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Software Marks Advances at the Connected Health Conference (Part 2 of 2)

Posted on October 31, 2018 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 part of this article focused on FDA precertification of apps and the state of interoperability. This part covers other interesting topics at the Connected Health conference.

Presentation at Connected Health Conference

Presentation at Connected Health Conference

Patient engagement

A wonderful view upon the value of collecting patient data was provided by Steve Van, a patient champion who has used intensive examination of vital signs and behavioral data to improve his diabetic condition. He said that the doctor understands the data and the patient knows how he feels, but without laying the data out, they tend to talk past each other. Explicit data on vital signs and behavior moves them from monologue to dialogue. George Savage, MD, co-founder and CMO of Proteus, described the value of data as “closing the loop”–in other words, providing immediate and accurate information back to the patient about the effects of his behavior.

I also gained an interesting perspective from Gregory Makoul, founder and CEO of PatientWisdom, a company that collects a different kind of data from patients over mobile devices. The goal of PatientWisdom is to focus questions and make sure they have an impact: the questionnaire asks patients to share “stories” about themselves, their health, and their care (e.g., goals and feelings) before a doctor visit. A one-screen summary is then provided to clinical staff via the EHR. The key to high adoption is that they don’t “drill” the patient over things such as medications taken, allergies, etc. They focus instead on distilling open-ended responses about what matters to patients as people, which patients like and providers also value.

Sam Margolis, VP of client strategy and growth at Cantina, saw several aspects of the user experience (UX) as the main hurdle for health IT companies. This focus was reasonable, given that Cantina combines strengths in design and development. Margolis said that companies find it hard to make their interfaces simple and to integrate into the environments where their products operate. He pointed out that health care involves complex environments with many considerations. He also said they should be thinking holistically and design a service, not just a product–a theme I have seen across modern business in general, where companies are striving to engage customers over long periods of time, not just sell isolated objects.

Phil Marshall, MD, co-founder and chief product officer of Conversa Health, described how they offer a chatbot to patients discharged from one partnering hospital, in pursuit of the universal goal by US hospitals to avoid penalties from Medicare for readmissions. The app asks the patient for information about her condition and applies the same standards the hospital uses when its staff evaluates discharged patients. Marshall said that the standards make the chatbot highly accurate, and is tuned regularly. It is also popular: 80 percent of the patients offered the app use it, and 97 percent of these say it is helpful. The chat is tailored to each patient. In addition to relieving the staff of a routine task, the hospital found that the app reduces variation among outcomes among physicians, because the chatbot will ask for information they might forget.

Jay V. Patel, Clinical Transformation Officer at Seniorlink, described a care management program that balances technology and the human touch to help caregivers of people with dementia. Called VOICE (Vital Outcomes Inspired by Caregiver Engagement) Dementia Care, the program connects a coach to family caregivers and their care teams through Vela, Seniorlink’s collaboration platform. The VOICE DC program reduced ER visits by 51 percent and hospitalizations by 18 percent in the six-month pilot. It was also good for caregivers, reducing their stress and increasing their confidence.

Despite the name, VOICE DC is text-based (with video content) rather than voice-based. An example of the advances in voice interfaces was provided at this conference by Boston Children’s Hospital. Elizabeth Kidder, manager of their digital health accelerator, reported using voice interfaces to let patients ask common questions, such as when to get vaccinations and whether an illness was bad enough to keep children home from school and day care. Another non-voice app they use is a game that identifies early whether a child has a risk of dyslexia. Starting treatment before the children are old enough to learn reading in school can greatly increase success.

Nathan Treloar, president of Orbita, reported that at a recent conference on voice interfaces, participants in a hackathon found nine use cases for them in health.

Pattie Maes of the MIT Media Lab–one of the most celebrated research institutions in digital innovation–envisions using devices to strengthen the very skills that our devices are now blamed for weakening, such as how to concentrate. Of course, she warned, there is a danger that users will become dependent on the device while using it for such skills.

Working at the top of one’s license

I heard that appealing phrase from Christine Goscila, a family nurse practitioner at Massachusetts General Hospital Revere. She was describing how an app makes it easier for nurses to collect data from remote patients and spend more time on patient care. This shift from routine tasks to high-level interactions is a major part of the promise of connected health.

I heard a similar goal from Gregory Pelton, MD, CMO of ICmed, one of the many companies providing an integrated messaging platform for patients, clinicians, and family caregivers. Pelton talks of handling problems at the lowest possible level. In particular, the doctor is relieved of entering data because other team members can do it. Furthermore, messages can prepare the patient for a visit, rendering him more informed and better able to make decisions.

Clinical trials get smarter

While most health IT and connected health practitioners focus on the doctor/patient interaction and health in the community, the biggest contribution connected health might make to cost-cutting may come from its use by pharmaceutical companies. As we watch the astounding rise in drug costs–caused by a range of factors I will cover in a later article, but only partly by deliberate overcharging–we could benefit from anything that makes research and clinical trials more efficient.

