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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.

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.

How the Young Unity Health Score Company Handles The Dilemmas of Health IT Adoption

Posted on June 25, 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.

I have been talking to a young company called Unity Health Score with big plans for improving the collection and sharing of data on patients. Their 55-page business plans covers the recruitment of individuals to share health data, the storage of that data, and services to researchers, clinicians, and insurers. Along the way, Unity Health Score tussles with many problems presented by patient data.
Unity Health Score logo
The goals articulated for this company by founder Austin Jones include getting better data to researchers and insurers so they can reduce costs and find cures, improving communications and thus care coordination among clinicians and patients, and putting patients in control of their health data so they can decide where it goes. The multi-faceted business plan covers:

  • Getting permission from patients to store data in a cloud service maintained by Unity Health Score
  • Running data by the patients’ doctors to ensure accuracy
  • Giving patients control over what researchers or other data users receive their data, in exchange for monetary rewards
  • Earning revenue for the company and the patients by selling data to researchers and insurers
  • Helping insurers adjust their plans based on analysis of incoming data

The data collected is not limited to payment data or even clinical data, but could include a grab-bag of personal data, such financial and lifestyle information. All this might yield health benefits to analytics–after all, the strategy of using powerful modern deep learning is being pursued by many other health care entities. At the same time, Jones plans to ensure might higher quality data than traditional data brokers such as Acxiom.

Now let’s see what Unity Health Score has to overcome to meet its goals. These challenges are by no means unique to these energetic entrepreneurs–they define the barriers faced by institutions throughout health care, from the smallest start-up to the Centers for Medicare & Medicaid Services.

Outreach to achieve a critical mass of patients
We can talk for weeks about quality of care and modernizing cures, but everybody who works in medicine agrees that the key problem we face is indifference. Most people don’t want to think too much about their health, are apathetic when presented with options, and stubbornly resist the simplist interventions–even taking their prescribed medication. So explaining the long-term benefits of uploading data and approving its use will be an uphill journey.

Many app developers seek adoption by major institutions, such as large insurers, hospital conglomerates, and HMOs like Kaiser. This is the smoothest path toward adoption by large numbers of consumers, and Unity Health Score includes a similar plan in its business model, According to Jones, they will require the insurance company to reduce premiums based on each patient’s health score. In return, they should be able to use the data collected to save money.

Protecting patient data
Health data is probably the most sensitive information most of us produce over our lifetimes. Financial information is important to keep safe, but you can change your bank account or credit card if your financial information is leaked–you can’t change your medical history. Security and privacy guarantees are therefore crucial for patient records. Indeed, the Unity Health Score business plan cites fears of privacy as a key risk.

Although some researchers have tried distributed patient records, stored in some repository chosen by each individual, Unith Health Score opts for central storage, like most current personal health records. This not only requires great care to secure, but places on them the burden of persuading patients that the data really will be used only for purposes chosen by the patients. Too many apps and institutions play three-card Monte with privacy policies, slipping in unauthorized uses (just think back to the recent Facebook/Cambridge Analytica scandal), so Internet users have become hypervigilant.

Unity Health Score also has to sign up physicians to check data for accuracy. This, of course, should be the priority for any data entered into any medical record. Because doctors’ time is going more and more toward the frustrating task of data entry, the company offers an enticing trade-off: the patients takes the time to enter their data, and the doctor merely verifies its accuracy. Furthermore, a consolidated medical record online can be used to speed check-in times on visits and to make data sharing on mobile devices easier.

Making the data useful
Once the patients and clinicians join Unity Health Score, the company has to follow through on its promise. This is a challenge with multiple stages.

First, much of the data will be in unstructured doctors’ notes. Jones plans to use OCR, like many other health data aggregators, to extract useful information from the notes. OCR and natural language processing may indeed be more accurate than relying on doctors to meticulously fill out dozens of structured fields in a database. But there is always room for missed diagnoses or allergies, and even for misinterpretations.

Next, data sources must be harmonized. They are likely to use different units and different lexicons. Although many parts of the medical industry are trying to standardize their codings, progress is incomplete.

The notion of a single number defining one’s health is appealing, but it might be too crude for many uses. Whether you’re making actuarial predictions (when will the individual die, or have to stop working?), estimating future health care costs, or guessing where to allocate public health resources, details about conditions may be more important than an all-encompassing number. However, many purchasers of the Unity Health Score information may still find the simplicity of a single integer useful.

