Comings and goings: CVS-Aetna finalizing, Anthem sued over merger, top changes at IBM Watson Health

imageWhat better way to introduce this new feature than with a picture of a Raymond Loewy-designed 1947 Studebaker Starlight Coupe, where wags of the time joked that you couldn’t tell whether it was coming or going?

Is it the turkey or the stuffing? In any case, it will be the place you’ll be going for the Pepto. The CVS-Aetna merger, CVS says, will close by Thanksgiving. This is despite various objections floated by California’s insurance commissioner, New York’s financial services superintendent, and the advocacy group Consumers Union. CEO Larry Merlo is confident that all three can be dealt with rapidly, with thumbs up from 23 of the 28 states needed and is close to getting the remaining five including resolving California and NY. The Q3 earnings call was buoyant, with CVS exceeding their projected overall revenue with $47.3 billion. up 2.4% or $1.1 billion from the same quarter in 2017. The divestiture of Aetna’s Medicare Part D prescription drug plans to WellCare, helpful in speeding the approvals, will not take effect until 2020. Healthcare Dive speculates, as we did, that a merged CVS-Aetna will be expanding MinuteClinics to create urgent care facilities where it makes sense–it is not a big lift. And they will get into this far sooner than Amazon. which will split its ‘second headquarters’ among the warehouses and apartment buildings of Long Island City and the office towers of Crystal City VA.

Whatever happened to the Delaware Chancery Court battle between Anthem and Cigna? Surprisingly, no news from Wilmington, but that didn’t stop Anthem shareholder Henry Bittmann from suing both companies this week in Marion (Indiana) Superior Court. The basis of the suit is Anthem’s willfully going ahead with the attempted merger despite having member plans under the Blue Cross Blue Shield Association meant the merger was doomed to fail, and they intended all along for “Anthem to swallow, and then sideline, Cigna to eliminate a competitor, in violation of the antitrust laws.” On top of this, both companies hated each other. A match made in hell. Cigna has moved on with its money and bought Express Scripts.

IBM Watson Health division head Deborah DiSanzo departs, to no one’s surprise. Healthcare IT News received a confirmation from IBM that Ms. DiSanzo will be joining IBM Cognitive Solutions’ strategy team, though no capacity or title was stated. She was hired from Philips to lead the division through some high profile years, starting her tenure along with the splashy new Cambridge HQ in 2015, but setbacks mounted later as their massive data crunching and compilation was outflanked by machine learning, other AI methodologies, and blockchain. According to an article in STAT+ (subscription needed), they didn’t get the glitches in their patient record language processing software fixed in ‘Project Josephine’, and that was it for her. High profile partner departures in the past year such as MD Anderson Cancer Centers, troubles and lack of growth at acquired companies, topped by the damning IEEE Spectrum and Der Spiegel articles, made it not if, but when. No announcement yet of a successor.

Coffee break reading: a ‘thumbs down’ on IBM Watson Health from IEEE Spectrum and ‘Der Spiegel’

In a few short years (2012 to now), IBM Watson Health has gone from being a 9,000 lb Harbinger of the Future to a Flopping Flounder. It was first MD Anderson Cancer Center at the University of Texas last year [TTA 22 Feb 17] kicking Watson to the curb after spending $62 million, then all these machine learning, blockchain, and AI upstarts doing most of what Watson was going to do, but cheaper and faster, which this Editor observed early on [TTA 3 Feb 17]. At the end of May, IBM laid off hundreds of workers primarily at three recently acquired data analytics companies. All came on board as market leaders with significant books of business: Phytel, Explorys, and Truven. Clients have evaporated; Phytel, before the acquisition ranked #1 by KLAS in analytics for its patient communication system, reportedly went from 150 to 80 clients. IBM denies the layoffs were anything but much-needed post-acquisition restructuring and refocusing on high-value segments of the IT market.

