News roundup: docs dim on AI without purpose, ‘medtail’ a mall trend, CVS goes SDH, Kvedar to ATA, Biden ‘moonshot’ shorts out, and Short Takes

Docs not crazy about AI. And Dog Bites Man. In Medscape‘s survey of 1,500 doctors in the US, Europe, and Latin America, they are skeptical (49 percent-US) and uncomfortable (35 percent-Europe, 30 percent-Latin America). Only 20 percent fess up to actually using an AI application, and aren’t crazy about voice tech even at home. Two-thirds are willing to take a look at AI-powered tech if it proves to be better than humans at diagnosis, but only 44 percent actually believe that will happen. FierceHealthcare

This dim view, in the estimation of a chief analytics and information officer in healthcare, Vikas Chowdhry, is not the fault of AI nor of the doctors. There’s a disconnect between the tech and the larger purpose. “Without a national urgency to focus on health instead of medical care, and without scalable patient person-centered reforms, no technology will make a meaningful impact, especially in a hybrid public goods area like health.” The analogy is to power of computing–that somehow when we focused behind a goal, we were able to have multiple moon missions with computing equivalent to a really old smartphone, but now we send out funny cat videos instead of being on Mars. (And this Editor growing up in NJ thought the space program was there to market Tang orange drink.) HIStalk.

Those vacant stores at malls? Fill ’em with healthcare clinics! And go out for Jamba Juice after! CNN finally caught up with the trend, apparent on suburbia’s Boulevards and Main Streets, that clinics can fill those mall spots which have been vacated by retail. No longer confined to ‘medical buildings’, outpatient care is popping up everywhere. In your Editor’s metro area, you see CityMDs next to Walmarts, Northwell Health next to a burger spot, a Kessler Health rehab clinic replacing a dance studio, and so on. The clever name for it is ‘medtail’, and landlords love them because they sign long leases and pay for premium spots, brighten up dim concourses, and perhaps stimulate food court and other shopping traffic. Of course, CVS and Aetna spotted this about years ago in their merger but are working expansion in the other direction with expanding CVS locations and on the healthcare side, testing the addition of social determinants of health (SDH) services via a pilot partnership, Destination: Health with non-profit Unite Us to connect better with community services. This is in addition to previous affordable housing investments and a five-year community health initiative. Forbes, Mobihealthnews

ATA announces Joseph Kvedar, MD, as President-Elect. Dr. Kvedar was previously president in 2004-5 and replaces John Glaser, PhD, Executive Senior Advisor, Cerner. He will remain as Vice President of Connected Health at Partners HealthCare and Professor of Dermatology at Harvard Medical School. A question mark for those of us in the industry is his extensive engagement with October’s Connected Health Conference in Boston, one of the earliest and now a HIMSS event. ATA’s next event is ATA2020 3-5 May 2020 in Phoenix–apparently no Fall Forum this year.

The Biden Cancer Initiative has shut down after two years in operation. This spinoff of the White House-sponsored ‘moonshot’ initiative was founded after the death of Beau Biden, son of Democrat presidential candidate Joe Biden. Both Mr. Biden and wife Jill Biden withdrew due to ethics concerns in April. According to Fortune, the nonprofit had trouble maintaining momentum without their presence. However, the setup invited conflict of interest concerns. The Initiative engaged and was funded by pharmas and other health tech companies, directly for Initiative support but mainly for indirect pledges to fund research. Most of these organizations do business with Federal, state and local governments. Shortly after the formal announcement, Mr. Biden the Candidate announced a rural health plan to expand a federal grant program to include rural telehealth for mental health and specialized services. Politico   But isn’t that already underway with the FCC’s Connected Care Pilot Program, coming to a vote soon? [TTA 20 June]

And…Short Takes

  • Philips Healthcare bought Boston-based patient engagement/management start-up Medumo. Terms not disclosed. CNBC
  • London’s Medopad launched with Royal Wolverhampton NHS Trust (RWT) in a three-year RPM deal. DigitalHealthNews
  • Parks Associates’ Connected Health Summit will be again in San Diego 27-29 August with an outstanding lineup of speakers. More information and registration here.

And in other news, Matt Hancock holds tight to his portfolio as UK Secretary of State for Health and Social Care in the newly formed Government under new PM Boris Johnson. Luckier than the other 50 percent!

 

 

Health tech bubble watch: Rock Health’s mid-2019 funding assessment amid Big IPOs (updated: Health Catalyst, Livongo, more)

Updated for IPOs and analysis. The big time IPOs add extra bubbles to the digital health bath. Rock Health’s mid-year digital health market update continues its frothy way with a topline of $4.2 bn across 180 deals invested in digital health during the first half of 2019. 2019 is tracking to last year’s spending rate across fewer deals and is projected to end the year at $8.4 bn and 360 deals versus 2018’s $8.2 bn and 376 deals.

This year has been notable for Big IPOs, which have been absent from the digital health scene for three years. Exits come in three flavors: mergers and acquisitions (43 in their count so far), IPOs, and shutdowns (like Call9). IPOs are a reasonable outcome of last year’s trend of mega deals over $100 million and a more direct way for VCs to return their money to investors. So far in 2019, 30 percent of venture dollars went to these mega deals. (Rock Health tracks only US digital health deals over $2 million, so not a global picture.)

