Health Regulations

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Get Your Engines Ready for CSM 2015 Indianapolis

CSM2015Marquee_960x222I’m not a physical therapist, healthcare professional, nor do I play one on TV, but I can’t wait for my third American Physical Therapy Association conference. While I’ll be spending most of my time at our booth (2114 if you’re looking) on the exhibition floor, I’ve managed to find a shortlist of 46 sessions I’d like to attend, and this is from someone who is not looking for clinical practice sessions.

Screen Shot 2015-01-27 at 11.10.50 AMNext week over 10,000 physical therapists, doctors of physical therapy, PhD researchers, and students will converge on Indianapolis (yes, in winter) for the annual American Physical Therapy Association Combined Sections Meeting. The Combined Sections Meeting or CSM as it’s often referred to (we do love our acronyms in healthcare) combines all the interest groups and professional associations within the association including private practice, oncology, neurology, homecare, acute care, orthopedics, sports medicine, and students and academic researchers. The result is a diversity of topics that represent the major trends in healthcare today including: concussions in youth sports; the impact of the Affordable Care Act on practice; high-intensity interval training; caring for an aging population; managing chronic disease; preventative medicine, health and wellness; healthcare technology; and the psychology of pain.

See for yourself in a selection of some of the 46 sessions we’ve flagged:

Sports Concussions in Youth: The Role of PT for a Surging Population

Transforming Physical Therapy Practice for Healthcare Reform

Exercise Prescription for the Older Adult With Multiple Chronic Conditions

Getting Patients Into Cardiac Rehab and Other Wellness Programs and Keeping Them Exercising After Rehab

Google Glass in Physical Therapy Education and Clinical Practice

High-Intensity Interval Training: Rehab Considerations for Health and Cardiovascular Risk

Practice Issues Forum: Does Medicare Really Cover Maintenance Therapy?

I Have Arthritis. Is My Running Career Over? Evidence-Based Management of the Runner With Osteoarthritis

Called to Care: Integration of Positive Psychology

Integrating Physical Therapy in Emerging Health Care Models

Virtual Reality and Serious Game-Based Rehabilitation for Injured Service Members

Of course, our most anticipated session will be “Use of Mobile Health Technology to Facilitate Long-Term Engagement in Exercise in Persons with Chronic Neurological Conditions” where Dr. Terry Ellis Director of the Center for Neurorehabilitation and a Associate Professor at Boston University will be presenting the results of a study where they used Wellpepper and Fitbit to improve adherence to home exercise programs for people with Parkinson’s disease. For a sneak preview of what she will present, see this article from Inside Sargent Magazine.

As in 2013 and 2014, we will do our best to blog about as many sessions as we can so that if you can’t make it to the conference this year, you can still experience some of the flavor.

If you’re going to CSM, what sessions are you looking forward to most?

Posted in: Adherence, Aging, Exercise Physiology, Health Regulations, Physical Therapy, Prehabilitation, Rehabilitation Business, Sports Medicine

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Improving Healthcare Quality, Costs, and Outcomes in Washington State

Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has. Margaret Mead

Naysayers who can’t see how healthcare is going to move from a fee-for-service to an outcome and value-based model should look at the work being done by organizations like the Institute for Healthcare Innovation, the American Board of Internal Medicine Foundation’s Choosing Wisely program, and The Bree Collaborative.

Last week, I attended a meeting of the Dr. Robert Bree Collaborative, an initiative in Washington State spearheaded by Governor Christine Gregoire in 2011 and named in memory of a physician who focused on cutting back use of inappropriate medical imaging in the state. The goal of the collaborative is:

“…to provide a mechanism through which public and private health care stakeholders can work together to improve quality, health outcomes, and cost effectiveness of care in Washington State.”

Dr. Robert Bree CollaborativeMembers represent some of the top healthcare organizations in the state, as well as representatives from government, and payers. All meetings are open to the public, and the public is encouraged to attend and provide comments. (At the meeting I attended, most of the public seemed to be made up of healthcare industry folks like myself, although there was one attendee who spoke both as a physician and as a patient.)

The Collaborative’s mandate is to tackle four topics per year for quality and process improvements with the aim of statewide adoption in healthcare. Previous recommendations have included those for total joint replacement which is a hot topic due to new Medicare fines for readmission and lumbar spinal fusion, another hot topic due to the rising costs of back pain to employers, health systems, and in lost productivity. Recommendations include not just process recommendations and standardized ways to track outcomes, but also how to deliver care in a bundle. Payers like bundles because they provide some predictability to costs. Patients like bundles for the predictability of costs but also what they can expect from their care. Bundles pose the greatest challenge for providers, as often many of the services are provided by different organizations, for example skilled nursing or specialized physical therapy. Often surgeons are not even employed directly by the hospital where the patient undergoes a procedure. In this situation the hospital or healthcare organization needs to play quarterback and make sure the other organizations are staying within cost and quality guidelines. Add into this the fact that outcomes are so dependent on patient behavior and you can see what a tall order the Bree Collaborative, and organizations like it, have taken on.

At last week’s meeting topics included updates from groups focused on End of Life Care, Addiction/Dependence Treatment, as well as, an update from the state of Washington on state-wide measures to track quality and outcomes. New initiatives that were approved for 2015 workgroups included Coronary Artery Disease, Prostate Screening, Opioid Use, and Oncology. If you are a patient, provider, or payer stakeholder with an interest in any of these topics, you may want to subscribe to The Bree Collaborative’s newsletter to stay abreast of the workgroup’s progress and any recommendations.

In Western Washington, a new purchasing coalition made up of employers with less than 5000 people has formed. The Northwest Healthcare Purchaser’s Coalition is hoping to drive better outcomes and lower costs by combining the purchasing power of many smaller employers. In particular this group is working with local payers and providers Western Washington to try to lower the costs of back pain by implementing Bree Collaborative Workgroup recommendations at the community level. This means both clinical adoption within local healthcare organizations but also public education and awareness about recommendations for reducing back pain.

Going back to the quote from Margaret Mead that started this post, there is no doubt that The Bree Collaborative members are thoughtful, committed, and working for change. Possibly the one thing that is missing is more voices from citizens. All meetings are open to the public. If you have personal experience either positive or negative, especially around care, outcomes, and costs for any of the topics that the Bree is tackling, you’d be welcome at the next public forum. See you there?

And if you’re not in Washington State, there are initiatives like this going on across the United States. Not all are as friendly to the general public, but it’s our health and everyone needs to find a way to participate.

Posted in: Health Regulations, Healthcare Disruption, Healthcare transformation, Seattle

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Support for Telemedicine in Rehabilitation

Recognized barriers to telemedicine in rehabilitation, for example, the need for hands on intervention, a lack of billing codes, and not enough studies on cost-effectiveness, did not damper the enthusiasm for the potential of the field and the inevitability of future interventions at American Congress of Rehabilitation Medicine annual conference in Toronto. Presenters in numerous sessions demonstrated the many benefits of tele-rehabilitation for patients, providers, healthcare systems and payers.

Two sessions we attended, “Use Of Telemedicine In Spinal Cord Injury And Pressure Sore. A Pilot Project “ and “Tele-rehabilitation: A New Frontier In Geriatric Rehabilitation” debunked many of the common myths of telemedicine including:

  • Concerns about patient privacy
  • Ability of seniors to use telemedicine
  • Diminished care quality

Instead what they showed was:

  • Patients were more than willing to invite the video into their homes
  • Seniors and people with severe disabilities can use technology with the right support
  • Care quality can be improved by telemedicine

However, even with solid data presented in all of these sessions, presenters joked that telemedicine still largely suffers from a disease called “pilotitis”, that is never progressing past the pilot stage and a proliferation of pilots.

The Use of Telemedicine In Spinal Cord Injury And Pressure Sore: A Pilot Project

Norwegian Health SystemThis session showcased another great example of an interdisciplinary team, common at this conference. This team was from Norway, as they called it “land of trolls and polar bears.” Norway has a total area of 385,252 square kilometres and a population of 5,109,059 people (2014). 84% of the population has smart phones. Like most countries other than the US, they also have socialized medicine. Telemedicine was first introduced in Norway in 1980, so the fact that this project was still a pilot points to some of that “pilotitis.”

The driver for this particular project was two-fold: improve patient care by enabling patients to stay in their home, extend the reach of specialists to rural areas. Both are common reasons for telemedicine, and also can help lower healthcare costs in this case by decreasing transportation of the patient to a medical center located a few hours away. This particular intervention focused on helping Paraplegic patients manage pressure ulcers. Due to both cost and patient preference, patients with spinal cord injuries are being released earlier from hospital. However the risk of developing a pressure ulcer is greater and local healthcare support often does not have the expertise needed.

