A change of vetting for the NHS Apps Library by spring 2020

NHSX, the multi-department team from NHS England, the Department of Health and Social Care, and NHS Improvement established earlier this year [TTA 18 Apr], announced last week a new approach to the accreditation of digital health apps for the NHS Apps Library. The plan is to transition from the present direct assessment into accrediting independent assessors using an open standard. NHSX announced that they will undertake this change in a two-step process:

  • Create a digital health technology standard based on those existing for industry and health, combining present questions with other data and interoperability standards
  • Develop a clearer review, assessment and evaluation approach for digital health tools, including a list of external assessors who will be in turn accredited to apply the new standard

This approach to the perennial problem of app vetting is scheduled to be completed by spring of 2020, not too far away.

In related developments:

  • NHSX will also work with the Accelerated Access Collaborative on a pipeline to deliver digital products through to priority areas
  • NHSX’s departing (as of October end) director of digital development Dr. Sam Shah has been ranked fourth in the #IB100, a list of the top 100 most influential black, Asian and minority ethnic (BAME) leaders in the tech sector. HealthcareITNews Europe/UK

UKAuthority.com  Hat tip to Alistair Appleby of Wokingham Borough Council 

Short takes: Outcome Health pays up, Teladoc’s up in double-digits, Walgreens closing 40% of clinics, a health kiosk for hospital employees?

Outcome Health settles with DOJ, pays $70 million. Former health unicorn ‘patient ed’ company Outcome Health entered into a non-prosecution agreement with the US Department of Justice (DOJ). In return for settling up with its advertisers, with a fund now at $70 million, it has overhauled its procedures, including third-party auditing and internal controls. That includes a near-complete change of management. A summary of its earlier problems is here. Release

It also looks like Teladoc is on the right path after last year’s financial and moral rocky patch and this year’s NCQA corrective action with Q3 revenue of $138 million, up 24 percent year-to-year, and nine-month revenue up 34 percent to $396.8 million. The year forecast is tracking with total revenue estimated at $149 million to $153 million and the losses pared down to between $5 to 9 million. Seeking Alpha

The news that Walgreens Boots is closing 40 percent of its US clinics–about 150–by end of year is perhaps a sign that the in-store ‘minute clinic’ is not producing the kind of traffic that’s wanted. They will retain the clinics run in partnership with healthcare providers. In August, Walgreens also announced the closure of about 200 stores, about 3 percent of their national total. Is this also a concession that CVS and its clinic strategy are edging out Walgreens? Often the two chains are located within minutes (sic) of each other. USA Today

A city hospital is an unlikely place for a health diagnostic kiosk, especially for employees, but Tampa General Hospital is trying out neighboring Clearwater’s OnMed stations in its locations. The station is connected to OnMed’s virtual clinic via high-definition video and multiple diagnostic tools. The station is also its own pharmacy, able to store up to 1,000 different medications, which are dispensed if prescribed by the doctor on the consult. Interestingly, employees quoted in the article seemed to like it as fast and convenient–and free for their use. Tampa General and OnMed plan to co-brand in the area and roll out about 20 for public use, at an estimated $65-75 per visit. Tampa Bay Times

 

The biggest care gap: the fear of going home after discharge

Roy Lilley’s NHS Managers.net newsletter is always interesting and worth subscribing to, but this week’s issue had a special resonance. Many of us have had to ‘manage’ a situation when you or a family member comes home after an illness, accident, or even minor injury. The actions you took for granted are now difficult, painful, or simply cannot be done. Climbing stairs, making a bed, lifting a full pot, even getting on a coat or jacket or tucking in a shirt are just a few. These have special resonance for those of us who have a few ‘cycles’ on us (as aviation terms a takeoff and landing), even if mentally we’re about 35 (!) Will we ever be quite right again? What happens when the home help goes home, or you’re by yourself?

Of interest to American readers is that the British Red Cross is pivoting to fill the care gap of discharge to home. The BRC has a long history of working with the NHS, which was a surprise to this Editor, as the American Red Cross’ emphasis is on disaster relief (of which we have aplenty). Home to the unknown: Getting hospital discharge right is their umbrella report with briefings for England, Scotland, and Northern Ireland. The BRC provides ambulance support, helps people get home from hospital, carries out home assessments and supports older and vulnerable people to live independently at home. As Mr. Lilley put it, referring to the traditional Red Cross mission:

Refugees? About 900,000 people used to get care and support from local council services. The eligibility criteria have been raised, now they get no help. They are refugees in our care system.

