Archive for Healthcare Technology
Just 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.
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.
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.
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.
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.
We 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.
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.
The goal of Triple Aim is to say that, despite what any project manager will tell you, you can have all three.
This provocative statement, set the tone for this third installment in Seattle’s Health Innovator’s Collaborative, a talk called “Demonstrating Value in Health Innovation: Lessons from Comparative Effectiveness Research” by Larry Kessler, Professor and Chair, Department of Health Services, UW School of Public Health and formerly of the FDA, NIH, and NIMH. Dr. Kessler believes that the new accountable care organizations are mandated to deliver on all three and used the example of the Institute for Healthcare Improvement which was founded in 1991 on this principle and brings together leading hospitals, policy people, and researchers who are finding the best ways to deliver triple aim across many specialties.
Changes in how healthcare systems deliver care will drive innovation; however, innovation for its own sake will not win. Innovation must show evidence, cost savings, and revenue drivers. At the same time, it must satisfy a much wider group of stakeholders than previously including patients, physicians and clinicians, payers and providers. Innovative approaches and technology will take the leap past simply showing evidence of clinical outcomes to delivering value. This is a dramatically different approach from how typical NIH or FDA studies are done today. Those studies are done with a small slice of the population that is homogeneous, for example, they only have one issue and no co-morbidities. This type of study may prove outcomes with this particular population, but it doesn’t show cost or revenue based value and is no indicator of how something would work in the population at large, where the sickest patients are usually struggling with more than one issue.
Quality needs to be redefined as the best service AND the best health outcomes AND the best cost outcomes. Dr. Kessler went on to show some clear examples where solutions needed to go to the next level to be adopted and show results.
The first example provided a model that showed over a 5 year period, gastric bypass surgery proved cost effective. However, insurance plans do not include this surgery and require copious paperwork to justify it. This may make sense though, as the determinates of whether surgery is actually cost effective include a number of additional factors like the population and especially whether they will be part of your problem in 5 years. This is where the new accountable care organizations that are charged with population health will have an easier time with the cost benefit analysis as they be responsible for these patients in 5 years.
Another similar example is the new drug Solvaldi for the treatment of Hepititis C. It’s recently been in the news for its staggering price tag: $84,000 for a 12-week course. However, the drug has proved to be extremely effective, and University of Washington health economist Sean Sullivan points out “the drug is far cheaper than the alternative, which is a liver transplant and a lifetime of immunosuppressant drugs.” Again, though, whether this is a bargain or not depends on how long the payer thinks they will be responsible for the patient.
Successful business outcomes based on cost savings were shown in the example of two diagnostic tests for whether breast cancer would reoccur. The FDA-approved test MammaPrint could predict the recurrence of breast cancer. The non-FDA approved test Oncotype DX could predict the recurrence of breast cancer AND whether chemotherapy would work for the patient. This test, while not FDA-approved became far more popular as it showed very clear cost savings and quality of life for patients who did not undertake unnecessary chemotherapy.
Another study, Back Pain Outcomes Using Longitudinal Data-Extension of Research (BOLDER) was able to consider the patient experience as part of treatment. This study looked at 5,239 patients over 65 with new primary care visits for back pain across 3 integrated systems: Kaiser Permanente of Northern California, Henry Ford Health System, Harvard Vanguard/Harvard Pilgrim. The study goal was to determine the impact of early imaging as an intervention. The results are not yet published, but a couple of observations were already apparent. First, patients sent for MRIs, delay getting physical therapy and if the MRI shows they need physical therapy rather than surgery they have delayed their recovery by the time they waited for the MRI. In this case, the intervention of imaging if it was not needed produced less positive results for patients.
This study used the Roland-Morris Disability Questionnaire and it was also noted that many of the standardized testing tools do not account for what the patient actually considers a good outcome, like whether they can sleep soundly or have sex. Again, this shows that studies need to go a step further into the real world application of the patient’s situation.
