Has the ‘river of knowledge’ reversed its natural course? A lighter look at technology’s other effects.

A long-time TTA Reader, John Boden, takes a rueful glance at how ‘smart’ technology has not just disrupted the phone and computing markets, but has disrupted the ‘natural order’ between generations today. A virus-free look at a phenomenon that’s changed a natural dynamic.

As I am writing my experiences, and thinking about my grandparents and parents, I remember how many of the little things they taught me. It is not the big lessons I am talking about, but the details. A few examples: how to sharpen a knife; how to ground a sparkplug without getting shocked; how to tie a bowline; how to saw a board; how to chop down a tree, and hundreds of other skills. The most amazing change has taken place today. Now, so many times it is the grandchildren teaching the grandparents. The advent of technology is the cause. Cell phones, e-readers, Google, directions to anywhere from anywhere, Amazon shopping, Uber, movies, music, and on and on. All came screaming into our lives in the last decade or two, like an avalanche filling those little machines we hold in our hand.

The acquisition of the new skills needed is no longer based on the experience and hard-learned lessons that were passed down from one generation to the next, from the master craftsman to the apprentice, from parent to child, as has always been the way.

Suddenly we elders were having to learn new ways of doing things and it felt like we were drinking from a firehose. We finally gave in and bought ourselves one of those new phones we can carry around with us and flip open to use wherever we are, and then, BAM, there is a newer one, and then a newer one, and now it is much more than a phone. It is a map with a guide that tells you directions and even insists on telling you when to turn. It is a record player, a camera, a mailman that delivers immediately and you can even answer back immediately.

WHOA – WHOA – WHOA, this is too much. I cannot even get it out of my pocket before it stops ringing. Then, which button do I push to see who called? Oops, did they leave a message? Why is this screen blinking? Icon? What icon? (And what’s an icon anyway?) Do I push? Oops! Tap! Do not push! And this is just the phone part of the thing.

Where have all the dials gone? Where are the gauges with needles that told us how everything was working? What do you mean I just walk up to my car and it will know who I am and unlock the doors so I can get in? How can all this stuff that did not exist even a few years ago have so completely taken over our lives?

Ah, the instruction manual, that will explain it all! Where is it? What do you mean it is on the phone? I cannot see it. Where is it? Just go to the URL, we are told. The URL? What is that? Is it in the bathroom near the URinaL?

At about at this point that there is only one way out of the mess. Call a child or grandchild to help lead you out of this technology maze we have found ourselves in. Right now there never seems to be a skill that we have learned in our many years of experience that they need. So, today the river of knowledge seems to be in reverse of how it has been for centuries, flowing uphill.

Pretty soon our employment laws will be saying only those under the age of 16 are allowed to do this type of work!

After the COVID Deluge: a Topol-esque view of what (tele)medicine will look like

A typically cheery view by Eric Topol, MD of what medical practice will look like after COVID is over. With the full court press to go remote in hospitals and practices worldwide, telehealth and telemedicine has gone fast forward in a matter of under two months. But what will it look like after it’s over? Most of what the good doctor is prognosticating will be familiar to our Readers who’ve followed him for years–certainly he was right on mobile health overall and especially AliveCor/Kardia Mobile— but not so on point with mobile body scanners (anyone remember VScan?)

When the high tide recedes, what will the beach look like?

  • “Telemedicine will play the role of the first consultation, akin to the house-call of yore.” (Terminology note–interesting that Dr. T still uses ‘telemedicine’ versus ‘telehealth’–Ed.)
  • Chatbots will serve as screeners–once they are proven to be effective (a ways to go here, as the Babylon debate rages on)
  • Smartphones will be the hub, connecting with all sorts of monitoring devices (the ‘connected health’ Tyto Care and Vivify Health model–which makes the Editor’s former company, the late Viterion Digital Health, even more of a pioneer that died crossing the Donner Pass of 2016)
  • Smartwatches are also part of this hub (this Editor remains a skeptic) 
  • Now is the time to harness technology by both health systems and individual practices, but multiple barriers remain. (This Editor can speak to the difficulties for both primary care and specialty practices in not only practice but also reimbursement–and acceptance by patients.) Device expense is also a problem for the non-affluent.

