Will Technology Lower Health Care Costs?

For the past six months, I��ve been working with Byron Davies of the Medical Informatics Department at Arizona School of Health Sciences (a unit of A.T. Still University of Osteopathic Medicine) under a grant from St.Luke��s Health Systems. We applied for, and received, the grant, because we and St. Luke��s believed that technology is one of the only ways to lower health care costs, and that it could be used more effectively, especially in remote monitoring of patients with chronic diseases, who are the ones costing the health care system billions of dollars.

We decided to start with studying diabetes, for obvious reasons. (It��s an epidemic).Like most researchers, we started with a theory, and we thought if we could prove it we could change the world. But now that we��re a ways down the road, we��ve come to learn some really interesting things.

We used a focus group approach. We know this isn��t the most accurate way to do research, but we thought we could at least start here and learn what questions to ask in a larger investigation. We have done two focus groups so far, both in disadvantaged communities, with the incredible help of the Arizona Association of Community Health Centers and its members (more about them in the future! THEY ROCK!) We will do a third group to check our results, so this little interim report is only a snapshot. But what an illuminating snapshot!

The groups consist of a combination of patients, payers, and providers: diabetics, nurses and doctors, diabetes educators, and insurance companies. First, we arrange for lunch �� .

Then we introduce the health system crisis and the role of chronic disease in healthcare costs.We introduce ��healthcare transformation�� and disease management as overall solutions, with the focus on using the best care today to avoid higher costs down the road.We contrast the advances in medical technology with the relative paucity of technology for self-management, including behavioral change.We talk about possible roles for technology in self-management.

And then we listen �V to learn what people think about the technology they use, what they think about technological possibilities for tools to support self-management, and what they value in human support of self-management.

There have been some big surprises for us along the way, and likely there will be more before we finish the groups. Bottom line: patients are indeed using technology, even though its clumsy and often not really working for them. They��re not really averse to it, but they often use it incorrectly, for reasons of education, availability, and affordability.

For example, they monitor their blood sugar, using glucometers with the wrong test strips, because they don��t know that the strips and glucometers aren��t interchangeable. Many patients carefully monitor themselves and produce useless data!

Clinicians want to see an easy-to-use, easy-to-read, standardized glucometer that supports data uploads for computer-based trending. There are too many different glucometers and too much payor-related ��churn��.

Another problem is that clinicians fear getting too much data about their patients with no reimbursable time to do anything with it. Right now, the insurance reimbursement system favors critical intervention, rather than prevention. No one is reimbursed for helping a patient use a glucometer correctly, or for trending the data that is received.
However, this is NOT a reluctance to use technology. Clinicians and patients alike think that real-time transmission of the data to their clinician's computer would make patients more likely to do regular monitoring and more likely to maintain healthy behavior.

What��s more, patients are unconcerned about sharing additional data with healthcare providers, despite all the hoopla about HIPAA.

The major roadblock to technology deployment and adoption, both by providers and patients, is the payment issue.

But for the populations we've looked at so far (community clinics in disadvantaged areas), remote patient monitoring is not the technology at the top of people's lists. First and foremost must come the electronic medical record. EMR's are neither universal nor standardized, so both data collection and data sharing remain difficult and time-consuming tasks. And you can��t do remote monitoring without a cyber-repository for the information.

Actually, in our target populations, the most impressive efforts have come from the diabetes educators and case managers who spend time with the patients on a regular basis, teaching them how best to live with their conditions. Time after time, focused case management of patient with diabetes has been demonstrated to be effective in improving a broad variety of health measures. We��re not finished yet, but I bet that when all is said and done, the best use of technology in the management of chronic diseases will be to make face-to-face interaction more effective and more efficient.

Every year, when I attend the Demo Conference at Kierland, I see awesome technology. Remarkably, very few people from Arizona attend this conference, and fewer still are presenters. This year, Viack was the lone Arizona company with a presence. I have never understood this, since there were more VCs at the Demo conference than at the Arizona Venture Capital Conference, and it�s a great way to identify the new hot spaces (and your competition, if you are already in one of them.)

Last year Demo 2003 was all about organizing information: Picasa for organizing photos, and Grokker, a visual, intuitive search engine. This year, the exciting stuff for individuals is around blogs. I've been blogging for five years now, but there's an awful lot of new technology out there for us bloggers. The reigning question was: is there a business model for blogging? But that�s what they used to say about the Internet.

As you know, blogs are another form of information you might want to keep up with, but they�re often hard to find and laborious to stay up with. Google has started indexing blogs, but not many. So in the past few years, aggregators of blogs have appeared, such as www.bloglines.com, and they can feed the blogs you want directly into your mailbox.