These examples showed that it’s not enough to show that an intervention or new technology worked in a study, they also need to work in the real world. For payers that means lowering costs, for providers that means lowering costs or generating revenue while improving outcomes, and for patients that means delivering outcomes that are important to them, not just clinically validated.
The final lecture in this series will be June 3rd with Peter Neupert of Health Innovation Partners. See you there!
“IT can make a big difference in health: Why hasn’t it?”
Health Innovators Collaborative
4:30 PM, W.H. Foege Building, UW Campus
Seminar: Foege Auditorium (S060)
Reception: Foege North 1st Floor Lobby
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 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.
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.
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: It 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.
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.
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.
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.
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.
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.
Less than a year ago, I was at an event sponsored by the Washington Biotechnology and Biomedical Association, where a room full of health IT and consumer health startup CEOs bemoaned the lack of a healthtech community in Seattle. We have all the elements here: talent, world-class healthcare facilities, and b2b or enterprise IT pedigree. Events like Seattle’s Health Innovators Forum Meetup and Health 2.0 are trying to change that by bringing together startups, investors, and general health enthusiasts for learning and sharing. This month’s Health Meetup, organized by Edmund Butler, was focused on Consumer Health and Wellness, and featured local startups in this space. Speakers were:
Julie Kientz (@juliekientz) is the director of the Computing for Healthy Living and Learning Lab (CHiLL), a group of UW researchers interested in designing, developing, and evaluating apps that aim to promote healthy lifestyles and education.
Rebecca Norlander (@rebatwork) is the Co-Founder and CEO of Health123, a consumer health company that helps people make decisions and track the small changes in their lives that can make a big difference in their health.
The three speakers shared a passion for designing person friendly applications for consumers to manage and improve their health. The three talks provided different perspectives on the topics of how to engage users and overcome their barriers or burdens to both application use and improving their health.
Marcelo kicked it off with his “8 Pet Peeves of Health Apps.” (I’m sensing an Everymove love of numbers as I also attended another talk by CEO Russell Benaroya called 25 Reasons You Suck At Sales. They also like to have provocative titles. 😉 )
Here they are in order:
- Calling people patients. Marcello pointed out that for all other applications they are users. He prefers people or member. (Later Rebecca noted that some industry conventions need to stay in order to communicate with your target customer. Patients is a tough one. People don’t like to be called patients, but the entire healthcare industry refers to them this way.)
- Trying to be all things to all people. This was a criticism of apps that try to track too many things. Figure out what behavior you’re trying to affect and do a great job of that.
- Putting the organization rather than the person at the center. This would be designing for the healthcare organization rather than the patient or worse yet for the insurance company rather than the patient.
- Misaligned or misguided incentives. Marcelo used the example of paying people to track something for example finding out their BMI rather than trying to incent them to change something, like become more active (and then lose weight). Historically there has been an idea in the health and wellness area that if you have information you will change. Information is really only one component (as Julie elaborated on in her session).
- Health Risk Assessments. Marcelo thought that these were particularly dangerous as people tend to associate these types of assessments with tests and then inflate their answers and then assume they are healthier than they thought.
- Bad UX and bad visual design. Marcelo showed an EMR screenshot saying “the 90s called, they want their interface back”.
- Treating a person as a condition. The person’s condition is not who they are and is only one component of the information a healthcare provider or application needs to understand to care for or help support that person.
- Making you change to fit the application or service. Wearables still fall into this category. You need to remember them, you need to wear them, and in the case of the new FitBit force, you need to get medical attention after wearing them.
Julie Kientz was up next, and her human-centered design approach provided practical advice to solve many of the pet peeves that Marcelo mentioned. The goal of Julie’s research is to understand and reduce the burdens in healthcare design. She described 8 key burdens that can impact adoption of healthcare technology.
Physical: Is the technology comfortable to use or to wear? Does it fit in with my surroundings or what I am doing? With wearables, physical is obvious, but physical could also be how you access the application, for example which tasks are better for a mobile device versus a PC?
Privacy: Where does the data go? Who is able to see it? For applications that have social sharing, are others able to track you? (Did you call in sick and then go for a 15K run?)
