In this post, Valerie Rogers, director for state government affairs for HIMSS and Dr. Chris Gibbons, CEO of the Greystone Group discuss the value of the innovations and systems transformation generated by Smart Cities and Communities and how local, state and federal governments can leverage this movement to impact health and wellness outcomes.   

Tell us about yourself, and how you became interested and involved in the Smart Cities/Communities movement?

I am a physician by training, I went to Medical school at the University of Alabama. I did all of my training at Medical school at Johns Hopkins in Baltimore and I trained in surgery and preventative medicine, and did a fellowship on the Hill, several years of molecular neuro-oncology and epigenetics research. While I did a fellowship at CMS, I became the point person for a project that was very interesting when disparities were just becoming more widely known. Congress passed a law that CMS should do a study to understand this phenomenon in the Medicare population. Some people said if we had a single payer system, that would take care of disparities. Ultimately I became the leader of this project. We found, and limited to cancer outcomes, there were significant disparities, even in the Medicare population. We gave them recommendations, one of the recommendations was that the government should put more computer and IT infrastructure into the problem. Shortly after that, I was recruited back to be on faculty to Johns Hopkins where I previously trained. As I began to think about my academic focus, I thought on this work we had done. About that same time, I heard of a meeting that was happening on the NIH campus, a term I never heard of before, on e-health. So I went out there and I was absolutely fascinated. They were talking about the future of society, future of healthcare and how technology was going to help us solve things. There was no EHR’s at this time and technology was a new phenomenon at the time. I walked away from that meeting that there was no one talking about technology in underserved populations and disparities equities and I said, you know what, that is going to be my field. Smart cities and smart care and variations and that theme of technology and health for everyone, is kind of how it all got started.

Reference Point- I finished the fellowship at CMS in 2001, so 1999-2001 and I came on the faculty in 2001.

There are currently over 100 definitions of a Smart City-Community, most with limited consideration of healthcare or public heath as a core tenet. What is your definition of a Smart “Health” Community-City?

There are a lot of definitions and a lot of ideas of what this could be but for me it is pretty foreign. But first, let me say I think there is tremendous opportunity for technology, broadly speaking, to help us accomplish amazing things in the health sector, and not just to do the things we have been doing in the health sector for all these years, but do them faster or more accurately, but technology can help us do things that were simply not possible in the past. So do entirely new things and entirely differently.

So let me start with the word ‘smart’ and sort of give you a little background on that since people are using these terms in a number of different ways.

So if you remember when we used to talk about mainframe computers versus personal computers. Mainframes were those large, large computers that filled up old buildings in the 50’s and 60’s that housed the CPU’s which were the brains of the computer system and the main memory of those older computers. The word mainframe really distinguished high end, commercial computers from the less powerful PC’s. As our CPU’s became more powerful, led by Intel, it enabled things like smartphones and mobile computers to eventually become more powerful than those early mainframes. What that allowed is that more of the brains of the CPU can actually embed in the phone itself, it didn’t have to be embedded just in the mainframe somewhere else. If you follow that, you could embed that intelligence in a whole variety of things. It enabled the computational power of the CPU to move to the edge of the network where those things were in the remote devices, instead of being at the center of the network (where the mainframes were). That simple change right there enabled faster computations, because now you didn’t have to send the information back to the mainframe and then send it back to the client and also enabled more complex computations and decreased the impact of network issues. So that was one major development that happened to this idea of smart.

The other development was sensor technologies, which as the word implies, sense things in objects far away from the mainframe or the computer itself. It could detect changes in physical status and even environments, in addition to doing computations. Then miniaturization and even Nano technology advances meant that smaller things could have these sensors on them and then could interact and connect to each other, in fact, things as small as blood cells and some people are talking about particles as small as dust could then be embedded within these powerful CPU’s. So smart then, ultimately with this background, devices that are smart are those devices that are embedded with chips within themselves that then can detect and react appropriately to what is being detected without any human intervention at all, because of the algorithms and the computation ability of those chips.

So think about self-opening doors, that is the early smart. Now we talk about self-driving cars or from health, continuous glucose monitors which continuously check a person’s blood sugar level and at that moment gives them the correct dose of insulin without the need of a doctor or a syringe. So these are all examples of smart devices, devices with the chips embedded in them which enable them to detect and react appropriately without human intervention. Smart services then, are services that can be delivered, at least in part, by smart technologies.

Smart communities and smart cities are communities in which consumers engage with services via smart technologies. Finally, smart health communities or healthy communities are communities where the residents can engage with smart services that are specifically designed to improve their health.

Given your definition, what value can the healthcare information and technology sector bring to the table?

How might the (a) health care and (b) governmental public health community leverage this movement to address common goals – namely the triple aim and public heath imperatives (SDoH)?

There are many opportunities to increase healthcare and value. We have to shape the question to value for whom. In the past, we largely placed the value proposition of healthcare on clinical processes. To an extent, there is truth in this, but it is not enough to get us to our national health goals. In the present, we have pivoted to not only clinical processes, but population outcomes (beginnings of ACO’s and managed care). Still not where we want to be, inequalities and disparities have not systematically improved. Value will be increasingly about the consumer and the patient. It will require a greater focus on social determinants of health. The patients team is always much larger than the clinical team. We have to develop a system that can interact and engage with all of the things that patients rely on to optimize and improve their health in order to help them manage all of those things.