In this case, a team from the hospital would check in with the patient via video conference through a web camera at the patient site. Now, here’s where we debunk the myth of patient privacy. The patient in this case was so happy with the remote support and care he received that he agreed to have the recording of his sessions shown at the conference. For those unfamiliar, pressure ulcers occur in intimate locations like the buttocks. The team did a great job of showing how they manage to capture high-quality video over speeds as low as 256k and keep the privacy of the patient protected by positioning the camera only on the ulcer with no identifyiable patient visuals. (The video presented in the session was not for the faint of heart though.)

Patient benefits

Telemed costs

 

 

 

 

 

 

 

 

Benefits that the team saw were:

  • Cost-savings from decreased hospital stay
  • Decreasing travel exhaustion for the patient
  • Supporting the nurses in the community and helping them improve skills
  • Time-saving as the patient was always ready at the exact appointment time
  • Continuity of care, although interestingly, summer vacations caused some discontinuity and showed that this is not ensured simply by having Telemed.

Some best practices they identified included making sure that all introductions were completed for context, safety, and dignity before starting the examination, excluding personally identifiable information from sensitive video, and working with an interdisciplinary team to deliver results.

 

Tele-rehabilitation: A New Frontier In Geriatric Rehabilitation”

This session reinforced the need for telemedicine to support patients in their own homes. Dr. Helen Hoenig from Veterans Affairs described the gap between what the patient was able to do in the hospital and what they were able to do at home. For example, one veteran was released from the hospital proficient at using a walker but had no way of getting into his house because of the large number of steps. Having the veteran capture photo and video and send it for review (a method known as “store and forward” or “asynchronous telehealth”), enables staff at the hospital to provide advice and programs that are more applicable to the veteran’s real home situation.

Another example was of a patient who was given a shower chair and taught to use it during occupational therapy sessions at the hospital. When he returned home, it was obvious that the chair didn’t fit in the shower, and needed to be replaced with a bench. During the next video telemedicine session, the veteran practiced getting in and out of the shower using the shower bench while the occupational therapist coached remotely. (Unlike our Norwegian example, this person was fully clothed on the video.)

Veterans Affairs spends up to $6000 per person on home renovations for disabled veterans who need it. Having occupational therapists who are able to see the home remotely and help the veteran navigate it, as well as provide suggestions for modifications can help maximize the benefit of spending this money.

Our favorite part of this session was the presentation by Nancy Latham from Boston University who shared preliminary results from their study using Wellpepper and FitBit to keep activity levels high for people with Parkinson’s. People with Parkinson’s often see a dramatic decline in activity levels. However, the healthcare system has little or no support for long-term exercise needs. This randomized control trial had one group receiving the usual care condition which was an in-person visit and exercise prescription. The m-health group received an in-person visit but their exercise program was assigned using Wellpepper for their program with custom video, reminders, and messaging with a physical therapist. They were also given a FitBit. The results are extremely positive for exercise adherence, self-efficacy, patient satisfaction, and most importantly outcomes, judged using the 6-minute walk test. Stay tuned for early 2015 when we’ll have the final results to share with you. If you’d like to see the preliminary results, contact us.

Posted in: Health Regulations, Healthcare Disruption, Healthcare Technology, M-health, Rehabilitation Business, Telemedicine

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Helping Patients Protect Their Own Personal Health Information

Last week I was leaving a meeting at a large hospital when I saw a patient record sitting on top of the payment machine in the parking garage. Incredibly this is the second time that I’ve seen documents left here. People put them down when they pull out their wallets to pay for parking and then walk away.

Patient Record on ParkingThe information the patients left behind included treatment plan instructions – so you can be pretty sure they are not doing their follow up home care – but worse than that it contained a schedule of future appointments with the patient’s name, date of birth, and social security number. Yes, you read that right: a perfect package for anyone practicing identity theft. This was all on a page that was printed directly from the EMR. The DOB and SSN were probably included on the record to verify that the information was for the correct patient, but this could be verified by asking the patient without printing it on a schedule of appointments.

So – first things first – I took the paper records back into the hospital. But afterwards it got me thinking about information protection and privacy, and in particular about the many people who still think that a paper print out is more secure than the cloud.

Although concerns about information protection and privacy are valid, many of the major HIPAA breaches of the last few years have had nothing to do with the cloud and usually are related to human error and not great security practices.

A few examples:

Good protection of patient information is important whether that information is in the cloud, on an internal computer or system, or on paper. HIPAA regulations encourage building good encrypted software, however we also need to have safeguards to protect against human error.

If patient information were in the cloud, the patient would either access the information through a secure portal, email, or application on their mobile device. He or she would then authenticate themselves to receive the information, and would not need to worry about accidentally forgetting their treatment plans sitting on a parking payment machine.

While patients expect to be able to interact with their healthcare providers through portals and mobile applications in the same way they interact with their banks, many healthcare CIOs we’ve encountered are still extremely wary of cloud-based systems. Financial services is another heavily regulated industry that has been able to successfully move to the cloud to better serve its customers.

Wellpepper is a cloud-based application, which in the healthcare world, makes us a business associate and on the hook for any breaches of patient health information. On the hook means that we need to sign a HIPAA agreement with any organization and we have liability for breaches of information. This is a job we take very seriously and we do our utmost to protect all information that flows through Wellpepper. This includes encrypting information at rest and in transit, ensuring strong passwords, and conducting audits of our system as well as making sure we are well-insured.

With Wellpepper, we provide the same level of encryption and safeguards to the patient’s own device as we do on the clinical devices. Information is not stored locally so if a device is lost or stolen there is much lower risk than in the laptop examples. Patient can do whatever they like with their own data. If I want to post my x-rays on the lamppost in-front of my house I can do that. However, that doesn’t mean that a healthcare organization should facilitate me in sharing my personal health information, which is actually significantly easier with paper-based systems than cloud based.

Yes this information would have been transferred over the Internet which could leave it open for hacking but a secure cloud system is no less, and sometimes more secure than internal IT systems which are also vulnerable. The key is to ensure that everyone in the chain, from internal IT to external partners, and finally to the providers and the patients understands the importance of protecting health data, and has the tools they need to do so, whether that’s on paper, online, or in the cloud.

Posted in: Data Protection, Health Regulations, Healthcare Technology, Healthcare transformation, M-health

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Adopting Technology in Healthcare for the Right Reasons

Regulations, process, and records keeping are all important parts of managing health IT; however, when implemented without a strategy focused on patient and business value, they can create headaches for CIOs, not to mention patients and healthcare providers. This was an emerging theme Institute for Health Technology Transformation Conference held in Seattle at the end of August.

IHT2 Summit in SeattleThe conference featured speakers from across major healthcare organizations. Mayo Clinic CIO Chris Ross gave the final keynote which summarized many themes of the conference and provided direction for the future. He described Mayo’s tradition of using industrial and process engineering to deliver on Mayo’s promise of team-based integrated care. Viewed through this lens, imperatives to integrate EMRs, adopt ICD-10 and attest to Meaningful Use became opportunities that aided the business, and enhanced patient care. However, he was clear that while these projects were necessary, they were not sufficient by themselves to achieve Mayo’s vision. He went on to describe projects underway to optimize the workflow for their clinicians, in one instance reducing the amount of time doctors spent using IT tools from 30 minutes to 5 minutes per patient. He also described the vision of having hundreds-of-millions of lives under Mayo’s care, and the patient-centric model that they were following to achieve this. This included projects like delivering the Mayo app deeply integrated with Apple’s HealthKit technology.

Ross also asked his peers to consider the move to electronic records keeping to be a move to digitizing the healthcare industry to keep pace with the innovation available in other industries instead of a regulatory requirement. He envisions a system where a unified data platform provides digital care and knowledge management and recording keeping is a by-product of that system.

Focusing on the right strategy was also a theme in a talk by Dr. Nick Wolter of the Billings Clinic. Wolter described a 1993 merger with Deaconess that nearly bankrupted the organization. The merger was focused on regulatory and process integration while ignoring the vision for the new organization. In 1997, with financial losses posted, they hired turnaround experts who focused on physician leadership development. By 2005 they had established a vision to be best in the nation for patient safety, quality, and service. In 2010 Billings Clinic added value to their mandate and are looking closely at ACO metrics to make sure they are delivering on these promises.

Throughout the two-day conference, panelists called out EMRs as a significant driver of physician dissatisfaction. While meaningful use requirements have increased the focus on moving to electronic records, in many cases this is apparently happening without a vision that leverages these transformations to improve physician efficacy and patient care, which is unfortunate as these two areas if provided with appropriate electronic tools could see some of the biggest benefits.