Reviewing the IPOs and pending IPOs to date:

  • Practice intake and patient management system Phreesia closed its NYSE IPO of 10.7 million shares at $18 per share on 22 July. The company earned approximately $140.6 million and the total gross proceeds to the selling stockholders were approximately $51.6 million for a value over $600 million. The market cap as of 26 July exceeded $949 million with shares rising past $26. Not bad for a company that raised a frugal $92.6 million over seven rounds since 2005.  Yahoo Finance, Crunchbase
  • Chronic condition management company Livongo’s picture is frothier. Their 22 July SEC filing has their IPO at 10.7 million shares at $24 to $26 per share offered on NASDAQ. This would total a $267.5 million raise and a $2.2 bn valuation. This is a stunning amount for a company with reportedly $55 million at the end of its most recent reporting period, increasing losses, and rising cash burn. Livongo raised $235 million since 2014 from private investors. Crunchbase 
  • Analytics company Health Catalyst’s IPO, which will probably take place this week on NASDAQ with Livongo’s, expects to float 7 million shares. Shares will be in a range of $24 to $25 with a raise in excess of $171 million. Their quarterly revenue is above $35 million with an operating loss of $9.8 million. Since 2008, they’ve raised $377 million. IPO analysts call both Livongo’s and Health Catalyst’s IPOs ‘essentially oversubscribed’. Investors Business Daily, Crunchbase
    • UPDATE: Both Livongo and Health Catalyst IPOs debuted on Thursday 25 July, with Livongo raising $356 million on an upsized 12.7 million shares at $28/share, while Health Catalyst’s 7 million shares brought in $182 million at $26/share.  Friday’s shares closed way up from the IPOs Livongo at $38.12 and $38.30 for Health Catalyst. Bubbly indeed! Investors Business Daily, Yahoo Finance
  • Change Healthcare is also planning a NASDAQ IPO at a recently repriced $13 per share, raising $557.7 million from 42.8 million shares. With the IPO, Change is also offering an equity raise and senior amortizing note to pay off its over $5 bn in debt. The excruciating details are here. Investors here are taking a much bigger chance than with the above IPOs, but the market action above will be a definite boost for Change.
  • Connected fitness device company Peloton, after raising $900 million, is scheduled to IPO soon after a confidential SEC filing. (UPDATED–Ed. Note: Included as in the Rock Health report; however this Editor believes that their continued inclusion of Peleton in digital health is specious and should be disregarded by those looking at actual funding trends in health tech.) Forbes

Rock Health itself raised the ‘bubble’ question in considering 2018 results. Their six points of a bubble are:

  1. Hype supersedes business fundamentals
  2. High cash burn rates
  3. High valuations decoupled from fundamentals
  4. Surge of cash from new investors
  5. Fraud or misuse of funds
  6. Unclear exit pathways

This Editor’s further analysis of these six points [TTA 21 Jan] wasn’t quite as reassuring as Rock Health’s. As in 2018, #2, #3, and #6 are rated ‘moderately bubbly’ with even Rock Health admitting that #2 had some added froth. #3–high valuations decoupled from fundamentals–is, in this Editor’s experience, the most daunting, as as it represents the widest divergence from reality and is the least fixable. The three new ‘digital health unicorns’ they cite are companies you’ve likely never heard of and in ‘interesting’ but not exactly mainstream niches in health tech except, perhaps, for the last: Zipline (medicine via drone to clinics in Rwanda and Ghana), Gympass (corporate employee gym passes), and Hims (prescription service and delivery).

Editor’s opinion: When there are too many companies with high valuations paired with a high ‘huh?’ quotient (#3)–that one is slightly incredulous at the valuation granted ‘for that??’–it’s time to take a step back from the screen and do something constructive like rebuild an engine or take a swim. Having observed or worked for companies in bubbles since 1980 in three industries– post-deregulation airlines in the 1980s, internet (dot.com) from the mid-1990s to 2001, first stage telecare/telehealth (2006-8), and healthcare today (Theranos/Outcome Health), a moderate bubble never, ever deflates–it expands, then bursts. The textbook #3 was the dot.com boom/bust; it not only fried internet companies but many vendors all over the US and kicked off a recession.

Rock Health also downplayed #5, fraud and misuse of funds. It’s hard to tell why with troubles around uBiome, Nurx, and Cleo in the news, Teladoc isn’t mentioned, but their lack of disclosure for a public company around critical NCQA accreditation only two months ago and their 2018 accounting problems make for an interesting omission [TTA 16 May]. (And absurdly, they excluded Theranos from 2018’s digital health category, yet include drones, gym passes, connected fitness devices…shall we go on?)

Rock Health’s analysis goes deeper on the private investment picture, particularly their interesting concept of ‘net liquidity overhang’, the amount of money where investors have yet to realize any return, as an indicator of the pressure investors have to exit. Pressure, both in healthcare and in early-stage companies, is a double-edged sword. There’s also a nifty annual IPO Watch List which includes the five above and why buying innovation works for both early-stage and mature healthcare companies. 

(Editor’s final note: The above is not to be excessively critical of Rock Health’s needed analysis, made available to us for free, but in line with our traditionally ‘gimlety’ industry view.)

Care Technology Landscape Review: Socitm Advisory for Essex County Council (UK)

A independent report on the UK care technology market was released earlier this month which has both UK and international implications. Commissioned by Essex County Council and produced by Socitm Advisory, it is must reading for those engaged in the procurement and development of local care technology. In a wider sense, the study is part of a larger international trend around community-based health and wellbeing, data utilization and digital tools to promote self-care, mitigate acute illness, and better management of chronic conditions, including social determinants of health (SDH). Digital tools are integrated into care and measured on enabling outcomes, versus being ends in themselves as they tend to be today.

The envisioned emerging care technology solutions framework looks like this: Adrian Scaife of Alcuris Ltd was kind enough to send a link and hard copy of this study, which we are pleased to provide to our Readers (PDF). (You may also download it from Socitm’s website.) He has written a blog post in HousingLIN, Is it time for the next generation of telecare?, which provides a more detailed analysis of the 52-page study and its implications. 

A measured look at the uncertainty around the CVS-Aetna merger

Within two to three weeks, we will know whether Judge Richard Leon of the Federal District Court will–or can–block the CVS-Aetna merger. Already a fait accompli, the merger itself would have to unwound if this is the decision–and uncertainty reigns on whether this actually can be done, as the companies have been merged for several months and have divested what DOJ requested (e.g. PDP to WellCare).

