It’s not a bubble, really! Or developing? Analysis of Rock Health’s verdict on 2018’s digital health funding.

The doors were blown off funding last quarter, so whither the year? Our first take 10 January on Rock Health’s 2018 report was that digital health was a cheery, seltzery fizzy, not bubbly as in economic bubbles.  Total funding came in at $8.1 billion–a full $2.3 bn or 42 percent–over 2017’s $5.7 bn, as projected in Q3 [TTA 11 Oct]–which indicates confidence and movement in the right direction.

What’s of concern? A continued concentration in funding–and lack of exiting.

  • From Q3, the full year total added $1.3 bn ($6.8 bn YTD Q3, full year $8.1 bn) 
  • The deals continue to be bigger and fewer–368 versus 359 for 2017, barely a rounding error
  • Seed funding declined; A, B, C rounds grew healthily–and D+ ballooned to $59M from $28M in 2017, nearly twice as much as C rounds
  • Length of time between funding rounds is declining at all levels

Exits continue to be anemic, with no IPOs (none since 2016!) and only 110 acquisitions by Rock Health’s count. (Rock only counts US only deals over $2 million, so this does not reflect a global picture.)

It’s not a bubble. Really! Or is it a developing one? Most of the article delivers on conclusions why Rock Health and its advisors do not believe there is a bubble in funding by examining six key attributes of bubbles. Yet even on their Bubble Meter, three out of the six are rated ‘Moderately Bubbly’–#2, #3, and #5–my brief comments follow. 

  1. Hype supersedes business fundamentals (well, we passed this fun cocktail party chatter point about 2013)
  2. High cash burn rates (not out of line for early stage companies)
  3. Unclear exit pathways (no IPOs since ’16 which bring market scrutiny into play. Oddly, Best Buy‘s August acquisition of GreatCall, and the latter’s earlier acquisitions of Lively and Healthsense didn’t rate a mention)
  4. Surge of cash from new investors (rising valuations per #5–and a more prosperous environment for investments of all types)
  5. High valuations decoupled from fundamentals (Rock Health didn’t consider Verily’s billion, which was after all in January)
  6. Fraud or misuse of funds (Theranos, Outcome dismissed by Rock as ‘outliers’, but no mention of Zenefits or HealthTap)

Having observed bubbles since 1980 in three industries– post-deregulation airlines in the 1980s, internet (dot.com) in the 1990s, and healthcare today (Theranos/Outcome), ‘moderately’ doesn’t diminish–it builds to a peak, then bursts. Dot.com’s bursting bubble led to a recession, hand in hand with an event called 9/11.

This Editor is most concerned with the #5 rating as it represents the largest divergence from reality and is the least fixable. While Verily has basically functioned as a ‘skunk works’ (or shell game–see here) for other areas of Google like Google Health, it hardly justifies a billion-dollar investment on that basis alone. $2 bn unicorn Zocdoc reportedly lives on boiler-room style sales to doctors with high churn, still has not fulfilled its long-promised international expansion, and has ceased its endless promises of transforming healthcare. Peleton is a health tech company that plumps out Rock Health’s expansive view of Health Tech Reality–it’s a tricked out internet connected fitness device. (One may as well include every fitness watch made.)

What is the largest divergence from reality? The longer term faltering of health tech/telecare/telehealth companies with real books of business. Two failures readily come to mind: Viterion (founded in 2003–disclosure, a former employer of this Editor) and 3rings (2015). Healthsense (2001) and Lively were bought by GreatCall for their IP, though Healthsense had a LTC business. Withings was bought back by the founder after Nokia failed to make a go of it. Canary Care was sold out of administration and reorganized. Even with larger companies, the well-publicized financial and management problems of publicly traded, highly valued, and dominant US telemed company Teladoc (since 2015 losing $239 million) and worldwide, Tunstall Healthcare’s doldrums (and lack of sale by Charterhouse) feed into this. 

All too many companies apparently cannot get funding or the fresh business guidance to develop. It is rare to see an RPM survivor of the early ’00s like GrandCare (2005). There are other long-term companies reportedly on the verge–names which this Editor cannot mention.

The reasons why are many. Some have lurched back and forth from the abyss or have made strategic errors a/k/a bad bets. Others like 3rings fall into the ‘running out of road and time’ category in a constrained NHS healthcare system. Beyond the Rock Health list and the eternal optimism of new companies, business duration correlates negatively with success. Perhaps it is that healthcare technology acceptance and profitability largely rests on stony, arid ground, no matter what side of the Atlantic. All that money moves on to the next shiny object.(Babylon Health?) There are of course some exceptions like Legrand which has bought several strong UK companies such as Tynetec (a long-time TTA supporter) and Jontek.

Debate welcomed in Comments.

Related: Becker’s Hospital Review has a list of seven highly valued early stage companies that failed in 2018–including the Theranos fraud. Bubble photo by Marc Sendra martorell on Unsplash

Is Babylon Health the next Theranos? Or just being made out to be by the press? (Soapbox)

There, it’s said. A recent investigative article by a Forbes staff writer, European-based Parmy Olson (as opposed to their innumerable guest writers), that dropped a week before Christmas Eve raised some uncomfortable questions about Babylon Health, certainly the star health tech company on the UK scene. These uncomfortable bits are not unknown to our Readers from these pages and for those in the UK independently following the company in their engagement with the NHS.

