‘Before the Ashes Fall’: the story behind the book and the movie in development about dementia

August 25, 2020 | by

Editor’s Note: The author of the post below, David Serafine, is a corporate security professional in the US. He is not like most of our Readers, a professional in healthcare technology or social care. What compelled him to write a novel about a father and son, and a family affected by the onset of Alzheimer’s Disease, is his own family’s story. We deal with dementia as professionals, but it has also touched and affected our family lives, and in many cases, our work lives. 

David reached out to me through a post on LinkedIn and after some discussion, I have decided to share his message with you. He and his production team are now reaching out to people like us to find financing for a film treatment, to be shot in Western New York State. Through the film, they will tell not only a story, but also to use the film to promote education and societal awareness, especially among minority and underserved communities heavily impacted by this disease.

Through our networks and our companies, you may know a funder, or funders, who are interested in backing this cause. More information on the production is attached (Release–PDF). You may contact David at serafinedavid@gmail.com, phone 512.571.0418, or via LinkedIn .

Before the Ashes Fall by David Serafine

I first encountered Dementia in June 2016.  It was my wife’s grandfather, a sturdy and tough as nails Texas farmer, who was diagnosed with Alzheimer’s.   The man’s diagnosis came only a  year removed from tending crops beneath the relentless noon sun while seamlessly conversing with a razor-sharp precision. “And we need to hide his truck keys for good”. The words, stinging with an exactness and finality, didn’t quite measure up.  The man still looked normal.

One year later, I observed half of the same man blankly staring at a birthday cake, not realizing it was his. The celebration carried on around him, with each attendee recalling stories of his life. I stared hard at his face, almost willing a quiver or smile, anything to suggest the words resonated. Nothing moved. Finally, I noticed his jutting collarbones which resembled a cheap wooden hanger. My eyes traced the sharp rise and fall around his shoulders and the blanched fabric which hung from them.

I contemplated whether Alzheimer’s solely left this wake of damage. Or, was it exacerbated by his daughter’s own Frontotemporal Dementia diagnosis, relegating her final days to a Memory Care Facility?  I never knew the answer as two months later, the man succumbed to Alzheimer’s complications.  To this day, his daughter was never told that he died.   That type of message, with a woman in her condition,  could be a potential catalyst for further emotional distress. 

Sometime during that journey, I wrote a fictional novel called ‘Before the Ashes Fall’.   In short, the novel is a race for “Love, Forgiveness, and Redemption” between a father and son beneath the cloud of Alzheimer’s. The process was as equally heartbreaking as cathartic. I mostly bled and cried into pages for a year, completed it, and put it to bed.

However, the book elicited correspondence from Malaysia, Ireland, Brazil, and Chile. The messages always began the same: “I had a (insert family member) die from various forms of Dementia.  Thank you for writing this story”. Two observations became clear over time. First, ‘Dementia’ didn’t stay in lanes, either geographically or demographically.  It was global and touched everyone either directly or indirectly.

Secondly, and arguably the crueler facet, is the insidious nature of Dementia.  In many circumstances, the readers’ initially described  Dementia as a ‘normal’ part of aging.  It wasn’t until an unequivocal tipping point- “my husband left the stovetop gas on’’-that it was no longer ‘normal’. That same moment generated guilt within the de facto caretaker (spouse, daughter, etc.) of what could have been prevented.

I researched the diseases of Dementia -Alzheimer’s is but one diagnosis and it alone will cost over $1 trillion (globally) in 2020 alone.  I also learned life choices and even traumatic events had a dramatic impact on the diseases’ progression.  Those two points are the most critical: we have some control and hope with increased awareness.

In July of 2020,  my book was adapted for film by a multiple award-winning Director. The story and approach are unique, unlike the other Dementia-based films. As we will target 60 global film festivals, three primary goals materialized.

First, and the most unique aspect of the approach, is our desire to facilitate pragmatic and current medical forums.  The engagements will include not only allopathic guidance but more importantly, non-allopathic guidance.  We seek to educate communities on life choices – diet, exercise, early testing before the disease has advanced. There are informed choices we can make that can delay and lessen the impact of Dementia. This is least understood globally.

Secondly, we will use film and outreach to galvanize communities.  A search of Dementia-themed films will yield 2  most recognizable (Still Alice and The Notebook).  Our film will feature a different demographic, one illustrating the ‘absence of lanes’ with the disease.  This will be represented in the cast, crew, and artwork produced by local Dementia patients.

These goals have been welcomed by medical practitioners, podcasters, and Corporate Social Responsibility Executives.  In addition to a strong storyline, we believe film fans will sense a collective ownership of this film during its production and engagement in their communities.   Additionally, it’s supportive and empowering to overcome tragedy alongside others, particularly those who strive for a better future.

Finally, and unique to the film industry, we seek to re-invest 50% of all profits into Dementia-related awareness campaigns.  If funded, we believe “Before the Ashes Fall” has a 3X delivery back into the programs we seek to support.

“Before the Ashes Fall” is a fiscally sponsored film through the Film Collaborative and individual or corporate donations are tax-deductible.   It’s an amazing opportunity to shape the future for current and generations to come, all desiring the same goal: a cure for Alzheimer’s. 

[More information on the production here: PDF]

Will the rise of technology mean the fall of privacy–and what can be done? UK seeks a new National Data Guardian.

August 21, 2020 | by

Can we have data sharing and interoperability while retaining control by individuals on what they want shared? This keeps surfacing as a concern in the US, UK, Europe, and Australia, especially with COVID testing.

In recent news, last week’s acquisition of Ancestry by Blackstone [TTA 13 August] raised questions in minds other than this Editor’s of how a business model based on the value of genomic data to others is going to serve two masters–investors and its customers who simply want to know their genetic profile and disease predispositions, and may not be clear about or confused about how to limit where their data is going, however de-identified. The consolidation of digital health companies, practices, and payers–Teladoc and Livongo, CVS Health and Aetna, and even Village MD and Walgreens–are also dependent on data. Terms you hear are ‘tracking the patient journey’, ‘improving population health’, and a Big ’80s term, ‘synergy’. This does not include all the platforms that are solely about the data and making it more available in the healthcare universe.

