health, you might think gamification was a natural solution.  Of course, if you’ve never heard of gamification, let me provide a basic definition from Wikipedia.

Gamification is the use of game thinking and game mechanics in non-game contexts to engage users in solving problems.

Here’s several articles for more information:

  1. Four Factors Driving Gamification in Healthcare
  2. From FitBit to Fitocracy
  3. The Wellness Game
  4. Gamification: Drugmakers And Health Campaigners Turn To Games To Promote Health

I think this quote from the Perficient white paper on this topic is a good one.

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.”

You can also look at a post by Jane Sarasohn-Kahn (one of my favorite bloggers) on this topic where she highlights several trends from a recent paper on gamification in healthcare.

Now, why should you care?

  1. Gamification should improve engagement which is critical to changing behavior.
  2. Gamification creates opportunities to make healthcare fun which can be difficult.
  3. People are different and respond to different “incentives”.  Competition and leader boards are concepts that excite lots of people to take action.

The forecasts for the gamification market are huge.  They show a nice hockey stick which gets every investor excited.


Of course, the important question is who uses games.  Is it just teenage boys?  It’s not.  Here’s a good report which shows you breakdown by age, gender, and many other stats.


Another quick article about gamification is from TEDMED.  The video is below, but it reminds me of some of my personal perspectives.  The sites also lists out several vendors and solutions in the obesity gamification space.

While one “easy” opportunity in my mind is to use gamification to address the rising number of kids with chronic diseases and to help address childhood obesity, there are many other opportunities like adherence.  A few examples of games out there include:

Companies like Ayogo, Mango Health, and Akili are ones that I’ve heard about, but I know there are a lot more out there.

One example I think of from watching my kids play games is from Webkinz which was a blend of real stuffed animals with online digital personas.  The animals could get sick if you didn’t nurture them and visit them.  It made me think of how an avatar could get fatter or slower based on their pedometer or eating habits.

The 15 Year Old Technology Missing From

I talked about my experience trying to use the site day one. I honestly hoped it was an anomaly but it doesn’t seem to be.

But, as I think about and the general benefits selection process, I see two huge gaps.

Back in 1999, I was working with a company called Firepond. The had what was called a product configurator. At the time, I was at E&Y and Empire BCBS and several other Blues hired them to build a tool for brokers. The tool sat behind a really slick web interface which allowed the broker to ask a consumer less than 10 questions. They would move a sliding bar across the screen and it would dynamically rank their plan options to tell them what was the best option for them to buy. It seems like that wold be great for and

What we were missing then which Big Data might actually help us solve now is individual claims data. This is what drives me crazy when you have to pick your benefits at work. Why can’t I upload my benefits information and have a tool actually tell me what to buy? If I had my claims history plus a predictive model, I could make smarter decisions about how to select my benefits.

The #QuantifiedSelf and “Walking Interview”

If you haven’t heard, “sitting is the new smoking” in terms of health status.  And, unfortunately, you can’t just get up and exercise for an hour and then go sit all day.  That brief spurt of exercise doesn’t change the fact that we sit for 9+ hours a day.

If you think about our shift in work from a very manual work environment to a service and technology work environment, we’ve made activity during the day harder and harder to achieve.  Between e-mail and meetings, most of us are stagnant to accomplish our work.

That got me thinking about the #QuantifiedSelf movement and all of the activity trackers (e.g., FitBit, BodyMedia).  We know companies definitely look online to see people’s social media activity as part of the interview process.  Will they begin to ask about their activity data as a proxy for health?

On the flipside, perhaps the person interviewing should really be asking to see their potential boss’ activity data.  I’d be as interested in knowing what happens during the day.  It would provide a lot of insight into what happens in terms of meetings, face-t0-face activity, and be a good proxy for the real work experience.

Of course, the other option would be to introduce “walking interviews”.  People talk about walking meetings.  I’ve even done a running meeting going for a jog with a potential partner to discuss how we work together.  (It was the only time we could find to meet at a conference.)

Walking interviews would tell you a lot about someone’s health.  You could go up some stairs.  You could walk a few miles in an hour.

Since we know that health, happiness, and wealth are all correlated, this type of insight for the interviewer and interviewee seems very valuable.


Presidential Physical Fitness Award – Reasonable? Role Models?

I must admit that I don’t remember taking the presidential fitness test as a kid. With that being said, I was surprised to learn from my daughter that in her class of club soccer, volleyball, and baseball players she was the only kid to meet the highest level (greater than the 85th percentile across several measures). She made it today by running her mile in 7:37.

