Rajiv has led strategy and execution in numerous technologies for more than two decades, including mobile devices, wireless technologies, laser systems, digital imaging, stereo-vision systems and natural language processing technologies. He has played key leadership roles at Apple Computer, Adobe Systems, Interval Research, Regis McKenna and Symbol Technologies. Rajiv has also been a startup CEO twice before – at Tyzx, a spin-out of Interval Research Corporation focused on commercializing a ground-breaking vision technology and at Dejima, a startup that developed proprietary natural-language-understanding technology.
Zume Life supports you as you follow through with you individual health regimen and wellness program. The Zume Life personal health management system enables you to have on-going health activities (such as for chronic disease, weight loss, or treatment recovery) to draw inspiration and support from those in your personal support network, and helps you better track and adhere to your programs and regimens.
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Mohammad Al-Ubaydli: Welcome to the Patients Know Best Podcast. My name is Mohammad and, today, we’re lucky to have Rajiv on the Phone.
Rajiv: Hi, Mohammad!
Mohammad Al-Ubaydli: How are you doing Rajiv? Rajiv, give us some background about yourself, and how you got started in all of this?
Rajiv: Well, my background on the whole is for the last 20 odd years or so I have been involved in really driving forward a radical innovation, disruptive innovation in a wide variety of fields from photography to laser technologies and wireless and so forth. But for the last several years, I have been focused a lot on health, on helping individuals have more success with their own health efforts which led to a company that I started-up, called Zume Life, as well as a lot of consulting and writing in this space that’s what brought us together.
Mohammad Al-Ubaydli: So, given the pretty interesting background what made switch, now is the time that you’re tacking healthcare?
Rajiv: It’s never that clear that there’s some particular thing that happened. This is sort of a combination of a couple of things. One of my good friends and one of the co-founders of Zume Life was someone who’s been involved in healthcare her entire career; med school, practicing physician in the healthcare industry and so forth.
For a very long time ever since she graduated from medical school, we’ve had this conversation about what is health really, and what is the role of the physician? In essence once she started practicing as a doctor, she came to this realization that well in fact there’s not a whole lot she can do about people’s health because most of it happens elsewhere. Doctors are there to deal with the acute issues, emergencies, and so forth; but on the whole, they can’t really do much else because – well they don’t live with you 24 hours a day.
So, we had this conversation over a long time about what the challenge is, what that means. A few years ago things came together where from a professional perspective we were both in a position where we could start working on something together and we had the germ of an idea of a product or solution or the approach to people’s problems that may bare some fruit, which then lead us to start this company Zume Life.
So since then about, since the last four year I’ve been just very heavily focused on both understanding the challenge of health and well-being from the person’s point of view and then what kind of solutions, what kind of products, technologies, services could be developed that would help people do that.
Mohammad Al-Ubaydli: So tell what the company does? What are the kinds of products you offer to individuals?
Rajiv: So what Zume Life did was start off at the basic challenge as, of initially we started off focussing on the challenge of compliance in the US at least, it’s often referred to as adherence, it’s supposedly a more PC word but basically the issue is the difficulty people have in following through with their doctor’s recommendations.
Again, this a well-known phenomenon that happens everywhere and the usual approach, the usual mindset of this has been that people failed to comply either because of a lack of education so they don’t know that they really should do this or a lack of motivation and the idea is perhaps we can educate them more or we can provide more carrots or sticks to get them to do the right thing.
A lot of solutions have been developed along that line, a lot of interventions. Our perspective started off being rather different, in the sense that we noticed that even people, well like the two of us on this podcast who are very well educated, are able to do very complex tasks in other fields. We set ourselves goals and are able to achieve them and so on and so forth, we have just as much of a problem with compliance as anybody else.
So, it’s apparently not simply a problem of education, awareness, motivation and as I looked into some more, it became obvious that in fact the challenges are much more fundamental in the sense life is busy than these tasks of caring for yourself is just part of a daily laundry list of things that must be done and certain things drop of the plate and certain things get done.
So, it’s more of challenge of logistics that needed to be addressed first and foremost. It’s not particularly helpful to point out to people that why you’re not doing something if they’re simply not able to do it. And we felt that a lot of the healthcare regimens that doctors ask us to follow are at a very practical sense logistically impossible in our busy lives.
So, the goal was to develop a solution that helps people with that. And so the Zume Life solution that we developed, we developed a prototype and so forth and tested it extensively over time, it helps people do that, it gives them reminders in a very sophisticated way for anything that they consider health related that requires reminders. It helps them keep track of anything and everything that’s health related primarily from the perspective of helping them get through their day, basically reducing the hassles of life.
As a side benefit, almost, it turned out to be a very valuable side benefit; but as a side benefit, the fact that all of this information was tracked then makes it a lot easier in the long-term to maintain health. Both you and your caregivers can see a lot of patterns, trends, correlations, and so forth that can impact your health.
Mohammad Al-Ubaydli: This is a very interesting area that you’re working on and by the way just as a side point, your mention of the new word for compliance being adherence in. So when I was getting through medical school that was the kind of generation where they try and teach us that you don’t say noncompliance, you say non-concordance. The reason is compliance; it basically implies that the doctor has the correct opinion and the patient is obeying it. Whereas, Malcolm Gordon says, “The doctor has an opinion and the patient has an opinion and the two opinions happen to be different, but we’re not making any judgment about who’s correct it is that we happen to disagree on.”
