The IxCenter, IDEO and the California HealthCare Foundation (CHCF) have just published a new report, “Innovating with Information Therapy (Ix): Prompting Transformational Change with Safety-Net Populations.” The report represents our findings and learnings from a collaborative project between the IxCenter and IDEO with funding and guidance from CHCF, as well as input from several experts and physicians who serve safety-net populations.

The project had two primary goals:

1. Identify and illustrate new information delivery mechanisms that prompt patients to improve their self-care behaviors.
2. Help safety-net organizations understand how prototyping methodologies can increase the efficiency of implementing new ideas.

One of the first things that we did was to learn directly from consumers themselves through ethnographic observation and structured consumer interviews. From there, we reconvened as a group to do storytelling and share insights we gained from consumers. The process then shifted to a group exercise of generating themes and how-might-we statements.

The second day began with intense brainstorming, followed rapid prototyping in which we develop what IDEO calls “10-dollar, 10-minute” prototypes. The idea was to actually develop something concrete and then we presented these prototypes to three people who live with chronic conditions. Before building out more fully, it’s critically important to get direct feedback from the target audience for your innovations.

Far more detail about what we learned and what we developed can be found in the report. We look forward to lots of feedback on our findings, and suggestions for where we might take this work next.

When Obama Administration Chief Technology Officer Aneesh Chopra started his keynote at today’s Health 2.0 Conference in San Francisco, he began by mentioning the work that I did when the two of us were at the Advisory Board Company (that’s him there pointing to me), where I first began experimenting with the concept of information prescriptions. That came out of a two-year project (1999-2001) where we developed in-depth consumer health content. Just as (or maybe more) importantly, we shadowed patients and clinicians in hospitals and clinics and conducted dozens of structured interviews with people with diabetes (and their families).

The first panel that followed Chopra, I saw some cool tools demo-ed, but I didn’t get a sense of whether they truly support patient-centered care and meet consumers’ real health needs. After the panel on “Clinical Groupware and the Next Generation of Clinician-Patient Interaction Tools,” I asked the question:

“How did you collect information from consumers in advance of developing your applications? Did you do focus groups, structured interviews, or direct ethnographic observation to understand what tasks consumers really want to accomplish? And, at what point in the development process, did you do that critical research?”

Only one of the panelists chose to respond to the question (I think it was Arien Malec, VP, Product Management, Relay Health, but I’m not sure). His answer was somewhat vague (compared to my rather specific question), with the exception of discussing how they incorporate user feedback they receive after the deployment of tools. Although I agree that user feedback (a core part of the Health 2.0 model) is invaluable for refining tools, it is a fundamentally different part of the research & development arsenal.  And, more to the point, it was not an answer to my question.

So, when (following an excellent “The Patient Is In” session) I moderated the “Search & Content” session that featured six different Health 2.0 demos, I decided to keep asking the question until I got an answer that satisfies me. After all, the main reason that I could see for creating a panel with the diversity of demos covering all of search and content was because they basically address how we can help consumers get the right information at the right time to meet their decision-making and health management needs (basically colloquial for information therapy).  I figured that I might get a better answer if I re-framed the question:

“What did you do in advance of building your technology to ensure that what you were building met specific consumer needs?”

I admit it was a loaded question in that I have a strong bias. Before investing millions of dollars in product development, I believe that — if the goal is to develop consumer-centric tools — every company should begin with some combination of these patient-centered research approaches:

• Consumer surveys
• Focus groups with patients and families/caregivers
• Structured, extensive interviews with consumers
• Shadowing of patients and clinicians
• Direct, ethnographic observations of consumers in the settings where they “do” most of their health care (e.g., their homes, workplaces, schools, etc.)

If we want to meet Chopra’s call for robust innovation that transforms our economy and the health care delivery system, we first need to identify the health tasks that consumers want to accomplish. The best way to figure that out is to get answers directly from consumers before we write a single line of programming code.

The following is a guest post from Arna Ionescu, who is Domain Director, Connected Health for a leading innovation design firm, IDEO, an IxAction Alliance member. This follows up on earlier guest post she wrote, explaining how this innovation test evolved. You can also find more background on the IxCenter’s increasing emphasis on Ix innovation design. 

