What are scalable best practices to spread smart health?

1. What are scalable best practices to spread smart health?

2. Chaired by: Jayne Plunkett, Head of Casualty Reinsurance at Swiss Re, YGL Class of 2010 Misha Pavel, Program Director of Smart and Connected Health at the NSF Dharma Singh Khalsa, President of the Alzheimer’s Research and Prevention Foundation Josh Wright, Managing Director of ideas42 What are scalable best practices to spread smart health?

3. Misha Pavel, Program Director of Smart and Connected Health at the National Science Foundation What are scalable best practices to spread smart health?

4. 4 Smart and Connected Health Misha Pavel College of Computer and Information Science Bouvé College of Health Sciences Northeastern University & National Science Foundation Computer & Information Science & Engineering Directorate Information and Intelligent Systems Division Any opinion, finding, and conclusions or recommendations expressed in this material; are those of the author and do not necessarily reflect the views of the National Science Foundation

5. Road ahead I. Healthcare in Crisis II. Smart & Connected Health III. Behaviors including Big Data 5 Wactlar H., Pavel M., and Barkis W., "Can Computer Science Save Healthcare?," Intelligent Systems, IEEE, vol. 26, pp. 79-83, Sept. 2011.

6. PART I: Healthcare in Crisis Advances in Technology 6

7. The healthcare crisis – Some troubling statistics • The cost of healthcare in the U.S. is the highest in the world (> $8,000 per capita, 16% GDP) • The U.S. ranked 37th in the 2000 WHO study of healthcare system performance (8 underlying measures) • 98,000 deaths per year due to medical errors • Current individual medical records have an error rate of 20% • 50% Americans have 1 or more chronic diseases; age of onset is getting younger • Medicare and Medicaid costs to be at a staggering 25% of the U.S. economy by 2050 • 3 lifestyle behaviors (poor diet, lack of exercise, smoking) cause estimated 1/3rd of U.S. deaths 7

8. Dependency Ratio: Retired/Working 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 Dependency Ratio [Over 64] /[20-65] Year Estimates Projections Silver Tsunami

9. A sample of recent strategic visions & activities Focus on transforming healthcare with technology and innovation

10. From traditional medicine to smart health NSF Perspective EPISODIC, REACTIVE FOCUS ON DISEASE PROACTIVE and PREVENTIVE FOCUS ON WELLBEING QUALITY OF LIFE HOSPITAL-CENTRIC PATIENT-CENTRIC, HOME-BASED FRAGMENTED, LOCAL DATA INTEROPERABLE, EHR AVAILBLE ANYWHERE, ANYTIME NAÏVE,PASSIVE, PATIENTS EMPOWERED, ENAGAGED, INFORMED, PARTICIPATING TRAINING & EXPERIENCE BASED MORE EVIDENCE – BASED DECISION SUPPORT

11. Quality of Life over Life-Span 0 20 40 60 80 100 120 Age [Years] Quality of Life Rectangularization after Fries, 1983 11

12. Source: Sajal Das, Keith Marzullo Person al Sensing Public Sensing Social Sensing People-Centric Sensing Actions (controllers) Percepts (sensors) Agent (Reasoning) Smart Health Situation Awareness: Humans as sensors feed multi- modal data streams Pervasive Computing Social Informatics Sense Identify Assess Intervene Evaluate Emergency Response Environment Sensing The Age of Observation – Smart Sensing, Reasoning and Decision: BIG DATA

13. PART II: Smart & Connected Health (SCH) Inter-Agency Program National Institutes of Health National Science Foundation 13 NSF Solicitation: NSF-13-543 NIH Notice Number: NOT-OD-13-041

14. Objectives of the Smart and Connected Health Program • To fill in research gaps that exist in science and technology in support of health and wellness • To advance the fields of health, wellness, improve quality of care and reduce cost by leveraging the fundamental science research Seek improvements in safe, effective, efficient, equitable, and patient-centered health and wellness services through innovations in computer and information science, engineering, social, behavioral and economic science and medical science