As to the rest, it is pretty much what we’ve heard from Dr. T before.  The Economist

Your Editor will add:

  • Easy to use, secure platforms that don’t put users through multiple security steps remain a concern for users. This Editor’s concern is that easy to use = insecure. Skype and Zoom are inherently insecure–Skype’s user unfriendliness and insecurity outside enterprise platforms and Zoom’s major security problems on its platform and user flaws are well-known (ZDNet).
  • Reimbursement, again! CMS has done a creditable job in broadening reimbursement for telehealth a/v and telephonic services, but coding remains a nightmare for practices struggling to remain open and with some lights on. After COVID, will CMS and HHS get religion, or put it right back in its rural bottle? Covered in the CARES Act passed at the close of March, $200 million sounds like a lot from the FCC to bankroll telecom equipment for providers, but these funds will go quickly. At least they are not delayed in endless rule making, as the Connected Care Pilot Program has been for two years. Mobihealthnews 

The wind may finally be at the back of telehealth distribution and payment (US)

Medicare Advantage may lead, but Medicaid and regular Medicare are not far behind. The Centers for Medicare & Medicaid Services (CMS) has announced in two proposed rules changes expansion of telehealth access for both privately issued Medicare Advantage (MA) plans (26 Oct) and state-run Medicaid and CHIP (Children’s Health Insurance Plan) (14 Nov) plan members. This may mean greater acceptance by providers because they will be paid for these services.

For MA, the proposal would, starting in 2020 as part of government funded basic benefits, eliminate geographic restrictions (rural telehealth) and allow members in urban areas to access telehealth services. It would also broaden present location restrictions, allowing MA members to receive telehealth from home versus traveling to a health care facility. The most intriguing wording is here: “Plans would also have greater flexibility to offer clinically-appropriate telehealth benefits that are not otherwise available to Medicare beneficiaries.” which very well could mean remote patient monitoring in conjunction with visits. MA plans have always had more latitude to offer telehealth benefits to members, which are about 1/3 of Medicare-eligibles (over 65). Over 11 percent growth is forecast and it is highly competitive though dominated by United Healthcare and Aetna–over 600 new plans are entering the market next year. Enrollments close on 7 Dec for 2019. CMS.gov release, mHealth Intelligence, Healthcare Finance News.

For Medicaid and CHIP, which states use to extend insurance to low-income individuals and families via private plans, states would be able to, under an approved rule, to more flexibly determine what criteria determine telehealth access. Currently, states use proximity factors–distance from provider and time. The proposed criteria under 10. Network Adequacy (pages 15-16) recommends that time and distance be deleted and instead “adding a more flexible requirement that states set a quantitative minimum access standard (later listed) for specified health care providers and LTSS (long term services and supports) providers”. The reasons why are the limited supply of providers and the functional limitations of the LTSS population. Also notable was language in section 8 discussing access to provider directories via smartphone, as 64 percent of the population with incomes less than $30,000 own a smartphone and use it to access health information.  CMS proposed rule, POLITICO Morning eHealth

This adds to the momentum of the Medicare Physician Fee Schedule published on 1 Nov that added even more:

  • Virtual brief patient checkins and evaluation of patient-recorded photos and video to payments
  • CMS is also finalizing separate payments for three new codes covering chronic care remote physiologic monitoring that unbundle 99091 (CPT codes 99453, 99454, and 99457) and interprofessional internet consultation (CPT codes 99451, 99452, 99446, 99447, 99448, and 99449).
  • Two new codes covering telehealth for prolonged preventive services
  • Finalizing the addition of renal dialysis facilities and the homes of ESRD beneficiaries receiving home dialysis as originating sites
  • After 1 July, the home will be permitted as a permissible originating site for telehealth services furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder. CMS.gov fact sheet 

The importance of this is that more digital health covered by Medicare and government payments in public/private programs such as Medicaid and MA lead private insurers to pay doctors for these services, who will then be willing to pay vendors for providing them. For the telehealth and telemedicine companies that have weathered the storms and lean times of the past decade, there may be light at the end of the tunnel that is not an oncoming train.

