Engagement: The Sixth Vital Sign
Bringing the “Quality” back to Quality Measurement
Medicine utilizes vital signs to help navigate the health and well-being of patients in the context of illness and health. These signs, like any other signs in life, inform us as to our level of concern as well as orient us as to what should we do next, if anything.
The five official vital signs are blood pressure, pulse, respiratory rate, temperature and pain. The numerical essence of each of these measures is is pretty much binary. That is, a heart rate of 10 and a heart rate of 250 both mean the same thing: You’re likely going to die unless something changes fast. Heart rate, as all vital signs, has a very small range that we call normal. Temperature has a very narrow band of normal…no one is alive for long at 94F or 107F.
Furthermore, each vital sign must be taken in context with the others to appreciate the holism of the medical ‘state’ of the human we are measuring. A heart rate of 130 could be someone at rest after two double espressos, someone who just ran up 4 flights of stairs, someone who has just had sex, or someone who was scared by a car that nearly hit them. Without proximal or distal environmental and cultural cues, these numbers are a bit shallow in their ability to project depth, nuance or real understanding.
This begs the question: is there a connection between vitals and vitality? How can we expand what we are looking at in patients, and focus on “vitality signs” as the next generation of markers of people’s well-being?
Humans are equipped with many natural and elegant sensors. The obvious ones are sight, hearing, touch, taste, and smell. These senses inform humans how to interact with their environment. A foul smell sends us backwards, a sweet smell forward. We move through our day informed by many of our senses, yet when it comes to our social behaviors, we’re mostly informed by our eyes and ears.
As fundamentally social animals, our key driver is communication. Over millennia of human history, communication has been confined to voice — only recently has it evolved to the written word. The internet is spawning new media forms that enable communication through images, videos, text messages, emoji’s, and a whole lot more.
Yet despite existing in a world of ‘mobile-first’ everything, healthcare seems to overlook even the most basic communication in the context of medical care. For a litany of reasons, health care communication is wrought with inconsistency, suspicion, fragmentation, and other forms of dysfunction. When we talk about “engagement,” we’re talking about the act of being connected and interactive over time. This is what leads to trust. The simple, real-time, back and forth dialogues that once served as the hallmark of medical practice have been replaced by fancy, expensive, non-interoperable ‘wait-a-bases.’
Don’t get me wrong — the digitization of healthcare is a welcome upgrade from the paper prisons of yesterday’s medical practices. Yet, as the cottage industry has evolved into a castle industry, the tech strategy has been to hoard data largely for the sake of hoarding data.The multi-billion dollar data and analytics industries have perpetuated shiny object syndrome at every level:
At the system level, most of the data we have collected in our carnival of measurements is self-serving, to improve the system’s performance and improve payments, not patients. Furthermore even these lack meaningful validation: no long term studies at the individual level, just hunches and guesstimates that they mean something or could mean something.
At the level of medical practice, there is a growing tendency to overlook the quality of data in favor of quantity. The latest fad is real-time tracking or remote monitoring, based on data derived by sensors; these are mostly passive data, which the easiest to collect, yet they are often mono-dimensional and lacking in context.
At the consumer level, we are buying gadgets that measure things, yet we stop using them because after a few months, they’ve told us a lot about what they’re measuring, but they haven’t listened to our questions or goals or told us about our health over that time. Most of today’s mobile tools are built help health systems talk TO patients, but rarely WITH them.
It’s the difference between hearing someone talk and listening to what they’re saying.
WWhat about analog data? What about a two way street that honors both what you say, what your data says and what you hear? Specifically, how you feel about what you hear or read? We often forget that of all the sensors at our disposal, the two most elegantly designed sensors are built into our heads; our eyes and our ears.
What we really need is a dose of humanity and analog sensibilities, to represent the the people, from whom that the data will only ever be able to create a crude re-representation.
People want to communicate when they’re healthy: It’s fun, and it’s part of our social existence. When we are ill, we crave even more communication — we are scared, full of uncomfortable thoughts sporadically racing through our minds. We can’t help it. The anxious mind is the mind that uncomfortably juggles probability and existentialism…..a cocktail that thirsts for soothing communication.
We need a narrative system that communicates relevant information between appropriate parties in a way that enables the retrieval of quality information — quality, in this case, defined by the ability of the conversation to help patients help doctors help patients.
This doesn’t require a technology upgrade — it requires a humanity upgrade. In some cases this is harder — the good news is, it’s free. It takes an empathic ‘how are you feeling?’, or ‘what’s bothering you?’, or ‘what are you able to do?’ These basic questions are antithetical to the digital era and are absent in the realm of vital signs. In fact, they expose the cold, medical-industrial-complex’s self-serving fascination with measurement as a best business practice. What would happen if altruism, listening and communicating were part of billing codes and payment models?
The definition of an ‘engagement unit’ is simple:
Did a person get a message? Did they read it? Did they understand it? Did they interact with it? Do they have any questions about it?
An engagement, by definition propels the engagement process forward. It lubricates feedback, without which we are flying blind. The health of a person is predicated on knowledge; it is an imperative to know whether sick people are recovering or if they are not.
By not communicating, engaging and listening, we are tacitly embracing a ‘hope strategy.’ We hope they get better, we hope that pain goes away, we hope the doctor can see us today. Hope is not a good medical strategy — but it’s here to stay, built on the broader hopes of stockholders, shareholders, but no hand holders: we hope this technology works, we hope we get a return on this investment, we hope we’ll get paid for our performance.
In today’s environment, we expect progress to happen immediately and in bite-sized metrics. Yet we know all too well that the Engagement required for lasting behavior change happens over time, as people build trust and insight based on their ongoing communication as social animals. Understanding how someone is doing over time is more a reflection of vitality than any of the other vital signs…which are really just numeric signs. Looking for quantitative quality without qualitative quality means the numbers lose their meaning. It’s time to evolve from the quantified self movement to the engaged qualified self.
This is why I propose Engagement The Sixth Vital Sign. If you agree, please press the heart icon at the bottom of this post and let’s start a movement.
Disclosure: I founded a medical practice and built a technology platform based on some of the above principles.