A recent HIMSS virtual session, reported in Healthcare Finance, addressed the issue in a soft and jargony way which is easy to dismiss. From one of the five panelists:  

Dr. Alex Cahana, chief medical officer at ConsenSys Health.”And so if we are in essence our data, then any third party that takes that data – with a partial or even complete agreement of consent from my end, and uses it, abuses it or loses it – takes actually a piece of me as a human.”

Dignity-Preserving Technology: Addressing Global Health Disparities in Vulnerable Populations

But then when you dig into it and the further comments, it’s absolutely true. Most data sharing, most of the time, is helpful. Not having to keep track of everything on paper, or being able to store your data digitally, or your primary care practice or radiologist having it and interpretation accessible, makes life easier. The average person tends to block the possibility of misuse, except if it turns around and bites us. So what is the solution? Quite a bit of this discussion was about improving “literacy” which is a Catch-22 of vulnerability– ‘lacking skill and ability’ to understand how their data is being used versus ‘the system’ actually creating these vulnerable populations. But when the priority, from the government on to private payers, is ‘value-based care’ and saving money, how does this prevent ‘nefarious use’ of sharing data and identifying de-identified data for which you, the vulnerable, have given consent, to that end? 

It’s exhausting. Why avoid the problem in the first place? Having observed the uses and misuses of genomics data, this Editor will harp on again that we should have a Genomic Data Bill of Rights [TTA 29 Aug 18] for consumers to be fully transparent on where their data is going, how it is being used, and to easily keep their data private without jumping through a ridiculous number of hoops. This could be expandable to all health data. While I’d prefer this to be enforced by private entities, I don’t see it having a chance. In the US, we have HIPAA which is enforced by HHS’ Office of Civil Rights (OCR), which also watchdogs and fines for internal data breaches. Data privacy is also a problem of international scope, what with data hacking coming from state-sponsored entities in China and North Korea, as well as Eastern European pirates.

Thus it is encouraging that the UK’s Department of Health and Social Care is seeking a new national data guardian (NDG) to figure out how to safeguard patient data, based on the December 2018 Act. This replaces Dame Fiona Caldicott who was the first NDG starting in 2014 well before the Act. The specs for the job in Public Appointments are here. You’ll be paid £45,000 per annum, for a 2-3 day per week, primarily working remote with some travel to Leeds and London. (But if you’d like it, apply quickly–it closes 3 Sept!). It’s not full time, which is slightly dismaying given the situation’s growing importance. The HealthcareITNews article has a HIMSS interview video with Dame Fiona discussing the role of trust in this process starting with the clinician, and why the Care.data program was scrapped. Of related interest is Public Health England’s inter-mortem of lessons learned in data management from COVID-19, while reportedly Secretary Matt Hancock is replacing it with a new agency with a sole focus on health protection from pandemics. Hmmmmm…..HealthcareITNews.

CB Insights rounds up a 2020 Digital Health Top 150

August 21, 2020 | by

Actually this Editor added the ‘Top’ to the Digital Health 150, as it emulates the Top 40 or Top 100 when Music Radio ruled, but Billboard or Melody Maker would hardly recognize the format. CB Insights evaluates the promising, primarily US digital health startups from its research. It’s their second Digital Health 150 and like last year’s, it organizes the aspiring hot companies into groups and sub-groups. Many companies are repeats, though the categories are different than last year’s, reflecting a change in what is considered ‘hot’:

  • Administrative automation and digitization
  • Disease management and therapeutics
  • Screening and diagnostics
  • Drug discovery
  • Clinical trials
  • Clinical intelligence and enablement
  • Online-offline care
    • Primary and urgent care
    • Specialty care
  • Pharma supply chain
  • Health plans and benefit management
  • Real-world evidence (RWE)
  • Virtual care delivery

Telehealth is hot (of course) in the Online-Offline and Virtual Care categories. CB Insights singles out in telemedicine Heartbeat Health, Doctor On Demand, and Livi (UK) (Kry in the Nordics), while in remote monitoring they named Oura (a ring), Element Science (a cardiac wearable), and Dental Monitoring (a dental treatment/care management platform different than The Teledentists). We also noted Parsley Health’s NY clinics and VillageMD, a Chicago-based primary care provider group which just inked a major deal with Walgreens Boots [TTA 9 July]. Early-stage companies do well when they have big partnerships. 

CB Insights also provided a compare/contrast summary against the 2019 Digital Health list [TTA 10 Oct 19]:

  • Unicorns: 17 of the 2019 Digital Health 150 (11%) have remained or since become unicorns with a $1B+ valuation
  • Exits: 2 companies have gone public and 2 have been acquired
  • Deals, funding, and mega-rounds:  raised over $4bn across 70+ deals, including 14 mega-rounds ($100 million+ investments), as of 10 August

They do not mention that one, Proteus Digital Health, one of those unicorns, went bankrupt this year and was sold on Wednesday for its IP for $15 million.

2020 Digital Health 150

News Roundup of acquisitions, funding: Health Catalyst-Vitalware, Change Healthcare-Nucleus.io, Medtronic-Companion Medical, Cecelia Health; Proteus Health sale contested, but sold (updated 20 Aug)

August 19, 2020 | by

Spin that lasso, round up the dogies, because we’re going to the rodeo! Data and analytics company Health Catalyst is acquiring Vitalware, which provides ‘chargemaster’ revenue workflow optimization and analytics SaaS technology to healthcare organizations. The deal is expected to come in at about $120 million with a $30 million earnout, funded by stock and cash, and close later this year.  Health Catalyst is on a buying tear, having acquired Healthfinch, a prescription refill management and visit planning platform to close care gaps, for $40 million in cash and shares in July. Health Catalyst went public in July 2019 and is trading at a market cap of nearly $1.3 bn (Unicorn Status isn’t what it used to be!). They’ve also inked a partnership deal with Northwell Health, the largest provider in New York State, to expand Northwell’s enterprise data and analytics capabilities with EHR integration. Health Catalyst releases on Vitalware, Healthfinch, and Northwell Health. Also FierceHealthcare.