Most of the skepticism is around their chatbot symptom checker, which has been improved over time and tested, but even the testing has been doubted. The Royal College of Physicians, Stanford University and Yale New Haven Health subjected Babylon and seven primary care physicians to 100 independently-devised symptom sets in the MRCGP, with Babylon achieving a much-publicized 80 test score. A letter published in the Lancet (correspondence) questioned the study’s methodology and the results: the data was entered by doctors, not by the typical user of Babylon Health; there was no statistical significance testing and the letter claims that the poor performance of one doctor in the sample skewed results in Babylon’s favor.  [TTA 8 Nov]. 

The real questions raised by the Lancet correspondence and the article are around establishing standards, testing the app around existing standards, and accurate follow up–in other words, if Babylon were a drug or a medical device, close to a clinical trial:

  • Real-world evaluation is not being done, following a gradual escalation of steps testing usability, effectiveness, and safety.
  • How does the checker balance the probability of a disease with the risk of missing a critical diagnosis?
  • How do users interact with these symptom checkers? What do they do afterwards? What are the outcomes?

Former Babylon staffers, according to the Forbes article, claim there is no follow up. The article also states that “Babylon says its GP at Hand app sends a message to its users 24 hours after they engage with its chatbot. The notification asks about further symptoms, according to one user.” Where is the research on that followup?

Rectifying this is where Babylon gets sketchy and less than transparent. None of their testing or results have been published in peer-reviewed journals. Moreover, they are not helped by, in this Editor’s view, their chief medical officer stating that they will publish in journals when “when Babylon produces medical research.” This is a sad statement, given the crying need for triaging symptoms within the UK medical system to lessen wait times at GPs and hospitals. But even then, Babylon is referring patients to the ED 30 percent of the time, compared to NHS’ 111 line at 20 percent. Is no one there or at the NHS curious about the difference?

And the chatbot is evidently still missing things. (more…)

Is Babylon Health’s AI on par with a human diagnostician? Claim questioned in ‘The Lancet’.

In July, Babylon Health released the results of their testing against the MRCGP (Member of the Royal College of General Practitioners) exam based on publicly available questions. As we reported at the time, its AI system passed the exam with a score of 81 percent. A separate test where Babylon worked with the Royal College of Physicians, Stanford University and Yale New Haven Health subjected Babylon and seven primary care physicians to 100 independently-devised symptom sets. Babylon passed with an 80 score.

Now these results are being questioned in a letter to The Lancet. The authors–a medical doctor and two medical informatics academics–argue that the methodology used was questionable. ‘Safety of patient-facing digital symptom checkers’  shows there ‘is a possibility that it [Babylon’s service] might perform significantly worse’. The symptom checking methodology was questioned for not being real world–that the data in the latter test was entered by doctors only, not by patients or other clinicians. While the authors commended Babylon for being open about their research, they felt there was an “urgent need” for improvements in evaluation methods. “Such guidelines should form the basis of a regulatory framework, as there is currently minimal regulatory oversight of these technologies.” Babylon promises a response and additional improvements, presumably from its $100 million investment in AI announced in SeptemberDigitalHealth (UK), Mobihealthnews

AI promises, promises! Babylon Health to spend $100m, hire 1,000 to develop leading AI platform

Babylon Health’s CEO Ali Parsa announced at their headquarters last week that the company would be spending $100 million to develop the ‘world’s leading AI healthcare platform’. In the company of Health Secretary Matt Hancock, an admitted GP at hand fan (nothing goes better after poring over your red boxes), Mr. Parsa confirmed that the 1,000 data scientists, programmers, and clinicians would be based in London after a global search of suitable cities. They will be helping to design the next generation of health AI for diagnosis and to support patients with long-term conditions. 

The report in Digital Health noted that the audience included key figures such as Malcolm Grant, chairman of NHS England; Dr Simon Eccles, NHS England CCIO; and Juliette Bauer, head of digital experience. This is despite Babylon challenging the Care Quality Commission (CQC) over an unfavorable report [TTA 11 Dec] and being put on hold by Birmingham as well as Hammersmith and Fulham CCGs [TTA 23 Aug].

Babylon is well able to afford this as Prudential Asia (Prudential plc) has licensed Babylon’s software for its own apps across 12 countries in Asia for an estimated $100 million over several years. Forbes  It also inked a deal in June to provide insurer Bupa’s Instant GP to corporate clients [TTA 21 June]. Will this include a foray into the US? No clues so far!

Despite recruiting, Babylon Health’s GP at hand still on hold in Birmingham (UK); CEO steps down at rival Push Doctor

GP at hand, Babylon Health’s NHS app and service for scheduling patients with local GPs, was expected to roll out in Birmingham, but the Hammersmith and Fulham CCG, from which Babylon operates, continues to halt its the expansion since the beginning of this month on patient safety concerns.

The app, which schedules patients with GPs and requires registration that effectively changes what we in the US call ‘attribution’, was set to add GP surgeries in Birmingham starting this month and was setting up an HQ at Badger House, an out-of-hours GP services provider based in Birmingham’s inner city. GP recruitment had started, according to Pulse, in late July. Patients would register in Babylon’s host practice Dr. Jefferies and Partner in southwest London through NHS’ out-of-area registration scheme.

The objections to Babylon’s expansion came initially from Paul Jennings, the chief executive of Birmingham and Solihull CCG. According to Digital Health, “he wrote to Hammersmith and Fulham to lodge a formal objection to the expansion. He argued the digital service was “not yet robust or tested for a national service to be delivered from a single practice outside of Birmingham”. Hammersmith and Fulham then stated that “further information is required to provide assurance on the safety of patients” before the Birmingham roll-out could be approved. 