65+ smartphone ownership is up to 42 percent–but slumps with increased age

[grow_thumb image=”https://telecareaware.com/wp-content/uploads/2016/03/elderly-smartphone.jpg” thumb_width=”150″ /]A report of progress in smartphone ownership by those over 65 years of age is mixed indeed. There’s progress–ownership is up to 42 percent of the age group, and 64 percent of these smartphone owners are users of the Internet according to Pew Research‘s 2016 study. But mitigating factors to this good news is that ownership is very much a function of income and age. According to the US Census’ American Community Survey 2015, 66 percent of those aged 65+ households with income $70,000+ own smartphones, but that declines to 33 percent in the 75+ age range and 27 percent of those 80+. Perhaps Laurie Orlov exaggerates the cost of smartphones, especially Android–this Editor has never bought an LG phone over $200 and has a miserly data plan, using Wi-Fi most of the time; Verizon has plenty of new older models at lighter prices and other carriers like Consumer Cellular and GreatCall have excellent deals. But what is true is that interest wanes with age–and that phones, especially Apple, still present legibility and usability barriers to those with low vision or hand arthritis. Ms Orlov also notes Pew’s discovery that 65+ users are less likely to secure their phones with lock codes and regularly update their apps. Aging in Place Technology Watch

Patient engagement: a digital divide in health technology accessibility

[grow_thumb image=”https://telecareaware.com/wp-content/uploads/2013/09/earthquake.jpg” thumb_width=”150″ /]Guest editor Sarianne Gruber (@subtleimpact) scopes the ‘digital divide’ separating those who need health services the most from the patient engagement and other tools they need in this article. The studies are US, but the lessons apply anywhere in the world. This Editor notes that many patient engagement tools are over-designed and over-complicated for users, even if they are fairly competent and frequently use online and mobile. (I entered a ‘pilot’ of a stress reduction program which proved to be anything but–and quitting because it is invasive and the reporting is ludicrously burdensome.)

To developers: Imagine your patient engagement platform being used by a person on the less sophisticated, less educated and disconnected end of the spectrum–or by someone less able due to physical (vision, touch) or cognitive impairment. Put on bad glasses and gloves–and start. Better yet, find a few people and put it in front of them. If we can make the mental shift in developing mobile apps for Africa or India, certainly we can do so for Americans, Britons and Europeans.

What the Studies are Showing

Hallmarked as a solution to improve healthcare quality, cost and safety, studies are showing health technology is up against a “digital divide” when it comes to patient engagement. At the Internet Governance Forum, Pew Research Center’s Lee Rainie, Director of Internet, Science and Technology Research presented the Fact Tank Report discussing the “digital divide” that exists in 2016. The report documents that lower income, less educated, non-white, seniors and rural communities are the least likely to have home internet, home broadband, mobile connectors and smartphones. This summer’s medical publications, the Journal of the American Medical Association and the Journal of the American Board of Family Medicine, released studies where demographic and socioeconomic data marked the root causes to limited or no access to digital technology, thus hindering the benefits and improved outcomes it can bring to the neediest and most costly populations. Here are the highlights from each study.

Trends in Seniors’ Use of Digital Health Technology in the United States, 2011-2014, a research letter submitted from Harvard Medical School’s Brigham and Women’s Hospital, appeared in the August 2, 2016, JAMA. Authors, David M. Levine, MD, MA, Stuart Lipsitz, ScD, and Jeffrey A. Linder, MD, MPH,FACP made mention that this study, based on the National Health and Aging Trends survey (NHATS), was exempted from the Partners HealthCare Human Research/IRB Committee. The research team included participates to the longitudinal NHATS survey in 2011. The participants were re-surveyed annually on everyday (nonhealth) and digital health use until 2014. The research team acknowledged that this may be the first nationally representative study to examine trends in the adoption of digital health technology by seniors age 65 years and older who are community-dwelling Medicare beneficiaries.

Here are some the reported statistics from the study: (more…)

A weekend potpourri of health tech news: mergers, cyber-ransom, Obama as VC?

As we approach what we in these less-than-United States think of as the quarter-mile of the summer (our Independence Day holiday), and while vacations and picnics are top of mind, there’s a lot of news from all over which this Editor will touch on, gently (well, maybe not so gently). Grab that hot dog and soda, and read on….