Making the service attractive to data purchasers
The business plan points out that most rsearch depends on large data sets. During the company’s ramp-up phase–which could take years–they just won’t have enough patients suffering from a particular condition to interest many researchers, such as pharma companies looking for subjects. However, the company can start by selling data to academic researchers, who often can accomplish a lot with a relatively small sample. Biotech, pharma, and agencies can sign up later.

Clinicians may warm to the service much more quickly. They will appreciate having easy access to patient data for emergency room visits and care coordination in general. However, this is a very common use case for patient data, and one where many competing services are vying for a business niche.

Aligning goals of stakeholders
In some ways I have saved the hardest dilemma for last. Unity Health Care is trying to tie together many sets of stakeholders–patients, doctors, marketers, researchers, insurers–and between many of these stakeholders there are irreconcilable conflicts.

For instance, insurers will want the health score to adjust their clients’ payments, charging more for sick people. This will be feared and resented by people with pre-existing conditions, who will therefore withhold their information. In some cases, such insurer practices will worsen existing disparities for the poor and underpriviledged. The Unity Health Score business plan rejects redlining, but there may be subtler practices that many observers would consider unethical. Sometimes, incentives can also be counterproductive.

Also, as the business plan points out, many companies that currently purchase health data have goals that run counter to good health: they want to sell doctors or patients products that don’t actually help, and that run up health care costs. Some purchasers are even data thieves. Unity Health Score has a superior business model here to other data brokers, because it lets the patients approve each distribution of their data. But doing so greatly narrows the range of purchasers. Hopefully, there will be enough ethical health data users to support Unity Health Score!

This is an intriguing company with a sophisticated strategy–but one with obstacles to overcome. We can all learn from the challenges they face, because many others who want to succeed in the field of health care reform will come up against those challenges.

#HIMSS18: Oh The Humanity

Posted on April 2, 2018 I Written By

The following is a guest blog post by Sean Erreger, LCSW or @StuckonSW as some of you may know him.

It was a privilege to attend the 2018 HIMSS global conference this year. Having blogged and tweeted about Health IT for a couple of years, it was great to finally live it. By taking a deep dive, attending presentations, demoing products, and networking; I came to a greater understanding of how Health IT tackles the problems I hope to solve. From a social work perspective, I continue to be fascinated with the idea that technology can facilitate change.  Getting lost in artificial intelligence, machine learning, natural language processing, and predictive analytics was easy. It was exciting to learn the landscape of solutions, amount of automation, and workflow management possible. As a care manager, I believe these tools can be incredibly impactful.

However, despite all the technology and solutions, came the reminder that Health IT is a human process. There were two presentations that argued that we can’t divorce the humanity from health information technology process.  First was on the value of behavioral science and secondly a presentation on provider burnout and physician suicide.

The Value Of Behavioral Science

This was a panel presentation and discussion moderated by Dr. Amy Bucher of Mad*Pow including Dr. Heather Cole-Lewis of Johnson and Johnson, Dr. David Ahern of the FCC, and Dr. John Torous of Harvard Medical school. All experts were a part of projects related to Personal Connected Health Alliance. They asked attendees to consider the following challenges and how behavior science play a role…

Questions like how do we measure outcome and defining what “engagement” look like are key to how we build Health IT.  Yes, things like apps and wearables are cool but how do we measure their success. This can often be a challenge. It often feels like health IT is trying to outdo each other about who is coming up with the coolest piece of technology. However, when we get down to the nuts and bolts and start to measure engagement in technology, we might not like the results…

This presentation reminded me that technology is not often enough. Valuing the importance of “meeting people where they are”, may not include technology at all. We have to challenge ourselves to look ethically at the evidence and ensure that digital health is something a patient may or may not want.

Technology as a Solution to Physician Burnout and Suicide

It was reassuring to know even before I got to HIMSS that suicide prevention was going to be part of the conversation. Janae Sharpe and Melissa McCool presented on physician suicide and tools to potentially prevent it. This presents another human aspect of Health IT, the clinicians that use them. The facts about physician suicide are hard to ignore…

As someone who has done presentations about burnout and secondary trauma, I am acutely aware of how stressful clinical care can be.  It is unclear whether technology is a cause but it is certainly a factor, even in physician suicide. The research on this complex, but to blame the paperwork demands for burnout and physician suicide is tricky. To attribute a cause to things is always a challenge but my take away is that the Health IT community might be part of the problem but the presenters made a compelling case that it should be part of the solution. That not only reducing clicks and improving workflow is needed but providing support is critical.