The CVS-Aetna vision is for HealthHubs–combined stores, data, MinuteClinics, kiosks, and the retail business, ultimately combined at a macro level with pharmacy benefit management, external data, and also Aetna’s insurance business. While the HealthHubs are in test, the reach of CVS on both the national and local/individual levels will be huge, if only starting with the data and analytics side. And the retail side is no slouch. Their growth on the retail pharmacy side has been over three times the industry.

In the prescription drug plan (Medicare PDP) market, that horse already left the barn. 70 percent of the PDP market is controlled by three companies: CVS Health, Express Scripts (Cigna), and Optum (UnitedHealth Group). The concerns expressed at the hearings about premiums rising and reduction of competition has already largely happened, with a market not truly private and highly restricted.

Uncertainty may very well be the theme of the rest of the year as it has been since last fall. The smart money is betting that Judge Leon will block the merger on anti-competitive grounds, leading to another round of court actions. Both companies are healthy and will fight it. If forced to part, the  Seeking Alpha analyst bets on CVS doing just fine long term, which leaves little in choices for Aetna with its way forward in merging with other insurers blocked.

SNF emergency telehealth provider Call9 shuts down most operations, after $34M raise (updated)

Is it a symptom of a bubble’s downside? In an interview with CNBC, Dr. Timothy Peck, the CEO of Call9, profiled in TTA only a month ago, confirmed that his company will be shutting down operations. Call9 provided embedded emergency first responders in skilled nursing facilities (SNFs) on call to staff nurses. The first responders not only could provide immediate care to patients with over a dozen diagnostic tools, but also would connect via video to emergency doctors on call. 

Headquartered in Brooklyn, the shuttering of the four-year-old company has laid off over 100 employees as it winds down operations. They claimed 142,000 telemedicine visits and 11,000 patients who were treated via its services. In the past few months, Call9 had inked deals with Lyft for patient transportation and was expanding to Albany NY. They also operated a community paramedicine division utilizing their emergency doctor network.  

This Editor can now reveal that through a reliable industry source, I was informed of Call9’s difficulties earlier this month. Not wanting to ‘run with a rumor’, I contacted Dr. Peck. He confirmed to me information that later appeared in the CNBC article: that the company was refining its model in the face of a change in previous funders and working with some new partners to stay in a model with embedded clinical care specialists in nursing homes. While they would scale back, they still had current contracts. However, the changes in their model would mean that the company would be in a ‘bit of a stealth mode’. After we discussed the business situations that most early-stage health tech companies have faced with funding, we agreed to touch base in a few weeks when things developed.

CNBC, with a different source, had essentially the same information from Dr. Peck on the winding down of the company but in this case also confirmed layoffs, including a ‘pivot’ of the company into a different model around technology in nursing homes. They also confirmed that a part of the company, Call9 Medical, will remain in operations.

Update: Skilled Nursing News had additional detail on Call9’s partnerships which included SNF providers Centers Health Care, CareRite, and the Archdiocese of New York’s long-term care arm, ArchCare. Their first client was Central Island Healthcare, where Dr. Peck lived for three months testing the model. The article goes on with Central Island’s executive director explaining that he is now seeking a telemedicine provider, as they adjusted their services to Call9’s capabilities.

Payer providers included Anthem, Blue Cross Blue Shield, and Healthfirst, plus some Medicare Advantage plans, splitting the savings from avoiding unnecessary ER admissions. Another appeal made by the company for its services was to keep in place higher acuity–sicker–patients in SNFs who would otherwise have to go into the hospital.

As our Readers know, these pages have covered the comings and goings of many health tech and app companies. Some succeed on their own, are acquired/combined with others and go on in different form, or are bought out at their peak, leaving their founders and some employees cheerful indeed. On the other hand, and far more common: the demise of some is understandable, others regrettable, and nearly none of them are cause for celebration in our field–Theranos and Outcome Health being exceptions. This Editor has been a marketing head of two of them (now deceased except for their technology, out there somewhere), and has discussed marketing, funding, and business models with more startups and early-stage companies than she can count.

If anything, investors have less patience than they did back in the Grizzled Pioneer period of the early 2000s, when a $5 million round put together from a few personally (more…)

CVS-Aetna merger will run off the tracks in Federal court: reports

Reports emerging this past Monday after the close of last week’s DC Federal District Court hearings in indicate that the CVS-Aetna merger may be nixed by Judge Richard Leon. This may result in the full unwinding of the already-closed merger, a derailing of the settlement which involved selling the Aetna Medicare Part D business to government-plan insurer WellCare, or something in between.

The original report was in Monday’s New York Post. A source working with CVS and Aetna stated “I think Leon rules against us. If he rejects the settlement, we would have to figure out the next steps.” That settlement is significant because it represents the only major overlap between the CVS and Aetna businesses. In other words, there’s nothing left to divest or concede.

Judge Leon, based on reports, was consistently irritated with the Department of Justice, questioning everything from the Part D divestiture to the effects of adding 21 million Aetna customers to CVS’s pharmacy benefits management (PBM) business not being revealed in DOJ documents to him. Conversely, the sale of the Part D business to WellCare was batted one way–as not enough to reduce CVS’ market control and not competitive–and then the other, as WellCare remains a CVS PBM customer for 2.2 million members in its health plans. What was also clear from his selection of expert witnesses that Judge Leon was more interested in the anti-competitive effects of the merger than any of the benefits.

It is obvious both from Judge Leon’s in-court actions (such as not permitting DOJ attorneys to cross-examine any witnesses), assorted remarks, and delay for now over six months, that this merger is coming to a pre-ordained conclusion, at least by this judge. This is already a first under the Tunney Act enacted in 1974. A negative decision will certainly be appealed by CVS-Aetna and DOJ, which will drag out any finalization even if successful–and the sale of the Part D business, important to WellCare as part of its own pending acquisition by Centene–to the end of the year and possibly beyond.