Rajiv: That’s right and that’s a valuable perspective. What we noticed was that we, as individuals, are not so successful in adhering or complying with our own self-defined regimen.
Mohammad Al-Ubaydli: Better learn someone else’s right?
Rajiv: Yeah, never mind somebody else, if you can’t do what you yourself decide to do then there’s something else going on.
Mohammad Al-Ubaydli: That’s interesting. I think pretty much everyone knows now that smoking is bad for you right? But that’s not the barrier to stopping smoking, people know that it is bad smoking.
Rajiv: That’s right and in fact it brings us to what I think is really accord to this, and this is, these are 8 years back I found as I looked into it, in many other places I found that these are not particularly novel but never mind they were new to me, which is, when we’re dealing with these issues of health and especially as you and I are looking to develop solutions, products, services that can impact health.
We know that framing the problem is critical to developing a good solution, if you define the problem one way, you’ll try to develop solutions for that. If you defined it a different way, you might develop other kinds of solution.
So framing what is the problem is really, really important and in this challenge of developing solutions in fact I believe that we’re framing the problem incorrectly. This is despite sort of a long-term view that’s different from the way that healthcare is actually implemented. If I could take a moment to explain this thinking, the frame of traditional healthcare is really around eliminating or minimizing acute diseases or infirmities. Something nasty happens, you go to see the doctor and he helps you get back together.
So on those circumstances it’s really the healthcare professionals that take the lead, with your permission, take the lead and applying the tools of the trade, the medicines and therapies and so forth, and medical science has developed, to deal with this acute issue. It’s a very professional centric point of view because in fact they’re the ones that have the expertise to do something about it. As we moved on to the issue of chronic illnesses, chronic conditions, we have still applied this traditional mindset, this traditional frame and altered just a little bit and called it health management. But we still end up with medicines and therapies that are prescribed by physicians and we as patients are supposed to follow them, but that’s really the approach.
In fact, even today in some of the advanced thinking on health solutions, we talk about moving to patient centric care. However it’s still patient, and a patient is sort of a subservient to the experts, the physicians. And so again this is very much kind of a medicine folk centered view of health. But in fact health is much, much broader than that and we see that in the lack of success of a lot of these patient centric health related approaches.
The kinds of traditional approaches that have come from this traditional frame of health management includes giving kind of a long list of suggestions, recommendations to us, patients, ranging from the trivial of take your medication as directed to things like walk 10,000 steps a day, or get eight hours of sleep, or there is ever more rules on what you are supposed to follow with regard to your diet.
We know that most of us don’t seem to pay very good attention to these things. We have also developed a lot of tools but they’re often very narrow pathologically focused solutions, we have a solution for asthma, you have a solution for chronic heart failure, we have got pill reminder systems, you’ve got trackers for diet or exercise, you got these biometric devices, they are very narrowly focused kind of very medically defined, very pathologically focused solutions.
As we know even the best of them have had relatively modest impact on health. I mean we celebrate when we notice in clinical trials that you got 5% improvement on this population versus that population. I don’t want to smear at the progress, because even that has been a hard one and yet it’s just such a small change that’s not what we’re looking for.
From my perspective, we really need to step back and one place to step back is if you look at the World Health Organization’s definition of health that they adapted gosh back in 1946, 1947, whenever the organization first got set-up.
It’s something along the lines of health is state of complete physical, mental and social well being and not merely the absence of disease and infirmity. And that later phrase not merely the absence of disease or infirmity is part of the definition.
Mohammad Al-Ubaydli: They explicitly say that in the WHO founding document.
Rajiv: Exactly I mean their definition of health is that simple sense, health is a state of complete physical, mental and social well being and not merely the absence of disease or infirmity. But this is not novel thinking and yet obviously in the day-to-day sense of healthcare it’s not at all taken, that is not the fundamental. The fundament is disease and infirmity.
So even though there have been many greater thinkers in the past who view health in a much broader way that’s not the reality of our healthcare institutions or most of our healthcare practices. But if we accept that health is this much larger thing, then you can understand that health is impacted by far, far more than medicine. At a very sort of simple simplistic view perhaps the absence of things like earthquakes and war or the presence of clean water and air has more to do with your health than practically anything you can do yourself.
Similarly, in the UK there has been these wonderful long term Whitehall studies that have shown that in fact the largest, one of the largest factors with regards to your health is your work environment. More specifically the thing that they have noted is more important than anything else is the level of autonomy you have with regards to your homework.
So whatever your work maybe, do you have the freedom to sort of just go about and do it or are you micromanaged. Yeah it’s a very trivial, trivial description of their work.
Mohammad Al-Ubaydli: So this not just that if you work in coal mine you might get a number of diseases from that, it’s actually, white collar worker and the degree of autonomy you have is that they get, or one of the biggest indicators about your health.
Rajiv: Far more than your own health habits astonishingly. So if you are not familiar with these, you should look it up, it’s called the Whitehall studies. And as a brief background it started off, I think the first Whitehall study was done in the late 60s and the shocking discovery at the time was that there was a very dramatic health gradient with respect to, if you will, the pay scale but it was opposite of what they had imagined.
They had imagined that the further up you got in the British civil service, the more stressful your job and therefore greater incidence of heart disease and so forth. What they found was the direct opposite. In a sense, the closer you got to the mail clerk the higher incident of health issues and the closer presumedly you got to the Prime Minister, the lower.