Updated. Another major 2019 IPO, Change Healthcare, is acquiring Nucleus.io, a  cloud-based imaging and workflow platform, from San Diego-based developer NucleusHealth. This is a significant move, fitting into their Enterprise Imaging area and accelerating their implementation of a complete cloud-based, end-to-end solution within their Enterprise Imaging Network. Nucleus.io serves over 7,500 organizations and will add to Change Healthcare’s imaging customer base. Change is acquiring the Nucleus.io technology and team. NucleusHealth will continue to operate under its own name; they also operate a teleradiology platform, StatRad. Terms were not disclosed. Release. HealthcareITNews (Updated to clarify that the Change Healthcare acquisition is the Nucleus.io technology and not NucleusHealth the company)

Medtronic, which insiders dub the 9,000 lb. elephant of medical devices and remote patient management, has been quiet of late, but that doesn’t mean the elephant isn’t moving and sitting where it wants to sit. Continuing to build in diabetes care, they have just acquired Companion Medical, developer and marketer of the InPen, a insulin pen with a companion app, which was FDA cleared in 2016 and remains the only ‘smart insulin pen’ system. Eli Lilly and K2 Health Ventures were Companion’s major funders. Closing is expected within two months. Terms were not disclosed. Medtronic is clearly constructing a closed-loop diabetes management system through acquisitions such as Companion as well as diet-management startups Klue and Nutrino.  Release, Mobihealthnews. 

And in diabetes management, Cecelia Health (the renamed Fit4D), scored a healthy $13 million in Series B funding. Rittenhouse Ventures and Endo Investors co-led the round, with participants Boston Millennia Partners, SustainVC, G100 Capital and others, for a total of $22.4 million in funding (Crunchbase). Fit4D developed clinical virtual coaching with certified diabetes educators, and partners with health plans, self-insured employers, medical device and pharma companies. The funding will go to developing a first-in-kind ‘Virtual Clinic’ for diabetes, which will offer continuous glucose monitoring (CGM) training, education on medication adherence and lifestyle and behavior change, mental health screening and counseling. These will be then supported by algorithms recommending necessary dosage and titration changes that will be reviewed and approved by Cecelia Health’s Certified Diabetes Care and Education Specialists (CDCES) and endocrinologists.  Release, Mobihealthnews  A few days before the funding, Cecelia announced their participation with the Jaeb Center for Health Research Foundation in Tampa in their research to develop a virtual specialty clinic model, funded by a $5 million grant from the Helmsley Foundation. Release

Updated for Proteus sale. The troubled ‘smart pill’ pioneering company and one-time unicorn Proteus Digital Health, which filed for Chapter 11 (reorganization) bankruptcy on 16 June [TTA 17 June], planned to exit it with a $15 million ‘stalking horse’ deal with Otsuka Pharmaceuticals in advance of a bankruptcy auction. ‘Stalking horse’ deals set a floor at an auction and essentially set a minimum price. Investors, including Novartis and two Hong Kong funds, contested that fire sale earlier this week, claiming the sale to Otsuka was undervalued and if the IP and other assets were divided, a higher price would be obtained. One could understand their feelings, as Proteus raised nearly $500 million from them which essentially has vanished.

On Wednesday 19 August, the US Bankruptcy Court for the District of Delaware approved the sale to Otsuka, which was filed on Thursday. A key part of the hearings was Proteus’ investment banker, Raymond James & Associates, fruitlessly reaching out to over 240 potential buyers. What scared them off was Proteus’ burn rate–between $2 million and $2.5 million a month–with no clear prospect of positive cash flow or profitability (the latter quite elusive even in public companies). The purchase by Otsuka, which was deemed fair in the ruling with the opportunity for others to provide higher offers, covers information technology assets, intellectual property, and equipment, including equipment used to design and manufacture wearable sensors. Related court documents.

Otsuka was Proteus’ last major partnership for Abilify MyCite that ended suddenly in January. From the case documents schedule, this will be wrapped by end of September. FierceHealthcare 12 Aug, 27 July    STAT+ (paywalled) 20 Aug, HealthcareITNews

Medical education going digital, virtual, and virtual reality (US/UK)

August 19, 2020 | by

How do you educate medical and nursing students when class is no longer in session? What about clinical training when hospitals are restricted due to COVID? It’s no surprise that remote learning and pre-recorded classes plus active lecturer-student discussions on Zoom (or more secure video meeting platforms) in the spring filled the gap of the first two years of med school, which are primarily tied to class instruction. For incoming and resuming classes, most have a mix of online and in-person classes, depending on school location. Nursing schools faced and resolved similar situations.

But what happens in the second two years, when lectures mix with in-person clinical learning? Most schools pulled students from clinical work in the spring, but some, like Mount Sinai in New York, continued. The University of Houston has developed some other approaches. Their medical school, starting this year, was co-founded with insurance payer Humana as part of the Humana Integrated Health Systems Science Institute. Nursing school students who would typically join nurses on house calls shadowed these nurses on virtual visits as part of their clinical training. 

The Association of American Medical Colleges (AAMC) is also looking at ways to integrate telehealth into medical school curricula, and is publishing a guide this fall detailing core competencies around telemedicine.  FierceHealthcare

Virtual reality (VR) is providing a more interactive training environment for clinicians with realistic scenarios and feedback. Computer simulations have been common for years in specialty surgery and diagnostics. With reductions in pricing on headsets like the Oculus Rift and Quest, several companies are introducing a different kind of virtual visit, one in a realistic clinic setting, simulating a pressured situation. These come complete with interaction between doctors, nurses, and other clinicians, can be ‘multi-player’, and provide performance analysis/feedback. This Editor noted Oxford Medical Simulation’s work with NHS England in Wessex on treatment for diabetic emergencies [News Roundup, TTA 3 Apr 19] and another pilot at OxSTaR (Oxford Simulation, Teaching and Research) center [News Roundup, TTA 8 Aug 19]. In surgery, Southern Methodist University (which has a leading graduate school for video game design), Virti, and Medical Realities (the latter two UK firms) have pioneered training in US, UK, and Europe plus specialized trainings for surgeons in Africa replicating conditions faced in ORs there. The trainings not only teach procedure, but reduce surgeon and fellow clinician stress. Digital Trends

News roundup: Ancestry sells 75% to Blackstone, Cornwall NHS partners with Tunstall, most dangerous health IT trends, Slovenski departs from Walmart Health

August 13, 2020 | by

Ancestry sells 75 percent of the genealogy/genetics company to Blackstone for $4.7 bn. The acquisition by the private equity company buys out other equity holders: Silver Lake, GIC, Spectrum Equity, Permira, and others. Ancestry’s business combines their genealogy database with consumer genomics for both heritage and health. The Blackstone release notes that their goals in the acquisition are to expand data, functionality, and product development across the Ancestry platform as part of their investment in growth businesses. If an acquisition cost of $4.7 bn seems high, Ancestry’s revenue is cited as $1 bn annually.