They talked about the need to measure “burnout” and see how the Health IT community can design technology to support those at risk.  They have created a scale called the Sharp Index to try to measure physician burnout and also build technology to provide support. This seems to be striving for that right mix between measurement in the hopes of making space for human processes in a complex technology space.

Cooking The Mix Between Tech and Human Care

These presentations leave Health IT with many questions. Apps to provide a means of clinical care exist but are they working? How can we tell we are getting digital health right? How can we tell if technology is making a difference in patients’ lives? How do we define “success” of an app? Is technology having a negative impact on clinical care and clinicians themselves? If so, how do we measure that?

These questions force us to take an intentional look at how we measure outcomes but more importantly how we define them. Both presentations stressed the multi-disciplinary nature of health information technology development.  That no matter what the technology, you need to ask what problem does it solve and for who? As we consider building out AI and other automation we need to keep the humanity in healthcare.  So we can better care for ourselves as providers and ask what patients need in a human centered manner.

For a deeper dive into each presentation, I have created twitter recaps of both the Behavioral Science Panel and the presentation on Physician Suicide.

About Sean Erreger
Sean is Licensed Clinical Social Worker in New York. He is interested in technology and how it is facilitating change in a variety of areas. Within Health IT is interested in how it can include mental health, substance abuse, and information about social determinants. He can be found at his blog www.stuckonsocialwork.com.

Health IT Leaders Spending On Security, Not AI And Wearables

Posted on December 18, 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.

While breakout technologies like wearables and AI are hot, health system leaders don’t seem to be that excited about adopting them, according to a new study which reached out to more than 20 US health systems.

Nine out of 10 health systems said they increased their spending on cybersecurity technology, according to research by the Center for Connected Medicine (CCM) in partnership with the Health Management Academy.

However, many other emerging technologies don’t seem to be making the cut. For example, despite the publicity it’s received, two-thirds of health IT leaders said using AI was a low or very low priority. It seems that they don’t see a business model for using it.

The same goes for many other technologies that fascinate analysts and editors. For example, while many observers which expect otherwise, less than a quarter of respondents (17%) were paying much attention to wearables or making any bets on mobile health apps (21%).

When it comes to telemedicine, hospitals and health systems noted that they were in a bind. Less than half said they receive reimbursement for virtual consults (39%) or remote monitoring (46%}. Things may resolve next year, however. Seventy-one percent of those not getting paid right now expect to be reimbursed for such care in 2018.

Despite all of this pessimism about the latest emerging technologies, health IT leaders were somewhat optimistic about the benefits of predictive analytics, with more than half of respondents using or planning to begin using genomic testing for personalized medicine. The study reported that many of these episodes will be focused on oncology, anesthesia and pharmacogenetics.

What should we make of these results? After all, many seem to fly in the face of predictions industry watchers have offered.

Well, for one thing, it’s good to see that hospitals and health systems are engaging in long-overdue beefing up of their security infrastructure. As we’ve noted here in the past, hospital spending on cybersecurity has been meager at best.

Another thing is that while a few innovative hospitals are taking patient-generated health data seriously, many others are taking a rather conservative position here. While nobody seems to disagree that such data will change the business, it seems many hospitals are waiting for somebody else to take the risks inherent in investing in any new data scheme.

Finally, it seems that we are seeing a critical mass of influential hospitals that expect good things from telemedicine going forward. We are already seeing some large, influential academic medical centers treat virtual care as a routine part of their service offerings and a way to minimize gaps in care.

All told, it seems that at the moment, study respondents are less interested in sexy new innovations than the VCs showering them with money. That being said, it looks like many of these emerging strategies might pay off in 2018. It should be an interesting year.

AMA Connects Doctors With Health IT Ventures

Posted on November 22, 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.

Maybe I’m wrong, but the following strikes me as coming straight from the Redundancy Department of Redundancy…but let’s see. Maybe I’m just being mean. Or maybe it’s because I just couldn’t taste The Rainbow in my last package of Skittles.

Anyway, recently AMA announced the launch of an online platform, the Physician Innovation Network (PIN), designed to connect physicians together with health tech firms.