Although there is was definitely a dissatisfaction expressed with the current state of health IT, it was promising to see shifts towards tools that are more focused on provider workflow and patient engagement. Even more promising was the general understanding at this conference that digital healthcare can and should be better delivered. At Wellpepper we’re excited to support this shift to a patient- and value-centered system.

Posted in: Health Regulations, Healthcare Disruption, Healthcare Technology, Seattle

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Just Because You Can, Does That Mean You Should?

Facebook’s recent experiments in social media mood contagion got us thinking about user-based testing in general and especially how that applies in healthcare technology that is intended to influence behavior.

The Experiment

happyFor one week in January 2012, Facebook manipulated the feeds of users to show content that was either positive or negative and then looked at whether this had an influence on users. The main point of contention or dissention is that this was human subject research without consent from the subjects and without the oversight of a review board as would be expected for university research. If the research hadn’t been published in a scientific journal then there might not have been so much controversy. What is the difference between A/B testing and what Facebook did? In A/B testing, marketers test different landing pages or campaigns and see which one works the best for their desired goal. Consumers don’t know that they are part of an experiment to test messages. However, consumers did freely follow a link that brought them to the content. The difference with Facebook is probably first, that they have significant power due to the volume of users and more importantly what they know about those users, and second although Facebook lawyers will tell you their terms of use covered it, Facebook users probably did not sign up with the expectation that Facebook itself would actively attempt to make them happy or sad.

How Do You Test Behavior Change?

It’s an interesting question for those involved in healthcare, and in particular trying to help people modify their behavior. In our case, at Wellpepper we are helping people be more adherent to home treatment programs. To do that we use a number of motivating factors including personalization and notifications. As part of building our application we test which features are effective in motivating people. We continually improve and change the application based on what we learn. Is this testing on human subjects? Yes. Did we get permission? Yes. This is part of our terms of use and it is also an essential part of how the industry builds software that people will use: by testing that software with real users. When people start using our software they use it to help them with a specific problem and they are happy when we make improvements to make it more effective to solve that problem. We encourage user feedback and implement new features based on it. So while, we may test new features, it is part of the implicit agreement of delivering software to users. (If you’ve ever used software that was not tested with real end-users, you’ll know the difference.)

When we test and add features that help improve user experience and become more adherent to their treatment program users are happy because we have helped them with their goals for using our software and the implicit contract with them. If we started testing and adding features that made them less adherent or changed some other type of behavior that they weren’t trying to change using our application we would have broken that contract and they might vote with their feet or in this case fingers and stop using the application.

What’s Your Implied User Contract?

The same thing could happen with Facebook, and it stems back to what their intention is with this research. The unfortunate thing is that they probably have enough data to have figured out that positive newfeeds make you happy and negative newsfeeds make you unhappy without actually manipulating the feeds. The fact that they did this, and did this without consent, brings up a bigger question of what their intention is, and what exactly is the implicit contract you have with Facebook. What exactly is their motive in trying to manipulate your emotions? For marketing experiments of this type the motive is pretty clear: consume more of their product. For Facebook it might be the same, but the fact that they tested negative messages does cause some alarm. Let’s hope they use their power for good.

Wellpepper2-1216aFor software developers that aim at healthcare behavior change there is an additional challenge as we think about testing features with real users. In order to help someone change behavior you need to test what works and that does need to be with real users. In general software development there are industry best-practices, for example, where you test different designs to find out which is most effective. This may be considered “experimentation” as users will not see the same features and some of the features they do see may not make it into the final version of the product. When you are doing this type of testing, you are looking for what is most effective in helping users achieve their goals. However, this testing must be done while protecting personal health information and not providing any harmful impact to the patient. Software developers can partner with research organizations whose internal review board will ensure that research on human subjects is conducted in the right way. To prove out efficacy of an entire application, this is often the best way to go but not practical for feature testing.

Guidelines for User Testing in Consumer Healthcare Applications

While looking at specific feature testing, these guidelines can help make sure you respect your end-user testers:

  • Unless you have explicit consent, all user testing must be anonymous. This is because if you are dealing with PHI and have signed a HIPAA BAA you have agreed to only access PHI when absolutely necessary. If you need to know demographics of your users for user testing, then you should err on the side of getting their explicit consent. This could be either via a form, or simply a non-anonymous feedback form on your application or website. By providing you with direct feedback the user has agreed to not be anonymous. (The good thing here is that patients can do whatever they want with their own data, so if they give you consent, to look at it, you have it.) That said, if you are working with healthcare organizations you will also have an agreement with them about contacting their patients: you need to make sure they have agreed to this as well. When possible err on the side of making data anonymous before analyzing it.
  • Think about the implicit contract you have with the user. If you are providing them with an application that does one thing, but you discover it may have applications for something else, don’t test features for that something else without getting consent. That is breaking the contract you have with them. Let’s look purely hypothetical example: at Wellpepper we have an application that increases patient adherence to home treatment programs for those undergoing physical rehabilitation. Let’s say we found out that people in physical rehabilitation are also often fighting with their spouses and started adding features or asking questions about the user’s relationship with his or her spouse, users would find this both unnerving and intrusive because that was not their expectation that we would help them with marital issues when they signed up for the application. Obviously this is a bit far-fetched, but you get the point.
  • Don’t get in the middle of human-to-human communication. This is essentially where Facebook broke the implicit contract with users by dis-intermediating the newsfeed. Your expectation with Facebook is that it’s a way for you to communicate with people (and sometimes organizations) you like. By changing what showed up in your feed, Facebook got in the middle of this. In healthcare this is even more important: don’t get between healthcare professionals and their patients. Make sure it’s clear when it’s you (the application, the company) talking and when it’s the caregiver and patient.
  • Consider where you’d get more value by partnering with a research organization. Sure it will take longer and may require more effort, but you will be able learn a lot more about why or how people are using your features by getting explicit research consent. I am not sure if it’s a coincidence or not but about a month ago I noticed that my Facebook newsfeed was full of extremely depressing stories. I remember wondering what was going on both with Facebook and the world in general and I remember wanting to post something depressing but then thought, “No I don’t want to add to this. I will only post positive things.” It’s possible that I was part of another study by Facebook and if so, they didn’t get the full picture that they would have if they’d been upfront about it, got my consent, and were able to ask me questions later about my thought process.

There is no doubt that we will see more discussions of ethics and consent in the space of user testing, especially as it relates to consumer-facing health applications. Having no regulation or guidelines is not good for consumer. However, only doing research with IRB and third party researchers is also not good for the consumer as innovation that could really help them can be slowed dramatically. Most people, whether healthcare practitioners or entrepreneurs got into the space because they wanted to help people. If we remember this, and we consider the ethical implications of our actions, we should be able to balance the two worlds.

For more reading on this topic as it applies to the software industry, see:

http://en.wikipedia.org/wiki/A/B_testing

http://ai.stanford.edu/~ronnyk/2009controlledExperimentsOnTheWebSurvey.pdf

http://www.exp-platform.com/Pages/expMicrosoft.aspx

Posted in: Behavior Change, Data Protection, Health Regulations, Healthcare motivation, Healthcare Social Media, Healthcare Technology, M-health

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Big Distances Make the Case for Telemedicine: Recap from the Canadian E-Health Conference

Vancouver Convention CentreJust back from the American Telemedicine Conference, and we took a short trip over the border (and back to the motherland), to the Canadian E-Health Conference in Vancouver, BC. Due to the short timeframe between conferences, it’s hard not to compare and contrast the two, although the healthcare systems between Canada and the US could not be more different. The E-health conference had a broader scope than the ATA conference, with telehealth as a sub-topic and electronic records management featured more broadly, in fact, all the major EMR vendors were there, with the exception of Epic.

Know Me in Powerchart

Know Me in Powerchart

In a session sponsored by Cerner, Island Health CMIO and Acting Executive Medical Director, Dr. Mary-Lyn Fyfe shared their patient-centered approach to EMR implementation called “Know Me.” Island Health Authority has been a Cerner customer for 5 years, and have a robust implementation with plans to extend to patient recorded profiles. Dr. Fyfe talked about how what is most important to patients is not always evident or even apparent to healthcare providers, for example, a patient admitted for heart issues but who is more concerned about who will care for his spouse at home with dementia rather than his own condition. Only by treating the whole patient does Dr. Fyfe believe that healthcare providers can have real impact.