Mohammad Al-Ubaydli: And that was causative, so it wasn’t that you got to be Prime Minister because you had better health, it was because —
Rajiv: So that was Whitehall I was merely the collection of the data that resulted in this observation. Then the Whitehall II studies were started I believe in the late 80s and they continue, extensive studies of the civil service in the UK that have gone deeply into understanding what’s this all about, why is this so, and to understand in much greater detail.
So, those have been ongoing and again I’m trivializing their extensive findings by saying that the most important factor in the person’s health turns out to be sort of the level of flexibility and control they have over their own tasks. It’s far and more important than your own health habits and so forth.
I bring this all out just to point out that when we think about a person’s health, there is a lot that is completely outside the control of the individual or their healthcare providers and to the extent that we try turning the dials on things that the physicians and the patients can do without appreciating the larger context, we’ll never have a whole lot of success.
Mohammad Al-Ubaydli: That’s interesting, so thinking about the sort of 16% of the U.S. economy that goes on healthcare funding, that’s making a very small contribution relative to the much smaller spending on infrastructure for road, sewage, education, people having control over their life that actually makes a big contribution to healthcare?
Rajiv: Yes, yes and the many large corporations are extremely concerned about their health requirements of their employees primarily from a productivity perspective or a healthcare cause perspective. So there is all of these wellness programs and so forth which are well intended, but if we take the Whitehall studies to heart, the changes that have to happen are in sense outside the individual. It’s how is the organization, run, managed.
Mohammad Al-Ubaydli: They started to give me incentive to become Prime Minister.
Rajiv: Well, there you go. Let’s put aside these things that are in a sense outside the individual’s control. Even within the things that are in the sphere of the individuals’ life, we know that so much goes into your health that’s beyond just medicine. It’s how what’s your social interactions or, like if you are happy or not, if you are doing things that are meaningful to you and so forth. And to the extent if there is a tradeoff to be made on any particular day, you may in fact be better off focusing on those things that make your life better, which will in turn make your health better than just focusing on very narrow, sort of pathologically oriented efforts.
We have to keep this in mind, but the World Health Organization actually went further and in the late 80s they had something, a meeting that eventually got called I believe the Ottawa Charter. The Ottawa Charter was the document that came out of this large sort of a gathering to rethink the whole issue of health and they didn’t end up changing the definition of health. However, they did note its relative priority and they noted in particular that health is a resource for life, not the objective of living.
So, they were just emphasizing that what we care about and what we should care about is quality of life. It’s the living not whether you are in good health or not. Health is simply a means to an end, not the end itself; we have to very much keep this in mind. Back when we were trying to develop products and services to help people with their health and well being, keep in mind this is not their priority, and in a very real, but philosophical sense it shouldn’t be their priority. Life is for living not for managing your health.
So we are to develop solutions that make a significant difference to the individual for the health and wellbeing, we have to appreciate that these tasks of health, these chores of health are really just that their chores, they’re not the point and to the extend that they are going to help people they have to make life easier, better not more difficult and —
Mohammad Al-Ubaydli: Again this is how and the services of life sort of endeavors?
Rajiv: Exactly, that’s exactly it. No, you are about to say something.
Mohammad Al-Ubaydli: Well, I was going to ask kind of I was really
intrigued the first time I spoke to you about that the focus that you had on your product it was exactly that it wasn’t something too knaggy about yet another failure you have in here into the health guidelines, it was actually trying to serve you with some useful tools.
Rajiv: That’s right.
Mohammad Al-Ubaydli: So I was kind wondering what of problems do people solve using the Zume Life products?
Rajiv: Well, there is a couple of things to start off again with a kind of an earlier bit of conversation that, let’s focus on the persons self defined health tasks, so we get rid of this issue of concordance and so forth. It’s what they want to do. What the would like to be doing and so then the problem simply becomes how do you manage to do that during the course of your busy days, right you have other things that are far more important.
So, what kind of things can we provide to make your life easier. One of the things that is a huge mental burden is being able to remember all these things and lot of times we look at these health solution and say this is so trivial because in a sense well how hard can it be to take that pill or how hard can it be to weigh yourself once a day and that kind of thing. We look at this very minute little task not realizing that if you added up all the little tasks in the course of a day that has something to do with your health.
They’re enormous; especially, for people with multiple chronic diseases, which is getting to, unfortunately, be ever more the case. There is just a lot between your medications, between your biometrics, between symptoms, and things that you’re supposed to keep track of between tasks that you simply suppose to be — and stay aware of it so forth, even if there’s self defined.
In the US there is a very popular writer named Michael Pollan who has written a lot of books about foods and healthy eating and so forth. His most recent book is a set of something like a 100 rules you should follow for good eating. And each individual rule makes sense, but try to keep all of these in mind if it’s possible.
So, again, on a daily basis if you are trying to follow a set of things how do we make the simple doing of it easier and so this notion of being able to remind people at the right time that they need to do something is a very valuable aid. The other thing is being able to track what you have done and especially for its short-term benefits. We normally think of these tracking of health for its long-term benefits that you can analyze the data and so forth.
Think of the short-term, sort of the immediate benefits tracking something really comes from the fact that well 10 minutes later you can ask yourself how did I do that? And you can easily see that you have and so you can get on with your day.
Mohammad Al-Ubaydli: Can you give me an example of that was being tracked — short-term?
Rajiv: That’s an important question because the key is, it should be anything that you think you want to track, okay, and so whether it’s things like medications or you have decide that you want to drink five glasses of water a day or you want to remind yourself because perhaps you have carpal tunnel you need to step back from your computer once in a hour and take a five minute break, whatever it is that you think is important for your health you want to track.
