E-skin? Bionic skin? No matter the name, the ‘ultimate wearable’ for monitoring is advancing.

‘Bionic skin’ as the ultimate wearable has been taking several dimensions. TTA Editors have previously reported on tattoo-like stretchy sensors applied to the skin for monitoring vital signs from a variety of academic and commercial developers. Here are two new advances of interest for those who follow the progress of wearables:

  • click to enlargeFrom University of Tokyo’s Graduate School of Engineering, a team led by Professor Takao Someya has developed an e-skin (left) that can measure vital signs and basic images, send them to clinicians, and–in what may be a first–display them on the surface in real time. This feature is useful for anyone, but especially for those who have difficulty communicating information due to speech or cognitive impairments. According to EurekaAlert, it combines a flexible, deformable display with a lightweight sensor composed of a breathable nanomesh electrode and wireless communication module. Developed in conjunction with Dai Nippon Printing (DNP), it is a 16 x 24 array of micro LEDs and stretchable wiring mounted on a rubber sheet. In its test form, it communicated temperature, pressure, myoelectricity (the electrical properties of muscle), and recorded an ECG. DNP expects to commercialize it in three years and improving its coverage for larger surfaces. It lasts about one week without creating irritation, another major factor in skin sensors. Video on EurekaAlert. Also Engadget. A paper on this research was delivered at AAAS last week
  • More information on Prof. Someya’s research is available in this IEEE Spectrum article, largely about the challenges of e-skin flexibility for use in patches and in prosthetics. Their research is utilizing TFTs (thin film transistors) and plastic skin one-tenth the thickness of common plastic wrap as the most sensitive and adaptable technologies.
  • University of Colorado Boulder has developed a monitoring e-skin that self-heals if damaged, which may extend e-skin life and usability. It uses a polymer (polyimine) laced with silver nanoparticles which can be repaired by easily available ethanol compounds and is fully recyclable with another solution that separates out the silver. The test patch conducts temperature and pressure. This looks thicker than plastic wrap, however. Engadget

Health tech for stroke prevention and rehab from Kardia Mobile, Watch BP, Northwestern U (UK/US)

click to enlargeIs stroke avoidable? We know it is an expensive medical event at $20-23,000 for hospitalization alone (NIH), which does not count rehabilitation or the devastation to individuals and their families, including loss of ability and work. NHS England is testing two devices, the Kardia Mobile and Watch BP, with an eye to preventing stroke in those vulnerable to it. 6,000 devices are being distributed to GP practices in England in a program through 15 NHS and care innovation bodies known as Academic Health Science Networks (AHSNs). The Alivecor‘s Kardia Mobile is a smartphone add-on clip that captures a medical-grade ECG in 30 seconds, stores, and sends readings to physicians. The application to stroke is primarily in atrial fibrillation (AF) and irregular heart rhythms, which according to statistics, more than 420,000 people across England have. Watch BP is a blood pressure cuff device which is also equipped with an AF detection system. The goal of the project is to identify 130,000 new cases of AF over two years, to prevent at least 3,650 strokes and potentially save 900 lives. Savings to NHS are being estimated at £81 million annually. Digital Health News

Post-stroke rehabilitation treatment is also being boosted by a new device developed at Northwestern University and being tested at the Shirley Ryan AbilityLab, a Chicago research hospital. It is a Band-Aid® like device which can be applied to key areas such as the throat (left above, credit AbilityLab), chest, or limbs to send back information to doctors on how a patient in treatment post-discharge, especially at home, progresses. The sensors and platform measure heart activity, muscle movement, sleep quality, swallowing ability, and patterns of speech. Especially revolutionary is the monitoring of speech communication and swallowing, which are often impaired in stroke patients but hard to track once the patient is out of a facility. The team’s research was presented last week at the American Association for the Advancement of Science (AAAS) annual meeting. New Atlas. Hat tip to Toni Bunting.

UK roundup: CCIO Simon Eccles warns against ‘shiny objects’, NHS Liverpool CCG award to Docobo, 87% concerned with NHS info security

click to enlargeNHS Digital CCIO doesn’t like ‘shiny objects’. Dr. Simon Eccles used his first NHS Digital board meeting as national CCIO to encourage delivering the current agenda first and not getting distracted by the ‘shiny objects’ of new innovations which also divert funding. “It is our collective challenge to make sure that doesn’t happen to things that are valued by the NHS – to do what we said we’d do and not be too distracted by new and shiny things.” This seems to be at odds with non-executive director Daniel Benton, who “suggested that NHS Digital needed to become more flexible as an organisation so that it was in a better position to roll with the punches in future.” Digital Health News

