Reaching more people, more effectively through health technology

In a previous post from September 2014 I summarised the key innovation hotspots identified in a Price Waterhouse Coopers health industry report HealthCast: Global Best Practices in Bending the Cost Curve.  Hotspot 4, was:

1. Care anywhere through technology development 

As an example, in 2009-10 I was involved as a provider and course facilitator with 'The Life Program' a diabetes prevention program established and operated by Diabetes Australia Victoria for people diagnosed with 'pre-diabetes' that made use of technology to enhance program reach and effectiveness.  The program was established to be run through a network of statewide providers in Victoria, with a population of over 5 million people spread throughout lots of cities, towns and regions.

The program is still running and has evolved from when I was involved, but at that time innovative solutions were employed to support program management.  An online portal was built and utilized to provide value in a number of ways.

• The program was actively promoted through the portal.
• Program administration was centralised through the portal with client details and medical records were securely stored, accessed and updated through it, both by a centrally located administration team and course facilitators located throughout the state.
• The portal was also linked to a database management tool which provided ability to analyse records, compare results and identify trends which was a powerful tool for evaluating program effectiveness.

 The program also employed tele-health innovation with an telephone coaching service.  This element was in its infancy at the time I was involved with the program, but it has developed into a significant offering in its own right.  This program provides a real life example of the use of technology to provide better access to healthcare.

Having worked in occupational health over the last few years I have had the opportunity to be involved in a number of different programs that have utilized technology solutions to administer programs remotely or via networks of providers, manage cases with multiple providers and more effectively manage data and reporting.

A recent Pilot study conducted by Partners Connected Health and published in the April issue of Journal of Medical Internet Research, shows another example of technology innovation improving healthcare for cardiac patients by facilitating better remote care (Thank you to Jennifer Priester for the link).  They names their system iGetBetter, and explained how their system included: 

• a web platform
• interactive voice response (IVR) telephone system 
• wireless personal connected health devices that measure and collect key vital signs. 

They further explained how patients received a Bluetooth weight scale and self-inflating blood pressure cuff to measure their weight, blood pressure and heart rate each morning. 

With the iGetBetter system participants were provided an iPad Mini tablet computer equipped with cellular connectivity to view their measurements via the Internet. The IVR system provided patients with an alternative way to manually record their measurement and care activities. 

The iGetBetter system includes a web platform, interactive voice response (IVR) telephone system and wireless personal connected health devices that measure and collect key vital signs. Patients received a Bluetooth weight scale and self-inflating blood pressure cuff to measure their weight, blood pressure and heart rate each morning. Participants were also provided an iPad Mini tablet computer equipped with cellular connectivity to view their measurements via the Internet. The IVR system provided patients with an alternative way to manually record their measurement and care activities. - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

The iGetBetter system includes a web platform, interactive voice response (IVR) telephone system and wireless personal connected health devices that measure and collect key vital signs. Patients received a Bluetooth weight scale and self-inflating blood pressure cuff to measure their weight, blood pressure and heart rate each morning. Participants were also provided an iPad Mini tablet computer equipped with cellular connectivity to view their measurements via the Internet. The IVR system provided patients with an alternative way to manually record their measurement and care activities. - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

The iGetBetter system includes a web platform, interactive voice response (IVR) telephone system and wireless personal connected health devices that measure and collect key vital signs. Patients received a Bluetooth weight scale and self-inflating blood pressure cuff to measure their weight, blood pressure and heart rate each morning. Participants were also provided an iPad Mini tablet computer equipped with cellular connectivity to view their measurements via the Internet. The IVR system provided patients with an alternative way to manually record their measurement and care activities. - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

For more details you can Visit their website here.

Its important to acknowledge that this is a only a pilot study and too small to have statistical significance and also that there are elements of this type of program that would be difficult to replicate on a big scale (i.e. providing people with iPads).  Furthermore its important to implement technology solutions that are more appropriate for your organisation and ojectives and budget.  That said, it is useful to have awareness of the successes organisations are having with technology initiatives.