Mental: How do you feel about the technology? Julie said she feels sad when she forgets to put her FitBit on, and often goes back home to get it. As well, she is on her 6th FitBit in 3.5 years due to losing them, so is also feeling some guilt about the loss.
Access: Is the technology designed for diversity? For example, many nutrition trackers do not include foods that are popular with different ethnic groups.
Time: How much effort is required to enter or review data? Julie personally doesn’t look at her FitBit data online, just at the step count on the display. The online reporting is too much effort for her.
Emotional: What is the emotional impact of not meeting the goals the technology is tracking? Do you feel like a failure?
Financial: How much does it cost? Does it require expensive equipment like a smartphone? Are there added costs like a data plan?
Social: Does others use of tracking make you feel better or worse? Do you feel guilty when someone posts their runs online?
Because these burdens compete with each other it’s impossible to design to eliminate all of them at once, and so you have to understand which are the most important or provide the biggest barriers for the audience you’re designing for. Julie and her lab published a paper on this if you want to know more “Understanding the emotional burden of health technologies”. She also provided some practical examples of how her team has developed technologies and studies to accommodate these burdens.
One example is the ShutEye sleep tracker that’s designed for people who have some trouble sleeping but are not motivated enough to seek professional help. ShutEye is an Android app that displays on the homescreen with recommendations based on the time of day. For example, it will tell you whether it is too late to have caffeine if you want to get a good night’s sleep.
Another application, BabySteps deals with the emotional component of child development, by displaying development stages as trees in different stages of growth. This removes the stigma of clinical terms like delayed. BabySteps is designed to be used over the first 5 years of a child’s life so the team is also experimenting with different interactions to keep parents engaged for example, a Twitter feed that asks questions about child development. You can find links to all of Julie’s research here.
Julie then summarized with these words of advice:
- Embed actions in activities people are already doing
- Provide multiple options for tracking/achieving goals
- Balance between manual and automated tracking
- Priortize which burdens you will resolve based on your user’s desire and what your application is intended to accomplish
- Match the burden to the motivation level of your user
Rebecca took the stage next and tied the two previous talks together with examples from how they built Health 1-2-3 to overcome barriers to engagement in health. While 85% of people say they want to feel better, a number of factors prevent them from reaching that goal. The absence of the following can be barriers to wellness:
Awareness: Not knowing what the actual situation is. (See Marcelo’s Pet Peeve # 5 on Health Risk Assessments.)
Knowledge: Once you have awareness, what can you actually do? Health information is often not delivered in a way that is actionable.
Self-efficacy: People cannot make big changes all at once. How do you make small and incremental changes towards health?
Personalized Solutions: Generic solutions don’t speak to the person or help them take personal responsibility for their health. Personalized solutions are customized based on information about that patient and provide options appropriate for that person’s health.
Time: Solutions need to integrate with people’s lives. Behavior change cannot take so much time as to be prohibitive. What small steps can be integrated?
Support: What types of social support does a person need to make a change? For example, there are many great fitness and health communities, like Strava for cyclists, where people support each other’s goals. On the other hand, social support needs to be in the control of the person. Applications shouldn’t be posting updates on the person’s behalf.
Rebecca walked through all of the above in the context of a Health 123 demo that showed how they simply address the issues. For example, awareness takes the form of a series of simple health questions. Knowledge is tailored health information based on the questions the patients answered. Self-efficacy is addressed by making health challenges reasonable to fit into a person’s day and week.
If you’re interested in or working in health technology in Seattle, I highly recommend these meetups. The content and discussions are packed with inspiration and information, and the burgeoning Seattle Health IT community needs your support.
You can find out about the next meetup here.
Justin Elliott, NA
Matthew Elrod, PT, DPT, MEd, NCS
Alan Lee, PT, PhD, DPT, CWS, GCS
Christopher Peterson, DPT
Telehealth, which originated as a way to provide care to rural settings, has become an accepted way although not widely adopted method of delivering healthcare. Benefits include convenience for patients, the ability to access specialists in other locations, and being able to monitor chronic conditions at lower costs. Advances in technology, that have put powerful microcomputers in everyone’s pocket, have made telehealth significantly more in demand and more feasible than ever before and as a result the telehealth market is forecasted to grow to a 4.5B market by 2018.