This is despite the release of a equality impact assessment by Verve Communications on behalf of Hammersmith and Fulham finding mainly positive results, such as GP at hand “more likely to address most barriers than traditional GP services” in 10 out of 11 protected groups” and that “carers may benefit from [the] use of GP at Hand as this will allow them to consult a primary care practitioner whilst continuing with their care responsibilities.” The new Health Secretary Matt Hancock, a major advocate of technology in care, is himself registered with Babylon. Mobihealthnews

(If you are in the UK, you can hear it straight from Babylon’s CEO Ali Parsa, interviewed by Roy Lilley of nhsmanagers.net, on 10 September at the RSM.)

Rival telemedicine service Push Doctor is also undergoing changes with CEO and co-founder Eren Ozagir’s departure. It appears that he and the board had a difference around company direction, with the board recommending a cut of 40 jobs (Sunday Times). Their COO, Wais Shaifta, became acting CEO in July. In June 2017, a report by the Care Quality Commission (CQC) found the service to be delivering unsafe care via antidepressant and blood thinner prescriptions being given without requisite blood tests and monitoring. Digital Health

Late summer and early autumn event updates: Save 20% on Connected Health Summit, SEHTA Health + Space, Lilley’s talk with Ali Parsa, PATH Summit, Connected Health Conference, HealthIMPACT

It’s always a little sad to realize that summer is winding down. Some (like your Editor) stretch the summer past Labor Day (the DMZ in the US) into early autumn, taking the philosophy that woolies are way too warm till November. Here are eight substantial events on your calendar to look forward to:

Connected Health Summit, 28-30 August next week, San Diego–Readers Save 20%!

Parks Associates have offered our readers 20% off registration at ‘Connected Health, Independent Living and Engaging Consumers’, the fifth Connected Health Summit organized by Parks Associates. The conference will analyze the roles of connected health technologies and innovations in driving changes in consumer behaviors and business models. Lead speakers are from IBM Watson Health, Alarm.com, Uber Health, and Qualcomm Life. More information and registration here. As a preview, download their latest white papers:  Market Snapshot – Consumer Health Attitudes and IoT Home Living Features and Sleep Tech and IoT. #CONNHealth18

Healthcare and Space Funding Call Brief, 4 September, Cocoon Networks, 4 Christopher Street, London, EC2A 2BS, 10:00 – 13:00

Sponsored by SEHTA, The Knowledge Transfer Network, and MedCity, this will cover funding opportunities for converting innovation from the space sector, from exploration to satellite communications, to new solutions for the health sector and medical applications that improve NHS treatment and care. At this event attendees will hear about them plus have the opportunity to network with organizations from both the health and space sectors. This event is part of the MedTech London programme supported by the GLA. For further information, contact Clare Ansett, Head of Communications, SEHTA

Health Chat with Ali Parsa of Babylon Health, 10 September, RSM, 1 Wimpole Street, London (new venue!)

This Health Chat conducted by Roy Lilley of nhsmanagers.net promises to be eventful. “Has the tide turned in primary care? What effect might Babylon produce? Who are the beneficiaries? What is the future for the traditional primary care GP model?” Tickets are a modest £19.95 – £39.95 and are going quickly. Sponsored by UK HealthGateway, the publishers of nhsmanagers.net. Register here.

PATH Summit, 30 September – 2 October, Omni Shoreham Hotel, Washington DC

Those of us who wondered what long-time CEO Jonathan Linkous of the American Telemedicine Association has moved on to now have their answer: CEO of PATH, the Partnership for Artificial Intelligence and Automation in Healthcare. Their first Summit will attempt to answer questions like: “Is artificial intelligence, automation, robotics and sensors the future of healthcare or a passing fad?” It will cover AI innovations, best practices, and barriers to beware (boo!) Find out more and register here, but this Editor’s advice (not that it will be taken) is to drop the silly home page quote from the buffoonish and irrelevant Mark Cuban. 

Connected Health Conference, 17-19 October, Boston

The second year of the combined PCHAlliance Connected Health Conference and the Partners Connected Health Symposium at the impressive Seaport World Trade Center kicks off with co-located conferences followed by two full days of events and expo. Preview it and register here

HealthIMPACT has three events from September into December:

HealthIMPACT Midwest – Rev1 Ventures, Columbus, OH, September 27

NODE.Health Evidence in Digital Medicine Roundtable – Microsoft Technology Center Boston – October 16

NODE.Health Digital Medicine Conference – Microsoft Technology Center, New York, NY – December 5-7

Will Matt Hancock be a refreshing change for NHS? Or another promise unfulfilled? (updated)

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2018/07/matt-in-a-binder.jpg” thumb_width=”200″ /]Matt In A Binder? With the sudden departure of Jeremy Hunt from the Department of Health and Social Care in the Cabinet’s ‘change partners and dance’, the new Secretary of State Matt Hancock comes over from heading Digital, Culture, Media and Sport. A couple of weeks in, it can be determined that he is a big advocate of technology and looking forward, not back (which Mr. Hunt spent a great deal of time doing):

Technology has a proven ability to radically change the world for the better – be it in finance, in education and in transport. But nowhere does technology have greater potential to improve lives than in healthcare. (Statement on Gov.UK/Health Service Journal 12 July )

And he glows again about increasing the use of apps within the NHS, though Digital Health goes a little overboard in calling the Rt Hon Mr. Hancock ‘app-happy’ even though he’s built his own this year so that his West Suffolk constituents can keep track of his activities. 