So, what does this require? It made me curious. Here’s what you have to do:


Could you do that?  These seem pretty difficult to me.  I could probably do the mile in 6:06, but I doubt I could do 53 pull-ups.  And, I doubt I could sit and reach 7 inches beyond my toes.  (Looking at the 17 year old male standards.)

On the other hand, we certainly need our kids to be more fit.  We have a big childhood obesity issue.

Childhood Obesity

But, it also made me think about Michelle Obama’s efforts in this space.

Lets Move

I think these programs are good starts, but lets not forget that obesity is a social issue and kids learn from those around them.  Let me ask the uncomfortable questions about those who our kids look up to.

  • How many overweight coaches do you know?
  • How about overweight teachers?
  • How about policemen and firefighters?
  • How about clergy?

These are all key role models…not to mention us parents who are often overweight.

I guess my suggestion here to the President would be to think about how to use our massive government payrolls as a foundation for change. Let’s think about the Presidential Fitness Challenge and create a broader wellness solution to change the visual role models for our kids and figure out how to help companies invest in this.

For example, we know that sleeping is correlated to weight and health.  I was talking to my brother-in-law who is a police officer when he told me that they are expected to get 8 hours of sleep a night.  Imagine if companies set this expectation for their employees (sleep impact on work).  

“Sitting Disease” may make a great late night comedy story line, but it’s a reality of our information economy that has to be addressed.


How The CVS Program Will Change The Employer – Employee Contract

Have you heard that CVS Caremark is requiring employees to go get biometrics and going to take action on it? OMG!

I’m not sure I understand why people are all upset. Let’s look at the facts:

And, by the way, have we forgotten how much healthcare costs have gone up over time and who pays that bill. It’s either the employer or the government. Both of those things impact our pay as individuals either in terms of lower raises to cover healthcare costs, shifting healthcare costs to us, or taxes. It’s not sustainable so the person who pays the bill has to step in since we’re not. (Which is also why I support the NY ban on soda.)

Now, let’s look at our healthcare system where in the current fee-for-service model, there isn’t an incentive for physicians to address this.

For now, people should be happy. They’re only being required to do the biometrics. The penalty isn’t linked to whether they’re fat or have high blood pressure or smoke or have high cholesterol or have diabetes. A recent study by Towers Watson shows that while 16% of employers do this type of outcome based incentive program today (2013) that this is going to jump to 47% in 2014. So, this will be the norm.

And, guess what…sticks often work better than carrots in some cases.

And, healthcare costs are making us uncompetitive globally as a country.

  • The cost of healthcare is greater than the cost of steel in a car.
  • The cost of healthcare is greater than the cost of coffee in a Starbuck’s cup of coffee.

And, health reform is allowing (even enabling) this to happen. It says that you can treat people differently and create up to a 50% differential in costs associated with their health. (Not a legal definition so read the fine print.)

But, what I think all of us (consumers and employers) will need to realize is that moving to this (which I agree with) will change the employer and employee relationship in several ways.

  1. You can’t put these programs in place without something to help me manage my obesity, cholesterol, and/or other chronic condition. This will drive wellness and disease management programs to be more engaging and successful.
  2. This will put pressure on employers to create a culture of health since we spend so much time at work and work contributes to our health conditions.
    1. Need more time to be active. Less sitting. Treadmill desks. Standing meetings. Nap time. Walking breaks. Use of devices to track steps. Incentives. Gym discounts. Healthy food discounts.
    2. Need less stress.
    3. Need more sleep.
    4. Better food choices at work.
  3. This will drive a lot of the new tools and run counter to some trends about limiting dependent coverage since you can’t address obesity without engaging the entire family and the social network.
  4. This will also create a whole exception process by which people who gain weight due to certain drugs have to be excluded. People who can’t exercise may have to be excluded. People may have to see short-term goals (i.e., dropping BMI from 35 to 32). Physicians will have to be engaged.
  5. Coaching will have to expand to include dieticians, social workers, and others to help people beyond the historical nurse centric coaching model.

If none of this motivates you, then just think about the “gift” we’re giving our kids and maybe that will be a wake-up call why someone has to do something here. (As I shared the other day, I struggle with my weight so don’t think I’m some super skinny, high metabolism person who thinks this is easy.)

The Prescribing Apps ERA – Will Clinicians Be Ready? #mHealth

Dr. Kraft (@daniel_kraft) recently spoke at FutureMed and talked about the prescribing apps era.  I’ve talked about this concept many times, and I agree that we are rapidly moving in that direction.  And, there’s lots of buzz about whether apps will change behavior and how soon we’ll see “clinical trials” or published data to prove this.

