Service Tools For Innovating Chronic Disease Management

Innovating a New HEALTH CARE Service Compact title slide Service Innovation Design & Development June 22, 2009, Chicago by Michael Eckersley, PhD HumanCentered Except where otherwise noted, this work is licensed under a Creative Commons Attribution 3.0 License.

Employers Health Network* St. John’s Health Plans* Medical Management Services Medical Management Springﬁeld, Missouri Springﬁeld, Missouri www.employershealthnetwork.com www.stjohns.com Kezia Lilly, RN, BSN Janet Pursley, RN Ann Cave, RN and team members Thanks to all the dedicated people who contributed so generously to this exploratory study. It’s a modest beginning toward the goal of making a difference in the lives of those who struggle with chronic disease. *Note: This document does not necessarily reflect the opinions or policies of EHN, St Johns, or The Sisters of Mercy System Graduate Design Management Students and Interaction Design Students from The University of Kansas, School of Architecture, Design & Planning Jeffrey Albritton Hedi Heinz Rachel Magario Mason Pine Lu Bever Jennifer Knight Care Miller Angel Stahl Randall Blair Kevin Lafferty Tom Petty Denise Staples Except where otherwise noted, this work is licensed under a Creative Commons Attribution 3.0 License.

“The greatest threat to America’s fiscal health is not Social Security... It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our national’s balance sheet is the skyrocketing cost of health care. It’s not even close.” “Where are the game-changers, the investments that we make now that are going to reduce costs now? Even if they don’t reduce them this year or next year, but ten years from now or twenty years from now, we are going to see substantially lower costs.” “...(W)e are going to...invest more in prevention and wellness programs. -President Barack Obama

The Premise

Solutions to explosive health care costs won’t come from medical science, from government, from the insurance industry or even from health care itself. The economics of health care are not ultimately about payer systems, utilization levels, or supply, but about the behaviors, lifestyles and cultural norms that lead to massive health care demand. That demand can be traced to a handful of well known and mostly avoidable diseases. The simple fact is, we know how to prevent most of them or, at least, mitigate their most tragic and costly effects. Any sustainable health care solution will have to stem the demand for such services and not just pay the costs of supplying them.

Our Study

Our Activities frame insights form hypotheses explore concepts make plans UNDERSTAND articulate intent MAKE research & discovery represent & prototype offerings know context & users • health care industry modeling REALIZE • bench research chronic disease • interviews (cdm professionals) • disposable camera study • ethnographic interviews (patients) – adapted from V. Kumar, ID-IIT & IDEO

Develop a Systems Understanding of The Problem High 4 High Search: environmental global 3 & market factors macro economic 2 market/industrial 1 Systems Scope organizational 0 “street-level” issues & operations physical/biological 1 socio-cultural 2 Deep Search: human psychological 3 factors spiritual 4 Deep Learning Learning (time) Cycle 0 Cycle 1

what’s viable? te ch ics no om lo on g y ec back stage wellness, prevention and what’s feasible? health management services front stage services customer experience what’s desirable?

global macro economic market/industrial organizational “what is” The economics, institutional, and market factors around chronic disease

20,000 classifiable diseases

cardiovascular disease Data Source: National Health Library, NIH Rendered with Many Eyes, IBM

diabetes Data Source: National Health Library, NIH Rendered with Many Eyes, IBM

chronic obstructive pulmonary disease Data Source: National Health Library, NIH Rendered with Many Eyes, IBM

cancer (neoplasms) Data Source: National Health Library, NIH Rendered with Many Eyes, IBM

liver cirrhosis Data Source: National Health Library, NIH Rendered with Many Eyes, IBM

asthma Data Source: National Health Library, NIH Rendered with Many Eyes, IBM

cardiovascular disease diabetes COPD These six diseases account for the vast majority of deaths, disabilities & health care costs cancer liver cirrhosis asthma

Chronic diseases are non-infectious, long term, mostly avoidable. Worst effects are preventable. Determinants include poor diet, inactivity, obesity, smoking, psychosocial stresses, genetic predisposition. Causes or compounding factors include lifestyle choices and behaviors, lack of regular health check-ups and preventive care.