The PIN will give HIT companies will have a straightforward channel for collecting physician input on the products and services they’re developing. The health IT ventures will also be able to search for physicians who have the expertise they need and are willing to exchange information with them. Meanwhile, the platform will help physicians to find paid and volunteer opportunities to work with health tech companies to work with the health take ventures that suit them.

In recent years, the AMA has taken several steps to bring the world of health IT and physicians closer together. Most recently, the trade group announced that it had created a data standardization organization known as the Integrated Health Model Initiative. The physician group and its partners say the new data model will include clinically-validated data elements designed to speed up the development of improved data organization, management, and analytics.

Its other HIT initiatives include:

  • Co-founding Health2047, a company designed (like PIN) to bring together physicians with established healthcare companies and help them launch useful services and products
  • Serving as one of four founding organizations behind Xcertia, an organization intended to foster knowledge about clinical content, usability, privacy, security and evidence of efficacy for mHealth apps
  • Managing a student-run biotechnology incubator in collaboration with Sling Health,

But what is there to say about PIN that distinguishes it from all of these efforts? It resembles Health2047, mais non? And what benefit does it add over LinkedIn? Specialty interest groups within the MGMA and HIMSS? AngelList? A giant digital corkboard and some virtual Post-It notes?

Don’t get me wrong, I know I’ve come down hard on the AMA’s product launch announcements rather often, perhaps too often. Depending on how it actually works, PIN may actually offer some incremental value over all of these other options. And hey, if the trade group wants to throw its money around, whom am I to say that they shouldn’t have at it.

The thing is, though, the AMA doesn’t work in a vacuum.

Look, as we all know, we’re absolutely drowning in initiatives and proposals and great new ideas for interoperability and the collection of consumer-generated health data. And don’t forget scoping out the best architecture for deploying two tin cans with a piece of string between them, getting budget approval from a Magic 8 Ball (signs point to no), and repurposing some BASIC code from a  Commodore 64 to develop your next mobile health app. (Yes, it tired me out to write that sentence but it was worth it.)

Silliness aside, when you have the kind of resources the AMA does, you want to the profession to say something meaningful when you open your mouth, professionally speaking. Other than that, you’re just sucking air out of the room that could be used for people with a differentiated idea in real value to deliver.  Hey, but other than that, the PIN announcement is just fine.

Where HIMSS Can Take Health 2.0

Posted on April 24, 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.

I was quite privileged to talk to the leaders of Health 2.0, Dr. Indu Subaiya and Matthew Holt, in the busy days after their announced merger with HIMSS. I was revving to talk to them because the Health 2.0 events I have attended have always been stimulating and challenging. I wanted to make sure that after their incorporation into the HIMSS empire they would continue to push clinicians as well as technologists to re-evaluate their workflows, goals, and philosophies.

I’m not sure there is such a thing as a typical Health 2.0 event, but I generally see in such events a twofold mission. Sometimes they orient technologists to consider the needs of doctors and patients (as at a developer challenge). Other times they orient clinicians and health care institutions to consider the changes in goals and means that technology requires, as well as the strains caused by its adoption (as in a HxRefactored conference). Both of these activities disturb the cozy status quo in health IT, prodding its practitioners to try out new forms of research, design, and interaction. Health 2.0 was also happy to publish my own articles trying to untangle the standard confusion around health care.

For HIMSS, absorbing Health 2.0 is about as consequential as an ocean liner picking up a band of performing musicians along its ports of call. For Health 2.0, the impact could be much larger. Certainly, they gain the stability, funding opportunities, and administrative support that typically come with incorporation into a large, established institution. But can they keep their edge?

Subaiya and Holt assured me that Health 2.0 maintains its independence as part of HIMSS. They will be responsible for some presentations at the mammoth annual HIMSS conferences. They also hope to bring more buyers and sellers together through the HIMSS connection. They see three functions they can provide HIMSS:

  • A scanner for what’s new. HIMSS tends to showcase valuable new technologies a couple years after Health 2.0 discovers them.

  • A magnet to attract and retain highly innovative people in health IT.

  • A mechanism for finding partners for early-stage companies.

Aside from that, they will continue and expand their international presence, which includes the US, Japan, South Korea, China, and India. Interestingly, Subaiya told me that the needs expressed in different countries are similar. There aren’t separate mHealth or IT revolutions for the US and India. Instead, both call for increased used of IT for patient education, for remote monitoring and care, and for point-of-care diagnostics. Whether talking about busy yuppies in the city or isolated rural areas lacking doctors, clinicians find that health care has to go to the patient because the patient can’t always come to a health care center. If somebody can run a test using a cheap strip of paper and send results to a doctor over a cell phone, health coverage becomes more universal. Many areas are also dealing with the strains of aging populations.