From this site, you can get a recap, but here are the key points that he made:

1) Mobile Phones (quantified self) are becoming constant monitoring devices that create feedback loops which help individuals lead a healthy lifestyle.  Examples include; monitoring glucose levels, blood pressure levels, stress levels, temperature, calories burned, heart rate, arrythmias. Gathering all this information can potentially help the patient make lifestyle changes to avoid a complication, decrease progression of a particular disease, and have quality information regarding his physical emotional state for their physician to tailor his treatment in a more efficient manner.

2) The App prescription ERA:  Just as we prescribe medications prescribing apps to patients will be the future. The reason why this is important is that apps created for particular cases can help the patients understand their disease better and empower them to take better control.

3) Gamification: using games in order to change lifestyle, habits, have been mentioned before. A very interesting concept was that created in the Hope Labs of Stanford. The labs created a game in which children would receive points after there therapeutic regiment, once points were optioned they could shoot and attack the tumor. Helping with the compliance rate of the treatments

4) Lab on a chip and point of care testing

5) Artificial Intelligence like Watson and its application in medicine.

6) Procedure Simulation: Several procedures done by medical professionals follow (not 100%) a see one, do one teach one scenario.  Probably very few people agree with this concept and that is why simulation has great potential. In this case residents, fellows in training can see one, simulate many and then when comfortable do one.

7) Social Networks and Augmented Reality

At the same time, a recent ePocrates study hammered home the point that while this is taking off physicians don’t have a mechanism for which ones to recommend and why.

According to the Epocrates survey, more than 40 percent of physicians are recommending apps to their patients. In terms of the apps being recommended, 72 percent are for patient education, 57 percent are lifestyle change tools, 37 percent are for drug information, 37 percent are for chronic disease management, 24 percent are for medical adherence and 11 percent are to connect the patient to an electronic health record portal.

Physicians also have several different sources for identifying which apps to recommend to their patients. According to the survey, 41 percent get advice from a friend or colleague, while 38 percent use an app store, another 38 percent use an Internet search engine, 23 percent learn of an app from another patient or patients, and 21 percent use the app themselves.

That said, the survey also notes that more than half of the physicians contacted said they don’t know which apps are “good to share.”

As I’ve discussed before, this is somewhat of the Wild West.  Patients are buying and downloading apps based on what they learn about.  They’d love for physicians, nurses, pharmacists, and other trusted sources to help them.  But, those clinicians are often not technology savvy (or at least many of the ones who are actively practicing).  There are exceptions to the norm and those are the ones in the news and speaking at conferences.

IMHO…consumers want to know the following:

  1. Which apps make sense for me based on my condition?
  2. Will that app be relevant as I move from newly diagnosed to maintenance?
  3. Should I pay for an app or stick with the free version?
  4. Is my data secure?
  5. Will this app allow me to share data with my caregiver or case manager?
  6. Will this app have an open API for integration with my other apps or devices?
  7. Is it intuitive to use?
  8. Will this company be around or will I be able to port my data to another app if the company goes away?
  9. Is the information clinically sound?
  10. Is the content consumer friendly?
  11. Is it easy to use?
  12. Is there an escalation path if I need help with clinical information?
  13. Will my employer or health plan pay for it for me?
  14. Is my data secure?

And, employers and payers also have lots of questions (on top of many of the ones above):

  1. Is this tool effective in changing behavior?
  2. Should I promote any apps to my members?
  3. Should I pay for the apps?
  4. How should I integrate them into my care system?
  5. Do my staff need to have them, use them, and be able to discuss them with the patient?  (Do they do that today with their member portal?)


How Quickly Do Healthcare Companies Respond To Twitter Comments? (Test)

I was intrigued by this test done over in the UK to look at how quickly retailers responded to comments via Twitter (you can see an infographic about similar US data below).  Obviously, more and more consumers are using social media.  And, we know that comments can go viral quickly especially when they’re negative.

“A recent Spherion Staffing Services survey shows that when consumers have a good customer service experience, 47 percent are likely to tell a company representative; 17 percent will express their opinions via social media; and 15 percent will write a review. The same survey from 2010 showed that only 40 percent of consumers were likely to share a great experience with a company representative—proving that consumers are becoming more vocal with companies they interact with. If consumers have a poor experience, 36 percent are willing to write a complaint directly to the company, and one in four will express their opinions on social media. Nineteen percent, the same statistic as last year, will choose to write a review online.” (December 2011 Study)

Of course, some people actively monitor their social media feeds while others view them more as a PR channel.  It also depends on whether the feed management is outsourced or insource and whether it’s monitored by marketing, operations, customer service, sales, or some combined team.