IEEE Spectrum rated the causes as corporate mismanagement (mashing Phytel and Explorys; IBM’s ‘bluewashing’ acquired companies; the inept ‘offering management’ product development process; the crushed innovation) plus inroads made by competition (those upstarts again!). What’s unusual is the sourcing from former engineers–IEEE is the trade group for tech and engineering professionals. The former IBM-ers were willing to talk in detail and depth, albeit anonymously. 

Der Spiegel takes the German and clinical perspective of what IBM Watson Health has gone wrong, starting with the well-documented failures of Watson at hospitals in Marburg and Giessen. The CEO of Rhön-Klinikum AG, which owns the university hospital at Marburg, reviewed it in action in February. “The performance was unacceptable — the medical understanding at IBM just wasn’t there.” It stumbled over and past diagnoses even a first-year resident would have considered. The test at Marburg ended before a single patient was treated.

The article also outlines several reasons why, including that Watson, after all this time, still has trouble crunching real doctor and physical data. It does not comprehend physician shorthand and negation language, which this Editor imagines is multiplied in languages other than American English. “Some are even questioning whether Watson is more of a marketing bluff by IBM than a crowning achievement in the world of artificial intelligence.” More scathingly, the Rhön-Klinikum AG CEO: “IBM acted as if it had reinvented medicine from scratch. In reality, they were all gloss and didn’t have a plan. Our experts had to take them by the hand.”

Hardly The Blue Wave of the Future. Perhaps the analogy is Dr. Watson as The Great Oz.

Blockchain deployment not matching the hype–so far. 34% of CIOs have ‘no interest’.

A Gartner study confirms blockchain’s Peak of Inflated Expectations position on the Hype Curve. Despite all the chatter, blockchain isn’t being deployed in a commensurate way. Among over 3,100 CIOs surveyed, only 1 percent reported “any kind of blockchain adoption” in their organization. On the other hand, 34 percent have ‘no interest.’ 8 percent said they were conducting short-term testing with blockchain, 14 percent had graduated to medium or long-term planning, and 43 percent said it was on the radar, but they had no plans to test or develop or deploy it. A major reason is a dearth of skills; 23 percent said the effort requires the “most new skills to implement” of any IT tool.

But spending on blockchain technology is geometrically increasing: estimates for 2018 are $2.1 bn, a 122 percent increase over 2017’s $945 million. More information in Gartner’s press release and blockchain page. Also Angus Loten in The Wall Street Journal.

As our Editor in Chief Emeritus Steve Hards explained in his recent must-read article on blockchain, especially in healthcare, “distributed ledger technologies are not just in their infancy, they are still at a baby stage. Many are still gestating. It may be worth waiting to see which ones thrive.” In healthcare, we have a far greater problem with interoperability and secure data exchange which blockchain can only partially address. 

Blockchains, EHRs, roadblocks and baby steps

TTA founder and former editor Steve Hards crawls out of his retirement tent to squint at the misty landscape of blockchain technology.

In a recent dream I was observing an auditorium full of people chanting “Blockchain! Blockchain! Blockchain!” and yes, mantra-like, blockchain is now popping up all the time in health technology articles and presentations.

It has taken a while to get to this stage. It was January 2016 when Editor-in-Chief Donna first mentioned blockchain. Since then there appears to have been more talk than action.

A year ago, in February 2017, health IT guru Brian Ahier was able to say in a comment here “Blockchain of course, is going to sneak up on a lot of people…”

Where we have seen developments occurring is in the trickle of ‘coins’ or ‘tokens’ in health-related Initial Coin Offerings (ICOs) of dubious investment worthiness. I may rant about those in a follow-up article if anyone is interested. (Let me know in a comment.)

The terminology is still in its ‘shakedown phase’ (see this great terminology rant) and, because of the publicity around Bitcoin, which is on a blockchain, the distinction between blockchains and distributed ledger databases is blurred. There are technical differences: blockchains are a sub-set of distributed ledgers (Wikipedia), which is the term I’ll generally use in this article.

