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Measuring the Vital Signs of Health Care Progress at the Connected Health Conference (Part 3 of 3)

Posted on November 17, 2017 I Written By

Andy Oram is an editor at O’Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space.

Andy also writes often for O’Reilly’s Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O’Reilly’s Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous segment of this article covered one of the crucial themes in health care today: simplifying technology’s interactions with individuals over health care. This segment finishes my coverage of this year’s Connected Health Conference with two more themes: improved data sharing and blockchains.

Keynote at Connected Health Conference

Keynote at Connected Health Conference

Improved data sharing
The third trend I’m pursuing is interoperability. If data collection is the oxygen that fuels connected health, data sharing is the trachea that brings it where it’s needed. Without interoperability, clinicians cannot aid patients in their homes, analysts cannot derive insights that inform treatments, and transitions to assisted living facilities or other environments will lead to poor care.

But the health care field is notoriously bad at data sharing. The usual explanation is that doctors want to make it hard for competitors to win away their patients. If that’s true, fee-for-value reimbursements will make them even more possessive. After all, under fee-for-value, clinicians are held accountable for patient outcomes over a long period of time. They won’t want to lose control of the patient. I first heard of this danger at a 2012 conference (described in the section titled “Low-hanging fruit signals a new path for cost savings”).

So the trade press routinely and ponderously reports that once again, years have gone by without much progress in data sharing. The US government recognizes that support for interoperability is unsatisfactory, and has recently changed the ONC certification program to focus on it.

Carla Kriwet, CEO of Connected Care and Health Informatics at Philips, was asked in her keynote Fireside Chat to rate the interoperability of health data on a scale from 0 to 10, and chose a measly 3. She declared that “we don’t believe in closed systems at all” and told me in an interview that Philips is committed to creating integrated solutions that work with any and all products. Although Philips devices are legendary in many domains, Kriwet wants customers to pay for outcomes, not devices.

For instance, Philips recently acquired the Wellcentive platform that allows better care in hospitals by adopting population health approaches that look at whole patient populations to find what works. The platform works with a wide range of input sources and is meant to understand patient populations, navigate care and activate patients. Philips also creates dashboards with output driven by artificial intelligence–the Philips IntelliVue Guardian solution with Early Warning Scoring (EWS)–that leverages predictive analytics to present critical information about patient deterioration to nurses and physicians. This lets them intervene quickly before an adverse event occurs, without the need for logging in repeatedly. (This is an example of another trend I cover in this article, the search for simpler interfaces.)

Kriwet also told me that Philips has incorporated the principles of agile programming throughout the company. Sprints of a few weeks develop their products, and “the boundary comes down” between R&D and the sales team.

I also met with Jon Michaeli, EVP of Strategic Partnerships with Medisafe, a company that I covered two years ago. Medisafe is one of a slew of companies that encourage medication adherence. Always intensely based on taking in data and engaging patients in a personalized way, Medisafe has upped the sophistication of their solution, partly by integrating with other technologies. One recent example is its Safety Net, provided by artificial intelligence platform Neura. For instance, if you normally cart your cell phone around with you, but it’s lying quiet from 10:00 PM until 6:00 AM, Safety Net may determine your reason for missing your bedtime dose at 11:00 PM was that you had already fallen asleep. If Safety Net sees recurring patterns of behavior, it will adjust reminder time automatically.

Medisafe also gives users the option of recording the medication adherence through sensors rather than responding to reminders. They can communicate over Bluetooth to a pill bottle cap (“iCap”) that replaces the standard medicine cap and lets the service know when you have opened the bottle. The iCap fits the vast majority of medicine bottles dispensed by U.S. pharmacies and costs only $20 ($40 for a pack of 2), so you can buy several and use them for as long as you’re taking your medicine.

On another level, Mivatek provides some of the low-level scaffolding to connected health by furnishing data from devices to systems developed by the company’s clients. Suppose, for instance, that a company is developing a system that responds to patients who fall. Mivatek can help them take input from a button on the patient’s phone, from a camera, from a fall detector, or anything else to which Mivatek can connect. The user can add a device to his system simply by taking a picture of the bar code with his phone.

Jorge Perdomo, Senior Vice President Corporate Strategy & Development at Mivatek, told me that these devices work with virtually all of the available protocols on the market that have been developed to promote interoperability. In supporting WiFi, Mivatek loads an agent into its system to provide an additional level of security. This prevents device hacking and creates an easy-to-install experience with no setup requirements.

Blockchains
Most famous as a key technological innovation supporting BitCoin, blockchains have a broad application as data stores that record transactions securely. They can be used in health care for granting permissions to data and other contractual matters. The enticement offered by this technology is that no central institution controls or stores the blockchain. One can distribute the responsibility for storage and avoid ceding control to one institution.

Blockchains do, however, suffer from inherent scaling problems by design: they grow linearly as people add transactions, the additions must be done synchronously, and the whole chain must be stored in its entirety. But for a limited set of participants and relatively rate updates (for instance, recording just the granting of permissions to data and not each chunk of data exchanged), the technology holds great promise.

Although I see a limited role for blockchains, the conference gave considerable bandwidth to the concept. In a keynote that was devoted to blockchains, Dr. Samir Damani described how one of his companies, MintHealth, planned to use them to give individuals control over health data that is currently held by clinicians or researchers–and withheld from the individuals themselves.

I have previously covered the importance patient health records, and the open source project spotlighted by that article, HIE of One, now intends to use blockchain in a manner similar to MintHealth. In both projects, the patient owns his own data. MintHealth adds the innovation of offering rewards for patients who share their data with researchers, all delivered through the blockchain. The reward system is quite intriguing, because it would create for the first time a real market for highly valuable patient data, and thus lead to more research use along with fair compensation for the patients. MintHealth’s reward system also fits the connected health vision of promoting healthy behavior on a daily basis, to reduce chronic illness and health care costs.