In our July IxAction Alliance webinar, we interactively brainstormed ways we could leverage curiosity to prompt higher engagement with information therapy. Out of all the ideas generated, participants picked the “High Blood Pressure Club” to explore further. A few weeks ago, I wrote a blog entry about our efforts to better understand the parameters of this club through a “$10, 10 minute prototype.”

Since reducing blood pressure takes a long time, we used the analogous context of gas guzzling to run our experiment. Our three participants self-reported long commutes and minimal awareness of gas consumption. After a week of measuring their baseline gas usage, we inducted them into the “Gas Guzzler Club” and provided a week of information therapy. This involved a short video and daily tips through a channel of their choice (email, text or voice – all three chose email).

So did it work? In terms of the before and after gas consumption one participant did better, one worse and one stayed the same. While the numbers are inconclusive, our follow-up conversations with each participant revealed interesting and sometimes unexpected insights.

1. Our guilt trip was effective only to a degree. Participants juxtaposed words like “pejorative” and “pariah” with “motivational,” and they wanted to take action to get out of the club. However, the guilt only got them so far. One participant said he decided not to remove his roof rack because of the status he associated with that accessory. Name-calling did not outweigh his ego’s need to posture.
2. Feeling that the others are real, living, breathing people is critical. Our participants commented that being asked to participate by a person they knew was critical to keep them going. They commented that receiving the tips from a real person named “Emily” made them feel accountable. They commented that they wished they had more connection with others who do the same drive so they can learn from others’ successes. They commented that they wished they could see the group’s success – how much gas and money had their group of x people saved – since that would feel more significant than just their solitary success. It was clear that the secondary motivation prompted by continuous interaction with real people was as motivational, if not more so, than the primary motivation of reducing gas usage. The design of the club and communications should elevate that human connection and support.
3. The information therapy and the rewards must be personalized. People crave a genuine connection, and if their specific situation and preferences aren’t taken into account, then they’ll tune it all out. Participants commented that both tips and rewards must be personalized; tips must be relevant to their particular drives and rewards must correlate to what matters most to each individual.
4. Getting past the initial skepticism takes effort – so be prepared for it. Participants didn’t buy that small changes would make a difference. The design of this club should include a mechanism that provides constant feedback correlating the output data with a person’s actions. People forget what they did and have trouble relating cause and effect, so we need to help them with that.

This is a sample of the insights we culled from our $10, 10-minute experiment. This experiment wasn’t about statistical significance, but about developing a good sense of what matters to people and where our risk factors lay should we pilot an actual High Blood Pressure Club. Given our experience, we feel the idea holds merit, and we know more about where and how to focus our design efforts.

Who’s interested in taking this further?

Jon Gabel from the National Opinion Research Center has an excellent op-ed piece in today’s New York Times. The basic argument is summarized in his conclusion:

“The Congressional Budget Office’s integrity is beyond questioning. But the record shows that it has substantially overestimated the cost of health care reform three times out of three. As Congress now works on its greatest push for reform in generations, the budget office needs to revise the methods it uses to make predictions about costs.”

Far from being an arcane methodological debate, CBO’s approach has profound consequences for health care reform and for the long-term health and economic conditions of the country. As Gabel puts it:

“The budget office’s cautious methods may have unintended consequences in the current health care reform effort. By underestimating the savings that can come from improved Medicare payment procedures and other cost-control initiatives, the budget office leads Congress to think that politically unpopular cost-cutting initiatives will have, at best, only modest effects. This, in turn, forces Congress to believe it can pay for reform only by raising taxes, which then makes reform legislation more difficult to pass.”

The reason that CBO has underestimated savings from past reforms of Medicare is that it makes the assumption that — without convincing empirical evidence of an initiative’s cost impact — it basically “scores” it as delivering zero savings. No doubt that CBO is consistent and conservative, but that doesn’t necessarily produce the most accurate budgetary forecast.

Perhaps more so than any other area in the federal budget, there are an enormous number of unknowns in health care. CBO has historically built its model on the premise that absence of evidence equates with evidence of absence.

But there is a major distinction. “Evidence of absence” means that we have an empirical reason to believe that there is no effect of an intervention (in this case on cost). In that case, it makes sense to score zero savings.

In contrast, “absence of evidence” simply means that we do not have sufficient evidence that an intervention produces any effect.  The problem is that, by definition, any true “innovation” (defined by Merriam-Webster as “the introduction of something new”) has no evidence. Which is to say: CBO has effectively ruled out scoring savings for true innovation.