Distributed ledgers and EHRs

What are the implications of distributed ledgers for the biggest databases in healthcare, electronic health records (EHRs)?

The two principal characteristics that differentiate distributed ledgers from the databases with which we are familiar are that they are more robust and, potentially, more private. Some even claim to be quantum computing hack proof although we will have to wait for hackers with quantum computers to test that.

Traditional databases are formed from one large or several linked entities that have a centralised control from where performance, data integrity and security are monitored and managed. There are human and technological factors that introduce weaknesses to all such systems, as the number of data breaches reported here over the years testify.

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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…)

Thinking about a location for your health tech startup? Consider…’virtual’ Estonia!

‘Extreme digital living’ is the norm in the Baltic country of Estonia, which rebuilt itself from the ground up after the formal dissolution of the Soviet Union (and each citizen receiving a distribution of €10) to one of the most advanced online-only countries in the world, far ahead of the US, the UK, and the rest of the EU. Internet access is by law a basic human right in Estonia. Digital signatures are equal in every way to paper signatures, except for marriage and divorce (a nostalgic touch). Everyday living is paperless and programming is taught in early grades. Live in picturesque Tallinn and need a delivery? It may come to your door via Starship robot, founded by one of the former Skype team. (Did you know that former Skypers have funded much of the Estonian tech and investment boom?) They take data security seriously with the Russian Bear growling (and hacking) on the border, so they created a NATO-accredited cyberdefense center in Tallinn and a whole country backup in a Luxembourg ‘data embassy’. Blockchain is a large part of this–and the government is working on using it for mapping the genome data of its 1.3 million citizens and sell it (deidentified) to precision medicine researchers.

So if you are a US, UK, EU, or even Australian-based developer, or already have a small tech company, why is this of interest? Estonia has opened a door for foreigners that is a most attractive one–virtual residency, no matter where you live. Once you’re an e-resident, simply register your company (online of course) and pay a fee of €145. You now can do business in euros–and fully access the EU. Most companies pay monthly administrative and accounting fees in Estonia, providing the country with income. About 1,400 companies have taken advantage of e-residency. It isn’t a tax haven, but if you do have income in Estonia, their corporate taxes are low–20 percent, compared to 19 percent for the UK, 30 percent for Australia, and a shattering 39 percent for the US (at present). Trading Economics And there is that tech and digital-savvy workforce as an additional incentive. Is This Tiny European Nation a Preview of Our Tech Future? (FortuneHat tip to TTA Founder Steve Hards

How to unblock that health data in your EHR? Blockchain. (UK)

The solution to that huge pile of patient-generated data, blocked and stymied in those non-interoperable EHRs [TTA 15 Mar], may be a system based on blockchain. DeepMind, Alphabet’s AI ‘skunk works’, is building a tool that it calls Verifiable Data Audit. It will be tested first in UK hospitals with which DeepMind is already working, including London’s Royal Free Hospital. What VDA will do is use cryptographic math to keep an accurate record of data used in the past to see exactly who is using health-care records, and for what purpose. When data is used, it generates a code based on all past activity. Any alteration to one part of the data alters the others and is quick to spot.

The UK test results will be interesting because, according to the MIT Technology Review article, patient records are considered to be highly fragmented. Another issue that DeepMind had in the UK was the NHS oversharing data with it for other projects, such as AI systems to diagnose eye disease, early warning signs of illness, and machine-learning approaches to guide cancer treatment. The VDA approach would, ironically, create an audit trail of that data. Another reason why we may be moving from Data Despare to Hope. Hat tip to contributor Sarianne Gruber of RCM Answers.

Why do hackers love bitcoin? Blockchain. And why are healthcare, IoT liking blockchain?

