Week 14: Strategies for Increasing Consumer Participation in the Policy Process

This last blog of the semester is about strategies for increasing consumer participation in the policy process. I originally felt like I was going to be repeating myself quite a bit from last week, because the general strategy of engagement and motivation to increase participation in policy processes is also in part what will sustain innovative environments for policy change. When considering employee participation in workplace wellness program components, and especially development of strategies that promote decreased sitting time, there has to be some general connection and understanding that 1) sedentary behavior in the workplace is important enough to demand policy attention, 2) employees can be empowered to participate in the solution 3) all possible solutions can be freely put out on the table for consideration 4) people can still be free to participate or not. An additional point I’d like to add also is the corollary to point #4 that if you do not participate when having an option or opportunity to do so, you really can’t complain when the solutions don’t include you. We all have known co-workers (or perhaps ourselves at times) that are uninvolved, but are the first to gripe and moan about why something in their workplace isn’t working well. So, I just never want to be “that guy”.

Much has been written about employee participation (or lack thereof) in voluntary workplace wellness programs—it was identified as one of the key reasons that many of the programs aren’t successful. While there are some great, innovative programs out there, in many small businesses, there has been a reticence to create expensive programs or those involving up front investment when company’s operating margins are already thin, and there is not much current evidence of program success. A review of worksite health promotion interventions conducted by Kahn-Marshall and Gallant found inconclusive evidence that implementation of environmental and policy changes alone were successful, but more promising results were found when the policy and environmental changes were instituted in combination with individually focused health behavior change strategies (Kahn-Marshall & Gallant, 2012).

What does this even mean? Well, first of all, it means that no matter what “policy” is implemented, people still will not change their health behavior unless they are personally motivated to do so, feel some engagement in the process, and believe that what they are embarking on addresses their own life circumstances, needs, and priorities. Also, the RIGHT problems need to be solved, and perhaps employees are in the best position to tell what those real problems are, and how to solve them. Motivation is the key to consumer participation at any level—as well as education about the problem, and social network (workplace and other) support.

One of the main reasons I am researching the science of sitting and sedentary behavior as opposed to physical activity promotion is that the preponderance of evidence is showing that despite the availability of 30,000 gyms and health clubs, fitness bands, and commercialization of fast “weight loss” plans, Garcinia Cambogia (you can lose weight just taking a pill, doing NOTHING!), reality weight loss depicted in “The Greatest Loser”, our society is still sitting too much, and getting fatter, and sicker by the decade. Also, unfortunately we have almost developed too many electronic and technological advances for our own good (health), which contributes to our general lack of activity as a society—convenience has become engrained in our culture as a general timesaver–but convenience is slowly killing us.

Physical activity and exercise takes actual intent, and actualized EFFORT–a certain degree of motivation, and unfortunately many people just don’t like to “exercise”, say they don’t have time, or there are other ‘barriers”, and will find many other excuses to not exercise.  Health behaviors are impacted by one’s motivation, just like activating intent to engage in workplace wellness programs and policy processes.  Leaders and employers can help increase employee engagement and personal motivation to change their health behavior as well as be involved in policy change processes by modeling good practices, and demonstrating to employees that their ideas and preferences are considered, and make a difference.

Despite the well-documented scientific knowledge that sitting too much is REALLY bad for you, almost all of the health promotion programs, federal and state included, have chosen specifically NOT to address sedentary behavior in their own suggestions or strategies presented to workplaces for worksite health interventions. For example, the National Healthy Worksite has lots of training materials for employers, with intervention strategies taken directly from the CDC Worksite Health Scorecard.

It is a very nice boilerplate for organizations and employee worksite wellness teams to use in building their own programs. It is comprehensive, with one key exception: There is NO MENTION of strategies to decrease sedentary behavior in the workplace.  The strategies address the following topics:

  • Organizational supports
  • Tobacco
  • Nutrition
  • Physical Activity (education and promotion of exercise)
  • Weight Management
  • Stress Management
  • Depression
  • High blood pressure
  • High Cholesterol
  • Diabetes
  • Heart attack and Stroke
  • Lactation support
  • Occupational Health and safety (no mention of desk ergonomics here)
  • Community Resources

I think what is happening is that because the state and federal programs aren’t addressing sedentary behavior yet, and there are all of these program planning templates out there available for general use, and the workplaces are using these as a template, without asking employees if there is anything ELSE that is important to THEM, as well as providing some good evidence based education to people about what happens when people sit too much. Thus, workplaces themselves aren’t perhaps considering something like standing desks or other workplace interventions that are “outside the CDC box” for their employees, but could be fairly straightforward to implement with provide a tremendous benefit, although there is an upfront cost.