Feedster (www.feedster.com) , for example, tracks and searches RSS feeds to send you the blogs you want, without you having to go anywhere. It calls itself the search engine that keeps on giving. You can save your searches and it will crawl the Internet looking for your information. You can subscribe to each of its search results forever. As long as you want to receive specific information, you will get it sent to you. And the information from Feedster is coming from thousands of sources, some of them mainstream (CNET or PR Newswire), some of them blogs. This is important for me, because when I do a PR campaign I like to be able to track my results. I can do that by asking Feedster to look for the company or product I�m trying to make visible in the market.

John Kerry's campaign is using Feedster to raise money, and also to aggregate all the feeds that support Kerry to show that he's supported by the little people.

Newsdash which isn�t really available yet, appears to be a similar product, but it allows a blogger to post to it from a mobile device, as well as from a conventional web browser. Newsdash will also automatically subscribe you to the newsfeeds you want to receive.

Six Apart's new TypePad product also allows you to post audio, video, or anything to your blog from the desktop or from a mobile device. I�m going to try it in the next few weeks, so if you usually get this e-zine from my site, http://blog.stealthmode.com or from an RSS feed you may see some changes. Right now, the test site is up at http://hardaway.typepad.com/hardaway/ . Let me know what you think.


Now that I�ve spent a day learning about all this new stuff, I�m going to be trying some of it. I�m already testing a new search-based email client from Stata Labs called Bloomba. It�s supposed to help you find ANYTHING in your email with a maximum of four seconds. And it also searches attachments.

Stay tuned for what I think about it. I�m so ready to get away from Outlook, but not give up its conveniences, that I will try anything. I already tried Netscape and Eudora (didn�t like their non-integrated characteristics) so if Bloomba is anything close to what I need, I�m there.

I�m also going to test the new Chinese competitor to Microsoft Office, called Evermore Integrated Office. When I saw it demo�ed, it blew me away because I didn�t have to open three different programs and windows to collect information for a presentation and then cut and paste. EIO, which the presenter pronounced �YOW�, begins shipping in May and currently runs on Linux and Windows.

At Demo, Chris Shipley asked whether there was a place for products that compete with Microsoft Office, and many people said no, because the enterprise would have such high switching costs. But most jobs in this country are now created by small business, where the switching costs would be minimal, and the savings huge. Also, the time is coming when a Chinese software company won�t need the u.s. market to succeed, because China is its own market.

I know this makes me sound old, but how can I fight the feeling I have that our country is in a moral quagmire and a decline as a civilization? On the TV behind me, I am watching (well, mostly listening to) the cross-examination of 68-year-old Bishop Thomas O�Brien by a young Maricopa County prosecutor. The Bishop is accused of hitting a drunk pedestrian with his car and leaving the scene of the crime. His defense is that he didn�t know he had hit a person; in fact, he never looked to see what he had hit. Hardly a strong defense for a man of the cloth.

The prosecutor is doing the equivalent of beating the crap out of the Bishop, who I�m sure has been advised by his very good defense attorney not to remember as much as possible.

The Bishop, however, can barely conceal his contempt for the prosecutor. A lifetime of being in control must be difficult to abandon, and the Bishop is in danger of being caught in his own subterfuges and cover-ups. It�s becoming clear that the Bishop didn�t answer his phone because he was afraid it was the police calling to implicate him, and that he was going continue in denial as long as possible.

Listening to this trial is like watching a tennis match or a basketball game where the momentum shifts back and forth. Right now, the prosecutor has the mo; fifteen minutes ago, the Bishop had it, because he sounded sincere and concerned while the prosecutor hammered him. But the Bishop has become clearly disgusted by being endlessly asked to remember things he considers trivial, even though the prosecutor thinks they are critical. In revealing his contempt for the youthful prosecutor, the Bishop also reveals that he still considers himself an authority figure who shouldn�t be subjected to his indignity.

I�m not a religious person, but I would like to think that Bishop O�Brien is a sincerely committed cleric whose spiritual life is more highly developed than his practical life, which is why he testifies that he doesn�t know where to take his car to get the windshield replaced. But I am nagged by the suspicion that he is just another executive trying to get his secretary to take care of an errand he doesn�t want to run himself.

Taking a break from the trial, I read an article in the New York Times online. Howard Dean has decided to stay in the race, even if he loses in Wisconsin. Dean says his supporters, who have raised him $1.1 million over the Internet, won�t allow him to drop out. They are begging him to stay in, so their money doesn�t go to waste.

This complicates the field for the Democrats, forcing the ABB (anything but Bush) faction to wait longer before aligning behind a single candidate. But it also complicates things for Dean, who may well know he can�t win and wish to drop out, but must bow to pressure from the people who give him money.

To me, this �in and out� waffle clearly demonstrates how politicians are controlled by their contributors � the Howard Deans as well as the George Bushes.

So religion is broken, and politics is broken, and if you look further, you will find that health care is also broken and education as well.