Here’s a good post on measuring response and activity within Twitter accounts.

So, what I’ve decided to do is a Twitter test similar to the one above.  I’m going to post the following to different categories of healthcare companies and see how quickly they respond.

  1. To retail pharmacies:  Are you using social media to handle customer service?
  2. To PBMs:  Are you using social media to handle customer service?
  3. To Managed Care: Where’s the best place to find out about your Medicare products?
  4. To mHealth companies:  Can you share examples of how employers are promoting your products?
  5. To pharma:  Are you doing any value-based contracting with PBMs?
  6. To device companies:  Can you share examples of how employers are promoting your products?

Who do you think will be the fastest to respond?  Will the bigger companies simply have more resources to monitor and staff their teams or with more digital companies be more in tune with social media?


Google Glass Plus The Checklist Manifesto

I continue to think about all the cool ways that Google Glass could be used to change healthcare.  Here’s my thought from today.

You could combine The Checklist Manifesto concept with Google Glass to allow surgeons to be reminded of the things they need to do with a patient while they were during the encounter or during the procedure.

In complex situations – such as those which arise in almost every profession and industry today – the solutions to problems are technical and demanding. There are often a variety of different ways to solve a problem. It’s all too easy to get so caught up dealing with all these complexities that the most obvious and common sense immediate solutions are not tried first. To overcome this problem, take a leaf from the commercial aviation industry and develop checklists people can use to make sure every base is covered quickly and concisely. Checklists are a forgotten or ignored business tool. It’s time for them to come in from the cold. 

“Here, then, is our situation at the start of the twenty-first century:We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And with it, they have accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields – from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us. That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our human inadequacies. And there is such a strategy – though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies. It is a checklist.”

(This is from this PDF on The Checklist Manifesto.)

Here’s an example of a checklist from the WHO.


Limiting Factor For Behavior Change is We Don’t Believe We Will Change

One of the biggest challenges in healthcare is getting people to change behavior or as Express Scripts would frame it – activating intent.  Since approximately 75% of healthcare costs are due to preventable conditions, it’s important that we can help people see the future value of change.  People often discount that future value of change based on the amount of effort required to get there.  They see the short-term pain not the long-term gain.

A new study puts an interesting perspective on this.  It shows that people can generally see the amount of change they’ve made in the past decade, but they fail to realize that change will continue for the next decade.  They appear to see themselves as stable at the current moment without significant change in the future.  I believe this is really important as we think about Motivational Interviewing techniques and communications for engaging consumers.

So, as you think about behavior change in healthcare for things like diabetes, you will likely continue to see more and more emphasis on behavior change and research in this area (see example from RWJF last year or Cigna whitepaper).

To learn more about this topic of behavior economics, you might look a few places:

And, here’s a good list of books to start with.

How And Why I Use Twitter

I often get stopped by people I know who say things like:

  • I see a lot of your tweets in LinkedIn.
  • You use Twitter. Why? I don’t really want to tell people that I’m going to eat dinner or some other miscellaneous fact.
  • Can you really get anything out of 140 characters?

So…let me share my perspective on how my use of Twitter has evolved and what I get out of it.

It took me a few tries before I found out how to use Twitter effectively.

  1. First, I tried just using it to share thoughts or opinions across a variety of topics. I didn’t find that valuable and wondered why anyone would follow me to know that.
  2. Second, I tried using it to pose questions about healthcare topics that I was interested in. That worked ok because it synched with LinkedIn, but I didn’t have enough Twitter followers for that to make a difference.
  3. Finally, I decided to just use it as a “notebook” to capture facts while I read or to bookmark articles that I found interesting. (Of course, some of this became possible as every web article now offers a “share” feature.) This works especially great when you’re at a conference and is even a good way to follow a conference that you miss.

The next thing that I had to figure out was just understanding the technology.

  1. Reading things in Twitter is ok, but a lot of people post links. Often times, it’s not that effective to be constantly going out to the links to see what they say. In comes Flipboard to save the day. (see older post here)
  2. To make things more searchable, you have to use hashtags where you put a “#” in front of a key expression or search term.
  3. Most people don’t get a lot of followers although you hear about all the celebrities with millions of followers. (see HubSpot presentation below for general Twitter statistics)

I figure it must be working for me now. I have over 1,000 followers which according to this site is true for less than 1% of people on Twitter. But, I don’t think followers is the best indication (especially since almost ½ of followers might be bots and you can buy followers). I know that it’s working for now since I can post a question and sometimes get an answer. I can connect with companies and meet people. I’ve even heard from people at conferences that they follow my feed. Probably my best experience was when I read an article early in the morning, posted a quick summary, and then had a national reporter call me to ask me for the source so he could write an AP article…all before 8 am.