Conclusion
Although progress toward connected health comes in fits and starts, the Connected Health Conference is still a bright spot in health care each year. For the first time this year, Partners’ Center for Connected Health partnered with another organization, the Personal Connected Health Alliance, and the combination seems to be a positive one. Certain changes were noticeable: for instance, all the breakout sessions were panels, and the keynotes were punctuated by annoying ads. An interesting focus this year was wellness in aging, the topic of the final panel. One surprising difference was the absence of the patient advocates from the Society for Participatory Medicine whom I’m used to meeting each year at this conference, perhaps because they held their own conference the day before.

The Center for Connected Health’s Joseph Kvedar still ran the program team, and the themes were familiar from previous years. This conference has become my touchstone for understanding health IT, and it will continue to be the place to go to track the progress of health care reform from a technological standpoint.

Measuring the Vital Signs of Health Care Progress at the Connected Health Conference (Part 2 of 3)

Posted on November 15, 2017 I Written By

Andy Oram is an editor at O’Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space.

Andy also writes often for O’Reilly’s Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O’Reilly’s Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The first segment of this article introduced the themes of the Connected Health Conference and talked about the importance of validating what new technologies do using trials or studies like traditional medical advances. This segment continues my investigation into another major theme in health care: advanced interfaces.

Speaker from Validic at Connected Health Conference

Speaker from Validic at Connected Health Conference

Advanced interfaces
The compulsory picture of health care we’re accustomed to seeing, whenever we view hospital propaganda or marketing from health care companies, shows a patient in an awkward gown seated on an uncomfortable examination table. A doctor faces him or her full on–not a computer screen in site–exuding concern, wisdom, friendliness, and professionalism.

More and more, however, health sites are replacing this canonical photograph with one of a mobile phone screen speckled with indicators of our vital signs or thumbnail shot of our caregivers. The promise being conveyed is no longer care from a trusted clinician in the office, but instant access to all our information through a medium familiar to almost everyone everywhere–the personal mobile device.

But even touchscreen access to the world of the cloud is beginning to seem fusty. Typing in everything you eat with your thumbs, or even answering daily surveys about your mental state, gets old fast. As Dr. Yechiel Engelhard of TEVA said in his keynote, patients don’t want to put a lot of time into managing their illnesses, nor do doctors want to change their workflows. So I’m fascinated with connected health solutions that take the friction out of data collection and transmission.

One clear trend is the move to voice–or rather, I should say back to voice, because it is the original form of human communication for precise data. The popularity of Amazon Echo, along with Siri and similar interfaces, shows that this technology will hit a fever pitch soon. One research firm found that voice-triggered devices more than doubled in popularity between 2015 and 2016, and that more than half of Americans would like such a device in the home.

I recently covered a health care challenge using Amazon Alexa that demonstrates how the technology can power connected health solutions. Most of the finalists in the challenge were doing the things that the Connected Health Conference talks about incessantly: easy and frequent interactions with patients, analytics to uncover health problems, integration with health care providers, personalization, and so on.

Orbita is another company capitalizing on voice interfaces to deliver a range of connected health solutions, from simple medication reminders to complete care management applications for diabetes. I talked to CEO Bill Rogers, who explained that they provide a platform for integrating with AI engines provided by other services to carry out communication with individuals through whatever technology they have available. Thus, Orbita can talk through Echo, send SMS messages, interact with a fitness device or smart scale, or even deliver a reminder over a plain telephone interface.

One client of Orbita uses it platform to run a voice bot that talks to patients during their discharge process. The bot provides post-discharge care instructions and answers patients’ questions about things like pain management and surgery wound care. The results show that patients are more willing to ask questions of the bot than of a discharge nurse, perhaps because they’re not afraid of wasting someone’s time. Rogers also said services are improving their affective interfaces, which respond to the emotional tone of the patient.

Another trick to avoid complex interfaces is to gather as much data as possible from the patient’s behavior (with her consent, of course) to eliminate totally the need for her to manually enter data, or even press a button. Devices are getting closer to this kind of context-awareness. Following are some of the advances I enjoyed seeing at the Connected Health Conference.

  • PulseOn puts more health data collection into a wrist device than I’ve ever seen. Among the usual applications to fitness, they claim to detect atrial fibrillation and sleep apnea by shining a light on the user’s skin and measuring changes in reflections caused by variations in blood flow.
  • A finger-sized device called Gocap, from Common Sensing, measures insulin use and reports it over wireless connections to clinical care-takers. The device is placed over the needle end of an insulin pen, determines how much was injected by measuring the amount of fluid dispensed after a dose, and transmits care activity to clinicians through a companion app on the user’s smartphone. Thus, without having to enter any information by hand, people with diabetes can keep the clinicians up to date on their treatment.
  • One of the cleverest devices I saw was a comprehensive examination tool from Tyto Care. A small kit can carry the elements of a home health care exam, all focused on a cute little sphere that fits easily in the palm. Jeff Cutler, Chief Revenue Officer, showed me a simple check on the heart, ear, and throat that anyone can perform. You can do it with a doctor on the other end of a video connection, or save the data and send it to a doctor for later evaluation.

    Tyto Care has a home version that is currently being used and distributed by partners such as Heath Systems, providers, payers and employers, but will ultimately be available for sale to consumers for $299. They also offer a professional and remote clinic version that’s tailor-made for a school or assisted living facility.

A new Digital Therapeutics Alliance was announced just before the conference, hoping to promote more effective medical devices and allow solutions to scale up through such things as improving standards and regulations. Among other things, the alliance will encourage clinical trials, which I have already highlighted as critical.