HIMSS leadership and Health 2.0 share the recognition that health happens outside the walls of hospitals: in relationships, communities, schools, and homes. Health 2.0 will push that philosophy strongly at HIMSS. They will also hammer on what Subaiya calls health care’s “unacceptables”: disparities across race, gender, and geographic region, continued growth in chronic disease, and resulting cost burdens.

Subaiya and Holt see the original mission of HIMSS as a beneficial one: to create technologies that enhance physician workflows. Old technologies turned out to be brittle and unable to evolve, though, as workflows radically changed. As patient engagement and collaboration became more important, EHRs and other systems fell behind.

Meanwhile, the mobile revolution brought new attention to apps that could empower patients, improve monitoring, and connect everybody in the health care system. But technologists and venture capitalists jumped into health care without adequate research into what the users needed. Health 2.0 was created several years ago to represent the users, particular patients and health care consumers.

Holt says that investment is still increasing, although it may go into services instead of pure tech companies. Some is money moving from life sciences to computer technologies such as digital therapeutics. Furthermore, there are fewer companies getting funded than a few years ago, but each company is getting more money than before and getting it faster.

Subaiya and Holt celebrate the continued pull of health care for technologists, citing not only start-ups but substantial investment by large tech corporations, such as the Alphabet company Verily Life Sciences, Samsung, and Apple. There’s a particularly big increase in the use of data science within health care.

Some companies are integrating with Alexa to make interactions with consumers more natural. Intelligent decision support (as seen for instance in IBM’s Watson) is taking some of the burden off the clinician. For mental health, behavioral health, and addiction, digital tech is reducing stigma and barriers to those who need help.

In short, Health 2.0 should not be constrained by its new-found partner. The environment and funding is here for a tech transformation of health care, and Health 2.0’s work is cut out for it.

Patient Engagement Platforms Are 2017’s Sexiest Tech

Posted on January 3, 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.

Over the last few months, I’ve become convinced that the predictable star of 2017 — population health management — isn’t going to be as hot as people think.

Instead, I’d argue that the trend to watch is the emergence of new technologies that guide, reach out to and engage with patients at key moments in their care process. We’re at the start of a period of spectacular growth for patient engagement platforms, with one analyst firm predicting that the global market for these solutions will hit $34.94 billion by 2023.

We all seem to agree already that we need to foster patient engagement if we want to meet population health goals. But until recently, most of the approaches I’ve seen put in place are manual, laborious and resource-intensive. Yes, the patient portal is an exception to that rule – and seems to help patients and clinicians connect – but there’s only so much you can do with a portal interface. We need more powerful, flexible solutions if we hope to make a dent in the patient engagement problem.

In the coming year, I think we’ll see a growing number of providers adopt technology that helps them interact and engage with patients more effectively. I’m talking about initiatives like the rollout of technology by vendor HealthGrid at ColumbiaDoctors, a large multispecialty group affiliated with Columbia University Medical Center, which was announced last month.

While I haven’t used the technology first hand, it seems to offer the right functions, all available via mobile phone. These include pre- and post-visit communications, access to care information and a clinically-based rules engine which drives outreach regarding appointments, educations, medications and screening. That being said, HealthGrid definitely has some powerful competitors coming at the same problem, including the Salesforce.com Health Cloud.

Truth be told, it was probably inevitable that vendors would turn up to automate key patient outreach efforts. After all, unless providers boost their ability to target patients’ individual needs – ideally, without hiring lots of costly human care managers – they aren’t likely to do well under value-based payment schemes. One-off experiments with mobile apps or one-by-one interventions by nurse care coordinators simply don’t scale.

Of course, these technologies are probably pretty expensive right now – as new tech in an emerging market usually is — which will probably slow adoption somewhat. I admit that when I did a Google search on “patient engagement solutions,” I ran into a vendor touting a $399 a month option for doctors, which isn’t too bad if it can actually deliver. But enterprise solutions are likely to be a big investment, and also, call for a good deal of integration work. After all, if nothing else, health systems will want to connect patient engagement software to their back-office systems and EMR, at minimum, which is no joke.