Perhaps some would argue that’s an overstatement in that we certainly commonly use the term innovation to describe something that has been around long enough to be tested. Yes and no. There’s no doubt that new and innovation are relative terms, but there are still important reasons why that approach for CBO remains flawed.

First, evaluation takes time. To design a study, appropriately manage it, collect and analyze data, submit to peer review, and publish often takes many years.

Second, the level of evidence that CBO typically requires takes A LOT of time.

Third, innovation often comes from combining different initiatives and strategies that create a combined effect greater than the sum of their parts. Information therapy, patient decision aids, comparative effectiveness research, and other delivery system reforms may have a powerful impact when thoughtfully and appropriately combined together.

Fourth, the pace of innovation and the greatest innovative impacts can be dramatically robust. There is no way, in its current model, for CBO to capture those things that will have the most important effects on the federal health budget.

Like Jon Gabel, I don’t question the CBO’s integrity or analytical capacity, but I do believe that its methodological approach requires amendment. As I have written before, we — as health services researchers (and I admit to being one myself) — need to maintain our analytical rigor while being as creative in our research methods as the innovators are at innovating.

We should not shy away from the empirical idiosyncrasies that innovative care delivery initiatives create. Rather, we should rise to the challenge by employing a broader set of research and analytical skills to tackle these compelling research questions about new innovations. Indeed, the new care delivery strategies create opportunities for health services researchers to develop their own innovative research techniques.

I hope that health services researchers out there are up to that challenge.

If we aren’t, we will continue to create perverse public policy incentives.

The following is a guest post from Arna Ionescu, who is Domain Director, Connected Health for a leading innovation design firm, IDEO, an IxAction Alliance member. You can also find more background on the IxCenter’s increasing emphasis on Ix innovation design.

Thank you to the IxAction Alliance members who participated in our interactive webinar last Tuesday. During the webinar we used IDEO’s design approach to tackle the challenge of providing effective Information Therapy (Ix) to a fictional character named Vernon, who has minimal resources and was recently diagnosed with high blood pressure.

To inspire solutions for this challenge, members of the IxAction Alliance submitted images of unexpected learning moments in their daily lives. These images spanned from public service billboards to Snapple caps and restaurant placemats. In advance of the webinar, the IDEO team synthesized the images into brainstorm questions.

The webinar attendees voted and selected the brainstorm question, “How Might We leverage curiosity to prompt Vernon to engage with Ix?” Following IDEO’s brainstorm rules, attendees submitted ideas using the webinar software.

More than 30 ideas were generated in the ten minute brainstorm, and a second vote allowed the attendees to select which idea to pursue further. Attendees selected the “High Blood Pressure Club.” We discussed “$10, 10 minute prototypes” – an approach that allows us to try out fast and cheap experiments to gain insight before costly design and implementation efforts.

Two members of the Alliance community volunteered to explore the High Blood Pressure Club further. In subsequent discussions, we refined the idea to an online forum that people join when diagnosed with high blood pressure. We hypothesized that members would compete to reach emeritus status. We further hypothesized that people might feel more supported if they were paired with a buddy in the club, making the competition a team sport.

As we refined the idea, a number of questions came up, including: How do we reward people? Is emeritus status enough of a motivation to participate actively? Should buddy pairs be random or selected by club members? What’s the best recruiting mechanism for new members?

We decided to explore our questions around emeritus status using a $10, 10 minute prototype. Because feedback in healthcare takes a long time, we identified an analogous context in which to run the test. Instead of focusing on lowering blood pressure, we would focus on lowering gas usage when driving.

Next week we will start a two-week experiment about our “Gas Guzzler Club.” Three participants will measure a week-long baseline of their gas usage. At the beginning of the second week, we will “induct” our participants into the Gas Guzzler Club, letting them know they can achieve emeritus status, and provide a short tutorial on how to use less gas. Additionally, we will send daily tips in a medium of their choice (text, email, or voice). At the end of the second week the most successful participant will be granted emeritus status. We will then interview each participant about their experience to gain insight into how well we motivated them.

This plan will take relatively little effort yet should reveal a lot well before we invest significant time and money. We will follow up with another post next week to fill you in on the start of our experiment!