MITRE, a non-profit that began in the defense industry but recently has created a lot of open source tools and standards for health care, presented their Synthea platform, offering synthetic data for researchers. The idea behind synthetic data is that, when you handle a large data set, you don’t need to know that a particular patient has congestive heart failure, is in his sixties, and weighs 225 pounds. Even if the data is deidentified, giving information about each patient raises risks of reidentification. All you need to know is a collection of facts about diagnoses, age, weights, etc. that match a typical real patient population. If generated using rigorous statistical algorithms, fake data in large quantities can be perfectly usable for research purposes. Synthea includes data on health care costs as well as patients, and is used for FHIR connectathons, education, the free SMART Health IT Sandbox, and many other purposes.

Telemedicine

Payers are gradually adapting their reimbursements to telemedicine. The simplest change is just to pay for a video call as they would pay for an office visit, but this does not exploit the potential for connected health to create long-range, continuous interactions between doctor, patient, and other staff. But many current telemedicine services work outside the insurance system, simply charging patients for visits. This up-front payment obviously limits the ability of these services to reach most of the population.

The uncertainties, as well as the potential, of this evolving market are illustrated by the business model chosen by American Telephysicians, which goes so far as to recruit patients internationally, such as from Pakistan and Dubai, to create a telemedicine market for U.S. specialists. They will be starting services in some American communities soon, though. Taking advantage of the ubiquity of mobil devices, they extend virtual visits with online patient records and a marketplace for pharmaceuticals, labs, and radiology. Waqas Ahmed, MD, founder and CEO, says: “ATP is addressing global health care problems that include inaccessibility of primary, specialty, and high-quality healthcare services, lack of price transparency, substandard patient education, escalating costs and affordability, a lack of healthcare integration, and fragmentation along the continuum of care.”

The network is the treatment center

We were honored with a keynote from FCC chair Ajit Pai, who achieved notoriety recently in the contentious “net neutrality” debate and was highlighted in WIRED for his position. Pai is not the most famous FCC chair, however; that honor goes to Newton Minow, who as chair from 1961 to 1963 called television a “vast wasteland.” More recently, Michael Powell (who became chair in 2001, before the confounding term “net neutrality” was invented) garnered a lot of attention for changing Internet regulations. Newton Minow, by the way, is still on the scene. I heard him talk recently at a different conference, and Pai mentioned talking to Minow about Internet access.

Pai has made expansion of Internet access his key issue (it was mentioned in the WIRED article) and talked about the medical benefits of bringing fast, continuous access to rural areas. His talk fit well with the focus many companies at the Connected Health conference placed on telemedicine. But Pai did not vaunt competition or innovation as a solution to reaching rural areas. Instead, he seemed happy with the current oligopoly that characterizes Internet access in most areas, and promoted an increase in funding to get them to do more of what they’re now doing (slowly).

The next day, Nancy Green of Verizon offered a related suggestion that 5G wireless will make batteries in devices last longer. This is not intuitive, but I think can be justified by the decrease in the time it will take for devices to communicate with the cloud, decreasing in turn the drain on the batteries.

Devices that were just cool

One device I liked at Connected Health coll was the Eko stethoscope, which sends EKG data to a computer for display. Patients will soon be able to use Eko devices to view their own EKGs, along with interpretations that help non-specialists make sense of the results. Of course, the results are also sent to the patients’ doctors.

Another device is a smart pillbox by CUEMED that doubles as a voice-interactive health assistant, HEXIS. Many companies make smart pill boxes that keep track of whether you open them, and flash or speak up to remind you when it’s time to take the pills. (Non-compliance with prescription medications is rampant.) HEXIS is a more advanced innovation that incorporates Alexa-like voice interactivity with the user and can connect to other medical devices and wearables such as Apple Watch and blood pressure monitors. The device uses the data and vital signs to motivate the user, and provides suggestions for the user to feel better. Another nice feature is that if you’re going out, you can remove one day’s meds and take them with you, while the device continues to do its job of reminding and tracking.

I couldn’t get to every valuable session at the Connected Health conference, or cover every speaker I heard. However, the conference seems to be achieving its goals of bringing together innovators and of prodding the health care industry toward the effective use of technology.

Software Marks Advances at the Connected Health Conference (Part 1 of 2)

Posted on October 29, 2018 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 precepts of connected health were laid out years ago, and merely get updated with nuances and technological advances at each year’s Connected Health conference. The ideal of connected health combines matching the insights of analytics with the real-life concerns of patients; monitoring people in everyday settings through devices that communicate back to clinicians and other caregivers; and using automation to free up doctors to better carry out human contact. Pilots and deployments are being carried out successfully in scattered places, while in others connected health languishes while waiting for the slow adoption of value-based payments.

Because I have written at length about the Connected Health conference in 2015, 2016, and 2017, I will focus this article on recent trends I ran into at this year’s conference. Key themes include precertification at the FDA, the state of interoperability (which is poor), and patient engagement.