Once again, you might think I have seriously digressed from discussion of strategies to encourage consumer participation in the policy process–but there was a method to my madness–The bottom line word to employers–consumers aren’t going to participate in policy processes to improve workplace health until they own the problem—until it is personally theirs. In order to “own” the problem, they have to identify a GAP between what they want,  and what currently IS (available), and feel like they can truly have a voice in implementing that change. This means that you, the employer have to ASK, and then LISTEN. Social support from work leadership, co-workers and others, empowering education, and motivational support are key intervention strategies to motivate behavior change, even related to getting people more involved in workplace health policy. Ironically these strategies are also key constructs in the Wellness Motivation Theory, which conceptualizes motivation as “empowering potential”, which uses individuals unique needs, priorities, and personal health goals in initiating and sustaining health behavior change (Fleury, 1991).


References:

Bankoski, Andrea, et al. Sedentary activity associated with metabolic syndrome independent of physical activity. Diabetes care 34.2 (2011): 497-503.

Centers for Disease Control and Prevention. The CDC Worksite Health ScoreCard: An Assessment Tool for Employers to Prevent Heart Disease, Stroke, and Related Health Conditions. Atlanta: U.S. Department of Health and Human Services; 2014.

Centers for Disease Control and Prevention & Viridian Health Management. Worksite Health 101: Making the Case for Worksite Health, Healthy Arizona Worksites training module, accessed on April 20, 2015.

Fleury, J. D. (1991). Empowering potential: A theory of wellness motivation. Nursing Research, 40(5), 286-291.

Kahn-Marshall, J. L., & Gallant, M. P. (2012). Making healthy behaviors the easy choice for employees: A review of the literature on environmental and policy changes in worksite health promotion. Health Education & Behavior, 39(6), 752-776.

Levine JA, Vander MW, Hill JO, Klesges RC.). Non-Exercise Activity Thermogenesis: The Crouching Tiger Hidden Dragon of Societal Weight Gain. Arteriosclerosis, Thrombosis, and Vascular Biology, American Heart Association, 729-736. 2006.

Levine JA. Non-exercise activity thermogenesis—liberating the life-force.Journal of Internal Medicine, 2007; 262(3), 273-287.

Advertisements

Week 13-Sustaining Innovative Environments

While last week’s blog was about innovation, this week’s blog topic is about sustaining innovative environments. First of all, as a total side note, Arizona State University is probably one of the most progressive institutions of higher learning in the world–what other university that has both a School of SUSTAINABILITY AND a College of Nursing and Health INNOVATION?

Just for fun, (and because we all should be thinking in a highly interdisciplinary fashion in doctoral school), I went to the ASU’s School of Sustainability website to check out what some professors and administrators had to say about “sustainability”. While several individuals had some interesting ways to address sustainability from an ecological systems perspective, I found the comment from Dr. Charles Redman, Founding Director and Professor, most profound, and quite applicable to how we can approach the development of innovative environments for health policy change in a sustainable manner:

 “Sustainability is an awareness of the connectivity of the world and the implications of our actions. It is finding solutions through innovative approaches, expanding future options by practicing environmental stewardship, building governance institutions that continually learn, and instilling values that promote justice…” 

I especially appreciated the comment about building governance institutions that continually learn—this means that hopefully “policy” developed by our “governing institutions (at whatever level they exist) should live, breath, change, and adapt, as what we know about our world (or policy environment) changes. This is an awesome concept, but for some reason I have a bit of difficulty resonating with this on a practical level, given the long length of time from our awareness that a federal or state policy or rule needs revision to the time the actual rule change gets implemented…

As I think about this topic relative to the issue of workplace wellness programs and policies/programs to foster reduction of sedentary behavior in the workplace, what comes to mind is the related concept of engagement. From a health and wellness perspective, innovative work environments and workspaces can be encouraged and enabled from the company leadership, but can only truly flourish and succeed when employees have the freedom and desire to engage in the process—and when they have a say in the types of programs that are developed or available to them. Creating and fostering sustainable environments for health innovation and policy change doesn’t happen overnight—people are usually very resistant to change, even when they know that they need to make a personal change in their own health habits, and move more—many mitigating factors and barriers arise. Engagement happens when individuals make a personal connection—identify with the concept and the goal—this is much more likely to occur with leadership and supervisors who are modeling the behaviors, as well as creating supportive, collaborative work environments that reward constructive “thinking outside the box”.

