Behavior, including adherence behavior, are the keys to improving outcome in a variety of diseases. We must rethink our adherence strategy by using Intelligent Engagement to control the plecosystem of adherence technologies.
First of a Series: Behavior is the Problem
For nearly a half century our nation has watched a rising wave that is now becoming a tsunami; the rise in prediabetes and diabetes. This series of articles will use prediabetes and diabetes as a proof that existing approaches to create a healthy nation do not work and define possible tactical approaches as well as a strategy for a comprehensive solution.
But, do not get caught up with diabetes. Virtually all diseases can benefit from an integrated solution. Our primary problem in healthcare is behavior. Not adherence, not lack of the latest pharmaceutical, not lack of managed care; simply behavior.
If you think about it, most disease has a behavioral component that contributes to the development or worsening of the disease or condition; a behavior that can be modified. A review of the National Health and Nutrition Examination Survey (NHANES) data set over time clearly demonstrates that our health has deteriorated for more than a half century. An analysis of the NHANES data published in JAMA in 2013 concluded that the healthiest generation was composed of those who lived through World War II—the parents of the baby boomers. All other generations following are demonstrating a state of worse health than the war generation. Just as a reminder, longer life span does not indicate better health. The baby boomers are living longer, but only because of advanced, expensive medical intervention. The war generation had fewer people with diabetes, fewer using canes and other measures of health. But, this can be reversed if we dramatically change behavior.
Behavior good and bad, affects virtually all diseases. Some diseases are directly related to bad health; ie smoking and obesity. Other health conditions are made worse by behavior, or probably better said, bad behavior. This omitted or committed behavior prevents the promise of evidence based medical outcome; from arthritis to Alzheimer’s disease, HIV to cardiovascular disease, from fractures in the elderly to diabetes; behavior can make a difference. Managed care companies, employers and other large organizations such as Walgreens have taken notice by creating programs to address this issue.
This move from “healthcare to health” is being embraced in a variety of ways by the explosion of wearables, apps, devices, systems, software applications, and other technology approaches hoping that it may make a meaningful difference. John Mattison, MD, chief medical information officer of Kaiser Permanente coined the word “plecosystem” to describe his vision of the future; an ecosystem composed of technology platforms to handle healthcare.
But it is a stretch of logic to assume that one approach, app, device, drug, technology, or even a “plecosystem” will solve our massive primary issues in healthcare without a fundamental change in our approach to the person facing a disease. Dennis Robbins, healthcare futurist, has used the phrase "person-centric" to describe a healthcare delivery system focused not on patients, who he considers passive and dependent, but on people; people who can then be activated to focus on their health and effectively change health behavior. He feels that anyone who has studied health and disease in the United States cannot ignore the fact that lack of adherence to evidence based guidelines and positive lifestyle change is the foundation for our ill society and the key to changing it.
What is needed is an integrated approach that fits into the natural flow of our busy day; that can tie together a variety of technologies and even plecosystems … to change health behavior. And, we must also take into account behavioral economics. Humans can always be counted on to take the route of least resistance; one that requires the least thinking. We are certainly “creatures of habit.” In addition, any comprehensive solution must take into account both the intrinsic and extrinsic motivational pathways. I envision the use of artificial intelligence and natural language processing to create avatars that then become a key component of the plecosystem to finally lead the change so desperately needed in the US.
It is important that any solution becomes so easy to use that it ties into System 1 or “fast brain” thinking. As a quick review, System 1 Thinking is efficient, requires little active thought process, is automatic, rapid, contextualized, intuitive, independent of working memory; and basically a series of habits or reflexes. This is important because it is estimated that over 95% of our actions do not involve the conscious reasoning or System 2 Thinking. System 2 Thinking (slow brain) is slow, controlled, requires high effort, is rule based, logical; but is not used much by humans for day-to-day activity as it just takes too much energy and concentration.
As stated earlier, no single technology will suffice. Probably every reader of this series has been approached by dozens or even hundreds of companies suggesting that their innovation, their device, their program or their approach will forever solve the problem of too many sick patients using too many resources and requiring ever more expensive medical care. But all of the “solutions” up until now have been lacking- until now.
A new technology, the Virtual Health Assistant combined with a variety of wearables, adherence devices and data-bases hopes to change all of this! But, I get ahead of my self…
Thousands of health behavior studies dating back more than a lifetime have lead to more than 50 theories and models on health behavioral change. These models and theories have guided the actions of hundreds of thousands of physicians, nurses and health educators attempting to promote wellness and improve disease management. In her textbook, Health Behavior and Health Education, Theory, Research and Practice Karen Glanz, a professor at Emory University lists the five most cited health behavior theories: Social Cognitive Theory, the Trans-Theoretical/Stages of Change Model (Prochasta), Health Belief Model, the Social Support Model and Social Networks Model.
These as well as dozens of other less recognized theories have been proven in small clinical trials to improve health behavior in humans. But, putting these theories into practice has been a challenge. A recent systemic review by authored by Nieuwlaat et. al, Interventions for Enhancing Medication Adherence concluded: “Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective… the full benefits of treatment cannot be realized.”
The basic approach at health plans and integrated systems is to use a call center approach or face-to-face appointments along with email and text messaging. Physicians use face-to-face visits. But, human-to-human interaction efforts are very resource intense. So in real world settings, the behavioral health theories and models can be effective but face scalability and cost barriers.
The Annals of Internal Medicine in 2012 published a study funded by AHRQ authored by Meera Viswanathan, PhD, et al; Interventions to Improve Adherence to Self-administered Medications in Chronic Disease in the United States. In this study, the authors found 4,124 citations concerning the concept of “improving adherence” in published, searchable medical literature. Of course, one of the conclusions was that the out-of-pocket cost influenced adherence. But, in addition their conclusion stated: “…case management, and patient education with behavioral support all improved medication adherence,” but …“evidence is limited on whether these approaches are broadly applicable…”
These conclusions are demonstrated tangibly by the dramatic increase in obesity along with the almost unimaginable rise in the incidence and prevalence of diabetes and prediabetes. Given the facts, how can anyone conclude that a healthcare-provider-focused approach to adherence, ie lifestyle, diet and exercise, over a lifetime is not futile? Our healthcare delivery system is poorly equipped to “educate,” and “case manage a population at scale."
But, technology can, and it will aid in not only these aspects of care, but also in many others.
The second article in this series will focus on the general classes of technologies being developed and deployed for improving health behavior.