Exhibition floor at Connected Health conference

Exhibition floor at Connected Health conference

Precertification: the status of streamlining approval for medical software

One of the ongoing challenges in the progress of patient involvement and connected health is the approval of software for diagnosis and treatment. Traditionally, the FDA regulated software and hardware together in all devices used in medicine, requiring rigorous demonstrations of safety and efficacy in a manner similar to drugs. This was reasonable until recently, because anything that the doctor gives to the patient needs to be carefully checked. Otherwise, insurers can waste a lot of money on treatments that don’t work, and patients can even be harmed.

But more and more software is offered on generic computers or mobile devices, not specialized medical equipment. And the techniques used to develop the software inherit the “move fast and break things” mentality notoriously popular in Silicon Valley. (The phrase was supposedly a Facebook company motto.) Software can be updated several times a day. Although A/B testing (an interesting parallel to randomized controlled trials) might be employed to see what is popular with users, quality control is done in completely different ways. Modern software tends to rely for safety and quality on unit tests (which make sure individual features work as expected), regression tests (which look for things that no longer work they way they should), continuous integration (which forces testing to run each time a change is submitted to the central repository), and a battery of other techniques that bear such names as static testing, dynamic testing, and fuzz testing. Security testing is yet another source of reliability, using techniques such as penetration testing that may be automated or manual. (Medical devices, which are notoriously insecure, might benefit from an updated development model.

The FDA has realized that reliable software can be developed within the Silicon Valley model, so long as rigor and integrity are respected. Thus, it has started a Pre-Cert Pilot Program that works with nine brave vendors to find guidelines the FDA can apply in the future to other software developers.

Representatives of four vendors reported at the Connected Health conference that the pilot is going quite well, with none of the contentious and adversarial atmosphere that characterizes the interactions between the FDA with most device manufacturers. Every step of the software process is available for discussion and checking, and the inquiries go quite deep. All participants are acutely aware of the risk–cited by critics of the program–that it will end up giving vendors too much leeway and leaving the public open to risks. The participants are committed to closing loopholes and making sure everyone can trust the resulting guidelines.

The critical importance of open source software became clear in the report of the single open source vendor who is participating in the pilot: Tidepool. Because it is open source, according to CEO Howard Look, Tidepool was willing to show its code as well as its software development practices to independent experts using multiple evaluation assessment methods, including a “peer appraisal” by fellow precert participants Verily and Pear Therapeutics. One other test appraisal (CMMI, using external auditors) was done by both Tidepool and Johnson & Johnson; no other participants did a test appraisal. Thus, if the FDA comes out with new guidelines that stimulate a tremendous development of new software for medical use, we can thank open source.

Making devices first-class players in health care

Several exhibitors at the conference were consulting firms who provide specific services to start-ups and other vendors trying to bring products to market. I asked a couple of these consultants what they saw as the major problems their clients face. Marcus Fontaine, president of Impresiv Health, said their biggest problem is the availability of data, particularly because of a lack of interoperable data exchange. I wanted to exclaim, “Still?”

Joseph Kvedar, MD, who chairs the Connected Health conference, spoke of a new mobile app developed by his organization, Partners Connected Health, to bring device data into their EHR. This greatly improves the collection of data and guarantees accuracy, because patients no longer have to manually enter vital signs or other information. In addition to serving Partners in improving patient care, the data can be used for research and public health. In developing this app, Partners depended heavily for interoperable data exchange on work by Validic, the most prominent company in the device interoperability space, and one that I have profiled and whose evolution I have followed.

Ideally, each device could communicate directly with the EHR. Why would Partners Connected Health invest heavily in creating a special app as an intermediary? Kvedar cited several reasons. First, each device currently offers its own app as a user interface, and users with multiple devices get confused and annoyed by the proliferation of apps. Second, many devices are not designed to communicate cleanly with EHRs. Finally, the way networks are set up, communicating would require a separate cellular connection and SIM card for each device, raising costs.

A similar effort is pursued by Indie Health, trying to solve the problem of data access by making it easy to create Bluetooth connections between devices and mobile phones using a variety of Bluetooth, IEEE, Continua, and other standards.

The CEO of Validic, Drew Schiller, spoke on another panel about maximizing the value of patient-generated data. He pointed out that Validic, as an intermediary for a huge number of devices and health care providers, possesses a correspondingly huge data set on how patients are using the devices, and in particular when they stop using the devices. I assume that Validic does not preserve the data generated by the devices, such as blood pressure or steps taken–at least, Schiller did not say they have that data, and it would be intrusive to collect it. However, the metadata they do collect can be very useful in designing interactions with patients. He also talked about the value of what he dubs “invisible health care,” where behavior change and other constructive uses of data can flow easily from the data.

Barry Reinhold, president and CTO of Lamprey Networks, was manning the Continua booth when I came by. Continua defines standard for devices used in the home, in nursing faciliies, and in other places outside the hospital. This effort should be open source, supported by fees by all affected stakeholders (hospitals, device manufacturers, etc.). But open source is spurned by the health care field, so Continua does the work as a private company. Reinhold told me that device manufacturers rarely contract with Continua, which I treat as a sign that device manufacturers value data silos as a business model. Instead, Continua contracts come from the institutions that desperately need access to the data, such as nursing facilities. Continua does the best it can to exploit existing standards, including the “continuing data” profile from FHIR.