Engaging employee involvement and responsibility to address and account for personal health goals supports the “whole”, as well as the individual. A book entitled “Whole” by T. Colin Campbell also addressed the concept of “reductionist” behavior in our health care system, considering the science of nutrition, and the creation of silos for approaching health systems and treatment of diseases. We need to think more globally and sustainably about how we approach wellness, even in the workplace, for according to Campbell, the “whole” is greater than the sum of its parts. So too with a fit workplace—there is individual benefit to improving ones health, and reducing risk, as well everyone collectively benefits from a more collegial workplace, higher productivity and fewer health complaints.

I am just starting to read what I think will be a very interesting book by Paul Irving about aging, innovation, health, work, and policy– I will pass it along to those interested—the title was a very appropriate attention grabber!

Irving, P. (2014). Upside of Aging : How Long Life Is Changing the World of Health, Work, Innovation, Policy and Purpose. Somerset, NJ, USA: John Wiley & Sons, Incorporated. Retrieved from http://www.ebrary.com


References:

Campbell, TC. (2014). Whole: Rethinking the Science of Nutrition. Dallas, TX: BenBella Books, Inc.

Irving, P. (2014). Upside of Aging : How Long Life Is Changing the World of Health, Work, Innovation, Policy and Purpose. Somerset, NJ, USA: John Wiley & Sons, Incorporated. Retrieved from http://www.ebrary.com

Longest, B.B. Jr. (2010). Health policymaking in the United States (5th ed.). Chicago, IL: Health Administration Press

Redman, C., (2015) What is Sustainability?. School of Sustainability website, Arizona State University, accessed at: https://schoolofsustainability.asu.edu/about/what-is-sustainability/

Week 12 Blog- Healthcare Financing and Wellness Programs

Although I had heard of the Congressional Budget Office often, I had not really focused much on what the Congressional Budget Office actually did until this week’s reading assignment. As a non-partisan Congressional agency, its charge is to make no recommendation, but to inform policymaking by providing financial and cost analyses. I found the CBO website (www.cbo.com) generally very informative, but I was especially interested in the section on Health Care, and specifically the Public Health and Prevention section.

In late 2013, the CBO issued a report outlining options for reducing the federal deficit—with a special volume released with 16 options related to health. The federal government’s outlays for mandatory health care programs combined with health care subsidies exceeded $1.0 trillion in 2013. Discretionary spending in health care has increased significantly over recent decades, and government spending on health care will continue to be a source of significant pressure because of the growth in health care spending per beneficiary. Assuming no changes to laws, net federal spending for Medicare, Medicaid, CHIP, and other costs related to the health insurance exchanges will reach 5.9 percent of the GDP (gross domestic product) in 2023. Increases in the numbers of federal health program beneficiaries will occur for two primary reasons—the aging population, and increases in low income support. Medicare eligible are expected to increase by one third over the next 10 years as the baby boomers hit 65. By 2023, only about one-fifth of major health program spending will finance care for non-elderly healthy individuals. One-fifth will care for those that are blind or disabled, and three fifths of funding will go toward Medicare coverage for those 65 and over. The 16 options to address the federal health care spending deficit would address either spending reductions, or increases in revenues (via increases in taxes).

It is interesting to note that not only is the population aging, but many people are delaying retirement, and staying in the workforce longer. Thus, the focus on employee wellness and health is very important—according to The Institute for Health Care Consumerism, health care costs can consume up to half of a company’s profits. As the population ages, and has increased risk for health-related employer costs, employers are wise to carefully consider the financial benefits of implementing wellness programs. Nearly 22 percent of companies do not offer wellness programs to employees due to challenges in analyzing the return on their investment. According to the Aflac WorkForces Report survey, companies that implemented wellness programs saw an average 28 percent reduction in sick days, 26 percent reduction in health care costs, a 30 percent reduction in disability and workman’s compensation claims. The companies surveyed had an average of $5.93 in savings for every $1.00 spent. Thus, the management of federal health care financing and the management of employer wellness programs are inextricably tied to our overall outlays and expenditures to keep Americans well, and to promote health. Regardless of the amount of healthcare policy and financing available, or the financial incentives provided by a company to its employee health and wellness programs, the success of these programs still depends upon the motivation and participation by beneficiaries and employees.


