Your reporter from this conference is Donna Cusano

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Thurs 22 October: Morning

Apologies for the delay in posting this. Unlike yesterday when I could retreat to my room and write, the need to check out from the hotel room and end of day running for the Acela back to NYC meant writing on the train (no WiFi on Acela – why?) and (finally) at home. Drink your morning coffee and read on….it may have been like drinking from a fire hose, but it was worth every drop…DC

The first morning keynote extended the ‘Overhauling Healthcare’ theme with a ‘disruptive’ and I believe significant presentation by Jason Hwang, MD, Executive Director of the Innosight Institute. How Disruptive Innovation Will Change Healthcare was researched for and drawn from his book, The Innovator’s Prescription, co-authored with Clayton Christensen and Jerome Grossman, MD. Disruptive innovations are breakthroughs in technology that, in their adoption, upset existing business models and force decentralization of distribution or usage. Examples: computer mainframe to mini-computer to PC (PC and now smart phones being the disrupters), the transistor, and online e-commerce in travel purchasing (on the last, from personal experience, being in the wrong side of disruption is a painful place to be). Dr. Huang’s point was that it is often futile to cram new technologies into old business models. The current centralized medical center is the old business model and rapidly becoming non-viable, much like Digital Computer.

What is driving decentralization in healthcare? Technologies that enhance the ability of technicians and non-physician clinicians to perform procedures, move care into the home and provide information directly to individuals and social networks. The former medical center becomes a ‘solution shop’ – the home of highly specialized expertise for diagnosis, even with the physicians themselves becoming more generalists. The ‘value added’ process (procedures following diagnosis) and follow up care will include more technicians and nurses doing routine, skilled procedures, with physicians taking a smaller role. Consumer information? Facilitated networks will distribute information through provider and patient communities. It’s all still evolving, no one is there yet, and the new ‘value network’ needed to gain traction is still undefined. At the end of this presentation I did understand one thing; if you wake up some mornings wondering what you’ve gotten yourself into, be reassured that you have lots of company.

Take all this disruption in our semi-free markets, empower the consumer and he or she will make rational decisions for their personal health, right? Peter Ubel, MD says, “I don’t think so”. His keynote presentation, Irrational Decisions and the Limits of Free Market Medicine (drawn from his book Free Market Madness, www.peterubel.com), examined how we as individuals and even medical professionals may make our decisions quite irrationally. Negative factors are our perception of risk, how the information is presented, perception of consequences and emotions. To him free markets have their limits, freedom and well-being are to be balanced. How? Ubel suggested negative incentives (e.g. taxes) on unhealthy behaviors (high fat or calorie food) and to subsidize healthy food and behaviors (fitness centers). We returned to this topic later in Drilling Down.

These were wrapped up with a panel moderated by Robert Hanscom, JD of CRICO/Risk Management Foundation; panelists were John Glaser, PhD, John Halamka, MD of CareGroup Health System, Peter Neupert of Microsoft and Jim Tosone of Pfizer Healthcare Informatics. The bulk of the discussion was on disruptive innovation, with Dr. Glaser focusing on the complexity of issues that result, such as accountability of both institutions and patients, plus the adoption rate of PHRs, but that second and third order effects are not predictable at this point. A differing view was held by Mr. Tosone, stating that disease management models were proving to be very difficult in terms of scale and business model. Decision support systems (DSS) were a ‘hot button’: Dr. Halamka projected that DSS would help patients make decisions and Dr. Glaser predicting that some high-value aspects of care would be pushed to trained clinicians (non-physicians) with DSS as a guide, but he was also sanguine on DSS’ limitations (e.g. not radiology). Neupert’s dash of realism was on what it will take to get to personalized medicine– the great investment in IT and support needed, he could not see happening right now.

On Ubel’s topic, it was a rational discussion on how much irrationalism there was out there and setting limits. Dr. Halamka believed that a clear set of probabilities would help patients make rational decisions; Dr. Glaser advocated DSS to set the boundaries in clinical decisions; and Mr. Tosone proposed a book sequel called “Mandated Madness” detailing the irrational decisions made by legislators and policy makers.