Once blazingly hot, both Ancestry and 23andMe saw their consumer businesses crater late last year, with layoffs in January and February. It’s an example of a quickly saturated market (one test and you’re done) flogged by annoying TV commercials over the holidays [TTA 13 Feb]. Where the profit is, of course, is not in consumer tests but in selling the genomic data to other companies, something which the market leader, 23andMe, realized early on with half-ownership by GSK ($300 million, a real bargain). 23andMe is also intensively marketing as a premium subscription service updates on health information derived from member testing. Ancestry has followed, but reportedly has not been as proactive in linking genetic information to health outcomes. STAT

 This Editor noted back in August 2018 that it was long past time for a Genomic Data Bill of Rights for consumers to be fully transparent on where their data is going, how it is being used, and to easily keep their data private without jumping through a ridiculous number of hoops. It’s a conclusion now being reached by various privacy groups according to MedCityNews. Also noted is that Ancestry, in its complex and long privacy policy, can use your “personal information to market new products from the company or its business partners, but says it will not share users’ genetic information with insurers, employers or third-party marketers without their express consent.” But when your 75 percent owner has real estate and other healthcare holdings, can you trust them?

Cornwall Partnership NHS Foundation Trust partnered with Tunstall Healthcare UK on a 26-week support program during the pandemic for young people 11+ with a range of eating disorders. The patient group used the myMobile app and the ICP triagemanager software to send in weekly reports on their vital signs and answer symptom-related questions, which are tracked over time via a secure portal to monitor progress. The myMobile app has parameters set for individual patients, where readings outside them generate a system alert that is sent to clinicians. The program was able to ascertain that 32 patients were at high risk and have been referred. Cornwall/Tunstall white paper, ATToday.co.uk

As if COVID Fear weren’t bad enough, now we have to be frightened of Dangerous IT Trends. Becker’s Health IT interviewed eight healthcare executives and came up with a list of what keeps them up at night:

  • The sluggish rate at which healthcare systems embrace new technology
  • We won’t be going back to the pre-pandemic normal and how healthcare deals with that
  • Overlooking data security and medical device vulnerabilities
  • Cutting IT staff and budgets without acknowledging the consequences
  • The consequences of hastily moving workers remote and securing their devices

All of the above are not new, and it’s rather shocking that they haven’t been addressed.

And in Comings and Goings, we have a Notable Going. Sean Slovenski, who for the past two years has been heading up Walmart US’ Health and Wellness initiatives, departed the company last week with a replacement to be named in the coming weeks. Mr. Slovenski had been heading up a variety of healthcare initiatives, including in-store primary and dental care clinics which have opened up in four Arkansas and Georgia locations with an additional eight planned plus Florida. Walmart also opened up 100 COVID testing locations in store parking lots. His efforts were acknowledged in Walmart’s departure statement to staff. Mr. Slovenski “and his team have successfully stood up the strategy we hired him to create,” Walmart’s CEO John Furner said in a memo to staff. Walmart has also laid off over 1,000 corporate employees in a recent restructuring. Mr. Slovenski is most noted in digital health circles as CEO of Care Innovations for 2 1/2 years during the Intel-GE ownership. He was also with Healthways-ShareCare and Humana. Walmart is up against a long list of heavyweight challengers in retail health, including Amazon, CVS Aetna, and Walgreens–and may be deciding that an independent run is not worth it.

Propel@YH digital health accelerator open now for applications to 24 September (UK)

August 12, 2020 | by

The Yorkshire & Humber AHSN (Academic Health Science Networks) returns for a second year with Propel@YH, their regional digital health accelerator program.

We will cut to the chase and the key dates: 

Applications Open – Thursday 6th Aug 09:00
Webinar – 2nd September 13:00 GMT
Applications Close – Thursday 24th September 23:59
Assessment Starts – Monday 28th September
Assessment day – Friday 9th October
Cohort Launch – Friday 16th October
Programme commences – Monday 26th October

While Propel is regional, the program’s objective is to attract global applicants who are interested in solutions for the Yorkshire & Humber area. Backing it is the University of Leeds and the Leeds City Council. The accelerator will provide advisory, guidance, and supportive services, enabling digital health solutions to accelerate their growth and market presence in the longer term. An example is masterclasses on how to build clinical safety cases, develop evidence-based proposals, and understanding procurement in the NHS.

What companies accepted for the 2020 cohort will engage with:

  • How the NHS works – an introduction to the health system in England
  • Clinical safety by design – how to design in clinical safety throughout the digital development process
  • Making the grade – how to develop your digital product to meet the requirements of the NHS Digital Tools library
  • Digital by design – how to implement a human-centred design approach to developing digital products and services
  • NASSS Framework assessment clinic
  • Building the evidence base – how to develop a benefits realisation case and generate evidence that really counts
  • Understanding procurement in the NHS – find out from the experts about how procurement works in the NHS
  • Cohort-defined learning clinics

For more information on the program, content providers, partners, and applying–start here. Download application here. 

Doro AB acquires Eldercare (UK) Limited, creating #2 in telecare

August 11, 2020 | by

Healthcare acquisitions are not bypassing the UK and Europe. Today (11 Aug), Sweden’s Doro announced its acquisition of Eldercare (UK) Limited of Lancashire. Terms were announced as cash approximately UK £2.2 million on cash and debt free basis. It is effective immediately and Eldercare’s revenue will be consolidated into Doro’s from 11 August.

Eldercare adds 50,000 connections to the Doro portfolio, bringing them into second place in UK telecare with over 230,000 connections. Doro’s earlier UK acquisitions were in 2019, Invicta Telecare, parent of Centra Pulse and Connect, from Clarion Housing in the southeast [TTA 19 Sept 19] and in 2018, Welbeing in Eastbourne [7 June 18].