References

Duchovny, N. (2013). Options for Reducing the Deficit: Health. Congressional Budget Office. (2015). Accessed 4/8/2015 at https://www.cbo.gov/publication/44936

Longest, B.B. Jr. (2010). Health policymaking in the United States (5th ed.). Chicago, IL: Health Administration Press.

Tillman, A. (2015). The Impact of Wellness Programs on America’s Workforce. The Institute for HealthCare Consumerism™, Accessed 4/8/2015 at http://www.theihcc.com/en/media_center/editors_picks/the-impact-of-wellness-programs-on-america’s-workf_h2jeegra.html

Week11-Innovative Characteristics and Innovators in Sedentary Behavior Research

This week’s blog is about the characteristics of innovators and change agents in the health care sector. I expected that there would be some timely research emanating from the College of Nursing and Health Innovation regarding the concept of innovation and leadership, and there was! First, to address the characteristics of innovators–Dan Weberg’s 2013 PhD CONHI dissertation studied complexity leadership and innovation (Weberg, 2013). Some key characteristics of innovators emerged. Weberg proposed that one of the reasons that healthcare organizations were plagued with high costs and poor outcomes is that many organizations had outdated leadership practices, engaged in linear thinking, and were not ready for healthcare innovation. He conducted a qualitative case study analysis of an organizational implementation of an innovation to discover a new framework of innovative leadership. The characteristics of leadership that he defined in his study were: boundary spanning, risk taking, visioning, leveraging opportunity, adaptation, coordination of information flow, and facilitation (Weberg, 2013). These characteristics were instrumental in describing how leaders in the healthcare system were able to implement an innovation by influencing connections, relationships, flow of information, and organizational context (Weberg, 2013).

Innovation is all about timing and sometimes radically switching up one’s view of how to skin the proverbial cat. Innovative ideas take advantage of opportunities to improve health, and also move the “state of the science” forward. Health innovations address an existing or new health concern in ways that have not been done before. Sedentary behavior has emerged as an innovative research focus in physical activity and health. Emerging research in obesity has identified the concept of excessive sitting (sedentary) behavior as extremely hazardous to health—independently associated with obesity, metabolic syndrome, weight gain, and increased cardiovascular disease risk (Wijndaele, 2010). Sedentary behavior is defined as those activities that do not increase energy expenditure above resting metabolic levels (Pate, 2008). More than half of all waking hours of middle aged and older adults are spent in sedentary activities (Matthews, 2008). Individuals who ‘sit’ for more than 4.5 hours per day on average have a 40% greater risk of mortality than those who are not sedentary (Levine, 2006). Non-exercise activity thermogenesis (NEAT) is a promising approach to addressing sedentary behavior and associated health risks. NEAT reflects the lower level kinetic energy expended in everyday activities of living, including standing, walking, and upright postural movement– “little movements” rather than purposeful exercise. While these movements aren’t volitional “exercise” for the purpose of raising a sweat, they actually make up most of the relative energy expenditure we have throughout the day (Levine, 2006).

One of the best innovations to reduce sitting time at work was the result of collaboration between industrial and ergonomic design and the result of nearly 20 years of endocrine research in obesity. Walking workstations are a relatively recent innovation (for about the last 6 -7 years) that specifically addresses the sedentary behavior of people who must sit at desks to do their work. The Walkstation® was designed by Steelcase, a Michigan-based company that is a global leader in office furniture design. It was designed in collaboration with Dr. Jim Levine, a British researcher at the Mayo Clinic, (and currently the co-director of ASU’s College of Obesity Solutions). The Walkstation is essentially a computer workstation set up to double as a slow-moving treadmill. Since the advent of the Walkstation in 2008, many other companies have entered the foray into products and workstation elements designed to reduce sitting time utilizing the concept of NEAT.

Dr. Levine’s innovative endocrine research in the concept of NEAT energy led to the idea to increase movement at work, using a walking workstation. If you only walked one mile per hour at work while you were at your computer, you could increase energy expenditure by 100 calories per hour. If you walked on the treadmill slowly (from .5-2.0 mph) for 4-5 hours of your day, that adds up to an extra 500+ calories burned just doing your job. While I do not have a Walkstation® at my home, I do have an innovative and handy husband whose first degree was in industrial design (at ASU) who did build a removable, adjustable platform for our home treadmill. I am typing this blog walking 2.0 miles per hour, burning more energy and doing a much better job for my health than sitting constantly while typing.