Docobo announced their win of the NHS Liverpool Clinical Commissioning Group‘s scale up of telehealth as part of the Healthy Liverpool program. The three to five-year contract has a maximum value of £11.5 million. The current Mi Programme (More Independent) partly funded by the Innovate UK dallas initiative and using Philips equipment is at 900 patients with 5,300 total patients since 2013. The plan is to scale up the program to 4-5,000 patients a year and support new clinical pathways and conditions including lung conditions, heart failure, and diabetes. Docobo’s platform is Doc@Home which uses patient information from the CarePortal device or their own digital devices. Docobo release. NHS Innovation Accelerator, Digital Health News

A survey of 500 British adults conducted by UK IT VAR Proband found that perceptions of public sector information security are poor. 87 percent were concerned about the security of their information with the NHS. Of that 87 percent, 34 percent were ‘very concerned’ about their cybersecurity. Taking this with a grain of salt, 80 percent distrusted security at the Driver and Vehicle Licensing Agency (DVLA) and 78 percent on data held by the police. The General Data Protection Regulation (GDPR) can’t come too soon [TTA 17 Feb] — but are you ready? More in Proband’s Online Security Audit (PDF).

Telehealth policy and reimbursement changes summarized by Center for Connected Health Policy (US)

A significant barrier to the adoption of telehealth (defined here as video consults, store and forward imaging, and remote patient monitoring) is the issue of reimbursement gaps. Basic Medicare (the Federal program for those over 65) pays for video and store and forward only under certain conditions (primarily under rural telehealth programs) but does pay for RPM as part of chronic care management (albeit under a maze of codes and procedures). Medicaid (the state low-income insurance program) is far more lenient, and private pay in states varies widely, with 36 states having some form of parity payment legislation. However, Medicare is planning expansion beyond what is covered in private plans (Medicare Advantage) by 2020. Some Federal programs such as the advanced Next Generation ACO program and the bundled payment Comprehensive Care for Joint Replacement model have telehealth waivers.

The always-helpful Center for Connected Health Policy (CCHP) has published a five-page guide to where these programs stand. Becker’s Hospital Review. CCHP PDF 

VA moves closer to doing Cerner EHR deal, real Choice for veterans (updated)

The Cerner EHR deal with the VA edges closer to closing. Another VA contractor, MITRE, reviewed the agreement and recommended 50 changes that, according to POLITICO Morning eHealth’s source, address many of the interoperability-related usability features “that irritate EHR users” such as reconciling data coming from outside sources (Home Telehealth, perhaps?–Ed.). VA officially updated the status with Congressional Veterans Affairs staff on Tuesday. The deal could be inked as early as next week, but never bet on this when the Secretary seems doubtful of the agreement date. In any case, it will be a decade before VA is fully transitioned from VistA. Speaking of the Secretary, Dr. Shulkin’s crisis of last week seems to have passed with a White House vote of confidence. He can ‘cashier’ his critics and according to him, everyone’s on board with a clear direction. We’ll see. 

Updated. Well, it’s 2 March and still no word on closing the Cerner contract. Meanwhile, the VA ‘revolt’ continues, with either true or false reports of demands for Dr. Shulkin’s resignation. It’s exhausting, and meanwhile who pays? Staff and veterans. See POLITICO from 1 March here.

Modern Healthcare reported that important reforms in the VA Choice legislation are closer to reality with the Senate Veterans Affairs committee. They are proposing changes, supported by the White House, that would open up VA Choice eligibility to nearly all veterans by “making VA facilities responsible for meeting access standards set by the VA secretary. If a facility can’t, the patient can seek out a community provider if both patient and a VA provider or an authorized provider in the community working closely with VA deem that a better option than a VA facility.” This is a step beyond the earlier proposed access standards which would have given the VA Secretary discretion to relax restrictions to community care provision. Currently the VA Choice program is used by only 1 million veterans who have to prove that they are facing wait times of 30 days or more, or 40-mile travel time to a VA clinic. While the tone in the article is slightly disparaging, firm standards and opening the VA to limited market pressures to this Editor is a good thing–and getting effective care faster to veterans, many of whom live in exurban or rural areas, is beyond all considerations, absolutely necessary. How this affects veterans monitored by telehealth programs–and interoperability of their records–are open questions.

Digital health is not here. Or it is. Or it’s still “the future” and we’re waiting for the ship to come in.

click to enlargeAnother bit of convergence this week and last is the appearance of several articles, closely together, about digital health a/k/a health tech or ‘Dr. Robot’. It seems like that for every pundit, writer, and guru who believes “We’ve Arrived”, there’s some discouraging study or contra-news saying “We’re Nowhere Near The New Jerusalem”. This Editor’s been on the train since 2006 (making her a Pioneer but not as Grizzled as some), and wonders if we will ever Get There. 

