‘Deconstructing the Telehealth Industry’ positively, focusing on ‘virtual care’ of older adults

A Big Study must-read. Just published is healthcare-specialized investment banking firm Ziegler’s 28-page update on their 2016 survey of the telehealth industry. Unlike some industry observers who believe that health tech has been ‘next year’s Big Thing’ far too long, with unproven effectiveness and savings, Ziegler believes it’s about to substantially ramp up in investment spending and tech integration.

The study looks forward and goes deeply into the markets. In their view, “We believe the next generation of successful virtual care companies will be those who understand the critical marriage between chronic care management, behavioral health, and social determinants.” Their focus is on the aging (50+) population and their higher risk for developing chronic conditions and the 50 percent/5 percent spread (50 percent of the spending is generated by 5 percent of the population). Their picture is that virtual care will ‘meet patients where they are’ in their daily lives.

The study sees trend confirmation in the adoption of virtual care by health systems (the widest–telestroke and tele-ICU), low-acuity care, and 2019 expansion of Federal reimbursement in Medicare Advantage Plan B with ACOs having more flexibility in telehealth-supported services. Ziegler promotes a change in terminology–‘virtual care’ as the ‘naturally integrated tool used to streamline the complex healthcare ecosystem.” Another difference: they place virtual care in the ‘smart aging continuum’ including its effect on decision makers, payers, care options, aging in place, and residential care.

A strong reference paper our Readers will be referring to for months to come. Deconstructing the Telehealth Industry, Part II (option for printable and viewable PDFs).

The race to develop a blood glucose skin patch monitor speeds up with UCSD pilot

Are thin-film/adhesive patch glucose monitors the thing this year? University of California San Diego Health (UCSD Health)  opened earlier this month a clinical trial of their self-adhesive ‘tattoo’ type glucose monitor. This monitor measures the glucose present in perspiration through two electrodes embedded in the thin adhesive film that apply a small amount of electrical current to make glucose molecules in the skin rise. The clinical trial sampling people with Types 1 and 2 diabetes ages 18-60 with fasting plasma glucose (FPG) > 126 mg/dL, or hemoglobin A1c (HbA1c) > 6.5%. Those in the trial will be comparing their readings from the thin film monitor with a standard glucometer through June 2019. Patients wearing the sensors will receive a minimum of two doses of pilocarpine gel to induce sweat, at fasting and at time points ranging between 15 to 200 minutes post meal. Neither the article nor the clinical trial explain the reading process.

In a Mobihealthnews interview with Patrick Mercier, codirector of UCSD’s Center for Wearable Sensors, the sensor can be produced for under $1, comparable to a blood glucose test strip.

Tattoo-type sensors and strips made the news about two-three years ago in their early stages of development and now are resurfacing with both trials and investment. Sano received $6 million from Fitbit for its combination of sensor and mobile app. The University of Bath has designed a multi-sensor patch that doesn’t need gel to raise a sweat; it measures interstitial fluid located between cells within the body-hair follicles [TTA 24 Apr]. We are rapidly moving towards less-invasive monitoring systems and better diabetes management.

The health tech events of summer: The King’s Fund (London) and Parks Associates (San Diego) (Updated)

Summer is coming, even if it’s difficult to believe that April Showers (or Snow) bring May Flowers. Here’s a preview of two health tech events to put on your calendar later on this year in mid and late summer.

The King’s Fund Digital Health and Care Congress 10-11 July, at their location in London. Content and case studies include creating the right culture for large-scale digital change, using digital technology to improve quality of care, prevention and changing behaviors, population health informatics, tools for self-management, and much more. Speakers include Matthew Swindell of NHS England and the Rt. Hon. Paul Burstow of the TSA. Information and registration are now available here. (Updated this week!) Follow The King’s Fund on Twitter here: #KFdigital18. TTA is a media partner of the Digital Health Congress.