✔ Leading Causes of US Deaths, 2006 ✔ ✔ ✔ ✔ 34% 30% 7.3% 6.7% 6.5% 3.9% 3.9% 3.0% 2.4% 1.8% A A Ki Ca In eu St cc D lz D CO Po H isea Bl son Pn dn as D ﬂu m ia ise he id nc ro ea se oo in i PD be ey e en en on ke im er rt d g te t za ia er s s ’s Source: National Center for Health Statistics, 2006 &

Total U.S. Health Spending 2007 Total spending =$2.2 trillion 25% 75% Share spent treating patients with one or more chronic conditions = $1.7 trillion Source: CMS

Chronic Disease Prevalence Among American Workers, 2007 Five or more None 19% 23% Four 8% Three One 12% 22% Two 16% Source: Newsweek Web Exclusive

Projected Rise in Cases of Seven of the Most Common Chronic Diseases, 2003-2023 ➜ Cancers 62% ➜ Diabetes 53% ➜ ➜ Hypertension Mental Disorders 39% 54% ➜ Heart Disease ➜ 41% Pulmonary Conditions ➜ Stroke 31% 29% Source: The Miliken Institute

The best strategy against soaring health care costs? Investment in prevention, health risk reduction and disease management. Such programs are cheap compared to the staggering costs of not implementing them. our objective: chronic disease reduction & mitigation

health care services, facilities, personnel

Less than 1% of health care expenditures go toward prevention or managed care of chronic disease. Source: Institute of Medicine, Health Affairs, JAMA Data Source: National Health Library, NIH Rendered with Many Eyes, IBM

preventive health services Data Source: National Health Library, NIH Rendered with Many Eyes, IBM

managed care programs Data Source: National Health Library, NIH Rendered with Many Eyes, IBM

attention Health Care succeeds or fails knowledge on the basis of having the right mix of information empathy imagination ...and having an effective process in place to translate that mix into an effective system solution.

Treatment Expenditures and Lost Economic Output (in Billions) Per Chronic Condition* $ Stroke $22 Diabetes $27 $105 Treatment Expenditures Pulmonary $45 $94 Lost Economic Output Conditions Heart $65 $105 Disease Mental $46 $171 Disorders Hypertension $33 $280 Cancers $48 $271 0 50 100 150 200 250 300 Source: The Miliken Institute

Health care expenditures in the US are highly concentrated, with 5% of the patient population accounting for 49% of costs. Reducing these numbers even slightly will result in large system savings Health Care Costs Patient Population Sickest 1% Very Sick 4% $ Sickest 28% $ Relatively Healthy 51% $ Relatively Healthy Very Sick 95% 21%

The human costs are much higher

"Consumers of health care need choices. Individually they need to value the preciousness of their own health in order to conserve and prolong it, and to manage their own aging. The governing agent is behavior". –Sam Keihl, MD Columbus, Ohio

Stemming the demand for avoidable health care services is the silver bullet in any serious, sustainable health care solution. For everyday Americans, whether covered by health insurance or not, that means modifying risky behaviors (i.e., smoking, excessive drinking, drug use, overweight and obesity) and altering personal lifestyle factors (i.e., exercise, diet), that compromise health, and ultimately require intervention. – Michael Eckersley, “Solving The Economics of Health Care: How Employer-Provider Partnerships Are Producing Cost Savings and Healthier People”

There are solid benchmarks for assessing good medical judgment. The medical science is clear. What no program has yet mastered is the formula for persuading or motivating large numbers of Americans to get their lifestyles and behaviors in line with their health and economic self interests. – Michael Eckersley, “Solving The Economics of Health Care: How Employer-Provider Partnerships Are Producing Cost Savings and Healthier People”

What’s Needed: A Truly Patient-Centered Managed Care Model

“what is” The human factors of chronic disease physical/biological socio-cultural psychological spiritual dig here

qualitative, naturalistic data “Anecdotes carefully collected and reported are the important data of cultural understanding. Anecdotes can reveal truths below the surface that broader market statistics conceal” – Clarence Page

breaking the “human code” The real focus of an ethnography is not behavior per se, but the symbolic systems that guide human behaviors, inform beliefs, and shape the things in use. – Rick Robinson & Jim Hackett

“Marcus” 5 y/o male Sparta, MO Conditions: Asthma, Heart Mom & Dad: “Stacy & Ron” “Asthma: another word for frustrating”

“We have put our son in the hands of so many doctors and have been lucky. But doctors need to be more accessible to special needs kids.”