Big advances were also announced by Validic, which I covered last year. Formerly a connectivity solution that unraveled the varying quasi-standard or non-standard protocols of different devices in order to take their data into electronic health records, Validic has created a new streaming API that allows much faster data transfers, at a much higher volume. On top of this platform they have built a notification service called Inform, which takes them from a networking solution to a part of the clinicians’ workflow.

Considerable new infrastructure is required to provide such services. For instance, like many medication adherence services, Validic can recognize when time has gone by without a patient reporting that’s he’s taken his pill. This level of monitoring requires storing large amounts of longitudinal data–and in fact, Validic is storing all transactions carried out over its platform. The value of such a large data set for discovering future health care solutions through analytics can make data scientists salivate.

The next segment of this article wraps up coverage of the conference with two more themes.

Measuring the Vital Signs of Health Care Progress at the Connected Health Conference (Part 1 of 3)

Posted on November 13, 2017 I Written By

Andy Oram is an editor at O’Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space.

Andy also writes often for O’Reilly’s Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O’Reilly’s Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Attendees at each Connected Health Conference know by now the architecture of health reform promoted there. The term “connected health” has been associated with a sophisticated amalgam of detailed wellness plans, modern sensors, continuous data collection in the field, patient control over data, frequent alerts and reminders, and analytics to create a learning health care system. The mix remains the same each year, so I go each time to seek out progress toward the collective goal. This year, I’ve been researching what’s happening in these areas:

  • Validation through clinical trials
  • Advanced interfaces to make user interaction easier
  • Improved data sharing (interoperability)
  • Blockchains

Panel at Connected Health Conference

Panel at Connected Health Conference

There were a few other trends of interest, which I’ll mention briefly here. Virtual reality (VR) and augmented reality (AR) turned up at some exhibitor booths and were the topic of a panel. Some of these technologies run on generic digital devices–such as the obsession-inducing Pokémon GO game–while others require special goggles such as the Oculus Rift (the first VR technology to show a promise for widespread adoption, and now acquired by Facebook) or Microsoft’s HoloLens. VR shuts out the user’s surroundings and presents her with a 360-degree fantasy world, whereas AR imposes information or images on the surroundings. Both VR and AR are useful for teaching, such as showing an organ in 3D organ in front of a medical student on a HoloLens, and rotating it or splitting it apart to show details.

I haven’t yet mentioned the popular buzzword “telehealth,” because it’s subsumed under the larger goal of connected health. I do use the term “artificial intelligence,” certainly a phrase that has gotten thrown around too much, and whose meaning is subject of much dissension. Everybody wants to claim the use of artificial intelligence, just as a few years ago everybody talked about “the cloud.” At the conference, a panel of three experts took up the topic and gave three different definitions of the term. Rather than try to identify the exact algorithms used by each product in this article and parse out whether they constitute “real” artificial intelligence, I go ahead and use the term as my interviewees use it.

Exhibition hall at Connected Health Conference

Exhibition hall at Connected Health Conference

Let’s look now at my main research topics.

Validation through clinical trials
Health apps and consumer devices can be marketed like vitamin pills, on vague impressions that they’re virtuous and that doing something is better than doing nothing. But if you want to hook into the movement for wellness–connected health–you need to prove your value to the whole ecosystem of clinicians and caretakers. The consumer market just doesn’t work for serious health care solutions. Expecting an individual to pay for a service or product would limit you to those who can afford it out-of-pocket, and who are concerned enough about wellness to drag out their wallets.

So a successful business model involves broaching the gates of Mordor and persuading insurers or clinicians to recommend your solution. And these institutions won’t budge until you have trials or studies showing that you actually make a difference–and that you won’t hurt anybody.

A few savvy app and device developers build in such studies early in their existence. For instance, last year I covered a typical connected health solution called Twine Health, detailing their successful diabetes and hypertension trials. Twine Health combines the key elements that one finds all over the Connected Health Conference: a care plan, patient tracking, data analysis, and regular check-ins. Their business model is to work with employer-owned health plans, and to expand to clinicians as they gradually migrate to fee-for-value reimbursement.

I sense that awareness is growing among app and device developers that the way to open doors in health care is to test their solutions rigorously and objectively. But I haven’t found many who do so yet.

In the next segment of this article continues my exploration of the key themes I identified at the start of this article.

E-Patient Update:  You Need Our Help

Posted on January 20, 2017 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she’s served as editor in chief of several healthcare B2B sites.

I just read the results of a survey by Black Book Research suggesting that many typical consumers don’t trust, like or understand health IT.

The survey, which reached out to 12,090 adult consumers in September 2016, found that 57% of those interacting with health IT at hospitals or medical practices were skeptical of its benefit. Worse, 87% said they weren’t willing to share all of their information.

Up to 70% of consumers reported that they distrusted patient portals, medical apps and EMRs. Meanwhile, while many respondents said they were interested in using health trackers, 94% said that their physicians weren’t willing or able to synch wearables data with their EMR.

On the surface, these stats are discouraging. At a minimum, they suggest that getting patients and doctors on the same page about health IT continues to be an uphill battle. But there’s a powerful tactic providers can use which – to my knowledge – hasn’t been tried with consumers.

Introducing the consumer health IT champion

As you probably know, many providers have recruited physician or nurse “champions” to help their peers understand and adjust to EMRs. I’m sure this tactic hasn’t worked perfectly for everyone who’s tried it, but it seems to have an impact. And why not? Most people are far more comfortable learning something new from someone who understands their work and shares their concerns.

The thing is, few if any providers are taking the same approach in rolling out consumer health IT. But they certainly could. I’d bet that there’s at least a few patients in every population who like, use and understand consumer health technologies, as well as having at least a sense of why providers are adopting back-end technology like EMRs. And we know how to get Great-Aunt Mildred to consider wearing a FitBit or entering data into a portal.