Although telehealth was not more advanced in Canada than what we’ve observed in the US, Canada has real financial incentives for telehealth. Vast distances and sparse populations make delivering a high-level of care in many parts of Canada very expensive. The more that can be done remotely, the better. One group covering First Nations groups boasted that they had delivered nine telebabies, that is babies delivered with the help of a doctor over telemedicine. Another doctor talked about how his being able to coach a medical assistant onsite through a video call prevented a $10,000 emergency helicopter flight. Others talked about the environmental benefits of thousands of car trips of 3-4 hours that were avoided by using telemedicine, not to mention the quality of life improvements for patients. Another benefit of telemedicine that we hadn’t seen cited before was doctor education, this is in the scenario where a local primary care physician calls a specialist and together they meet with a patient. In an in-person specialist care scenario the patient would not see these two physicians at the same time. Having both in the same patient visit enables knowledge sharing between the doctors, for the specialist more context on the patient, and for the primary care physician education about the specialist’s area of expertise and the patient’s condition. You could call this collaborative telemedicine.Hackathon

While telemedicine is well established in Northern Canada, it seemed that the benefits in parts of Canada closer to the US border where most of the population lives were not as well established, and a surprising number of telemedicine initiatives were still in pilot mode. Similarly there seemed to be a great disparity in electronic records management with some health authorities still entirely on paper.

Kicking off the Canadian Telehealth Forum, which was a pre-conference session and also an annual event, Joseph Cafazzo of the Center for Global E-Health Innovation showed examples of home monitoring technology that did not take into account the users, who are primarily seniors, and called on the audience to consider empathy in the design of products. One of the key reasons for this is that the only person capable of managing a chronic illness is the patient themselves, and yet many don’t want to identify with their illness or be reminded that they have it. Empathy to the patients experience can help in designing products that make it less intrusive for patients to manage their health. The Juvenile Diabetes Foundation has been putting pressure on manufacturers for this as teens in particular don’t want to take their blood sugar readings although it’s crucial to their health. The Center for E-Health developed an application that identified the times that teens really don’t want to take readings (at lunch when they are at school for example), and offered rewards like iTunes giftcards for doing so, a great example of a carrot that is attuned to the patient’s preferences.

Mobile health seemed in the same place as in the US: a lot of very interesting, patient-centered applications like the 30-day stroke assessment from the Center for E-Health and the Heart & Stroke Foundation of Canada, which used AirMiles rewards to entice a high-risk group of men to download and complete the assessment. Engagement was 12% across all groups, including seniors. One of they keys to the app was that it focused on a short-timeframe, although this does bring up the question of how to keep patients engaged over the long-run.

Not surprisingly a number of solutions were based on lowering costs of population health management. Because healthcare is government funded, unlike the US there are real incentives for decreasing costs as well as keeping the population out of long-term care. While many solutions addressing issues such as CHF and COPD are in early stages, we heard lofty goals of increasing the number of outpatients managed by one nurse to over 200, and also using wellness coaches to scale further.

Considering that unlike the US, all the economic and patient incentives are aligned for e-health, it was a bit surprising that so many of the solutions and presentations were about pilots rather than completely implemented systems. However, that might be a tradeoff of having government run programs. Regardless, the conference featured many passionate speakers who are using innovative solutions to both improve patient outcomes and experience while being cost-effective.

Posted in: Behavior Change, Health Regulations, Healthcare Disruption, Healthcare motivation, Healthcare Technology, M-health, Telemedicine, Uncategorized

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IT Can Make a Big Difference in Healthcare, Why Hasn’t It?

The final in the excellent collaborative healthcare series from the University of Washington and the Washington Biotechnology and Biomedical association did not necessarily end the series on a high note: speaker Peter Neupert presented a view of the near-term realities of healthcare evolution that was sobering for technology vendors. Basically Neupert’s thesis (and investing thesis) is that technology alone cannot have an impact on healthcare process and outcome improvement, and that pure technical solutions are doomed in the current situation where there is a lack of symmetry between the recipient of service and the payer of the service.Determinants of Health

The benefit of technology historically has been to create efficiencies and economies of scale by reducing manual efforts and waste. In the current system, the payers are incented to decrease costs, however, the way many providers are paid (fee for service) result in no incentives for them to reduce cost. Also, we currently have a disjointed system where payers and employers are responsible for the health of people until age 65 and the government is responsible afterwards, which is not conducive to preventative medicine or efforts to help the long-term health of the population.  Changes in healthcare models as part of the Affordable Care Act will drive the need for providers to be concerned about both population and long-term health but right now, we are in transition, which is why Neupert is betting (at least in the mid-term) on services that are delivered with technology rather than technology on its own unlike other industries. Neupert believes the winners will be those who can deliver a healthcare service more efficiently with technology, for example, home care systems that are able to do remote monitoring with telehealth and sensors and find problems before they become major issues.

Another reason Neupert cited as a reason that Health IT has not made the impact it could have is that in the US in particular, 5% of the people represent 50% of the cost. The reasons for poor health in this 5% are heterogeneous, which also makes it hard for a pure technology solution to address and do what technology does best which is scale. Neupert gave the example of an outpatient care company that produced better outcomes by simply making sure that patients had a ride to their follow-up care, a decidedly low-tech solution. As we think about preventative health solutions, it’s not enough to consider the person in treatment, we also have to consider the environment, for example, if you want to change a person’s diet you also have to change the diet of their family. Technology could help here, for example visual food journals have proven to be effective, but step one is often making sure the family has access to fresh food and knows how to prepare it.

Big data is another lauded savior of healthcare. But if data is not used it is not accurate. Again, there needs to be incentive to use it and that will drive data accuracy and results. Neupert gave the example of New York Presbyterian who have over 100 hospital applications and consequently very good data and contrasted that with the statistic that cause of death is cited incorrectly 25% of the time. Applying analytics to that data would be futile as we’d be trying to prevent the wrong cause of death.

Healthcare IT is grappling with problems that other industries faced years ago, for example, moving to the cloud, bring your own devices, or single-sign on. The key is for both healthcare organizations and technology companies not to see IT or the implementation of an EMR as the savior of improved healthcare, but as a tool that can enhance human-based processes. At Wellpepper we know that a key driver of patient adherence to outpatient treatment plans is the connection and relationship patients feel with their healthcare provider and think that technology is a great tool to enhance and extend that relationship.

We’d like to thank the Health Innovator’s Collaborative, the University of Washington, and the WBBA for this series. It provided inspiration, innovation, and an important dose of reality to big thorny problems. We hope to see this continue.

Posted in: Health Regulations, Healthcare Disruption, Healthcare Technology, Healthcare transformation, Seattle

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Dispatches from the 2014 American Telemedicine Association Conference

BaltimoreWe just returned from the 19th annual American Telemedicine Conference in Baltimore, MD. It was an amazing opportunity to network, meet telemedicine pioneers, and get energized about the opportunities to improve patient care. While there are still some major barriers to care, first in the way of billing codes and second in the way of cross-state licensing, speakers were confident that these legislative issues will be solved for a number of reasons: telemedicine is effective, it’s what patients want, and it can improve access to care and decrease costs.

Telehealth in Practice: Chronic Disease Management

Similar to what we’re seeing in all healthcare, a one-size fits all approach does not work when it comes to telehealth either. For some patients it works extremely well, and for some even the most rudimentary telehealth (i.e. phone calls) doesn’t work. We heard many discussions about green, yellow, and red patients. Green are those that are able to take care of themselves and their recovery. Yellow are those that have some risk, particularly of hospital readmissions. Red are those who are a definite readmissions risk. While Red patients often cost the most money, they may not be the best candidates for the cost savings of telehealth. One speaker pointed out that the most challenging of “red” patients often move without notice or have their phones cut off which makes even the simplest intervention, either a phone call or a house call impossible. This speaker suggested that while the healthcare system needs to figure out a solution for these patients, they are often used as examples of why telemedicine doesn’t work. Using this as the standard will definitely set us up for failure as the benefits for those green and yellow patients are real.

Congestive Heart Failure is the number 1 reason for hospital readmissions, and not-surprisingly a number of sessions dealt with follow-up care for this population. As well, repeated CHF readmissions also lead to long-term mortality. In practice ensuring follow-up visits reduced readmissions, however, in-person follow up visits are both expensive and inconvenient for patients. Carolinas Healthcare Systems started a telehealth follow-up program for CHF in June of last year, and are already seeing results for their Heart Success Virtual Clinic. First, patients have been saved over 3,900 miles and 380 hours of travel. Second, the follow-up rate for virtual visits is >95% compared to 70% at the in-person clinic, and the no-show rate is 3% compared to 10%. Telehealth visits are more convenient and as one speaker pointed out “it’s hard to miss a visit that’s in your house” so no-shows decreased as well. While the study hasn’t been completed yet, they are expecting a 50% decrease in readmissions for the patients that are participating in telehealth visits.photo 2

The University of Arkansas Center for Distance Health also saw positive results for CHF by using a call center to manage 30-day post-discharge follow-up coupled with an EMR. While on the phone with the patient, an RN verifies whether the patient has been seen by a nutritionist, is on a special diet, is managing fluid intake, has been in touch with a patient educator, and has scheduled a 1-week follow up appointment. Patients were instructed to call the hotline with any questions, concerns, or worsening symptoms. During the pilot from May-July of 2013 the program saw a 31% decline in readmissions resulting in $60,000 in cost savings to the organization (this did not include the costs of any Medicare fines). When the program was rolled-out to the entire patient population in Q1 of 2014, 34 readmissions were prevented with a total cost savings of $418,000.