There are users, especially, in our prototypes and stuff just as a rattle off, they track a variety of medications and medications rather a catch on term, it meant anything from prescription meds and over-the-counter things, but also included herbal remedies and whatever you happen to make yourself, those of us with an Indian background often had milk with turmeric for colds and coughs and things like that, that counts. There is also —
Mohammad Al-Ubaydli: You’re making me hungry now.
Rajiv: Yeah, there is also therapies in the sense that you are doing breathing exercise or you’re diabetic and so you want to remind yourself to massage your foot a couple of times a day, things like that. There is, of course, keeping track of — again, it varies by person, but some people want to keep track of their diet, keep a food journal and for certain it’s far more important to do it in meticulous way than others.
So if you have things like a crohn’s disease or colitis or things like that you want to actually keep very careful track of your food, not so much in a nutritional sense that well I had so many grams of salt and so forth, but actually what did you eat, you had ham here, you had broccoli there and so forth because that might help you to keep your health issues sort of under control.
People kept track of a variety of activities ranging from the obvious things like walking and swimming and whatever, but we had one user who wanted to — who is important for her to keep track of her physical activity sort of her exertions and one other things she listed was shoveling maneuver, turned out she lived at a farm and she explained that that’s really hard work.
People also kept track of different symptoms and stuff, we had, for example some people kept very careful track of episodes of pain for various reasons people kept track of their productivity their sense of well being, their occasions of asthma attack. It varied quite tremendously and this is actually a very important learning, which is rather obvious in retrospect but that each individuals needs are unique.
You can’t just bucketize them as people with diabetes or people with asthma or people with lower back pain, these sort of pathological buckets because each person circumstances are so different and as we were talking earlier, their context, their job, their family situation where they live and so forth has a such a huge impact on their health, that everybody’s health situation and health activities are truly unique and so what — any solutions supports them what needs to acknowledge and cope with this uniqueness.
One of the papers that I’m working on right now which is meant to provide some guidance for those designing health solutions makes an important point about this that we need to be designing frameworks for health, which then are ultimately customized by the users rather than making very tightly fixed products. They simply don’t fit with the reality of our lives and norms variations.
Mohammad Al-Ubaydli: That is very interesting thing, are you describing all these things I’m just, I’ve been writing a book, recently, called “Switch: How to Change Things When Change Is Hard,” which I highly recommend by the way. It’s by Chip Heath and Dan Heath.
So, they start with this one experiment in the beginning which is – they have these volunteers who come in and they come in to the room and a plate of warm delicious chocolate chip cookies and other plate of dry granolas and, of course, you can tell what everyone wants to eat; but the task they’re given is, half people are told you can eat as many hot chocolates as you want, but you can’t eat the granolas and the other half are told the reverse. They’re told we are watching to see what happens with the experiment.
Pretty much — so the volunteers, all of them, they are all adults and so they stick to that rule. Then the they come back after half an hour and say thank you very much for doing that, “Oh! By the way, can you also do this puzzle?” And they are set a task for this puzzle which actually is impossible to do, and the real experiment is they’re testing out how long until you give up.
So, what they find is that the people who had to resist chocolate chip cookies give up much earlier than those who had to resist granolas. So what they are saying is, basically, there is a finite amount of willpower you have in a day and as the demand of that willpower went up, you just get exhausted, and you just give up.
So, it’s not that you don’t know that you should be doing stuff it’s just you only are able to do so much and so the book is all about minimizing the burdens and things you can do to guide people, because they are in willpower fatigue and so I was intrigued by that.
Rajiv: Yes, that’s very much along sort of the right direction, but there is, there’s also a term that’s been used in some places, bio-cost, which is just reflective of this. But anything that you do has a certain amount of cost even if it’s not measurable. There’s financial cost, but also there is the cost in time, in mental energy, in physical energy and so forth, and we ignore that to our peril.
We do only have a finite supply of it, and in fact, there’s lot of studies kind of about the increasing busyness of life. There always seems to be one more thing that you’re supposed to keep on top of. In the US right now, there is a movement of the smart grids. The idea is that the solutions will be in your home and you will be able to get detailed information about the electricity usage of various appliances you got plugged into the house.
That with this information you can do a smarter job of balancing your power needs and so forth and the long term effect of reducing our energy consumption. All very nice in theory, but I wonder where exactly is this mental overhead going come from, that will allow us to manage one more thing.
Mohammad Al-Ubaydli: No one counts that right?
Rajiv: No one seems to count that, yeah. We seem to be constantly overburdening ourselves and there is this analogy of that the straw that broke the camel’s back and I think that doesn’t fit here. It’s rather more that we’re constantly adding one more grain of sand to the machinery and it’s just ever more sort of slowly grinding and just wearing away. And in a sense that’s what it feels like. That we’re just constantly throwing more things at people saying, oh you can do this one more thing, it’s so trivial. But the accumulation of it like those resisting the chocolate chip cookies, it takes a lot of energy.
Mohammad Al-Ubaydli: You said something, “I always think of them, Animal Farm; the character Boxer, the horse.”
Mohammad Al-Ubaydli: Who, whose catch phrase is “I will work harder” and he just keeps on heaping on more and more tasks and, of course, Boxer ends up in a glue factory. It’s not a sustainable way of working. I’d say I’m kind of — I was really interested when you described your product, because it was all about trying to do things smarter and avoiding the constant guilt tripping of there’s yet another task that you’ve missed.
