VIMEO 479621408 Seattle talk by Marc Pierson on behavior change and health.
It is a privilege to be here. I have to say the last two days have been a whirlwind. Reminds me of a health 2.0 . When you go you learn a lot and you don't know whether to be excited or depressed because you see all these wonderful people doing this wonderful work and you can't quite imagine it ever coming together and affecting patients and the communities we live in. What Michael wanted me to talk about, I'm barely going to talk about at all, so I'll get it done at the first, so that at least I've satisfied Michael. There's an innovation, an idea that , Michael and I refined. That is, you can't really pull just bits and pieces together and suddenly have healthcare be better. You actually have to **create an ecosystem in which you can actually do innovation** for many of these pieces and parts that we've been talking about could actually come together and be applied in a programmatic systematic way, so they affected whole communities. At least that's the belief. And since then, PeaceHealth has seen fit to create the center for innovation or actually give me the mandate to great the center for innovation, for all the PeaceHealth across three States. So that's pretty interesting, but when he asked me to come and talk to a conference that was predominantly about behavior change it was exciting, but also I'm going, why me? I tried to talk him out of it on at least three occasions. My friends who have PhDs are all pretty quick to tell me they're real doctors and I'm not, and there are a whole lot of real doctors here. I'll just give you my views from the frontline. You'll see question marks throughout the entire thing. I say in the very beginning--questions and speculations, because I don't know. There are a lot more questions than there are answers in my mind for the things that we're going to talk about. Okay. again, what am I going to speculate about? I want to think a little bit about the need to **disrupt our minds** before we start innovating. We talk about disruptive innovations, but I think that disruption, at least for those of us that are doctors or run healthcare systems, we really need to whack our minds around a little bit and get it straight so we might do something interesting. And then I want to focus on what I think is a key piece, and that is a **whole communities as healthy ecosystems**. And talk a little bit about networks. I think **human flourishing**, and the science behind it, positive psychology, is got to be the key to how we change things, unless we can somehow trick people into continuing to pay us for visits. If we've got to get paid for results, we've actually got to figure out how ourselves, the workers, the patients, and their families can actually get in a **psychological state of flourishing** so they can take on difficult problems. And then, briefly if we have time at the end, and we may well not, talk about **supporting technologies**. If you've passed by the shared care plan and stuff in the back, that's, some of the stuff we've been developing for about eight years. Why the growing interest in **behavior change**? Because I think it is growing. The cynical or pragmatic part of me says, yes, because they're at least threatening to start paying us for outcomes instead of visits. When you contemplate getting paid for population health, that's behavior change, that's not operated on your heart, or I got you to come to the office. It really will be things that only occur, through a behavior change. This is a slide that I promised myself about eight years ago. I would put in every slide deck. I haven't failed. I think these two questions are really in critical. There's very **seldom ask and they're almost always answered** are answered before the conversation starts. So you know who you're. Protecting who you're taking care of and where your home is. I would say ask yourself, **for the sake of what**, first and who's really in this together. I see healthcare as, too long been taking care of itself. And I think the problem space for anything we've been talking about in the last two days, has to be at least as big as the community. So I think the, "we" has to be at least my community.