The Institute of Medicine (IOM) released its list of the top 100 topics that should be addressed in comparative effectiveness research (CER) now — thanks to $1.1 billion in the American Recovery & Reinvestment Act — that the federal government actually has the resources to do substantial CER. IOM has prioritized the list by creating four quartiles, noting that the first quartile is the highest priority group, etc.

In order for the federal government to make good use of the huge pot of CER money, there are at least five things that they need to do to ensure its value and actually change care delivery. I’m all for trying to find out whether me-too drugs add any significant value. However, the greatest opportunities for implementing delivery system change that improves care effectiveness and efficiency relate to innovations in how care is organized and delivered, and how insights are communicated to the broad range of health care actors — most notably consumers.

That’s why I was heartened by the IOM’s top 100 list — though certainly I’d move a few up a quartile or two. The list has many projects that fit my priorities, including a strong emphasis on CER to reduce health disparities.

Here are some examples of potentially valuable CER projects in the first quartile:

• Compare the effectiveness of dissemination and translation techniques to facilitate the use of CER by patients, clinicians, payers, and others.
• Compare the effectiveness of comprehensive care coordination programs, such as the medical home, and usual care in managing children and adults with severe chronic disease, especially in populations with known health disparities.
• Compare the effectiveness of interventions (e.g., community-based multi-level interventions, simple health education, usual care) to reduce health disparities in cardiovascular disease, diabetes, cancer, musculoskeletal diseases, and birth outcomes.
• Compare the effectiveness of literacy-sensitive disease management programs and usual care in reducing disparities in children and adults with low literacy and chronic disease (e.g., heart disease).

And those in the second quartile that really should be moved up:

• Compare the effectiveness of shared decision making and usual care on decision outcomes (treatment choice, knowledge, treatment-preference concordance, and decisional conflict) in children and adults with chronic disease such as stable angina and asthma.
• Compare the effectiveness of strategies for enhancing patients’ adherence to medication regimens.
• Compare the effectiveness of patient decision support tools on informing diagnostic and treatment decisions (e.g., treatment choice, knowledge acquisition, treatment-preference concordance, decisional conflict) for elective surgical and nonsurgical procedures—especially in patients with limited English-language proficiency, limited education, hearing or visual impairments, or mental health problems.
• Compare the effectiveness (including resource utilization, workforce needs, net health care expenditures, and requirements for large-scale deployment) of new remote patient monitoring and management technologies (e.g., telemedicine, Internet, remote sensing) and usual care in managing chronic disease, especially in rural settings.

Some from the third quartile that definitely could be prioritized higher:

• Compare the effectiveness and cost-effectiveness of conventional medical management of type 2 diabetes in adolescents and adults, versus conventional therapy plus intensive educational programs or programs incorporating support groups and educational resources.
• Compare the effectiveness of alternative redesign strategies—using decision support capabilities, electronic health records, and personal health records—for increasing health professionals’ compliance with evidence-based guidelines and patients’ adherence to guideline-based regimens for chronic disease care.
• Compare the effectiveness of different quality improvement strategies in disease prevention, acute care, chronic disease care, and rehabilitation services for diverse populations of children and adults.
• Compare the effectiveness of different strategies to engage and retain patients in care and to delineate barriers to care, especially for members of populations that experience health disparities.

And finally some from the fourth quartile that I also think deserve higher ranking:

• Compare the effectiveness of different techniques (e.g., audio, visual, written) for informing patients about proposed treatments during the process of informed consent.
• Compare the effectiveness of different disease management strategies for activating patients with chronic disease.
• Compare the effectiveness of different delivery models (e.g., home blood pressure monitors, utilization of pharmacists or other allied health providers) for controlling hypertension, especially in racial minorities.

These examples are not meant to be an exhaustive accounting of all the worthy projects proposed by the IOM. There was considerable attention to re-thinking the locus of care delivery — that is, evaluating the comparative effectiveness of emphasizing care that transpires outside traditional health care delivery settings. It’s also important to note that there are also a number of projects on the list that specify the need to assess CER using patient-reported outcomes.

I’m looking forward to the evolution of the CER agenda.

A multinational, multidisciplinary team apparently has won $1 million for improving the algorithms that Netflix uses to recommend movies to its users. The winning team — which includes statisticians, computer engineers and machine learning experts from the US, Austria, Israel and Canada — developed a program that improves the accuracy of movie recommendations by more than 10%.

Ix innovation design is a new focus for the Center for Information Therapy, in part through our collaboration with IDEO and the California HealthCare Foundation. We are eager to identify more robust methods for driving breakthrough innovations in patient-centered HIT applications.