So why not make us your health IT champions? After all, if you asked me to, say, hold a patient workshop explaining how I use these tools in my life, and why they matter, I’d jump at the chance. E-patients like myself are by our nature evangelists, and we’re happy to share our excitement if you give us a chance. Maybe you’d need to offer some HIT power users a stipend or a gift card, but I doubt it would take much to get one of us to share our interests.

It’s worth the effort

Of course, most people who read this will probably flinch a bit, as taking this on might seem like a big hassle. But consider the following:

  • Finding such people shouldn’t be too tough. For example, I talk about wearables, mobile health options and connected health often with my PCP, and my enthusiasm for them is a little hard to miss. I doubt I’m alone in this respect.
  • All it would take to get started is to get a few of us on board. Yes, providers may have to market such events to patients, offer them coffee and snacks when they attend, and perhaps spend time evaluating the results on the back end. But we’re not talking major investments here.
  • You can’t afford to have patients fear or reject IT categorically. As value-based care becomes the standard, you’ll need their cooperation to meet your goals, and that will almost certainly include access to patient-generated data from mobile apps and wearables. People like me can address their fears and demonstrate the benefits of these technologies without making them defensive.

I hope hospitals and medical practices take advantage of people like me soon. We’re waiting in the wings, and we truly want to see the public support health IT. Let’s work together!

The “Disconnects” That Threaten The Connected World

Posted on January 11, 2017 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she’s served as editor in chief of several healthcare B2B sites.

I’m betting that most readers are intimately familiar with the connected health world. I’m also pretty confident that you’re pretty excited about its potential – after all, who wouldn’t be?  But from what I’ve seen, the health IT world has paid too little attention to problems that could arise in building out a connected health infrastructure. That’s what makes a recent blog post on connected health problems so interesting.

Phil Baumann, an RN and digital strategist at Telerx, writes that while the concept of connecting things is useful, there’s a virtually endless list of “disconnects” that could lead to problems with connected health. Some examples he cites include:

  • The disconnect between IoT hardware and software
  • The disconnect between IoT software and patches (which, he notes, might not even exist)
  • The disconnect between the Internet’s original purpose and the fast-evolving purposes created in the Connected World
  • The disconnects among communication protocols
  • The disconnect between influencers and reality (which he says is “painfully wide”)
  • The disconnects among IoT manufacturers
  • The disconnects among supply chains and vendors

According to Baumann, businesses that use IoT devices and other connected health technologies may be diving in too quickly, without taking enough time to consider the implications of their decisions. He writes:

Idea generation and deployment of IoT are tasks with enormous ethical, moral, economic, security, health and safety responsibilities. But without considering – deeply, diligently – the disconnects, then the Connected World will be nothing of the sort. It will be a nightmare without morning.

In his piece, Baumann stuck to general tech issues rather than pointing a finger at the healthcare industry specifically. But I’d argue that the points he makes are important for health IT leaders to consider.

For example, it’s interesting to think about vulnerable IoT devices posing a mission-critical security threat to healthcare organizations. To date, as Baumann rightly notes, manufacturers have often fallen way behind in issuing software updates and security patches, leaving patient data exposed. Various organizations – such as the FDA – are attempting to address medical device cybersecurity, but these issues won’t be addressed quickly.

Another item on his disconnect list – that connected health deployment goes far beyond the original design of the Internet – also strikes me as particularly worth taking to heart. While past networking innovations (say, Ethernet) have led to rapid change, the changes brought on by the IoT are sprawling and almost unmanageable under current conditions. We’re seeing chaotic rather than incremental or even disruptive change. And given that we’re dealing with patient lives, rather than, for example, sensors tracking packages, this is a potentially dangerous problem.

I’m not at all suggesting that healthcare leaders should pull the plug on connected health innovations. It seems clear that the benefits that derive from such approaches will outweigh the risks, especially over time. But it does seem like a good idea to stop and think about those risks more carefully.

A New Meaning for Connected Health at 2016 Symposium (Part 4 of 4)

Posted on November 8, 2016 I Written By

Andy Oram is an editor at O’Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space.

Andy also writes often for O’Reilly’s Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O’Reilly’s Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this article continued our exploration of the integration of health care into daily life. This section wraps up the article with related insights, including some thoughts about the future.

Memorable moments
I had the chance to meet with Casper de Clercq, who has set up a venture capital plan devoted to health as a General Partner at Norwest Venture Partners. He recommends that manufacturers and clinicians give patients a device that collects data while doing something else they find useful, so that they are motivated to keep wearing it. As an example, he cited the Beddit sleep tracker, which works through sensors embedded (no pun intended) in the user’s bed.

He has found that successful companies pursue gradual, incremental steps toward automated programs. It is important to start with a manual process that works (such as phoning or texting patients from the provider), then move to semi-automation and finally, if feasible, full automation. The product must also be field-tested; one cannot depend on a pilot. This advice matches what Glen Tullman, CEO of Livongo Health, said in his keynote: instead of doing a pilot, try something out in the field and change quickly if it doesn’t work.

Despite his call for gradual change, de Clercq advises that companies show an ROI within one year–otherwise, the field of health care may have evolved and the solution may be irrelevant.

He also recommends a human component in any health program. The chief barrier to success is getting the individual to go along with both the initial activation and continuing motivation. Gamification, behavioral economics, and social connections can all enhance this participation.