Mobile Web-Based Remote Monitoring Study Demonstrates Improved Patient Engagement - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

Mobile Web-Based Remote Monitoring Study Demonstrates Improved Patient Engagement - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

Study Conducted by Partners Connected Health Demonstrates Improved Patient Engagement and Self-Management in Patients with Heart Failure - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

Study Conducted by Partners Connected Health Demonstrates Improved Patient Engagement and Self-Management in Patients with Heart Failure - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpufMore specifically it identifies how mobile web-based remote monitoring demonstrates improved patient engagement and self management in patients with heart failure. 

April issue of the Journal of Medical Internet Research mHealth and uHealth - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

April issue of the Journal of Medical Internet Research mHealth and uHealth - See more at: http://connectedhealth.partners.org/news-and-events/media-center/announcements/mobile-web-based-remote-monitoring-study-igetbetter.aspx#sthash.KqLBooCE.dpuf

Healthcare Integration Self Assessment.

Those of us working in healthcare management and even those working to evolve and improve the system can all have days where we feel bogged down by the complexities, or what seems to simply be a lack of a good system. 

Its understandable!  Some people will even argue that modern healthcare systems in countries like Australia, New Zealand or the UK are not actually single coordinated systems, but a complex collection of inter-related services and products that can vary extremely in levels of integration.  In simple language...at times it can appear to be a bit of an overwhelming mess!

When we have days like this and we're feeling a bit overwhelmed, it can be useful to have a reference point to turn to.  A simple set of reminders, that clarifies what we are striving to work towards and achieve.  With that in mind, the following systemic review, published by Karoline Nicholson and colleagues from the Western University in London, provides just that.  Published in December 2013, it still holds relevance today.  The systemic review is written in article format and offers 'A Governance model for Integrated Primary/Secondary Care for the Health-Reforming First World'.

They explain clearly that their aim is to synthesise the existing published literature on elements of current integrated primary/seconday health care.  Their focus was clearly on studies that evaluated the structure and governance models of services rather than those that evaluated the success of the actual intervention.

In summary, they identified ten elements that are relevant for integrated primary/secondary health care governance across a regional setting. 

1. Joint planning
2. integrated infomration communication technology
3. change management
4. shared clinical priorities
5. incentives
6. population focus
7. measurement - using data as a quality improvement tool
8. continuing professional development supporting joint working
9. patient/community engagement; and,
10. innovation

They found that 'all examples of successful primary/secondary care integration reported in the literature have focused on a combination of some, if not all, of the ten elements.'  They highlighted that ' whilst no one model fits all systems, these elements provide a focus for setting up integration initiatives which need to be flexible for adapting to local conditions and settings.'    

So if you are a health management professional and you are feeling stuck, or bogged down by the system, try something different.  Go and find a quiet place to review your program or your project against these ten elements.  You can make it as simple:

1. assessing how well your project scores against each of the elements
2. create an action plan to address one or more of the low scorers.

I am managing occupational health programs in my current role, and have even been able to apply this review process to my work as a 'check in'.  For access to the fully article visit http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4234138/

 

Innovative Payment Systems

A very interesting 'alternative' payment system (and operating model) is the one practiced by Westgate Health, in western Melbourne.  I am not directly involved with the organisation so am speaking about second hand knowledge, but a look at their website highlights immediately that they are a 'Co-op'. 

The organisation doesn't just engage with patients...its owned by patients!  approximately 5000 community members who are called upon to be board members and who are actively surveyed on a regular basis.

Community member fees are used to subsidise the costs and spread them across the local community, and membership entitles you to a range of benefits, which is a similar model to that utilised successfully within the insurance industry.  The difference with alot of insurance companies is the philosophy and investment back into the organistion as a not-for profit entity.  They highlight on their 'Fees & Payments' page that 'They help cover the costs associated with operating our two clinics. We believe that the Co-op’s philosophy of membership fees provides a more equitable system of providing high-quality health care to the whole community, rather than having to charge a fee for every medical service'.   