In his maiden speech, Mr. Hancock promoted a drive to replace pagers with smartphone apps as part of a £487 million funding package and connecting Amazon Echo with the NHS Choices website. It was overshadowed by a seeming walking back of the 95 percent four-hour A&E treatment target. Telegraph

Much of the criticism comes from those who see his appointment as yet another step in the privatization and regional devolution of the NHS due to campaign donations from the chair of pro-market group the Institute of Economic Affairs (IEA). However, Mr. Hunt faced the realization that NHS trusts are $1.2bn in debt and sought workarounds such as adoption of an ACO-type model (which in the US has a strong element of public incentive) and increased use of private health insurance to cost-shift. He wasn’t a technophobe, having inked a deal with the UK Space Agency to repurpose space tech for health tech and funding innovators in this conversion up to £4 million–which can be said to be ‘out there’.

Mr. Hancock also announced this week the £37.5 million funding of three and five ‘Digital Innovation Hubs’ over the next three years. These will connect regional healthcare data with genetic and biomedical information for R&D purposes.

Will he last? Will there be positive changed fueled by technology? Will the May Government last? Only time will tell.

What are your thoughts? (If you’d like to post anonymously, write Editor Donna in confidence)

Here’s select opinion from across the spectrum:

Don’t be fooled, Matt Hancock will be no better for the NHS than Jeremy Hunt was (The Independent)

New health secretary Matt Hancock received £32,000 in donations from chair of think tank that wants NHS ‘abolished’ (The Independent)

Roy Lilley’s always tart take on things NHS extends to the new Secretary dubbed ‘No18’. A deft wielding of Occam’s Razor and a saber on reflexive phraseology such as ‘driving culture change’ (it can be cultivated not driven–this Editor agrees but the tone and structure need to be set from the top), dealing with suppliers, and the danger of creating an electronic Tower of Babel due to lack of interoperability. (Does this resonate in the US? You bet!) (See NHSManagers.net if the link does not work.)

Margaret McCartney: Health technology and the modern inverse care law (BMJ) — to paraphrase, that the greatest need for healthcare is by those least likely to have the right care at the right time available. She points to Babylon Health, which counts Mr. Hancock as a member, as not only unproven, but also not needed by those able to afford other options. (But didn’t we know that already?)

RCGP chair at The King’s Fund: destroy Babylon Health’s GP at Hand ‘amazing model’, the present financial model–or both

A whole lot of disrupting goin’ on. At The King’s Fund’s June conference on ‘Reimagining general practice’, Royal College of General Practitioners (RCGP) chair Professor Helen Stokes-Lampard at the opening plenary seemingly did the impossible–praising Babylon Health’s GP at Hand while wishing its destruction, along with the present UK practice payment method. First, health leaders had a ‘lot to learn’ from the GP at Hand model–and that NHS IT systems at present were inadequate in meeting patients’ needs. “‘Let’s have tech that works and use innovative ways of consulting. Because the reality is we’re looking foolish and people are looking for alternatives. The rise of the private GP health sector is not a coincidence – it’s an inevitable consequence of the NHS not keeping up.”

If you cannot beat them, join them–and figure out a new way of paying GPs. ‘[We] have to totally adopt that technology right throughout the NHS for everybody so it destroys [Babylon’s] business model and it is normal across the whole of general practice – tech tsunami stuff. Or we have to tear up the financial model by which we pay [practices]. And one of those things has to happen fast. I would suggest we need to do both.’   

Her remarks are in the face of GP at Hand cresting at over 30,000 patients, with over 3,000 signing up in May.

Both Professor Stokes-Lampard and following speaker Professor Steve Field, CQC chief inspector of general practice, pointed to a model such as GP at Hand ‘cherry picking’ primarily healthy patients rather than a broad population and destabilizing surgeries. Both agreed that the disruption had major implications for ‘the financial contracting model in general practice’.

Earlier, GPonline exclusively revealed that market research firm Ipsos Mori is investigating–at a cost of £250,000–the impact of GP at Hand, including its long-term implications for the sustainability of traditional general practice.

Instant GP, don’t even add water; Babylon Health taps into the corporate market via insurer Bupa (UK)

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2018/06/instant-gp-300×300.jpg” thumb_width=”150″ /]Is digital health gaining some traction in the UK? One insurer is making the bet. Earlier this week, Babylon Health announced a UK partnership with Bupa’s corporate insurance area to open Babylon’s digital health services to corporate employees insured by Bupa.  Bupa’s Instant GP app offers these employees Babylon services, such as the ability to book virtual appointments with GPs, be transferred to specialists, and receive prescriptions. The app is free to download through the Apple App Store or Google Play for Bupa-covered employees.

Bupa and Babylon have been working together in a limited way since 2015–see this Bupa press release.

Some extras for employees in the program: unlimited 24/7 online GP consultations; Babylon’s clinical triage service, and access to the Babylon’s new “digital twin” service. This medical assessment method works with a smartphone tapping key parts of their body. It’s being previewed by Bupa and is scheduled to be released nationwide later this year.

Reportedly Bupa is seeking to provide Babylon services to their UK SME business (micro, small and medium-sized enterprises) later this year. Telegraph (paid access for full article), Digital Health News

For Babylon, it’s been an extraordinarily busy time. They have a new agreement with Samsung to be included in Samsung Health on smartphones [TTA 14 June], and China’s Tencent offering of Babylon through their WeChat platform. Babylon also recently announced passing the 26,500 patient mark with London NHS GP at Hand.

