Health inSite: Decision Support, Games, and making people healthier


I’m a bit of a trivia nerd. In fact, I play trivia with a group of friends every week. We do alright, and obviously there are good weeks (I mean, we keep going back) and then there are bad weeks. I play team captain for our group. The responsibilities of team captain are to record our progress (each question gets a wager based on our confidence in our answer) and recording the success or failure of each question in a running total, and helping to marshal the resources of the team (points, knowledge bases of the players, ranking answer likelihood, etc.). The final trivia question of the night is a challenge. Each team is given the question that requires four answers in rank order, usually. When turning in one’s response, a point value between 1 and 15 is assigned to the answer. If any part of the question is wrong, the wager is subtracted from the team’s total score. If the answer is 100% correct, the team gains the wagered points. So it’s no surprise that I would be really intrigued by Watson, a supercomputer that was able to best two of Jeopardy’s greatest champions in a tournament back in 2011. Research into Watson is really interesting.


Watson was trained to respond only when a certain threshold had been met in the likelihood that Watson was correct in its assumptions. This confidence was determined based on cross-referencing the available answers and identifying the highest scored answer based on a number of algorithms. While Watson is not right 100% of the time, its significant domination of the final score ($77,147 vs. 2nd place’s $24,000) is no small feat for a computer responding to natural language, searching natural language information, and culling a response to an “open-domain” question.

Game State Evaluation

Part of the programming behind Watson required not just an understanding of the likelihood that Watson was right, but also what the potential for gain or loss in relation to the other players might be. Because Jeopardy includes wagering for daily doubles and Final Jeopardy, Watson had to strategically wager in relation to the likelihood not only that it was right, but also what it would mean if the other players were right or wrong. This is well-illustrated by the final wager that Watson placed in response to the final jeopardy question, which was $17,973. This is a statistically-determined wager based on total game state evaluation at the time of this final question using the above variables.


While there is plenty of room for argument as to whether or not Watson is thinking, there is absolutely no question as to whether Watson is logical. As I’ve mentioned before in a couple of articles related to the work of Daniel Kahneman, (if you haven’t, make sure to check out Thinking Fast and Slow) human rationality is very rarely very rational. This is due to a number of intervening variables that interrupt our ability to make rational decisions all of the time. These “biases” can be intentionally or unintentionally applied during the decision-making process. While Watson has a number of heuristics, no-doubt, built into its logical processing, it is probably not as likely to respond to cognitive biases such as anchoring, duration neglect, and certainly curse-of-knowledge as seen in its commanding performance in the Jeopardy games.

Decision Support Systems

Watson is now being used in a number of healthcare applications assisting in the support of clinicians as diagnostic support. Watson is not making decisions, but it is able to cull the plethora of information available in the medical field to provide confidence-rated responses to data that is provided regarding a patient. This marks a big step for the advancement of Health IT as we can standardize clinical response to symptoms, and stabilize health information as it is consolidated into big data stores. And because Watson is able to learn as it answers and receives feedback as to success and failure based on those responses, Watson can only get better at diagnostic prediction and likelihood of treatment success or adherence based on the results of those treatments.

What does this mean for making people healthier?

There are some obvious benefits to these advances in Health IT, but one of the things that may not be fully clear yet is the application of Watson to understanding more about human behavior. While Watson can absolutely tell a clinician the likelihood of a set of symptoms’ association with a given disease, I’ll bet Watson can’t tell you how the patients’ family impacts their overall wellbeing through behavior reinforcement. If Watson knew who the patients’ workout buddy was, Watson might be able to help identify with a high confidence whether that workout buddy was a statistically-sound partner in the overall health management of the patient. Further, Watson would be able to weigh in on the evaluation of treatment adherence based on real-time data pouring into the health record for the given individual.  This is the game state evaluation of the health of the individual in a real and meaningful way.  With this, a total and complete understanding of the long-term treatment of chronic conditions (and even more important to the salutogenic framework that I’ve discussed previously in this blog series, total health production) through the understanding of actual human behavior devoid of the clinical separation from reality is the “social human” version of epigenetics that will become more useful in the coming years.  This is where the data comes to life.

To our health,
Ryan Lucas
Supervisor, Marketing
To stay ahead on topics related to this, follow me on Twitter @dz45tr


Health inSite: Placebo, by any other name, is just as effective?


The Placebo App

A review of a year and a half of Health inSite research and how I think one group is probably more on target than some might think.

I’m going to start out by laying out a couple of concepts for review.

