A Lesson In Clinical Decision Support: We Cannot Defeat Human Nature

      Our UCSF Clinical Informatics group met a few months ago with several representatives from a major Health IT vendor. The vendor, we’ll call them RxLabs, is a provider of pharmaceutical related knowledge in many domains, including decision support tools for the EHR. Our conversation centered around how to better customize medication alerts. We talked about the popular topic of “alert fatigue,” and how to improve EHR decision support tools to improve their impact, rather than just being white noise annoying clinicians.
      The vendor was walking us through a slide-deck about their hypotheses and data about EHR medication alerts and we were having a vibrant discussion about how to improve provider adherence with decision support. We saw slide after slide about how to make pop-ups smarter and about trying to get more buy-in from providers with paying attention to alerts. After all, why would a provider trying to take care of her patient ignore an alert that is trying to help provide an important message? It must be sloppiness or laziness on the part of providers!
      Ten minutes in to this conversation about drug alerts, up pops the following:
Windows 7 Display Alert
      I’ll give you a second to guess what happened next.
      Without a moment’s hesitation or thought, the presenter clicked the little X in the upper right corner. Our conversation went on. More slides. More data about medication alerts in the EHR. Ten minutes later, guess what happened?
      Up came the same pop-up Windows alert. The presenter again, hastily, without paying attention, and perhaps giving a small huff of displeasure, clicked the little X in the upper right corner. More slides, ten more minutes, same thing. You get the idea.
      This happened three times, with each passing pop-up, the presenter becoming slightly more annoyed. The fourth time the pop-up appeared, my colleague Russ Cucina, the Associate CMIO at UCSF, paused the presenter to have us all read the pop-up alert message. We took ten seconds together to learn that selecting any of the three choices rather than clicking the “x” would have satisfied the alert and kept it from coming back.
      The room broke out into laughter. We all understood our own hypocrisy. We cannot defeat human nature.

UCSF Lean Launchpad: The right way to redesign healthcare

I recently had the fortunate opportunity to be part of the inaugural UCSF Lean Launchpad course, formed by Erik Lium and Stephanie Marrus at UCSF, founded by Steve Blank, and taught by Steve and our digital health cohort instructor, Abhas Gupta.  This was a very intense and demanding ten week class that was not about reading and memorizing and taking tests, but about going out and talking to people; “getting out of the building,” as Steve famously says.  The fundamental insight that led to the offering of this course was that scientific and clinical innovation in healthcare does not happen in a vacuum.  While everyone knows how important it is to test and validate scientific hypotheses, it turns out that it is just as important to test and validate your business hypotheses.  Moreover, these should happen in parallel.  This business model hypothesis testing cannot be outsourced after your scientific validation is completed.  This business hypothesis testing cannot be done by sitting in your office and bouncing ideas off colleagues.  Just as we demand data to prove scientific hypotheses, we need data to prove business hypotheses.  Otherwise we’re just guessing.

The Business Model Canvas and Lean Launchpad provide the framework for innovators to literally get out of the building and talk to dozens of customers, partners, and others to help validate, or more often, invalidate, their hypotheses.  Without doing this, talented people will often waste literally years of effort pursuing a product that nobody really wants to use and that nobody will pay for.

This is not news to the world of entrepreneurs at large, who have heard these ideas from Steve, Eric Ries, and others for years.  However, I think this is still a novel concept in the life sciences and healthcare.  Without validating product-market fit, revenue strategy, channels, and the other parts of the business model canvas, healthcare innovators are hurting their chances at disseminating their products to reach broad audiences.  To fully realize the efficiencies of translational medicine, healthcare has to buck the belief that science and commercialization happen sequentially rather than in parallel.  One caveat: There’s obviously something still to be said for early basic science, where one can explore basic mechanisms without having the constraints of having to worry about commercialization.  But for anybody who is working on the more translational end of the innovation spectrum (i.e. the entire digital health industry), doing this is mandatory.

It was amazing to see the changes in strategy among the teams in our class as the weeks went by.  Making Friends started out planning to build a game to help socialize children with autism, but realized along the way that parents and special needs schools were much more interested in having a dashboard to communicate and track the childrens’ progress.  Tidepool, for whom I’m a medical advisor, started out thinking that our early customers would be tech-savvy 20-somethings with type 1 diabetes, but quickly learned that the most interested customers would be parents of children with type 1 diabetes (see the video about our process here).  The Lean Launchpad class was filled with similar stories — we all found that most of our initial guesses were flat out wrong once we went out and talked to people.  As Steve always notes, one smart person is not as smart as the collective wisdom of hundreds of customers.