After a short break, we returned to man’s irrationality with Drilling Down on Mad Markets; Gentle Nudges and Behavioral Economics. Michael Barrett, JD of Critical Mass Consulting presented behavioral economics 101 [i.e. the basics] and typical biases such as conformity effect, loss aversion, anchoring and adjustment. The meaning for healthcare lies in pivoting BE for ‘prescription’ and creating ‘choice architects’ who bend the architecture of choice to produce a result, creating a small downside if you choose the other way. In public affairs, other terms used are ‘libertarian paternalism’ and the ‘nudge state’ which arrange the choices in a way to leverage them for the ‘common good’ (Cass Sunstein, 2008 CHS speaker and author of Nudge, now a policy czar in the current administration). For instance, you can limit cafeteria food consumption by not providing trays; encourage more people to use the stairs rather than elevators for extra exercise; unfortunately for fitness, many internal stairs are unsecured, thus unsafe (walk stairs with pepper spray in hand, I assume). (Comment–It all sounds rather benign, but the political process ‘nudges’ morph into ‘mandates’ all too easily.) Robert Schwarzberg, MD of Sensei described that everyone’s daily life has a conflict in values vs. health, and not to be given a choice is often a problem; also be careful in what you wish for, as you can create stigmas (e.g. overweight children singled out in school weigh-ins). Further illustrating the Law of Unintended Consequences was Laurie Orlov: ending gym in grammar schools for additional instructional time has been one more contributor to childhood obesity; living to an older age has meant more need for universal design and assistive technologies.

Thurs 22 October: Afternoon and Final

The final full breakout I attended was also with Laurie Orlov (aka Agent 99) here very firmly in her space – Get (Your House) Smart: Aging in Place, at Home, Aided by Technology. Joined by Charles Hillman of GrandCare Systems, Joe Coughlin, PhD of MIT AgeLab, Tom Ryden of North End Technologies and moderated by Marc Holland of System Research Services, this panel had much to say in their 50 minutes and could have easily filled an additional engaging 15.

This area is where much real-world tech is happening, but adoption has a long way to go.

The ‘smart house’ for Dr. Coughlin is the nexus of innovation, hardware, software and health information. It is not about devices but lifestyle and services, not about making up for health ‘loss’ but ‘gain’. The current business model is now oriented to what Medicare will reimburse (not much) and nothing is right in terms of the technology. Right now it is all about a home for those who are obviously old and frail – the paradox is that if you design a home for them, no one will buy it, including the old and frail.

Mr. Hillman approached the smart house as (Gregory) House – we’ve become masters of acute care, but not very good at assisting independent living and aging ‘responsibly’. Systems should be designed holistically and include 1) physiologic sensing (vital signs), 2) activity monitoring, 3) social connectedness and 4) home controls that light rooms at night, turn on outside lights, etc. The service he developed, GrandCare, has incorporated all four.

The smart home in Ms. Orlov’s view uses technology to more tightly connect the senior to others and to be safe, through communications and engagement, home safety and security, health and wellness and continuous learning and participation in social networks. Older people ARE interested in technology – broadband is being adopted by them in increasing numbers. But it has to be acceptable to the senior and can’t be imposed by family.

Mr. Ryden added robotics to the smart home, especially the development of small robots that can aid in everyday activities (versus the Japanese model of robopets for socialization).

Mr. Hillman pointed out that ADL (activities of daily living) monitoring is growing; currently it is largely a private pay service as LTC insurance and Medicare do not pay for it at present. LTC insurance should be paying for monitoring and other smart home assistive services, as they do for home care.

Homes, especially in this tired market, need something extra to sell and older homes need to upgrade; as Mr. Ryden put it, the ideal for technology would be ‘available at Best Buy’ and reimbursable. But the potential disrupters – home builders and remodelers–seem to avoid the older market except for ‘senior communities.’ Ms. Orlov described attempting to work with builders in her state, Florida, to create a ‘smart home’ demo incorporating universal design and technology in one of those plentiful unsold homes, and amazingly has not succeeded as of yet. (Keep trying, Laurie!)

NORCs – naturally occurring retirement communities – often need upgrading. And alternatives such as ‘intentional communities’ must be explored for the rising single population, especially those in the suburbs and exurbs. If they would realize it, the real disrupters and the new model may be via home builders, retailers and (Dr. Coughlin) utility companies. (In the US utilities are increasing selling ‘value added’ in products and services.)