Just to check, I went out to the StatusPeople application which tells you how many of your followers are bots versus simply inactive. I was pleased with the results.

Are You Turning Data Into Knowlege?

I’ve used this framework for years, but I wanted to post it here as I think about outcomes reporting. (image source)

This is key as you move to add value around data and use the knowledge and wisdom to create informed actions.


Using Social Media For Underwriting

As healthcare moves towards an individual market where prior conditions can’t be excluded, will health plans be able to use social media data in underwriting? It seems logical. If I can understand your behaviors, I can asses your risk for life insurance, and I can predict some healthcare costs.

  • Do you talk about going to the gym?
  • Do you talk about drinking and smoking?
  • Do you share pictures of food and is it healthy?
  • Are you checking in at places like McDonalds or places like the park?
  • Do you have an active social network?
  • Are you going to the dentist and getting flu shots?

As companies like integrate social media through things like Radian6, can this type of tagging and data use be far behind?

The other question is whether is should get used?

Communications: Get To The Point

I got to catch up with one of my first bosses tonight.  He taught me a lot about strategy, consulting, and people.

One of the lessons I never forgot was about communicating.  I don’t always do it, but he used to tell me two things:

  1. If you’re going to leave me a voicemail, tell me the key points in the first 30 seconds.
  2. If you send me an e-mail, make sure you get to the point in the first few sentences.  I’m only going to look at what I see in the window in outlook and won’t open it.
What did I learn?
  • Think ahead about what I’m going to say.
  • Layout my key points and why to listen to the rest of the message (or read the entire e-mail)
  • Just provide enough information to justify a call or meeting
I’m always surprised at how people talk on and on in voicemails and e-mails.  I’m sure I do sometimes also, but I’ve tried to continue to practice what I learned years ago.

Enchantment Infographics (by Guy Kawasaki)

I’ve had the privilege to hear Guy Kawasaki speak and have read a lot of the stuff he’s written over the years.  I haven’t read the new book Enchantment, but these infographics might get me to go out and do that.

I’d love to think about similar graphics which blend his work and the work of David Shore on trust in healthcare…how to you engage and build trust as a healthcare entity!

A Few E-mail Facts

Fast Company had an article the other day with some great stats on email:

  • There are 3B email accounts worldwide.
  • Email use by seniors increased by 28% from 2009-2010 while use by teens dropped 59% in. That same time.
  • The average business person sends 33 emails per day. [maybe on a day when I’m in meetings for 9 hours…that’s really low]
  • 89% of all emails sent are spam!
  • Only 8% of emails sent are business related.
  • In 2010, there were 107 trillion emails sent; 25 billion tweets; and 170 billion pieces of mail.

Real-Time PBM “Pricing” From Prescription Solutions

I don’t do a whole lot in the PBM pricing world these days, but I remember some of the process and the underwriting steps.  That being said, I was really impressed with the new Prescription Solutions online Pharmacy Benefit Advisor Tool (go to 

You go through a few basic steps to get an idea of how much you (payer) could save (with a very nice GUI). 

  1. Rank the features that matter to you – net cost, compliance, shifting cost to the consumer
  2. Rank the importance of different clinical programs
  3. Make some trade-offs in programs (A is more important than B)
  4. Enter some baseline data

Now, in reality, PBM pricing is never that simple, but what it effectively does is help articulate the savings that different decisions can create in a real-time setting.  It also forces some dialogue around issues – adhererence versus drug cost…which matters more to you?

I also think it could be a great way to help consumers understand the costs and savings associated with certain decisions.  I would also guess that the sales team at Prescription Solutions will find it helpful especially in the smaller, self-funded world.

Rules Based Communications

After working with data warehouses, configuration engines, and workflow management systems, I’m a big believer in embedding rules into a process. Communications is no different.