On a different note, this issue’s sidebar contains a link to a short article about the scientific pioneer Marie Curie and a few tidbits about anti-inflammatory drugs being used to treat depression, tick-borne diseases spreading in the UK, and medtech fighting breast cancer 10 ways. 

Last call for DHACA Day on 9th November, plus an excellent RSM event on 3rd December

Two quick notifications:

DHACA Day

The Digital Health & Care Alliance’s next quarterly update for medtech entrepreneurs is coming up on 9th November in London, with just ten spaces left. Covering all the hot areas that those working in the digital health & care sector need to be concerned about, it is kindly sponsored by Baker Botts and Kent Surrey & Sussex AHSN to ensure you get great value from the event. For more information, and to book, go here.

Behavioural science for better outcomes in health and care services

The Royal Society of Medicine is running a one day conference on how to use behavioural science to develop, optimise and evaluate a digital health intervention on 3rd December. The RSM name attracts the world’s best speakers and their charitable status means that prices are cut to the bone so this is guaranteed to be a great day. More details and to book are here.

(Disclosure: Editor Charles is involved with both the above organisations)

Short Takes: Amazon buys symptom checker Health Navigator; Ettain Group acquires EHR consultant Leidos Health (updated)

Amazon’s acquisition of startup Health Navigator, a developer of online symptom checking and triage tools sold to other digital companies to integrate into their digital health solutions, is another foray into healthcare. In this case, Health Navigator is a straightforward fit into their Amazon Care unit which provides enterprise virtual care benefits. No transaction amount, leadership, nor timing are mentioned. This is unlike their purchase earlier this year of online pharmacy PillPack for a stunning $700+ million. After roadblocks on getting the patient data they need [TTA 12 Sept], and other stumbles, PillPack has been folded into their consumables group and right now is not challenging CVS or Walgreens in any meaningful way. CNBC

Charlotte NC-based ettain group has purchased EHR consultancy Leidos Health. The divesting parent, Leidos Inc. is best known to our Readers for its contract with the US Department of Defense in the replacement of the ancient AHLTA EHR with a Cerner system. The acquisition will reinforce Ettain’s healthcare IT sector. Leidos Inc. remains in business in the government and private healthcare sectors for consulting and retains the MHS Genesis contract. Unfortunately, the announcement is dimmed by a poorly written and elliptical release.

Update: A spokesperson for ettain group (lower case correction) has clarified via email that they have “acquired Leidos Health LLC which is a commercial EHR staff augmentation services business. This is not to be confused with Leidos Inc, the original parent company that still maintains a health business that manages the DOD MHS Genesis program. Basically, the ettain group transaction doesn’t include MHS Genesis.”

Is ‘age-tech’ a stereotype that misses the larger mark–and market?

Two thoughtful articles this week comment on the difference between the highly touted ‘age-tech’ and products and services that older people actually need and want. The first is by the Centre for Ageing Better’s Jemma Mouland, who quite ably points out that ‘age-tech’ as a category (apologies to Laurie Orlov) inherently screams ‘old’, ‘feeble’, and ‘ill’–while it searches desperately for the ‘silver unicorn’. Yes, older people (and the disabled) do need solutions that help with changes as we age, but even the things that we need tend to be couched in negatives, feel like they don’t fit in our lives, reinforce a feeling of decline, or stigmatize. (The real hot button issues are hearing, vision, and driving.)

Moreover, older consumers often feel left behind or neglected by (formerly) favorite brands or services. A recent UK retail study stated that this is the belief of over 80 percent of 55+ consumers–now edging into the older cohort of Gen X. (One observation this Editor will make is that a huge negative is current clothing appearance, fit and cut.) It’s disappointing to your Editor as a marketer–that means that this group, with 83 percent of household wealth in age 50+ hands, keeps their wallets shut.