Thanks to Dr. Levine, and many other researchers such as Neville Owen, the science of sitting, and “disease” of sitting is becoming better understood—but there is still much work to do. Moving the science forward means that innovative interventions using NEAT ideas need to be tested in a variety of populations. My proposed PhD research will involve an RCT feasibility study of a NEAT intervention to decrease sedentary behavior in midlife women, an innovative approach to physical activity research. My idea and exploration grew from reading much physical activity research that showed limited long term maintenance effects, and growing statistics on obesity and heart disease, especially in older women. So, I thought, if we aren’t successful at helping women motivate to be more physically active, can we at least help them motivate to be less physically inactive? Thus, the idea to use NEAT as a potential intervention strategy grew out of an idea to start “small”, and do something totally different than just more “exercise” to address lack of motivation for exercising. We can all do our part to create innovation in health care by using what we know and what we don’t know about health problems to “think outside the box”.


Buell, J. M. (2014). INNOVATION IN HEALTHCARE: IT IS POSSIBLE, AND IT IS HAPPENING. Healthcare Executive, 29(3), 32-34,37-40. Retrieved from http://login.ezproxy1.lib.asu.edu/login?url=http://search.proquest.com/docview/1526402401?accountid=4485

Campbell, RJ. (2008). Change Management in Health Care. The Health Care Manager. ; Vol 27 (1):23-39.

Johanna King For the Journal. (2008). WALKING WORKSPACE: Dream machine’ combines low-speed treadmill with desk. Albuquerque Journal, pp. 3.

Levine JA, Vander MW, Hill JO, Klesges RC.). Non-Exercise Activity Thermogenesis: The Crouching Tiger Hidden Dragon of Societal Weight Gain. Arteriosclerosis, Thrombosis, and Vascular Biology, American Heart Association, 729-736.

Matthews CE, Chen KY, Freedson PS, Buchowski MS, Beech BM, Pate RR,Troiano RP. (2008). Amount of time spent in sedentary behaviors in the United States, 2003-2004. Am J. Epidemiol.167 (7); 875-881.

Owen N, Sugiyama, T, Eakin, E, Gardiner, PA, Tremblay MS, Sallis JF. (2011). Adults’ Sedentary Behavior: Determinants and Interventions. Am J. Prev Med. 41(2) 189-196.

Pate, RR, O’Neill, JR., Lobelo, F. The evolving definition of “sedentary”. (2008). Exercise and sport sciences reviews,; 36(4): 173-178.

Rob Lever. (2008). Hey! get fit while on the job; treadmill computer workstation bringing exercise to the office. The Province, pp. A.47.

Weberg, D. R. (2013). Complexity leadership theory and innovation: A new framework for innovation leadership (Order No. 3564600). Available from Dissertations & Theses @ Arizona State University; ProQuest Dissertations & Theses Global. (1408914438). Retrieved from http://login.ezproxy1.lib.asu.edu/login?url=http://search.proquest.com/docview/1408914438?accountid=4485

Wijndaele, K. Brage, S; Besson H, etal. (2010). Television viewing time independently predicts all-cause and cardiovascular mortality: The EPIC Norfolk Study. Int J. Epidemiol.; 40 (1) :150-159.

Week 10–Change Management and Innovation—Top Down versus Bottom Up

This excerpt from a Monty Python skit provides a great example of leadership and organizational management irony.

Robert Campbell in his article on Change Management in Health Care, presents philosophies of John Kotter and William Bridges and explains how these philosophies can be utilized to “implement” a change management project (perhaps as a result of a policy directive). Kotter’s 8 step “non-linear” change management model includes the following steps: 1) increase urgency, 2) build guiding teams, 3) get the vision right, 4) communicate for buy-in, 5) enable action 6) create short-term wins, 7) don’t let up, and 8) make it stick (Campbell, 2008).

While these steps sound logical, and look like they would “work” in a healthcare policy context, there appears to be something significantly missing—Kotter’s change management model focuses on the leader’s actions, and what the leader or team does externally to “implement” the policy change, and not much on the other individuals comprising the organization (e.g., employees). Regardless of any discussion about “organizational”, changes are “adopted” one unit (or individual at a time). The model is a top-down, as opposed to a “bottom-up” approach to change. All individuals within an organization (all of the “cells” in the metaphorical organizational “body”) must make personal changes in intent, action, extended behavior, processes, and attitudes to maintain the change, and incorporate this change into the organizational culture—even if the “change” is externally mandated.