Doro’s CEO notes that Eldercare adds to their position in the North of England, important as telecare is a localized and council-focused business in the UK. With over 100 employees, Eldercare is also a Care Quality Commission (CQC) registered business and provides domiciliary care services. Eldercare’s CEO Chris Hopkinson is quoted in the release: “When we decided the time was right to step-change the development of our telecare services, we knew we needed an excellent partner. We chose Doro because we were impressed by their record of providing quality products and experience of delivering digital telecare solutions. They have shown their commitment to continue to improve and innovate the services we offer to our customers, as well as facilitating the transition to digital telecare in the UK.” 

Eldercare’s last independent financial report was for the financial year 2018/19, with revenue of UK £4.6 million (approximately SEK 52 million). 

Doro in many of its countries is best known for senior-friendly, easy to use wireless, mobile, and smart phones with add ons such as PERS apps. Eldercare, Invicta, and Welbeing are part of Doro Care, which markets social alarms and other home devices for the safety of older adults such as chair and epilepsy sensors. Hat tip to one of our faithful Readers.

Drug discounter GoodRx plans US IPO; Ginger mental health coaching raises $50 million

August 11, 2020 | by

The bubble bath got soapier with more IPOs and big raises on tap. 

GoodRx, the relentlessly advertised prescription discount scheme with spokespeople Martin Sheen and son Charlie, has filed initial paperwork with the US Securities and Exchange Commission (SEC) for a potential initial public offering (IPO). This has been in the rumor mill for a while. Timing would be about 4th Quarter or early in 2021, according to Reuters.

It may at least a partial exit for Sand Road PE giant Silver Lake Partners, which took a one-third interest in GoodRx in August 2018, creating an estimated value at $2.8bn. CNBC  Both their growth since then and key hires have indicated preparation for going public. According to MedCityNews, their revenue is up by 55 percent since 2018 and they now employ 350 people. As mentioned above, they advertise heavily on TV with celebrity endorsers. In June, two IPO-experienced executives joined the company (release): new president Bansi Nagji, McKesson’s former chief strategy officer who was on Change Healthcare’s board during its IPO; and CFO Karsten Voermann from acquisition company Mercer Advisors and who led Mercury Payment Systems through its 2014 IPO.

Ginger, formally known as Ginger.io, raised $50 million in Series D funding. Lead investors are Advance Venture Partners and Bessemer Venture Partners, with participation from Cigna Ventures, Kaiser Permanente Ventures, and LinkedIn Executive Chairman Jeff Weiner. Ginger provides on-demand mental health coaching as part of employee benefits within the US. Their release claims 200 companies, health plans Optum Behavioral Health, Anthem California, and Aetna Resources for Living, and tripled revenue in the past year. According to Crunchbase, this is their ninth funding round with a raise total of $120 million. Mobihealthnews

Reflections in a Gimlet Eye: further skeptical thoughts on the Teladoc acquisition of Livongo (updated)

August 11, 2020 | by

Gimlet EyePerhaps it’s Reflections in a Gimlet Eye, but this Editor remains bemused and slightly dyspeptic about the acquisition of ‘health signals’ remote patient monitoring management platform Livongo by telehealth giant Teladoc.

Here’s the latest, courtesy of Credit Suisse equity research analyst Jailendra Singh on deal rationale and the potential synergies, based on his Q&A with Teladoc and Livongo management (link here):

  • Livongo: “The company was not for sale, and LVGO did not view the transaction with TDOC as a sale. Instead, management views the deal as a merger of the two leaders in virtual care.” 
  • It had nothing to do with pressure from CVS and UnitedHealth Group (UNH). 
  • There are major cross-selling opportunities, starting with an overlap of 25 percent of their clients. There are also opportunities with the InTouch Health client base in acute care, Aetna plus UNH on the health plan side, and employer administrative services only (ASO) plans. This is part of the calculation of synergies totaling $500 million in 2025 which they believe are conservative given the math.
  • They are also seeking to approach their client base before the closing through a reseller agreement, as Teladoc was able to do with InTouch.

Mr. Singh’s analysis is conservative and sober from a strictly financial viewpoint. His two-page analysis is, as usual, worth the read. 

But then we stumble across one particularly helium-charged claim. It’s projected that Teladoc and Livongo would have a combined company market cap of $38 bn, whereas the pre-pandemic value of the companies was $8 bn. (Steve Kraus, Partner at Bessemer Venture Partners, now on the board of Ginger, as quoted in Forbes). That is optimistic, considering that patient primary care virtual visits have flattened down to about 7.4 percent of visits as of June (Commonwealth Fund/Harvard/Phreesia study). It’s assuming a great deal that people will continue to shy away from in-person care going forward. Perhaps to a degree this will, as in-person fear is only starting to flatten, but not everything can be done virtually, even RPM. Telehealth and RPM also present challenges for practices in value-based care models, in workflows, and even with the liberalization of Medicare reimbursements, financially.

Livongo’s great asset, which was understandably compelling for Teladoc, is chronic condition management, RPM, and all that patient data, which can be broadened past their diabetes base (with a small one in behavioral health courtesy of their myStrength acquisition) into other chronic conditions which was Livongo’s strategy anyway. To be determined is how compelling this will be for Teladoc’s customer base and for new customers, particularly if the economic environment is constrained and health plans don’t get on board. 

So why is Mr. Market not mad about this ‘merger’? TDOC has taken a spill since its (adjusted) close on 4 August at $249, and is trading below $200 at $193. LVGO took a lesser hit, from $144 to $121. Another Bessemer Venture Partners investor, Morgan Cheatham, in the Forbes article linked above, was quoted that Livongo had clear market leadership in the employer and health plan market, then expressed surprise at why Livongo agreed to be acquired: “The company had a real shot at becoming a $100 billion business by running the ‘digital hospital’ playbook. In some ways, the acquisition feels premature.” Teladoc’s COO David Sides promised that the combined company will aid practices in the transition from hospital to home care, touting the consumer focus of both companies. (Have they consulted already burdened and strained providers how this can be made easier for them and fit into value-based care models as well as their financials?) But they may have to make more acquisitions to facilitate this. So $18.5 billion plus $1 bn for InTouch isn’t enough to get the job done?

Is it synergy, the wave of the future, or an overloaded Christmas Tree of features, not benefits?

Reminder: to date, neither company has been profitable.