Other examples from the conference involved care team and peer support for patients. A bariatric program run by DPS Health included patient discussion groups that were moderated by healthcare professionals. Moderators were present to guide the discussion and ensure that patient questions were answered, but they did this by prompting patients to answer each other’s questions rather than having the moderator jump in. This peer support helped participants achieve an average weight loss of 4-5%.

Sensors and Information Overload

It seems that the greatest promise for telemedicine though comes at the convergence of patient self-care, collaborative team care, and access to information, and patient provider communication. Patients can take more responsibility for their care outside the clinic using monitoring, apps, and sensors. However, the best results were seen when those patients were able to communicate remotely with healthcare professionals, and when those healthcare professionals also had access to information. However, none of this should come at the expense of care. While sensors were a hot topic, tools must be developed to help healthcare professionals deal with the influx of data. They need to be able to triage the information and get to the relevant and actionable information. One physician said that we don’t have a primary care physician shortage, but due to the extraordinary demands of documentation, we do have a shortage of physician time. Trackers and sensors should not increase this burden if they want to have an impact on care.

At the conference we saw sensors for just about everything, including a few questionable brain scanners. The sizes of scanners ranged from ankle bracelets to band-aids, and from flashy consumer designs to highly clinical. One speaker was adamant that disposable sensors are the future, citing the “razor/razor blade” model. While disposable are appealing in that they are usually designed to be worn under clothes and are small, we’re not sure about the analogy as the software that comes with sensors is usually free. However, given the number of FitBits we’ve had to replace at Wellpepper due to loss, the idea of a cheap disposable sensor is highly appealing.

What Patients Want

We’ve know since we founded Wellpepper that patients want information, convenience, and access to support from healthcare providers everywhere. It was heartening to see this echoed throughout the conference. Perhaps the most interesting was the data presented by Carena on what happened when a major employer in Seattle moved to a high deductible plan: the total number of PCP visits decreased 52% and the remaining shifted to telehealth. If this doesn’t prove without a doubt that patients are cost-conscious consumers, we’re not sure what does, especially since we happen to know that major employer pays pretty well. It also probably shows that if services are unlimited, people will overuse them.

This was really just a small glimpse of an extremely busy conference. On the one hand, it’s heartening to see all the passion about change, however, it’s also sobering to realize that this was the 19th year for this conference, and yet we still are debating the merits of telehealth, and some states do not allow telehealth. Hopefully though between patient demand, increased access to technology, and the need to reevaluate both the costs of care and how to support population health, this will change.

We will definitely see you next year at ATA 2015, and are looking forward to see how small the sensors have become and how much more ubiquitous telemedicine has become.

Posted in: Health Regulations, Healthcare Disruption, Healthcare Technology, M-health, Telemedicine

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Transforming Healthcare Through IT in Washington State

It seems every week there’s another health IT event in Seattle these days and we’re pretty excited about that. The grassroots efforts to build a health community really seem to be starting to take hold.  This week we had the pleasure of attending and presenting about Wellpepper at a Technology Alliance and WBBA event called “Transforming Healthcare Through IT: Investment Opportunities in an Emerging Sector”  held at K&L Gates beautiful offices. The WBBA officially launched their new Innovative Health initiative at the event: they are adding a third focus area to their current biomedical and biotechnology pillars and taking up the mantle of healthcare IT. Given that the lines are blurring between medical devices and mobile devices and software in particular, and that the WBBA are experts in healthcare regulations, this is a welcome move.

The view from K&L Gates Seattle, copyright K&L Gates

The view from K&L Gates Seattle, it was that beautiful this week. Source: K&L Gates

The event was kicked off by Rob Arnold of VantagePoint Investments, who outlined why health IT is so hot right now with a review of a number of trends including patient-centered care and the new requirements of the Affordable Care Act. However, he pointed out that Seattle really didn’t register as a center of healthcare IT investment. San Francisco, New York, Chicago, and even Atlanta and Nashville were far ahead. And yet, as we’ve heard many times we have some of the best healthcare systems in the country and some of the best software developers in the world. What we don’t have is investment, but this event, by bringing together investors, startups, and providers was aiming to change this.

Next up was a panel focused on the landscape of and future of IT moderated by John Koster, MD and former CEO of Providence Health & Services, with panelists Todd Cozzens from Sequoia Capital, Mark Gargett, VP of Digital Integration, Providence Health & Services, and Ralph Sabin from Fortis Advisors. The current state of health IT is not great: 80% of health records are running on a 45-year old technology called MUMPS (ie Epic), and 65% of providers continue to look for cost savings instead of at the $1T opportunity to fundamentally change how we do healthcare.  The current systems were characterized as a “big calcified hairball.”

EMRs need to transform and unlock the data in them to change this system, to be able to be prescriptive rather than reactive, for example, imagine identifying asthma patients and telling them about environmental changes that might impact their health.

All the panelists agreed that the transformation needs to come from within the healthcare system, and cited Microsoft, Google, and GE’s entrance and exit from personal and electronic health records as examples of why technology alone without a keen understanding of the process and system will not effect change.

On the other hand, there are lots of opportunities to fix small problems, for example, patient workflow or outpatient care. However, these incremental changes are harder to predict: it’s easier to see the large scale changes necessary than to fully understand the steps on the road to get there. This may be why the venture money shies away.

The panel also agreed that healthcare is becoming a retail model with patients as consumers driven by both high-deductibles and also expectations from conveniences in other industries. Providence recognized that consumers are increasingly in control of their health decisions and “want to be delighted.” Todd Cozzens from Sequoia predicted the winners would be those who could deliver on a retail experience, and close to or possibly even in a patient’s home.

Similar to discussion we’ve heard at other conferences about the future of healthcare, there was a belief that the fundamental skillset of individual healthcare providers needed to change: in the past remembering a number of facts and applying them in a particular situation was important. With technological advances like IBM’s Watson, computers can do a much better job of diagnosis and the role of the doctor changes to a social role of translating diagnosis into an effective care plan. Or as we’ve heard it characterized: “putting the care back in caregiving.”

Next up Mary Haggard and Joe Piper from Point B Managing Consultants and Capital, showed their “Health IT Landscape Matrix” which was an attempt to characterize Washington’s health IT companies according to the big buckets of Triple Aim categorized as “Creating Efficiency,” “Unlocking the Data,” and “Improving the Delivery of Care.” At the same time they attempted to categorize by the buyer (consumer, employer, provider, or payer), which wasn’t quite as easy and probably reflects the changing landscape of healthcare. What was amazing about the exercise was to see the diversity and number of players in Washington State. This is a great start to hopefully what will become a definitive reference source for the local industry.

Next up were the startup pitches from Corengi, Owl Outcomes, Health123, MedaNext, Spiral Genetics, 2Morrow, CadenceMD, TransformativeMed, and Wellpepper, which ranged from patient engagement to unlocking data genomics to unlocking data in the EMR (not sure which is harder ;)). We’ve been at events with most of these companies before and it was great to hear how they have gained traction and how their businesses and stories are evolving. As a presenting startup, we were happy to be in such great company both with our fellow audience and with attendees.

Posted in: Health Regulations, Healthcare Disruption, Healthcare Technology, Healthcare transformation, Lean Healthcare, M-health, Seattle

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UW Medicine’s Journey To Become An Accountable Care Organization

As part of the newly forming Health IT community in Seattle, the Unveristity of Washington and the Washington Biotechnology and Biomedical Association have partnered on the “Health Innovator’s Collaborative” which launched with a series of seminars on how the coming changes in US healthcare affect organizations and innovation.

Accountable Care OrganizationsThis past Tuesday, I attended a talk by Paul Ramsey, MD, and CEO of University of Washington Medicine entitled “The Transformation of Healthcare: Forces, Directions and Implications.” Despite this lofty title, Dr. Ramsey focused on the nuts and bolts of the new Affordable Care Act (ACA) with specific examples of how UW Medicine is becoming an Accountable Care Organization (ACO).