The good news is that telerehabilitation is part of this growing market, and people are already practicing today. The bad news is there’s still a lot of confusion about reimbursement and regulation. A show of hands at the beginning of this session revealed that while 5 out of approximately 50 attendees were practicing telehealth, no one put their hand up when asked if they felt confident about the rules and regulations, and most people seemed to not be getting reimbursed.
The goal of the session was to provide some clarity on the definition of telehealth, examples of how it is used in physical therapy, a survey of the current regulatory and reimbursement situation, and a toolkit for those who are interested in moving forward with a telehealth practice.
Telehealth communication is used in two settings, between a healthcare provider in an office and a patient at home, or between two clinical settings where one healthcare provider wants to consult with or have the patient consult with a specialist in another clinical location.
There are two types of telehealth:
- Synchronous, or real-time where the two parties communicate directly via video conference.
- Asynchronous, or store and forward where video, text, or voice communication is transmitted between the two parties but they do not respond to it in real time. Email, texting, and even voicemail are all forms of asynchronous communication. (Wellpepper is an example of asynchronous telehealth.)
Synchronous communication more closely resembles a typical clinic visit, as it is a dedicated and scheduled visit, with the difference being that the two parties are not in the same location. Asynchronous is better for remote patient monitoring, check-ins, and chronic disease management were the parties do not require constant face-to-face communications. In fact, one of the areas that telehealth has shown real promise is in chronic disease management, first because most of the management of chronic diseases occurs outside the clinic, and second because these patients often need access to specialists who are not local.
Telehealth should be considered a way to augment in person treatment but not replace it, especially in the musculoskeletal world where treatment is often hands-on. Follow-up treatment, home treatment plans, questions and answers, and consultations with specialists are all areas where telehealth can add value in treatment. Telehealth also provides more convenient options for patients, not just rural ones. With busy lives many patients find it difficult to get to a clinic to an in-person appointment. It can also help lower costs of care.
While telehealth has many benefits, there currently many potential blockers. For example, before embarking on a telehealth program, make sure you fully understand privacy laws. All communication needs to be encrypted, and tools like Skype, while very convenient, do not deliver the level of security required by healthcare law.
The elephant(s) in the room in the whole discussion are regulations and reimbursement. This session provided hope that these will be resolved: both the APTA and the The Federation of State Boards of Physical Therapy are working to define and eventually change the legislation to enable more widespread adoption of telehealth. Unfortunately, it seems that the change may be slower than consumer demand and certainly than innovations in technology.
Currently 21 states have private coverage legislation for telehealth billing and 11 states have Medicare billing with 6 more in proposal stage. This legislation applies to intra-state practice, that is the patient and the physical therapist are within the same state. Inter-state practice where the physical therapist and the patient are in different states is only possible if the physical therapist is licensed in the state where the patient resides. Note that Medicare does not include telehealth for PT, OT, Audiology, or Speech Therapy. Since some of the real power of telemedicine is being able to practice across state boundaries (and possible across country boundaries in the future), we need to solve this inter-state issue.
It’s not really feasible for physical therapists to get licensed in each state so that they can practice telemedicine regardless of patient location. There are two possible solutions to this problem. One is a “telemedicine license” which is a license to practice telemedicine in a particular state even if you don’t reside in that state. Louisiana is a state that has this license type. The other, and more practical long-term solution is to create an interstate licensure compact. This would enable the portability of licenses from one state to another. The most common example of this is the driver’s license. Your driver’s license may be granted by the state of Washington but it is recognized and honored in all the other states (as well as Canada). The Federation of State Boards of Physical Therapy is leading a committee to put forward a proposal for an interstate licensure compact, and there is some discussion at the global level as well. (Nurses are much further ahead in this area, 24 states have joined a nursing licensure compact that enables nurses to be licensed in their home state and practice in any of these states, which is great for both telehealth and for portability of nursing careers.)