So I'm going to read something and this is where I may alienate a lot of the audience. I can assure you that's not my intent and hopefully my worst fear won't come true. I'm going to read a bit of the introduction, to, **The Careless Society, Community and its Counterfeits**, by John L. McKnight, which was written about 20 years ago. I shared it with a few of my friends, but I've certainly never done this before because I didn't know what the treatment was. John, is a researcher at Northwestern University and it's a pretty strident call for caring communities. So here it is. There are studies everywhere indicating the loss of faith Americans have in their basic institutions. The most common response as a call for **institutional reform**. Leaders, urge total quality management programs, new technologies, right-sizing, lifelong learning, new highways for information that will renew the services provided by our systems. This book outlines the reason that these reforms will fail and it points toward the path that will allow us to create an effective satisfying society. We point out that our problem is not --in the book--they point out that the problem is not ineffective service producing institutions. In fact, **our institutions are too powerful**, authoritative and strong. Our problem is weak communities, made ever more impotent by our strong service systems. The relationships formed by consent and manifested as care or the center of community. It is this **care** that is the essence of our role as citizens and it is the ability of citizens to care that creates strong communities, enabled democracies, the most significant development transforming America since world war II has been the **growth of a powerful service economy**. and its pervasive serving institutions. Those institutions have commodified the care of the community and called that substitution a service. As citizens have seen the professionalization of service commodities invade their communities, they have grown doubtful of their common capacity to care. And so it is that we have become a careless society populated by impotent citizens and ineffectual communities dependent on the counterfeit of care called human services. So you might imagine why I would not have read that or presented that to many people I work with, and I think John overstates. Okay. he spent his career trying to get the slums of Chicago back on their feet where people like us left when there was no money. So he had a pretty cynical view, but I think he does make a really strong point. And this is the first time that it felt safe enough to talk about that because with the old system, the system that has to go out we benefit when the patients are impotent and dependent upon us--more visits. In the future, we actually fail because we won't get results. So **now that there is an incentive to turn this around, the question becomes how**, and that's where it's just question marks everywhere I have a whole talk I give that's called Between. Life occurs in the large spaces between visits, between organizations, between, EMRs . Which organizations and technology will support people in between, I think is a big question. It is person's home where almost all the decisions and actions occur, where medications are taken or not, or diets and exercise occur or not needs information and decision support, probably more than we need our EMR. So you've got John's book and you've got what a bunch of people have actually been talking about, which is quite a pleasant surprise for me, this idea of positive psychology and what can people do so that they can actually flourish and play an active role in taking care of themselves. This slide is, I think, a very important slide because we've become pretty myopic if I work in the healthcare system, thinking that I'm somehow effecting everything. We're such a small part of it. Behavior change and genetics just outweigh us entirely. And what do we have to do with social circumstances? And I hate to see healthcare decide that they're going to take on all of those. I have to say that's the most expensive and ineffective solution I could possibly imagine. The organization I work for, I joined because of this mission. Its great. It actually focuses on community health, It has to do with social justice. My dad was a Methodist minister, so it works even though they're Catholic and I'm not. And then we had a vision since 1990, it was seamless care across the whole community. So I live in a really unique sort of Camelot place where we actually have always intended to work together instead of compete with each other. We've done some interesting things. We actually ran an accountable care organization . I was the medical director from 93 to 97. RWJ selected us for the pursuing perfection thing. We did that for five or six years. We did something really strange. We talked to patients, which is just really weird. We ask them for years what it was, the redesigning American healthcare would look like to them and nothing that Ed Wagner said, who was a friend of mine, nothing that Don Berwick said, who's a friend of mine, did they have any interest in. What they wanted were navigator coaches and their own medical record that they could share with anyone they wanted. That was pre-Facebook, but they were asking for Facebook for health. So there's a book I think is really important. Zuboff from Harvard wrote a book in 98 called The Support Economy. And her, theory is that the next big increase in value in the world will be when all of us have concierge functions around us that are enabled by technology. And I'm reading that at the same time, I'm actually listening to these patients and I'm going, I think Zuboff is saying for everyone, what patients are saying for themselves. So we talk about them. We tend to make them ours, with care managers and so forth, but the bigger idea, the more correct idea is, you want a perfect matching function. Somebody who knows you and knows what's out there and can get you what you want. I think in healthcare, this is missing role and this shouldn't be doctors. This would be the people who help you pick your doctor by the way. This is a slide that evolved over the last few years. I used to give talks on technology and say, it's not technology. So its got to have sociology. And I put this sort of play on, the computer stack, if you will, the information stack together. And I will say that almost everything I've heard here, is data information, communication. Great. But if you don't get to the top of that stack, no value has been created. Everything below is literally waste. So the real nexus and what I think most of the important