I think I�m beginning to see why. In our lives, we rarely focus fully on anything, and even more rarely focus on one thing for long enough to consider the consequences.
Bishop O�Brien was preoccupied by issues in the Diocese involving pedophile priests, and he was driving home from an event when he heard something strike his windshield.
He was not focussed on driving, nor was he focussed on helping the victim of his accident, even if it were an actual human being. He didn�t call the police, and he didn�t focus on the consequences of that, either. Or of not answering his phone when the police called him.

Howard Dean didn�t focus on his contributors, even when he took their money. He wasn�t focussed on the fact that by taking the money he might be responsible to them, and might have to alter his decisions and positions accordingly. Now, when it makes the most political and financial sense for him to leave the race, he is forced to focus on them, because they won�t let him drop out.

Can�t we all just find some focus?

I've just returned from a board meeting of Social Venture Partners International, the national (and soon to be international) network of affiliates that grew out of a group of former Microsoft executives' desire to become knowledgeable philanthropists. Young and rich (not to put too fine a point on it), these people wanted to make a difference in their communities, and not just write a check.
Out of their entrepreneurial experience (their successful day jobs) came the concept of "venture philanthropy," --charitable giving that treats not-for-profits like businesses and funds them as venture capitalists would. Social Venture Partners pools the $5000 annual contributions of its partners into a "venture fund" that is "invested" by an investment committee of partners. Those partners invest the funds, but they also call upon other partners to be part of volunteer teams to work with the investees on strategic planning, marketing, HR, accounting, and technology issues that can be lumped together as "capacity building" for the investees.
The investees must show progress, or they don't receive another grant for the following year, but in the best case scenario we commit to a three-year phased investment, working to help the organization reach sustainability. In a for-profit business that would mean supporting itself through sales to customers, but in this case it's often developing the non-profit so it can seek further support from foundations and corporate donors who have deeper pockets than we do. We're kind of the "angel round."
SVP started in Seattle in 1996-7, and by 1999 my good friend Jerry Hirsch had heard about it and decided he loved the concept and it ought to be in Arizona. He put the arm on a bunch of his friends, myself included, and we launched an Arizona chapter in the same year. SVP Seattle told us it took twenty-five partners to have enough money to make meaningful contributions, and therefore twenty-five partners were the go-no go gating factor. Bless Jerry and his passion and conviction; we made it. Oh, and bless his foundation, too, the Lodestar Foundation, which was funded to create new concepts in delivering social services and solving social problems.
I've been involved since the get-go, and ironically, I think the major value of Social Venture Partners to me lies not in the money it gives away (it's tough to measure outcomes meaningfully when you're looking at slow social change), but the consciousness it develops in the partners about social issues and about how to become an educated philanthropist.
I've handled the corporate giving for a number of my clients over the years, and I saw how little they knew about where and how to give away their dollars. In fact, I think many individuals still give the way corporations used to: they choose a problem that appeals to them and give to anyone who comes to them with a proposal to solve it.
What happens in that case is a proliferation of non-profits addressing the same issue -- a phenomenon I first observed during the AIDS crisis in the '80s. One organization would start, and then dissatisfied board members or staff would spin out and form their own non-profit, tweaking the treatment model or the vision. Eventually, corporate donors faced dozens of proposals from rival AIDs organizations (now it's like that with at-risk youth organizations) and could no longer make their minds up who to fund. They would end up giving each organization a small donation, which didn't allow any of them to get traction.
Finally one day the corporations got together and said: we're only going to fund one AIDS organization, forcing a consolidation.
Consolidation in the not-for-profit realm is a difficult concept to pitch, but smart philanthropists urge it. Businesses merge and consolidate as industries mature, achieving economies of scale. Why not charities? Phoenix philanthropists just forced this kind of consolidation among the providers to the homeless, in exchange for a brand new homeless campus.
But these kinds of informed decisions require engagement and education. And that's what I think is great about Social Venture Partners: it allows donors to engage with its investees, and provides information about new trends in social service and philanthropy.
Perhaps because coaching entrepreneurs is my own "day job," I continue to find the concept of venture philanthropy (or perhaps the better term is engaged philanthropy) appealing. I joined the board of Social Venture Partners International not because I have an empty life and was looking for some more meetings to attend, but because I would like to see this kind of charitable giving become a national movement. There are already 22 affiliates in the Social Venture Partners network, with three more "in the pipeline."
If we then pool the resources of all the partners in all the affiliates, we may be able to address on a national or international basis some of the pressing problems we all face in our individual communities: insufficient early childhood education, imperfect programs for youth at risk, a completely inadequate and under funded foster care program, and blah, blah blah---the beat goes on.


"It's not what happens to you; it's how you come to it."
Francine Hardaway, Ph.D.
Stealthmode Partners
http://www.stealthmode.com
francine@stealthmode.com
602.910.5622(c)