Hey man, can we have a quick chat? I’d like to pick your brain on the concentration of curcumin that we should be aiming for. Can we talk about dosage? Cheers.
I receive emails like this from friends and acquaintances on a range of health-related topics, especially from startups looking to create or tweak their product offerings.
How could one answer this question? The first response that pops into one’s mind might sound like MBA-speak. It depends, one might think. And it’s true that it does depend on what aspect of the market one wants to address. But how would one go about looking at the market in the first place?
The notion of framing references - a lens through which one could look at a problem or situation - first arose when I was researching institutional innovation during my MBA (see endnotes). The authors talk about framing as a dialectical process, engaged in by actors - or agents (my word) - of innovation. They further argue that actors of innovation frame - or provide meaning to - aspects of events which in turn shape meaning or perception of the said event. An example would be to view social movements as a cultural phenomenon. The framing reference here is culture, the lens through which one could view social movements. If the framing reference is appropriate, then certain social movements won’t make sense, or will not resonate with, those that are outside the cultural boundary. This is best observed in generational gaps or ethnic differences. Note, the idea of framing itself arose from social movement literature.
To elaborate further, a framing reference then becomes a commonly agreed upon assumption, which if correct, modifies or gives meaning to the information being analyzed in that context. The usage here is also analogous to the use of frame of reference in Physics. So while framing as described by Hargrave, Timothy, and Ven, is a dialectical process, a framing reference could be a result of the dialectical process or an acceptance that there wasn’t a dialectical process required. In the latter, some individuals may also go far as to use the words first principles, and while that can be contentious and sometimes irrelevant to the marketplace - market makers may disagree with that - first principles are a good way to establish a framing reference.
Using this construct, how could we view Healthcare Innovation? What framing reference is useful? In my opinion, Epidemiology and Ethnography provide good starting points. While business models in healthcare are divided into what can or cannot be billed, or what the consumer will or will not pay out-of-pocket, the human body cares little for how business models affect the continuum of care. Having established that, even non-profits need revenue, so creative business models are important.
Continuum of care: Think of a circular loop between prevention and treatment - rehabilitation with all the steps in between, is another useful framing reference with which to understand the patient or user journey, and hence opportunities for innovation.
Looking at health states through the above lens, allows us to ask questions, such as, what information informs decisions made at each step of the continuum? or even, who are the actors involved in making decisions at each stage?
Behaviour, hence decision making, is a driver of business models - profitable or otherwise - and one can see how establishing framing references could be a useful heuristic for healthcare, a space notorious for opacity in pricing and complicated decision-making modalities.
I was traveling in a rideshare to my dentist’s appointment, recently. The Coronavirus outbreak was top of mind, and I couldn’t help but think of the materials used in the vehicle, and how the vehicle could be a vector of contagion. A similar thought occurred to me as I was on BART, en route to meet a friend, after playing squash. The cold metal railing would be a poor surface for a virus to survive, however, the hand strap could be more prone to retaining moisture; definitely the handles of my leather gym bag. I began to think about humans touching different surfaces with their hands and then using their phones and their wallets. And while thoughts of how interconnected the world can be, are usually an exciting thought for someone who works with startups, in this case, one can understand why people are afraid of something they cannot see and understand, the spread of which they don’t know, etc…
What framing reference makes sense here? Once again, epidemiology is a good place to start. The human skin is a marvelous organ and the most resistant to coronavirus in general - the common cold can be caused by a type of coronavirus - however, mucous membranes and conjunctiva, less so. This isn’t an article on the spread of viral infections, so I won’t go into details - the CDC is a good source - but this topic is a good way to walk through the idea(s) of using framing references for complicated, systems-level thinking.
Framing references are useful in understanding which data to collect, which models to use, and which analyses to apply, for example. How could BlueDot predict the outbreak before the WHO? Wired magazine, correctly, calls them an AI Epidemiologist. Can rideshare and BART information be used similarly to advise certain neighborhoods to take extra precaution? Will this information make individuals from other neighborhoods complacent? Would smokers with chronic coughs fail to cough in their elbows versus non-smokers? The framing references here, within the broader epidemiological framework, are obvious. Moisture extends the habitable zone for a virus when it isn’t in a living organism, and some anatomical structures are more resistant to the viral - human cell mechanisms which allow the virus to enter the host. Conversely, other structures are less resistant ie mucosa and conjunctiva.
Viewing the outbreak through this lens, one could ask the question, Which behaviors or actions lead to the provision of a moist environment for a virus? or Which actions or behaviors result in viral contamination of conjunctiva and mucous membranes or even ingestion? And while this sounds simplistic, and to a large degree it does sound like common sense, one would be surprised that simplicity isn’t always appreciated in the sciences, medical or otherwise. A case in point. When the HPV vaccine came out, and young women were advised to get vaccinated, the basic tenet of preventing sexually transmitted diseases ie treat the partner too (another framing reference perhaps) seemed to have been overlooked. Why weren’t young men being advised to get vaccinated too? This example, of course, isn’t the first time healthcare has befallen to prudishness, but it illustrates a point.