MIT Technology Review this month is cited in Ms. Mouland’s article. Building on Joseph Coughlin’s work at the MIT AgeLab in its ‘Old Age Is Over!’ issue, he cites that old age and even retirement is an obsolete construct built on early 19th century beliefs around the depletion of ‘vital energy’ and 20th century social policy around that. The stereotype the latter built was one was either needy–needing social support, or greedy–living the easy retirement life off a pension and looking for early-bird specials.  That tends to frame how we look at older people in employment, in living at home, or in social policy as driving up the cost of care–just a problem to be solved, and certainly not productive or, in Ezekiel Emanuel’s end game, even worthy of anything other than palliative medical care or being part of the political polity.

Mr. Coughlin’s close may be a bit reductionist, but this Editor will take it. “By treating older adults not as an ancillary market but as a core constituency, the tech sector can do much of the work required to redefine old age. But tech workplaces also skew infamously young. Asking young designers to merely step into the shoes of older consumers (and we at the MIT AgeLab have literally developed a physiological aging simulation suit for that purpose) is a good start, but it is not enough to give them true insight into the desires of older consumers. Luckily there’s a simpler route: hire older workers.” And work on making your products and service meet the needs of a broad spectrum of people. Hat tip to Alistair Appleby of Optalis–whose team, in a bit of news, is moving over to Wokingham Borough Council at the end of the month.

Over half of Americans of all ages use digital health tools, self-diagnose after internet search: ResMed/Edelman survey

Compensating for shortcomings? ResMed, a remote patient monitoring company, with Edelman Intelligence, found in their research on the consumer acceptance of digital health technology some interesting behavioral information as well that demonstrates frustration with the status quo in healthcare. Over 3,000 individuals were surveyed, across 37 percent Baby Boomers, 26 percent Gen Xers, 28 percent Millennials and 9 percent Gen Zers. 

  1. 56 percent of those surveyed currently monitor their health with at least one digital data collection tool
  2. 60 percent attempt to diagnose themselves after browsing symptoms on the Internet – including 76% of millennials (confirming an earlier survey by Harmony HealthcareIT citing 73 percent of millennials self-diagnosed via internet research)
  3. 78 percent stated it should be easier to find medical care
  4. 63 percent said they were sick of feeling like their healthcare doesn’t matter in the current healthcare system
  5. 47 percent of responders said they would like to communicate through text
  6. 38 percent said they would like to participate in video chats.

While the percentages in #5 and #6 have been fairly standard responses over the years in other surveys and to this Editor should be higher by now, the frustration level experienced in #3 and #4, after years of ‘new healthcare models’ that supposedly empower the patient and the rise of urgent care clinics almost everywhere, is perhaps indicative of an increasing awareness of the flaws of the healthcare system and its shortcomings. It’s not cost–it’s delivery. ResMed release, Mobihealthnews

Cleveland Clinic, American Well extend partnership to high-acuity telehealth services with ‘The Clinic’

Proof that the realm of virtual consults is growing more competitive and specialized than ever is the announcement of a joint venture between the Cleveland Clinic and American Well. Dubbed The Clinic, the partnership will give patients access to comprehensive and high-acuity care services by integrating Cleveland Clinic’s specialists with American Well’s platform. 

While Cleveland Clinic and American Well have worked together in telehealth for non-emergency and specialty care since 2014, this new partnership takes it a giant step further to the care and management of complex conditions. Cleveland Clinic has also stated that telehealth is a key part of their growth strategy to double the number of patients served in the next five years. The Clinic will provide both national and international reach beyond their physical locations that include Abu Dhabi and London, according to a quote in the press release from Tom Mihaljevic, MD, their CEO and president. 

Cleveland Clinic reported that in 2018, the number of annual virtual visits grew 68 percent, anticipating that in five years, 50 percent of their outpatient visits will be virtual.

No timing for a go-live of The Clinic has been announced. Release, Mobihealthnews

Tyto Care partners with Avera eCARE for telehealth delivered to medically underserved populations

Following on last week’s announcement of Tyto Care‘s partnership with Novant Health, Sioux Falls SD-based telemedicine provider Avera eCARE will be introducing Tyto Care’s professional version, TytoPro, into its telemedicine service using high-definition video for virtual consults. What TytoPro will add is remote diagnostic capability and collection via the TytoVisit platform, using the TytoApp and Clinician dashboard. Avera will use TytoPro’s hand-held device with exam camera, thermometer, otoscope, stethoscope (with volume, bell, and diaphragm filters), and tongue depressor adaptors.