Building evidence-based healthcare systems requires careful attention to efficient and effective allocation of resources, and improving performance and programs by setting and adhering to data-driven, outcome-focused goals. It is easy to see how changing political climates and resulting changes in agency (i.e., “research funding stream”) priorities can pull public policymakers off target.

Don Berwick, former head of the Centers for Medicare & Medicaid (CMS) wrote an excellent article in 2003 entitled “Disseminating Innovations in Health Care”, which eloquently describes the modern contributions of Everett Rogers and Andrew Van de Ven in the context of 1) perceptions of an innovation; 2) characteristics of individuals and their “stage” of acceptance and adoption of the innovation–innovators, early majority, early adopters, late majority, laggards (or ‘traditionalists’); and 3) organizational contextual or managerial factors (Berwick, 2003).

Berwick presents some speculative considerations for disseminating healthcare innovations. These include:

1. Find sound innovations

2. Find and support innovators

3. Invest in early adopters (those who want to test a change)

4. Make early adopter activity observable (face-to-face social networking)

5. Trust and enable reinvention

6. Create slack for change

7. Lead by example (Berwick, 2003).

While the “dissemination” of a policy implies seeding, or actions done by the leaders to “plant” the ideas/changes/policies, there is also much “growing” of the seed as individuals, units, and groups within the organization accept and incorporate the changes (or not).  The diffusion of innovations model and these recommendations appear to honor and account for the input of employees and other individual efforts in the implementation of the “policy” or innovation.

Liebman also challenges policymakers to produce better policy through better policymaking processes that include evaluation studies as a key component. “…we have either failed to develop effective solutions, failed to prove that the solutions work, or failed to scale the solutions that do work widely” (Liebman, 2013).

Pure “top-down” approaches to policy implementation may not work well for a variety of reasons, but perhaps one of the most obvious ones is that the real or actual problems that are capable of being changed were not correctly identified at their root cause. This is where input of people “in the trenches” and actually doing the work is so critical.

The study of sedentary behavior and its effects in the workplace comprises a relatively new and innovative approach to physical activity research. Effective, well-utilized and “diffused” corporate wellness programs are those that are developed from “the bottom up”, consider individual health goals, and provide a leadership climate and organizational culture that supports, embraces, and rewards healthy behaviors.


“Not every change is an improvement but every improvement is a change”…

Eliezer Yudkowsky, Harry Potter and the Methods of Rationality


References:

Berwick DM. (2003). Disseminating Innovations in Health Care. JAMA.;289(15):1969-1975. doi:10.1001/jama.289.15.1969.

Campbell, RJ. (2008). Change Management in Health Care. The Health Care Manager. ; Vol 27 (1):23-39.

Change theory. (2009). In The SAGE glossary of the social and behavioral sciences. Thousand Oaks, CA: Sage Publications. Retrieved from https://login.ezproxy1.lib.asu.edu/login?url=http://literati.credoreference.

Koeck, C. (1998). Time for organisational development in healthcare organisations : Improving quality for patients means changing the organisation . BMJ: British Medical Journal, 317(7168), 1267–1268.

Liebman, J. (2013). Building on recent advances in evidence-based policymaking. Results for America, https://myasucourses.asu.edu/bbcswebdav/pid-10373799-dt-content-rid-43813528_1/courses/2015Spring-D-DNP711-14365-17926-23680-17927/Liebman2013-Evidence-Based_Policymaking.pdf

Week 9–Activity Trackers–Regulatory Limbo for Commercial/Self-Monitor

This blog topic addresses policy that governs access to data, and privacy protection in an electronic and genomic age. Analysts estimate that in 2013, the retail market for “wearable technology”, activity bands and monitors, was about $1.4 billion, and that by 2024 the industry will top $70 billion (Gothing, 2015). This ‘wearable technology’ comes in many different shapes and sizes, is worn on different areas of the body, and is becoming more commonplace for healthcare providers to use as a monitoring tool. Accelerometers and other monitors track, exercise, steps taken, heart rate, glucose, and other movements of patients with chronic disease such as diabetes, or who are at risk for cardiovascular disease. Many physicians and health care providers want to take advantage of this technology to get a jump start on recognizing signs and symptoms in their patients that benefit from early intervention (Dwoskin, 2014).