To wrap up, it’s amazing what proper hand-washing can prevent. From hospital infections to Delhi-belly, and even the reduction in the spread of the common cold, flu, or in this case reducing the impact of 2019-nCoV. I’m always surprised at how many people don’t wash their hands properly before or after eating food. Men’s public bathroom habits are worth an entirely separate post. Moving along …
It is generally accepted in the health-tech space that the burden - or cost of prevention - is to be borne by the consumer; the changes under the ACA did help though. Here the word consumer is being used to describe behavior or activities that would not be compensated by anyone but the individual. However, with the ACA came the notion of value-based care, and married to that was the idea of an individual as the comptroller general of their own health. It is of no surprise that activities that don’t necessarily bill but are yet useful for healthcare, are being digitized. As are aspects of care that can be billed but don’t require a physical input, or if they do require physical input, is it a human that’s required for that input? I think one can see where I’m going here. The ROC in healthcare is low, as compared to other industries, and Healthcare costs aren’t sustainable, so it’s inevitable there will be, and is, a massive push for digitization of Healthcare.
But while digitization has become a commonly accepted framing reference, hidden within it, the fact that consumers are the deciders of their healthcare, perhaps leads us to understand the recent NPR article on why access to care is voluntarily being shunned. The authors of the research referenced in the article posit that the cause could be the rising out-of-pocket costs faced by health consumers. If this is so, as good friend Sanjay Joshi points out in an LI comment, isn’t primary and preventative care the gateway to personalized medicine, the future of healthcare? If so, what does that say about our healthcare system now, and the attempts to drive towards personalized medicine?
And perhaps related to this phenomenon is the fact that despite changes in the US healthcare system, maternal and child healthcare at and around the time of delivery have not improved in the last 10 years; an example of which is the still terrible maternal mortality rates in the US. Note, if the ACA was going to have an impact, it would have done so already, since Maternal and Infant mortality and morbidity indicators are some of the quicker ones to change, as compared to say chronic disease indicators.
Those of us who have studied healthcare financing in the US won’t be surprised. Why? If one looks at the out-of-pocket costs borne by consumers in the US, there has been a steady increase since the ’70s. That’s the framing reference I use for advocating for a public option. Why not Medicare for all? The political shenanigans in Australia and the UK around their public health system, the framing reference I use, should be avoided in the US, if possible. It’s all too easy for politicians to dangle the healthcare issue in front of voters. It’s much more difficult to deliver on their promises. The NHS funding in lieu of Brexit is a good case in point.
What to make of this miasma? While there are many, here are a few framing references I use.
Individuals as the owners of their health = provide them with the tools with which to make informed and hence easier decisions. Easy decision making leads to better decision making and hence better compliance. How are decisions made by different age groups?
Imagine human life-span to be a series of events. One is born (point A), one dies (point C), and one develops chronic disease (point B). Segment A-B is ok for most people, barring acute illnesses. Segment B-C is worrisome for everyone. B-C is also where 80% of costs are incurred in most healthcare systems. B-C traditionally has been the purview of Medicare. How to best delay point B?
Humans are prone to group-think. If one wants to do something new, expecting the same people to come up with novel ways of identifying problems (hence the right solutions) won’t work. That may give you an idea of why I think diversity, and hence diversity of thought, is important.
This one is easy but was met with eyebrows some time ago. Computation is cheaper than the cost of good data acquisition, hence any way to gather good data cheaply is a competitive advantage.
I’m happy to share other ones on a specific problem or issue. Feel free to comment or discuss below.
The addition of large quantities of turmeric in Indian food is a curious culinary addition. I read somewhere reputable that the quantities used, go beyond just a culinary need, and that it seemed that the aim was, for it, to be medicinal. I can’t find the reference in Zotero, so feel free to ignore the assumption. The Charaka Samhita makes for interesting reading, but that isn’t what I’m referring to.
Of course, the subcontinent’s tradition has always maintained Turmeric’s health benefit, but modern science has started to pick apart why milk, honey, turmeric, and pepper, along with some ghee, could be a useful tonic. Or for that matter, why a poultice of turmeric and neem could have wound healing and antibacterial (or at least bacteriostatic) properties. Indigenous knowledge bases, of course, need to be scientifically verified, but it’s well understood, that they are a great source for scientific inspiration. Does that change your view of ecological diversity, or do you think we can AI our way out of relying on biomimicry?
If one views food as preventative medicine, a framing reference used by many in the Subcontinent and Asia, then it’s clear what sort of concentrations one should aim for, and hence, what would inform one’s literature search. This just scratches the surface of supplements but that’s a separate post too.
To conclude. A framing reference can be viewed as a set of assumptions, which if correct, modify the perception or meaning of subsequent data points, in a manner that solves problems. This is how one can position solutions towards a product-market fit. From this perspective, the use of framing references fits well with conditional probabilities, and even Bayesian statistics. And that’s where things become interesting, don’t they?
Hargrave, Timothy & Ven, Andrew. (2006). A Collective Action Model of Institutional Innovation. Academy of Management Review. 31. 864–888. 10.5465/AMR.2006.22527458.