With respect to billing, there are billing codes for telehealth for physical therapy but they vary depending on state and by insurer. Two state practice acts, Washington and Alaska, recognize telehealth. In California, physical therapists are covered under a general assembly bill that allows for telehealth. Arizona, Kentucky, Minnesota, Nebraska, and New Mexico, list physical therapy and/or telerehabilitation services in their Medicaid policies. Perhaps the most promising change that will move telehealth forward is the new “accountable care organization” and bundled payments. With bundled payments, the organization is paid based on patient diagnosis and outcome not by the number of procedures that are provided, so there is built-in incentive to focus on the most effective and cost effective way to get a great outcome.
If you’re interested in moving telehealth forward for the physical therapy profession, the APTA has a lot of great resources in their telehealth toolkit. At Wellpepper, we’re very excited about the prospects and look forward to working with you on these new ways of treatment.
Doesn’t it seem like there’s never enough time? Nowhere is this more prevalent than with our healthcare system. We don’t have enough time to do things that keep us well, and increasingly doctors don’t have time to spend with us to thoroughly understand our issues. A spate of recent articles tries to blame the implementation of technology and the EMR as taking even more time away from the patient/doctor relationship.
Electronic health records have become a disease in need of a cure, as physicians do their best to diagnose and treat patients while continuously feeding the data-hungry computer. “A Busy Doctor’s Right Hand, Ever Ready to Type“
This isn’t necessarily the fault of the EMR. It really stems back to money. One of the primary purposes of the EMR is to document for billing purposes and federal rebates. They weren’t designed to improve face-to-face care.
This New York Times article describes how scribes are helping to increase doctor face time with patients, but hiring another person to record what the patient is saying seems more like a band-aid solution.
Without much fanfare or planning, scribes have entered the scene in hundreds of clinics and emergency rooms. Physicians who use them say they feel liberated from the constant note-taking that modern electronic health records systems demand. Indeed, many of those doctors say that scribes have helped restore joy in the practice of medicine, which has been transformed — for good and for bad — by digital record-keeping.
What we really need is something like the “flipped doctor’s visit” being explored by the Robert Wood Johnson Foundation and inspired by Sal Khan, of the Khan Academy, an organization that has already made headway into education innovation by suggesting that classrooms are for homework and viewing lectures can be done at home. The idea of the flipped classroom is to maximize the interaction between teacher and pupil. The RWJF project suggests we need to do the same thing for the doctor’s visit.
The project is looking at ways that can turn the doctor’s visit on its head to get better results for patients and healthcare providers. While the example of EMR scribes seems like it might fit, to us it seems like a bit of a placebo. From personal experience, I had a doctor’s visit where an intern recorded my information and then read it back to the doctor and me. She had gotten some major facts wrong, for example, somehow she understood I worked in construction, not software. Open Notes and Blue Button, where patients see their own notes are two examples of trying to take this a step further. Who better than the patient to review what was written about them? We also need to return to documentation to improve patient care, not documentation for billing. The point of good documentation should be to accurately describe the situation and for continuity of care. Sadly, again technology is being blamed for an underlying issue of time, in this example the ability to copy and paste is being used for false records and billing. Again, it’s not the technology, it’s that people are pressed for time and again that time is money.
I recently had a few doctor visits that gave me time to pause and consider the flipped visit. The main thing that struck me is how different the doctor’s visit is from any other type of business interaction. As I was thinking about preparing for the visits with my list of things to make sure we cover, I thought about comparing this to a business meeting. The doctor had no agenda in advance, no idea why I was coming in, or even who she was meeting with until I walked in the room, and spent the first few minutes of a 10 minute visit looking at notes to try to remember who I was and what had happened before. Imagine you’d hired a consultant for a project (ie manage your health) who approached the project in this manner. You’d want your money back. You’d expect them to come to a meeting prepared. As the client you’d send them any pertinent information or updates for the project before the meeting. I was also trying to imagine the day of a doctor: every 10-15 minutes changing context with a new patient and no prep time while trying to care for patients and sometimes facing life-threatening decisions. Hairdressers have more insight into how their day is going to go: cut, color, cut, blow-out. We talk about moving to a preventative model for healthcare. First step would be to enable doctors to prepare to see patients and decrease the documentation burden after they see them.