Parks Associates’ 2018 Connected Health Summit: Engaging Consumers will be held 28-30 August at the Manchester Grand Hyatt in San Diego, California. This year will analyze the role of innovative connected health solutions in driving changes in consumer behaviors as well as how healthcare systems, insurers, and hospital networks interact with consumers. Updated: Confirmed keynotes are Deborah DiSanzo, General Manager, IBM Watson Health and–just added–Christopher Weber, General Manager of Uber Health [see this Editor’s thoughts on Uber from last month]. Speaker submissions are open until 1 June–more information is here. Early registration is now open. TTA is a media partner of the Connected Health Summit.

UK-developed non-invasive skin patch monitors blood glucose; a ‘slow-mo’ injection to regulate it

click to enlargeA team from the University of Bath has developed a graphene-based blood glucose sensor that if successfully commercialized could eliminate the diabetic finger-stick. The sensor patch measures the interstitial fluid located between cells within the body-hair follicles–each mini sensor measures an individual follicle, where glucose collects in tiny reservoirs. The sensor patch can monitor every 10-15 minutes for continuous measurement. At this developmental point, readings are not sent to a smartphone. The researchers are focusing on optimizing the number of sensors in the patch, demonstrating successful use over 24 hours, and clinical trials. The University of Bath study with researchers from their Centre for Graphene Science, Centre for Nanoscience & Nanotechnology, and the Department of Pharmacy & Pharmacology, was published in Nature Nanotechnology in March. New Atlas

A possible combination? Treating Type 2 diabetes usually requires medication to regulate insulin. Glucagon-like peptide-1 (GLP1) causes the pancreas to release insulin but has a short half-life. Researchers at Duke University have developed a way to bind GLP1 to a heat-sensitive elastin-like polypeptide which forms a gel-like depot that releases slowly into the body. In early tests with mice and monkeys, the ‘depot’ releases a constant rate of GLP1 for up to 14 days. The slower human metabolism means that this may be a feasible 14-30 day treatment–and translate to the controlled release of other medications. New Atlas

UK health grassroots programs not waiting for the NHS: VR for COPD patient exercise, Now Patient for chronic care management

With the painfully slow adoption of health technology (besides telecare and limited telemedicine) in the UK, it’s heartening to see that there are some ingenious approaches outside the NHS gaining traction. The stories behind these two are interesting and inspiring.

Pulmonary Rehabilitation in Virtual Reality (PRinVR) from Concept Health was developed by a GP in a rural area of South Cumbria. Dr. Muhammad Farhan Amin of the Burnett Edgar Medical Centre on Walney Island in Barrow-in-Furness has many patients with pulmonary and lung problems who need to exercise and do specific breathing exercises. To aid them, he developed a five-step VR assessment and rehab program, It uses only a smartphone and a VR headset to transport a patient to a virtual beach where they can interact in an exercise class. The VR program connected via data to the internet can also tailor the breathing exercises individually and send the exercise record back to the health professional. It’s part of the ‘Better Care Together’ program that provides educational help, coaching on breathing strategies, and nutritional advice. Using VR this way is not new–we have reported on VR-aided rehab for several years going back to Microsoft Kinect and Army Medical–but what is different is its use in specific pulmonary conditions and its development in a very remote area. Dr. Amin’s Concept Health is only a year old, according to LinkedInThe Academy of Fabulous Stuff

On the waterfront in Salford Quays, Manchester, a local digital ad exec father who couldn’t book a GP for his son a few years ago has developed a telemedicine app that has virtual doctor visits and prescribing. Lee Dentith’s Now Healthcare has a private individual service (NowGP) that claims to be Europe’s largest, Now Healthcare (group/corporate), and the free Now Patient which combines pharmacy and the virtual visit. The apps and services have been inspected by the Quality Care Commission (QCC). 