First off, Dr. Ramsey started with some definitions of the goals of the Affordable Care Act and Accountable Care Organizations. When asked if the ACA is having a profound effect, he stated that regardless of any other measures, the number of individuals who are now insured is significant. Harborview Medical Center, a member of the UW Medicine System that covers a diverse and often low-income population, has already seen a 2% decrease in patients without coverage.

What was striking about the session was Dr. Ramsey’s clear conviction that while the ACA is morally just (we need to stop pricing people out of healthcare) organizations becoming ACOs were currently doing it because it makes human sense, while not currently financial sense. The reason it doesn’t currently make financial sense is that the first ACO contracts between payers and providers are still in negotiation and in the switch between reimbursements for procedures to reimbursement for outcomes providers initially see lower revenues as they decrease the number of unnecessary procedures. In the long run, this is mitigated by getting the right care to patients and by managing population health in addition to individual health

The triple aim of the ACA is to improve experiences for individuals, improve overall population health, and reduce the cost of care: lofty but extremely important goals. While managed care and HMOs were supposed to do this in the 90s, their main failure was having the primary care physician as the gatekeeper to all other services. This did not guarantee that the patient received the best and most cost effective care. Dr. Ramsey contrasted this to the goals of an ACO, where a patient might call a nurse hotline and be referred to emergency, their primary care physician, or receives an e-care visit, depending on which was best for the patient and most cost effective in the long run.

When asked if this model was a capitated model, Dr. Ramsey said yes, but at a population level, and that is why the current negotiations between payers and providers are so important. Providers are choosing which measures they will be held accountable for in their first year as an ACO. UW Medicine is choosing seven disease management measures, three health status and screening measures, and number of caesarian sections, which is apparently a hot button measure for CMS. Because all measures will not be implemented immediately UW Medicine will spend some time transitioning between models, however, this does not mean they won’t continue to improve care in all areas. He cited his own recent experience as a cataract patient at UW Medicine as of an example where high quality outcomes, patient care, and cost-effectiveness were combined.

As a guide for these types of measures, and as an example of the medical profession taking on best practices regardless of financial incentives, Dr. Ramsey cited http://www.choosingwisely.org where each medical specialty association provides their own guidelines for reducing unnecessary procedures and promoting best practices. This is a great resource for patients as well to review whether costly procedures are actually recommended and effective.

Accountable Care OrganizationsThere was some discussion that the US medical system as a whole could decrease costs by 25% without reducing the quality of care. UW Medicine has been able to reduce costs by $90M annually which is only a 2-3% of their operating budget and remain a top hospital. UW Medicine will continue to improve on both costs and their overall ratings.

Interestingly, the most important factor in patient satisfaction, a key health system rating, is the communication with their healthcare provider, rather than the outcomes. Improving patient/provider communication is an extremely cost effective way to ensure great care.

This was a great talk, realistic yet optimistic about the challenges and opportunities inherent in this transition to the new models of care we so desperately need.

The two remaining talks are:

May 13, 2014: “Demonstrating Value in Health Innovation: Lessons from Comparative Effectiveness Research”

Larry Kessler, ScD, Chair of UW Department of Health Services and former Director, Center for Devices and Radiological Health, FDA, will consider the coming necessity for innovations to demonstrably provide value and how the experience with comparative effectiveness can help innovators gather the needed evidence.

June 3, 2014: “IT can make a big difference in health: Why hasn’t it?”

Peter Neupert, Operating Partner of Health Evolution Partners and former VP of the Health Solutions Group at Microsoft will draw on his extensive experience with both institutional and consumer aspects of health IT to consider the enormous potential and serious pitfalls that make this area of innovation so challenging.

Editor’s Note: The primary care physician as gatekeeper is a failure in the single payer system as well. It denies patients access to the care they need and also adds waste into the system. In Canada for example, a referral to a specialist must be done by a primary care physician and expires every 6 months. So, if a patient has a chronic disease that they need to see a specialist for, the patient cannot keep seeing that specialist without getting another referral, even if all parties agree the patient should keep seeing that specialist.

Posted in: Health Regulations, Healthcare Disruption, Lean Healthcare

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23 and Who? The results

This post is the 2nd in a 2-part series on our experiences with 23andMe.

Wellpepper: What made you want to try 23andMe?

Anne Weiler: I wanted to see what the customer experience was like. It seemed so simple. $99 and they promise to tell you about your ancestry and DNA.

Jacquie Scarlett: I was really interested in getting back the results and seeing if the information I received from 23andMe was consistent with what I already knew about myself and my family history.

Wellpepper: What did you think you would learn?

Anne: I was curious about my ancestry. I had a theory that somewhere in my family someone was Jewish. They weren’t.

Jacquie: I figured that I would get confirmation that I was mostly European and that arthritis ran deep in my history and would be a high risk for me.

Wellpepper: Were you surprised by the results?

Anne: Originally, I was surprised at being 99.9% European. People are always asking where I’m from and they aren’t satisfied with “Canada” as an answer. When I was travelling in Nepal people thought I was half Nepalese. However, since I originally received results, they have been refined, and I’m now only 99.5.% European. I am not sure if that explains anything though.Anne Weiler Ancestry from 23andMe

Jacquie: I wasn’t overly surprised by the results, but found some items very interesting. I knew that I would be mostly European, and I was – 99.7% (mostly British and Irish) – but it was fun to find out that I was .1% Jewish and .1% Native American.  It was also pretty cool to see 479 DNA relatives pop up in my results from all over North America and the UK.

Wellpepper: What was the most surprising result?

Anne: Most surprising were results that contradict my actual experience. For example, 23andMe says I’m at reduced risk for Psoriasis, a hereditary disease that runs in my family and that I do in fact have. This does make me question other results.

Jacquie: There were a few illnesses in the Elevated Risk section that took me back for a moment, but then when I dove into the results I realized that I was merely a few % points above the average for all people and I relaxed. It is a bit surprising to see those illnesses listed in front of you.

Wellpepper: What was the least surprising?

Anne: That I’m at risk for glaucoma. It’s hereditary and I’m familiar with my family history.

Jacquie: High risk for arthritis – very prevalent in my family history and I already have the illness.

Wellpepper: What is your understanding of the accuracy of this test?

Anne: I don’t know the statistical accuracy, but I know that 23andMe was trying to get to 1M DNA records sampled so that they could claim accuracy. I also saw the NY Times article showing the discrepancies between tests. Based on some of my results that are wrong it’s hard to know. The brain is funny though: I definitely want to believe that the results showing low risk for Parkinson’s or MS are correct even though I have other results that are incorrect based on my personal experience.

Jacquie:  I do not know. I have the understanding that the more DNA they receive from the population, the more accurate the results will be and the more information they will be able to find out. I took this as an opportunity to learn more about DNA and the possibilities of what you could learn versus that this is the absolute truth.

Wellpepper: What was it like to receive your results?

Anne: Anne Weiler Norovirus ResistanceIt was addictive. We all want to know about ourselves, and here it was, in great detail. I really loved the random things I found out, like I’m resistant to Norovirus (stomach flu) or that I am likely to sneeze in bright sunlight. I intuitively sensed those things, but had no idea they were genetic.

Jacquie: It was pretty fun and interesting. I love learning more about myself and family history. Even though there was a lot of information, I found myself wanting more and wanting to dive deeper. Every time there was an unknown listed – I wanted the answer – this is what keeps me coming back to the site.

Wellpepper: Since you have received your results how have you engaged with 23andMe?

Anne: They are very good at pulling you back in, either through relatives who want to connect or by releasing new test results. That’s the really interesting (and scary) part. Once your DNA is analyzed it remains on file and they run new tests or more accurate versions of previous tests on it. I didn’t realize that it was going to be such a sticky experience.Anne Weiler DNA Relatives

Jacquie: I have checked in from time to time to see if any of my results have been updated. I also really enjoy doing the surveys – I am very interested in the research that 23andMe is doing and want to help in any way I can.

Wellpepper: Have you shared your information with anyone? Who and how?

Anne: I’ve connected with two 2nd or 3rd cousins on the 23andMe website. I’m interested in finding my maternal grandmother’s family. We don’t know as much about them.

Jacquie: I have shared my results with close friends and family, mostly with family to entice them to do the test as well.

Wellpepper: Would you share it with your doctor?

Anne: If I thought it was relevant to symptoms I was experiencing yes, but otherwise not unless my doctor asked. Doctors are being overloaded with data these days.

Jacquie: I would share the results with them if they would find it helpful.

Wellpepper: Do you think 23andMe will continue to engage you?

Anne: I don’t seem myself using it all the time, but as I mentioned before they do a good job of bringing you back in, and maybe I’ll become more interested in genealogy as I get older.