Current technology is NOT fun, interactive or particularly desired to consumers. If it were, it could be a lot more appealing and useful. So where are the game designers? In fact, as Ms. Orlov pointed out, the terminology – aging – is terrifying; large companies are avoiding it in their messaging and we don’t have good terminology to replace it. Her final note: ‘patients’ are really people, and we should be referring to them that way.

A tip of the hat to Laurie Orlov’s Aging In Place Technology blog and her POV on the Symposium

The last word…

The final general session launched the Journal of Participatory Medicine (online at as of 3:30pm 22 October) and its editorial staff: Jessie Gruman, PhD (co-editor), Gilles Frydman, Alan Greene, MD (deputy editor), Dan Hoch, MD, PhD and Charles W. Smith, MD (co-editor). In their words, “Participatory medicine is a cooperative model of health care that encourages, supports and expects active involvement by all parties (clinicians, patients, caregivers, administrators, payers and communities) in the prevention, management and treatment of disease and disability and the promotion of health.” The journal is open peer review, and articles can be sourced from the medical community, consumers, caregivers, employers, administrators etc. It is one more example of convergence, and appropriately was the last business of this excellent Symposium.

Donna Cusano

Your reporter from this conference is Donna Cusano

Wed 21 October: morning

The theme of this conference is Up from Crisis: Overhauling Healthcare Information, Payment and Delivery in Extraordinary Times. So far, this observer senses little of the desperation that crisis conveys, but its corollary – great opportunity in connection and integration of the products and services out there with patients/clients and clinicians.

The conference opened, of course, with what is happening on healthcare reform on the Federal level.

The morning keynote speaker, Stuart Altman, PhD, an expert in Federal and state policy, set the tone. As head of the healthcare policy office in the Nixon administration back in 1971, when the “crisis” was that healthcare spending was 7.5% of US GDP @ $75 billion and was a factor in the infamous wage and price controls – to today when it is 17% of GDP @ $2.5 trillion, healthcare expenditures have been in one crisis after another that neither Carter, Clinton or Bush could control. He stated that costs will probably not go down – but there will be shifting from Federal spending (down) to private spending (up). Though Americans use less healthcare on average than UK/EU citizens, our prices continue to go up and Medicare costs continue to be the 800lb gorilla in the corner, with bankruptcy projected now for 2017. We need to change the payment and delivery systems, and the bills in Congress will not do much because Altman’s Law prevails – “Most every powerful constituent group favors health reform – but if it is not their plan, they prefer the status quo.” Right now, the winners appear to be hospitals, doctors, pharmaceutical/device companies and equipment manufacturers; the losers are insurance companies who will not experience the huge influx of new insureds that they were counting on.

This wasn’t a gloomy talk by any means – Dr. Altman is a great speaker and having reform put into historical context was reassuring to the audience – and he had some good news for our sector in that there will be increased incentives for home based services (Rep. Ed Markey’s “Independence at Home Program”), working with comparative effectiveness systems. But dreaded cost controls may rear their head….

The aforementioned Rep. Markey (D-MA) teleconferenced in from Washington with more on the bills and “Independence at Home” which he had included into the House healthcare reform bill. As the chair of the Telecommunications Subcommittee he also has a great deal to do with communications and interoperability of systems. One excellent point he brought up about ‘the gorilla’ as that 10% of the Medicare population has 5+ diseases, and account for 50% of the costs. We’ll have a part of managing that, as well as preserving patient privacy which is a major concern of his.

The morning networking break was jam-packed in the narrow exhibit area, so I joined Verizon’s Addressing Interoperability session with Rajeev Kapoor, Global Managing Director of Verizon’s Healthcare business. From the start in the 1970s of “laying the pipeline” to today’s broadband and FiOS systems, where Verizon is leading is in interoperability and creating a hub for secure information exchanged and levels of connectedness. His model of ‘crawl-walk-run’ illustrated that not every area of healthcare would have or need the same approach, and most of all, systems needed to be kept simple a la Apple and Google models. Applying interoperability in healthcare systems must address critical issues: identity, integrity, access to data, telemedicine analysis and human interfacing, regulatory and privacy. Most of what he had to say seemed most applicable to hospitals, clinics and medical practice, so my question was on how this model related to at-home services and applications. Home would be a ‘hub’ for information, and outside the home the cellphone would be the personal health device (including wireless handheld data devices using mobile technology, GPS, body sensors) using 4G technology.