Rajiv: I’m bringing it at a higher level of alleviating the user’s workload.
Mohammad Al-Ubaydli: Yes. When people, when users start using the product, what do you advise them?
Rajiv: Quite importantly, we don’t give them any particular advice in the sense of what they should be doing for their health, we really don’t know. How do we know your particular circumstance? We simply don’t.
So the advice that we give is more, is just at the very simple level of how do you use the tool. Along those lines, we just advise people to start off with whatever is on your list right now. Don’t worry about what else you should be doing. Just, whatever you’re trying to do, just start with that. Then see where it goes. There has been a lot of learning from in a sense others who have used to tool, that we then pass on to people, but it turns out in retrospect to be a lot of common sense.
As it turns out once people start using these sorts of solutions and find that, hey there, they’re actually able to be successful at their self defined health regimen. Then, well, simple things happen. They start being more confident about their ability to do things. They start seeing for themselves what things matter, what don’t.
So they start changing what they might be doing. They also start getting the confidence that they can take on tasks and accomplish them. Then they sometimes give themselves more to do, because it’s doable. Since we’ve lowered the cost of these things significantly, they’re able now to do more.
So in a sense, people may initially start off for example in terms of keeping track of symptoms, do the sort of pathologically oriented symptoms such as if you have asthma, keeping track of your wheezing or shortness of breath. Then over time people start often keeping track of more things, how they slept or how they felt and so forth, partly because they find it so much easier to add things to their to-do list and accomplish them, because they’re learning from themselves, their self observation what may or may not be meaningful. In a sense it encourages them to do what I think of as tiny self experiments and seeing if this makes a difference or not.
Mohammad Al-Ubaydli: So this is interesting, because one of the things you touched on, basically, is you watch your different users began using the product for. What have you learnt from watching them do that and the things they track for themselves?
Rajiv: Well, a couple of very important sort of high-level observations. One is this notion that health is dynamic. That it is just constantly changing, both your health and what you might do for your health.
Some of these changes are driven by the context. Your health deteriorates because your body is aging or there is more pollution of the air or your job changes and becomes more stressful, things like that. But your health is just constantly changing. Some of these are long term cycles, such as aging. Some of them come and go with the seasons or job changes and things like that.
So one important thing was just this notion that your particular health regimen or your particular health status at the moment is basically guaranteed to be different a few weeks from now, a few months from now. So this isn’t a static problem, but a dynamic problem, and so the products and services and solutions need to just be aware of that, sort of be built around that.
The other thing was also this notion life is focused on health, and so there were times when people’s health was say more influx, that they would use the solution in greater sort of detail than they would when their health was fine and they simply focused on other aspects of their life. And sometimes this was quite dramatic, in the sense we had one user whose health was actually getting worse, but she had less and less time to focus on herself because she had serious illnesses to deal with, with other family members.
She has only got 24 hours a day and she has only got so much mental energy and in a sense consciously just having to allow her health to deteriorate while she deals with other things. And you can’t argue with that. That’s a very reasonable approach, and a very different more positive kind of thing. So, there’s a person who was a user who had, he’s been dealing with chronic health issues for the last couple of decade, because he was an organ transplant recipient and then just sign up for a life time of managing your health with that.
He knew that there were going to bad times and there would be positive times and so he just kind of went with the flow. When his health was getting of out of whack, he would be keeping track of various things and he would make sure to do all of his health activities as close to his self defined regimen as possible, give high priority to it everyday.
Then, once things stabilized, he’d just have to go back to a more laissez-faire approach, so that he could concentrate on other aspects of his life. So, from someone who is providing a solution or say a healthcare practitioner is trying to help the person, you have to step back and say their life, the flow of their life is going to rule more than this particular task in front of them.
Mohammad Al-Ubaydli: So do people come to that realization eventually, I guess what do people worry about when they start using this software that you don’t think they should be worrying about?
Rajiv: We didn’t actually get a whole lot of that, that I can really give you an answer to it. We didn’t have a whole lot of people —
Mohammad Al-Ubaydli: I guess the stories you are telling me and the feedback you’re drawing, is that from people kind of posting in a social forum and then the community or is that from interviews you’ve done with other users?
Rajiv: We followed up with, as I said we did a lot of pilots and the purpose of the pilots was to learn, and so we did a lot of that. What we found, to your question, there’s perhaps a slightly different twist on it, but when we looked at what value did people find from using our solution, that was very interesting as well.
So one particular story out really had to do with a person who had been relatively, recently diagnosed with type-II diabetes when she first started using the solution. At the time, she was just coping with this, for her this life shattering discovery that she was going to have to manage her life differently than she had done before, she had to pay attention to her food, she’s got this whole counter full of medications and so forth.
So just the whole notion of living with this illness was, was just very confusing, very challenging, just very hard to accept. In that situation when she first started using our solution she told us that the most valuable thing was that whenever she kind of used the solution or just noticed it lying around, it gave her comfort from knowing that well, there were other people like her and that there were people like us who cared enough to be developing solutions for her.
So it just gave her this comfort of not being isolated. Whereas when we talked to her four or five months later, she had come to terms with her new situation, had come to terms with the fact that was she would be able to deal with it just as a few other millions of people around the world have done. So then the value of the solution sort of started becoming more of the pragmatic stuff that she could now rely on the solution to do things, the mundane things of reminding her to keep on top of things that the benefit now was sort of the mental unburdening on to the solution for things she had to stand up, but it varied.