Placebos and psychology

A placebo is defined as “a simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient.”  This causes what is called the placebo effect.  A patient is said to have experienced a placebo effect when the intended deception manifests experienced results.  While the research indicates that there is a small range of people that are susceptible to the effect, that range hovers at around 30% of the population.


One might ask, “How is it possible that the effects of a non-drug could be experienced as having the results of an actual drug that has the intended, or actual, impact on a patient?”  This is explained as the product of self-fulfilling prophesy, or a form of expectation bias.  If you recall the previous posting on Thinking Fast and Slow, one of the difficulties we face as human beings is both our difficulty in matching up experience and memory, as well as overcoming biases that tint our understanding of rational data.  In a word, we are not always rational beings and sometimes our understanding of an experience or idea is subject to our memory and cognitive constructs that allow us to think fast.  We respond the way that our mind has told our body it expected to experience the event.  The concept, “Where your mind goes, the energy goes,” has been mentioned extensively by my colleague Dr. Mines in his series on Psychology of Performance, beginning with his first posting.

Hysteria (or mass psychogenic illness)

If you happened to miss the events in Le Roy, NY, where 18 people experienced Tourette’s-like symptoms for an extended period of time, there were many that identified the cause of the experience of these individuals as mass psychogenic illness.  Mass psychogenic illness has been largely attributed to situations in which individuals are experiencing similar physical effects (tics, for example) without any clear physical reasons (e.g., environmental toxins, viral or biological triggers, etc.).  Historically, this has been referred to as mass hysteria.  The complexity of the condition has led many to write it off, but the core assumptions of mass psychogenic illness are sound given what we know about social influence.  Oftentimes in mass psychogenic illness, an index case is discovered in which someone’s conversion disorder acts as a catalyst to the development and spread of the illness through the network.

Assuming that this is the way in which mass psychogenic illness works, index cases could be used to induce behavior change in a network towards a positive outcome. In this way, it is not mass psychogenic illness, but mass psychogenic salutogenesis (widespread generation of health through the influence of the mind over the body within the social structure of a network).

CBT and treatment adherence

Critical to adherence to any health maintenance or treatment protocol plan is the ritualizing of new behavior.  In the chemical dependency field, we’ve known this for a long time.  By creating new routines that positively impact our behavior; we are able to more easily overcome the many triggers that previously caused our substance use.

Triggers are defined in the substance abuse field as events, emotions, or thoughts that trigger the addiction response.  They are a major focus in many treatment protocols and are especially important for recognition in the cognitive behavioral therapy (CBT) model.  The goal in CBT is to identify why it is that we respond to thoughts, emotions, and events and then to develop, for ourselves with the help of a therapist, ways to counter the effect of those triggers.  In this way, it’s not the abolition or avoidance of triggers so much as a rational understanding of the trigger and building tools to overcome that trigger’s effect on the coached patient/client.

Network theory, social comparison, and braggadocian behavior

If you’ve read all of the links to other blog postings in the Health inSite category, but missed the posting on braggadocian behavior, the concept is very simply that social media has enabled us to engage in bragging around the things that we are doing and that this activity can influence the way that others perceive us – and we do this to intentionally accomplish that change in perception.  This gives us the ability to influence the way that others behave as they engage in responses which may include trying to match our behavior (wittingly or unwittingly)  or rejection of our behavior as a method of coping with one’s own deficiency in the category of behavior being expressed.  This has a powerful impact on the social network in which agents operate as they can directly and indirectly influence the behaviors of individuals that are proximally or distally connected to them.

In their book ConnectedChristakis and Fowler explore the significant effects that our social network has on our health and health behaviors.  Social networks, of course, are not just websites like Facebook or Twitter, but all forms of interaction that we have with various people in our lives, including our family, friends, co-workers, neighbors, and even the people at the grocery store.  The power of individuals to have an effect across a network based on their location within the network is a clear and well-documented reality.

Suspension of disbelief

As I mentioned in an earlier blog posting on the fourth and fifth wall, suspension of disbelief is critical to the effectiveness of theater.  Without the audience allowing suspension of disbelief, a presentation falls flat in its ability to engage the audience emotionally.  Think back to a PowerPoint presentation that was particularly awful because the speaker failed to actively paint a picture that the audience could connect with.  Similarly, engagement strategies are starting to use these concepts to create thick tapestries of story that immerse the audience in the story-line, and even sometimes ask them to co-create the story, as in the case of the Lizzie Bennet Diaries spin-off series, Welcome to Sanditon.