In a test of Avera eCARE plus Tyto Care in an assisted living community, the pairing of the two systems reduced emergency department transfers by 20 percent, with 93% of residents treated in place.

Avera eCARE, a part of Avera Health, provides telemedicine services to medically underserved populations via local healthcare systems, rural hospitals, outpatient clinics, skilled nursing facilities, assisted living communities, schools, and correctional facilities. It has over 400 providers in its comprehensive virtual health network across the US. A ‘white paper’ on the Avera/Tyto Care partnership is here. Release 

Call for abstracts extended: ISG’s 12th World Conference of Gerontechnology (Norway)

ISG’s 12th World Conference of Gerontechnology, to be held on 18-20 May 2020 in Trondheim, Norway, has extended its call for conference abstracts to Friday 15 November. There are two types of abstracts:

  • Format No.1 – Free Paper, Poster, or an individual presentation as part of a symposium
  • Format No.2 – ONLY if you are the Convener of a Symposium

The link to the call for abstracts is here on their site. 

The conference will be held at the Clarion Hotel & Congress, located at Brattørkaia 1 in historic Trondheim. The conference theme is “Measures to achieve better quality of life and active healthy aging”. From the website, the conference “addresses the potential power of technology to both enhance quality of life older people and prevent age-related disabilities through health promotion. Technological solutions can also support independence and meaningful activities, and they can prevent loneliness, boredom and helplessness. This aligns with the main goals of gerontechnology which is divided into seven achievements: Satisfaction and enjoyment; Prevention; Support; Compensation; Caring; Care support; and Care organization.” More information is here. To register, see this page. Hat tip to Professor Anthea Tinker of the Institute of Gerontology, King’s College London.

News, moves and M&A roundup: Appello acquires RedAssure, Shaw departs NHS Digital, NHS App goes biometric, GP at Hand in Manchester, Verita Singapore’s three startup buys, Novant Health and Tyto Care partner

Appello telecare acquires RedAssure Independent Living from Worthing Homes. A 20-year provider of telecare services to about 700 homes in the Worthing area in West Sussex, the acquisition by Appello closed on 1 October. Previously, Appello provided monitoring services for RedAssure since 2010. Terms were not disclosed. Release.

Another NHS Digital departure is Rob Shaw, deputy CEO. He will be leaving to pursue a consulting career advising foreign governments on national health and care infrastructure. He is credited with moving the NHS Spine in-house and establishing NHS Digital’s cybersecurity function. The Digital Health article times it for around Christmas. Mr. Shaw’s departure follows other high-profile executives this year such as former chief digital officer Juliet Bauer who controversially moved to Kry/LIVI after penning a glowing article about them [TTA 24 Jan], Will Smart, Matthew Swindells, and Richard Corbridge.

One initiative that NHS Digital has lately implemented is passwordless, biometric facial or fingerprint-based log in for the NHS App, based on the FIDO (Fast-Identity Online) UAF (Universal Authentication Framework) protocol (whew!). NHS Digital’s most recent related announcement is the release of two pieces of code under open-source that will allow developers to include biometric verification for log in into their products.

Babylon Health’s GP at Hand plans Manchester expansion. The formal notification will likely be this month to commissioners of plans to open a Manchester clinic as a center for GP at Hand’s primarily virtual consults. This follows on their recent expansion into Birmingham via Hammersmith and Fulham CCG which will be notified. How it will work is that patients registering in Manchester would be added initially to a single patient list for GP at Hand located at Hammersmith and Fulham CCG. Babylon is now totalling 60,000 patients through GP at Hand.  GP Online

Singapore’s Verita Healthcare Group has acquired three digital health startups. The two from Singapore are nBuddy and CelliHealth, in addition to Germany’s Hanako. Verita has operations in Singapore, the US, Asia-Pacific and Europe, with 35 alliance partnerships with medical clinics and hospitals across Australia, Southeast Asia and Europe. Mobihealthnews APAC