With this background and oral arguments delayed until 17 July, according to Judge Leon, the legal teams on all sides won’t have much of a summer.  Also Barrons, video on NBR.

Digital health: why is it a luxury good in a world crying for health as a commodity?

Why digital health still struggles to find its stride. Those of us in the healthcare field, especially Grizzled Pioneers, have been wondering for the past decade why Digital Health’s Year is always Next Year. Or Next Decade. 

Looking back only to 2000, we’ve had 9-11, a dot-com bust, a few years in between when the economy thrived and the seed money started to pollinate young companies, a prolonged recession that killed off many, and now finally a few good economic years where money has flooded into the sector, to good companies and those walking the fine line of mismanagement or fraud. We’ve seen the rise/fall/rise of sensors, wearables, and remote monitoring, giants like Google and Microsoft out and back in, the establishment of EHRs, acceptance by government and private payers, quite a bit of integration, and more. All one has to look is at the investment trends breaking all records, with funding rounds of over $10 million raising barely a notice–enough to raise fears of a bubble. Then there’s another rising tide–that of cyberattack, ransomware, insider and outsider hacking.

Is it this year? It may not be. Despite the sunshine, interoperability holds it all back. Those giant EHRs–Cerner, Epic, Athenahealth, Allscripts–are largely walled gardens and so customized by provider application that they barely are able to talk to their like systems. There are regional health exchanges such as New York’s SHIN-NY, Maryland’s CRISP, and others, but they are limited in scope to their states. The VA’s VistA, the granddaddy of the integrated system, died of old age in its garden. Paul Markovich, CEO of Blue Shield of California cites the lack of interoperability and being able to access their personal health data as a major barrier to both patients and to the large companies who want to advance AI and need the data for modeling. (China and its companies, as we’ve noted, neatly solve this problem by force. [TTA 17 Apr]) Apple is back in with Health Records, but Mr. Markovich estimates it may take 10 years to gather the volume of data it needs to establish AI modeling. Some wags demand that Apple buy Epic, as if Epic was up for sale. BSC, like others, is testing interoperability workarounds like Notable, Ooda Health, and Manifest MedEx. Mr. Markovich cites interoperability and scaling as reasons why healthcare is expensive. CNBC

And what about those thriving startups? Hold on. During the Google Cloud/Rock Health 3 June event, one of the panelists–from Partners HealthCare, which works both side of the street with Pivot Labs–noted that hospitals have figured out their own revenue models, and co-development with hospitals is key. Even if validated, not every tech is commercially ready or lowers cost. And employers are far worse than hospitals at buying in because they ultimately look at financial value, even if initially they adopt for other reasons. In addition, the bar moved higher. The new validation standard is now provider-centric–workload, provider satisfaction, and implementation metrics, because meeting clinical outcomes is a given. Mobihealthnews

And still another barrier–data breaches and cyberattack–is still with us, and growing. Quest Diagnostics’ data breach affects nearly 12 million patients. It was traced to an individual at a vendor, American Medical Collection Agency, and it involved Optum360, a Quest contractor and part of healthcare giant Optum. The unauthorized person had access to the network for eight months – between 1 August 2018, and 30 March 2019–and involved both financial and some health records. Quest now is in the #2 slot behind the massive 79 million person Anthem breach, which, based on a Federal grand jury indictment in Indianapolis in May, was executed by a Chinese group in 2015 using spearfishing and backdoors that gathered data and sent it to China. There were three other US businesses in the indictment which are not identified. Securing health data is expensive — and another limitation on the cost-lowering effects of interoperability. Healthcare IT News

Digital Health’s Year, for now, will remain Next Year–and digital health for now will remain fractional, unable to do much to commoditize healthcare or lower major costs.

The CVS-Aetna hearing is on the move–finally

The train that is the CVS-Aetna hearing, in the courtroom presided over by Judge Richard Leon of the US District Court for the District of Columbia, is at long last chugging down the tracks. And Pauline is still tied up. Tuesday 4 June was Day 1 of this hearing. Early reports are just being filed. The issue is whether Judge Leon will authorize the Department of Justice’s approval of the merger or dissolve a closed merger, based on his authority under the Tunney Act and his own repeated intent to search for harm that the merger might do to the public. 

Today’s hearing focused on Aetna’s divestiture of its Medicare Part D business as a prelude to the merger, and whether it was quite enough. Much of the discussion was on the relative strength of the buyer, WellCare (itself in the early stages of being acquired), and whether it could be truly competitive in the Part D market. The other factor is that CVS as a dominant pharmacy benefits manager (PBM) could undermine WellCare in several ways. PBMs operate opaquely and are highly concentrated, with CVS, Optum (UnitedHealthcare), and Cigna-Express Scripts accounting for 70 percent of the market. Modern Healthcare

Other issues for Days 2 and 3 will cover the effects on competition in health insurance, retail pharmacy and specialty pharmacy.

Healthcare Dive discusses how these hearings are already setting precedent on how Tunney Act hearings are conducted, their scope (Judge Leon has ruled against every attempt by CVS-Aetna to limit it), and the unprecedented live testimony.  There is the good possibility that Judge Leon will decide to dissolve the merger for competitive reasons, which DOJ likely would appeal. Add to this the cost of the delayed integration and the precedent set by the District Court on scrutiny of any healthcare merger, and this tedious hearing along with Judge Leon’s actions leading to it hold major consequences.

China’s getting set to be the healthcare AI leader–on the backs of sick, rural citizens’ data privacy

Picture this: a mobile rural health clinic arrives at a rural village in Jia County, in China’s Henan province. The clinic staff check the villagers, many of them elderly and infirm from their hard-working lives. The staff collect vital signs, take blood, urine, ECGs, and other tests. It’s all free, versus going to the hospital 30 miles away.