Following these lessons will be crucial to future successful innovations in healthcare and I sincerely hope that this curriculum spreads throughout the healthcare community.  We in healthcare have to have the courage to get out of the building and test our assumptions early instead of blindly plowing forward.  We should apply the same rigor to our business plans and dissemination strategy as we do to our science.  We should shed the attitude that, “if we build it, they will come.”

A hearty thank you goes out to all of those who designed this curriculum and ran this class.

Redesigning HealthCare: More Thoughtful, More Caring

I went in to the dermatologist last week for an annual skin check and, instead of a humiliating, cold, and uncomfortable paper gown, this cotton spa robe was instead waiting for me to change into.  My experience of whether I was working with an empathetic and caring physician was shaped before she even set foot in the exam room.  Small touches like this robe can make a dramatic difference in the patient experience.  This does not mean that “luxury” can or should replace high-level medical care.  However, thoughtful touches like this robe can enhance and augment high quality medical care to make it even better, and we should not ignore these opportunities to make our patients feel more comfortable.

Spa Robe and Sonos at Doctor's Office




TEDMED 2013: Reactions and Themes

I am just finishing up a packed few days at TEDMED 2013 as a FrontLine Scholar.  There were over 1,800 people there, from a broad spectrum of occupational backgrounds, countries, skills, and areas of interest within healthcare.  This made for an unending cascade of “unexpected connections,” the theme of the conference.  Indeed, though there were many engaging speakers who told stories about turning personal tragedies into discoveries and new passions, to me, the real action at TEDMED was away from the conference stage at “The Hive” (set up with booths showcasing innovators as well as comfortable and open meeting spaces).  I met dozens of amazing people, with whom I had dozens of thought-provoking conversations.  I will follow with another blog post about some of the specific companies that I met and spoke with at The Hive.  There is more to write about from 3 1/2 days at TEDMED than can fit in a “short” blog post.

Here are some of the overall themes that emerged at TEDMED this year:

  • Watch your backs! Those entrenched in the current model of the healthcare system need to be innovating and disrupting themselves from within their own organizations, or else risk being out of business in a short number of years.  Lip service to change will not suffice.  There are many, many companies and innovators taking aim at current models of healthcare, and while most of these companies will fail, and while change may be slow and halting, it will happen.
  • Bottom-up innovation: Change in healthcare cannot come only from the ivory towers and healthcare professionals.  As a doctor at UCSF, I recognize that this means me.  America Bracho spoke passionately about how innovative ideas should come from within local communities in a bottom-up fashion rather than a top-down manner.  We in the healthcare establishment need not only to listen, but to include the people who are most easily able to identify their actual problems and the potential solutions.
  • Interdisciplinary problem-solving: As discussed by Tim Brown in Design Thinking, to creatively and successfully tackle a big problem, an interdisciplinary team is needed.  Five doctors sitting in a room are not going to solve a major healthcare problem.  We need engineers and patients, designers and artists, marketers and people in finance.  We need them to work together.  The cross-disciplinary problems in healthcare require cross-disciplinary attention.  I was encouraged to see how many talented people with backgrounds outside of healthcare are now turning their attention to solving healthcare-related problems.  While some are doing so with a Willie Sutton “that’s where the money is” philosophy, most are truly dedicated to innovating and solving important problems, and we need their energy and their ideas.
  • Courage: Have the courage to ask difficult questions that everyone else is afraid to ask, and to pursue the answers in ways that other people are afraid to pursue.

The popular themes among the startup companies at the Hive (or discussed in speeches):

