Six Questions with Dr. Brennan Spiegel

by Michael Joseph | @HealthData4All


Dr. Brennan Spiegel, Director of Health Services Research at Cedars-Sinai, will be speaking on Sunday, Feb. 19. His session, Top 10 Lessons Learned Using Virtual Reality for Patient Care, will be at 1:55pm - 2:35pm, Plaza International G-H Ballroom during the Digital and Personal Connected Health Forum.


Prior to his talk at HIMSS17, Dr. Spiegel joined me for an interview to share his thoughts and perspective on digital transformation related to personal connected health.

Would you share your background and professional journey in digital health?

First and foremost, I am a physician.  I take care of patients. I am trained to manage people and their illnesses, and improve their outcomes, improve their survival and their quality of life. That’s how I’ve been trained.  Secondarily, I am a health services researcher. I am interested in how to improve the value of healthcare, how to improve outcomes and reduce cost of care. And I teach this at the UCLA School of Public Health, plus we have a new Master’s Degree Program here at Cedars Sinai focused entirely on health delivery science. But you will notice that nowhere in there did I discuss digital health.

I came to digital health over time because I see digital health as an extension of population health and health delivery science. As a professor of public health, I view digital health as a branch of public health because it allows us to scale healthcare delivery into the community to wider populations.  

99.9% of patients’ lives are spent far away from the four walls of a hospital or clinic. If we’re really going to engage patients where they are and if we’re really going to reach beyond the four walls of the hospital, then we have to find ways to reach out to where patients live, work and play.

And digital health offers a set of electronic platforms where we can engage patients in their native environment, in their free-range lives. So I came to digital health, not because I’m a technophile necessarily, but because I am a clinician and a population health scientist who is trying to figure out how to improve the lives and outcomes of our patients. Naturally, digital health has evolved into a science unto itself that enabled me to do just that and that’s how I came to digital health. Through that journey, I created a wearable biosensor that’s now approved by the FDA. I created apps that we’re using for patient care and clinical decision support. I am deeply involved in understanding how to use virtual reality to improve patient outcomes. I have created a laboratory that focuses on testing and validating digital health solutions in the clinical trenches from the perspective of doctors and patients.

How do you scale and accelerate user adoption of digital solutions?

We just published a paper in December of 2016, describing our experience in offering a connection between digital devices and our EHR to nearly 80,000 of our patients. We informed them that they now have the ability to connect their own wearable devices – Apple HealthKit, Fitbit, etc. – directly to our EHR through HIPAA-compliant channels. And we found that only 0.8% took us up on the offer, primarily younger, healthier group and employees of our hospital. To be fair, our marketing outreach was pretty minimal – it was just a message through the patient portal to inform patients they could now connect their wearables with our EHR.  Few did it, which taught us that if we build it, they will not necessarily come. Patients need to understand how they will benefit. For me, digital health is not a technical or engineering or computer science; it is a social and behavioral science. 

What I’ve learned increasingly is that to be successful in digital health, you need to be successful in behavioral health.  You need to understand the motivations of patients and meet them exactly where they are, and build solutions that meet their needs, first and foremost. Create solutions in concert with patients from the ground up, as opposed to creating solutions and then foisting them on patients who may or may not have any interest in those solutions.

How would you characterize the pace of digital transformation in healthcare? Why is it lagging practically every other industry?

I do not want to be overly cynical, and I am a technophile at heart, but I characterize the pace as over-promising and under-delivering. We know about the Gartner Hype Cycle. I think we’ve crested the peak of inflated expectations, and we are now sliding down the trough of disillusionment. Where we are now, in my opinion, is the pragmatic realization that it's extraordinarily hard to do digital health. But there is hope. And we now need to start scaling up the slope of enlightenment, where we figure out whether, when and how to interface technology with the profound human experience of being a patient. And that requires social science, behavioral science and clinicians closely working hand in hand with patients. It doesn't necessarily require getting increasingly sophisticated machine learning, artificial intelligence, computer science, as much as it requires sophisticated social science.  I think that message has been lost – or at least not sufficiently broadcast – and that part of the reason we are lagging is a failure to recognize the importance of social science, and also not appreciating that healthcare is truly unlike any other field in the world. It is not like banking. It is not entertainment. It is not like the airline industry.

And anyone who might mistake healthcare for these other fields hasn’t spent an hour in my clinic because there is nothing messier, more complicated and more difficult than managing the biopsychosocial illness experiences of profoundly sick people.

What do you feel are the critical success factors and major considerations in the pursuit of digital transformation in healthcare? 