The catch: the data collected is uploaded to WeDoctor, a private healthcare company specializing in online medical diagnostics and related services that is part of Tencent, the Chinese technology conglomerate which is also devoted to AI. All that data is uploaded to WeDoctor’s AI-powered cloud. The good part: the agreement with the local government that permits this also provides medical services, health insurance, pharmaceuticals and healthcare education to the local people. In addition, it creates a “auxiliary treatment system for general practice” database that Jia County doctors can access for local patients. According to the WIRED article on this, it’s impressive at an IBM Watson level: 

Doctors simply have to input a patient’s symptoms and the system provides them with suggested diagnoses and treatments, calculated from a database of over 5,000 symptoms and 2,000 diseases. WeDoctor claims that the system has an accuracy rate of 90 per cent.

and 

Dr Zhang Qiaofen, in nearby Ren Zhuang village, says the system it has made her life easier. “Since WeDoctor came to my clinic, I feel more comfortable and have more confidence,” she says. “I’m thankful to the device for helping me make decisions.”

The bad part: The patients have no consent or control over the data, nor any privacy restrictions on its use by WeDoctor, Tencent, or the Chinese government. Regional government officials are next pictured in the article reviewing data on Jia County’s citizens: village, gender, age, ailment and whether or not a person has registered with a village health check. Yes, attending these health checks is mandatory for the villagers. 

What is happening is that China is building the world’s largest medical database, free of those pesky Western democracy privacy restrictions, and using AI/machine learning to create a massive set of diagnostic tools. The immediate application is to supplement their paucity of doctors and medical facilities (1.5 doctors per 1,000 people compared to almost double in the UK). All this is being built by an estimated 130 private companies as part of the “Made in China 2025” plan. Long term, the Chinese government gets to know even more intimate details about their 1.3 billion citizens. And these private companies can make money off the data. Such a deal! The difference between China’s attitude towards privacy and Western concerns on same could not be greater.  More on WeDoctor’s ambitions to be the Amazon of healthcare and yes, profit from this data, from Bloomberg. WeDoctor is valued at an incredible $5.5 billion. Hat tip to HISTalk’s Monday morning update.

A telemedicine ‘robot’ delivers end of life news to patient: is there an ethical problem here, Kaiser Permanente?

Bad, bad press for in-hospital telemedicine. A 78 year-old man is in the ICU in a Kaiser Permanente hospital in Fremont, California. He has end-stage chronic lung disease and is accompanied by his granddaughter. A nurse wheels in an InTouch Telemedicine ‘robot’ (brand is clearly visible on the videos; KP is one of their marquee customers). The mobile monitor screen is connected to a live doctor on audio/video for a virtual consult. The doctor is delivering terminal news: that not much can be done for Mr. Quintana other than to keep him comfortable in the hospital on a morphine drip, and that he would likely be unable to return home to hospice care.

Granddaughter Annalisia Wilharm videoed the consult. The screen is high above the bed, the doctor is wearing headphones, and is looking down. The doctor’s voice is accented and hard to understand through the speakers–is the volume low because it’s set low or due to privacy regulations? In any case, the doctor is asked time and again to repeat himself by the granddaughter as the patient cannot hear or understand the doctor. Another factor apparent on the video to this Editor is that the patient is on a ventilator–and ventilators make noise that mask other sounds.

Mr. Quintana passed away in the hospital last Tuesday 5 March, after a two-day stay.

The video has gone viral here in the US, with the family going to local press first (KTVU). The story was picked up in regional Northern California coverage and blew up into national coverage from USA Today (edited video complete with emotive background music), Fox News (San Jose Mercury News video), and picked up in media as diverse as the Gateway Pundit–if you want to get a feel for vox populi, see the comments.

Kaiser Permanente has apologized in guarded terms: “We offer our sincere condolences,” said Kaiser Permanente Senior Vice-President Michelle Gaskill-Hames. “We use video technology as an appropriate enhancement to the care team, and a way to bring additional consultative expertise to the bedside.” Also: “The use of the term ‘robot’ is inaccurate and inappropriate,” she exclaimed. “This secure video technology is a live conversation with a physician using tele-video technology, and always with a nurse or other physician in the room to explain the purpose and function of the technology. It does not, and did not, replace ongoing in-person evaluations and conversations with a patient and family members.” The family also was well aware of Mr. Quintana’s status but is equally upset at his treatment at this critical time.

Despite all this exclaiming, this Editor, an advocate of innovations in telemedicine and telehealth since 2006, finds fault with Kaiser Permanente’s deploying a telemedicine consult in this situation on the following grounds:

  • End-of-life news this serious needs to be delivered by a human. Period.
  • Despite Ms. Gaskill-Hames’s statement, the video consult was not intermediated by a human. There is someone in scrubs behind the InTouch mobile monitor, but there is no standing by the monitor nor any effort to interpret what the doctor is saying. Explaining the technology is not explaining what the patient and family can do.
  • The patient had difficulty understanding the doctor’s voice, either through hearing or language comprehension. A ventilator could be blocking or masking the audio. Even so, the audio, depending on the source, is muddy, and the video worse than you get on a smartphone. 
  • The monitor is at the foot of the bed, not close to the patient. The patient may not be able to see the monitor at that distance due to poor vision.
  • It doesn’t take much thought to believe there may be an issue of cultural inappropriateness.
  • There is no patient advocate or a chaplain present. Whether one visited later is not known.
  • Another open question: why was additional comfort care and a ventilator not available at home if Mr. Quintana was truly terminal? Did this man die needlessly in an ICU?

The popular takeaway about Kaiser, the VA, and other health systems which are deploying telemedicine by their patients is that robots are replacing doctors. We may know better, but that is what the consumer press runs with–an emotional video that, BTW, breaks patient-doctor confidentiality by showing the (unnamed, but not for long) doctor giving medical instructions to Mr. Quintana.

It is not the telemedicine technology, it is how it is being used. In this case, with insensitivity. The blame will be laid, in this shallow time, at the feet of the ‘robot’. Rightly, blame should also be laid at the feet of the increasingly ‘robotic’ practices of major health systems.

