The Coeducation of Civic Tech and Digital Health

Startup in Residence (STiR) connects startups with government agencies to develop technology products that address civic issues. I was fortunate to attend STiR’s Demo Day last week at the Nasdaq Entrepreneurial Center. With over a dozen startups showcasing both the impact and the market for technological innovations that improve the lives of city residents and while making a pretty healthy profit, it was both inspiring and educational to observe.

I will admit I’m new to the civic tech space with my experience largely linked to the services-first redesign of the City of Oakland site. Unbeknownst to many City employees that beautiful new website masked much-needed business process and service redesign and change management necessary to reenvision essential service delivery in a increasingly complex world. Although I’m still learning about civic tech, I am pretty well-versed in digital health. I wanted to see what we could learn from the significant commonalities as well as points of divergence between the two tech niches.

Definitions

Terminology matters much more than we think despite how much we actually discuss it.

Civic Tech

Stacy Donahue, an investment partner at Omidyar Network defines civic tech as

…technologies that are deployed to enhance the relationship between people and government, by giving people more of a voice to participate in public decision making and/or to improve the delivery of services (usually by gov’t) to people.

Candace Faber, the chief technology advocate for the City of Seattle offers the following definition:

Civic tech is technology that enables greater participation in government or otherwise assists government in delivering citizen services and strengthening ties with the public….Civic tech is where the public lends its talents, usually voluntarily, to help government do a better job.

The key features of these definitions: enhancing relationships, strengthening ties, greater participation and voice in decision making, and improved service delivery.

Digital Health

Eric Topol provides the following definition:

Digital health — or my preferred term “digital medicine” — refers to the ability to digitize human beings, by a variety of means (sequencing, sensors, imaging, etc.) fully exploiting our digital infrastructure of ever-increasing bandwidth, connectivity, social networking, the Internet of all things, and health information systems.

Researchers Bertalan Meskó and Zsófia Drobni wrote in a recent Mhealth journal article the following:

the cultural transformation of how disruptive technologies that provide digital and objective data accessible to both caregivers and patients leads to an equal level doctor-patient relationship with shared decision-making and the democratization of care.

I personally prefer Mesko and Drobni’s definition because it mimics a few of the positive attributes of the civic tech definitions:

1. Improved relationships
2. Greater participation in decision making
3. Democratizing care parallels the aim for greater participation in civic spaces

Topol’s definition almost removes the humanity and relationships from digital health completely, leaving the impression that innovation is for the sake of technological achievement rather than reinforcing human connection. I often say that good technology reinforces rather than replaces human relationships. In particular, I appreciate Mesko and Drobni’s focus on democratizing care which brings access and equity to the forefront.

First impressions

The room was so much more diverse and “normal” in appearance. And no I don’t mean basic, but rather normal in terms of statistics. I saw people of all ages and racial and ethnic backgrounds. This is rarely the case at digital health demo days and conferences which tend to be full of middle-aged white men all named Michael. In short, this was refreshing. Fewer manels please and more people with diverse loved experiences.

Language

Emcee Monique Woodard and City of San Francisco Chief Innovation Officer Krista Cannelakis kicked off the main event with a tongue-in-cheek skit about the alphabet soup of both venture investing and city government procurement. Even for someone like me who speaks both “languages,” I had a hard time following along.

The vignette highlighted the importance of a shared language as a foundation and requirement for innovation which unfortunately is still lacking in healthcare. I cannot stress enough how many times I have been in conversations with brilliant people who are confused due to a rogue acronym or overused buzzword that has made the real term lose all meaning. This terminology paralyzes decision making and dramatically slows innovation. Please stop doing this. Start adopting the habit of explaining every acronym, portmanteau, and bit of jargon in your job.

This work of simplification and translation tends to reveal easy-to-overcome barriers to innovation. Going back to City of Oakland, until we began to instruct all departments to bring their content down to a 5th-8th grade reading level, we didn’t know how flawed some of the business processes were simply because they were opaque, which made it difficult for even other city employees to understand.

Key Themes

Operational efficiency through AI and data-driven decision making

Do we know the specific people, information and resources to connect to the right people at the right time with the right resources? There were a few startups that answered this questions very well for housing, service requests and street cleanliness.

One startup leveraged data to better scope affordable housing development to meet demand based on characteristics like family size. It’s not enough to simply provide more housing but rather housing tailored to needs. This ensures better use of limited resources and helped community members have access to a basic need.

ZenCity accelerated the response time for 311 service requests through AI, decreasing avoidable waste of already limited staff time and resources and increasing resident satisfaction with city services.

How can digital health do a better job of demonstrating responsiveness to patients and consumers? One step might treating patient empowerment as less of a buzzword and more of a starting point for engagement.

Knowledge of how to marry legacy and innovation

When thinking about commonalities between civic tech and digital health, the issue of introducing and integrating innovations within outdated legacy systems rises to the top. Over the last several years, I’ve seen the hype of digital health, promising to cure all of healthcare’s ills through the power of technology. Unfortunately, we can’t build our tech stack from scratch in healthcare which fundamentally changes the innovation process from one of total disruption to incorporate more work toward integration.

At City of Oakland, we realized this need to focus on marrying legacy and innovation at the outside. It’s part of the reason it took so long to see the outward manifestation of the digital transformation because so much of the work was behind the scenes and not technical at all: securing buy in and initiating enterprise-level change management.

The City of Oakland’s digital transformation offers as an example of what the goal ought to be in civic tech and digital health.