“The cardiologist came back into the room with the pediatrician and they both sat down. That’s when I knew there was something wrong... All I remember is “open heart surgery”.

“Beth” 45 y/o female Nixa, MO Conditions: Type 1 diabetes, hypothyroidism, hypertension, asthma, severe allergies, depression & anxiety “Eye. I have been told I have pretty eyes. I was diagnosed w/glaucoma last year. I am only 45. I am scared.”

“Food outlets. It is everywhere. I am hungry all the time. I crave sweets, so bad for a diabetic. After eating a large amount of sugar or carbs I will usually awake in the middle of the night nauseated and having to vomit. Yet I wake up later craving carbs.”

“Pills, a weeks worth. A daily reminder that at 45 yrs old my body is not well.”

“Cat, her name is Millie, I call her Mimi. She follows me everywhere & loves me unconditionally, skinny or fat. Since I became diabetic I am 70lbs heavier.”

“For years, I “Teresa” think I was 48 y/o female in denial... I Nixa, MO Conditions: Diabetes, high did not want blood-pressure, high cholesterol diabetes & thought it was an older person’s disease”

“I’m on medication to combat high-cholesterol... I don’t want to be on any more medication... In February 09 my A1C was over 8. I know I need to do something.”

“Even with physical problems, there were times over the last eight years when I did use my treadmill or take walks. I did lose some weight and feel better when I did.”

“Controlling sugar levels is a lifetime commitment. I am eating smaller amounts. I am almost a vegetarian”

“Sam” 67 y/o male Springﬁeld, MO (CD Risk) Conditions: High blood- pressure, asthma, allergies, leg disabilities, overweight “I used to work in construction, dirt work, and asphalt work. I think this has effected my breathing”.

“I have high blood pressure. I think I eat too much pizza and beer maybe. I have to cut down on these things. I seem to eat too much fast food and this has caused me to gain weight.”

“I go to my doctor at SGC (clinic) in Springﬁeld. I have a handicap Parking pass since I can’t walk very far.”

“I use a lot of medicine now. This is for my blood pressure and breathing. Allergy medicine too.

“Mary” Chronic Disease Case Manager, RN Springﬁeld, MO • “We've moved into a new level of nursing. • ”Working with our chronic disease patients requires patience, empathy and persuasion.” • “Our medical management database equips our team to see the whole system picture down to the patient level.”

“what if?” What kinds of service tools and motivational supports could help people with chronic disease, and people at risk, better manage and improve their health? How can we make it easier for them to succeed and harder to fail?

Tentative Recommendations 1. Focus upstream: target people across a wellness spectrum– from well, to at-risk, to sick. Offer a network of incentives and supports appropriate to their individual situation. 2.Develop a platform of effective psychological, socio-cultural, and spiritual affordances to enable positive behavior and lifestyle changes. 3.Augment existing medical management, prevention, and wellness programs with integrated service tools that empower people to monitor and self-manage their health.

Create a culture of wellness empowerment

Track the status across a wellness spectrum GOOD HEALTH AT RISK POOR HEALTH 1 2 3 4 5 6 1 Healthy, good diet, high activity level, no signs of a chronic disease. Healthy, good diet, moderate to high activity level. Age and lifestyle may start 2 to create favorable variables of chronic disease. Moderately healthy, moderate diet, little to no activity level. May start to show 3 signs of a chronic disease. Moderately healthy, moderate diet, little to no activity level. Starting to show 4 deﬁnite signs of chronic disease, or diagnosed with a pre- condition. Health problems associated with a diagnosed chronic disease. 5 Daily activity level is affected. Treatments plans advised. Severe health problems associated with a diagnosed chronic disease. 6 Daily activity level is impaired. Hospitalization required.