Mohammad Al-Ubaydli: Now that’s interesting and so I’m intrigued also by the temporal aspect that things change at a time. So if I’m going to start using your product, I’m already 00:42:31 now. So what do you think I should worry about that traditionally people don’t worry about when they first begin or what should I know that people often don’t know when they start?
Rajiv: Well, I want to just throw in here a little caveat on sort of jumping in and encouraging people to use this solution because the Zume Life Solution has been developed very much at a prototype and so forth, it’s not ready for prime time. It’s very much directional of the kinds of things that need to be done, but it’s not exactly available for widespread use and at the moment in fact we are not taking on anymore users while we —
Mohammad Al-Ubaydli: I’m very disappointed Rajiv.
Rajiv: — while we take the learning of it, and improve this significantly. So it’s more the learning, the direction of what kinds of solutions should we be developing that is really important here. And well like recently I just read this wonderful report that came out of the UK from an organization called NESTA, called The Human Factor and talking about how we can transform healthcare by involving the public much more in it.
I like one of the things they say at the beginning, sort of arguing for why such an approach is necessary by saying simply that why doing the same things only more cheaply won’t solve the problem, that we have to have sort of dramatic leaps forward not just keep trying to make things more efficient. So this is all very positive and yet as you go deeper into this particular report, which, again, on the whole is really well written but the focus ends up being on this innovation of patient-centered care and this is where I think a lot of these innovation efforts are just falling so far short.
If we keep insisting on seeing patients, we’ll never get there. We have to have people-centered care and in fact people-driven care. We need to reframe healthcare from being something that these professional providers do for us to reframing healthcare to sort of self-management of well being. So the solutions we really need to be driving towards and whether that’s at Zume Life or at the NHS or at Kaiser or wherever is putting the individual at the center of their care, putting the individual as the person in charge and everybody else is simply an advisor.
Making sure then that we’re developing solutions that suit the person, they make their life easier everyday, they address whatever that person feels is their important health goals, that acknowledges that whether we like it or not they are going to focus on life not health, that health is multi-factorial. And so these solutions have to be designed with that in mind not these narrow asthma solution or diabetes solution, or lower back pain solution.
So these are the kinds of things that I would like to emphasize rather than, hey everybody go, try the Zume Life solution. It’s really the start, it’s a directional thing, it’s not the end-all product.
Mohammad Al-Ubaydli: I appreciate you highlighting the bigger picture. The NESTA reports, you were talking about them, and I was there on the day they presented it and on then on the PKB Wiki there’s a video of the event as well as the reports. So, I watched them; watching and reading. So the thing that disappointed me is the same thing that you were describing which is the, the focus was on how do we do what we currently do but more efficiently, right?
Mohammad Al-Ubaydli: So, we don’t want to do the wrong thing right, you want to do the right thing and you have to switch away from, at the moment, talking to the existing members of the healthcare system all of whom are very well meaning. Yet, with always in the presume of doing what we currently do, which I think is the wrong thing, but doing it more efficiently and start saying, “Well, let’s do it the right way, which is people-centered as you’re describing in a dramatically just completely different way that traditional presume just wouldn’t allow you to even contemplate escaping.”
Rajiv: That’s right, that’s right. I think a very positive irony in this is that if we do that, if we focus on helping people take care of themselves in whatever way they want to, we will actually accelerate the kind of learning that the medical community wants to do more of. And as an example you know, you described that chocolate chip cookie Granola example. But the reality is that so much of our clinical trail, so much of our medical learning type of efforts by nature have to focus on very, very simple experiments because we simply can’t cope with things that are as diverse as humanity.
So we come up with these very difficult to do, but in the end simple experiments and try to extrapolate from that learning. And the challenge there is humanity is so varied that we learn so little unfortunately from these carefully controlled scientific experiments. The challenges that from a medical, from a science perspective, we cannot possibly afford to do huge complex multi-variant studies, how can you mange that, simples ones are hard enough.
If you actually develop the kinds of tools that sort of Zume Life is pointing towards and we allow people to take care of their health in whatever ways they want, then we will end up with in a sense this big data, this enormous collection of enormously varied data, which can then be mined to extract the kinds of information that we are looking for in our clinical trails but actually get presumably much more information than we are able to today.
Rajiv: I’m glad you brought this up because I remember, you remember the Robert Wood Johnson foundation about observations of daily living where they, they’re basically ask people to create tools that track things that people care about rather than the traditional randomized control trial chases about.
I just remember when I was reading the call for proposals that, like I was thinking did Robert Wood Johnson foundation talk to Zume Life or something because they are doing, they are asking for exactly what Zume Life is focused on, which is let the people declare what they find interesting and let’s give them tools to track down in a mass scale, so both sort of mass customization. I was, kind of, curious whether you definitely make it easier to collect that data than it has ever been possible to do so.
So you can actually begin to answer useful questions which traditional randomized control trial have not touched on because of the scaling problem you are describing. But I’m kind of wondering whether you’ve had people come back to you from Johnson foundation or people from the ODL movement kind of saying, what Zume Life learned or what Zume Life doing around?
Rajiv: No, it’s sort of an interesting thing there, which sort of goes to the heart of the problem we are talking about, about people not being able to really go far a feel from what has always been done. So the Project Health Design that you speak off, I think just in the last few days announced publically, you know, the selected five projects for the next round, you know, you spoke about when they’d put out the call for proposals last year, well you look at these projects and they are again so tightly pathologically focused.