Other speakers at the conference, including Andrew Hayek, CEO of OptumHealth, confirmed Reinhold’s observation that interoperability still lags among devices and EHRs. And Schiller of Validic admitted that in order to get data from some devices into a health system, the patient has to take a photo of the device’s screen. Validic not only developed an app to process the photo, but patented it–a somewhat odd indication that they consider it a major contribution to health care.

Tasha van Es and Claire Huber of Redox, a company focused on healthcare interoperability and data integration, said that they are eager to work with FHIR, and that it’s a major part of their platform, but they think it has to develop more before being ready for widespread use. This made me worry about recent calls by health IT specialists for the ONC, CMS, and FDA to make FHIR a requirement.

It was a pleasure to reconnect at the conference with goinvo, which creates open source health care software on a contract basis, but offers much of it under a free license.

A non-profit named Xcertia also works on standards in health care. Backed by the American Medical Association, American Heart Association, DHX Group, and HIMSS, they focus on security, privacy, and usability. Although they don’t take on certification, they design their written standards so that other organizations can offer certification, and a law considered in California would mandate the use of their standards. The guidelines have just been released for public comment.

The second section of this article covers patient engagement and other topics of interest that turned up at the conference.

Will UnitedHealth’s New Personal Health Record Make An Impact?

Posted on October 26, 2018 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.

Though the idea of a personal health record was a hot thing for a while, it didn’t become the fixture of the healthcare market that pundits had predicted. In fact, as many readers will recall, even deep pockets like Google and Microsoft couldn’t get their users to sign on to their PHRs en masse.

One of the main reasons the PHR model didn’t take is that people simply didn’t want to use them. In fact, at least at the time, the PHR was almost entirely a solution in search of a problem. After all, if a health data power user and patient advocate like myself didn’t want one, what hope did PHR backers have of interesting your average Joe Blow in aggregating their health data online?

Over time, however, the personal health data landscape has changed, with patient records becoming a bit more portable. While consumers still aren’t beating down the doors to get their own PHR, those who are interested in pulling together their medical records electronically have better access to their history.

Not only that, wearables makers like Apple and Fitbit are sweetening the pot, primarily by helping people pull self-generated data into their health record. Arguably, patient-generated data may not be as valuable as traditional records just yet, but consumers are likely to find it more interesting than the jargon-laden text found in provider records.

Given recent developments like these, I wasn’t entirely surprised to learn that UnitedHealth Group is picking up the PHR torch. According to an article in MedCity News, the giant payer plans to launch what sounds like an updated PHR platform next year to its 50 million benefited plan members.

Apparently, on an earnings call last week UnitedHealth CEO Dave Wichmann said that the company will launch a “fully integrated and fully portable individual health record” in 2019. Notably, this is not just a data repository, but rather an interactive tool that “delivers personalized next-best health actions to people and their caregivers.”

The new health record will be based on UnitedHealth’s Rally health and wellness platform, which the insurer picked up when it acquired Audax Health in 2014. The platform, which has 20 million registered users, works to influence members to perform healthy behaviors in exchange for the incentive dollars,

Over time, Wichmann said, UHG intends to build Rally into a platform which collects and distributes “deeply personalized” health information to individual members, MedCity reported. The idea behind this effort is to highlight gaps in care and help patients assess the care that they get.  Wichmann told earnings call listeners that the platform data will be packaged and presented to clinicians in a form similar to that used by existing EHRs.

UHG’s plans here are certainly worth keeping an eye on over the next year or two. I have no doubt that the nation’s largest commercial payer has some idea of how to format data and make it digestible by systems like Cerner and Epic.

But while patients have become a bit more familiar with the benefits of having their health data on hand, we’re not exactly seeing consumers stampede the providers demanding their own health record either, and I’m far from convinced that this effort will win new converts.

My skepticism comes partly from first-hand experience. As a recent UnitedHealth beneficiary, I’ve used the Rally application, and I didn’t find it all that motivating. Honestly, I doubt any online platform will make much of an impact on patient health on its own, as the reasons for many health issues are multifactorial and can’t be resolved by handing one of us a few Rally bucks.

Personal gripes aside, though, the bigger question remains whether consumers think they’ll get something valuable out of using the new UHG tool. As always, you can never count on them coming just because you built it.

AMA Releases Great Guide To Digital Health Implementation

Posted on October 25, 2018 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.

In the past, I’ve been pretty hard on the AMA when it comes to digital health. Last year I gave the organization a particularly hard time when it rolled out its Physician Innovation Network platform, which is designed to help physicians network directly with health tech firms, as it seemed to be breaking little to no ground.

However, to be fair the AMA has been a relatively quiet but solid presence in health IT for quite some time.  Its health IT efforts include cofounding Health2047, which brings together doctors with established health IT companies to help the companies launch services and products, serving as one of four organizations behind mHealth app standards venture Xcertia and managing a student-run biotechnology incubator in collaboration with Sling Health.