Rounding up the news: Babylon’s Samsung Health UK deal, smartphone urine test debuts, a VA Home Telehealth ‘announcement’, Aging 2.0’s NY Happy Hour

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2017/12/Lasso.jpg” thumb_width=”125″ /]Huge or Ho-Hum? Babylon’s ‘Ask an Expert’ feature is now available within the Samsung Health app as of the start of June. It will need to be activated at a cost of £50 per year, or £25 for a single consultation. Babylon’s service with over 200 GPs is now available on millions of Samsung Galaxy devices in the UK. Babylon now claims half a million users of its private GP services and 26,500 registered in London with its NHS-funded and controversial GP at Hand app.

Is it as our Editor Charles, quoting Niccolo Machiavelli writing in The Prince, “Nothing is more difficult to undertake, more perilous to conduct or more uncertain in its outcome than to take the lead in introducing a new order of things. For the innovator has for enemies all those who have done well under the old and lukewarm defenders who may do well under the new”. The debate rages–see the comments below the Pulse Today article. 

Healthy.io is introducing a test of its urinalysis by smartphone test with Salford Royal NHS Foundation Trust’s new Virtual Renal Clinic. 50 patients will received the Dip.io kit to test their urine. Dip.io uses the standard urine dipstick test combined with a smartphone application that guides the user through scanning in the results with a smartphone camera and sends the result to their doctor. Healthy.io claims this is a first-of-kind technology and system. According to Salford Royal, chronic kidney disease (CKD) costs the NHS £1.45 billion in England alone. The company is part of the NHS Innovation Accelerator Programme. Digital Health News

In what has been the worst kept secret in US telehealth, 1Vision LLC and AMC Health finally announced they were partners in 1Vision’s over $258 million Home Telehealth award by the Department of Veterans Affairs (VA) [TTA 6 Feb 17]. The news here is that the AMCH release states that they have an “Authority to Operate (ATO)”, which means they can provide Home Telehealth services using AMC Health’s CareConsole to VA-enrolled veterans and their families. This last step is very important because it is a common post-award point of failure for new awardees. Earlier this year, the Iron Bow/Vivify Health award failed on the country of origin of Vivify’s kit, dooming the implementation [TTA 16 Jan] and Iron Bow’s award. (Vivify Health has gone on.) Medtronic, as a long-term incumbent, has few worries in this regard, though any new equipment has to be cleared. The mystery is if Intel-GE Care Innovations, the last new awardee, has passed the ATO bar. AMC Health/1Vision release. 

And on the social front for New Yorkers, raise a Pint 2.0 at Aging 2.0’s NYC Happy Hour, Tuesday 18 July at 310 Bowery Bar, 6pm. Aging 2.0 website, where you can check for a chapter and events near you.

Robots, robots, everywhere…even when they’re NHS 111 online algorithms

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2014/01/Overrun-by-Robots1-183×108.jpg” thumb_width=”150″ /]The NHS continues to grope its way towards technology adoption, gets slammed–but is it justified? The Daily Telegraph (paywalled–see The Sun) revealed a draft December NHS report that recommended that the NHS 111 urgent non-emergency care line’s “enquiries will be handled by robots within two years.” Moreover, “The evaluation by NHS England says smartphones could become “the primary method of accessing health services,” with almost 16 million inquiries dealt with by algorithms, rather than over the telephone, by 2020.” (That is one-third of demand, with one-quarter by 2019.)

Let’s unpack these reported statements.

  • An algorithm is not a ‘robot’. This is a robot.[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2016/06/robottoy-1.jpg” thumb_width=”100″ /]
  • What is so surprising about using algorithmically based questions for quick screening? Zipnosis in the US has been using this method for years as a pre-screener in major health systems. They call it an ‘online adaptive interview’ guiding the patient through branching logic of relevant questions; a provider can review the provided clinical note and make a diagnosis and treatment recommendation in 2 minutes. It also captures significant data before moving to an in-person or telemedicine visit if needed. Babylon Health uses a similar methodology in its chatbot-AI assisted service [TTA 26 Apr 17].
  • Smartphones as a primary means of accessing health services? How is this surprising when the Office of National Statistics says that 73 percent of adults use the internet from their mobiles? 51 percent go online for health information.
  • Based on the above, 66 percent would still be using telephonic 111 services.

It seems like when the NHS tries to move forward technologically, it’s criticized heavily, which is hardly an incentive. Over New Year’s, NHS 111 had a 20 percent unanswered call rate on its busiest day when the flu epidemic raged (Sun). Would an online 111 be more effective? Based on the four-location six-month test, for those under 35, absolutely. Yes, older people are far less likely to use it, as undoubtedly (but unreported) the disabled, sight-impaired, the internet-less, and those who don’t communicate in English well–but the NHS estimates that the majority of 111 users would still use the phone. This also assumes that the online site doesn’t crash with demand, and that the algorithms are constructed well.

Not that the present service has been long-term satisfactory. David Doherty at mHealth Insight/3G Doctor takes a 4G scalpel to its performance and offers up some alternatives, starting with scrapping 111.

Babylon Health’s ‘GP at hand’ not at hand for NHS England–yet. When will technology be? Is Carillion’s collapse a spanner in the works?