So one is ODLs be a mobile platforms for use with obesity and depression. Another one is focused on to collecting ODLs from children whit Crohn’s disease and so forth. They are very pathological focused also another sort of aspect of the whole Project Health Design was that no proposals were accepted unless the clinicians were involved. In fact the project had to be led by a clinician.
Mohammad Al-Ubaydli: Exactly.
Rajiv: My whole point here is that I am sorry but that is a very small subset of health. Again if you go back to the World Health Organization’s definition of, underlying definition of health and the expansion of the concept with the Ottawa Charter, this notion of clinicians driving, this is really the wrong place. Right I think Project Health Design you know they’ve done a lot of good work, there has been a lot of interesting learning’s from it, but it’s more along the lines, we are doing what we do slightly more efficiently.
Mohammad Al-Ubaydli: Yes and they kind of picked the obvious traditional things and it slightly turned away but they are getting back.
Rajiv: Yes, in fact it was quite ironic is that we looked into it, we found from Zume Life perspective that well we were basically ineligible to apply one because —
Mohammad Al-Ubaydli: It’s getting, I thought —
Rajiv: Yes, well the problem was, one we were driven by what the user wants and whether a clinician is involved or not, secondly what they wanted to do is to spend the first year, I mean in 2010 developing the concepts for what a solution should be and then in 2011 perhaps building some prototypes. Well we did this a few years ago and so we are —
Mohammad Al-Ubaydli: And that’s kind of the bad thing.
Rajiv: That’s just the bad thing exactly. So again I don’t mean to criticize their efforts, they have been a lot of really good things within the constraints that in a sense these sorts of foundation proposals are stuck with and from the academic point of view. But the important thing here is that these sorts of projects and most of the projects are driven to in a sense learn, they are — it’s a scientific effort to learn defined norms that can then be turned to treatment plans that doctors can advise and so forth.
Our goal its sort of, in the sense of Zume Life but also my personal passion and focus here is how we do help individuals take control of their health and do whatever is best for them, whether or not it is useful for the world. In the sense if for you Mohammed, if eating broccoli is the only thing you need to do to sort of fix your health great, we’ll let you help you learn that whether or not it makes any sense for the rest of us. It’s like how do we help the individual with his health.
Mohammad Al-Ubaydli: And I approach at the same time it’s being very helpful that broccoli is not the only thing that’s trying to give me health.
Rajiv: Yes, one would hope but —
Mohammad Al-Ubaydli: But that’s what I will expect, a cool faith that —
Rajiv: That’s true; Mr. President, George Bush, didn’t like this stuff so —
Mohammad Al-Ubaydli: What else do you wish I ask you for, because, that you’ll find very interesting?
Rajiv: Well I think the, the thing that I’d be curious about, is reason is what’s going in Europe that along these lines that quite honestly that I could participate in, that I could help with, I have to imagine that these ideas are certainly not limited to the U.S. and what I’ve seen from a far is that even within talk about the healthcare assistance the ones in Europe are far more holistic than what is in U.S. so that’s sort of my question to you.
Mohammad Al-Ubaydli: I was really looking forward to this phone call today, because we just started a project with NHS Choices, today, and NHS Choices is the National Health Service equivalent to WebMd in the USA. One of the things we are doing with them is integrating all that content, so we can merge around this information.
The project we’re doing at moment is a pilot with a social game provider on the iPhone where they create social games for people doing exercising (ph) activity and what we were doing is integrating with their iPhone apps. So whatever the person is exercising with that becomes a feed that goes in to their clinical team or whoever they want to share with secure clinical information online.
So, what I am kind of now thinking about is, what are the other observations that they 00:56:07 like applications that are available that I can then feed back to the UK clinical system; because you are getting different members of the healthcare system who are saying, “Well, the overall budget, I am responsible for healthcare. So, it’s no longer about shuffling back and forth between different specialists or this year’s budget and next year’s, I am responsible for the healthcare budget, anything I can do this year will pay dividends next year.”
So, they’re thinking fairly progressively about, well, what are the different things we can track and I wanted to start giving them different beta feeds, but without falling in to the trap of everything the patient does or the person does must be registered and given permission by doctor or nurse.
Rajiv: Right, right.
Mohammad Al-Ubaydli: So, I’m interested in different things we can do, things like and all the different things you collect that are personal specific.
Rajiv: Yeah that would be, that would be great to work together on. And it is important that even while there needs to be an essence of filter between, here is what the user is doing, but here is all that the healthcare professional cares about, that’s fine, we’ve got sort of a comedy in that, but let’s not stop to prevent the individual from doing what he needs to do. So sort of accommodate both sides.
Mohammad Al-Ubaydli: Yes and then just for us, we do the medical record in the social network, so it begins with inviting your clinical team but actually you then invite the people who really contribute to health, your relatives, your friends other people would send you these and they will get to look at the data with you because they are the ones who are going to make the real difference to you, okay.
Rajiv: That’s right, that’s right. Yes, in fact this notion of others like me is really important and this is a place where sort of mining of big data will prove to be invaluable because it’s really at the movement finding others like you is not trivial. It’s not just a bucket of diabetes etc. It’s how do you find people sort of your ethnic descent living kind of in your type of environment doing your kind of profession with your kind of health issue or probably much more you know have similar kind of health constraint than someone else with the same label.