Let’s look at a few rules:

  • Don’t communicate with someone more than X times per week.
  • Don’t call these people.
  • Use Spanish for people with that language preference.
  • Send a text message to people who have provided their mobile number and opted in to the program.
  • When applicable, use a preferred method of communication for reaching out to someone.
  • If a caregiver is identified and permission is on file, send the caregiver a copy of all communications to the patient.
  • Call the patient if the amount being billed for their prescription is greater than $75.
  • For patients between these ages, use the following messaging.
  • If the patient hasn’t opened the e-mail after 48 hours, then call them.
  • For clinical information, use this channel of communications.
  • For John Smith, only call them on Tuesdays between 5-6 pm ET.
  • For Medicare recipients, use this font in all letters.
  • For Hispanic consumers, use this particular voice in all call programs.
  • If the patient doesn’t respond after two attempts, send a fax to their physician.
  • For patients with an e-mail on file, send them an e-mail after you leave them a voicemail.
  • For patients who are supported by Nurse Smith, only call them when she is on duty and use her name in the caller ID.

I could go on. But, the point is that communications, like healthcare, is a personalized experience. We have to use data to become smarter (historical behavior, segmentation, preferences). We have to use customization to create the right experience. AND, probably the most difficult thing for lots of companies, we have to coordinate communications across modes (i.e., e-mail, direct mail, SMS, automated call, call center, web).

Ultimately, I believe consumers will get to a point where they can help set these rules themselves to create a personalized profile for what they want to know, how they want it delivered, and ultimately provide some perspective on how to frame information to best capture their attention.

To learn more, you should reach out to us at Silverlink Communications.

The MBA Oath

This is a little off topic, but I think it applies well within health care.  Health care is a profession where managers (like clinicians) should feel a responsibility to improve the lives of their members while making money.  With that in mind, I wanted to highlight this effort.  To learn more, go to to learn about the history and efforts of this group (along with a new book).


As a business leader I recognize my role in society.

•  My purpose is to lead people and manage resources to create value that no single individual can create alone.

•  My decisions affect the well-being of individuals inside and outside my enterprise, today and tomorrow.

Therefore, I promise that:

•  I will manage my enterprise with loyalty and care, and will not advance my personal interests at the expense of my enterprise or society.

•  I will understand and uphold, in letter and spirit, the laws and contracts governing my conduct and that of my enterprise.

•  I will refrain from corruption, unfair competition, or business practices harmful to society.

•  I will protect the human rights and dignity of all people affected by my enterprise, and I will oppose discrimination and exploitation.

•  I will protect the right of future generations to advance their standard of living and enjoy a healthy planet.

•  I will report the performance and risks of my enterprise accurately and honestly.

•  I will invest in developing myself and others, helping the management profession continue to advance and create sustainable and inclusive prosperity.

In exercising my professional duties according to these principles, I recognize that my behavior must set an example of integrity, eliciting trust and esteem from those I serve. I will remain accountable to my peers and to society for my actions and for upholding these standards.

This oath I make freely, and upon my honor.

Technology Challenges (and Opportunities) For Pharmacy

Here’s the presentation that I’m going to deliver tomorrow (11/2/10) at the NCPDP education event in Portland.  The question posed was what are the busines models needed to survive and thrive in the new economy.  My mind immediately jumped to what are the challenges in the industry, what are the trends that got us to where we are, and how can pharmacies (or PBMs) think about turning these challenges into opportunities.

At the end of the day, I think there is still lots of white space for pharmacies to leverage technology to build relationships with their clients (consumers / customers / patients).  I think technology makes that scalable. 

One bias that I also have long-term is that (with the right economic model) retail pharmacies should focus on the acute drugs and new prescriptions and get compensated for the initial education and titration with the patient and the physician.  After that, maintenance drugs which are essentially just refills should be handled by the lowest cost option – kiosks, central fill, mail order.  I think that would encourage a different payment model centered around cognitive services and encourage greater collaboration between retail and the mail order pharmacies. 

Addressing Hospital Readmission Rates

High hospital readmission rates are a real source of concern for health plans, from both a quality and cost perspective. With 20% of Medicare patients being readmitted within 30 days of discharge, health plans and their partners have a significant opportunity to reduce readmission rates across all populations. Even just a half-point drop in readmissions for a Medicare plan with 1 million members can yield $10 to $15 million in annual medical cost savings.

In a new podcast, Dr. Jan Berger, Silverlink’s Chief Medical Officer, discusses how health plans can address this costly, growing issue affecting our healthcare system. Dr. Berger offers best practices for reducing readmissions such as:
• Expanding outreach to entire discharged population
• Reaching out within 24-72 hours of discharge
• Coordinating communications among members, physicians and care managers
• Identifying members at risk for readmissions

Download this podcast and visit our new Post Hospital Discharge Microsite to access other valuable resources on this important healthcare topic.

Why Integrated Communications Are Better?