conversations here today have been about how you have conversations that lead to commitments, to new behaviors. How, some people will see this, and this is news to them. No one in this room is this news to everyone has your own version of this. So the question is, how do we do those things? Sorry, that's falling apart . Question marks, okay, all over this, but this is my best thinking at the moment. We need positive health outcomes. We know from over 200 studies that high patient activation measurements, lead to better health and lower healthcare costs. So how do you get that? Bill Mahoney and Chris's company have done some research that really says most of the patient activation measure is actually defined by Fredrickson's positivity ratio. So if you want to have great outcomes, and lower costs, you need patients that have, a flourishing ratio, a ratio of positive to negative affect of three to one or more. So now if that's true and it seems to be true, then you're you start focusing on what you need to do. You have to do whatever it takes, to get those ratios up. And you might want to do it in your company as well because you'll have a more productive place. So the question is, how do you do that? Question marks everywhere. Bill Mahoney has been telling me to read Fredrickson for a decade and in preparation for this talk, I actually did go read her stuff. So I think you've got to have a care network. That's a, I think what McKnight is talking about, I'm working with the folks on Lummi Island. it's a real community, the saltwater round it, and then a ferry. And, they're starting to say, it's our health families. The people we actually know and care about that knit together to make a healthy neighborhood. These are the kinds of ideas I think we need to add to the other ideas that have been discussed here. Just a word about disruption and probably a lot of people who've read Clayton Christensen's book. And John is actually the guy who got him to write it and at least had a lot to do with it, but, and you can read it if you want. I think the first two, business models are probably not correct enough to be useful, but I think he nailed it with the third disruptive business model, which is a network model, meaning the kind of stuff we're talking about here. This is actually, Jane showed, her version of this. This is the same data from the transitions of care. This is from Whatcom County. And all I really want to say is these are everybody who left the hospital, where they went in Whatcom county. You see the big blue dot? What do you think that is? Home. Home! People go home and then they have very little technology and very little support to succeed with. One of those slides really didn't work well on your computer today. So human flourishing, it turns out, is measurable. About 10 of my friends are doing it everyday and emailing each other for the last two weeks because I started reading it prior to coming to this conference. And I'll tell you, it's very interesting to know what your ratio is every day and share with your friends and you really start going, wow, I could have fixed that. One day I was a 0.4, this is not good by the way. But my average is just about two, which isn't really where you should be, if you're a leader in it, you should get it up to three and it's not that hard to do. So it's actionable. And I think it's, as I said before, the core activation. Really sorry about those slides. Fear and anxiety, and this comes from my work and in the organization actually, but fear and anxiety. I added the top one so you didn't think I was an idiot, right? Clearly, it's inevitable and it's useful. But more than that, it kills creativity; it narrows choice; limits problem-solving; and adds to the burden of illness. So we really need to be doing things that decrease the amount of fear that people experience. So patient activation, I think you've heard a lot about it. So I didn't know it was going to be so prominent here. There are four levels and boy, you want people at level three or four, if you can get them there and you don't want to treat level ones like the level of four. Human flourishing, I think I just went through. Broaden and build. This is Fredrickson's real contribution to the planet. Is that. positive emotions, open our minds. And if you get to a three, they really open your mind and you start taking action and you literally see a different world and your kids, your family, and your coworkers and your neighbors will be in a lot better position. These are what I think the leverage points are big questions. Aren't everyone should have a question Mark after it, but I'm not just being general. I'm saying these places we need to actually work to, improve the, positivity ratio, which is imminently measurable. It takes one minute. Okay. It's 20 question and go online to positivity ratio and take yourself. And you read her book. What are the pivotal roles to do this? About half of the conversation maybe today has been pointing back toward healthcare professionals. But others have pointed out maybe that's not the way to go. Maybe it's others. We don't want to screw it up, but we certainly need to invite these other players into the game if you ask me. And when I talked to 400 CEOs in a meeting, I say, this is free care guys. These are the people you need to be helping help you succeed. Community, population health, population is, a number right . Community is actually a bunch of relationships. So we really need to get a lot smarter about what communities are. And we need to work for our shared health and shared wellbeing. So many people said in the last day that it is that sharing, that sense of helping others, of altruism-- that turns out is is a huge thing that makes you happier and makes you healthier. It's not just about saving money or getting some part of your copay, removed-- that actually pisses you off even reminding you that you have a copay, sorry. So connectivity. I'm just trying to say, look, if you knew what I'd done for the last 20 years, a lot of E connectivity in my past. I'm trying to say it's more than that. It's more than just living in proximity. It's really, how do we flourish together and how do we support our communities? Because McKnight is right. If we do that, not withdraw from the game, but help the communities come up to the level of service and sort of authority that we have, so they have equal authority. I think that's what we need to do is get our positivity ratios up. I think it's imminently doable. And I thought on no one's radar until I got here. It's clearly on three or four of the speakers' minds . I'll leave the technology for some other day. Thank you. .