  1. Medication adherence.  This was true at the mHealth Summit several months ago and remains true.  There is a lot of attention being paid to trying to track, measure, and improve medication adherence.  Some of the companies at TEDMED: AdhereTx, AdhereTech, GeckoCap, NudgeRx, RxAnte, and others.  There are a number of different approaches being tried, from “smart pill bottles” to reconciling claims data with EHR data.
  2. Crowdsourcing.  This concept is being applied across different fronts and in different ways.  Docphin is creating a social experience around reading medical journals, allowing clinicians to see what the most popular articles are in their field or across all fields.  Science Exchange is creating a TaskRabbit for scientific tasks, matching scientists who have a particular skill with those who have a specified task requiring that skill.  UpRise is converging all of the patient education materials that they can into one common platform for distribution to patients.  Crowdmed is applying the wisdom of the crowd to diagnosing diseases.  Roni Zeiger spoke about “networks of microexperts,” allowing patients to share their knowledge and best practices, announcing his company, SmartPatients.  Larry Brilliant spoke about infection monitoring tools for public health, like FluNearYou.
  3. Psychosocial and behavioral interventions.  The companies on this list included Empower Interactive, Healthify, Omada Health, and Sense Health.
  4. Digitizing the patient. (Slight tangent– Jay Walker made a great point that we don’t really have a word for what to call people in the healthcare context who aren’t sick, ie not “patients” in the traditional sense.  Do we just call them healthcare consumers?)  There is a ton of work being done in terms of capturing physical and biometric data to augment the clinical data available today, both expanding the scope of the type of data we currently collect but also expanding out into the home (shameless plug for my JAMA Internal Medicine commentary).  At MIT, they are developing a portable set of glasses that allow an easier view of the retina as a “window into systemic diseases.”  There are sensors for everything– oxygen, heart rate, falls– you name it, somebody is building it, and the data is most often now able to be transmitted wirelessly to somebody, somewhere (what we’re going to do with all of it workflow-wise is another question for another day!)

I would love to hear from others who were at TEDMED or following via Twitter or TEDMEDLive to hear your thoughts and opinions.  I’ll be blogging more later about other aspects of TEDMED…


TEDMED 2013 in Washington DC

I’m very excited to be attending TEDMED 2013 in Washington DC next month.  I was fortunate to be chosen to go as part of the Front Line Scholarship program.  The speaker line-up looks to be full of interesting talks on secondary uses of health data, patient engagement and activation, precision medicine, and a number of talks that blend the humanities with the health sciences.  There will be around 1,800 attendees, so in addition to the talks themselves, there should be great opportunities to meet people and share ideas among a passionate and engaged group.  Should be fun, and should provide some great fodder for future blog posts from the event and in its aftermath!

The Future of Diabetes Management: Social Networking and New Technologies

I gave a talk yesterday to a great crowd at the annual UCSF CME conference, Diabetes Update.  The slides from my presentation, “The Future of Diabetes Management: Social Networking and New Technologies,” can be viewed on Slideshare.

From “Pull” to “Push”: A Transformation in Medicine

Weitzman et al just published a very interesting article in JAMA Internal Medicine called “Participatory Surveillance of Hypoglycemia and Harms in an Online Social Network.”  They looked at using the online social network, TuDiabetes, as a method for surveillance for hypoglycemia.  You can read their very novel article here.

I was flattered to be asked to write a commentary on this article.  Below are the first few paragraphs of my commentary and a link to the full text PDF for download here: JAMA Internal Medicine, Feb 2013, Aaron Neinstein, From “Pull” to “Push”: A Transformation in Medicine: Comment on “Participatory Surveillance of Hypoglycemia and Harms in an Online Social Network.


Consider the words we use to describe what a physician does when she or he sits across from a patient to perform a history. Take. Obtain. Elicit.

These words all conjure images of physicians extracting information from patients. We pull information not just from our patients but also from our information sys- tems, calling up vital signs and laboratory results when we want them, on our time and our terms. However, this is rapidly changing, as information will be coming to us from the patients themselves to create “push” medicine. Are we ready? Not yet, but with some pivoting and some preparation, we can be.


Several synergistic technological and cultural trends are leading us toward “push” medicine. Increasingly ubiquitous technologies such as broadband Internet, smartphones, and cloud computing have created fertile ground. There is increased focus on patient-centered decision making. Patients are increasingly well-informed; nearly 60% of adults have looked online for information about health topics.1

Data are coming from many new sources. Mobile applications enable patients to actively create data, such as by answering symptom questionnaires, or allow wireless sensing devices to semipassively generate data like heart rate or physical activity. Other mobile applications use your calendar, text messages, and e-mails to passively generate meaningful health information, such as mood or quality of life.2 The realm of data collected in the home is expanding beyond blood pressure and glucose log books to tracking daily pain and functioning scores for rheumatoid arthritis. Patients are also contributing data through social networks and personal health records and by direct entry into the electronic health record. Patients are increasingly requesting their personal genomes—and to do so they need only curiosity, an Internet connection, and a credit card. These activities are increasingly common, and 27% of Internet users, or 20% of all adults, have tracked their health online.1


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