For years, I’ve wondered why we see so few examples in the health care world of the Netflix or Amazon approach to guiding consumers to the information that they want. A huge success factor in information therapy (Ix) is the degree to which information prescribing can develop algorithms that effectively translate individual pieces of data into information triggers. The more data we can collect and efficiently transfer through electronic infrastructure and the more information derived from the consumers themselves, the greater the chance that we can prescribe or deliver the right information to the right person at the right time.

Netflix knows what movies I request and often how I rate them. They also ask me (in a very quick, convenient way) to rate other movies that I’ve seen. They put these data points together and somehow electronically try to make sense of someone who loved “The Killing Fields” and “This Is Spinal Tap,” but who was not enamored with “The Matrix.” They seem to do a reasonably good job, and perhaps this new program that was developed by the interdisciplinary team will deliver better movie recommendations to me.

That’s all fun, but it’s not my health — or my family’s health. There, the stakes are higher, and the information needs are several orders of magnitude more complex.

In trying to meet that need and challenge, the X-Prize Foundation has developed a health care competition, putting $10 million on the line. Unlike Netflix, however, this isn’t all about 1’s and 0’s. Changing the way health care is delivered involves a lot more than modeling scenarios on a computer.

That said, we can probably borrow a lot from the computer engineers, statisticians and machine learning experts and transfer those learnings to Ix innovation. To do so, however, we need those experts to join forces with clinicians, patients and ethnographers/anthropologists in order to make sure that what we learn has meaning for consumers and can be embedded into the clinical workflow.

I had the opportunity to meet with Aneesh Chopra — our country’s first Chief Technology Officer — last week. The CTO serves as Associate Director of the Obama administration’s Office of Science & Technology Policy (OSTP), which “serves as a source of scientific and technological analysis and judgment for the President with respect to major policies, plans and programs of the Federal Government.” OSTP will also lead interagency efforts on a wide range of science and technology policy issues, certainly to include health information technology (HIT) in collaboration with David Blumenthal in the Office of the National Coordinator for HIT.

Chopra — whom I’ve known for years from our days together at the Advisory Board Company — is not only really sharp but very creative in thinking into the future about how technology can evolve. The opportunity is enormous, but capitalizing on it requires more than just technology development but policy planning as well. One could argue that the pace of technology advance over the last several decades arguably has outpaced our imagination, yet we haven’t harnessed those breakthroughs in the form of health care productivity or quality gains.

The New York Times Sunday Business section explored the government’s role in stimulating innovation yesterday. Steve Lohr cites Chopra’s interest in building “innovation platforms” to spur growth, but Lohr notes that there are at least nine countries that have been more aggressive than the U.S. in using government to drive innovation: Australia, Brazil, Britain, Chile, Colombia, Finland, India, Norway and Singapore.

The Center for Information Therapy (IxCenter) also has been focused recently on how stimulate more robust innovation in the field of information therapy (Ix). In some ways, this was a natural evolution of our partnership with Health 2.0, LLC, in preparing for the first-ever “Health 2.0 Meets Ix” conference we held two months ago. There, we explored (among other things) how innovative health 2.0 tools could be combined with Ix strategies to create new models for health care delivery.

We also have launched two collaborative projects with IDEO — the innovation design firm responsible for creating everything from the first Apple mouse to the Swiffer — in our search for rapid-cycle innovation in Ix strategies. Thanks to a grant from the California HealthCare Foundation, we will work with IDEO to develop Ix strategies to overcome barriers in implementing innovative consumer engagement strategies with safety-net populations in California. We will address text-messaging applications and other approaches to information prescribing.

Another experiment involves applying the IDEO model to Ix innovation design with our IxAction Alliance in its monthly webinar. In addition to trying to develop a robust model for Ix innovation design, we also are testing out whether we can apply the highly intensive in-person workshops and collective observation of users to the virtual and dispersed nature of our monthly IxInsights webinars. That has major policy planning implications in terms of the scalability and efficiency of how we stimulate innovation nationwide.

The IxCenter will be actively pursuing robust approaches Ix innovation design strategies over the coming months, and we’ll certainly be sharing everything we learn in this space. In the interim, it would be great to get suggestions and other input from readers on the best strategies for rapid-cycle, breakthrough innovation.