Split decision probable for US insurer mergers. The Aetna-Humana and Anthem-Cigna mergers will reduce the Big 5 to the Big 3, leading to much controversy on both the Federal and state levels. While state department of insurance opposition cannot scupper the deals, smaller states such as Missouri and the recent split decision from California on Aetna-Humana (the insurance commissioner said no, the managed care department said OK) plus the no on the smaller Anthem-Cigna merger are influential. There’s an already reluctant Department of Justice anti-trust division and a US Senate antitrust subcommittee heavily influenced by a liberal think tank’s (Center for American Progress) report back in March. Divestment may not solve all their problems. Doctors don’t like it. Anthem-Cigna have also had public disagreements concerning their merged future management and governance, but the betting line indicates they will be the sacrificial lamb anyway. Healthcare Dive today,  Healthcare Dive, CT Mirror, WSJ (may be paywalled) Editor’s prediction: an even tougher reimbursement road for most of RPM and other health tech as four companies will be in Musical Chairs-ville for years.

‘thedarkoverlord’ allegedly holding 9.3 million insurance records for cyber-ransom. 750 bitcoins, or about $485,000 is the reputed price in the DeepDotWeb report. Allegedly the names, DOBs and SSNs were lifted from a major insurance company in plain text. This appears to be in addition to 655,000 patient records from healthcare organizations in Georgia and the Midwest for sale for 151 – 607 bitcoins or $100,000 – $395,000. The hacker promises ‘we’re just getting started’ and recommends that these organizations ‘take the offer’. Leave the gun, take the cannoli.  HealthcareITNews  It makes the 4,300 record breach at Massachusetts General via the typical unauthorized access at a third party, once something noteworthy, look like small potatoes in comparison. HealthcareITNews  Further reading on hardening systems by focusing on removing admin rights, whitelisting and endpoint security. HealthcareDataManagement

Should VistA stay or go? It looks like this granddaddy of all EHRs used by the US Veterans Health Administration will be sunsetted around 2018, but even their undersecretary for health and their CIO seem to be ambivalent in last week’s Congressional hearings. According to POLITICO’s Morning eHealth newsletter, “The agency will be sticking with its homegrown software through 2018, at which point the VA will start creating a cloud-based platform that may include VistA elements at its core, an agency spokesman explained.” Supposedly even VA insiders are puzzled as to what that means, and some key Senators are losing patience. VistA covers 365 data centers, 130 separate VistA systems, and 834 custom installations, and is also the core of many foreign government systems and the private Medsphere OpenVista. 6/23 and 6/24

[grow_thumb image=”https://telecareaware.com/wp-content/uploads/2014/01/Overrun-by-Robots1-183×108.jpg” thumb_width=”150″ /]Dr Eric Topol grooves on ‘The Fourth Industrial Revolution’ of robotics and AI. (more…)

Eight TECS expected to change health and care

[grow_thumb image=”https://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

Smartphone measures heart and breathing rates without wearables

Researchers at MIT are working on a project to measure the heart rate and breathing using a smartphone’s accelerometer in the user’s pocket or bag without the need for wearable sensors. When the user is at rest the slight movements due to breathing and heart beat are measured using the smartphone and used to derive the heart and breathing rates.

According to a paper published recently, in a test with a dozen participants (a very small sample for this type of test) the heart rates measured using the new method were within one beat when compared to FDA approved sensors they were using simultaneously. The measurements of breathing rate were about a quarter of a breath of the approved sensors.

The aim is to sense when someone is stressed by using the heart rate and breathing and then help cope with the situtation by suggesting, say, breathing exercises or calling for help.

A brief article on the work is published on the MIT technology Review and the full paper is available here.

Does current digital health meet baby boomers needs and wants?

The answer, according to health tech industry analyst Laurie Orlov (Aging in Place Tech Watch, Boomer Health Tech Watch) is…not really. Despite its massive size (76 million in the US), spending power (by 2017, 70 percent of US disposable income), breadth (1946-64) and need (despite living longer, by 2030 37 million will be managing more than one chronic condition), most health apps, especially fitness apps, don’t resonate with boomers despite over 50 percent having smartphones. The reasons are many–they’re complicated, often hard to follow, view, and abandonment across all ages is still high. Even among Fitbit purchasers, abandonment is fully one-half. As income decreases, smartphone access also becomes a cuttable budget item. Much more in this paper published by the California Healthcare Foundation.