A dazzling keynote on videogames for health was delivered by Adam Gazzaley, who runs Neuroscience labs at the University of California at San Francisco. He pointed out that conventional treatments get feedback on patient reactions far too slowly–sometimes months after the reaction has occurred. In the field of mental health, His goal is to supplement (not replace) medications with videogames, and to provide instant feedback to game players and their treatment staff alike. Videogames not only provide a closed-loop system (meaning that feedback is instantaneous), but also engage patients by being fun and offering real-time rewards. Attention spans, anxiety, and memory are among the issues he expects games to improve. Education and wellness are also on his game plan. This is certainly one talk where I did not multitask (which is correlated with reduced performance)!

A future, hopefully bigger symposium
The Connected Health symposium has always been a production of the Boston Partners Health Care conglomerate, a part of their Connected Health division. The leader of the division, Dr. Joseph Kvedar, introduced the symposium by expressing satisfaction that so many companies and organizations are taking various steps to make connected health a reality, then labeled three areas where leadership is still required:

  • Reassuring patients that the technologies and practices work for them. Most people will be willing to adopt these practices when urged by their doctors. But their privacy must be protected. This requires low-cost solutions to the well-known security problems in EHRs and devices–the latter being part of the Internet of Things, whose vulnerability was exposed by the recent attack on Dyn and other major Internet sites.

  • Relieving the pressures on clinicians. Kvedar reported that 45 percent of providers would like to adopt connected health practices, but only 12 percent do so. One of the major concerns holding them back is the possibility of data overload, along with liability for some indicator of ill health that they miss in the flood of updates. Partners Connected Health will soon launch a provider adoption initiative that deals with their concerns.

  • Scaling. Pilot projects in connected health invest a lot of researcher time and offers a lot of incentives to develop engagement among their subjects. Because engagement is the whole goal of connected health, the pilot may succeed but prove hard to turn into a widespread practice. Another barrier to scaling is consumers’ lack of tolerance for the smallest glitches or barriers to adoption. Providers, also, insist that new practices fit their established workflows.

Dr. Kvedar announced at this symposium that they would be doing future symposia in conjunction with the Personal Connected Health Alliance (Formerly the mHealth Summit owned by HIMSS), a collaboration that makes sense. Large as Partners Health Care is, the symposium reaches much farther into the health care industry. The collaboration should bring more resources and more attendees, establishing the ideals of connected health as a national and even international movement.

A New Meaning for Connected Health at 2016 Symposium (Part 3 of 4)

Posted on November 7, 2016 I Written By

Andy Oram is an editor at O’Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space.

Andy also writes often for O’Reilly’s Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O’Reilly’s Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this article paused during a discussion of the accuracy and uses of devices. At a panel on patient generated data, a speaker said that one factor holding back the use of patient data was the lack of sophistication in EHRs. They must be enhanced to preserve the provenance of data: whether it came from a device or from a manual record by the patient, and whether the device was consumer-grade or a well-tested medical device. Doctors invest different levels of trust in different methods of collecting data: devices can provide more objective information than other ways of asking patients for data. A participant in the panel also pointed out that devices are more reliable in the lab than under real-world conditions. Consumers must be educated about the proper use of devices, such as whether to sit down and how to hold their arms when taking their blood pressure.

Costantini decried the continuing silos in both data sharing and health care delivery. She said only half of doctors share patient data with other doctors or caretakers. She also praised the recent collaboration between Philips and Qualcomm to make it easier for device data to get into medical records. Other organizations that have been addressing that issue for some time include Open mHealth, which I reviewed in an earlier article, and Validic.

Oozing into workflow
The biggest complaint I hear from clinicians about EHRs–aside from the time wasted in their use, which may be a symptom of the bigger problem-is that the EHRs disrupt workflow. Just as connected health must integrate with patient lives as seamlessly as possible, it should recognize how teams work and provide them with reasonable workflows. This includes not only entering existing workflows as naturally as capillary action, but helping providers adopt better ones.

The Veterans Administration is forging into this area with a new interface called the Enterprise Health Management Platform (eHMP). I mentioned it in a recent article on the future of the VA’s EHR. A data integration and display tool, eHMP is agnostic as to data source. It can be used to extend the VistA EHR (or potentially replace it) with other offerings. Although eHMP currently displays a modern dashboard format, as described in a video demo by Shane Mcnamee, the tool aims to be much more than that. It incorporates Business Process Modeling Notation (BPMN) and the WS-Human Task Specification to provide workflow support. The Activity Management Service in eHMP puts Clinical Best Practices directly into the workflow of health care providers.

Clinicians can use eHMP to determine where a consultation request goes; currently, the system is based on Red Hat’s BPMN engine. If one physician asks another to examine the patient, that task turns up on the receiving physician’s dashboard. Teams as well as individuals can be alerted to a patient need, and alerts can be marked as routine or urgent. The alerts can also be associated with time-outs, so that their importance is elevated if no one acts on them in the chosen amount of time.

eHMP is just in the beginning stages of workflow support. Developers are figuring out how to increase the sophistication of alerts, so that they offer a higher signal-to-noise ratio than most hospital CDS systems, and add intelligence to choose the best person to whom an alert should be directed. These improvements will hopefully free up time in the doctor’s session to discuss care in depth–what both patients and providers have long said they most want from the health care field.

At the Connected Health symposium, I found companies working on workflow as well. Dataiku (whose name is derived from “haiku”) has been offering data integration and analytics in several industries for the past three years. Workflows, including conditional branches and loops, can be defined through a graphical interface. Thus, a record may trigger a conditional inquiry: does a lab value exceed normal limits? if not, it is merely recorded, but if so, someone can be alerted to follow up.

Dataiku illustrates an all-in-one, comprehensive approach to analytics that remains open to extensions and integration with other systems. On the one hand, it covers the steps of receiving and processing data pretty well.