Mr. Dentith told the Manchester Evening News that his market for Now Patient is the 15 million people with chronic care conditions who need regular repeat prescriptions, and noted that GP practices, despite the NHS, are private businesses. Now Patient achieved 60,000 downloads shortly after its October 2017 debut. Their focus is on the individual, group, and private pay market. To date Now has a £4m investment from MediCash in a Series A (Crunchbase). Now aims to have 25 million users on the three platforms. 

Hat tip to Roy Lilley’s NHS Managers newsletter via Steve Hards.

DARPA’s $5.1M contract with Kryptowire to develop passive smartphone health monitoring, predictive analytics

click to enlargeTruly unobtrusive health monitoring on the horizon? The Defense Advanced Research Projects Agency (DARPA) has contracted with cybersecurity firm Kryptowire to develop a health monitoring and analytics app to assess the health and readiness of warfighters (to us civilians–soldiers, sailors, airmen, and Marines) especially in the field. The WASH program–Warfighter Analytics using Smartphones for Health–will use the data from smartphone sensors like microphones, cameras, pedometers, thermometers, and accelerometers (see DARPA illustration, left above). Through sensor-based information, physiological and cognitive symptoms can be captured and analyzed.

Based on their information, most of the assessment will be passive rather than actively diagnostic, and with an emphasis on predictive health and a real-time approach to disease detection and biomarker identification. Part of the challenge will be to filter out the ‘noise’–extraneous information also captured by these sensors on a daily and extraordinary basis. Security, of course, is a major concern. (Where better than to award the app development to a cybersecurity company?)

DARPA is fond of commercializing its technologies (remember something called DARPANET?) so this is planned for commercial release in due time. Usage in clinical trials is an area mentioned. One day we may all be wearing smartphones which unobtrusively monitor our health and positive behaviors. (I’ll leave it to our Readers to say Yay or Nay to this notion.)

The award is for $5.1 million. A development timeframe is not mentioned. Business Wire, DARPA WASH page, HealthcareITNews, Daily Mail (which amusingly tries to paint this as a spy program through an ACLU representative quote).

The Theranos Story, ch. 48: down to 24 employees in a last ditch before bankruptcy

click to enlargeThe ground is next. Theranos is down to its last two dozen employees or less, in a bid to buy a few more months of time before bankruptcy, according to a breaking report in the Wall Street Journal.

The announcement was made by Elizabeth Holmes Tuesday to approximately 125 remaining employees at its downscale Newark, California headquarters. (This Editor wonders if she wore a black turtleneck.) Interestingly, Ms. Holmes remains CEO after settling civil charges with the Securities and Exchange Commission (SEC) while a criminal investigation continues out of the US Attorney’s office in San Francisco. 

The WSJ article from the estimable John Carreyrou (who deserves an old-school Pulitzer Prize for his investigative reporting) recaps Theranos’ fall for those who need it. But…there’s more. Theranos received only $65 million of $100 million promised in their last (ditch) funding from Fortress Investment Group late last year, revealed by Ms. Holmes in an investor email this past Tuesday. The remainder is contingent on Theranos achieving an FDA Zika blood test approval using their miniLab. She stated that this test is still having problems and appealed to investors for yet more funding. The layoffs were designed to keep their cash reserve over $3 million until the end of July, below which Fortress is entitled to seize Theranos’ assets and liquidate them. This, as we have previously noted, is Fortress’ specialty–as now fan dancing is Ms. Holmes’.

According to Mr. Carreyrou’s sources, Ms. Holmes is still living large in basic black. “Until Tuesday, Ms. Holmes still had two personal assistants and two security guards who drove her around in a black Cadillac Escalade SUV, according to the people familiar with the matter.” This Editor wonders what happened after Tuesday. Public transit? A used car for a few thousand?

Theranos and the $900 million in lost investment may have also put a wet blanket on 2017 health tech funding, based on what we’ve learned in Rock Health’s report [TTA 5 Apr]. Other companies with real advances and promise may be paying the price for Theranos’ hype and fakery.