Hackers love bitcoin for their ransomware payment because it’s virtual money, impossible to trace and encrypted to the n-th degree. Technically, bitcoin is not a transfer of payment–it IS money of the unregulated sort. The ransomee has to pay into a bitcoin exchange and then deliver the payment to the hacker. However, what sounds straightforward is actually fraught with risks, such as the bitcoin exchanges themselves as targets of hacking and the fluctuations of bitcoin value meaning that a ransom may not actually be paid in full. ID Experts‘ article gives the basics of bitcoin, what to expect and when paying a ransom is the prudent thing to do.

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2016/07/blockchain-in-HC.jpg” thumb_width=”200″ /]Turn what is behind bitcoin around though, and it becomes intriguing to HIT and IoT. Blockchain is “a distributed, secure transaction ledger that uses open-source technology to maintain data. Records are shared and distributed over many computers of entities that do not know each other; records can be time-stamped and signed using a private key to prevent tampering.” Each record block has an identifying hash that links each block into a virtual chain. (Wikipedia has a more complete description.) For bitcoin, it ensures security, anonymity and transferability without a central bank. For healthcare, distributed data and security is the exact opposite of the highly centralized, locked down approach of standard HIT to enable interoperability and security (left above). The Federal ONC-HIT (Office of the National Coordinator for Health Information Technology) under HHS is soliciting up to 15 proposals for “Blockchain and Its Emerging Role in Healthcare and Health-related Research.” through July 29. Cash prizes range from $1,500 to $5,000. The final eight will present at the awards presentation September 26-27. Potential uses are:

  • Medical banking between dis-intermediated parties
  • Distributed EHRs
  • Inventory management
  • Forming a research “commons” and a remunerative model for data sharing
  • Identity verification for insurance purposes
  • An open “bazaar” for services that accommodates transparency in pricing

Health Data Management, Information Management, Federal Register announcement

Why hackers feel the $$ love for healthcare: Brookings study

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2015/02/Hackermania.jpg” thumb_width=”150″ /]It’s the information, silly! A recent study by the Center for Technology Innovation at the Brookings Institution tells us what we already know: healthcare organizations hold high-value information electronically, and because they haven’t invested equally in cybersecurity, it’s all vulnerable. When those nifty EHRs hold names, dates of birth, addresses, Social Security numbers and health histories, they are eminently salable. What’s new here is that the vulnerability increases due to factors not based on security, but on legal and data exchange requirements:

  • Data sharing and accessing
  • Length of storage to comply with regulations
  • The size of the records–the more information they hold, the more vulnerable

Lay on top of this ransomware.

The worst threat is not the hacker in a Bulgarian basement, but what is termed ‘state actors’ who want health information for a variety of reasons. They may be compiling a big database:”…a dossier of individuals that they could use for social engineering for future attacks”–such as sending phishing emails to government employees with specific, accurate information that when opened, infect their computers with malware for another purpose. Some solutions presented are using an outside cloud storage provider; using blockchain, which requires both public and private encryption keys; intrusion-detection systems (IDS) and security information and event management (SIEM) software. CSO, Brookings report (28 pages)

Eight TECS expected to change health and care

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2016/01/8-technologies-8-connected-community.jpg” thumb_width=”175″ /]The King’s Fund is still bullish on the transformative capabilities of technology-enabled care services for health (even if others are not, see following article). This article (which almost passed this Editor by this month) highlights eight areas which have the greatest potential. Some are expected–but at least two are surprises. You be the judge!

  1. Smartphones: apps, as hubs/hub replacements, and research transmitters (voluntary but also involuntary?)
  2. At-home and portable diagnostics; smart assistive technology
  3. Smart or implantable drug delivery
  4. Digital therapeutics/interventions; cognitive behavioral therapy; lifestyle interventions
  5. Genome sequencing
  6. Machine learning (computers changing based on new data, spotting pattern) in big datasets (Surprise #1)
  7. Blockchain, the tech behind bitcoin; decentralised databases, secured using encryption, that keep an authoritative record of how data is created and changed over time, to bring together decentralized health records. (Surprise #2)
  8. The connected community; P2P support networks and research communities

The King’s Fund’s publications 1 Jan