But what it hasn’t done so far, at least to date, has been to offer physicians any hands-on guidance on using emerging health IT. Now, at long last, the AMA has taken the plunge, releasing a guide focused on helping physicians roll out digital health technology in their practice. At least this time around, I have to give the organization a high five.

The new guide takes a lifecycle perspective, helping practices work through the digital health implementation process from preparations to rollout to gathering data on the impact of the new technology. In other words, it lays out the process as a feedback loop rather than a discrete event in time, which is smart. And its approach to explaining each step is concise and clean.

One section identifies six straightforward steps for choosing a digital health technology, including identifying a need, defining success early on in the process, making the case for political and financial buy-in, forming the team, evaluating the vendor and executing the vendor contract.

Along the way, it makes the important but often-neglected point that the search should begin by looking at the practice’s challenges, including inefficiencies, staff pain points or patient health and satisfaction problems. “The focus on need will help you avoid the temptation to experiment with new technologies that ultimately will result in tangible improvements,” the guide notes.

Another offers advice on tackling more immediate implementation issues, including steps like designing workflows, preparing the care team and partnering with the patient. This section of the report differs from many of its peers by offering great advice on building workflow around remote patient monitoring-specific requirements, including handling device management, overseeing patient enrollment and interactions, and assuring that coding and billing for remote patient management activities is correct and properly documented.

The guide also walks practices through the stages of final implementation, including the nature of the rollout itself, evaluating the success of the project and scaling up as appropriate. I was particularly impressed by its section on scaling up, given that most of the advice one sees on this subject is generally aimed at giant enterprises rather than typically smaller medical practices. In other words, it’s not that the section said anything astonishing, but rather that it existed at all.

All told, it’s great to see the AMA flexing some of the knowledge it’s always had, particularly given that the report is available at no cost to anyone. Let’s hope to see more of this in the future.

2018 Thrival Festival. Are We Asking the Right Questions?

Posted on September 26, 2018 I Written By

Colin Hung is the co-founder of the #hcldr (healthcare leadership) tweetchat one of the most popular and active healthcare social media communities on Twitter. Colin speaks, tweets and blogs regularly about healthcare, technology, marketing and leadership. He is currently an independent marketing consultant working with leading healthIT companies. Colin is a member of #TheWalkingGallery. His Twitter handle is: @Colin_Hung.

Presentations in a botanical garden. Workshops in an actual work shop. Disco in a museum. The 2018 Thrival Festival eschewed tradition and challenged attendees to ponder: Are we asking the right questions when it comes to humanity + technology + art?

The annual Thrival Festival held in Pittsburgh PA is truly unique. It combines art, technology, philosophy, music, and yes, even healthcare, into an event that is part science fair and part theatre. Instead of holding the event in a traditional auditorium or hotel, the organizers chose the beautiful Phipps Conservatory and Botanical Gardens as the setting for this year’s event.

Rising like a glass armadillo out of lush grass splashed here and there with colorful flowers, the Conservatory welcomed attendees with a warm scent of green leaves and rich earth. It was immediately apparent we were in for something different as we passed through the mammoth glass entryway and wound our way through the maze of monarchs and waterfalls to reach the main session room.

With sunshine and mother nature as a backdrop, Thrival kicked off with a keynote from John Battelle @johnbattelle, CEO and Editor-in-Chief of WIRED. Battelle wasted no time in setting the tone for the day. Early in his presentation he put up the following picture from National Geographic with the caption: What makes us human?

© Martin Schoeller/National Geographic

The image was from National Geographic’s October 125th anniversary issue (2013) where they photographed the new faces of America – a reflection of the blurring of traditional racial and ethnic lines. Battelle used the slide to highlight that society will soon be challenged to define humanity more broadly than before – as we manipulate our genes, embed technology into our bodies and program human-like qualities into robots.

Later in the morning, the issue of do-it-yourself implantable devices and pseudo-scientific injectable cocktails was discussed by a panel of experts. Dr. Rasu Shrestha @RasuShrestha was asked: Is biohacking the future of medicine? With a smile and wink, he deftly answered the question by putting forward the notion that the original healers and physicians were themselves the biohackers of their day. Instead of nanobots they used herbs and crude instruments to try and cure our pre-industrial ancestors.

*Yes, Rasu did use “OG” in his answer, to the delight of the audience.

The panel also featured Rich Lee @lovetron9000 the controversial sex technologist who not only installed a vibrating implant in himself but also recently self-injected a gene therapy that he hopes will cure him of his color blindness. Vilified by authorities, Lee was decidedly normal both on and off the stage answering questions about his motivations.

Over lunch I had the opportunity to chat with Laura Montoya, Founder of Accel:AI and Director of Women Who Code. Montoya teaches development teams to consider the ethical issues relating to AI algorithms. She posed the most interesting question of the day: Would you get into a self-driving car if you knew the algorithm governing it would choose to save the life of a pedestrian over you the passenger?

