The Problem with Wellness

Hospital (n). From Old French, 13th century. “Hospital” shares etymology with the word “hospitality” which, despite its modern association with restaurant and hotel businesses, originally meant being generous and kind to strangers in need.

Every time I hear doctors and healthcare leaders say that the healthcare system needs to shift from “sick care” to wellness, I cringe. Not because wellness and prevention aren’t valuable. Rather, it’s about priorities, and which patient populations should be the primary focus of the US healthcare system. The danger in focusing on wellness and primary prevention is that when you build a system around relatively healthy patients, it ends up being poorly suited to the needs of more complicated care. Imagine building a house with lots of steps at the entry as well as on each floor, including steps up or down to each of the bathrooms. Now imagine retrofitting it for someone in a wheelchair. Not so easy. Building accessibility in at the early design and architecture stage is much less expensive, and gives a much better result. With healthcare, it’s not just the physical structures that are important; it’s also the systems and processes and communication and coordination (or lack thereof).

This should sound obvious, but the primary mission of medicine is to care for the sick and injured. Illness and injury will always exist, despite some peoples’ technologic fantasies. And healthcare systems are most appropriately designed around those with the complex needs, rather than around the relatively healthy. 

So let’s look at some recent examples of healthcare innovation efforts, specifically in digital health. This is a field close to my own informatics heart, and one with great potential for system improvement. First of all, the 2023 HLTH conference in Las Vegas just wrapped up. Their website declares the mission to be “Improve/Inspire/Enhance/Elevate Humanity.” Sounds aspirational. Let’s see how the program and announcements back up that claim.

I should acknowledge at this point that I didn’t actually attend HLTH 2023. At $4000 per person, on top of the priciness of Las Vegas hotels, it was way out of my budget. I’m guessing it was out of most clinicians’ budgets as well. A conference at that price point is realistically only going to appeal to executives and investors and the entrepreneurs trying to sell to the first two groups. What do attendees get for that sky-high entry fee? A-list celebs: Howie Mandel, Nick Jonas, Chelsea Clinton, and Ashanti and Fat Joe (Hip hop artists these last two. I confess I had to look them up.) But maybe in between the celebrity stuff, the execs and investors and entrepreneurs are focusing on the most needy patients?

The Walgreens presentation at HLTH was an announcement of a virtual care program to address problems such as seasonal allergies, refills on blood pressure meds, urgent care, and vaccinations; “Women’s health” including UTI antibiotics, birth control, and emergency contraception; and “Men’s health” including erectile dysfunction and hair loss. None of this feels game changing; all of it is simple retail-style services. And while these are all legitimate medical issues, they’re mainly services for relatively healthy individuals versus those with complicated medical issues. [Side note: why is it that “Men’s health” always seems to just be about sex and physical appearance?]

Unfortunately, there doesn’t seem to have been a lot of news coverage of HLTH 2023, despite the free attendee tickets they offered to journalists. Modern Healthcare posted a few updates, but I don’t have a subscription. So let’s move on to a different digital health update, namely this recent report from Becker’s Healthcare entitled “Empowering (and Delighting) Patients with Innovative Technology." Their report was based on a conference call with representatives from 13 different major health systems, hosted by RevSpring, a healthcare software company. The first theme in the report was the desire of healthcare systems to emulate the successes of online consumer companies such as Apple and Amazon. Which one one hand makes sense — there’s a lot that healthcare can and should learn from other industries — but on the other hand, companies like Apple and Amazon focus on a younger, more tech-enabled demographic than the individuals we mainly see in healthcare.

The report’s second theme is personalising tech to meet the needs and desires of individuals. No argument there. The third theme is making digital strategies “proactive and inclusive” by which they don’t actually mean inclusive of all patients, but rather inclusive of all internal stakeholders. Again, no argument here. The fourth theme is entitled, “Patients need to be aware, educated, and guided from the beginning.” Not terrible, but it implies that patients need to be brought to the technology rather than the other way around. Great tech meets people where they are and doesn’t require much if any education/training. The fifth theme is the need for organisational change management, which is basically an acknowledgement that health systems contain complicated interconnected processes that can trip up meaningful change. I agree with that one. Overall, the report contained a lot of reasonable-sounding generalities, but left me with the impression that these health systems continue to chase after technology that’s more a fit for a young healthy population.

The bottom line: Healthcare systems exist to serve the sick and injured, and they need to be designed for this purpose. It’s understandable why health systems (and companies like Walgreens) might be tempted to to try to build operations around straightforward medical issues, such as those experienced by young and mostly healthy individuals. But that’s not their core mission. As we work to improve healthcare, particularly through technology and digital health, the right place to start is with the needs of complicated, co-morbid patients with limited tech access. Think 80 year olds with cognitive impairment and multiple major chronic conditions whose only phones are landlines, not 25 year olds who want to use their iPhones to order hair loss meds. Complex patients are not not an easy entry point. But it’s the health systems and health tech companies who succeed at this harder formulation who will have the opportunities for meaningful impact at scale. More importantly, it's the approach that's consistent with their Hippocratic mission.