15. NSF Directorates Participating in SCH 15 Office of the Director Engineering (ENG) Geosciences (GEO) Mathematical and Physical Sciences (MPS) Budget, Finance Award Management Computer & Information Science and Engineering (CISE) Biological Sciences (BIO) Diversity and Inclusion Social, Behavioral and Economic Sciences (EBS) Education and Human Resources (EHR) General Counsel Information & Resource Management Legislative & Public Affairs National Science Board Office of Inspector General Cyber- infrastructure Integrative Activities International Science and Engineering Polar programs

16. NIH Institutes Officially Participating in SCH OBSSR NCI NIBIB NIA NHGRI NICHD National Human Genome Research Institute

17. Family Caregiver Coach Clinician Devices User Interfaces Inference Assessment Patient-centered framework for health, wellness and precision medicine (including behavioral assessment) Payers Employers Legal Environment Privacy Self-care Patient Physical Function Cognitive Function Chronic Disease Socialization Physio Sensors Activity Sensors Mobile Sensors EHR, PHR Mobile Health NIT: Networks, DB, API Software, EHR, PHR

18. ECG EEG Pulmonary Function Gait Balance Step Size Blood Pressure SpO2 Posture Step Height GPS Performance Early Detection Prediction Inference Datamining Training Health Information Coaching Chronic Care Social Networks Decision Support Population Statistics Epidemiology Evidence Mobile Health 18 Training Health Information Coaching Chronic Care Social Networks Wactlar H., Pavel M., and Barkis W., "Can Computer Science Save Healthcare?," Intelligent Systems, IEEE, vol. 26, pp. 79-83, Sept. 2011.

19. Smart and Connected Health Research Areas • Integration of EHR, pharma and clinical data • Access to information, data harmonization • Semantic representation, fusion, Digital Health Information Infrastructure Informatics and Infrastructure • Datamining and machine learning • Inference, cognitive decision support system • Bring raw image data to clinical practice Data to Knowledge to Decision Reasoning under uncertainty • Systems for empowering patient • Models of readiness to change • State assessment from images video Empowered Individuals Energized, enabled, educated • Assistive technologies embodying computational intelligence • Medical devices, co-robots, cognitive orthotics, rehab coaches Sensors, Devices, and Robotics Sensor-based actuation

20. Challenge: Extraction of Knowledge and Meaning Harmonizing/Coherence: Source-Invariant Decisions NIT (ICT) Network Layer, Databases, EHR, PHR, XHR Decisions Transform Decisions Decisions Transform Transform Transform Heterogeneous Sources/Sensors Adaptation, Calibration & Fusion Transform Transform Transform

21. PART III Focus on Behaviors Big Data Any opinion, finding, and conclusions or recommendations expressed in this material are those of the author and do not necessarily reflect the views of the National Science Foundation 21

22. Causes of Premature Mortality 22 30% 5% 15% 40% 10% Behavioral Social Circumstances Environmental Exposure Genetic Medical Care Deficiency McGinnis JM, Russo PG, Knickman, JR. Health Affairs, April 2002.

23. Changing habits and lifestyle is difficult 23

24. ECG EEG Pulmonary Function Gait Balance Step Size Blood Pressure SpO2 Posture Step Height GPS Performance Early Detection Prediction Inference Datamining Training Health Information Coaching Chronic Care Social Networks Decision Support Population Statistics Epidemiology Evidence Mobile Health 24 Training Health Information Coaching Chronic Care Social Networks Wactlar H., Pavel M., and Barkis W., "Can Computer Science Save Healthcare?," Intelligent Systems, IEEE, vol. 26, pp. 79-83, Sept. 2011.