By providing this example, I am not implying that the payment system for the wider primary health sector is ok.  I'm providing an example of how one health organisation is using social-innovation to deal with some of the issues raised about the current state of the health system including:

• being in it for the money more than for improving health  
• application of quality measures
• aligning funding systems towards prevention

 I'd love to hear what others think of the pro's and con's of this example.

$48 Billion on the table for the health industry!

I recently posted an article summarising a recent recent PricewaterhouseCoopers (PwC) health industry report (HealthCast: Global Best Practices in Bending the Cost Curve) which identifies a number of key trends for health organisations to focus on for performance improvement and what my personal experiences are with these 'on the ground'.  Out of all the current trends which I summarised in a previous blog, in this article I am going to discuss.

1. Data analytics and measurement

Why have I chosen these topics?  Well its for two reasons, firstly, I am currently heavily involved in a number of health innovation based technology projects including Lean-Agile run business transformation project.  Data management is a big topic within this project, so it's on my mind.

Secondly, those good people at PwC must be a very industrious lot because I noticed an article this week in The Australian newspaper highlighting a new PwC report identified that $48 billion was left on the table last year - unused, courtesy of the inability of Australian industry - and particularly the health industry - to fully leverage the potential of data-driven innovation.

According to PwC’s new Data Innovation Index, it is the health industry that is lagging behind the rest and therefore stands to benefit most in the future based on its size, international competitiveness, and assets including technical skill, talent, and volume of data.  For those of us involved in health innovation its not a surprise but still useful to be aware of.  

“It’s the lack of urgency to act on that data, that’s the issue,” Mr Sammy Kumar, PwC’s managing partner for PwC strategy; transformation, told Business Spectator.  He identified specifically that there is an inability to correlate the data set to achieve efficiencies that’s proving to be a problem.  Furthermore that there’s an urgent need to encourage wider awareness of the role data can play in driving efficiencies and productivity.

The key takeaway was that there’s plenty of room for improvement, especially when you compare Australia to a country like Canada. 

IT led innovation is a  core component of the organisation I work at.  UHG has created and developed some innovative solutions over the years and was recognised last year as the BRWs 19th most innovative company in Australia.  The work my team does, managing the delivery of occupational health and wellness services into orgnaisations is highly dependant on IT systems and in the course of providing health services we collect a reasonable amount of data.

In my experiences working with clients, I have observed that because this blossoming access to data is a relatively new phenomenom many people in occupational health management roles simply do not know how best to use it.  Many people in these decision making positions are experts in other areas of management but are not experts in data analysis or data management.  If you were in school in the 70s, 80s or even into the 90s, you would not have not been educated about 'databases' or 'mega-data trends' because they simply didn't exist.

Actually, electronic databases have been in existance since the 1960's.  In the 1980s and early 1990s dBASE was one of the top selling software titles.  But how many people remember that?  I certainly don't, I discovered it just now via Wikipedia!  This leads me into my point, that we need to embrace this new phenomenon and learn about how to get the most from data.

• Embrace learning about data...its here to stay

I figure that if a boofhead like me who spent school messing around on the sports field can embrace data anybody can.  If you're never going to be a PhD in data analytics its ok.  Find somebody else who is, type 'free data courses' in to google, or just commit to learning a little bit each month.  It just takes the right attitude and a bit of practice.  To make the most of data you need to know what you want to assess or measure.  The more data you collect, the more ways to slice and dice and compare it there are.  If you do not have a crystal clear idea of the objectives and/or the KPIs that are guiding your program or project, then its going to be difficult to know how to use your data.

Program or project objectives need to be determined right at the beginning of an activity.  This implies that part of making the most of data, is being disciplined in how you manage projects.  You have to take the time and effort to get to the essence of what you are trying to achieve so you can clearly articulate your aims.  This is the only way that you can then decide what data you will need and eventually look at to assess results.

•  Understand your objectives...simplify, simplify, simplify

My final point is that using data to uncover inefficiencies and achieve change requires leadership.
The PwC report highlighted that the health industry is conservative.  It is not the market leader in these areas of innovation and has a lot of areas of inefficiency.  Conservative people like to make changes slowly and can even be described by some as 'resistant to change'.