“Think of it this way,” explained Montoya. “When you sign up for a ride-sharing service, you have to agree to the company’s terms of use. Buried in that agreement is a waiver of liability. Essentially you as an individual are opting into the fact that you are okay with being driven around by a computer rather than an actual driver. The liability of the company for you is therefore limited. Now think about the pedestrian. They have not opted into the company’s self-driving car. They have not agreed that a self-driving car should be in their neighborhood. Therefore, the pedestrian represents a potentially high financial liability – being an innocent bystander. So if the car is faced with the choice of crashing into the pedestrian vs crashing into a tree, would the difference in the degree of liability influence it’s decision. And if it did, would you have knowingly gotten into the vehicle in the first place.”

*Note to self, uncheck the self-driving option from my Uber app.

My Thrival afternoon began with a short viewing of GAPPED – a documentary from Molten Media Group. The excerpt contained powerful and moving interviews of Pittsburgh residents who were in danger of being left behind by the innovation boom that the city is currently enjoying. After the screening, the producers of the film shared that they were seeking to answer a single question: Will Pittsburgh and its people have the chance to rise together or will those unwilling to adapt be left behind?

To me the film asks a much broader question: What happens when innovation wealth is unequally distributed within an ecosystem? And I don’t mean the spoils of innovation like money, equity stakes and fancy offices. What happens when public and private programs inadvertently leave out a portion of the local population? Is it fair that 95% of the innovation seed funding goes to middle-class college graduates while innovators living under the poverty line struggle to keep afloat? I can’t wait to see the entire film when it is released later this year.

I decided to end my Thrival day by attending the Moonshot Workshop led by the XPRIZE Foundation – the people behind the space competition that spawned Virgin Galactic and SpaceX. The workshop started with a short presentation by Amir Banifatemi, AI Lead at XPRIZE. Banifatemi explained the process they go through to curate, refine and define the incentive competitions that “entice the world to take action”. It turns out that it takes the team at XPRIZE over nine months to clearly define one of their challenges.

“If we define the challenge too broadly, teams become overwhelmed with where to start.” Said Banifatemi. “Problems need to be specific enough to spark the imagination but not so blue-sky that people get lost in the possibilities. If we make our challenges too difficult, we may discourage people from entering. It turns out that coming up with the right question, the right challenge is almost as hard as solving it. But if you get the question right, magic happens.

Banifatemi’s statement was the perfect bow on my day at Thrival Festival. Before innovation can happen, a problem or challenge must first exist. Once we understand that problem, our collective imaginations can be unleashed. Better definition of the problem leads to better innovation. The question of: “How can we look inside the human body?” begat X-ray machines. The more refined question of: “How can we look inside the human body without causing harm to the person and with sufficient detail to see tissue?” begat MRI machines (okay maybe a bit of a stretch, but you get the idea).

As the high-energy techno anthems from Veserium washed over me at the Thrival evening event, I found myself thinking about all the questions we are asking in healthcare. Perhaps we need to take a moment and ask ourselves if we are really asking the right ones.

Will The Fitbit Care Program Break New Ground?

Posted on September 21, 2018 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.

Wearables vendor Fitbit has launched a connected health program designed to help payers, employers and health systems prevent disease, improve wellness and manage diseases. The program is based on the technology Fitbit acquired when it acquired Twine Health.

As you’ll see, the program overview makes it sound as the Fitbit program is the greatest thing since sliced bread for health coaching and care management, I’m not so convinced, but judge for yourself.

Fitbit Care includes a mix of standard wearable features and coaching. Perhaps the most predictable option is built on standard Fitbit functions, which allow users to gather activity, sleep and heart rate data. However, unlike with individual use, users have the option to let the program harvest their health data and share it with care teams, which permits them to make personalized care recommendations.

Another option Fitbit Care offers is health coaching, in which the program offers participants personalized care plans and walks them through health challenges. Coaches communicate with them via in-communications, phone calls, and in-person meetings, targeting concerns like weight management, tobacco cessation, and management of chronic conditions like hypertension, diabetes, and depression. It also supports care for complex conditions such as COPD or congestive heart failure.

In addition, the program uses social tools such as private social groups and guided workouts. The idea here is to help participants make behavioral changes that support their health goals.

All this is supported by the new Fitbit Plus app, which improves patients’ communication capabilities and beefs up the device’s measurement capabilities. The Fitbit app allows users to integrate advanced health metrics such as blood glucose, blood pressure or medication adherence alongside data from Fitbit and other connected health devices.

The first customer to sign up for the program, Fitbit Care, is Humana, which will offer it as a coaching option to its employer group. This puts Fitbit Care at the fingertips of more than 5 million Humana members.

I have no doubt that employers and health systems would join Humana experimenting with wearables-enhanced programs like the one Fitbit is pitching. At least, in theory, the array of services sounds good.

On the other hand, to me, it’s notable that the description of Fitbit Care is light on the details when it comes to leveraging the patient-generated health data it captures. Yes, it’s definitely possible to get something out of continuous health data collection, but at least from the initial program description, the wearables maker isn’t doing anything terribly new.

Oh well. I guess Fitbit doesn’t have to do anything radical to offer something valuable to payers, employers and health plans. They continue to search for behavioral interventions that actually have an impact on disease management and wellness, but to my knowledge, they haven’t found any magic bullet. And while some of this sounds interesting, I see nothing to suggest that the Fitbit Care program can offer dramatic results either.