Nearing Arrival is the POV of Naomi Fried’s article in Mobihealthnews giving her readers the keys to unlock digital health. “Digital health will be the dominant form of non-acute care.” It has value in chopping through the thicket of the low clinical impact technologies that dominate the current scene (Research2Guidance counted only 325,000 health apps and 3.6bn downloads in 2017). Where the value lies:

  1. Diagnosis and evaluation–devices that generate analyzable data
  2. Virtual patient care–telehealth and remote patient monitoring
  3. Digiceuticals–digital therapeutics delivered via apps
  4. Medication compliance–apps, sensors, games, ingestibles (e.g. Proteus) 

At the Arrival Platform and changing the timetable is machine learning. Already algorithms have grown into artificial neural networks that mimic animal learning behavior. Though the descriptions seem like trial and error, they are fast cycling through cheap, fast cloud computing. Machine learning already can accurately diagnose skin cancer, lung cancer, seizure risk, and in-hospital events like mortality [TTA 14 Feb]. It’s being debated on how to regulate them which according to Editor Charles Lowe will be quite difficult [TTA 25 Oct 17]. Returning to machine learning, its effect on diagnosis, prognosis, and prediction may be seismic. Grab a coffee for The Training Of Dr. Robot: Data Wave Hits Medical Care (Kaiser Health News). Hat tip to EIC Emeritus Steve Hards.

The (necessary?) bucket of Cold Water comes from KQED Science which looked at two studies and more, and deduced that the Future Wasn’t Here. Yet.:

  1. NPJ Digital Medicine’s 15 Jan meta-analysis of 16 remote patient monitoring (RPM) studies using biosensors (from an initial scan of 777) and found little evidence that RPM improves outcomes. The researchers found that many patients are not yet interested in or willing to share RPM data with their physicians. The fact that only 16 randomized controlled trials (RCTs) made the cut is indicative of the lack of maturity (or priority on research) for RPM. 
  2. In JMIR 18 Jan, a systematic review of 23 systematic reviews of 371 studies found that efficacy of mobile health interventions was limited, but there was moderate quality evidence of improvement in asthma patients, attendance rates, and increased smoking abstinence rates. 

Even a cute tabletop socially assistive robot given to COPD patients that increases inhaler medication adherence by 20 points doesn’t seem to cut hospital readmissions. The iRobot Yujin Robot helping patients manage their condition through medication and exercise adherence lets patients admit that they are feeling unwell so that a clinician could check on them either through text or phone and if needed to see their regular doctor. The University of Auckland researchers recommended improvements to the robot, integration to the healthcare system, and comparisons to other remote monitoring technology. JMIR (18 Feb), Mobihealthnews.

As Dr. Robert Wachter of UCSF put it to the KQED reporter, we’re somewhere on the Gartner Hype Cycle past the Peak of Inflated Expectations. But this uneven picture may actually be progress. Perhaps we are moving somewhere between the Slough (ok, Trough) of Disillusionment and the Slope of Enlightment, which is why it’s so confusing?

Retail health convergence and ‘Amazon Effect’ continues with Albertsons’ acquisition of Rite Aid (updated)

The perceived ‘Amazon Effect’ continues. As predicted when the CVS-Aetna merger proposal made its first news last October while the Autumn Leaves were falling (cue the Ferrante and Teicher), other retail shoes would be dropping. Today’s major news is supermarket Albertsons buying most of drug store chain Rite Aid–the 2,600 stores that Walgreens Boots was prohibited from acquiring due to antitrust concerns. (Their eventual deal was for 1,932 stores.)

The terms are cash and stock with an estimated value of the combined companies of $24 billion (WSJ). Present Rite Aid shareholders will take 29 percent of the combined companies and present Albertson shareholders over 70 percent. Another benefit for Albertsons–it’s a quick and easy way to go public without an IPO using Rite Aid’s public status to effect a reverse takeover merger. It solves for Rite Aid (and Walgreens) the large problem of the unsold Rite Aid stores. 

Albertsons’ 2,200 supermarkets are in 38 states and the District of Columbia and comprise multiple brands such as Safeway and Acme in addition to Albertsons. Rite Aid stand-alone stores will continue to operate under their brand name as will most in-store pharmacies. The Rite Aid CEO John Standley will become CEO of the combined company with the Albertsons CEO moving up to chairman. CNBC, Seeking Alpha

Updated: For your weekend reading, here’s Jane Sarasohn-Kahn’s measured take on this acquisition in her HealthPopuli.

Who’s next? Place your bets here in Comments!