25. Examples from Oregon Center for Aging and Technology (ORCATECH) 25 Home Health

26. Hayes, ORCATECH 2007 26 Bedroom Bathroom Living Room Front Door Kitchen Sensor Events Private Home BIG BEHAVIORAL DATA

27. Challenges for closing the loop Continuous, Unobtrusive Monitoring of Activities Physiology and Genomic BIG DATA Computational Predictive Models Phenotyping Including Behavioral (Behavioral Markers) Prevention, Early Detection, Rehabilitation, Maintenance,

28. Monitoring and assessment of gait 28 • Unobtrusive assessment of everyday speed of walking • Modeling sensors and human gait Daniel Austin Stuart Hagler

29. Example: Relating Speed of Walking to Cognitive Function 06/07 11/08 03/10 40 50 60 70 80 90 100 110 120 Time Evolution of the gait velocity PDF for home 196 (dir=0). Velocity (cm/s) 0.005 0.01 0.015 0.02 0.025 0.03 0.035 0.04 CDR = 0.5 29 Daniel Austin, OHSU

30. Gait Sensors Multiscale Modeling: From sensors to brain function should include behavioral and cognitive factors • Unobtrusive measurement of gait characteristics • Model relationship between the sensory inputs and gait characteristics • Infer sensory-motor, perceptual and cognitive functions Cognition Perception Sensory Motor Inference of Gait Parameters Cognition Perception Sensory Motor Inference of Brain Function 30

31. Example: Monitoring Sleep with load cells under the bedposts 31

32. Sleep and Physiological Measurements using Load Cells Technology • Strain gauge transducers • Monitoring quality of sleep • Monitoring sleep hygiene • Monitoring weight 21:00 00:00 03:00 06:00 Time (hour) Total Force (N)

33. Apnea and Movement Detection 33 5. Z. Beattie, C. Hagen, M. Pavel, and T. Hayes, “Unobtrusive Monitoring of Sleep Apnea," SLEEP 2011 Abstract 25th Anniversary Meeting of the Associated Professional Sleep Societies, LLC, Minneapolis, Minnesota, Jun 11 – Jun 15, 2011.

34. Cognitive Assessment with Computer Interactions Example: Computer games (with embedded inference algorithms)

35. Example: Working Memory 35 Design Objectives • Address key cognitive functions • Self-motivating • Incorporate a model of underlying memory processes

36. Memory Model: Survival Analysis 36 0 5 10 15 0 0.5 1 Subject 1020, N = 8687 Probability of Correct Intervening Number of Events 0 5 10 15 20 25 0 0.5 1 Probability of Correct Intervening Time [sec]     1 b t a M t F t e         

37. Collaborators and Support Teams OHSU Team UCB Team • Holly Jimison • Tamara Hayes • Jeff Kaye • Jennifer Marcoe • Krystal Klein, Post-doc • Stuart Hagler, • Daniel Austin • Zephy McKanna • Steve Williamson • Tracy Zitleberger • Nicole Larimer • Don Young • Yves Vimegnon, • Jon Yeargers • Devin Williams • Ruzena Bajcsy, PI • Edmund Seto, Co-I • Gregorij Kurillo, Senior Researcher • Ferda Olfi, PhD Student • Štěpán Obdržálek, Post-doc 37 3/18/2022 Oregon Research Center for Aging and Technology

38. Take Home Messages 38 I. Healthcare is in crisis II. Smart & Connected Health is focused on developing technology-based solutions that can help making healthcare preventive and focused on quality of life III. Focus on behaviors using monitoring as well as cognitive and physical exercise can have a huge impact on improving quality of life IV. Analytics and computational modeling will play an essential component of the emerging technology

39. 39 Thank You

40. • Copyrighted material used under Fair Use. If you are the copyright holder and believe your material has been used unfairly, or if you have any suggestions, feedback, or support, please contact: ciseitsupport@nsf.gov • Except where otherwise indicated, permission is granted to copy, distribute, and/or modify all images in this document under the terms of the GNU Free Documentation license, Version 1.2 or any later version published by the Free Software Foundation; with no Invariant Sections, no Front-Cover Texts, and no Back-Cover Texts. A copy of the license is included in the section entitled “GNU Free Documentation license” (http://commons.wikimedia.org/wiki/Commons:GNU_Free_Documentati on_License) • The inclusion of a logo does not express or imply the endorsement by NSF of the entities' products, services or enterprises. Credits 40

41. Q&A 10 minutes (Included in session recording)

42. Dharma Singh Khalsa, President of the Alzheimer’s Research and Prevention Foundation What are scalable best practices to spread smart health?