We need better and more cost effective ways of communicating in healthcare. Ones that focus on patient care and are seamless for both patients and healthcare providers. We have applied technology for better communication and collaboration in business and in our personal lives, how can we extend this to healthcare? How can we flip the doctor’s visit and how can technology help?
If you’re interested, the Robert Wood Johnson Foundation is hosting a Google Hangout on the flipped clinic January 16 at 11:00 am PST.
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.
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!
Or, “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?
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.
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.
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.
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!
My Facebook and Twitter feeds are full of people talking about the new gadgets they got for Christmas. Tracking has gone mainstream as many of those gadgets are fitness and activity tracker devices. I thought I’d share a bit about what I’ve learned as an avid tracker for some of these newbies.
I have been using apps and devices to track my activities for over 7 years. When Nike in-shoe sensors came on the market in 2006, I was an early adopter and since then have upgraded to various GPS watches and apps like RunKeeper on my phone. I love tracking my runs and hikes. It adds an extra sense of accomplishment seeing exactly how far you’ve gone, elevation climbed and how fast you’ve traveled. Seeing my progress overtime was especially motivating and helpful when training for upcoming races. It led me to want to track more. I definitely felt myself getting caught up in the quantified self movement.
So when we decided to get Fitbit trackers at Wellpepper, I was all over it. I was very excited to start tracking activities outside of runs. I chose the wristband format while Mike and Anne chose the Fitibt Zips that clip onto your pocket or waistband. I liked the idea wearing the Fitbit at all times tracking all activities (including sleep) and thought I would have a better chance of not losing it. We found this to be true right away as Mike lost his first two Fitbits. (Protip: Clip your Fitbit with your Fitbit inside your pocket.) Anne wasn’t too keen on the look of the sporty black wristband so chose the smaller out of sight zip and also appreciated that the Zip didn’t need to be charged. (However, both Anne and Mike had over a week of no activity recorded when their batteries actually died.)
Initial findings were very fun and intriguing: an Ultimate Frisbee game is about 8,000 steps and a good round of golf about 18,000 steps with up to 20,000 steps if that happened to be a bad round of golf. The most lucrative activity turned out to be dancing, it’s surprising how many steps you can take while dancing at a wedding! (23k) Step counts varied between the different Fitbit types. As my steps were tracked by the movement of my arm, I definitely got credit for additional steps including a few 1000 from petting an upset dog during a thunderstorm. This caused some debates over the accuracy and fairness of the Wellpepper Fitbit leaderboard, which is definitely a fun and motivating feature of the Fitbit app.
Definitely the most surprising findings were how many steps could add up with regular day to day activities. I found that I generally took around 1000 steps just walking around the house and getting ready in the morning. A walk to the store to grab a few groceries could garner up to 2000 steps. Turn that trip into a walk to the farmer’s market and you could easily generate 4k steps! It was surprising how a few small decisions could turn a relatively normal day into highly productive and active day. I found this infographic: The Exercise Experiment: A Tale of Two Days does a great job of showing the difference small choices can make.
Even more surprising, or even shocking, was how many steps I didn’t take on an inactive day. I work from home and it’s not uncommon for me to grab a cup of coffee in the morning, jump on my laptop and get to work. Some days, the time can slip by and before you know it, the day is gone. I never used to worry about it because when I am not working, I am highly active. However, after I came across The Truth about Sitting, I decided I needed to be more aware of my overall activity. I think this has been the greatest impact of the Fitbit. I thought that I might dive deeper into analyzing my runs or hikes, but it has actually created this awareness to keep me moving all the time. It reminded me of something John Mattison (CIMO of Kaiser Permanente) said at FutureMed:
It’s not about wearing a million sensors, we don’t need digital nannies, it’s about becoming more mindful.