 

The Cultural Nuances of Communication

Posted on August 23, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

It’s amazing some of the insights you can get from Twitter. This is especially true when someone puts together a series of tweets (most people call them a tweetstorm) that shares a story or insights on a specific topic. Today, I gained some new insight into the cultural nuances of communication in this Twitter thread:

Why we need more black men in medicine. I had a patient this week who came in with left leg weakness over the last week. Younger black guy in his 30s. Brain MRI clearly indicates multiple sclerosis. So we all go in during morning rounds to give my man his diagnosis.

He has a bit of blank stare as he listens to my attending try to explain what he has. He was told earlier he mightve had a stroke, and now we’re telling him he doesnt have a stroke. But he’s clearly processing what he does have and just says “nah” to having any questions.

So we’re running the patient list after rounding, and as we get to him my attending says somn like “idk if apathy is the word, seems like he doesnt care”. Laughs and so does the rest of the team. I’m sitting there like, this aint it. And yes, I was the only one.

So after running the list, I don’t even stick around with the team. I go straight back to dude’s room and the code switch was automatic. “Look mane, I know all that was a lot. Did you really get what the doc was sayin?” Mans looked at me with a face of relief.

Now I’m goin into detail on MS, how it’s different from a stroke, and what it means for him long term. The real validation came when he interrupted me early on and said “OH so it’s a BRAIN thing I got?” “Yes my man it’s a brain thing.”

And now my dude understands what he has, why we need the tests we need, and what the rest of his life might look like. All because I could recognize what everyone else seemed to miss, from a cultural perspective. He’s not apathetic. Folk just weren’t connecting with him.

I’m in the right field fam.

We definitely underestimate the nuances required to communicate effectively across cultures. It’s such an important nuance that’s often missed. As we start to automate more of our healthcare communication with chat bots and other AI empowered communication, I wonder if we’ll take some of these cultural nuances into account. That’s a really challenging problem, but something we should consider a lot more in our healthcare communication.

Being Honest About Your Reasons For Cybersecurity Decisions

Posted on August 16, 2018 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.

This week, a team of McAfee researchers released a paper outlining a terrifying exploit. The paper describes, in great technical detail, how a malicious attacker could flip a cardiac rhythm display from 80 beats per minute to zero within less than five seconds.

This might not lead to severe harm or death, but it’s possible that other very negative outcomes could occur, notes Shaun Nordeck, MD, who’s quoted in the report. “Fictitious cardiac rhythms, even intermittent, could lead to extended hospitalization, additional testing, and side effects from medications prescribed to control heart rhythm and/or prevent clots,” he notes.

The paper does point out that if the bedside monitor is working normally, nurses have access to other accurate data, which could diminish the impact of such disruptions to some extent. However, the potential for adverse events is clearly higher than normal if someone scrambles a patient’s vitals.

Unfortunately, this is far from the only attack which wasn’t possible before connected devices became the norm. At various points, we’ve seen that pacemakers, insulin pumps and even MRIs can be hacked externally, particularly if their operating systems aren’t patched as required or haven’t put even basic security protections in place. (Think using “password” as a password.)

But while these vulnerabilities are largely known at this point, some healthcare organizations haven’t begun to tackle them. Solving these problems takes work, and costs money, The best-intentioned CIO might not get the budget to fix these problems if their CEO doesn’t see them as urgent.

Or let’s say the budget is available to begin the counterattack. Even if everyone agrees to tackle connected device vulnerabilities, where do we begin the counterattack? Which of these new connected health vulnerabilities are the most critical?  On the one hand, hacking individual pacemakers doesn’t seem profitable enough to attract many cybercriminals. On the other, if I were a crook I might see the threat of meddling with a hospitals’ worth of patient monitors to be a great source of ransom money.

And this brings us to some tough ethical questions. Should we evaluate these threats by how many patients would be affected, or how many of the sickest patients?  How do we calculate the clinical impact of vital signs hacking vs. generating inaccurate MRI results? To what extent should the administrative impact of these attacks be a factor in deciding how to defeat these challenges, if at all?

I know you’re going to tell me that this isn’t an all or nothing proposition, and that to some extent standard network intrusion detection techniques and tools will work. I’m not disputing this. However, I think we need to admit out loud that these kinds of attacks threaten individual lives in a way that traditional cyberattacks do not. For that reason, we need to get honest about who we need to protect — and why.

Lumeon Offers a Step Toward Usable Device Data in Health Care

Posted on August 8, 2018 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 health care field floats on oceans of patient data, but like the real oceans on our planet, patient data is polluted. Trying to ground evidence-based medicine on billing data is an exercise in frustration. Clinical data is hard to get access to, and has its own limitations. For instance, it is collected only when a patient visits the clinic or hospital. The FDA recently put 100 million dollars in its budget to get patient data from electronic health records (which the commissioner called “real-world experience”).