My final morning breakout was Wireless Tech and Patient Self-Management, a panel with Ted Blizzard of the MA Medical Society, Anand Iyer, CEO of WellDoc, Rajeev Kapoor, Jorge Perdomo of Generation One and Dr. Robert Schwartzberg of Sensei. Most of the discussion extended Mr. Kapoor’s remarks, concentrating on how wireless capabilities can ‘raise the bar’ on outcomes, ease of use and interactivity. I’ll report more on this later [see just below] …must run to join Remote Monitoring in 2014.

Wed 21 October: morning (continued)

Continuing with this breakout, Wireless Tech and Patient Self-Management, the panelists looked at the business model for wireless in patient self-management from several perspectives:

• have payors (insurance companies, self-insured employers) reimburse, justified by economic savings (in fewer/shorter hospitalizations, lowering care levels (Iyer)
• in changing behaviors and delivering information, wireless tech has to be affordable; there is a blurred line between medical conditions and wellness (is obesity a disease or does this simply drive other medical conditions) which make cost savings hard to gauge (Schwartzman)
• in self-management of chronic illness, there is a delicate balance between wireless solutions and adoption by clinicians and end users; it has to prove usefulness and be end to end (Perdomo)
• again, tech has to be kept simple to be acceptable; delivery of the right information at the right time is critical for motivating the patient to adopt it. He also questioned whether the payor should be the only revenue in this model – why not the patient?

The segment that needs self-management the most – older people – have the largest issues with devices; these need to be made acceptable with simple phones and M2M wireless in handheld devices. For this group, the technology has to work right the first time out of the box. The final issue discussed was data security – a regulatory issue that the FDA is going to be involved with within the next few months.

Wed 21 October: Afternoon

As much as I’m covering, I’m also missing some. A general session that I missed (to file the morning report) was Nicholas Christakis MD of Harvard Medical School on how social networks affect health for good or ill – for example how obesity can spread in a cohort group, and also using social networking to reverse certain trends (thanks Charlie Hillman, CEO of GrandCare, for this report).

On to Remote Monitoring in 2014. In projecting out their respective areas, the panelists Terry Duesterhoeft, President of Honeywell HomMed, Sandra Elliot, Director of Meridian Health (NJ), Don Jones, Qualcomm VP and Randy Williams, MD, President of Pharos Innovations, led by Steve Brown, CEO of 3banana, had views at variance on how adoption, payment sourcing and technology would look in five years. Duesterhoeft noted how Honeywell technology had already moved from the elderly to serving the chronic disease population, and how SaaS was key to integrating HomMed and other devices. Jones looked forward to new classes of devices, biosensors of the ‘band aid’ type and using wireless technology to ‘collapse space and time’. Williams defined the future question as how to most effectively change behavior around chronic disease and using connectivity in social networking and via healthcare providers to facilitate. Sandra Elliott’s model was consumer based – using data to change behavior around ‘pain points’, integrating social interaction and starting this process in the physician’s office – a phrase of hers was “where there’s pain, there’s gain” – and it has to be what the patient will pay for. On maintaining that changed behavior, Williams emphasized the role of trusted relations, routinizing and incentivizing the behavior and the need to ‘keep it simple.’

‘Wow’ session of the day

At the afternoon networking break, dropped in on the intriguingly named Remote Patient Monitoring: from Warfare to Homecare, presented by the even more intriguingly named Blue Highway. Blue Highway is the R&D arm of Welch Allyn. David Eilers and James DelloStritto presented their concept and technology in test: personal status monitoring (PSM) via thin, wafer-like bio-sensing materials or small SD card-like body monitors/recorders. For military use (developing in conjunction with Lockheed Martin), these multiple sensors in helmets, body armor, clothing and boots capture pressure, motion, respiration, heartbeat, gait, and probable action or position (e.g. running, lying down etc.), relaying the PSM information to a medic who can identify wounded or ‘down’ soldiers, predict problems (limping) and when coming to aid, gauge distance. If technically possible we will get their video embedded on this website next week. David Schieffelin, CEO of 24Eight, has partnered with Blue Highway to develop this PSM technology and concept for civilian healthcare, particularly fall detection AND prevention via gait tracking (aka The Holy Grail), through wearables such as bracelets, belt clips, shirts and insoles. For this observer, this was the ‘wow’ session of the day.