This morning is a perfect example of why integrated communications are better.  What do I mean by this?  I mean where a communication campaign is designed using rules to coordinate events across multiple channels.  Still too mumbo-jumbo…Where companies can interact with consumers across channels (e-mail, voice, print, web, call center) and create a seamless experience.

Here’s an example…

This morning, my kid’s school is closed due to snow.  [Although the snow has passed and they’ve already plowed the side streets.]  When I checked the Internet at 5:15, it wasn’t closed.  At 5:40, I got the call that it was closed.  BUT, the call comes on my home line, our home business line, and both our mobile phones.  Somehow it didn’t wake the kids, but it could have.

I don’t really care about the over-communication in this example, but in a professional setting, this would seem like overkill and potentially a waste of money.  In an integrated communications example, it might work like this:

  • An update was put on the Internet and everyone was sent an e-mail
  • At 5:50, the system would identify anyone who had either not opened their e-mail or had not visited the website (assuming they had cookies on their PC for tracking website visitors)
  • At 5:50, the system would call the primary number to play the recorded message by the principal
  • If there was no answer by a live person or the entire message was not listened to, the system would move on to additional numbers

This is always one of the big discussions we [Silverlink Communications] get in with clients in healthcare.  What are the rules for escalation of communications?  How do I track data in an integrated data set?  What is the right timing between communications?

This is critical.  Sending people a letter and a call or a letter or a call (for example) is pretty easy.  Determining the next action based on their final disposition in the initial outreach is not.

Of course, the other question this begs is how many companies actually track return mail.  I know a lot of companies don’t.  If it keeps getting returned, they’re not processing this return mail and taking the bad addresses out of their member database.

Nature’s Rules For Healthcare

I found this article – Nature’s 10 Simple Rules for Survival – on biomechanics and biomimicry interesting (Fast Company article).  It looks at how nature has survived all these years and translates that to lessons for business.  This is worth more pondering, but my Saturday morning thoughts on applying this to healthcare are in brackets.

  1. Diversify across generations.  [We need different strategies for different segments.  One size will not fit all.]
  2. Adapt to the changing environment — and specialize.  [We need a US centric healthcare model not a model from Canada or the UK.]
  3. Celebrate transparency. Every species knows which species will eat it and which will not.  [Be clear on incentives and roles.  Set up a win-win not a win-lose.  Don’t try to get government to run an efficient business which it never has.]
  4. Plan and execute systematically, not compartmentally. Every part of a plant contributes to its growth.  [A technology infrastructure and shared decision making across a care continuum is important.  The medical home concept has merit.]
  5. Form groups and protect the young. Most animals travel in flocks, gaggles, and prides. Packs offer strength and efficacy.  [Social networking and leveraging peer-to-peer education and support will improve health outcomes.]
  6. Integrate metrics. Nature brings the right information to the right place at the right time. When a tree needs water, the leaves curl; when there is rain, the curled leaves move more water to the root system.  [We need home monitoring and predictive metrics for preventative care.  Using genomics and other measures should save lives by allowing us to act early.]
  7. Improve with each cycle. Evolution is a strategy for long-term survival.  [Big bang improvement to the system won’t work.  Pick one problem at a time – e.g., un-insured – and solve for it.]
  8. Right-size regularly, rather than downsize occasionally. If an organism grows too big to support itself, it collapses; if it withers, it is eaten.  [Healthcare is inherently local.]
  9. Foster longevity, not immediate gratification. Nature does not buy on credit and uses resources only to the level that they can be renewed.  [We need to address the issue of hyperbolic discounting.  People want immediate value, but lots of healthcare improvements take time personally and systemically.]
  10. Waste nothing, recycle everything. Some of the greatest opportunities in the 21st century will be turning waste — including inefficiency and underutilization — into profit.  [Don’t overcomplicate the solution.  Sometimes the obvious can improve the difficult.]

CareScientific: MythBusters

A few former co-workers and friends of mine (Brenda Motheral and Steve Melnick) have formed a new company called CareScientific.  This is a follow-up to Brenda’s paper a few months ago on Disease Management.  You can now go to their site and see more about what they are doing:

  • Custom program evaluation
  • Provide a proprietary algorithm for selecting cost-effective patients for intervention

They also offer a Disease Management (DM) plausability and VBID plausability calculator to help you assess whether the saving you need are rational expectations.