43. Alzheimer’s Prevention 2013: From Drugs to Lifestyle Dharma Singh Khalsa, M.D. President/Medical Director Alzheimer’s Research and Prevention Foundation www.alzheimersprevention.org

44. 5.4 million people have Alzheimer’s >$150 billion dollars in annual costs >10 million unpaid caregivers 6th leading cause of death #1 worry a new case every 6833 seconds 2013 Alzheimer’s Disease Facts and Figures

45. Maintain a sharp brain with age Boomers’ #1 Fear Getting Alzheimer’s Boomers’ #1 Goal

46. FOR IMMEDIATE RELEASE May 15, 2012 Contact: HHS Press Office (202) 690-6343 News Release Obama administration presents national plan to fight Alzheimer’s disease (NAPA) HHS Secretary Sebelius outlines research funding, tools for health care providers, awareness campaign and new website Health and Human Services Secretary Kathleen Sebelius today released an ambitious national plan to fight Alzheimer’s disease. The plan was called for in the National Alzheimer’s Project Act (NAPA), which President Obama signed into law in January 2011. The National Plan to Address Alzheimer’s Disease sets forth five goals, including the development of effective prevention and treatment approaches for Alzheimer’s disease and related dementias by 2025.

47. Until 2012, Lifestyle Included in National Discussion 2013: Drugs and Genetics We need to re-introduce lifestyle into the conversation

48. The Four Pillars of Alzheimer’s Prevention 1. Diet and Brain Specific Nutrients 2. Stress Management 3. Exercise 4. Spiritual Wellbeing

49. What’s Missing?

50. Why Yoga/Meditation Should be Part of the Conversation 1. Stress is a risk factor for memory loss 2. Meditation lowers stress and improves brain function 3. KK is faster and easier and memory specific compared to other meditation techniques: a. The Relaxation Response – 20 min/ twice a day b. TM – 20 min/twice a day c. Mindfulness – 47 min average d. Kirtan Kriya (KK) – 12 min

51. The Benefits of KK in 12 Min/Day 1. Can be easily learned and practiced at home with a CD 2.Strengthens the brain, like going to the gym strengthens the body 3.Improves attention, concentration, focus and memory 4. Better mood, less depression and anxiety 5. More mental and physical energy 6. Enhanced Genetic Health Demonstration on Sept 27th

52. 1. FINGER Study 2. UCLA- KK & MCI 3. UWVA-KK & MCI Ongoing ARPF Research 4. UofAz- KK + virtual balance training vs bt, associated with cog dysfunction

53. And In The End… Spirit and Wisdom To Be Continued on Sept 27th….

55. Josh Wright, Managing Director of ideas42 What are scalable best practices to spread smart health?

56. Using Behavioral Economics To Improve Health 2013 SmartBrains Summit September 20th – 8:30-10:30 What are scalable best practices to spread smart health? Josh Wright josh@ideas42.org

59. 59 …A BEHAVIORAL IDEAS LAB AND CONSULTING FIRM (501c3) WITH AN AMBITIOUS GOAL ©2013 ideas42 59 Academics Theory Amazing understanding about human behavior from Behavioral Psychology & Behavioral Economics academic research Need To Apply Real World To Solve Hard Problems in: -Consumer Finance -Economic Opportunity -Health -Education -Energy Consumption To Help Millions of People

75. 401(k) PSYCHOLOGY Out of every 100 surveyed employees 68 self-report saving too little 24 plan to raise savings rate in next 2 months 3 actually follow through over the next four months ©2012 ideas42 75

77. CAUTION: DIAGNOSIS SHOULD DRIVE DESIGN • Defaults work in increasing 401(k) savings • Can we apply to savings in general? • Field experiment tested with low-income population receiving EITC. • Defaulted to placing 10% into savings bonds. ©2012 ideas42 77