Telehealth alternatives to in-person consultation found lacking in effectiveness: Alt-Con Study (UK)

It needs work and can’t be top down. That’s the conclusion of the Alt-Con Project and its researchers from several UK universities: Warwick, Bristol, Oxford (Nuffield) and Edinburgh. After examining the use of technological alternatives to GP consultations in eight general practices, they found that there were significant barriers to implementation, including insufficient training of non-clinical staff on these approaches’ benefits. The study includes recommendations to guide a more effective implementation.

Practices have been slow to adopt tech alternatives to F2F consults using telephone, email, e-consultation systems, and online video, despite NHS encouragement and programs such as the GP Access Fund. The paradox is that time devoted to non-F2F consults cuts into GPs time seeing live patients in the office.

  • They were adopted without a clear rationale or clearly thinking through cost-benefit for patients and practice staff.
  • Professor Sue Ziebland from Nuffield found that “…practices introduced alternative consultation methods for very different reasons and to solve problems that the practice had identified. These included a failure to be modern, to work more efficiently, to better serve commuters or dispersed populations, and to ensure appointments were available to those who needed them most.”
  • Other reasons: “the acknowledgment that the previous system was broken and unethical in providing a first-come, first-served system that left patients without appointments that they needed, and “the recognition that reception staff and phone lines were overwhelmed.”
  • Noted by other researchers were that ‘one-size-fits-all’, policy and financial incentive driven approaches were “not the best way forward”.

The study looked at GP practices of different sizes (1,938 to 18,353) covering over 85,000 patients, located in different geographic areas of England (6) and Scotland (2) including urban and rural areas, and with a mixture of patients’ socioeconomic status. 45 staff members and 39 patients were interviewed over eight months.

The University of Bristol Centre for Academic Primary Care has published a web page based on the Alt-Con research, offering guidance for GP practices. 

NHS England’s rejoinder: ‘This is a tiny study based on data that is almost two years old. Online consultations offer a convenient alternative to face-to-face appointments and patients are already seeing the benefits.’ Nuffield Department of Primary Care release, British Journal of General Practice, Daily Mail  Hat tip to former TTA Ireland editor Toni Bunting

Australia’s CNBP develops a 3D printed high-res microscope to clip on to your smartphone–and it’s DIY.

click to enlargeThe Australian Research Council Centre of Excellence for Nanoscale BioPhotonics (CNBP) has published a study by its researchers on a 3D printed, fully functional clip-on microscope which can examine specimens as small as 1/200th of a millimeter, including microscopic organisms, animal and plant cells, blood cells, cell nuclei and more. It does not require external light sources or power to function. It was created on a Formlabs Form 1 3D printer using an iPhone camera (number not disclosed) and flash. (CNBP illustration above at left.)

The 3D printing files and notes are publicly available here for anyone to recreate, along with a separate CNBP paper and tools on creating a portable bioanalytic device from a smartphone. 

Previous microscope clip-ons date back to 2010 with the development of the Ozcan microscope and app we covered in March 2012 and January 2013 (!) Current versions divide up into units that resemble bench microscopes or create hologram images, all requiring external light sources. This microscope is capable of, according to the study, “transmission [of] brightfield [flash on] and darkfield [flash off] microscopy on a mobile phone without any externally powered light source or additional illumination optics.” It also eliminates assembly, with the only requirement the fitting of the lens into the 3D printed clip. The camera’s digital zoom and imaging mode of the iPhone affect the apparent pixel size.

Why is this relevant? According to Dr. Anthony Orth, the lead researcher and CNBP Research Fellow at RMIT University, “Powerful microscopes can be few and far between in some regions. They’re often only found in larger population centres and not in remote or smaller communities. Yet their use in these areas can be essential—for determining water quality for drinking, through to analysing blood samples for parasites, or for disease diagnosis including malaria.” Aside from this use and similar such as healthcare provision in disaster sites or in rural/remote areas to send images for further analysis, when coupled with an app and machine learning, an initial analysis could be performed. Doctor house calls, telemedicine, telehealth vital signs monitoring, and home care monitoring (especially in infection situations) also come to mind.  Nature.com Scientific Reports, CNBP News. Also ZDNet and Gizmodo Australia.

Updated–Rounding up this week’s news: VA budget, Shulkin’s troubles, ATA’s new CEO, Allscripts’ wheeling-dealing, Roche buys Flatiron, Nokia out of health?, NHS Carillioning?

click to enlargeHere’s our roundup for the week of 12 February:

VA wins on the budget, but the Secretary’s in a spot of bother. Updated. Last week started off as a good week for Secretary Shulkin with a White House budget proposal that increased their $83.1 billion budget by 11.7 percent, including $1.2 billion for Year 1 of the Cerner EHR implementation in addition to the agency’s $4.2 billion IT budget which includes $204 million to modernize VistA and other VA legacy IT systems in the interim. While the Cerner contract went on hold in December while record-sharing is clarified, the freeze is expected to be lifted within a month. POLITICO  Where the trouble started for Dr. Shulkin was in the findings of a spending audit by the VA’s Inspector General’s Office of an official European trip to Copenhagen and London which included unreimbursed travel by Mrs. Shulkin and free tickets to Wimbledon, at least partly justified by a doctored email. This has led to the early retirement of the VA Chief of Staff Vivieca Wright Simpson and also an investigation of hacking into Wright Simpson’s email. It also appears that some political appointees in the VA are being investigated for misconduct. CNBC, FierceHealthcare.