NHS England won’t be rolling out the Babylon Health ‘GP at hand’ service anytime soon, despite some success in their London test with five GP practices [TTA 12 Jan]. Digital Health cites an October study by Hammersmith and Fulham CCG (Fulham being one of the test practices) that to this Editor expresses both excitement at an innovative approach but with the same easy-to-see drawback:

The GP at Hand service model represents an innovative approach to general practice that poses a number of challenges to existing NHS policy and legislation. The approach to patient registration – where a potentially large volume of patients are encouraged to register at a physical site that could be a significant distance from both their home and work address, arguably represents a distortion of the original intentions of the Choice of GP policy. (Page 12)

There are also concerns about complex needs plus other special needs patients (inequality of service), controlled drug policy, and the capacity of Babylon Health to expand the service. Since the October report, a Babylon spokesperson told Digital Health that “Commissioners have comprehensively signed off our roll-out plan and we look forward to working with them to expand GP at Hand across the country.” 

Re capitation, why ‘GP at hand’ use is tied into a mandatory change of GP practices has left this Editor puzzled. In the US, telemedicine visits, especially the ‘I’ve got the flu and can’t move’ type or to specialists (dermatology) are often (not always) separate from whomever your primary care physician is. Yes, centralizing the records winds up being mostly in the hands of US patients unless the PCP is copied or it is part of a payer/corporate health program, but this may be the only way that virtual visits can be rolled out in any volume. In the UK, is there a workaround where the patient’s electronic record can be accessed by a separate telemedicine doctor?

Another tech head-shaker: 45 percent of GPs want technology-enabled remote working. 48 percent expressed that flexible working and working from home would enable doctors to provide more personalized care. Allowing remote working to support out-of-hours care could not only free up time for thousands of patient appointments but also level out doctor capacity disparities between regions. The survey here of 100 GPs was conducted by a cloud-communications provider, Sesui. Digital Health. This is a special need that isn’t present in the US except in closed systems like the VA, which is finally addressing the problem. The wide use of clinical connectivity apps enables US doctors to split time from hospital to multiple practices–so much so on multiple devices, that app security is a concern. 

Another head-shaker. 48 percent of missed NHS hospital appointments are due to letter-related problems, such as the letter arriving too late (17 percent), not being received (17 percent) or being lost (8 percent). 68 percent prefer to manage their appointments online or via smartphone. This preference has real financial impact as the NHS estimates that 8 million appointments were missed in 2016-2017, at a cost of £1bn. Now this survey of 2,000 adults was sponsored by Healthcare Communications, a provider to 100 NHS trusts with patient communications technology, so there’s a dog in the hunt. However, they developed for Barnsley Hospital NHS Foundation Trust a digital letter technology that is claimed to reduce outpatient postal letters by 40 percent. Considering my dentist sends me three emails plus separate text messages before my twice-yearly exam…. Release (PDF).

Roy Lilley’s daily newsletter today also engages the Tech Question and the “IT desert” present in much of the daily life of the NHS. Trusts are addressing it, junior doctors are WhatsApping, and generally, clinicians are hot-wiring the system in order to get anything done. It is much like the US about five to seven years ago where US HHS had huge HIPAA concerns (more…)

Babylon’s ‘GP at hand’ has thousands of London patients in hand

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2017/11/Babylon-NHS-tube-advert.jpg” thumb_width=”150″ /]Apparently Babylon Health’s ‘GP at hand’ is a hit with Londoners, despite the requirement to shift GP practices. The Evening Standard reports that the Lillie Road Surgery in Hammersmith, one of the five London practices in the program (plus Victoria, Poplar, Euston, and Fulham), increased its patient list by nearly 7,000 (4,970 in November to 11,867 last month). (Was it the Tube adverts?–Ed.) No information is available on increases at the other surgeries. 

Helping matters may be the UK flu epidemic, where the incentive to stay at home and have a video consult would be great (and helpful in stemming the spread). These consults on average are available 2 1/2 hours after booking, which to us Yanks used to independent services seems a great delay. One-third are reportedly out of office hours. Duration of the visit is about 10 minutes, which is standard for in-person. What is suspected is that many do not realize that the GP at hand signup also changes your GP to the program. The GP partner quoted in the article claims that homeless people, those with mental health and multiple chronic conditions–not just the young and mobile-savvy–have signed up. 

This Editor will concur with others that it’s time for telehealth to be integrated into the NHS, but the tying of it to specific practices which alters capitation is a large wrinkle which needs ironing out. Our earlier coverage here. Hat tip to Roy Lilley.

Rounding up the roundups in health tech and digital health for 2017; looking forward to 2018’s Nitty-Gritty

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2017/12/Lasso.jpg” thumb_width=”100″ /]Our Editors will be lassoing our thoughts for what happened in 2017 and looking forward to 2018 in several articles. So let’s get started! Happy Trails!

2017’s digital health M&A is well-covered by Jonah Comstock’s Mobihealthnews overview. In this aggregation, the M&A trends to be seen are 1) merging of services that are rather alike (e.g. two diabetes app/education or telehealth/telemedicine providers) to buy market share, 2) services that complement each other by being similar but with strengths in different markets or broaden capabilities (Teladoc and Best Doctors, GlobalMed and TreatMD), 3) fill a gap in a portfolio (Philips‘ various acquisitions), or 4) payers trying yet again to cement themselves into digital health, which has had a checkered record indeed. This consolidation is to be expected in a fluid and relatively early stage environment.

In this roundup, we miss the telecom moves of prior years, most of which have misfired. WebMD, once an acquirer, once on the ropes, is being acquired into a fully corporate info provider structure with its pending acquisition by KKR’s Internet Brands, an information SaaS/web hoster in multiple verticals. This points to the commodification of healthcare information. 