Prior to the Health 2.0 Europe Conference there was a deep-dive 3 hour session called “Tools for the Elderly.” I was particularly interested in this session for two reasons, first we are doing some work with Boston University on a study using Wellpepper to manage the health of Parkinson’s patients the eldest of whom is 75 and second, a common criticism we hear from healthcare providers and investors is “old people can’t use technology.” We disagree wholeheartedly, but acknowledge that those who may have less than 20/20 vision or arthritic hands may require different types of interfaces and engagement than the stereotypical 20 year old developer is building for. Based on this, I was very interested to see what types of innovations and challenges this session presented.
Two of the most interesting were Many Happy Returns and Intelesant. Many Happy Returns is a memory, engagement, and conversation aid for people with dementia. It was developed originally as a not-for-profit by Sarah Reed who was introduced to the world of dementia when her mother was diagnosed over 10 years ago. Originally a card game, and now being developed into a mobile application, Many Happy Returns presents pictures from different decades to jog the memory of dementia sufferers and encourage inter-generational communication. People who have dementia have increasingly clear long-term memory with deteriorating short term memory and the cards provide the ability to have meaningful conversations with those with dementia and also learn family stories before they are lost. The app interface was simple and highly usable, and the benefit of using an iPad app over printed cards is huge: sound can be added, and sounds have proven to be very evocative for memory jogging, new card sets can be created by scanning and adding the person’s own photos, and finally, tracking can be done related to which photos, or sounds are most interesting to people.
Intelesant could have also been in the “unmentionables” session in the full conference. They provided an advance “end-of-life” care plan that was accessible by patients, their care givers, and could be shared with healthcare providers, especially in a care home setting. Too often this information is lost or not communicated clearly until it’s too late, and Intellesant aims to change this. What was compelling about the Intellesant presentation is that the interface, while capable of reporting clinical results, was designed for the patient and the caregiver who are really the most important constituents in this scenario.
There were also three startups that were focusing on building interfaces for the elderly, one to make it extremely simple to use a phone, one to make it extremely simple to use a tablet, and one to make it extremely simple to have a conference call or telehealth chat through your TV. The first two were solving the problem that Android interfaces are generally a lot less usable than other interfaces, which really seems like 1. A short term problem and 2 something that should be addressed by Android OS developers. (Are you listening Samsung?). The third, SpeakSet was solving a problem that of course affects the elderly, but also everyone else. According to some former colleagues of mine at Microsoft (Skype), it takes 10 minutes on average for any conference call to get started. While there are definitely tools that can help the elderly manage their health and wellbeing, good usable design should be available to everyone. I’d love to use a big button that says “start conference call” and have it work immediately.
The AARP has gone on record asking Silicon Valley to start building tools for the aging population. Based on this session at Health 2.0 Europe, they may want to look further afield.
Last week, I had the opportunity to demonstrate Wellpepper and participate on a panel on “Improving and Enriching the Patient-Provider Relationship” at the Health 2.0 Europe Conference in London. I’m grateful to the Washington Trade Association who funded a trade delegation to the conference and helped facilitate other meetings in London as well.
The panel format was that the moderator, in this case Health 2.0 CEO Indu Subaiya, and invited guests framed the conversation, and then invited companies to demonstrate their products related to the topic. After the demo, the panelists asked questions and discussed the implications and relevance of the product to the topic. The “Provider” view was represented by Dr Simon Brownlee, a primary care physician and Chief Medical Officer of Healthloop UK. The “Patient” view was represented by Susan Jones, a person living with ME also known as “chronic fatigue syndrome.” I spoke with Susan a bit backstage and learned that she was frustrated by the lack of knowledge about her condition, she took it upon herself to look for specialists and treatments outside of the UK, the epitome of an engaged patient.
Other startups on the panel were:
Mark Friess from WelVU, focused on patient education and engagement.
Nishant Bagadia from Nuehealth, helping patients find and connect to surgeons.
Tim Williams from myClinicalOutcomes, helping patients track and get information about long term conditions.