A physician in New Jersey at Hackensack University Medical Center asks patients at risk for heart failure to wear fitness trackers to monitor step counts and flights of stairs climbed, and are also asked to record what they eat, using bar code technology to scan food items from their cell phone apps. Data from the various trackers and applications is automatically uploaded to the patients Epic MyChart® app on an iPhone, and can be transferred to the hospital medical records system, (also Epic) (Jesdanun, 2015). Mayo Clinic uses Fitbit® trackers for one month post-op to track the progress of hip replacement patients, to determine daily step counts, and determine whether their patients are having trouble ambulating sufficiently after surgery (Jesdanun, 2015). While the premise of this technology is to assist in proactively monitoring patient’s status, doctors hope that patients will get more engaged in their own healthcare as well.

Wellness programs offered by employers are also taking advantage of this technology to support and incentivize employees to better monitor their own health. Companies such as BP Oil, UnitedHealth Group, Humana, Cigna are buying or subsidizing the purchase of fitness tracking technology to encourage employees to be more fit. BP oil gives employees with health risks such as high blood pressure and high cholesterol an option to earn points to cheaper health insurance by wearing fitness trackers. Employees wear the device, and the data is uploaded to verify the activity to give the individual their reward (Satariano, 2014).

Again, how does this relate to policies for reducing sedentary behavior in the workplace? Well, perhaps it is only indirectly related in that sedentary behavior is actually “not” movement on an activity band, which can be captured roughly via some of the more sensitive monitors. One thing is for sure–employers are definitely becoming much more conscientious about preventive health in the workplace, and are now doing much more to provide voluntary programs to incentivize and reward healthy behaviors—under the ACA, companies are allowed to spend up to 30 percent of annual insurance premiums on these rewards (Satariano, 2014).. Ironically, providing a Fitbit® activity tracker to an individual who has to sit at a desk all day to work (the Fitbit® is triggered by steps) may not be really making much impact, at least at work. With all of the corporate efforts thrust into paying for activity monitoring devices, you would think that requests for a few standing or adjustable desks here and there would not be unreasonable.

As the monitoring technology is refined to capture smaller and smaller movements, lack of movement, changes in movement, location and direction of movement through GPS tracking, and more and more “data bits” are now available to monitor, this compounds the ethical and policy questions of exactly who owns the data, what data will be used, and where does it go, who will be using the data, and for what purpose. In the workplace, as with medical care, considerable issues regarding personal data privacy are surfacing, and must be addressed.

The use of data from activity monitors is still in a grey area from a regulatory standpoint. The health privacy laws that prevent the use or disclosure of patient-identified data without consent do not apply to these consumer devices. This is complicated if a physician uses a commercial device in the context of his practice—in that context the data is covered under HIPAA regulations, and companies must comply with data security measures and protection of information from disclosure, or face stiff financial and other penalties (Gothing, 2014).

A very fascinating article by Scott R. Peppet describes issues with regulating the “internet of things”(Peppet, 2014).  Electronic sensor technology is used in  everything–from smartphones to cars, electric monitoring systems, health care devices, activity monitors, and workplaces.  As a result, there is an unprecedented amount of detailed information to about peoples habits, actions, preferences, and behavior.  He posits that there are 4 aspects of sensor based technology that create discrimination, privacy, security, and consent problems: 1) the compounding effects of “sensor fusion” 2) impossibility of  truly “de-identifying” all sensor data; 3) likelihood that the Internet of Things devices are inherently prone to security flaws; and 4) difficulties of meaningful consumer consent (Peppet, 2014).


References:

Andrea L Gothing, Seth A Northrop, & Li Zhu. (2015). Taking the pulse of digital health: Key legal issues surrounding wearable technology. Inside Counsel. Breaking News,

Andy Stonehouse. (2014). An apple a day?: Apple watch looks to advance in the wearable wellness market, but cost, security concerns may slow its role. Employee Benefit Adviser, 12(10), 62.

ANICK JESDANUN. (2015, ). Doctors say fitness trackers, health apps can boost care; but details about data use, privacy concerns are yet to be resolved. St. Louis Post – Dispatch, pp. A.11.

Elizabeth Dwoskin, & Joseph Walker. (2014, ). Can data from your fitbit transform medicine?; doctors study wearable gadgets to see if they motivate, collecting data in process. Wall Street Journal (Online)

Patrick Tucker. (2009, ). Be your own big brother. The Futurist, pp. 9.

PCHA statement from CES: Personal connected health alliance encourages fitbit to close the data loop for consumers with PCHA’s continua technical standards for secure, user-friendly data sharing. (2015, ). PR Newswire

Scott R Peppet. (2014). Regulating the internet of things: First steps toward managing discrimination, privacy, security, and consent. Texas Law Review, 93(1), 85.