To clean incoming data (the biggest task on most data projects), their DSS system can use filters and even cluster data to find patterns. For instance, if 100 items list “Ohio” for their location, and one lists “Oiho”, the system can determine that the outlier is a probably misspelling. The system can also assign data to belonging to broad categories (string or integer) as well as more narrowly defined categories (such as social security number or ZIP code).

For analysis, Dataiku offers generic algorithms that are in wide use, such as linear regressions, and a variety of advanced machine learning (artificial intelligence) algorithms in the visual backend of the program–so the users don’t need to write a single line of code. Advanced users can also add their own algorithms coded in a variety of popular languages such as Python, R, and SQL. The software platform offers options for less technically knowledgeable users, pre-packaged solutions for various industries such as health care, security features such as audits, and artificial intelligence to propose an algorithm that works on the particular input data.

Orbita Health handles workflows between patients and providers to help with such issues as pain management and medication adherence. The company addresses ease of use by supporting voice-activated devices such as Amazon Echo, as well as some 250 other devices. Thus, a patient can send a message to a provider through a single statement to a voice-activated device or over another Internet-connected device. For workflow management, the provider can load a care plan into the system, and use Orbita’s orchestration engine (similar to the Business Process Modeling Notation mentioned earlier) to set up activities, such as sending a response to a patient’s device or comparing a measurement to the patient’s other measurements over time. Orbita’s system supports conditional actions, nests, and trees.

CitiusTech, founded in 2005, integrates data from patient devices and apps into provider’s data, allowing enterprise tools and data to be used in designing communications and behavioral management in the patient’s everyday life. The company’s Integrated Analytix platform offer more than 100,000 apps and devices from third-party developers. Industry studies have shown effective use of devices, with one study showing a 40% reduction in emergency room admissions among congestive heart failure patients through the use of scales, engaging the patients in following health protocols at home.

In a panel on behavior change and the psychology of motivation, participants pointed out that long-range change requires multiple, complex incentives. At the start, the patient may be motivated by a zeal to regain lost functioning, or even by extrinsic rewards such as lower insurance premiums. But eventually the patient needs to enfold the exercise program or other practice into his life as a natural activity. Rewards can include things like having a beer at the end of a run, or sharing daily activities with friends on social media.

In his keynote on behavioral medicine, the Co-founder & CEO of Omada Health, Sean Duffy, put up a stunningly complex chart showing the incentives, social connections, and other factors that go into the public’s adoption of health practices. At a panel called “Preserving the Human Touch in the Expanding World of Digital Therapies”, a speaker also gave the plausible advice that we tell patients what we can give back to them when collecting data.

The next section of this article offers some memorable statements at the conference, and a look toward the symposium’s future.

A New Meaning for Connected Health at 2016 Symposium (Part 2 of 4)

Posted on November 4, 2016 I Written By

Andy Oram is an editor at O’Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space.

Andy also writes often for O’Reilly’s Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O’Reilly’s Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this article talked about making health a routine part of everyday life, particularly where consumer devices are concerned. We’ll continue in this section with other considerations aired at the symposium.

Tullman’s principles of simplicity, cited in the previous section, can be applied to a wide range of health IT. For instance, AdhereTech pill bottles can notify the patient with a phone call or text message if she misses a dose. Another example of a technology that is easily integrated into everyday life is a thermometer built into a vaginal ring that a woman can insert and use without special activation. This device was mentioned by Costantini during her keynote. The device can alert a woman–and, if she wants, her partner–to when she is most fertile.

Super-compact devices and fancy interfaces are not always necessary for a useful intervention. In a keynote, John Dwyer, Jr., President of the Global Alzheimer’s Platform Foundation, discussed a simple survey that his organization got large numbers of people to take. They uncovered a lot of undiagnosed cases of mental decline. I imagine that the people who chose to take the survey were experiencing possible symptoms and therefore were concerned about their mental abilities. Yet they apparently had not expressed concerns to their doctors; instead they responded to the online suggestion to take a survey.

Most of us spend a large chunk of our day at work, so wellness programs there are theoretically promising. A panel on workplace-connected health solutions talked about some of the barriers:

  • Inadequate communications. Employees need to be informed regularly that a program is available, and its benefits

  • Privacy guarantees. Employees must feel assured of a firewall between their employer and the organization handling their sensitive data.

  • Clear goals. A wellness program is not just a check-off box. Employers must know what they want to achieve and design programs around these goals.

I would add that employers should examine their own environment honestly before setting up a wellness program. It’s pretty hypocritical to offer a wellness program on the one hand while subjecting employees to stress, overwork, and bad ergonomics on the other.

Telehealth is also likely to grow, and in fact, 200 bills to improve regulation of telehealth are pending in Congress. A speaker at a panel on preserving the human touch said that the Centers for Medicare & Medicaid Services are held back by uncertainty about how to measure telehealth’s value. Another speaker pointed out that we have a severe shortage of mental health professionals, and that many areas lack access to them. Telehealth may improve access.

It all comes down to the environment
Health care has to fully acknowledge the role of environmental factors in creating sickness. These include the marketing of fatty and sugary foods, the trapping of poor and minority people in areas with air and water pollution, the barriers to getting health care (sick leave, geography, insurance gaps, ignorance of gender issues, and so forth), the government subsidization of gambling, and much more. Similar issues came up during a keynote by David Torchiana, President & CEO and Partners HealthCare.

In her keynote, Jo Ann Jenkins, the CEO of AARP, quoted Atul Gawande as saying that we have medicalized aging and are failing to support the elderly. We have to see them as functioning individuals and help to support their health instead of focusing on when things go wrong. This includes focusing on prevention and ensuring that they have access to professional health care while they are still well. It also means restructuring our living spaces and lifestyles so the elderly can remain safely in their homes, get regular exercise, and eat well.