To lead change in the health industry you need to be proactive and prepared to take action but you also need to bring those around you along for the ride.  There are always alot of hoops to jump through, so you have to be prepared to educate the health professionals and other colleagues around you, and help them understand the value and benefits of embracing innovation.  To do this you need to believe that change is possible, and that others around you can change.  You need to be committed, you need to be an effective leader.

• Effective use of data requires good leadership

This is not an exhaustive list by any means, just a few observations but hopefully it provides food for thought and action.
    

 

Real Life Experiences with Tele-Health

The purpose of this article is to provide examples of innovation in action and to encourage the health industry to try new ideas!  

A recent PWC health industry report (HealthCast: Global Best Practices in Bending the Cost Curve) identifies a number of themes with associated innovation hotspots for health organisations to focus on for performance improvement.  The themes are generally similar to what we see coming up time and time again in good industry reports but there are a couple of interesting ideas in there:

1. Leadership
2. Strategic partnership models
3. Integrated care
4. Care anywhere through technology development
5. Data analytics and measurement
6. Process improvement in hospitals
7. Caring for an aging population
8. Precision medicine through research developments (e.g. genetics)
9. Bioclusters

Whilst I do not have any direct experience with bioclusters, or genetic medicine advancements.  Its good to be able to say that I have experience in a number of these areas and also that my workplace, which is an insurance health services and occupational health provider, UHG is actively innovative in a number of these areas.

I believe that any innovation that supports improved productivity is useful and, due to its pervading effect on all aspects of business, I have a strong person interest in leadership and leadership systems that encourage and support collaborative workstyles and productivity improvement through increased engagement.  But this article will focus on point four involving 'Care anywhere'.

The PWC report explains Whether in the hands of individuals or institutions, technology frees patients to be treated anywhere, at any time, by a much broader array of providers. Consequently business leaders are embracing new models, such as mobile health (mHealth) and mobile applications.

So what are we doing in practice at UHG?  Well the UHG vision is 'connecting  business and healthcare' and our specialty is probably telephone based support services.  UHG is good at 'Tele-health'.  UHGs biggest innovation in the occupational health space is its telephone based medical advisory line.  It offers corporate clients with people and offices spread all over Australia a 24/7, telephone based triage service for injuries or biological exposure.  A good example of success is how we recently assisted a client during recent outbreaks of measles and swine flu.

The service provides direct access to skilled allied health professionals who triage calls, who can connect callers directly to occupational health specialist doctors over the phone, proactively book appointments within local clinics, and follow up with callers to proactively manage cases over a 3 day period.  Its an effective service that helps organisations reduce lost times injuries and it is a telehealth model that has potential application in the wider health industry.

This is only one of a wide range of services we provide to be able to provide health services to populations spread far and wide.  Another mobile health assessment program which provides onsite bi-annual health assessments for around 2500 emergency workers across Victoria is supported by a Melbourne based 'program manager' and online clinical case management software.  This allows for any follow up clinical issues to be managed centrally, records to be sent and recieved securely if required post appointment, and if required for telephone based follow up to be provided by an occupational physician.

So in short, UHG has the experience and strong evidence to show that telehealth can work.  The purpose of this article has been to provide some real life examples of innovation in action and to encourage health administrators to try new things!  I hope its been useful.  



 
 

Riding the titanic wave of mobile health apps

Thanks blackberrycool.com for this image

A recent MIT report By Nanette Byrnes aptly titled 'Mobile Health's Growing Pains' and referencing Endeavour Consultancy Partners research has identified that mobile health technology solutions are yet to be fully accepted by consumers.

You know the ones I mean...im talking about the new health apps on your iphone or Samsung and the wristbands like FitBit and Jawbone and all the other 'solutions' that are being advertised widely at the moment.  So what to health industry stakeholders like us need to be aware of?  Here is my take...

The report identifies that while entrepreneurs and investment organisations are throwing money at these new ideas, the most important group 'consumers/patients' are still yet to be fully convinced. 