One of the paths toward better data for research and treatment lies in the data from medical devices: it’s plentiful, detailed, and accurate. But device data has mountains to climb before researchers and clinicians can use it: getting this data in the first place, normalizing and standardizing it, and integrating it with the systems used for analysis and treatment. That’s what excites me about a recent new direction taken by Lumeon, a platform for workflow management and treatment coordination in health care.

I covered Lumeon’s platform a few months ago. The company already lays out an enticing display of tools for clinicians, along with EHR integration. What’s new is the addition of medical devices, an enhancement that required nine months of working with medical device manufacturers. Recently I had another chance to talk to Rick Halton, Vice President of Marketing and Product for Lumeon.

Along with the measurements provided by devices, Lumeon has tools for patient engagement and the measurement of outcomes. These outcomes go beyond simple quantitative scores such as limb rotation. Lumeon creates for each patient a patient-specific functional score (PSFS). For one patient, it may be whether he can play outside with his kids. For another, it’s whether she can they go back to work, and for another, how far she can walk.

Lumeon asks, how can a device be used in a patient journey? It uses the routine information to help provide consistent care throughout this journey pathway, and measures outcomes throughout to generate feedback that promotes better long-term outcomes.

Device data is currently stored in a Lumeon platform that may be on the clinician’s site or in the cloud. Using an API, Lumeon’s output can be embedded within an EHR (they currently do this with Epic) so that the output can be displayed as part of the EHR display, and the clinician doesn’t even have to know that the results are being generated outside the EHR. In the future, the data may be integrated directly into the EHR. However, Lumeon’s direct customers are the providers, not the EHR vendors.

Data from devices was popular among providers at first for discharge planning and other narrow applications. Lumeon’s device integration is now getting more attention from providers who are experiencing a squeeze on reimbursements, a growing alertness among payers for outcomes, and a slow move in the industry toward fee-for-value. One leading device manufacturer is already using Lumeon for better treatment of cardiovascular care, bariatric surgery, and diabetes. Other applications include chronic disease, perioperative care (readiness for the OR and enhanced recovery), the digital patient experience on the web or in an app, and the patient centered medical home.

If Lumeon can turn device data into better treatment, other clinical institutions and health care platforms should be able to do so as well. It’s time for health care to enter the 21st century and use the Internet of Things (or Internet of Healthy Things, as termed by Dr. Joseph Kvedar) for the benefit of patients.

A Missed Opportunity For Telemedicine Vendors

Posted on June 29, 2018 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.

Today, most direct-to-consumer telemedicine companies operate on a very simple model.

You pay for a visit up front. You talk to the doctor via video, the doctor issues as a prescription if needed and you sign off. Thanks to the availability of e-prescribing options, it’s likely your medication will be waiting for you when you get to the pharmacy.

In my experience, the whole process often takes 45 minutes or less. This beats the heck out of having to wait in line at an urgent care center or worse, the emergency department.

But what about caring for chronic illnesses that can’t be managed by a drive-by virtual visit? Can telemedicine vendors play a role here? Maybe so.

We already know that combining telemedicine with remote monitoring devices can be very effective. In fact, some health systems have gone all-in on virtual chronic care management.

One fascinating example is the $54 million Mercy Virtual Care Center, which describes itself as a “hospital without beds.” The Center, which has a few hundred employees, monitors more than 3,800 remote patients; sponsors a telehealth stroke program offering neurology services to EDs nationwide; manages a team of virtual hospitalists caring for patient around-the-clock using virtual visit tools; and runs Mercy SafeWatch, which the Center says is the largest single-hub electronic intensive care unit in the U.S.

Another example of such hospital-based programs is Intermountain Healthcare’s ConnectCare Pro, which brings together 35 telehealth programs and more than 500 clinicians. Its purpose is to supplement existing staffers and offer specialized services in rural communities where some of the services aren’t available.

Given the success of programs that maintain complex patients remotely, I think a private telemedicine company managing chronic care services might work as well. While hospitals have financial reasons to keep such care in-house, I believe an outside vendor could profit in other ways. That’s especially the case given the emergence of wearable trackers and smartwatches, which are far cheaper than the specialized tools needed in the past.

One likely buyer for this service would be health plans.

I’ve heard some complain publicly that in essence, telemedicine coverage just encourages patients to access care more often, which defeats the purpose of using it to lower healthcare costs. However, if an outside vendor offered to manage patients with chronic illnesses, it might be a more attractive proposition.

After all, health plans are understandably wringing their hands over the staggering cost of maintaining the health of millions of diabetics. In 2017, for example, the average medical expense for people diagnosed with diabetes was about $16,750 per year, with $9,600 due to diabetes. If health plans could lay the cost off to a specialized telemedicine vendor, some real savings might be possible.

Of course, being a telemedicine-based chronic care management company would be far different than offering direct-to-consumer telemedicine services on an occasional basis. The vendor would have to have comprehensive health data management tools, an army of case managers, tight relationships with clinicians and a boatload of remote monitoring devices on hand. None of this would come cheaply.

Still, while I haven’t fully run the numbers, my guess is that this could be a sustainable business model. It’s worth a try.