We must consider the health economics of digital health. Even at the point of inception of a new idea, at the point of creating the concept for a new digital intervention, it's exactly at that moment that we should start thinking about the cost utility of that intervention. And by cost utility, I mean how much will this cost, but also how much might it save. And by utility I mean, literally, the health utility or the health-related quality of life that will be engendered by this intervention. And we can do cost effectiveness models very early, even before a digital innovation is developed or validated and ask tough questions. Will this ever work? Who will ever pay for this? How effective does this intervention need to be and at what price point to be approved by a third-party payer? So these are questions that are not asked very often. Instead, somebody has great idea, and they bring it to engineers, technologists and computer scientists. There may be a clinician involved along the line and there may be some patients peripherally involved, but there is this drive to create a product. And then the product is standing there, looking for a problem to solve, looking for a payer model, and looking for the right patients. That's exactly the reverse of what it should be. Better is to first find out from the patients about their unmet needs. Let’s find out from the payers what their unmet need is. Then let’s create solutions that fill those needs. And if we were to reverse the model, thinking about health economics early, thinking about patient input and unmet needs early, then I think we would be much more successful and would truly transform healthcare. But we can’t transform in reverse.

Given the explosion of vendors offering cloud-based digital solutions and applications, where do organizations begin? How do you evaluate ROI? How does all of this relate to valuation models and the emphasis on valuation by entrepreneurs and VCs?

If I were sitting in a VC and looking at digital health products, I would want to know how many patients were involved in creating this product and exactly how were they involved and engaged. How was their feedback collected? What was the feedback and how did you act on it? Did you build a product that was suggested by a patient or a provider? Or, is this an idea that’s looking for patients and providers to adopt, because most often that's not going to work. I would want to know if it’s been used on patients and what did they said about it. How has it been proven to be effective? How do we know that it improves quality of life and survival? Were there any biological outcomes? I mean, could you imagine any other product or service where an investor wouldn’t ask questions like these? We must be asking these tough questions, but I’ve observed that many digital health concepts seem to avoid going through such rigorous due diligence.

Instead, VCs often place highest emphasis on the team’s proven experience and expertise, which of course is vital. But when it comes to digital health, I don’t think that’s enough. Great team, yes.  But is the product truly solving for a patient need and has rigorous evidence that it will actually work? Because, a team might be great, but what do they know about being a patient? The first slide of any pitch deck should explain why the health problem to be solved has been expressed by patients or other clinical stakeholders.  It should explain how we know there’s a problem and how the team has figured it out after working hand-in-hand with stakeholders – primarily patients themselves. Personal anecdotes about family members or personal illness are compelling, but are no substitute for hard-fought science and raw evidence, directly from key stakeholders, that the solution makes any sense.  I would want to know if and how the team worked with patients and clinicians to iterate and improve the product, until they got to this point.

Digital health is a major driver of personal connected health. What other are other key considerations? How do clinicians empower patients to become more involved their own health?

Well I'm going after start by addressing the word, “empower.” And this isn't directed to you at all. It's just a common word that I fear isn’t really appropriate in this context. I frequently hear that we're “empowering patients” with digital health and empowering them to do things that they couldn’t otherwise do. I never once had a patient walk into my clinic and say: “You know what, doctor, if you can just empower me today, I'll be fine. I just need you to instill me with your power.” And if you think about it, it’s sort of an insulting concept for non-patients to express, because it suggests that there is a power asymmetry, and that we, as doctors and scientists, have this power, we're going to transition it and empower others with digital devices. And I think it actually belies a deeper concern that we have over-promised what we can do and under-delivered on actual results, in general. There is difference between empowering somebody and enabling somebody. I don't empower people with blood pressure medications. I enable them to manage their blood pressure. I give people tools, and I work with them through shared decision-making to determine whether and when to use them.

I frequently refer to Dr. Joe Kvedar at Partners Connected Health. In his book, The Internet of Healthy Things, he discusses the concept of “readiness to change.” And this is a concept that goes back decades. It encompasses one’s readiness to change anything and change behavior. How willing are you to stop smoking? How willing are you to take your diabetes medications or to reduce salt intake or whatever? It turns out that this can be measured along a spectrum of five levels, from completely unwilling to even think about changing – precontemplative -- to fully committed to behavior change.  Knowing where somebody is along their “readiness to change” spectrum can really help in engaging patients around digital devices. As an example, right now, we're creating an app for patients with gastrointestinal issues, called “My GI Health,” and we’re adapting the push notifications on that app based upon the patient’s readiness to change. So, for example, this is an example of an ineffective automated message that does not acknowledge a patient’s readiness for change: “You have only walked 6,000 steps and you've have 4000 left.”  That’s not helpful.  A better, more meaningful, more contextually relevant message would be: “Evidence shows that exercise can help reduce the symptoms of irritable bowel syndrome. Today is a really nice day. When you’re ready to start improving your IBS, this would be the perfect kind of day to go out for a walk.” In the latter example, we are considering the patient’s readiness to change. We are titrating the message according to that level. In fact, the latest research suggests that giving people raw data on their steps without context can demotivate them. This is the difference between data, information, knowledge and wisdom. To scale up to wisdom, we need our personal connected health devices to be a lot smarter about where people are on the readiness to change spectrum.


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