Updated: POLITICO doesn’t feel the love for Dr. Shulkin in today’s Morning eHealth, linking to articles about the supposed ‘internal war’ at the VA, with veterans’ groups, with the Trump Administration, and within the VA. It’s the usual governmental infighting which within the 16 Feb article is being whipped by POLITICO and co-author ProPublica to a fevered pitch. Dr. Shulkin comes across as doctor/tech geek who underestimated the politicization of and challenges within an agency with the mission to care for our veterans. It’s also an agency having a hard time facing the current demands of a dispersed, younger and demanding veteran group plus aging, bureaucratic infrastructure. As usual the ‘privatization’ issue is being flogged as an either/or choice whereas a blend may serve veterans so much better.

Digital health entrepreneur named CEO of the American Telemedicine Association. A first for ATA is a chief from the health tech area who is also one of the all-too-rare executive women in the field. Ann Mond Johnson, who will be starting on 5 March, was previously head of Zest Health, board chair and advisor to Chicago start-up ConnectedHealth (now part of Connecture), and had sold her first start-up company Subimo to WebMD in 2006. She began her career in healthcare data and information with The Sachs Group (now part of Truven/IBM Watson). Ms. Johnson replaces founding CEO Jonathan Linkous, who remained for 24 years before resigning last August and is now a consultant. ATA release, mHealth Intelligence. ATA relocated in January from Washington DC to nearby Arlington Virginia. And a reminder that ATA2018 is 29 April – 1 May in Chicago and open for registration.

Allscripts’ ‘Such a Deal’! Following up on Allscripts’ acquisitions of Practice Fusion for $100 million (a loss to investors) and earlier McKesson’s HIT business for $185 million [TTA 9 Jan], it hasn’t quite paid for itself, but came very close with the sale of McKesson’s OneContent, a healthcare document-management system, for a tidy $260 million. Net price: $25 million. Their CEO is some horse trader! Some of the savings will undoubtedly go to remedying the cyberattack in January that affected two data centers in North Carolina, shutting down EHR and billing applications for approximately 1,500 physician practices, which have launched a class action lawsuit. FierceHealthcare 

Flatiron Health acquired by Roche. (more…)

How do digital health partnerships happen? Where do you go with them? Views from a developer and an app security provider.

This Editor recently covered a partnership between Doncaster UK’s MediBioSense Ltd.and San Francisco-based Blue Cedar, where Blue Cedar’s app security system will protect information from MediBioSense’s app through to the provider database. I was curious how two physically distant small companies, even in this global healthcare business, found each other, as well as how MediBioSense (MBS) adopted a US-developed sensor from VitalConnect. To find out more, I spoke with the company CEOs, Simon Beniston of MBS and John Aisien of Blue Cedar. Their respective experiences led me to three takeaways which are applicable to early-stage companies–wherever they are located.

Past business dealings of the principals and keeping connections ‘warm’ matter a great deal–when the time is right to partner. Both companies had a combination of people and past experience in common. “I had some interaction with Simon during my time at Mocana, the company from which Blue Cedar spun out.” Mr. Aisien noted. “Our sales leadership in the UK continued to be in touch with Simon, and as we continued to execute on our business plan and focused on healthcare, the relationship strengthened. Simon’s role as a healthcare global app developer made him even more attractive as a partner.” For Mr. Beniston considering Blue Cedar as a security partner, it was a combination of contacts and people he knew already, “driven by the realization that while our data was fairly secure by design, I was cognizant of the fact that data protection requirements were growing in the European market with GDPR (General Data Protection Regulation). As a forward-thinking company, we wanted to get to this early on. Given this, the partnership between MediBioSense and Blue Cedar was a perfect fit.”

MediBioSense’s relationship with VitalConnect is also unusual in that MediBioSense developed their platform that monitors data for the VitalPatch. Mr. Beniston founded the company because he believed that healthcare was where mobile technologies, his prior field, could make a real difference and be joined to the use of biosensors and wearables. His knowledge of the platform and app were thus from the ground up. “We then went on to ensure that their [Blue Cedar’s] technology fit with our technology and the testing was successful. We could then go to healthcare companies and tell them that we have data protection covered. It gives us a competitive edge.”