These problems call for a massive legislative and regulatory effort. But as a participant said on the panel of disruptive women in health care, plenty of money goes into promoting the interests of large hospitals, insurers, and device manufacturers, but nobody knows how to actually lobby for health care. Look at the barriers reached by Michelle Obama’s Let’s Move campaign, which fell short of ambitious goals in improving American’s nutrition.

Grounding devices on a firm foundation
A repeated theme at this symposium was making data collection by patients easier–so easy in fact that they can just launch data collection and not think about it. To be sure, some people are comfortable with health technology: according to Costantini, 60 percent of US smartphone users manage their health in some way through those devices. Nevertheless, if people have to consciously choose when to send data–even a click of a button–many will drop out of the program.

At a break-out session during the 2015 Health Datapalooza, I heard prospective device makers express anxiety over the gargantuan task of getting their products accepted by the industry. The gold standard for health care adoption, of course, is FDA approval based on rigorous clinical trials. One participant in the Datapalooza workshop assured the others that he had gotten his device through the FDA process, and that they could to.

Attitudes seem to have shifted over the past year, and many more manufacturers are treating FDA approval as a natural step in their development process, keeping their eyes on the prize of clinical adoption. Keith Carlton, CEO of HUINNO, in a panel on wearables, said that accuracy is critical to stand out in the marketplace and to counter the confusion caused by manufacturers that substitute hype for good performance.

Clinical trials for devices don’t have to be the billion-dollar, drawn-out ordeals suffered by pharma companies. Devices are rarely responsible for side effects (except for implantables) and therefore can be approved after a few months of testing.

A representative of BewellConnect told me that their road to approval took 9-12 months, and involved comparing the results of their devices to those of robust medical devices that had been previously approved. Typical BewellConnect devices include blood pressure cuffs and an infrared thermometer that quickly shows the patient’s temperature after being held near his temple. This thermometer has been used around the world in situations where it’s important to avoid contact with patients, such as in Ebola-plagued regions.

What’s new over the past three years is Bluetooth-enabled devices that can transmit their results over the network. BewellConnect includes this networking capability in 17 current devices. The company tries to provide a supremely easy path for the patient to transmit the device over a phone app to the cloud. The patient can register multiple family members on the app, and is prompted twice to indicate who was using the device so as to prevent errors. BewellConnect is working on an alert system for providers, a simple use case for data collection.

Many products from BewellConnect are in widespread use in France, where the company is based, and they have launched a major entry into the US market. I asked BewellConnect’s CEO, Olivier Hua, whether the US market presents greater problems than France. He said that the two markets are more similar than we think.

Health care in the US has historically been fragmented, whereas in France it was unified under government control. But the Affordable Care Act in the US has brought more regulation to the market here, whereas private health care providers (combining insurance and treatment) have been growing in France. As of January 1 of this year, France has required all employers to include a private option in their health care offerings. For the first time, French individuals are being hit with the copays and deductibles familiar to Americans, and are weighing how often to go to the doctor. Although the US market is still more diverse, and burdened by continuing fee-for-service plans, it is comparable to the French market for a vendor such as BewellConnect.

The next section of this article will continue with a discussion of barriers in the use of patient data, and other insights from the Connected Health symposium.

A New Meaning for Connected Health at 2016 Symposium (Part 1 of 4)

Posted on November 3, 2016 I Written By

Andy Oram is an editor at O’Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space.

Andy also writes often for O’Reilly’s Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O’Reilly’s Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Those of us engaged in health care think constantly about health. But at the Connected Health symposium, one is reminded that the vast majority of people don’t think much about health at all. They’re thinking about child care, about jobs, about bills, about leisure time. Health comes into the picture only through its impacts on those things.

Certainly, some people who have suffered catastrophic traumas–severe accidents, cancer, or the plethora of unfortunate genetic conditions–become obsessed about health to the same extent as health professionals. These people become e-patients and do all the things they need to do regain the precious state of being they enjoyed before their illness, often clashing with the traditional medical establishment in pursuit of health.

But for most people with chronic conditions, the opposite holds true. A whimsical posting points out that we willingly pay more to go to a masseur or hairdresser than to a doctor. I appreciate this observation more than the remedies offered by the author, which fall into the usual “patient engagment” activities that I have denigrated in an earlier article.

Understanding health as a facet and determinant of everyday life becomes even more important as we try to reverse the rise of costs, which in many nations are threatening economic progress and even the social contract. (Witness the popular anger in the current US election over rising insurance premiums and restrictions on choice.) We have to provide health solutions to people who are currently asymptomatic. The conventional focus on diagnosed conditions won’t serve us.

It’s thus commendable that the Connected Health symposium for 2016 has evolved to the point where participants can think not only of reaching out to patients, but to embedding their interventions so deeply into patient life that the patient no longer has to think about her health to benefit. This gives a new meaning to the word “connected”. Whereas, up to now, it referred to connecting a patient more closely with their clinicians and care-takers (through data collection, messaging, and online consultations), “connected” can also mean connecting our healthful interventions to the patient’s quotidian concerns about work, family, and leisure.

We can do this by such means as choosing data collection that the patient can enable and then stop thinking about, and integrating care with the social media they use regularly. In her keynote, Nancy Brown, CEO of the American Heart Association, pointed out that social connections are critical to health and are increasingly taking place online, instead of someone dropping by her neighbor for coffee. The AHA’s Go Red For Women program successfully exploited social connections to improve heart health.

If you want an overview of what people mean by the term “connected health,” you would do well to get The Internet of Healthy Things, by Dr. Joseph Kvedar, leader of Partners Connected Health and chief organizer of this symposium. For a shorter overview, you can read my review of the book, and my report from an earlier symposium. Now in its 13th year, the annual symposium signed up 1200 registered attendees–the biggest number yet. This article looks over the people and companies I heard from there.