New technology

Recently, an IndieGoGo campaign was started for a new project that would create a placebo app.  You might think to yourself, “How the heck could a placebo app affect someone’s health?”  The app, which leverages the power of mirror neuron activity and the placebo effect by creating positive thought-feelings in the brain, could actually override the systems in the brain that cause us to act irrationally in terms of triggers and cognitive biases by leveraging suspension of disbelief.  Further, the app allows individuals to interact with their social network around their use of the placebo app, creating a unique opportunity for mass psychogenic salutogenesis.  Now all we need are some index cases to start the process toward a tipping point.

It will be interesting to see the resulting data from this project as we would expect that there is a real opportunity for this to be leveraged to significant effect, not only for those directly accessing the placebo app, but also those that end up interacting with those users.  But the rest of the story is still to come.

Whew, that was quite a round-up of research, huh?  Comment or send questions!

For more…

…check out a G+ Hangout from HuffPost on placebos and their effect.

Ryan Lucas
Supervisor, Marketing
To stay ahead on topics related to this, follow me on Twitter @dz45tr

Health inSite: Salutogenesis


We are a cool species, engaging with our world in a very different way than any other species of which we know.  We shape our world physically, mentally, and socially to suit myriad fantasies, individually and collectively.  This results in a shifting landscape of reality in which we, as Daniel Kahneman points out in his final chapters of Thinking Fast and Slow, are subject to our cognitive biases that may have positive or negative sway in any given situation.  The key to best engage with that reality on a day to day basis is to recognize these imperfections in our cognitive wiring in a reflective way.

In those final chapters, Kahneman points to a need to recognize, that as remembering beings, our memory often fails us.  It’s subject to outside influence and shortcuts on our own behalf.  Taken together, this means that there is an opportunity for each to shift our remembering self towards a different understanding of an event than our experiencing self, the one that’s actually present during an event.  This is because our memory is subject to duration neglect and a product of our episodic memory – we are prone to ignore duration as opposed to intensity.  If we were to have a true recording of events, we might not remember correctly that vacation taken last year, when it rained for the first three days, but the last day was so gorgeous (and all of our pictures were from that day) that we may remember it more fondly than we experienced it.

What effect does this have on adherence?  Quite a lot actually, and this is where perception has a great opportunity to hop into the world of Behavioral Health and Substance Abuse treatment.  Simply by altering the treatment protocols to take into account this remembering self, it is possible to focus on the peak-end rule.  The peak-end rule says that when we are remembering an event, we more heavily weight the experience of the most painful or pleasurable event (peak) and the last thing (end) that occurred in a timeline.  If a treatment protocol were to decrease the peak of a particular episode and include a positive, context-provoking end to the episode, the remembering self will have a different memory as it progresses towards more positive outcomes.

There is another major implication of this very important understanding of the remembering self vs. the experiencing self and it is related to a concept called Salutogenesis (basically “from health”). Salutogenesis is a concept coined by Aaron Antonovsky, a Medical Sociologist, as a counter to our current health model, which has a pathogenic slant to it.  I would venture that our health system is as much a product of our two selves as potentially influenced by a change in the approach.  Our duration neglect and base-rate neglect lead us to an imperfect memory of the picture of health that we have for ourselves.  This leads us to looking at healthcare as episodic – we go to the doctor in a self-encapsulated event, we get ill, we deal with symptoms.  These are all pathogenic experiences of our overall wellbeing.  If we had a tool that helped our experiencing self more accurately engage with our health reality, that we are always to some level healthy and to some level ill, duration neglect would be mitigated, increasing our ability to engage with our health as if in two realms, time and space, rather than simply in a given moment in time.

So what does a salutogenic framework look like?  Mindfulness, resilience, focus on daily health-promoting activities that increase our ability to get healthier, rather than fend off illness.  Of course, a fee-for-service model doesn’t bode well with this concept, so unless you’re enrolled in a highly visionary health promotion healthcare system, you’re probably on your own – for now.  If so, here are some resources we’ve seen that might be helpful for you to consider when you begin working towards your healthiest self: – This site allows you to engage in a number of different challenge “packs” to help increase your emotional, social, mental, and physical resilience.  You can even invite your friends to help you complete these challenges!

FitBit – not simply a pedometer, this device will help track your sleeping patterns, too, giving you the opportunity to analyze some of your base-rate metrics and progress in your fitness.