Leverage the accessibility and acceleration of digital technologies to re-envision and redesign human-driven business processes for greater simplicity, equity and trust among institutions and individuals.

Technology can enable us to deliver services that are faster, cheaper and easier but only if we center human needs throughout that transformation process. Specifically, if your tech isn’t advancing, enabling, and/or accelerating equity, I would say that it’s not a transformation that ultimately that adds value to an already broken system.

At STiR’s Demo Day, Symblum demonstrated how their approach to computational law made a 2000 page planning code searchable, personalized and accelerated decision making for new business owners about where to open their business in the city.

Simplifying the opaque is a problem all over digital health, especially when considering the significant gaps in equity.

SeamlessDoc presented a beautiful solution to end the plague of paper in government, a problem that healthcare knows all too well. What I found remarkable was that their innovation wasn’t simply about digitizing forms but about connecting the person on one side of the form with the person on the other side: in short, reinforcing human relationships. Let’s see more technologies that aim to connect us not just to physicians but to other stakeholders who shape our health.

Less analysis, more real-time action

An intriguing trend I observed was one of using data to enable real-time action. Although government is not typically associated with action at all much less rapid action, a number of startups provided clear, data-driven insights that enabled cities to provide better services for their residents.

Nordsense equipped city trashcans with smart sensors to enable more effective deployment of trash collection teams that prevented overflowing trashcans for cleaner streets.

Biobot Analytics took the principle of “Everybody pees” to new levels. Their tests and analytics enable epidemic hotspotting through sewers to drive more more effective public health department responses to health issues in real time rather than at the close of an annual survey.

GovRock developed a volunteer platform to enable empathy-driven civic engagement for the City of West Sacramento. The mayor delivered a rousing address about how civic engagement is more than volunteerism. Community can seed and drive innovation and better services.

What was missing

There were so many innovations that involved infrastructure. This is completely understanding given the nature of dilapidated infrastructure across this country. I found two things to be conspicuously absent:

1. The role of health in the future of cities
2. The role of equity

The role of health in the future of cities

The afternoon keynote speaker Steve Westly gave a rousing talk about the major trends that we can expect in the future of smart cities: IoT, Big Data, Sharing Economy.

Based on this address and the line of startups participating in the demo day, it seems as though health is largely absent from the future of cities. Outside of Biobot Analytics, RideAlong was the only startup that addressed population health outcomes. RideAlong developed an app to support street outreach teams serving homeless populations to improve care coordination for both clinical and non-clinical services.

The keynote included relatively little discussion of health and its impact on adoption and implementation of many of these technologies or the human and financial costs of adverse effects and exacerbation of existing inequality. This is curious at best and terrifying at worst. Health represents nearly one-fifth of the American economy. Actually healthcare represents nearly one-fifth of the economy. If there’s one thing we know from research, healthcare is responsible for only one-fifth of health outcomes improvement. However, the social determinants of health contribute to the majority of positive health outcomes despite being minuscule levels of spending and investment.

If we are going to consider the trends, opportunities as well as the pitfalls of the future of cities and health, we need to look at how these trends affect the social determinants of health to anticipate the resulting outcomes.

With factors such as automation, climate change, and aging disrupting the future labor market amid a trend of stagnating and sometimes declining wages, we would expect to see worsening health outcomes. Higher income is typically associated with better health outcomes according to the World Health Organization. Amid growing affordability crises in most American cities, the conspicuous absence of health from the future of cities conversation is troubling. The sharing economy is already under fire for not paying a living wage and contract and freelance roles notoriously do not provide employee benefits including health coverage.

The role of equity

The biggest question about the future is equity.

1. How do we correct existing inequality which contributes to poor health outcomes?
2. How does technology mitigate or exacerbate existing inequality?
3. How can technology advance equity?
4. What measures do we need to have in place to correct for the adverse effects of certain technology advances?

While many tech luminaries either don’t have answers to these questions or think that technology will auto-magically solve issues related to equity, I think about equity differently.

Disruptive innovation that advances equity is vital to building the future of cities we want to live in. Unless we are intentional about increasing equity via tech adoption, we exacerbate inequality. We’ve already seen early signs of this in both civic tech and digital health. In the movie Minority Report, viewers learn about the concept of pre-crime: the ability to detect murder before it occurs and imprison the would-be perpetrator before an avoidable death occurs. We have plenty of early evidence that pre-crime adds a facade of objectivity to systemic bias.

We can also look at disparities in bike share adoption to anticipate potential issues with autonomous vehicles: concerns about safety, alternative payment methods, and hidden fees. Because we have more access to knowledge and education than ever before, the future of education requires tailoring and personalization much more. In a world driven by AI, we will have human teachers as well as automated teachers that surface knowledge personalized to the needs and interests of users. What if our education surfaces information that reinforces bias? In the era of fake news, this personalization can both mitigate and exacerbate inequality.

At the end of the day, no one has the ability to read tea leaves about the future and the role of equity. Trends in civic tech and digital health will come and go but there are a few principles that will be forever.

1. Simplicity: Is it easy to understand and do what must be done?
2. Equity: Have we done the work to ensure the greatest number of people can access information and complete the task at hand?
3. Trust: Have we demonstrated the reliability of the human relationships behind the work such that future tasks can be completed?

We can critically examine our present and our past for cues about how we should treat equity with regard to innovation. If we merely improve upon our present, we have only innovated a simpler way of scaling the inequity we already have. We need to put equity front and center to create civic and health innovation and aim to build technologies that are fundamentally different and more equitable.