The right partnerships build use cases, look forward to where their businesses can go in meeting customer needs, and are a step ahead of their clients. Mr. Aisien: “What Simon is doing is a wonderful example of using digital channels to improve healthcare outcomes and reduce costs. We think it’s a great proof point of the value of our app-centric approach as it relates to security in healthcare. MediBioSense’s app will be running on devices which are outside of the control of the entity using VitalPatch to capture [the patient’s] data. It’s not practical or economic for that entity to manage the device.”

When asked about whether healthcare users and developers are finally seeing the light about app security, Mr. Aisien acknowledged that it is developing. “The knowledge of the criticality of protecting oneself against security threats is unquestionably there and has been for awhile. With the increased use of digital channels–mobile, IoT, wearables–to improve business and reduce risks, the growth, the understanding, and most importantly, the funding are there. App-centric security continues to evolve because while other approaches like securing the whole device or containerization are technically sound, they are not necessarily economic or practical for all use cases. What makes universal sense is to download the app that already has the requisite levels of security in it.”

This is what attracted Mr. Beniston to use an app-based security approach for MediBioSense. “Historically it’s always been a device approach such as MDM [mobile device management]. One of our key USPs, when we approach our clients, is that one of the big expenses, aside from the VitalPatch, is hardware. One of our strengths is that our platform and interface can work on a consumer mobile device. We can utilize what your clinicians and patients already have in their pockets. They can use what they have, and to date, we haven’t seen any interference with mobile devices.”

He added, “We were surprised that even today, some are saying about GDPR that ‘we’ll wait until it happens’. That’s hiding your heads in the sand! (more…)

DHS’ Hidden Signals Challenge to improve tracking of biological and epidemiological threats

The US Department of Homeland Security (DHS) is on the biothreat/pandemic train–not quite in time for this bad influenza season, but perhaps for next–in developing an accelerator to fund companies researching mapping potential disease outbreaks. The DHS Science & Technology Directorate (S&T) is collaborating with the Office of Health Affairs National Biosurveillance Integration Center on finding novel ways to use existing data that will identify signals and achieve timelier alerts for biothreats from the local level up. 

Five companies won Stage 1 of the Challenge and were awarded $20,000 grants:

  • The Commuter Pattern Analysis for Early Biothreat Detection program, developed by Readiness Acceleration & Innovation Network (RAIN). This is designed to recognize commuter absenteeism to flag a possible disease outbreak.
  • Monitoring Emergency Department Wait Times to Detect Emergent Influenza Pandemics, developed by Vituity. This tracks spikes in emergency room wait times from a network of 142 hospitals in 19 states that can be attributed to emergent flu pandemics. 
  • The One Health Alert System. This program analyzes the Daily Disease Report’s top 10 symptoms, reported by 43 healthcare providers in North Carolina.
  • Pandemic Pulse, developed by the Computational Epidemiology Lab at Boston Children’s Hospital. This gathers data from Twitter, Google Search, HealthMap and transportation and news sites, then compares that to live transportation data and Flu Near You.
  • Pre-syndromic Surveillance. This AI-based platform detects emerging clusters of rare disease cases that do not correspond to known syndrome types through real-time emergency room chief complaint data with social media and news data.

In Stage 2 from now through April, finalists will further develop their concepts into detailed system designs with guidance from expert mentors. The winner, to be announced later this Spring, will receive the $200,000 grand prize. DHS Hidden Signals Challenge website, Challenge blog, mHealth Intelligence

Telemedicine’s still-sluggish adoption in health systems revealed in survey of health system executives

Sage Growth Partners, a Baltimore Maryland-based healthcare research and strategy firm, released a study surveying US C-level executives and service line leaders at a variety of larger health systems (integrated delivery networks (IDNs), academic medical centers (AMCs), community hospitals, and specialty hospitals) on their telemedicine use. It combined initial/exploratory qualitative interviews (total N=65) with online quantitative surveys (completed N=98) taken 2nd Quarter 2017.

Have we reached a tipping point? The findings indicated that just over 50 percent (56 percent) had developed in-house telemedicine systems or were already working with vendor/s on implementing telemedicine in their organizations. The study’s definition of telemedicine was broad, inclusive of any technology and programs that connect providers and patients not physically at the same location when care is provided. 