So, what does this mean for other digital health companies? Initially, it’s quite positive that Teladoc could round up nearly $20bn in six months. John Halamka MD, a well-known digital health visionary now at Mayo Clinic, sees it as a bridge to the digital health ecosystem including other companies. A contrarian view was expressed by Mr. Cheatham.  Teladoc-Livongo is a challenge for other digital health companies in that they won’t, and cannot, be Teladocs and Livongos–in other words, an unrealistically high bar for them. “Why can’t Telavongo build this?”

Finally, a personal and slightly jaundiced view from this Editor. Let’s take a good hard look at the Human Factors that make companies go. This is an acquisition by Teladoc of smaller Livongo, despite the merger statements. Employees in both companies are wondering who will go, who will stay, who they will report to if they stay, and where they will be. They have about four to six months to mull what their future might look like at a tough economic time. This will — not may, will–have an effect on operations and attitudes, especially at Livongo.

There are some doubleplus ungood signs that make the assertion that this is a “merger” of companies questionable:

  • Jennifer Schneider, MD, president of Livongo, has stated that both companies are currently hiring and don’t plan layoffs as a result of the merger (Becker’s Health IT). Blanket statements like this are usually made at the start to assure employees. Anyone who has been through a merger knows there are overlapping areas such as HR, marketing, and financial. There are only so many chairs at the organizational table especially at the director and above level. The happy talk doesn’t change the reality that not everyone will be given the option to stay.
  • Statements on similar cultures notwithstanding, the fact is that both companies have different cultures and experiences because they have radically different histories and personalities running them. This Editor would suspect that Livongo employees, having come up in a young and smaller company, in an intense entrepreneurial environment, with employees who were among the first 50 or 100, have a great identification with Livongo and pride in their success.
  • Not one Livongo senior executive was named publicly as taking a new operational role in the merged entity. (Board seats don’t count. But then again, they will be walking away with a major payday, reputed to be in the hundreds of millions for the top executives. What they will do with their future is a major unknown.)
  • The HQ will be in Purchase. Most Livongo employees are in California.
  • The company will be named Teladoc and will not be renamed. That says a lot, even though industry wags are calling it Telavongo and other names.

One would hope that both companies make every effort to reorganize the company staffs in a way where layoffs are minimal, those who are packaged out are treated generously, but better, valued employees from both companies are retained and incentivized to stay–sooner rather than in 4th quarter–in a fair and unbiased evaluative process in how they support their businesses presently and going forward as part of the combined companies future. But this is not typically the case.

One would also hope that the clients and individuals who pay the bills were told, timed with the public announcement, that this was happening and what it means for them. Leaving them to read the announcement online is usually what happens. It’s not automatic, and I’ve seen this treated as an afterthought in both large companies and small, with line of business folks scrambling to put together customer messages, and delayed in getting them approved as after all they have to go through both corporate and investor communications. This is typically the case, as communications cease to be a priority at the market/LOB level when the SEC or DOJ are involved.

Reminder: the Human Factors will fly this aircraft–or auger it in. 

Agree? Disagree? Comments welcomed.  TTA’s earlier ‘skeptical take’ commentary here.

More consolidation: BioTelemetry acquires population health platform from Envolve/Centene, inks agreement with Boston Scientific

August 6, 2020 | by

BioTelemetry , a RPM company in the cardiac monitoring, population health management, and clinical trials research, quietly announced last week two agreements that once again confirm the consolidation of now the remote patient monitoring market:

  • The acquisition of the On.Demand remote patient monitoring (RPM) and coaching platform, formerly owned and operated by Envolve People Care, Inc., a Centene Corporation subsidiary. The population health management platform contains real-time monitoring of biometric data with cellular- and web-based technology (including Alexa), proactive and reactive health coaching, population health reporting, and customizable interventions. While acquisition cost was not disclosed, BioTelemetry retains through a strategic partnership agreement Envolve and its base with Centene health plan members for diabetes RPM for the remainder of 2020. BioTelemetry is also free to pursue business with other health plans. Release.
  • BioTelemetry will also be a sales agent in the United States for the Boston Scientific LUX-Dx Insertable Cardiac Monitor (ICM) System. Release.

If you go back to 1994, up to 2013, BioTelemetry was CardioNet and one of the Ur-Companies in the RPM space. They went public in 2015 on Nasdaq, and have quietly made many acquisitions both before and after the IPO. Their 2nd Quarter results were $99 million in revenue; operations were profitable, despite a downturn in revenues from the pandemic and beat their estimates (Zacks). Unlike Teladoc and Livongo, their shares have been solidly up since end of July and they’re rated a ‘hold’. Nothing flashy, but solid work.

TechForce 19 follow up: Alcuris’ results on testing Memo Hub (UK)

August 6, 2020 | by

Often this Editor has been frustrated with lack of interesting follow up to these government initiatives to share with our Readers. Fortunately, Adrian Scaife of Alcuris, has stayed in touch, first on the experience of being a participant, and this week to provide their findings on their tested solution. From the release and the attached white paper, their results in testing the Activities of Daily Living (ADL) Memo service were as follows:

• Positive reassurance for families with the majority creating daily reassurance alerts and 40% creating alerts for events that worry them.
• 80% positive feedback from Memo Hub® users, with the remaining 20% neutral.
• An increase in early preventative interventions by families driven by new insight.
• 40% of care plans provided by Social Care amended due to the insight provided by the Memo service. Care plan size both increased and decreased, the common factor being a better-quality plan with a closer fit to user needs.

The study did not test other features in the Memo Hub suite, such as smart automated alerts, the alarm call safety net, and carer logging.

Alcuris’ press release and Executive Summary are available here. For a full report, email info@alcuris.co.uk

We invite other finalists to send us follow up on their Tech Force 19 studies and experience.

An admittedly skeptical take on the $18.5 billion Teladoc acquisition of Livongo (updated for additional analysis)

August 6, 2020 | by

Gimlet EyeIs it time to call back The Gimlet Eye from her peaceful Remote Pacific Island? Shock acquisitions like Wednesday’s news that Teladoc is buying ‘applied health signals’ platform developer Livongo may compel this Editor to Send a Message by Carrier Seagull. 