In a follow up article by Dan Verel (Medcitynews.com), he comments that while the report identifies one in 10 Americans owns some sort of health tracking device, from FitBit to Nike to Jawbone,  more than half of those devices are no longer being used by the patient.

The report and follow up article both report that with respect to mobile applications, while more than 100,000 are available, but “very few” have been downloaded 500 times, while more than two-thirds of consumers have stopped using the apps, according to a PWC report.

In addition the MIT report identifies that since the start of 2013, more than $750 million in venture capital has been invested in companies that do everything from turn your smartphone into a blood pressure gauge to snapping medical–quality images of the inner ear. Apple, Qualcomm, Microsoft, and other corporate giants are creating mobile health products and investing in startups.

This feels to me like a small scale version of the 2000's internet boom where money was being thrown around wildly for any 'good idea', in the hope of getting market leader advantage.  These initial ideas are sold as being appealing for all and they are sold on the promise of health, rather than a known understanding that they are the right solution for you.

This is because they are not actually properly tested on the people who are going to utimately use them.  Wild assumptions are made of an app that appeals to everybody rather than specific niches.  Or they are not properly tested to see how long they are going to be useful for.  This is just a normal part of the 'new technology' cycle.

Mobile apps will certainly have a big place in the future and it is great to have the new ideas becoming real, but the market has a long way to go to mature and have products that consumers want and find useful.  At the moment we still have a lot of 'coverall apps' that a expected to appeal to everybody for everything. 

But there certainly are those that are being developed with more specific uses and target groups in mind and this is a further step in the right direction.  For those of us working in health, its important not to get overawed by the excitement of these trends, but to stay aware of the good things that are being done so we can spot the opportunities when they arise (in my mind at least, anyway).  I believe that as next steps we need to better understand who actually wants to use apps, what specifically they want to use them for, how long they might need the app for and how they need it to look and feel.

The evolution of organisational performance and workplace wellness interventions

The industrial revolution in the 19th century dramatically changed the way people lived and worked.  Production of many goods moved into large urban factories.  Child labour was common.  The working week could range from 10 - 16hrs per day in harsh conditions.

This, amongst a myriad of other factors, lead to the push for a more effective and sustainable systems to manage the demands placed on workers.  These types of industrial changes and associated performance management responses were occurring all through the industrialising world including in Europe, North America and Australasia.  

In one example of the focus of the time, by 1817 in the UK a prominent campaigner Robert Owen had coined the slogan: "Eight hours labour, Eight hours recreation, Eight hours rest"(MUSV, Publicity Works, History Fact Sheet - www.8hourday.org.au.

In Australia and New Zealand, there were initial successes in achieving an eight-hour day for skilled workers in the 1840s and 1850s through the countries respective labour movements.  In Australia, Victorian based action was leading the way.   

On April 21st 1856, stonemasons and building workers marched through the city of Melbourne to demand regulated working hours with no pay loss.  Their demands were granted although it took much more campaigning and a number of decades for these successes to evolve into widespread legislation for all workers.

As the 8 hour day movement also grew 'across the ditch' in New Zealand, the government of the time acted a bit more swiftly and as such legislation was passed in the late 1800's.  By 1890 a day in October had became one of annual celebration.  It became known as Labour Day or Eight-Hour Demonstration Day.  Legislation eventually followed and in addition in 1899 government legislated for 'labour day' to become a public holiday.

In 1916 in the state of Victoria, Australia, the Victoria Eight Hours Act was finally passed granting the eight-hour day to all workers within the state.  Legislative acknowledgment was achieved nationally in the 1920s.

Shift forward to the 21st century and there is a general consensus that health and well-being of workers has a strong influence effect on workplace performance and that productivity of employees experiencing poor health is diminished. 

As a consequence, its widely understood that workplaces that support workers health and well-being can realise a benefit of enhanced organisational performance (State of the Service Report 2012-13, Ch 4 Employee Health and Well-being).

Its also widely acknowledged with growing acceptance in management circles that health and well-being refers to combined physical, mental, psychological and emotional state of employees (K. Danna and RW Griffin, Health and Well-being in the Workplace: A Review and Synthesis of the Literature, J Management (1999) vol25, no.3, p357-384).