Novant Health, a 640-location health system in North Carolina, is introducing Tyto Care’s TytoHome integrated telehealth diagnostic and consult device as part of its network service. Webpage, release

Slow gait speed at age 45 as an accelerated aging predictor–and result: Duke University study

Tracking gait not just for tracking acuity and functioning in older adults in care homes. A five-decade cohort study made of over 900 45 year-old adults in a single community–Dunedin, New Zealand–correlates slowness of gait with accelerated aging, including brain health measured as early as age 3. These markers include:

  • Decreased cortical thickness
  • Reduced brain volume
  • Poorer physical functions such as balance, hand grip, stepping, and physical-motor coordination
  • 19 biomarkers taken at ages 26, 32, 38, and 45 years including body mass index, waist-to-hip ratio, glycated hemoglobin level, leptin level, blood pressure, cholesterol, C-reactive protein level, white blood cell count, and dental health

Why this matters: the cohort study goes back to age 3. Assessed at that time by a pediatric neurologist were standardized tests of intelligence, receptive language, and motor skills; and examiner ratings of each child’s emotional and behavioral regulation. MRIs were not available for physical examination at that time and for many years after for children, but were used on the adult respondents to determine structural age-related features of the brain. 

At age 3 and later, poor scores on brain health judged from standardized tests were indicative of future slower gait and accelerated aging at 45, though the exact causality is not clear. In addition to the biomarkers and brain changes, their facial age was also older.

The study was conducted primarily by Duke University and New Zealand university researchers. The original cohort was 1037 participants (535 [51.6%] male). 997 were still alive at age 45 years, and 938 took part in the assessment at age 45 years between April 2017 and April 2019. Of the 997 still alive, 904 (90.7%; 455 [50.3%] male; 93% white) completed the gait test. Disabled (e.g. broken leg, amputation) were eliminated.

In looking back at this significant study, could a physical assessment of children’s health beyond the ordinary, with remedial work on motor skills and emotional state, stave off accelerated aging? Duke Today, JAMA Network Open, New Atlas

CB Insights names a Top 150 of digital health startups

Now the equivalent of Mrs. Astor’s Four Hundred? CB Insights has entered the list game with a brand new listing of digital health startups, the Digital Health 150, no ballroom needed–perhaps a convention hall? They are classified, sliced, and diced as follows:

Broad categories:

  • Digital therapeutics
  • Pharma supply chain
  • Insurance and benefits
  • Genomics
  • Consumer health and wellness
  • Providers: administrative tools, specialty care, primary care, clinical tools
  • Diagnostics: imaging, pathology, other diagnostics
  • Drug R&D: drug discovery and development, clinical trials, real-world evidence

Another slice is by deal stage from 2014 (the receding of seed funding and progression into Series B and C is notable), top well-funded companies, and ‘unicorn startups’. Unlike Rock Health, CB Insights also looks at where in the world the startups are from: 116 in the 150 from the US, 17 from Asia, 16 from Europe, and 1 from Canada (League employee health benefits).

Many of the usual suspects are here: 23andMe, Babylon Health (UK), American Well, Doctor on Demand, Proteus Digital Health, Iora Health, MDLive, Oscar, One Medical, the relentlessly advertised (in US) Noom, TytoCare, China’s WeDoctor and GoodRx (which last month acquired telemedicine provider HeyDoctor).  Others are surprising in various aspects: the new well-wired Medicare Advantage company Devoted Health, Let’s Get Checked (Ireland, though they list their HQ as NY on website), Protenus (breach tracking), Kry (Nordic/LIVI in UK), Zava (UK), Teckro (Ireland), AbleTo, Higi, ClearCare, and CarePredict. It’s nice to see nods to the un-sexy areas of senior telecare, home care, and cognitive health. CB Insights page

WOT with Proteus found equal to or better than DOT in TB medication adherence trial

Implications for administration of tuberculosis and other rigorous therapies. A test conducted by a California university team with tuberculosis (TB) patients comparing Wirelessly Observed Therapy (WOT) administered through Proteus Digital Health’s combination ingestible pill and sensor-based smartphone tracking, versus standard Directly Observed Therapy (DOT), found that WOT was equivalent to DOT in accuracy–and superior to DOT in supporting confirmed daily adherence to TB medications. It was also overwhelmingly preferred by participants. 