I had a chance to see them officially launch this a few months ago at a conference.  Here were a few of my notes and some of their slides from the event:

  • To reduce healthcare costs, you can look at pricing, disease management, and utilization management.  If you’re looking at DM, you need to focus on outcomes from both a quality and an ROI perspective.
  • The early models for DM were much more multi-disciplinary.
  • In a recent care coordination project, only 1 in 15 people showed a reduction in hospitalization…none showed an ROI.
  • Hewitt says that less than 40% of plan sponsors are satisfied with DM.
  • In 20 CMS studies, not one has shown an improvement in Rx adherence.
  • Most DM savings are simply regression to the mean.
  • Key things to focus on:
    • Behaviors that save money
    • Improving collaboration – where it matters
    • Rigorous evaluation
    • Determine savings plausability
  • There are 3 concentric circles of focus.  At the middle is cost savings then cost-effective and then clinically appropriate.  Most programs are clinically appropriate, but only 20% show cost savings.

Communication Strategy Regarding H1N1 (Swine) Flu

“There is a lot of media, a lot of news, a lot of rumor – the sooner you can get correct and accurate information to consumers, the better – otherwise people will look to other sources that may not always be accurate.”  (Jan Berger, President of Health Intelligence Partners on podcast)

We have been hearing a few things from our clients and have put some information up on the Silverlink website.  Some of the comments have been:

  1. I have seen a spike in call center volume about this topic.
  2. Clients want to change plan design to make sure Relenza and Tamiflu are covered and don’t require a prior authorization or have a quantity level limit on them.
  3. We want to proactively reach out to at risk populations – children, seniors, or people with a compromised immune system.
  4. We want to be able to flexibly target certain geographies.
  5. We want to remind people not to panic, drive them to quality information sources, and make sure they know the basics – wash your hands.

At a minimum, everyone is adding information to their websites.  Many consumers are Googling the topic or following updates from @CDCEmergency (on Twitter).

Healthplans, PBMs, and population health companies are at the heart of this.  They need a coordinated strategy to inform people appropriately as this issue continues to be top of mind.

We recorded a podcast last night with the Medical Director from Healthwise and Jan Berger who is the former Chief Medical Officer from CVS Caremark and is now president of Health Intelligence Partners.  In here, they answer some general questions about the situation and what companies should be doing to educate members.

The two standard solutions Silverlink is offering clients are:

  1. Offer an inbound FAQ (Frequently Asked Questions) line with CDC content and specifics about their plans.  This can help with overflow from their call center and/or be used as a direct line from their website or outbound communications.
  2. Selectively target populations (age, zip code, disease state) with a brief message reminding them to wash their hands and telling them where to get qualified information.

As with all our communications offerings, these can be customized (messaging, channel, targeting, etc.) to meet client requirements.  Additionally, since one of our technology advantages over others in the space is our flexibility, we can work with clients to keep these messages up-to-date as the situation changes and as new information has to be added.

Communication Evolution

I was thinking this morning about how communications evolve. Here are a few examples from the past few years:

1. Caller-ID replacing voicemail.
2. E-mails replacing memos (and getting much longer).
3. SMS and Twitter replacing e-mail.
4. Scanning replacing faxing.
5. Facebook replacing online photo albums.
6. Evite replacing invitations (with mixed success).
7. Twitter beginning to replace news clipping services.
8. Craigslist replacing newpaper listings.
9. Websites replacing brochures.
10. Virtual conferences eroding attendance at physical conferences.

Mayo Clinic On Using Twitter

This is a good presentation on using Twitter, etiquette, etc. For more on Twitter in Healthcare from Mayo Clinic, you can go here.

So…Google Was Indicative

I talked earlier about Google searches relative to the NextRx sale.  In the 3 days before the acquisition was announced, the majority of the searches (by far) that I could see and brought people to my site were about Express Scripts (or ESRX) and Wellpoint (or NextRx).  So, I am not sure if that was PR people looking for things to respond to or insiders doing some analysis, but it seems like Google searches could tell us something.

Again…the power of data.  Now, if I was a stock trader and had access to all of the Google search data, perhaps I would have a way to beat the market.

Sprint: What’s Happening Now

I am not sure how this helps Sprint sell more phones and/or services, but I enjoyed the advertisement. The concept of leveraging data to understand consumer behavior is essential. This is a topic we [Silverlink] are constantly working with our healthcare clients to address.

  • How do you know what members or patients are doing?
  • Do you understand their preferences?
  • What have they historically done?
  • Can you predict how they will act in the future?
  • What data is needed to do analysis and create a predictive algorithm?
  • How do you leverage that to create interactive and compelling communications?
  • How do you study their behavior change?  (e.g., did they get a flu shot after being reminded)
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