Our 47 past chapters and other Theranos mentions are for your perusal in our pages here

Soapbox: JPM’s Dimon takes the 50,000 foot view on the JP Morgan Chase-Berkshire Hathaway-Amazon health joint venture

Mr. Jamie Dimon, the chairman and CEO of JP Morgan Chase, had a few thoughts about the JPM-Berkshire Hathaway-Amazon healthcare JV for all three companies. You’ll have to fill up the tea or coffee mug (make it a small pot) for it’s an exceedingly prolix Annual Shareholder Letter you’ll have to sled through to find those comments. Your Editor has taken her punishment to find them, towards the end of the letter in ‘Public Policy’. 

They demonstrate what this Editor suspected–an headache-inducing mix of generalities and overreach, versus starting modestly and over-delivering.

  • Point #1 sets up what has gone wrong. Among several, “Our nation’s healthcare costs are twice the amount per person compared with most developed nations.” Under point 2 on how poor public policy happened, an admission that Obamacare fixed little:

Here’s another example: We all know that the U.S. healthcare system needs to be reformed. Many have advocated getting on the path to universal healthcare for all Americans. The creation of Obamacare, while a step in the right moral direction, was not well done. America has 290 million people who have insurance — 180 million through private enterprise and 110 million through Medicare and Medicaid. Obamacare slightly expanded both and created exchanges that insure 10 million people. But it did very little to fix our broken healthcare system and has, in fact, torn up the body politic over 10 years — and this tumult may go on for another 10 years.

  • Point #7 is about fixing the deficit and the ill effects if we don’t. In Mr. Dimon’s view, healthcare is a major part of this through the uncontrolled growth of entitlements, with Medicare, Medicaid and Social Security leading the pack–skipping over the fact that nearly all Americans pay into Medicare and SSI well in advance of any entitlement collection. Healthcare is also an offender through unnecessary costs such as administrative and fraud (25-40 percent),  and six mainly chronic conditions accounting for 75 percent of spending.
  • The experts–specifically, their experts–will fix it! “While we don’t know the exact fix to this problem, we do know the process that will help us fix it. We need to form a bipartisan group of experts whose direct charge is to fix our healthcare system. I am convinced that this can be done, and if done properly, it will actually improve the outcomes and satisfaction of all American citizens.”
  • The generalities continue with
    • The JV “will help improve the satisfaction of our healthcare services for our employees (that could be in terms of costs and outcomes) and possibly help inform public policy for the country.” 
    • Aligning incentives systemwide ‘because we’re getting what we incentivize’
    • “Studying the extraordinary amount of money spent on waste, administration and fraud costs.”
    • “Empowering employees to make better choices and have the best options available by owning their own healthcare data with access to excellent telemedicine options, where more consumer-driven health initiatives can help.”
    • “Developing better wellness programs, particularly around obesity and smoking — they account for approximately 25% of chronic diseases (e.g., cancer, stroke, heart disease and depression).”
    • “Determining why costly and specialized medicine and pharmaceuticals are frequently over- and under-utilized.”
    • “Examining the extraordinary amount of money spent on end-of-life care, often unwanted.”
    • “To attack these issues, we will be using top management, big data, virtual technology, better customer engagement and the improved creation of customer choice (high deductibles have barely worked”).

This Editor has observed from the vantage of the health tech, analytics, payer, and care model businesses that nearly every company has addressed or is addressing all these concerns. So what’s new here? Perhaps the scale, but will they tap into the knowledge base those businesses represent or reinvent the wheel? 

A bad sign is Mr. Dimon’s inclusion of ‘end of life care’. This last point is a prime example of overreach–how many of the JV’s employees are in this situation? The ‘attack’ tactics? We’ve seen, heard, and many of us have been part of similar efforts.

Prediction: This JV may be stuck at the 50,000 foot view. It will take a long time, if ever, to descend and produce the concrete, broadly applicable results that it eagerly promises to its million-plus employees, much less the polity. 