Most of the articles (listed at the bottom) list the facts as Teladoc listed them in their announcement. We’ll recap ‘just the facts’ here, like Joe Friday of ‘Dragnet’ fame:  

  • The merged company will be called Teladoc and be headquartered in Purchase, NY. There is no mention of what will happen to operations and staff currently at Livongo’s Mountain View California HQ. 
  • The value of the acquisition is estimated at $18.5 bn, based on the value of Teladoc’s shares on 4 August. As both are public companies (Livongo IPO’d 25 July 2019, barely a year ago), each share of Livongo will be exchanged for 0.5920x shares of Teladoc plus cash consideration of $11.33 for each Livongo share. When completed, existing Teladoc shareholders will own 58 percent of the company and Livongo shareholders 42 percent. 
  • Closing is stated as expected to be in 4th Quarter 2020
  • Expected 2020 pro forma revenue is expected to be approximately $1.3 billion, representing year over year pro forma growth of 85 percent.

The combination of the two is, this Editor admits, a powerhouse and quite advantageous for both. It is also another sign that digital health is both contracting and recombining. Teladoc has over 70 million users in the US alone for telemedicine services and operates in 175 countries. Livongo is much smaller, with 410,000 diabetes users (up over 113 percent) and over 1,300 clients. They reported 2nd Q results on Tuesday with a revenue lift of 119 percent to $91.9 million but with a net loss of $1.6 million. 

What makes Livongo worth $18.5 bn for Teladoc? Livongo has made a major name (to be discarded, apparently) in first, diabetes management, but has broadened it into a category it calls ‘Applied Health Signals’. Most of us would call it chronic condition management using a combination of vital signs monitoring, patient data sets, and information from its health coaches to make recommendations and effect behavior change. Perhaps we should call it their ‘secret sauce’. For Teladoc, Livongo extends their virtual care services and provider network with a data-driven health management company not dependent on virtual visits, and integrates the virtual visit with Livongo’s coaching. It also puts Teladoc miles ahead of competition: soon-to-IPO Amwell, Doctor on Demand ($75 million Series D, partnerships with Walmart and Humana), MDLive, and ‘blank check’ SOC Telehealth. For Livongo’s main competitor in the diabetes area, Omada Health, it puts Omada certainly in a less competitive spot, or makes it attractive as an acquisition target.

It is also a huge bet that given the huge boost given by the COVID pandemic, the trend towards remote, consumer healthcare and management is unstoppable. Their projection is (from the release): expected 2020 pro forma revenue of approximately $1.3 billion, representing year over year pro forma growth of 85 percent; in year 2, revenue synergies of $100 million, reaching $500 million on a run rate basis by 2025. 

Taking a look at this acquisition between the press release and press coverage lines:

  • The market same day responded poorly to this acquisition. Teladoc was off nearly 19 percent, Livongo off 11 percent. (Shares typically recover next day in this pattern.) Livongo had, as mentioned, recently IPO’d and was experiencing excellent growth compared to Teladoc which was boosted by the pandemic lockdown. This Editor also recalls Teladoc’s financial difficulties in late 2018 with the resignation of its COO/CFO on insider trading and #MeToo charges.
  • The projected closing is fast for a merger of this size–five months.
    • Teladoc does business in the Medicare (Federal) and Medicaid (state) segments. It would surprise this Editor if the acquisition does not require review on the Federal (CMS, DOJ) and state health insurance levels, in addition to the SEC.
    • Merging the two organizations operationally and experiencing all those synergies is not done quickly, and cannot officially happen until after the closing. A lot is done formally behind the scenes as permitted, which has the effect of hitting the rest of the company like a hammer.
  • Unusually, the release does not advise on what Livongo senior executives, including Livongo founder Glen Tullman and CEO Zane Burke, will be coming over to Teladoc. The only sharing announced will be on the Board of Directors. It’s quite an exit for the senior Livongo staff.
  • Both have grown through acquisition. These typically present small to large organizational problems in merging the operations of these companies yet another time into yet another structure. There’s also always some level of client discomfiture in these mergers as they are also the last ones to know.
    • Livongo bought myStrength in 2019, RetroFit in 2018, and Diabeto in 2017. 
    • Teladoc just closed on 1 August its acquisition of far smaller, specialized hospital/health system telehealth provider InTouch Health. Originally a bargain (in retrospect) at $600 million in $150M cash and 4.6 million shares of TDOC stock, after 1 July’s closing, due to the rise in Teladoc’s stock, the cost ballooned to well over $1bn.
  • Neither company has ever been profitable. 

Your Editor can speak personally and recently to the wrench in the works that acquisitions/mergers of this size present to both organizations. Livongo is a relatively young and entrepreneurial organization in California with about 700 employees, compared to Teladoc’s approximately 2,000 or more internationally. Their communications and persona stress strong mission-driven qualities. On both sides, but especially on the acquired company side, people have to do their short and long term work amid the uncertainty of what this will mean to them. Senior management is distracted in endless meetings on what the merged organization will look like–departments, where will they be, who stays, who is packaged out, and when. Especially when the press releases make a point of compatible cultures, on the contrary, you may be assured that the cultures are very different. The bottom line: companies do not achieve $60 million in cost synergies without interrupting the careers of more than a few of their employees.

Another delicate area is Livongo’s client base, both individual and enterprise. How they are being communicated with is not necessarily skillful and reassuring. Often this part is delayed because the people who do this in the field aren’t prepared.

One has to admire Teladoc, almost without needing a breath, coming up with $18.5 billion quite that quickly from their financing partners after the InTouch acquisition. The growth claimed for the combined organization is extremely aggressive, on top of already aggressive projections for them separately. It’s 18x 2021 enterprise value to sales (EV/S) targets. The premium paid on the Livongo shares is also stunning: $159 per share including $550 million in convertible debt.  If patients start to return to offices and urgent care, Teladoc may have trouble meeting its aggressive goals factored into both share prices, as Seeking Alpha will explain.

Editor’s final comment: In the early stage of her marketing career, this Editor had a seat on the sidelines to much the same happening in the post-deregulation airline business–debt, buyouts, LBOs, and huge financings. Then there is the morning after when it’s all sorted out.

Wednesday’s coverage: TechCrunch, Investors Business Daily, STATNews, mHealth Intelligence, FierceHealthcare, MotleyFool.com

Joint announcement website    Investor Presentation    Hat tip to an industry observer Reader for assistance with the financial analysis.