Wrapping up the day were three general session presentations by Mark Bard of Manhattan Research (Analyzing Digital Health by the Numbers), Joe Kvedar, MD of the Center for (Connected Health at Scale) and to close, a panel analyzing these presentations.

Attendance for this two day session was confirmed today at over 1000.

Additional product coverage from today’s meetings to come next week: Alcatel-Lucent/SaskTel, Meridian Health, iGetBetter, more.

*****

CCH’s Achievement Awards for distinguished service to healthcare and commitment to HIT innovation were presented to John Glaser, PhD, VP and CIO of Partners HealthCare System, and Jay Sanders, MD, CEO of the Global Telemedicine Group. Both were panelists during the Symposium.

Click here to go on to read Thursday 22nd’s reports

Fora TeleHealth System – Diabetes

Fora‘s parent company is Taiwanese Taidoc. At MedTrade they were exhibiting their homecare devices, their Telehealth Gateway, and their Diabetes Information Management System. The picture shows the new end-user device, the hub and, on the poster behind, the internet-based data montioring system.

DMT

Korea was well represented at MedTrade, and DMT‘s US arm was exhibiting its video-based telecare system. The picture shows one end of the setup – a set-top-box with built in camera and, on the TV screen, split views or the areas being monitored.

LogicMark

It was good to meet LogicMark‘s CEO Mark Gottleib after having followed the development of the company via press releases on Telecare Aware. LogicMark sells its ‘FreedomAlert’ (no-contract, no-call center ‘programmable 2-way emergency pendant communicator’) in the US via retailers rather than directly to the public. The photo shows the base unit settings that enable the user to choose their preferred dialing sequence and whether or not to call the emergency services, answering one of the initial criticisms raised by a Telecare Aware reader.

Philips’ new medication dispenser

This was spotted on my way past the Philips stand which was concentrating on respiration issues, but had an example of the recently announced cordless phone-based alert system (see Telecare Aware item). The handset can be seen on the right. What caught my eye, though, in the light of the recent discussion about medication dispensing devices, was the huge coffee machine sized medication dispenser by its side. Unfortunately there was no representative of Philips Lifeline present on the stand but their website confirms that the device includes remote monitoring of the dispensing. You may want to watch the video on that page.

Dr Kevin Doughty, an advisor for Centre for Usable Home technology, was the main speaker with an excellent presentation and good solid reasons why there has to be some radical thinking around the services the industry provides.

Dr Stephen Brewster, University of Glasgow, gave an excellent overview of their MATCH Project which is looking at different (quite radical) ways of communicating with computers using ‘earcons, tactons and aromacons’. Brilliant far-reaching stuff.

Unfortunately it went downhill from there on in, with ‘The Man From The Ministry’, Brian Kerr, telling us in no uncertain terms that we were in the risk business and then presenting the 10 or so government bodies and certifications we would need to pass before we could even consider selling product to the ‘institutions’. Ideal motivation for SMEs! David Kelly, the retiring MD of Tunstall who chaired the question session asked if this was why they (Tunstall) were only allowed to sell 40-year-old solutions…at last an admission in public. The answer was a shrug.

When it was suggested by a member of the audience at question time, that ‘it would seem that the only way to make changes in your departments, would require some form of nuclear explosion’, the reply was also a shrug.

One of the consultant speakers, Lynn Blair, pointed out that an aircraft carrier takes a couple of hours to change course (not quite true), so we need to be patient. I wondered which government body she works for!

Best of all was Graham Worsley of the Technology Strategy (Strategy?) Board who has a £50m budget which he wants to squander spend on one really big UK-wide trial of some sort, to be determined. No doubt backing the highly mobile and innovative aircraft carriers such as BT and IBM to develop products and services in this space. At question time it was suggested that such large, well entrenched organisations are about as innovative as Tunstall and that perhaps he should reconsider and use smaller, agile motor torpedo boats (the SMEs) who will adapt their products quickly to address the users’ problems and not try to adapt the users to their products.