Exhausting the possibilities of passive data collection
Glen Tullman, CEO of Livongo Health, offered basic principles for consumer health in a keynote: it must be personal, simple, context-aware, and actionable. As an example, he cited Livongo’s own program for sending text messages to diabetes patients: they are tailored to the individual and offer actionable advice such as, “Drink a glass of water”.

A panel on consumer technology extolled the value of what analysts like to call data exhaust: the use of data that can be collected from people’s everyday behavior. After all, this exhaust is what marketers used all the time to figure out what we want to buy, and what governments use to decide whether we’re dangerous actors. It can have value in health too.

As pointed out by Jim Harper, Co-Founder and COO of Sonde Health, providers and researchers can learn a lot from everyday interactions with devices–diagnosing activity levels from accelerometers, for instance, or depression from a drop in calls or text messages. Similarly, a symposium attendee suggested to me that colleges could examine social connections among students to determine which ones are at risk of abusing alcohol.

Lauren Costantini, President and CEO of Prima-Temp, said in a keynote that we can predict all kinds of things from your circadian rhythm–as measured by a sensor–such as an oncoming infection, or the best way to deliver chemotherapy.

Spire offers a device that claims to help people suffering from anxiety, with a low barrier to adoption and instant feedback. It’s a device worn on the body that can alert the user in various ways (buzzes, text messages) when the user’s anxiety level is rising.

Does the Spire device work? They got a partial answer to this in a study by Partners Health Care, where people had an option of using the device on its own or in conjunction with a headband from Muse that helps train people to meditate. (There was no control group.) Unlike the Spire device, which one can put on and forget about, the Muse purchaser is expected to make a conscious decision to meditate using the device regularly.

The Partners study showed modest benefits to these devices, but had mixed results. For instance, fewer than half the subjects continued use of the devices after the study finished. Those who did continue showed a strong positive effect on stress, and those who discontinued use showed a very small positive effect. Strangely there was a small overall increase in tension for all participants, even though they also demonstrated increases in “calm” periods. There is no correlation between the length of time that individuals used their devices and their outcomes.

Jonathan Palley, CEO & Co-founder of Spire, said participants often liked their devices, but stopped using them because they have learned from the devices how to identify stress and felt they could self-regulate and no longer needed the devices. I believe this finding may apply to other consumer devices as well. The huge rate at which devices are abandoned after six months, the subject of frequent reports and agonized commentaries, may simply indicate that users have reached their goal and can continue their fitness programs on their own. Graeme Moffat, VP of Scientific & Regulatory Affairs at Muse, reported that many purchasers use their headband for only three months, but come back to it over time to refresh their training.

We’ll look at some more aspects of integrating devices into patient lives in the next section of this article.

Steps In Integrating Patient-Generated Health Data

Posted on May 24, 2016 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she’s served as editor in chief of several healthcare B2B sites.

As the number of connected health devices in use has expanded, healthcare leaders have grappled with how to best leverage the data they generate. However, aside from a few largely experimental attempts, few providers are making active use of such data.

Part of the reason is that the connected health market is still maturing. With health tracking wearables, remote monitoring set-ups, mobile apps and more joining the chorus, it might be too soon to try and normalize all this data, much less harvest it for clinical use. Also, few healthcare organizations seem to have a mature strategy in place for digital health.

But technical issues may be the least of our problems. It’s important to note that providers have serious concerns around patient-generated health data (PGHD), ranging from questions about its validity to fears that such data will overwhelm them.

However, it’s possible to calm these fears, argues Christina Caraballo, senior healthcare strategist at Get Real Health.  Here’s her list of the top five concerns she’s heard from providers, with responses that may help put providers at ease:

  • Fear they’ll miss something in the flood of data. Add disclaimers, consent forms, video clips or easy-to-digest graphics clarifying what consumers can and can’t expect, explicitly limiting provider liability.
  • Worries over data privacy and security: Give consumers back some of the risk, by emphasizing that no medium is perfectly secure, including paper health records, and that they must determine whether the benefits of using digital health devices outweigh the risks.
  • Questions about data integrity and standardization: Emphasize that while the industry has made great process and standardization, interoperability, authentication, data provenance, reliability, validity, clinical value and even workflow, the bottom line is that the data still comes from patients, who don’t always report everything regardless of how you collect the data.
  • Concerns about impact on workflow: Underscore that if the data is presented in the right framework, it will be digestible in much the same way as other electronic medical data.
  • Resistance to pressure from consumers: Don’t demand that providers leverage PGHD out of the gate; instead, move incrementally into the PGHD management by letting patients collect data electronically, and then incorporate data into clinical systems once all stakeholders are on board.

Now, I’m not totally uncritical of Ms. Caraballo’s article. In particular, I take issue with her assertion that providers who balk at using PGHD are “naysayers” who “simply don’t want to change.” While there are always a few folks fitting this description in any profession, the concerns she outlines aren’t trivial, and brushing them off with vague reassurances won’t work.

Truthfully, if I were a provider I doubt I would be comfortable relying on PGHD, especially biometric data. As Ingrid Oakley-Girvan of Medable notes, wearables giant Fitbit was hit with a lawsuit earlier this year alleging that its heart rate monitoring technology is inaccurate, and I wouldn’t be surprised other such suits arise. Digital health trackers and apps have transitioned from novelty to quasi-official medical device very quickly — some might say too quickly – and being cautious about their output just makes sense.

Nonetheless, PGHD will play a role in patient care and management at some point in the future, and it makes sense to keep providers in the loop as these technologies progress. But rushing them into using such data would not be wise. Let’s make sure such technologies are vetted before they assume a routine role in care.