Interestingly, while we all focused on the patient-provider relationship, each took a different approach and the technologies ended up being complementary rather than competitive.
We discussed how patients are often confused by treatment plans and how care outside the clinic was becoming increasingly necessary as patient volumes increased. A recent study by Deloitte showed that elderly patients will increase the demand for in-person consultations by 33%. Given the expected shortage of healthcare providers, this isn’t going to be possible so we need new ways to engage. We also discussed the need to align outcomes between patients and providers. Oftentimes the patient has a very different view of a successful outcome as the provider, as outlined in this Harvard Business Review Infographic.
The conference was inspiring as healthcare providers, industry professionals, and startups acknowledged that we need to start doing things differently if we want to see better health outcomes. While there were similarities between the solutions presented across all the panels, there was actually very little duplication, which points to the vast challenges in healthcare today. Solutions came from all over the US, UK, and Europe and were tackling both local and international markets. The best solutions were on par with what you see coming out of Silicon Valley, and in particular we liked UMotif for it’s extremely usable approach to patient tracking and engagement and the as yet unreleased “You app” from Health Puzzle of Finland, that enables collaborative health challenges with friends.
My favorite session was the “Unmentionables” where startups tackled problems that often weren’t discussed like sexually transmitted diseases and alcohol abuse. My panel featured 3 US based startup and one UK, this session was a representation of European innovation, and organizers were pleased so showcase so many more local talents than in previous years. Presenters represented their countries well, and moderator Matthew Holt, pointed out that true to form and stereotypes, a Norwegian presented a light-based solution for depression, an Italian for sex information, and a Brit for drinking.
A few weeks ago, I had the opportunity to visit the PARC facility at the ICORD Spinal Cord Research Centre in Vancouver, BC with our guest blogger Lynda Bennett. Lynda is participating in an exercise study for people with spinal cord injuries and she wanted to show me around. The study is in pilot stage right now and has less than 50 participants all of whom have spinal cord injuries. Lynda doesn’t actually have an injury, she was born with Spina Bifida. However, she has recently started using an electric chair and is concerned about keeping up her core and upper body strength, especially for transfers from the chair. The pilot study is looking for positive outcomes associated with regular and increasing levels of exercise in people with spinal cord injury.
The equipment at the facility looks like that at any gym, however there are two key differences. Each machine is adapted so that a person can access it from a wheelchair. Actually the machines are designed both for able-bodied and disabled users and ICORD employees are allowed to use the gym if the study isn’t actively using it. If a machine has a seat, which an able-bodied person might use, it swings away to enable someone to wheel up to it. The other difference is that each machine is fitted with a smart card reader. Study participants enter their cards to start the weight program. The machines use air-pressure to provide resistance, and the resistance is increased automatically based on previous day’s activities. All the data is collected and can be reviewed by researchers. You can think of it as ‘quantified-self’ but with extremely expensive quantification.
While Lynda enjoyed her workouts and meeting with others at the facility, she would have liked to have seen active rather than passive goal setting. She wanted the goals to be translated into something that she needed to do in everyday life. “to be able to transfer from your chair to a truck, you’ll need X amount of core body strength.” As the study is designed, she is increasing the amount of weight but doesn’t know what outcomes this will provide in her daily life.
“I’d like to see how I am progressing towards a goal rather than try to correlate the increased weights to some improvement myself.”
Since this is just a pilot, and they are trying to keep the research relatively open to start, this might be able to be designed into future research.
Unfortunately, the pilot study isn’t guaranteed to go to a large scale study. The initial funding was used to set up the facility, and additional funding will be required to expand beyond the pilot. However, pilot organizers are hoping once they get enough data and can start to form hypotheses, they will attract the interest of the many researchers in the labs upstairs at ICORD, who are working with cells and microscopes but not as often with real human subjects like the people who volunteered for this study. Facilities like PARC and the data they collect can go a long way to bridge the gap between research and human outcomes.
Floatlearning.com takes a look at how mobile phones and mobile devices are changing health care.