TB is a disease where treatment requires strict adherence to medication protocols over a lengthy treatment course and usually requires a period of direct observation of patient dosage. In the first part of the test examining accuracy under direct observation, the researchers reported a 99.3 percent rate of positive detection accuracy (95% CI, 98.1% to 100%) among 77 TB patients under treatment with IS-Rifamate. The second part of the study among 66 patients took place in a randomized control test. The Proteus WOT system was found superior to DOT in supporting confirmed daily adherence to TB medications during the continuation phase of TB treatment by 93 percent to 63 percent. The treatment course was as long as 29 weeks. Participants rated preference for a WOT system at 100 percent.

The study was performed by researchers from the University of California, San Diego, Stanford University, HHS and Orange County Health Care Agency and published in PLOS Medicine on 4 October. The team recommended that a WOT system like Proteus be used within high-burden TB settings in low and middle-income countries, especially as it can be monitored seven days a week versus a standard five days.  Mobihealthnews

The Theranos Story, ch. 61: Elizabeth Holmes as legal deadbeat

Did her lawyers expect otherwise? This weekend’s news of Elizabeth Holmes’ legal team at Cooley LLP withdrawing their representation services due to non-payment should not have caused much surprise. Cooley’s attorney team petitioned the court to withdraw from the case, stating that “Ms. Holmes has not paid Cooley for any of its work as her counsel of record in this action for more than a year.”

Cooley was representing Ms. Holmes in a class-action civil suit in Phoenix brought against her, former Theranos president Sunny Balwani, and Walgreens, charging fraud and medical battery. (When they withdraw, will she seek public representation based on poverty?)

Perhaps Ms. Holmes is the one who’s setting priorities, as the civil suit would be for monetary damages, and no money means there will be none for the plaintiffs to collect. The DOJ charges are a different story. She is on the hook for nine counts of wire fraud and two counts of conspiracy related to her actions at Theranos. Conviction on these could send her to Club Fed for 20 years plus a fine of $250,000 plus restitution for each charge. [TTA 16 June]

Last Wednesday, both Ms. Holmes and lawyers for her and Mr. Balwani were in Federal court in San Jose on the wire fraud and conspiracy charges, demanding that the government release documents from the Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid Services (CMS) that allegedly would clear them. After an hour, Judge Davila set 4 November as the next hearing date. 

Defending oneself does not come cheap, but after your company’s value crashes to $0 from $9bn, one might be looking for change in your Roche-Bobois couch and wondering if your little black Silicon Valley-entrepreneur formal pantsuit/white shirt ensembles will last through the trial. CNBC 2 Oct, CNBC 4 OctFox Business, Business Insider

Health tech bubble watch: Alphabet-backed One Medical reportedly prepping for 2020 IPO

Another health tech company tests the IPO waters. One Medical, a primary care medical clinic group that digitizes the office experience by offering mobile apps with online scheduling, virtual consults, and same-day appointments–for an annual fee of $200 plus your insurance–is prepping for an IPO filing early next year. The sure sign is that it’s hired banks including J.P. Morgan and Morgan Stanley.

One Medical, backed by Alphabet, has 72 primary care practices in nine major US cities. It currently has a valuation of $1.5 to $2 bn based on private share sales and investment firm estimates. In 2008 it raised $220 million in a 2018 round led by The Carlyle Group for a total raise since 2007 of $408 million, backed by Alphabet’s GV venture arm and VC firm Benchmark. From an initial emphasis on individual enrollment and a ‘lite’ version of concierge medicine, it recently has concentrated on self-insured employers, corporate health plans, and service areas such as mental health and pediatrics. A big question for investors will be its valuation–tech or healthcare?

One Medical would join IPO brethren such as Health Catalyst, Livongo, Phreesia, and Change Healthcare, all of which had fairly strong openings and initial growth but have rollercoastered since then. Still, smaller IPOs such as Progyny, a company that manages fertility benefits for employees at large firms, have filed to IPO by the end of the year. Fierce Healthcare, CNBC, Business Insider