Mohammad Al-Ubaydli: This is just checking out because this is concentrated to try and explain to you, people in the healthcare profession but one of the most interesting things to me about web before facilitating a research is the evolution of a tag. So and these things are very trivial basically the idea of having multiple overlapping tags rather than hierarchical system classification means that actually finding people like me under different facets is much more interesting and possible whereas if you start with a hierarchy you’ll always be constrained by, I can find people under that classification just in — who are like me. But, if, originally we found out that classification system hadn’t sort of this particular way of looking the data, I can’t look at the data in that way.
Rajiv: That’s right.
Mohammad Al-Ubaydli: The web kind of lay outs tagging myself up from this ethnic background to tag myself to others, I like curry or I like Viking. And then allowing all kinds of new ways of finding people like me that who had never been envisioned or design.
Rajiv: — by yourself perhaps, you know because how many tags can we ever create, but this is an important idea in two perspectives, one is the one that we’ve just been talking about, how do you find other people like you by kind of doing this automated data analyses to find the affinities if you will, that really look like you. But there is a very different use of the same technology in a sense within the person, which is — so suppose someone has been using a Zume Life like system for a long time, whether it’s months or years, what have you. There are things that might occur to you or your caregivers that you might be looking at. Like did this medication work for you or not, that kind of thing.
So you could look the data and sort of proactively look for a correlation that you may or may not find. But just if you have this kind of data, we can use a lot of these deep data mining tools to find or spot patterns that we may not be able to think of ourselves.
So the system, I’ll give a trivial example, but the system may be able to note that, hey, you know whenever we have gone mountain biking in Yosemite National Park, five days later you’ve always had kind of a serious asthma attack. This is putting together three different pieces of information.
Maybe it’s the fact that you’ve gone mountain biking, which you’ve noted in your exercise activity. Maybe in some journals, you’ve noted that you’d gone to Yosemite and in some place else you’ve noted that you had asthma attacks and, but this is the pattern you may have never had spotted yourself. Now I just think of that example.
Mohammad Al-Ubaydli: So not only does data collection and data storage, obey Moore’s law of sort of exponential increases in capacity, but analytics also obey Moore’s law, that you can start answering questions would have been completely unimaginable 5 years ago because of the new onset of technology that you have as an individual available.
Rajiv: Yeah. I mean not all of the stuff is available to us yet. But I mean especially with your background you know that this is available. This isn’t science fiction stuff. We know it’s there. That could be applied to this. I mean ironically health as a field has relatively speaking a dearth of data.
Mohammad Al-Ubaydli: As in digitizable or digitized analytical data or just dearth of data?
Rajiv: Just dearth the data in general. I mean never mind whether it’s digitized or not. But think of the person, a normal person’s health record, even if every single piece of information that exists today on paper was in one place, it’s still such a tiny view of your health. Contrast it with even your modern car is collecting an enormous amounts of data about itself everyday. Never mind the latest Airbus or Boeing Airplane.
Mohammad Al-Ubaydli: [Audio Disturbance 01:02:42] So your medical record is really a series of transactions that you have had with the healthcare system.
Rajiv: That’s right.
Mohammad Al-Ubaydli: [Audio Disturbance 01:02:53] I’ll cut your call and just call you on another cell phone.
Rajiv: So there is enormous potential for both the creation of big data and then really valuable use of it.
Mohammad Al-Ubaydli: [Audio Disturbance – 01:03:09 – 01:03:47] And then coming back to your point, your focus on that normal person. So one of the things — especially, there will be the clinicians and patients or people that do cover this kind of this information and so if you look at 01:03:30 that a patient has 6,000 of megabytes of space available free of charge and a much better user interface than the securing of a check (ph) has for its clinicians which is 100 megabytes, that’s quite an expensive clinician. And I was doing calculations the other day that Facebook, for example, the amount of photographs it transfers everyday is the equivalent of 60 million x-rays every day, i.e., the entire population of the UK transferring x-rays everyday. This is being done free of charge everyday. Whereas a digital image system for clinicians is exceptionally expensive.
So it’s the patients who are encountering dramatically new technologies, order of the magnitude better than anything the clinicians have and I think it’s them who will find new ways of research before the clinicians even realize it’s even available, and they’ll bring the clinicians along with them rather than we’ll wait for a clinician to introduce it and ask them to track ODLs or whatever?
Rajiv: Yeah I mean it very much could work out that way. And of course at the same time I hope that the folks in the healthcare system do move more quickly, because they will certainly stand to benefit from these things as well. So they have very much some value in this happening anyway, and so I hope they do. And in that paper I had sent you a couple of months ago of A Billion Little Experiments I did a very quick back of the envelope calculation just on capturing data for a percentage of Americans with diabetes and it easily gets into the petabyte range.
Mohammad Al-Ubaydli: Remind me what are the data points collected for that, the petabyte?
Rajiv: Oh! It was — I just sort of — it’s like here’s a rather generic daily health regimen of a person with diabetes, of an adult with diabetes. They might be taking this many meds a day, they might be keeping track of their carbs, they might be keeping track of disease symptoms and so forth. If they were doing that everyday, through a system like Zume Life, how many people would you need to sort of be collecting a petabyte worth of data a year; it’s not that many.
You contrast it with the level of health data that we generate today through clinical trials and doctor visits and so forth, and it’s night and day.
Mohammad Al-Ubaydli: On that note, Rajiv, it’s been really interesting talking to you. Thank you very much for your help. We’ll put all these notes on the wiki in the blog and including the paper that you mentioned. Thank you very much for joining me today.
Rajiv: Oh! You are very welcome, Mohamed; it’s been a pleasure to talk to you as usual.