Work with people where they’re at GOOD HEALTH AT RISK POOR HEALTH 1 ➔ 2 3 ➔ 4 5 ➔ 6 John Margo Stuart “Mr. Indestructible” “Ms. Denial” “Down but not out” Age: 26 Age: 45 Age: 63 Non-Profit Admin High School Staffer Retired Salesman MBA Married, 2 Children Married, 2 Children Single Weight: 175 lbs Weight: 165 lbs Weight: 150 lbs Sedentary, Overweight High blood pressure Height: 5’-8” High cholesterol Diabetes High cholesterol Non-smoker Melanoma Non-smoker

Two Service Design Concepts • “My Health Network”. Live health & wellness resources; special health topics forums; peer mentoring and motivational coaching; real-time online “nurse/physician- on-call”; health behavior is self-directed, personal, social networking-type site, appropriate positive reinforcements. • “My Health Portal”. Personal health dashboard for ages 14 & up); pertinent health and wellness content; health tracker with real -time data feeds charted over time; lifestyle and simple diagnostic calculators; goal-setting and achievement tools; future health scenario projections; incentive programs and competitions for improving health indicators, e.g., blood pressure, cholesterol, and tracking them over time”.

The Service Technology Platform “My Health Portal” * “My Health Network” *

“My Health Network” Sports Leagues Wellness Counselors Clubs & Groups Peer Mentoring Virtual Social Networks Discount Programs Community Activities SOCIALIZATION MOTIVATION Customized Incentives Social “Meet Ups” Spiritual Support Travel Connections Support Groups MY HEALTH WELLNESS PORTAL CONCIERGE COACH Classes and Training Live Health Chat E-Health Record Financial Strategies EDUCATION Physician Database Mental Health Strategies Medical Treatment Information Physical Activity Strategies

“My Health Network” User Profile Socialization: Dinner Clubs Margo Motivation: Free Gym Membership • Likes to cook Education: Cooking Class • Wants to lose weight • Wants to exercise • Concerned about diabetes Margo uses the Wellness Concierge to help take her likes, dislikes 1 2 3 4 5 6 and priorities to ﬁnd a Health Network that works great for her. MARGOʼS RISK She now attends a Cooking with Diabetes class where she learns of LEVEL recipes to try out with her new friends in the Dinner Club she attends. She is also working on a weight loss goal of 20 pounds to win a free, year-long gym membership. With this network, Margo is well on her way to lowering her chronic- disease risk, and enjoying a new, active life.

Technology Mashup

What are the human and economic benefits of service design intervention?

Future Cost Savings Associated with Improved Chronic Disease Prevention and Management (in Billions) $1200 Lost economic output (indirect) $1000 Treatment expenditures (direct) $800 $600 $400 $200 $0 2004 06 08 10 12 14 16 18 20 22 2023 *This study evaluated the burden of seven of the most common chronic diseases/conditions (cancer, diabetes, heart disease, hypertension, mental disorders, pulmonary conditions, and stroke). Source: The Milken Institute

Savings By Year of Lowered CD Risk Factors GOOD HEALTH AT RISK POOR HEALTH 1 2 3 4 5 6 ➔ $190 Lowered CD risk of 10% of the population $180 would save $1.65 trillion over 10 years, and save over 1 million lives. $170 $160 $150 $140 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

What’s “The Compact”? The Compact For a Sustainable Health Care Future “Get a little healthier. Stay a little ﬁtter. Eat a little less. Walk and exercise a little more. Get your check-ups more regularly. In other words, take responsibility for getting yourself and your family healthier, and in return you and everybody else can have quality, affordable health care services for life – a longer life.”

Next Steps • Further user research • Strategic design planning • Service and technology design, prototyping • Iterative testing–by region, SES group, age group

Innovating a New HEALTH CARE Service Compact title slide Service Innovation Design & Development June 22, 2009, Chicago by Michael Eckersley, PhD HumanCentered Except where otherwise noted, this work is licensed under a Creative Commons Attribution 3.0 License.

Service Tools For Innovating Chronic Disease Management

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