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2017/12/canary-in-the-coal-mine.jpgw595.jpeg” thumb_width=”150″ /]Love that canary! We have a paradigm breaker in the pending CVS-Aetna merger into the very structure of how healthcare can be made more convenient, delivered, billed, and paid for–if it is approved and not challenged, which is a very real possibility. Over the next two years, if this works, look for supermarkets to get into the healthcare business. Payers, drug stores, and retailers have few places to go. The worldwide wild card: Walgreens Boots. Start with our article here and move to our previous articles linked at the end.

US telehealth and telemedicine’s march towards reimbursement and parity payment continues. See our article on the CCHP roundup and policy paper (for the most stalwart of wonks only). Another major change in the US is payment for more services under Medicare, issued in early November by the Centers for Medicare and Medicaid Services (CMS) in its Final Rule for the 2018 Medicare Physician Fee Schedule. This also increases payment to nearly $60 per month for remote patient monitoring, which will help struggling RPM providers. Not quite a stride, but less of a stumble for the Grizzled Survivors. MedCityNews

In the UK, our friends at The King’s Fund have rounded up their most popular content of 2017 here. Newer models of telehealth and telemedicine such as Babylon Health and PushDoctor continue to struggle to find a place in the national structure. (Babylon’s challenge to the CQC was dropped before Christmas at their cost of £11,000 in High Court costs.) Judging from our Tender Alerts, compared to the US, telecare integration into housing is far ahead for those most in need especially in support at home. Yet there are glaring disparities due to funding–witness the national scandal of NHS Kernow withdrawing telehealth from local residents earlier this year [TTA coverage here]. This Editor is pleased to report that as of 5 December, NHS Kernow’s Governing Body has approved plans to retain and reconfigure Telehealth services, working in partnership with the provider Cornwall Partnership NHS Foundation Trust (CFT). Their notice is here.

More UK roundups are available on Digital Health News: 2017 review, most read stories, and cybersecurity predictions for 2018. David Doherty’s compiled a group of the major international health tech events for 2018 over at 3G Doctor. Which reminds this Editor to tell him to list #MedMo18 November 29-30 in NYC and that he might want to consider updating the name to 5G Doctor to mark the transition over to 5G wireless service advancing in 2018.

Data breaches continue to be a worry. The Protenus/DataBreaches.net roundup for November continues the breach a day trend. The largest breach they detected was of over 16,000 patient records at the Hackensack Sleep and Pulmonary Center in New Jersey. The monthly total was almost 84,000 records, a low compared to the prior few months, but there may be some reporting shifting into December. Protenus blog, MedCityNews

And perhaps there’s a future for wearables, in the watch form. The Apple Watch’s disconnecting from the phone (and the slowness of older models) has led to companies like AliveCor’s KardiaBand EKG (ECG) providing add-ons to the watch. Apple is trying to develop its own non-invasive blood glucose monitor, with Alphabet’s (Google) Verily Study Watch in test having sensors that can collect data on heart rate, gait and skin temperature. More here from CNBC on Big Tech and healthcare, Apple’s wearables.

Telehealth saves lives, as an Australian nurse at an isolated Coral Bay clinic found out. He hooked himself up to the ECG machine and dialed into the Emergency Telehealth Service (ETS). With assistance from volunteers, he was able to medicate himself with clotbusters until the Royal Flying Doctor Service transferred him to a Perth hospital. Now if he had a KardiaBand….WAToday.com.au  Hat tip to Mike Clark

This Editor’s parting words for 2017 will be right down to the Real Nitty-Gritty, so read on!: (more…)

Babylon Health: correcting our NW London CCG report; objects to concerns raised by CQC report (latest updates)

Correcting and commenting on our earlier report. This Editor had earlier published on 11 Dec, as follow up to the extensive coverage on Babylon Health’s ‘GP at hand’ pilot activity in London, summarizing a report in Digital Health stating that the North West London Collaboration of Clinical Commissioning Groups (CCG) ended plans for expanding a test of the Babylon video consult/symptom checker app for GP practices in that area and that the app could be ‘manipulated’ to secure GP appointments faster and would not reduce demands on GPs. The original article was first corrected at an NHS England‘s representative’s request to reinforce that this was a local CCG project and that NHS England was not involved. The second request we received last Friday was from Babylon Health’s PR representative, Giles Kenningham, principal at Trafalgar Strategy. It was certainly strong and quoted here, edited as indicated to remove the link to the original article and Mr. Kenningham’s signature:

Your recent article on Babylon is factually wrong and misleading (link removed):
You claim the babylon app was dropped after being manipulated by patients. The term ‘manipualtion’ has been removed from the board papers and is wrong. Similarly the planned pilot had never begun so there so nothing to roll out.
This story is based on incorrect board papers which have now been corrected.

Please find a spokesman quote below. (closing signature removed)

A spokesperson for Babylon said:

“No pilot was ever carried out, nor any agreement signed with Babylon for such a pilot.

“Discussions were held after Babylon was selected in a competitive procurement exercise as the best technology to trial in GP practices across North West London. Subsequently, a decision was taken not to fund the pilot.”

This Editor then checked on the Digital Health article and found it had been removed without any follow-up or correction. Thus on Friday 8 Dec, this Editor removed the article, thanked Mr. Kenningham for bringing it to attention, and added that our report cited Digital Health as the source. I also requested a reference or third-party confirmation of his corrections. (This last request was not received as of the time of this writing.)