There will certainly be more to this story.

A view at some variance, but winding up in the same place, is expressed by Dr. Jayne in HIStalk.

About time: digital health grows a set of ethical guidelines

Is there a sense of embarrassment in the background? Fortune reports that the Stanford University Libraries are taking the lead in organizing an academic/industry group to establish ethical guidelines to govern digital health. These grew out of two meetings in July and November last year with the participation of over 30 representatives from health care, pharmaceutical, and nonprofit organizations. Proteus Digital Health, the developer of a formerly creepy sensor pill system, is prominently mentioned, but attending were representatives of Aetna CVS, Otsuka Pharmaceuticals (which works with Proteus), Kaiser Permanente, Intermountain Health, Tencent, and HSBC Holdings.

Here are the 10 Guiding Principles, which concentrate on data governance and sharing, as well as the use of the products themselves. They are expanded upon in this summary PDF:

  1. The products of digital health companies should always work in patients’ interests.
  2. Sharing digital health information should always be to improve a patient’s outcomes and those of others.
  3. “Do no harm” should apply to the use and sharing of all digital health information.
  4. Patients should never be forced to use digital health products against their wishes.
  5. Patients should be able to decide whether their information is shared, and to know how a digital health company uses information to generate revenues.
  6. Digital health information should be accurate.
  7. Digital health information should be protected with strong security tools.
  8. Security violations should be reported promptly along with what is being done to fix them.
  9. Digital health products should allow patients to be more connected to their care givers.
  10. Patients should be actively engaged in the community that is shaping digital health products.

We’ve already observed that best practices in design are putting some of these principals into action. Your Editors have long advocated, to the point of tiresomeness, that data security is not notional from the smallest device to the largest health system. Our photo at left may be vintage, but if anything the threat has both grown and expanded. 2018’s ten largest breaches affected almost 7 million US patients and disrupted their organizations’ operations. Social media is also vulnerable. Parts of the US government–Congress and the FTC through a complaint filing–are also coming down hard on Facebook for sharing personal health information with advertisers. This is PHI belonging to members of closed Facebook groups meant to support those with health and mental health conditions. (HIPAA Journal).

But here is where Stanford and the conference participants get all mushy. From their press release:

“We want this first set of ten statements to spur conversations in board rooms, classrooms and community centers around the country and ultimately be refined and adopted widely.” –Michael A. Keller, Stanford’s university librarian and vice provost for teaching and learning

So everyone gets to feel good and take home a trophy? Nowhere are there next steps, corporate statements of adoption, and so on.

Let’s keep in mind that Stanford University was the nexus of the Fraud That Was Theranos, which is discreetly not mentioned. If not a shadow hovering in the background, it should be. Perhaps there is some mea culpa, mea maxima culpa here, but this Editor will wait for more concrete signs of Action.

The Theranos Story, ch. 58: with HBO and ABC, let the mythmaking and psychiatric profiling begin! (updated)

This Editor thought that her next articles about Theranos would be trial coverage. There are court dates pending for Elizabeth Holmes and Not-So-Sunny Balwani–with the DOJ for 11 counts of wire fraud [TTA 16 June] and, for Mr. Balwani, with the SEC on (civil) securities fraud [TTA 15 March]. 

Instead, Theranos hits the headlines again. On 18 March, there’s the debut of an HBO documentary on Theranos. Titled The Inventor: Out For Blood In Silicon Valley (YouTube preview), we can treat ourselves once again to the SteveJobs-esque presence of Ms. Holmes, down to the unnaturally deep voice, blondined hair, and wide blue eyes, unpacking the deception and fraud that was part of the company from early days. But that’s not all! There’s a six-part ABC Radio ‘Nightline’ docu-podcast that started on 23 Jan and airs in six parts through February, which includes audio of depositions taken of board members, whistleblower Tyler Shultz, and patients affected by bad test results. (This Editor will give a listen on this alone.) Episode 5 and links to 1-4 are here via Yahoo.

On websites, we’re regaled with rehashes. The articles range from Teasing the Doc to Where The Ex (Balwani) Is Now (they don’t know) to What Is Her Net Worth (not $4.6 bn). There’s even a flurry of sensational podcasts and videos on YouTube–just Google them. 

Fascinating Fraud. There’s fascination in The Long Con perpetrated by the principals, and less examined, our tendency to Want To Believe. Many of us like legal procedurals and the drama inherent in them (the eternal appeal of the long-running Law & Order in several countries.) Let’s face it, there’s a substantial dollop of schadenfreude mixed in.

What we are witnessing is the building of a myth, increasingly divorced from the real world where it happened, and not improbably or with superpowers. 

Where it goes a little off the cliff. There is a curious article in Forbes that is written by a contributor who writes and teaches courses on stocks and entrepreneurship. He interviewed a former neighbor of Ms. Holmes, Richard Fuisz, MD. It turns out this psychiatrist, inventor, and former CIA asset knew her in childhood. The families were friends and Dr. Fuisz helped out her father when he hit a bad patch. There’s some sketchy profiling in this article, but it does make a fair attempt to get to the heart of the forces that put the gap in Elizabeth Holmes’ ethical makeup, including the Big Steal of Ian Gibbons’ IP. His position is somewhat complicated by a patent dispute (settled) between Dr. Fuisz & Son and Theranos. He’s still hammering on at it on Twitter (@rfuisz).

What’s missing? Much credit to the estimable John Carreyrou, who broke the story in the Wall Street Journal and got his livelihood (and perhaps a few other things) threatened a few times by Tough Guy Lawyer David Boies.

(Updated) At least it is here in a Vanity Fair article on the Last Days of Theranos, where they had to move to downscale Newark (California) and Ms. Holmes’ dog pooped where he wanted to poop. Her ‘persecution’ doesn’t seem to faze her from living in SF, frequenting cafes with said dog, and her new romance with a ‘younger hospitality heir’–a far cry from her former employees who wear the months or years of their lives at Theranos like a Scarlet Letter as they look for work and loose cash in the sofa.