Jacquie: I will check in here and there. I imagine that if I have a health situation, it will be helpful to be able to pull these results when needed.Anne Weiler Asparagus 23andMe

Wellpepper: Do you think people should have access to this type of personal health information? Is it dangerous?

Anne: They should definitely have access. I thought 23andMe did a good job of presenting potentially disturbing results with the appropriate cautions. For results for chronic and debilitating diseases they make everyone read information about the disease before they tell you if you have the marker for it. I think it could be dangerous if someone started to make changes before talking to their doctor, except for some basic things like avoiding tobacco or caffeine, which are good for you regardless of the markers you have.

Jacquie: Absolutely! I think it’s very beneficial for people to have the most information possible so that they know more about themselves and feel empowered to take care of themselves and their health.

Wellpepper: Based on receiving your results, will you make any personal changes?

Anne:  I will be more helpful to people with stomach flu since I know I can’t catch it, and I’ll be even more strict on my caffeine in the morning only policy.

Jacquie: The results weren’t surprising enough to cause any personal changes.

 

Posted in: Behavior Change, Health Regulations, Healthcare Disruption, Healthcare Technology

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Health 2.0 Seattle Meetup: How to Build Solutions in Healthcare

This was the second Seattle health meetup we attended in March, the previous was the Health Innovators Meetup. Health 2.0 is a global organization (we demoed at a Health 2.0 event in London back in November 2013) but the Seattle group is quite new. They are valiantly trying to help build a community of healthcare industry and startups, and those just interested in healthtech issues in Seattle.

The meetup was hosted and moderated by Tory Kelso of GenieMD, and formerly Microsoft HealthVault and Cerner, and panelists were:
Anand Gaddum, Director, Health & Life Sciences at iLink Systems.
Howard Mahran, CEO & Founder Deep Domain, Inc
Sailesh Chutan, CEO and co-Founder at Mobisante, Inc.

Each talked about the drivers for their participation in healthcare. For Howard Mahran, like many entrepreneurs we’ve met, ourselves included, it was frustration born from a personal experience. When Howard’s father was diagnosed with prostate cancer, he was amazed at the lack of information and data available about the diagnosis and prognosis. Sailesh Chutan was driven by a passion for accessibility to technology on a global basis. Anand Gadddum cited the opportunity for applying resources to the wealth of health data out there to make a difference.

When asked how to pinpoint the right problem to solve in healthcare, panelists discussed how to find the pain point by looking at something that doesn’t work today, and how to spot the disruption by seeing how a market or technology change could become amplified when applied to another industry. Sailesh used the example that the computing power in a smartphone today is more than enough to do complex image processing, and recalled his ‘aha’ moment when he realized to reduce cost and improve access, move access to services closest to the patient and find the lowest cost person to deliver the care. (We’ve written about this before. It’s often called “operating at the top of your license”, that is, making sure that if a lower licensed person can perform a task, enabling them to do it.)

Howard talked about the pain of trying to make sense of the “dumptruck” of data that the over 1100 non-standardized EMRs produce, an acute pain for smaller hospitals and clinics that do not have a large IT staff. Also related to the proliferation of non-standard EMRs, Anand talked about customers that are stuck with old technology that is siloed and not easily integrated. Services companies like iLink can help integrate and unlock this information.

Networking at Health 2.0 Seattle

Networking at Health 2.0 Seattle

At this point Tory pointed out that all three solutions had started with the technology, as technologists often do, and asked how to translate a technical solution to a customer focus. Howard readily agreed with the need to translate, saying that his customers don’t care about the technology at all, they care about the problem they have which is not being able to get information. He talked about how Deep Domain had completely changed their sales process to focus on customer pain rather than how great their technology is, and shared the enviable example of a sale that closed in 4 days after they took this approach.

Sailesh also talked about how they had adapted their sales strategy and focus based on what they’d learned in the field. In particular, they found that their mobile-phone based ultrasound offered new billing opportunities to small and particularly rural communities. Rather than providing a referral to a hospital for an ultrasound these clinics could perform ultrasounds themselves for a fraction of the cost resulting in a new revenue stream for the clinic and much higher convenience for the patient. He also realized in selling to these smaller customers, Mobisante had to provide a complete solution including training and image management.

The next topic was on healthcare’s slow embrace of platform, and perhaps the best quote of the night that the current crop of EMRs are why healthcare doesn’t understand platform. Certainly the lack of openness and data interoperability as well as the late adoption of many now standard enterprise IT practices pointed out by Anand are the key reasons behind this.
Some other reasons that healthcare has been slow to embrace platform and cloud technology is the very real fines for HIPAA breaches, although the panel pointed out that most breaches are not due to technology vendors but human error like losing laptops that have PHI on them.

Upcoming Health 2.0 Talks

Upcoming Health 2.0 Seattle Events

To conclude the session, Tory asked for some tips for anyone wanting to get into healthcare technology. Howard jokingly responded “don’t” but the underlying truth is that with long sales cycles, lack of standardization, and many regulations, health technology is not for the faint of heart. He also recommended to “look down not up”, that is don’t ignore the smaller hospitals that can implement more quickly or where your solution offers value they might not normally afford, like Deep Domain’s reporting or Mobisante’s ultrasound. Would-be entrepreneurs were also advised to seek out the early adopters in customers, those people who have passion, understand your value proposition, and are mission driven. These people will help you succeed.

Posted in: Data Protection, Health Regulations, Healthcare Disruption, Healthcare Technology, M-health

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The Healthcare System Is Family

Lynda Bennet and Carey

Lynda Bennet and Carey

The Canadian healthcare system has been my extended family since I was born.  I was born with Spina Bifida in the early 1950’s and it has been there to support me through years even to this day. So asking how healthcare affected decisions in my life is like asking me how my parents affected my life… it’s a long, involved, and murky story.

I can’t really remember my toddler years, but even then I had numerous encounters with doctors, nurses, and other medical practitioners. The first real glimmers memory are of learning how to walk on braces and crutches at Sick Children’s Hospital in Toronto. During my hospital stays, I rarely saw my family, as our home was a great distance away.  Even at that early age, I quickly learned that my ‘adoptive caregivers’ were potential ‘friends’… it was this understanding that launched my awareness of the health care system’s influence.

The hospital is where I learned that it didn’t really matter a caregiver’ s age, nationality, or position, as long as you gave them a quick grin and understood they were often busy, they would always be back with time for you. That was also when I learned that if I ate all of my broccoli, there was a picture of Peter Rabbit at the bottom of the dish; that the Italian person who cleaned my room had children my age and when asked would regale me with stories of the mischief they got into; and that that x-ray technician with the dark skin was from a fascinating far away island called Jamaica.

During my elementary school years, I underwent various corrective surgeries. The issue at that time was whether or not to undergo the procedures necessary to walk without braces and crutches. At that time, abandoning boots for shoes similar to my sister’s held a definite appeal and swayed my agreement much more than what might have been best for me in the longer term. Was the result totally my decision or was it collective judgment of the system, my parents, and me? I’m not sure I’ll ever know.

But again, my hospital visits resulted with life experiences and influences beyond the surgeries. That is when I learned how to make a bed with hospital corners (perhaps a ploy to get me to make my own bed or more likely to keep me ‘busy’). It is where I got to play and help feed the babies in the nursery, and when a bout with septicemia meant I was placed in a single room with a television set. (Remember that TV sets on wards were a rarity in those days even on children’s wards.)  One of my most vivid memories was that room crowded with nurses and interns on duty the night that the Beatles were on Ed Sullivan… and yes, I did get to stay up late!

Corrective surgery went on into my teenage years. Severe scoliosis and fear of pressure sores meant that I was on a Stryker frame for six months. The consequence of this hiatus and my changing body structure was relinquishing my braces and crutches for a manual wheelchair. Preference of the wheelchair over the hard work and potential failure to walk again was mostly my decision… the chair so much easier and faster for getting from point A to point B and with four siblings speed was an unwritten necessity. I am fairly certain that if I had insisted on continuing the use of braces and crutches, I would have had the support of my parents and the health care system to do so. Again though, that and subsequent hospitals stays resulted in life experiences and influences I would have never encountered at home. There was the lady in the bed next to me in an oxygen tent who urged me to promise her that I would never smoke (I kept that promise), the Toronto Maple Leaf player down the hall who told me I was the most beautiful person he had ever met (that one definitely left an impression), and that other patient’s visitors who told me that the reason I was born this way was because my parents had sinned.

Over my working career, my encounters with the healthcare system were few other than plastic surgeries for pressure sores. Although, even during this time health care still exerted its influence on my decision-making. Do I work fewer hours to avoid pressure sores or do I invest big money in a revolutionary new seating system? Do I purchase that new titanium wheelchair or face deterioration of my arm muscles? Do I accept a relocation to the United States with my employer and my workmates? (The healthcare system certainly influenced that decision. Although my employer would have provided private healthcare support, they wouldn’t guarantee my job for any length of time. With my medical history, I just couldn’t take the chance of losing the support of the health care system!)