Wanting to get to the bottom of this for our Readers–and as a marketer who’s corrected more than a few inaccurate reports, your Editor has located the CCG’s report which is here published 22 November. It corresponds with Mr. Kenningham’s full note. The CCG report appears to have been revised (the URL indicates a v3), there never was a Babylon pilot, this version does not use the word ‘manipulation’, and the end result was that the CCG decided not to proceed to the pilot stage. In short, it appears to this Editor that the Digital Health report was based on an earlier and incorrect version of the report (perhaps as early as 25 Oct) and we are of course happy to correct. My fault and apology to our Readers and to Babylon in that I should have located the 22 Nov revised report prior to publishing the article and essentially provided a correction to Digital Health‘s report.

However, the CCG’s report on their Babylon evaluation contains two findings that were included in Digital Health‘s now-deleted article and give some pause. The CCG used focus groups of potential users, which surfaced that, in the CCG’s words, “The focus groups had also commented that there is a risk of some people gaming the symptom checker to achieve a GP appointment. The insights gathered therefore revealed that the symptom checker in particular was unlikely to reduce demand for GP services.”

Our Editor Chrys has pointed out the Pulse article which also comments on this and was corrected for the CCG’s revised report. The comments here by practicing GPs are worth reading. Scroll down and you’ll see that  ‘gaming the system’ has happened using direct triage in practices using personal phone consults–no app required. Can this even work?

Focus groups are highly subjective, but they are great ways of surfacing the flaws that developers and companies have gone blind to.

We hope that Babylon Health does take this feedback seriously. This Editor makes no secret of her advocacy of technology that can speed the obtaining of care, but based on her experience with early-stage companies, every critique, every hole that can be kicked in a service, delivery, and logistics, exposing a weakness should be appreciated–and ruthlessly scrutinized for flaws that need solutions. This becomes harder to do when you’ve achieved Big Funding. Babylon is typically burning a hole through it (The Times, 1 Oct–hat tip to Chrys). The pressure on now to find The Road to Breakeven must be stunning.

Important updates: Speaking of finding solutions, Babylon differs strongly with the findings of the Care Quality Commission (CQC)(not to be confused with the CCG), in the CQC report on their service published on Friday 8 December. 

(more…)

NHS ‘GP at hand’ via Babylon Health tests in London–and generates controversy

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2017/11/Babylon-NHS-tube-advert.jpg” thumb_width=”150″ /]The GP at hand (literally) service debuted recently in London. Developed by Babylon Health for the NHS, it is available 24/7, and doctors are available for video consults, most within two hours. It is a free (for now) service to NHS-eligible London residents who live and work in Zones One through Three, but requires that the user switch their practice to one of the five ‘GP at hand’ practices (map). Office visits can be scheduled as well, with prescriptions delivered to the patient’s pharmacy of choice.

Other attractive features of the service are replays of the consult, a free interactive symptom checker, and a health record for your test results, activity levels and health information. 

While the FAQs specify that the “practice boundary” area is south of Talgarth Road and Cromwell Road in Fulham, and north of the River Thames, it is being advertised on London Transport (see advert left and above taken on the Piccadilly Line) and on billboards.

Reviewing the website FAQs, as telemedicine it is positioned to take fairly routine GP cases of healthy people (e.g. colds, flu, rashes) and dispatch them quickly. On the ‘can anyone register’ page, it’s stated that “the service may however be less appropriate for people with the conditions and characteristics listed below”. It then lists ten categories, such as pregnancy, dementia, end of life care, and complex mental health conditions. If anyone is confused about these and other rule-outs, there is a support line. 

Babylon Health is well financed, with a fundraise of £50 million ($60 million of a total $85 million) in April for what we profiled then as an AI-powered chatbot that sorted through symptoms which tested in London earlier this year. This is a full-on telemedicine consult service with other services attached.

Now to the American view of telemedicine, this is all fairly routine, expected, and convenient, except that there’d be a user fee and a possible insurance co-pay, as more states are adopting parity for telemedicine services. We don’t have an expectation that a PCP on a telemedicine consult will take care of any of these issues which Babylon rules out, though telemental health is a burgeoning and specialized area for short and long-term support. But the issues with the NHS and GPs are different.

First, signing up to ‘GP at hand’ requires you to change your GP to one in that program. US systems are supplementary–a telehealth consult changes nothing about your other doctor choices. This is largely structural; the NHS pays GPs on a capitation basis.

mHealth Insight/3G Doctor and David Doherty provide a lengthy (and updated) analysis with a critical view which this Editor will only highlight for your reading. It starts with the Royal College of GPs objections to the existence of the service as ‘cherry-picking’ patients away from GPs and creating a two-track system via technology. According to the article, “NHS GPs are only paying them [Babylon] £50 a year of the £151 per year that the NHS GP Practice will be paid for every new Patient they get to register with them” which, as a financial model, leads to doubts about sustainability. Mr. Doherty advises the RCGPs that they are fighting a losing battle and they need to get with mHealth for their practices, quickly–and that the NHS needs to reform their payment mechanisms (GPs are compensated on capitation rather than quality metrics).

But there are plenty of other questions beyond cherry-picking: the video recordings are owned by Babylon (or any future entity owning Babylon), what happens to the patient’s GP assignment if (when?) the program ends, and patients’ long-term care.

Oh, and that chatbot’s accuracy? Read this tweet from @DrMurphy11 with a purported video of Babylon advising a potential heart attack victim that his radiating shoulder pain needs some ice. Scary. Also Digital Health.