We’ve gotten to the point where the hard business analysis ends and the looser parts of psychologizing begins, as we attempt to understand why. Beyond a certain point, does why matter when damage to real patients has been done? Collateral damage persists in funding of startups and for entrepreneurial women in health tech.

For this Editor, she looks forward to the warmer weather, when it’s expected when the Legal Action–and reality–resumes. 

Roy Lilley’s tart-to-the-max view of The Topol Review on the digital future of the NHS

Well, it’s a blockbuster–at least in length. Over 100 pages long, and in the PDF form double-paged, which will be a tough slog for laptop and tablet readers. It’s Eric Topol’s view of the digital future of the NHS and it’s…expansive. In fact, you may not recognize it as the healthcare world you deal with every day.

Our UK readers may not be so familiar with Dr. Topol, but here you can get a good strong dose of his vision for the NHS’ future as delivered (electronic thunk) to Secretary Hancock. I haven’t read this, but Roy Lilley has. You should read his 12 February e-letter if you haven’t already.

Here is a choice quote: It’s a mixture of science faction, future-now-ism and away-with-the fairies.

Here’s some background. The Vision’s been around for awhile. Dr. Topol thinks and talks Big Picture, in Meta and MegaTrends. His view is patient-driven, self-managed, with their genomic sequenced and at their fingertips, with the doctor empowered by their records, his/her own digital tools for physical examination, with AI to scan the records and empower a partnership model of decision-making.

Topol In Person is quite compelling. This Editor’s in-person take from the 2014 NY eHealth Collaborative meeting is a review of vintage Topol. His expansive, hopeful view was in contrast to the almost totalitarian view (and it is fully meant) of Ezekiel Emanuel, with his vision of the perfectly compliant, low choice patient, and squeezed like a lemon medical system. At that time, I concluded:

One must be wary of presenters and ‘big thinkers’–and these doctors define the latter, especially Dr Emanuel who looks in the mirror and sees an iconoclast staring back. Fitting evidence selectively into a Weltanschauung is an occupational hazard and we in the field are often taken with ‘big pictures’ at the expense of what can and needs to be done now. Both Drs Topol and Emanuel, in this Editor’s view, have gaps in vision.

A year later, I reviewed his article The Future of Medicine Is in Your Smartphone which came out at the time of ‘The Patient Is In.’ which was quite the succès d’estime among us health tech types. “The article is at once optimistic–yes, we love the picture–yet somewhat unreal.” It seemed to fly in the face of the 2015 reality of accelerating government control of medicine (Obamacare), of payments, outcomes-based medicine which is gated and can be formulaic, and in the Editor’s view, a complete miss on the complexities of mental health and psychiatry.

Back to Roy Lilley:

There is an etherial quality to this report, spiritual, dainty. The advisory panel is 70 strong.

Studies and citations galore, from the world’s top research organizations. The advisory board–I believe well over 70–there’s not a soul down in the trenches running a hospital. Government, academics, and a few vendors (Babylon Health, natch). A lot of emphasis on AI, genomics, and training for ‘collective intelligence’. After reading but a few dizzying, dense pages, I admire the vision as before, but wonder again how we get from here to there.

Roy’s essay is a must read to bring you back to reality. 

Digital health versus eHealth: ‘here we go again’ with the confusion and the differences. Plus Women in eHealth (JISfTeH)

Editor Donna (and Editor Steve before her) always likes a good dust-up about terminology. One of the former’s pet peeves is the imprecise usage of telemedicine (virtual visits) versus telehealth (remote patient monitoring of vital signs); she will concede that the differences have been so trampled on that telemedicine has nearly faded from use.

The Journal of the International Society for Telemedicine and eHealth (JISfTeH) makes a grand attempt to parse the differing definitions of digital health and eHealth in their opening editorial of this month’s (24 Jan) issueeHealth has fallen so far from use that the few times one does see it is in associations such as ISfTeH and the New York eHealth Collaborative. Even the World Health Organization, which has always been a fair arbiter for the industry, defined eHealth back in the salad days of 2005 as “the use of Information and Communication Technologies (ICT) for health”–broad, but workable. After a witty aside in defining digital health as “an area of healthcare focused entirely on fingers and toes” (plus), and examining the overly broad definitions of Eric Topol and Paul Sonnier, the authors Richard E. Scott and Maurice Mars seem to settle on this: that while digital health is given a  much broader but nebulous definition (to the point of linguistic absurdity cited in Mesko et al.), and may incorporate related technologies like genomics (another poorly defined term) and ‘big data’, it would not work without that ICT. And that at least there’s a settled definition for eHealth, as stated above, for which this Editor assumes we should be happy. In the author’s closing, “Will we be sufficiently motivated to rise to such a challenge-globally agreed universal definitions? If not ……here we go again …..”

This month’s journal theme is also Women in eHealth, with articles on Brazilian eHealth distance education, digital technology in midwifery practice, and how online social networks can work for drug abuse treatment referral. There’s also a change in format, with article links opening to full PDFs of each article.

The telehealth ‘entrepreneur’ whose $5 million funding bought stays at the Ritz and portfolios at Bottega Veneta

This curious and cautionary tale should be better known. A young entrepreneur named Keisha L. Williams from Ashburn, Virginia had an attractive proposition. She needed immediate funding to bring to the US an Austrian telehealth system described as “software that would allow doctors to remotely examine and talk with patients.” Ms. Williams had degrees in both law and electrical engineering, so credibility. She also had a story. The software was in ‘escrow’ in Austria. There were taxes and fees that had to be paid immediately. And she had family situations, financial and medical emergencies. In other words, she had a ‘great line of ‘stuff’ on the technology, urgency, and personally, a few tugs on the heartstrings.