So what are the other main ways that organisations can and often do support employees health and well-being for the benefit of both the worker and the organisation?  I have compiled the following list of the the major initiatives an organisation can offer or implement  which impact on employee health and well-being.

1. Work Itself
2. Workplace Culture / Leadership
3. Paid Sick Leave
4. Flexibility / Reasonable Adjustment
5. Support for Line Managers
6. Injury / Illness Triage
7. Graduated Return to Work
8. Occupational Health Interventions
9. Wellness Programs

This is clearly a wide-ranging list so lets now explore these options in a bit more detail to see how they translate to actual actual activities and interventions that any organisation can implement.

1. Work itself - Work provides income, structure and purpose.  the 2010 Australasian Faculty of Occupational and Environmental Medicine Paper acknowledged that 'the findings are unambiguous, work is good for health and well-being'.
2. Paid Sick Leave -  Paid sick leave allows for an employee to access medical care, recover more quickly, prevent illness from developing, prevent the spread of disease in the workplace.  It also contributes to increased productivity by allowing unwell employees to recuperate more effectively and return to full productivity more quickly (Scheil-Adlung and L Sandner, The Case for Paid Sick Leave, World Health Organisation, (2010).) 
3. Flexibility / Reasonable adjustment  - This can include any adjustment in the way a person does their work, from flexibility in hours so they can care from family members to adjustments in  workplace furniture due to variations in size, shape or physical limitations.
4. Support for line managers  - in larger organisations, line managers are often the ones primarily responsible for managing employees health and well-being related issues as they arise.  This often occurs without any formal training or experience, and its widely acknowledged that organisations who do support line managers in this task will reap the rewards (Wellness in the Workplace, NZ, 2013) 
5. Injury / Illness triage - When people become ill or injured they don't always seek help straight away.  There are many reasons for this, but regardless, immediate access to appropriate support can dramatically improve outcomes.  There is a growing trend towards telephone based injury and illness triage services, for example UHG Injury Track which is a product my current employer offers.
6. Graduated Return to Work (RTW) - RTW programs are established programs that have been shown to reduce chronic illness and indirect productivity cost to the employer and demonstrate the value of the employee to the organisation (Scheil-Adlung and L Sandner, The Case for Paid Sick Leave, World Health Organisation, (2010), ComCare.First Steps Back: a guide to Suitable Employment for rehabilitation Case Managers) 
7. Occupational Health Interventions - Some workplaces or roles involve increased risk of illness or injury due to the nature of the work or environment.  Protective interventions like health assessments, task modification, toxin surveillance and vaccination can reduce and minimise risk of illness or injury
8. Wellness programs - With the rise in lifestyle related chronic health conditions, organisation wide wellness programs have been widely shown to be beneficial to individuals and provide a return on investment for organisations. 
9. Workplace Culture / Leadership style - high levels of employee engagement is widely understood to directly impact on workplace performance, but it has also been recognised as having a significant impact on personal and occupational illness, caring and both personal and work related injuries (NZ Wellness in the Workplace Report 2013).  The sense of control that employees have over their work, along wiht the demands of the workplace, combine to affect the likelihood of job strain and subsequently the likelihood of workplace stress. (R Karasek, Lower Health Risk with Increased Job Control among White Collar Workers’, Journal of Organizational Behavior, (1990), vol. 11, no. 3, pp. 171_185 ) 

In summary, employee health and wellness has a strong influence on their productivity and ability to help and organisation achieve high levels of performance.  In turn, there are a number of different mechanisms available to an organisation to ensure all employees are supported to be able to 'be well' and when required to manage health issues as effectively and efficiently as possible.

Whilst even work itself can have a positive effect on our health and well-being, in our modern society workplace mechanisms have evolved and 'revolved' and in many workplaces now link together as a sophisticated web of management tools. 

As a result organisations that acknowledge the value of people in improving productivity can gain a significant competitive advantage in their marketplaces by helping their people maintain good health and well-being.  Smart organisations and intelligent managers understand this and use all these interventions in their fullest capacity.