But many of the findings are dismaying:

  • Budgets–limited at best. Most (66 percent) had budgets under $250,000 per year 34 percent committed over $250,000 with most under $100,000, but three-quarters believe those budgets will increase next year. 
  • What it’s used for: Emergency use (29 percent), remote patient home monitoring (21 percent, and non-emergency cases (20 percent). 
  • How many vendors do they want to deal with?: One is quite enough–54 percent prefer a single telemedicine solution across the continuum of care (however defined), with 31 percent accepting two solutions. 
  • Has it changed the ‘standard of care’?: Yes for stroke, according to 70 percent surveyed. 75 percent believe it will potentially change the standard of care for behavioral health/psychiatry, followed by neurology (53 percent), primary care (52 percent), and cardiology (48 percent).
  • What about direct-to-consumer telemedicine?: The top must-haves are EMR integration, appointment scheduling, and store-and-forward messaging (60+ percent). What’s surprisingly not so desired: store-and-forward of images (47.9 percent–so much for home wound management) and vitals capture (45.9 percent–so much for connecting devices to telemedicine).

Perhaps it’s this Editor looking at the ‘glass half-full’ with a ‘Gimlet Eye’, but here we are in February 2018 still having this discussion at the executive and service line levels. The progress has been glacial at best on starvation budgets, yet telemedicine vendors are multiplying. What is also not promising: these executives’ preference for enterprise solutions which preclude small, innovative companies from getting past the pilot or trial phase. Another barrier: the insistence upon EMR (EHR) integration, which sounds appropriate except that Cerner and EPIC are ‘walled gardens’. Defining Telemedicine’s Role: The View from the C-Suite (PDF, free download from Sage). Also Clinical Innovation + Technology and Global Healthcare 

The UTOPIA Project evaluation of telecare in social care report published (UK)

click to enlargeAn important and comprehensive evaluation of telecare in use in UK social care has been published this past week by King’s College London. The UTOPIA Project (Using Telecare for Older People In Adult social care) surveyed local authority telecare managers (114 valid responses or 75 percent of responders) November 2016-January 2017 to find out how telecare is being used by local authority adult social care departments in England to support older people.

This study springboards from the £80m Whole System Demonstrator (WSD) and its “curious neglect” by those engaged in UK telecare. The WSD’s findings contradicted earlier research in finding that telecare did not have long-term improvement of outcomes, gauged after only 12 months. It created, in the UTOPIA’s study’s terms, a ‘policy problem’ among major stakeholders. “The WSD remains an important study and its neglect is curious. The research team wondered why the findings had been overlooked and what, if any, consequences might have flowed from this.” The study thus looks at local authority aims, how local evidence is being collected, and how telecare is operationalized and delivered.

The areas surveyed and some highlights of the findings are:

  • Use of research: 33 percent were informed by research and 47 percent were aware of but did not agree with the WSD’s findings which were negative on the long-term value of telecare.
  • Where does telecare fit in?:  “Telecare ‘fitted’ best if it was provided alongside social care (77%), to support reablement (77%), for people eligible for and funded by the adult social care department (75%) as well as for people who pay for their own care (75%).” Only 24 percent collaborated with the NHS or other partners. There was full (100 percent) agreement that telecare helps to reduce risk and promote safety and 81 percent agreement that it supports unpaid carers. 
  • Achieving strategic aims and monitoring of progress: Over half (53 percent) of respondents said their local authority was accredited to the Telecare Services Association (TSA) Codes of Practice for Telecare and Telehealth. 
  • Barriers and facilitators: Barriers mentioned were skill deficits among professionals and installers, as well as contract inflexibility with suppliers. There was also concern about the reduction of face-to-face contact and care. Access to telecare and availability of advice and support were good for both users and family carers, but levels of awareness about it were only average.
  • Financial commitment: Not surprisingly, funding is scarce and usually cobbled together from several sources including local authorities, CCGs, and users. 24 percent felt it saved money but many found it difficult to provide hard evidence.
  • What’s considered in telecare assessments?:  Nearly all (92 percent) agreed that a key assessment included the user’s ability to move around, their memory status, the person’s ability to communicate, and their daily routines. Flipping the script, “40% of respondents said that their local authority’s telecare assessment focused on what it was hoped would be achieved through using telecare.”
  • Who are the assessors, and is assessment always required?(more…)

Google ‘deep learning’ model more accurately predicts in-hospital mortality, readmissions, length of stay in seven-year study

A Google/Stanford/University of California San Francisco/University of Chicago Medicine study has developed a better predictive model for in-hospital admissions using ‘deep learning’ a/k/a machine learning or AI. Using a single data structure and the FHIR standard (Fast Healthcare Interoperability Resources) for each patient’s EHR record, they used de-identified EHR derived data from over 216,000 patients hospitalized for over 24 hours from 2009 to 2016 at UCSF and UCM. Over 47bn data points were utilized.