2017’s transition in digital health funding: is it maturity or a reconsideration?

Rock Health’s topline for 2017 digital health funding is impressively upbeat, casting it as “the end of the beginning in digital health, the start of a new era with new challenges”. Digging into it, there is a continued slowing that Rock Health itself predicted back in their 3rd Quarter report [TTA 3 Oct 17]. It seems that the big did get bigger, but if you weren’t on the train in 2016 or prior, 2017 wasn’t the year you left the station. Their findings bear this out, keeping in mind that their tracking is for US companies with deals over $2 million in value, which excludes much of the action from young and international companies:

  • No digital health IPOs this year, in a weak year in general for IPOs
  • For the companies already in public markets, they outperformed the S&P 500 31 percent to 19 percent
  • Average deals hit an all-time high of $16.7M ($5.8 bn over 345 deals) 
  • Big money went to better-developed, more mature companies like Outcome Health and Peloton exercise equipment at $500 million and $325 million. Rock Health duly notes Outcome Health’s troubles since. (To this Editor, Peloton is not a digital health company despite its glitzy overlay of video and exercise community.)  
  • Seven $100 million + mega-deals front-loaded in the first half of the year. Second half’s sole big deal was genetic testing and data marketer 23andme. The dominant category of business? Consumer health information represented by Outcome, 23andme, PatientPoint, PatientsLikeMe, and ShareCare, most with a B2B2C model.
  • Looking at deals by stage, not surprisingly the funding at D and later rounds soared to an average size of $74 million (from 2016’s $46 million). Seed and A rounds’ average funding at $7 million, while the majority, hasn’t varied much since 2011. Series B funding was also flat at $17 million on average.
  • Exits continued to be weak, indicating the reality of healthcare investing being long haul. M&A deals declined for the second straight year to 119–18 percent fewer than 2016 and 36 percent fewer than 2015

Also Modern Healthcare.

This Editor’s opinion? One damper on 2017 was the $900 million credulously blown on Theranos. Call it the Theranos Effect.

As usual we will look at StartUp Health‘s always numerically bigger report after release, but this Editor’s bet is that it won’t be ‘crazy’ like earlier in 2017. 

Breached healthcare records down 72% but incident numbers steady. Then there’s MyFitnessPal’s 150 million…

click to enlargeHackermania in healthcare may be running less wild…but what about consumer health devices? Year-end and top-of-year analyses indicate that the flood of breached records may be starting to drain. A Bitglass analysis of 2017 US Department of Health and Human Services (HHS) data from its infamous ‘Wall of Shame’ is encouraging. They found that the number of breached records decreased over the 2015-2017 period by 72 percent between 2015 and 2017 and by 95 percent from 2016. The calculation excludes the huge spike in breaches due to two 2015 incidents at Anthem and Premera Blue Cross [TTA 9 Sep 15]. Numerically, the breach incident numbers decreased but are relatively steady: 2017 at 294, 2016 at 328. Data security company Protenus in its tracking found more incidents in 2017 versus 2016 (477 in 2017 v. 450 in 2016) but the same reduction in records affected, with five times fewer records in 2017 versus 2016’s 27.3 million records.

What’s been successful has been reducing mega-breaches and containment of healthcare device loss and theft through education and enforcement of employee practices. What continues is the major cause of breaches continue to be insider-related via error and wrongdoing; this includes the major annual Verizon report. Healthcare Informatics

Protenus’ February report, while continuing the reduction trend, had its share of hacking and insider incidents. Of the 39 incidents in their report affecting over 348,000 records, insider actions such as the misuse of system credentials accounted for 51 percent of breached records while hacks were 46 percent, with the majority involving ransomware or malware. Hacking as a cause hasn’t disappeared but perhaps has shifted to easier targets.

UnderArmour’s MyFitnessPal delivers another breach blow. Late last month, the company revealed that 150 million user records were hacked in February. The MyFitnessPal mobile app (more…)