Optimizing clinical practices alone is a good thing, but it is not enough to guarantee good health of everybody. Technology is the only way we are going to be able to do that. How are we in the future going to touch every single one of those patients every single day without a greater reliance on technology?

We have got to rely more on technology to retool for a digital delivery system and market based value that brings better and lower costs.

Are there examples of communities using these innovative technologies to improve the health status of populations in Smart Communities-Cities that should be highlighted for the HIMSS global community? 

I fundamentally believe that the companies that excel are those that understand their target consumers the best and give them products that they want and need/value. What’s happening in healthcare is that healthcare hasn’t really been a market based system ever before and now that’s where we are going and that shift is very difficult for the sector to make so we haven’t really gotten to what consumers are demanding. In every other sector where technology comes in, technology changes consumer behavior. We (providers) still have the perspective in healthcare and public health that we know what’s best for you and we will decide this. What we risk is outside competitors becoming mature and lose our market share, (our patients). The CVS, Walmart’s and Walgreens are doing this, becoming primary healthcare providers for patients. They can offer patients clinical services, very little wait times, offer medications for low costs, how can traditional hospitals compete with that? They must do something radically different.

Help us understand role of patients/citizens/advocates in “Smart” systems…what are the ways in which Smart solutions (IoTH) could impact the socio-economic, cultural, and behavioral health wellbeing of a population? 

Social media has changes people’s behavior. Social media and those who get it right have figured out how to change behavior. The response in healthcare, how do we learn from the principles that make social media effective that can enable people to change their behavior in a way that improve their health.

The other side of the coin is the example of Groupon, which is a type of social media, which offers coupons for goods and services. They were putting out statistics that 15% of their coupons were categorized as health. One Ophthalmology group wanted to see if Groupon could be of valuable to them. They offered their services for a new visit for an eye exam for $75 instead of $275. They would need to sell at least 300 visits for it to be financially viable, with patients coming back at least once. The experience was nothing short of breathtaking. Not only did they sell out all 300, they sold them at a record rate. The head of the group said they saw the patients back within 6 months. They said the biggest thing that they learned was this benefitted not the wealthier clients, but the lower end clients the most, who couldn’t afford $275 but could afford $75. We had an alignment of market based forces of healthcare and healthcare services that preferentially helped the lower income classes in a way that was still financially viable for the healthcare system. This is exactly how we need to bring into healthcare to think about how we structure our services and how we deliver them in the technological age.

What are the economic drivers – cost benefits driving Smart City Connections with healthcare and public health?

In terms of funding and making it happen, almost 50% of programs that are doing smart programs, report that they use a variety of public and private funding mechanisms to cover the costs. Public funds such as bonds or grants from agencies. Public funds are the initial funds that are brought to bear and function as the de facto seed funding. Private funding does not like to be the initial funding, but private sector funding such as loans and private equity are viable. Philanthropy funding are funds that people might not think about. There are a number of small local philanthropy that your cities would know about.

Another part that traditional health has not spent a lot of time thinking about is what is the monetization opportunities outside of reimbursement for doctors through CMS, or the other kinds of revenue models. In fact, the most exciting thing about these proposals is it can become revenue generating that is new revenue for the communities. These can be from user fees, subscriptions, to license fees, advertisements, public-private partnerships.

Looking ahead into the future, what is your vision for a modernized, Smart Health System?  What are the practical steps to the health information and technology sector and leverage to get started expanding Smart Communities-Cities solutions to impact health? 

How might your vision impact the global health and wellness goals (e.g. response to climate change and natural disasters, disease outbreaks, climate, etc.)?

I am intrigued with what New Zealand is doing. At their government level, they have instituted a well-being budget. They are building into their national budget, specifically a focus on well-being. The reason they are doing it is that they believe that defining national success primarily on the financial health of the nation has limited value. In their minds, that doesn’t equate to where they want to be as a nation. They are using this well-being budget to not just define it on financial health terms, but also the health of the natural resources, the people and the communities.

They have implemented this in 5 key areas, mental health, reducing child poverty/improving child well-being, economic opportunity and skill development for poor and underserved, supporting national digital transformation in all sectors, supporting sustainable and low emissions economy. The way it will work is the legislature has agreed on these and then they will now move to identifying specific interventions that are evidence based and allocate a budget to them, implement them and measure them to determine degree of success and fine tune them. It is an iterative process to continue the cycle of refine, review measurement, repeat. It is potentially a model for other countries at a national level or a city/state level to think about these things.

The other is North Dakota. Mylynn Tufte, the health officer for North Dakota and Governor Burgum have started as a mission to make North Dakota the first smart state. This is even more transformative when you think about North Dakota being a predominately a rural state. Having the vision and working with those that want to go farther is the start.

Chris Gibbons, Greystone Group 

Dr. Gibbons is the Founder and CEO of The Greystone Group, a digital health research, innovation and strategy consulting firm. Dr. Gibbons is also on the faculty at Johns Hopkins and Duke University Schools of Medicine. Previously Dr. Gibbons was an Associate Director of the Johns Hopkins Urban Health Institute, and an Assistant Professor of Medicine, Public Health and Health Informatics at Johns Hopkins University.