Ms. Williams told this story enough times over four years, and to enough people who believed her–more than 50, who invested over $5.4 million.

What happened? 95% of the money was spent on over the top vacations to Bora Bora, Italy, the Bahamas, and Jamaica, plus the occasional yacht with ‘hand and foot services’ and shopping at top-end retail such as Bottega Veneta and Vuitton. $500,000 alone was spent on her girlfriend. About $300,000 was spent on the software.

The rest of the story involves 14 Federal fraud charges, four accomplices, and unwitting, likely vulnerable people who were talked into giving over their savings. Late in January, she was sentenced to 15.5 years in Federal prison.

Many of our Readers have started companies or worked with entrepreneurs who have a great story and need money. The stories touch our hearts–and sometimes our checkbooks. Apparently, Ms. Williams raised the money without exposing herself to anyone in the industry or private investors who would ask remotely leading questions. To us, this technology sounds hardly sexy–it’s telemedicine virtual visit software with maybe some remote patient monitoring thrown in. Yet to 50 people, who are now poorer or who were involved with the fraudulent scheme — it sounded really special. (The name is also common–there are quite a few people on LinkedIn with the same name, which may make life difficult for them.)

With the rising tide of telehealth, if your cousin or uncle has heard of a great way to visit your doctor over the phone and asks you if you’ve heard about it, you might want to ask Uncle to pass the pie as you switch the conversation to being on guard for fraudulent schemes. Washington Post (read the comments), Daily Mail, Seattle Post-Intelligencer, press releases 17 Oct and 18 Jan from the US Attorney’s office, Eastern District of Virginia

Where’s the evidence? Healthcare unicorns lack the proof and credibility of peer-reviewed studies.

Another sign that too many healthcare unicorns are decoupled from the rock-solid fundamental reality–that they work. Healthcare unicorns–those startups valued over $1 bn–are unicorns because they have patents, processes, or a line of business that has immense potential to be profitable. The standard in healthcare, unlike other tech, is the peer-reviewed study. Is this process or device effective based upon the study? Does this drug looks like it will work? Is this study validating, encouraging? Peer-reviewed research takes place before a drug or device goes into clinical trials — a precursor. It ensures a certain level of disclosure, validation, and transparency at an early stage.

Instead, these unicorns largely rely on ‘stealth research’–a term coined by Dr. John P.A. Ioannidis, the co-director of the Meta-Research Innovation Center at Stanford University (METRICS). He summed it up in his latest peer-reviewed paper, “Stealth research: lack of peer-reviewed evidence from healthcare unicorns” (co-authored with Ioana A. Cristea and Eli M. Cahan), published in the European Journal of Clinical Investigation 28 Jan: 

In 2014, one of us (JPAI) wrote a viewpoint article coining the term “stealth research” for touted biomedical innovation happening outside the peer-reviewed literature in a confusing mix of “possibly brilliant ideas, aggressive corporate announcements, and mass media hype.”

The term ‘stealth research’ was prompted to the author by the practices of Theranos–ironically, a company that started and was funded in the Stanford nexus. By the time Dr. Ioannidis’ viewpoint paper was published in JAMA in Feb 2015, Theranos had ballooned to a $9 bn valuation. His paper was the first to question Theranos’ science–and Theranos aggressively pushed back against Dr. Ioannidis, including their general counsel attempting to convince the author to recant his own writing. Three years later, we know the outcome.

This latest study concludes that there is a real dearth of peer-reviewed research among healthcare unicorns–and that it’s detrimental. It measured whether these unicorns published peer-reviewed articles and whether they publish highly-cited (in other publications) articles; compared them against companies with lower valuations; and whether founders or board members themselves impacted the scientific literature through their own citations.

The meta-study looked at 18 current and 29 exited healthcare unicorns. Highlights:

  • Two companies–23andMe and Adaptive Biotechnologies published almost half of all unicorn papers–196 combined
  • Three unicorns (Outcome Health, GuaHao and Oscar Health) had no published papers, and two more (Clover Health, Zocdoc) had published just one
  • Seven of the exited unicorns had zero to one papers
  • In fact, ‘there was a negative, non-statistically significant association between company valuation and number of published or highly-cited papers’

As our Readers know, Outcome Health had a little problem around artificially inflated advertising placement wrapped in health ed and placed in doctors’ offices [TTA 29 Jan 18]. Oscar and Clover Health are insurers. Zocdoc…well, we know their business model is to get as many doctors to sign up in their scheduling app and pay as much as possible. But it’s the drug and device companies that are especially worrisome in a stealth research model. The paper points out among other examples StemCentrx, bought for $10.2 bn in 2016 by AbbVie for its Rova T targeted antibody drug for cancer treatment, was halted at Phase III because it was not effective. Acerta Pharma, also focused on cancer treatments, was bought by AstraZeneca for $7.3 bn; two years ago, AstraZeneca had to withdraw the Acerta data and admit that Acerta falsified preclinical data for its drug.

The conclusions are that healthcare unicorns contribute minimally to relevant, high-impact published research, and that greater scrutiny by the scientific community through peer-reviewed research is needed to ensure credibility for the underlying work by these startups. “There is no need for numerous papers. Discrete pivotal, high-impact articles would suffice.”

This Editor returns to #5 on Rock Health’s Bubble Meter: high valuations decoupled from fundamentals. Based on this, the lack of publishing represents risk–to investors and to patients who would benefit from better vetted treatments. To these companies, however, the risk is in having their technology or researched poached–as well as the investment in time and money research represents.

The study authors point out several ways to minimize the risk, including collaborating with academic centers in research, validation without disclosing all technical details, secure patents, and contributing their technology to other research. A higher-risk way is to “withhold significant publications until successful validation from agencies such as the Food and Drug Administration (FDA) or the European Medicines Agency (EMA)” but usually investors won’t wait that long. ‘Stealth Research’ paper, TechCrunch review Hat tip to David Albert, MD, of AliveCor via Twitter