Approaching my senior years has resulted in renewed encounters with the healthcare system: surgeries for a malformation, cancer, and an encounter with Hashimoto’s encephalitis. The health care system continues to exert its influence in my life decisions. At one point, I was living in a lovely sea-side community in British Columbia, when my primary care physician suggested that I needed to move within the coverage area of an emergency hospital. Who would have thought that access to ambulances, the location of my home, and the structure of the Provincial Health Authorities could make such a big difference? But there it was… either move my home into the coverage area of emergency hospital coverage or face the communication and jurisdictional delays between health care authorities, doctors, and hospitals. Needless to say the decision to move was a no-brainer!

What’s ahead? Who knows! Looking back down the path of past years, I think you’d have to agree that the health care system not only directly affected key decisions in my life but also exposed me to experiences influencing life choices well beyond its designated sphere. It is comforting to know that it is still here for me and with any luck we will continue our relationship into the future.

Posted in: Aging, Health Regulations, Healthcare motivation, Managing Chronic Disease

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Wellpepper’s Top Health Tech Stories of 2013

It’s the time of year to reflect and make lists! It’s been a great year for Wellpepper: our first full year in business. We’ve enjoyed bringing new features to our users and learning more about the needs of both patients and healthcare providers. We’re committed to building useful tools that patients and providers love to use. We’ve been inspired at conferences meeting with end-users, hospital administrators, and other startups who share the same mission of changing how patients and providers engage around their health. We’ve experienced the power of social media, met new friends through Twitter, and learned so much from Tweetchats. As a young company, it’s been a year of firsts for us that, while monumental for us, pale in comparison with the changes going on in health IT, so rather than telling you more about us, let’s talk about the year in Health Tech.

There is no scientific basis to this list, just what we think stands out from the year in Health Tech.

Healthcare.gov

The beleaguered website was definitely the top Health IT story of the year. At Wellpepper we were unable to make it through the registration process ourselves, and ended up going to a broker to find out our healthcare options. As the news came out on why the site was so bad, it was pretty obvious there was a lack of accountability and no project management. It’s really unfortunate that the Affordable Care Act was mired in this mess of an implementation, but we’re very excited that former Microsoft exec Kurt DelBene is taking the reins. Ship It!

Quantified-Self Hits the Mainstream

tec-gift-guide-fitness-trackers.jpeg-1280x960Or, “everyone is tracking.” The mainstream press started writing about fitness gadgets and our Facebook feeds were full of friends who got new FitBits for Christmas. Not sure what this means about the trend though. We have found the FitBit to be really interesting to calibrate activities, for example, a game of Ultimate Frisbee but after you know how inactive or active you are do you really need to track? And do you become okay with your activity or lack thereof?

Meaningful Use Phase Delayed

The Centers for Medicare and Medicaid have delayed the deadlines for implementing Meaningful Use Stage 2. Stage 2 will be extended through 2016 and Stage 3 won’t begin until at least fiscal year 2017 for hospitals. Meaningful Use Stage 2 focuses on patient engagement, which is very minimally defined as patients interacting with healthcare information electronically. We’ve always said that electronic medical records vendors are not the best equipped to deliver tools that patients (ie consumers) want to use, so it’s not surprising that healthcare providers are struggling with this phase. That said, m-health is poised to deliver on these requirements.Wellpepper2-1195a

M-Health Comes of Age

While we can definitely debate where we are in the m-health hype cycle, there is no question that M-Health is a formidable category. The FDA is now monitoring and releasing guidelines, albeit with little clarification. Eric Topol made headlines by using an iPhone EKG on a plane to diagnose a heart attack and and advise the captain to make an emergency landing. Most positively, we’re hearing less talk of ‘apps’, and more talk of integrating mobile health into the overall patient experience and the official hospital records.

23andMe Ignores FDA

Source: Wikipedia commons

You might consider this one to be a bit specific, but it’s representative of a number of key stories in 2013: big data, the explosion of healthcare investing, and the dramatic gulf between current Health IT and other technologies, and between Silicon Valley and the FDA. 23andMe, which does cheap DNA testing, direct to consumer, was forced to stop providing genetic results and only include ancestry after effectively ignoring FDA warnings for over a year. Speculation is that they were trying to get to a million tests (they are at about 500K) so that they could prove their tests were valid and thereby circumvent long FDA approval processes. Those on the side of the FDA saw this as Silicon Valley thumbing their nose at patient safety and regulations. Those on the side of 23andMe saw this as tech disruption at its purest. As recipients of some of the last full genetic and ancestry tests before the shut-down, expect more from us on this topic. 😉

This one is not healthtech, but we’d be remiss if we didn’t mention the focus on costs of care. Time Magazine, and the New York Times both published rather scathing interactive features on the costs of healthcare in the US. One of Reddit’s top threads right now is about a $50,000 appendectomy. It’s great to see these issues called to light. Let’s hope we see progress in solving them in 2014.


NewYearWP

We’re pretty excited to see what 2014 brings Wellpepper and what new innovations, disruptions, and improvements are brought to the healthcare industry as a whole. Best to you and yours from all of us at Wellpepper!

Posted in: Health Regulations, Healthcare Disruption, Healthcare Technology, M-health

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Call the (NHS) Midwife!

I’ve been watching the BBC Series “Call the Midwife” on Netflix. It’s set in the late 1950’s and focuses on a group of young nurses working in London’s east end, riding their bicycles through the streets to deliver babies and running health clinics out of a gymnasium. If a situation becomes more than a nurse can handle, she’ll call in a doctor and sometimes expectant mothers are sent to the hospital but for most it’s home births. The series is sweet and fun to watch although doctors often spout slogans like “without the National Health Service this baby would have died” in the middle of a delivery. It’s a rosy commercial to reinforce a matter of national identity and pride in the UK.

Call the Midwife. Source PBS.org

Call the Midwife. Source PBS.org

The NHS is the largest health system in the world, serving over 65M patients. Every person in the UK has basic health services covered, and some, like pregnant women also receive dental services. It’s based on a model of Trusts that run their own organizations supported by some centralized services. I learned more about this system on my recent trip to attend Health 2.0 Europe, which was in London and had a large focus on how to engage with the NHS.

As the CEO of a m-Health and Health IT startup, my interest was largely in how information is managed across this vast system. Interestingly some areas are highly advanced while others are still paper-based.  For example, BT (British Telecom) implemented “The Spine” almost 10 years ago to deliver one system that has basic patient demographics that can be accessed from any health institution. The Spine authenticates patients using their health card and provides their health ID number, age, and basic demographics to any healthcare organization. This means, that say you are from London but are vacationing in Cornwall, over 250 miles away, you can walk into any clinic and get care. Alternatively, 80% of patient records are on paper, and while there are 65M patients there are 85M records suggesting that there is some potential error in the system. Some hospitals in Central London are moving to electronic records and saving millions of pounds annually just by not having to store the records in extremely expensive London real estate. This is quite impressive considering that many EMRs cost hundreds of millions of dollars to implement. 😉

While so many records are still paper-based in many areas,  digital technologies are being implemented for innovative uses. I learned about hospitals deploying hundreds of iPads to staff, as well as tele-health in use for cognitive behavioral therapy. Patients were able to record their therapy sessions and replay them later when they needed a refresher on the advice or what was said. Patient centered care was the reason for adopting these new technologies, however the 18-month waiting list for cognitive behavior therapy may also be driving new models of care.

Private hospitals have cropped up catering to the “worried wealthy” who want to access more frequent care or avoid waiting lists for surgery, MRI, or other popular treatments. I heard mixed feedback about whether these waiting lists were real. Some people said that they were exaggerated while others pointed to the popularity of private care as proof.

Another areas of contrasts was around portability and protection of health information. On the one hand, an NHS representative said that a major issue was consent: sharing of patient records across trusts or hospitals or even with someone not directly involved in the patient’s care. On the other hand personal health information regulations while important did not seem to be as big an emphasis as in the US. As for the portability of health data, patients often are given their paper file to carry directly to a specialist. While it would be great if they were able to do this on their mobile device, it’s great to see this level of access to information for patients.

As I’ve written before, there does not seem to be a magic bullet between private and public systems. Private can deliver a much higher level of service however, the right to healthcare seems like it should be universal. The trip provided an interesting peek into another model that has its share of advancements and opportunities to get even better.

Now, back to seeing what the girls are up to on Call The Midwife.

Posted in: Data Protection, Health Regulations

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