78. • Defaults work in increasing 401(k) savings • Can we apply to savings in general? • Field experiment tested with low-income population receiving EITC. • Defaulted to placing 10% into savings bonds. 0% 20% 40% 60% 80% 100% Opt In Opt Out 78 ©2012 ideas42 CAUTION: DIAGNOSIS SHOULD DRIVE DESIGN

79. EITC PSYCHOLOGY 0% 25% 50% 75% 100% Did not trust the government Did not feel comfortable buying bonds Did not like bonds because wanted more liquidity Did not have a baseline to compare to bonds interest rate Had specific plan for how they were going to spend refund ©2012 ideas42 79

80. PROJECT EXAMPLE – OREGON MEDICAID  Oregon had to limit the number of people who could receive Medicaid because of budget constraints.  Budget resources situation improved, Oregon could add more people to Medicaid program, but not everyone that is eligible.  Asked people to submit request to be put on wait list and to be selected at random for Medicaid.  People who are selected at random are asked by mail to fill out full application, and eligible applicants receive healthcare. 80 ©2013 ideas42

82. PROJECT EXAMPLE – OREGON MEDICAID 82 Mailed Offer 100 Do not Complete App. 40 60 Complete App. App. rejected – Not filled out properly or ineligible 30 30 App. approved Primary focus – increase uptake Secondary focus – increase proper fill outs ©2013 ideas42

83. DIAGNOSIS - 3 STATES OF ENGAGEMENT 1. How can we increase the opening of envelopes? Opening Understanding Taking Action 2. How can we help customers understand the letter? 3. How can we help customers quickly take action?  There are 3 states of engagement with the customer when sending a letter:  Opening the envelope  Understanding the letter and application  Taking Action, e.g., properly fill out application 83 BUT WE COULD NOT CHANGE THE APPLICATION ITSELF? ©2013 ideas42

84. DIAGNOSIS - TIMING DRIVES RECEPTIVENESS AND COGNITIVE DEMANDS 84 (LMI) Results Experiment • Mall shoppers participated in an experiment • Shoppers were randomly assigned to one of two groups. One group was asked to think through an easy financial situation, and the other was challenged with a hard financial situation • Afterwards, all the shoppers received a simple cognition test Cognitive Score and Financial Stress • The cognition scores of lower income shoppers who were asked to think about the hard financial scenario were significantly lower than those asked to think about the easy financial situation. • Shoppers with above median income showed very little variation in their cognition scores in the difficult financial situation ©2013 ideas42

89. DESIGN – FOUR ELEMENTS • Timing – Try to have some items hit during 1st week of the month, when financial cognition demands are lowest • Personalized/Humanized Post Card 7 days prior to application from the State • Second Application in a large blue envelope • Reminder post card with personalization and number to call 89 ©2013 ideas42

91. DESIGN – PERSONALIZED POST CARD 91 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !!!!!!!!!!!!!!!!!! ! ! ! ! ! Center& for& Outcomes& Research& and& Education& 5211!NE!Glisan!St.! Portland,!OR!97213! ! Address!Service!Requested! PRESORTED FIRST CLASS MAIL US POSTAGE PAID PORTLAND OR PERMIT NO. 5510 Recipient Name Street Address Address 2 City, ST ZIP Code ©2013 ideas42

92. 92 before& & You’ve'won'the'lottery'you'entered FREE& HEALTH& CARE Oregon& Health& Plan Call& toll& free& 1=877=215=0686& or& email& me& at& 'with& any& questions—& I& am& here& to& help!& & & [RA& circles& photo& and& handwrites& signature] DESIGN – PERSONALIZED POST CARD ©2013 ideas42

94. DESIGN – REMINDER 94 -0.40 -0.35 -0.30 -0.25 -0.20 -0.15 -0.10 -0.05 0.00 Number of Late Periods Number of Late Periods if Ever Late Behavioral treatments compared to control One relationship manager Different relationship managers Reminders ©2013 ideas42

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