For a follow-up analysis (with apologies to Carson McCullers): Reflections in a Gimlet Eye: further skeptical thoughts on the Teladoc acquisition of Livongo

SOC Telemed will go public in unusual ‘blank check’ acquisition

August 4, 2020 | by

Acute care telemedicine developer/provider SOC Telemed, formerly Specialists On Call, will be going public in an interesting maneuver called a ‘blank check’ acquisition. They are acquiring an already publicly-traded company, Healthcare Merger Corporation (HCMC) (NASDAQ: HCCO). HCMC is a special purpose acquisition company (SPAC) that had its own assets of $250 million of cash from a December 2019 IPO. A group of institutional investors, including funds and accounts managed by BlackRock Inc., Baron Capital Group, and ClearBridge Investments, have committed to a private additional investment of $165 million in common stock when the deal closes.  HCMC will disappear and the company will trade as SOC Telemed. The companies estimate the combined value to be about $720 million. 

The combination of the two companies allows SOC Telemed to go public fairly quickly without the usual routine and steeper climb of an IPO by acquiring a purpose-built public company. Given that telemedicine is hot, but markets are post-COVID volatile, it’s a smart move that others (Hims) are already rumored to be following.

According to the release, HCMC will file a registration statement (which will contain a joint proxy statement/consent solicitation statement/prospectus) with the SEC in connection with the transaction as part of their Form 8-K. The closing is expected to be in 4th Quarter 2020, subject to the usual approval and timing procedures present in public company acquisitions.

SOC Telemed is also an interesting company in that it specializes in telemedicine for the acute care market, supplying virtual consults in specialty areas such as neurology, psychiatry, and ICU. It claims to be the largest national telemedicine provider to hospitals, health systems, value-based care organizations, post-acute care, and physician networks. SOC provides services to 847 facilities including 543 acute care hospitals in 47 states, including 19 of the 25 largest U.S. health systems. It is also the largest provider of acute teleneurology and telepsychiatry. The company has delivered over one million acute care consultations. Recent acquisitions include behavioral health telemedicine company JSA in 2018 and NeuroCall in 2017.

From the release, some details about how the acquisition will work:

  • SOC’s current management and equity holders, including Warburg Pincus, will roll a portion of their equity into SOC.
  • SOC Telemed’s existing majority equity holder, Warburg Pincus, will remain SOC’s largest shareholder.
  • Proceeds generated by the transaction will be used to pay down existing debt, purchase a portion of the equity owned by existing SOC shareholders, and capitalize the SOC Telemed balance sheet.
  • Assuming no redemptions of HCMC public shares, current SOC equity holders will own 40%, HCMC shareholders will own 32%, PIPE investors will own 21%, and HCMC’s sponsor will own 7% of the issued and outstanding shares of common stock of SOC immediately following the closing, respectively.

SOC’s management team, based in Virginia, will also shuffle a bit. Paul Ricci, Interim Chief Executive Officer, will be stepping down (presumably back to Warburg Pincus where he is an advisor). John Kalix, currently President, will become CEO. Hai Tran, presently COO and CFO, will continue in those positions. At HCMC, Steve Shulman, currently CEO and a director of HCMC, will become the Chairman of the SOC Telemed board of directors.  Mobihealthnews, FierceHealthcare  Hat tip to reader Paul Costello of Boost Health Network.

En Vogue: smart clothing and wearables to track COVID spread and progression

July 29, 2020 | by

Wearables and smart clothing are having a ‘moment’ in the tracking of COVID symptoms and spread. After TTA noted Nanowear’s clinical trial with two major New York metro health systems last week, both POLITICO and Mobihealthnews catalogued additional trials and uses of innovative clothing and devices for detection: 

  • Apple watches and Fitbits
  • Oura rings (!) by the NBA to detect temperature and heart rate–at about $300 and up
  • Northwestern University and Shirley Ryan AbilityLab have developed a sensor that adheres in the visible dip at the base of the throat to monitor respiratory symptoms
  • Tufts University’s sweat sensor embedded in clothing, to analyze elements in perspiration such as electrolytes (sodium and ammonium ions), metabolites (lactate) and acidity (pH). NPJ Flexible Electronics
  • Paris-based Chronolife, which debuted the Nexkin smart T-shirt in December. It monitors heart rate, abdominal and thoracic breathing, body temperature, physical activity, and pulmonary impedance.

Part of the problem of wearable adoption is that without a specific ‘reason why’, wearables haven’t been all that compelling for the mainstream market beyond the trendy and pricey Apple Watch. Wearables have tried corporate wellness programs that almost give away the devices with the promise of lowering health costs long term. Venture funding (see the POLITICO chart) has been flowing into these companies for a decade. But in the eyes of many, wearables are a solution without a clear and compelling problem. COVID may resolve that.

Withings closes $60 million Series B round to fund expansion, B2B development

July 29, 2020 | by

Withings, a digital health developer with devices ranging from smart scales to analog-style smartwatches , this week closed on a substantial Series B funding of $60 million. Led by Gilde Healthcare, the round also had participation from long-term Withings partners and investors, Idinvest Partners and Bpifrance through their Large Venture funds, as well as BNP Paribas Development, Oddo BHF Private Equity, and Adelie Capital. Their total funding is now estimated at $93.8 million. According to their release, Withings will be using the funds to globally scale its dedicated business-to-business division MED PRO and further develop consumer health devices. With this, they will also add about 100 positions in the US and France, including expansion of sales, marketing and R&D.

Founded in 2008 in France, TTA has tracked Withings since 2009 with a scale that Tweets your weight (at a hefty $159). In April 2016, the company was sold to Nokia for a hefty €170 million and became Nokia Digital Health. Nokia’s hope was to use Withings and its pricey (at least in the US market) but stylish and innovative IoT devices to spur its own development of consumer digital health. Two years later, Nokia sold back Withings to co-founder and former chairman Éric Carreel, having not experienced much success in the consumer sector. Shortly thereafter, they premiered a revived Go (with an e-ink face) and the Steel HR Sport smartwatch, then progressed into heart and sleep monitoring.

MED PRO is a relatively new division that concentrates on professional uses of their devices and data analytics within health systems, health plans, disease management programs, and academic and pharma research. Withings also appointed a new global Medical Advisory Board which includes Dr. John Halamka, President of the Mayo Clinic Platform, Dr. Stéphane Laurent, former Head of Clinical Pharmacology in Hôpital Européen Georges Pompidou in Paris, and Craig Lipset, former Head of Clinical Innovation at Pfizer.  Mobihealthnews, Crunchbase