Various apps and websites – there are literally thousands of apps out there now for tracking everything from heart-rate to nutrition to fitness to mental resilience to even sobriety (check out sober24, an online community for alcoholics in recovery!).  Keep in mind that when you are looking at these programs, you are more likely to be successful if you are doing it with someone else.  And if you invite someone else to participate, they are as likely to make you healthier as you are to make them healthier!

Your EAP – while most people think of their EAP (Employee Assistance Program) as something they use when things are bad, keep in mind that MINES has many programs that may help you no matter what level of health you’re at – including career coaching, financial coaching for learning to save, and more.  You don’t have to be in pain to give us a call; we’re here whenever you want to talk.

To our health,

Ryan Lucas

Health inSite: Bring Your Own Health


Blended, not segmented

In an increasingly interconnected world, the rift between the person and the role within the workplace is diminishing.  Again, highlighting a moment from our presentation at the EAPA 2011 Conference back in October, we provided a brief demonstration of the change that is coming with the introduction of smart technology that is cheap, intuitive, and pervasive.  We added many of the ingredients of our everyday lives – personal photos, TPS reports, business cards, a beer (non-alcoholic, of course), and some others – to a blender.  After pureeing the ingredients, we had the mish mash of our lives in a soupy representation of its non-segmentation.  Slowly, but surely, we continue to blur the lines between our personal and professional lives.  The generation entering the workplace today, as well as the mavens that have been productively using social media over the past decade, are contending with very significant issues when it comes to their personal versus professional circles.

Which is perfectly fine for them as, characteristically, they are less concerned about the space between work and personal that has existed in previous generations.

But it does bring up a new combined reality wherein the interconnectedness of all things plays a new role, e.g., less applying for jobs and more networking with previous co-workers and current friends.  This is a powerful change in the culture of hiring as we can rely more on data points that are trusted, rather than on the various axes we might consider from an interview.

We’ll have chips, you bring the dip

This is further aided by the number of devices (and the consolidators like cloud computing and apps) on which we can maintain a seamless online life.  Our ability to share, connect, and compute through these various devices has led to a revolution for some workplaces.  We’ve gone from intentional VPN connections on desktops into the workplace, to push-based access to email on our phones.

Enter BYOD.

Now we have the opportunity for individual employees to Bring Your Own Device (BYOD).  Gone are the days where individuals carry two phones, or a personal phone and a work laptop.  A new tide is rising where an employee can use their personal device to connect to work.  This has obvious implications associated with it.  In my last blog, I walked through some of the changes in the landscape regarding social media in the workplace and its potential for the leaking of PCI (a play on Private Health Information, Private Corporate Information).  Imagine the concerns regarding that PCI on a device that can literally be left on a street corner!  Consider data from Lookout Security (a mobile app that tracks lost phones) alone: 9 million lost phones in 2011.  By the way, if you have employees using mobile devices for work purposes, either company owned or personally owned, you should have a solution like Lookout or iOS’s Find my iPhone in place.  It’s just another thing to add to the technology section of your HR manual.

We can access statistics and reports from virtually anywhere with a WiFi or data signal, and we can do it on the same devices as our social media and personal activities.  This means increased efficiency for some, and others less so as there are more distractions on the same device; however, it also means being less tied down to a workstation.  Enabling employees to function in their role fluidly and dynamically means a potential for faster response rates and less commuting or booting (as in booting up a computer) time.  So long as you are not also operating in System 1 by multi-tasking.

What does this have to do with health?

I’m so glad you asked.  The mobile revolution has another impact on our lives: the ability for our physical wellbeing to be more social and integrated with our daily activities.  For an employer, this can mean increased health outcomes to decrease premiums as awareness of one’s health can increase attention to keeping oneself healthier.  Integrated with Social Media, this also allows for real time feedback from our social network, encouraging and assisting in the process of growing our health.  And since we spend 1/3 of our week working, ignoring this time because it’s “work time” is simply the wrong way to go about creating a healthier workforce.  Population health strategies necessitate an integrated approach to health – and even more so when you are self-insured!

If that’s not interesting enough, using both hardware and software, new tracking of the quantified self enables a feedback system that helps provide data to be reviewed by System 2, resulting in increased awareness of our current health status.  Knowing your heart-rate through events, in real time, allows for biofeedback-based solutions to situations.  Literally translated, our at-the-moment health can enable greater productivity at work – whether that’s at a coffee shop, your home, or at the office.  As these pieces of technology become cheaper and more precise, BYOD might one day allow for the inclusion of health devices for work too.

To our health,