Still, to my mind there’s little question that patient engagement technologies are going to be the sexiest health IT niche to watch in 2017, one which will generate major buzz in healthcare boardrooms across the country. Whether you invest or not, definitely watch this space.

What Data Do You Need in Order to Guide Behavioral Change?

Posted on June 2, 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.

This is an exciting time for the health care field, as its aspirations toward value-based payments and behavioral responses to chronic conditions converge on a more and more precise solution. Dr. Joseph Kvedar has called this comprehensive approach connected health and has formed both a conference and a book around it. BaseHealth, a predictive analytics company in healthcare, has teamed up with TriVita to offer a consumer-based service around this approach, which combines access to peer-reviewed research with fine-tuned guidance that taps into personal health and behavioral data and leverages the individual interests of each participant.

I have previously written about BaseHealth’s assessment engine, which asks individuals for information about their activities, family history, and health conditions in order to evaluate their health profile and risk for common diseases. TriVita is a health coaching service with a wide-ranging assessment tool and a number of products, including cutely named supplements such as Joint Complex and Daily Cleanse. TriVita’s nutritionists, exercise coaches, and other staff are overseen by physicians, but their service is not medical: it does not enter the heavily regulated areas where clinicians practice.

I recently talked with BaseHealth’s CEO, Prakash Menon, and Dan Hoemke, its Vice President of Business Development. They describe BaseHealth’s predictive analytics as input that informs TriVita’s coaching service. What I found interesting is the sets of data that seem most useful for coaching and behavioral interventions.

In my earlier article, I wrote, “BaseHealth has trouble integrating EHR data.” Menon tells me that getting this data has become much easier over the past several months, because several companies have entered the market to gather and combine the data from different vendors. Still, BaseHealth focuses on a few sources of medical data, such as lab and biometric data. Overall, they focus on gathering data required to identify disease risk and guide behavior change, which in turn improves preventable conditions such as heart disease and diabetes.

Part of their choice springs from the philosophy driving BaseHealth’s model. Menon says, “BaseHealth wants to work with you before you have a chronic condition.” For instance, the American Diabetes Association estimated in 2012 that 86 million Americans over the age of 20 had prediabetes. Intervening before these people have developed the full condition is when behavioral change is easiest and most effective.

Certainly, BaseHealth wants to know your existing medical conditions. So they ask you about them when you sign up. Other vital signs, such as cholesterol, are also vital to BaseHealth’s analytics. Through a partnership with LabCo, a large diagnostics company in Europe, they are able to tap into lab systems to get these vital signs automatically. But users in the United States can enter them manually with little effort.

BaseHealth is not immune to the industry’s love affair with genetics and personalization, either. They take about 1500 genetic factors into account, helping them to quantify your risk of getting certain chronic conditions. But as a behavioral health service, Menon points out, BaseHealth is not designed to do much with genetic traits signifying a high chance of getting a disease. They deal with problems that you can do something about–preventable conditions. Menon cites a Health 2.0 presentation (see Figure 1) saying that our health can, on average, be attributed 60 percent to lifestyle, 30 percent to genetics, and 10 percent to clinical interventions. But genetics help to show what is achievable. Hoemke says BaseHealth likes to compare each person against the best she can be, whereas many sites just compare a user against the average population with similar health conditions.

Relative importance of health factors

Figure 1. Relative importance of health factors

BaseHealth gets most of its data from conditions known to you, your environment, family history, and more than 75 behavioral factors: your activity, food, over-the-counter meds, sleep activity, alcohol use, smoking, several measures of stress, etc. BaseHealth assessment recommendations and other insights are based on peer-reviewed research. BaseHealth will even point the individual to particular studies to provide the “why” for its recommendations.

So where does TriVita fit in? Hoemke says that BaseHealth has always stressed the importance of human intervention, refusing to fall into the fallacy that health can be achieved just through new technology. He also said that TriVita fits into the current trend of shifting accountability for health to the patient; he calls it a “health empowerment ecosystem.” As an example of the combined power of BaseHealth and TriVita, a patient can send his weight regularly to a coach, and both can view the implications of the changes in weight–such as changes in risk factors for various diseases–on charts. Some users make heavy use of the coaches, whereas others take the information and recommendations and feel they can follow their plan on their own.

As more and more companies enter connected health, we’ll get more data about what works. And even though BaseHealth and TriVita are confident they can achieve meaningful results with mostly patient-generated data, I believe that clinicians will use similar techniques to treat sicker people as well.