Would you wear a FitBit so you boss could track your weight loss? (2014, ). Daily Herald (Arlington Heights, IL), pp. 0.

BlogWeek 8: Private Sector Innovation and Healthy Arizona Worksites

Promoting reduction of sedentary behavior in the workplace is receiving increased attention as a potentially significant strategy to reduce cardiovascular risk. Hamilton and associates identified that sedentary behaviors have an independent association to increased morbidity and mortality, cardiovascular risk factors, diabetes, metabolic syndrome, and adverse lipid metabolism (Hamilton, 2007). Non-exercise activity thermogenesis (NEAT) refers to the spontaneous, everyday activities of daily living, such as light activity, standing, fidgeting while sitting, and other upright postural movement that is NOT volitional “exercise”. For many people the NEAT they perform each day is a significant source of energy expenditure. Thus, any policy efforts to reduce sitting time in a workplace setting can cause a significant increase in an individual’s daily energy expenditure, as well as contribute to an overall reduction in sedentary behavior, a known independent cardiovascular risk factor.

Workplace innovation to reduce employee sitting time can come in many forms. Aside from interventions to promote periodic breaks in sitting time, adjustable standing workstations, balancing ball chairs, and treadmill workstations are a few of the modifications to workplace design that give people additional flexibility to allow them to stand more during their workday (Carthenon, et al, 2009).


Two weeks ago, for my Health Policy “interview”, I had the opportunity to attend a 4 hour training session offered by the Healthy Arizona Worksites Program (HAWP). The training was developed to help Arizona worksites develop evidence-based workplace health initiatives to improve employee health and, subsequently, the health of businesses. Well employees are generally happier, have fewer sick days, and are more productive. The training was a collaborative effort between Maricopa County, the Arizona Department of Health Services, and FitPHX program. There were 22 people who attended the training from many types of industries—healthcare, business, manufacturing, and education. I think the training was way too short, and they could easily have spend a day or more on the fairly detailed and comprehensive material. There also could have been more time for networking, interaction, and sharing of experiences by the different businesses.

The training included the following components in 5 different modules: 1) Making the business case for a worksite health program; 2) leadership and culture; 3) Data Collection; 4) Planning and Implementation; and 5) Program Evaluation.


During the session, two guest presenters talked about their company, Able Engineering. Able Engineering is a successful aerospace company in Mesa that manufactures aircraft engine repair and replacement parts. The culture of the company is focused on wellness, and its 300+ employees (90% male) have access to a 3500 square foot facility. The company provides FULL coverage of health insurance premiums for employees who document attendance at the gym a minimum of 2 days per week. There are a wealth of wellness programs offered at Able, that do not include just exercise. There is an employee cafeteria onsite that provides healthy meals, and the wellness program offerings through the company also include stress reduction, “financial peace” counseling, and families are encouraged to participate as well. Their corporate workplace wellness program has saved $3.4 million in health care costs over four years, and those savings are given back to the employees. The program has been so successful that the wellness center has developed a new company to develop and implement workplace wellness programs for other companies.There are many opportunities to innovate in the workplace to improve health. Able Engineering is just one example, and there are likely many more evolving.  SO many people have sedentary jobs, where we sit more than 4.5 hours per day. Think about where you work, and your own workspace. Perhaps you are already “on your feet” all day, but if you are like many adults, the bulk of your workday is in front of a computer, seated at a desk, or standing or sitting in one place. What can be done in your own workspace to help minimize your sitting time over the course of the day?


References

Hamilton MT, Hamilton, DG, Zderic, TW, 2007. Role of low energy expenditure and sitting in obesity, metabolic syndrome, type 2 diabetes, and cardiovascular disease. Diabetes.; 56: 2655-2667.

Levine, JA. Non-exercise activity thermogenesis: liberating the life force. 2007, J Intern Med 262: 273-287.

Carthenon, M, Whitsel, LP, Franklin, BA, Kris-Etherton, P, Milani, R, Pratt, CA, & Wagner, GR. On behalf of the American Heart Association Coordinating Committee; Council on Epidemiology and Prevention; Council on the Kidney in Cardiovascular Disease; and Council on Nutrition, Physical Activity and Metabolism. Worksite Wellness Programs for Cardiovascular Disease Prevention: A Policy Statement from the American Heart Association. Circulation, 2009; 120:1725-1741.