The researchers then looked at four areas to develop predictive models for mortality, unplanned readmissions (quality of care), length of stay (resource utilization), and diagnoses (understanding of a patient’s problems). The models outperformed traditional predictive models in all cases and because they used a single data structure, are projected to be highly scalable. For instance, the accuracy of the model for mortality was achieved 24-48 hours earlier (page 11). The second part of the study concerned a neural-network attribution system where clinicians can gain transparency into the predictions. Available through Cornell University Library. AbstractPDF.

The MarketWatch article rhapsodizes about these models and neural networks’ potential for cutting healthcare costs but also illustrates the drawbacks of large-scale machine learning and AI: what’s in the EHR including those troublesome clinical notes (the study used three additional deep neural networks to discern which bits of the clinical data within the notes were relevant), lack of uniformity in the data sets, and most patient data not being static (e.g. temperature). 

And Google will make the chips which will get you there. Google’s Tensor Processing Units (TPUs), developed for its own services like Google Assistant and Translate, as well as powering identification systems for driverless cars, can now be accessed through their own cloud computing services. Kind of like Amazon Web Services, but even more powerful. New York Times

Scary Monsters, Take 4: further investor thoughts on CVS-Aetna, the Amazon Threat–and Aetna’s skeleton in the closet? (updated)

click to enlargeThis Editor is always interested in Following the Money as a way to cut through the Fog of Hype and Headlines. The proposed CVS-Aetna merger is no exception. This recent article in Seeking Alpha is a must-read despite its click-bait headline because it not only looks at CVS-Aetna (a thumbs up generally) but also dissects the ‘Amazon Threat‘ and finds that like Oakland, there is (not much) there, there. Let’s look at the writer’s POV–who represents an investor group with no position:

  • CVS is in retail. Amazon is in retail. But CVS’ difference is that by and large, their retail is not a ‘destination’ (only 25 percent of their retail revenue) but a stop-off while a prescription is filled or there’s a visit to the MinuteClinic. I’d differ with this as many of their stores are semi-convenience stores and, at least in this New York metro area, located away from both traditional supermarkets and convenience stores. Some of us also don’t like to pay shipping on a few necessities, want the items now, prefer to pay cash, or coupon-clip. (And I just remembered I need a quart of milk, saving me a trip to the market….)
  • Amazon has exhibited some hesitancy in entering the pharmacy area. They won’t use their licenses to sell prescription drugs (CNBC, Nov) and canceled a wholesaler application in Maine. In the writer’s estimation, the threat to traditional PBM and prescription drugs is exaggerated because “For some reason, the market has been temporarily duped into thinking that a non-existent company with zero customers and zero experience is a real threat to a $70 Billion behemoth that has been at the top of its field for over 50 years.” Pharmacy is also heavily mail order for recurrent prescriptions or needed immediately, not suitable for the Amazon model unless they develop a true PBM and retail delivery. That isn’t to say that Amazon will never be a threat–just not right away. And what will happen before that is…
  • Through a merger with Aetna, CVS is demonstrating to shareholders that they are willing to diversify revenue and profit streams by adding over $60 billion in insurance business. An integration with Aetna (and providers) will help the profitable MinuteClinics grow and thrive, perhaps in non-traditional ways (e.g. anchoring malls).

Again, Amazon needs to enter profitable businesses (see our Follow the Money article) and create shareholder value, even at a $500bn valuation.

What may be a skeleton in Aetna’s closet is prior authorization procedures. Possibly spoiling a rosy CVS-Aetna merger picture is an investigation by the California insurance commissioner into Aetna’s prior authorization practices. It’s a result of a lawsuit in California Superior Court by a patient denied coverage for an intravenous immunoglobulin (IVIG) treatment. A former Aetna medical director admitted under oath in the case that he never looked at patients’ case files before denying authorization, accepting Aetna’s procedure of nurses making recommendations. This will not only affect Aetna, but also any payer doing business in California. Aetna claims that the plaintiff didn’t have necessary blood testing done prior to the authorization review and in fact avoided having it done. A decision here will be watched closely by every doctor who slaves on prior authorizations. With the CNN exclusive, expect many headlines and scrutiny with the spotlight on Aetna. Hat tip to Reader Howard Green, MD, via LinkedIn.

Updated. Colorado’s Division of Insurance is reviewing this information to see if it violates Colorado laws concerning patients’ right to appeal and review procedures that meet standards of care for the state. Expect more states to follow.  Healthcare Dive  

But will this slow or stop the merger? Likely not, but roll ‘dem bones. Lawyers surveyed by the National Law Journal say probably not, as past conduct is usually known by the merging party and factored in. However, this merger must be approved by 50 states’ insurance departments (and more). The caveat is that they use a ‘public interest’ standard that is broader than the Federal anti-trust or fair trade regulations. Look for states to extract concessions before this merger is done.