Arizona plans using health tech to engage Medicaid recipients

Arizona’s smartphone app-based outreach plan for its Medicaid (low-income health insurance) program has raised a few eyebrows. The app/online site would:

* Help beneficiaries find primary and urgent care providers
* Provide beneficiaries access to chronic disease management tools
* Send beneficiaries appointment reminders

The programs would use mobile, online and texting, which doesn’t require a smartphone and has historically worked well in compliance and information (e.g. Text4Baby). For the critics, however, Pew Research found that half of those with incomes under $30,000 have smartphones. This number also includes the elderly, and does not take into account recent growth–smartphone prices have decreased smartly, and are now available on pay-go plans. iHealthBeat

Radiation from smartwatches, wearables: real, alarmist, or the NY Times?

[grow_thumb image=”https://telecareaware.com/wp-content/uploads/2013/02/gimlet-eye.jpg” thumb_width=”150″ /]The Gimlet Eye has that certain half-baked radioactive ‘glow’. The healtherati are all aTwitter over a New York Times Style (!) section article that does the unthinkable–it dares to raise the question of the possible harm of radiation that wearables, including smartwatches as well as smartphones, might present to both adults and children. The writer, Nick Bilton, is a regular tech columnist.

After an unfortunate baiting for attention at the start, making an analogy of cellphone/wearable radiation to 1930s adverts with doctors ‘endorsing’ cigarettes, he for the most part tries to take a balanced approach. By the end, he lines it up like this. Bluetooth LE and Wi-Fi–no evidence of harm in adults. 3G/4G cellphone radiation–you may want to be careful. He points out that studies aren’t definitive. Older studies, such as the WHO’s, a Swedish and some European studies point to harmful (carcinogenic) effects from phones held extensively too close to the head, but nothing is definitive in causality as the CDC pointed out and additional studies have proven no conclusive evidence of harm. Conclusion–use anything 3G/4G with caution, away from the head, limit exposure by children or pregnant women. Cautious enough?

Oddly, he advocates Bluetooth headsets but doesn’t mention using speakerphone settings–and then, for the smashing windup, won’t put the Bluetoothed Apple Watch near his head. It’s a weirdly sourced (an alternative doctor the only one cited? Old studies?) and half-baked, partially tossed salad article. Consider: most wearables are–surprise, Bluetooth or Wi-Fi connected. But it does bring up the inconvenient question, only partially answered, of All Those Rads and What (If Anything) Are They Doing To Us.

What’s really interesting? The immediate, twitchy and prolonged press response. As they say in New Jersey, they are ‘jumping ugly’. (more…)

Apple Watch may not be as ‘healthy’ as touted

[grow_thumb image=”https://telecareaware.com/wp-content/uploads/2014/09/apple-watch-beauty-shot.png” thumb_width=”150″ /]According to multiple press sources in the past 24 hours, the anxiously-awaited Apple Watch is rumored to be having big trouble with its more advanced healthcare measuring features. We noted at the time “Haptic engine and heart rate monitor; 4 lenses. infrared, LED, photo sensors detect pulse.” plus daily activity [TTA 9 Sep, 11 Sep 14]. Well, not quite. The Wall Street Journal broke the news that it will not debut in April including monitoring of “blood pressure, heart activity and stress levels” as originally planned because, simply, the watch did not measure them reliably and accurately (hairy, sweaty arms!), they were too complex or required regulatory approval (not so–see FDA and MDDS).

Apple has relied on the Watch to defend its Still Most Innovative Company Post-Jobs turf, (more…)

Smartphones, wearables are the future says NHS England

NHS England has sketched out the future of healthcare and it will be one using smartphones and wearable bio-sensors to monitor ourselves and alert clinicians. [grow_thumb image=”https://telecareaware.com/wp-content/uploads/2014/09/NHS-England.jpg” thumb_width=”150″ /]NHS National Medical Director Sir Bruce Keogh has written to around 250 organisations across health, social care, industry and third sector asking them to support the Technology Enabled Care Services (TECS) programme which he says will take the NHS into this new technological era.

The TECS programme, born out of the Three Million Lives (3ML) initiative (which didn’t quite go anywhere after all the song and dance, including from Prime Minister David Cameron), was reviewed last year resulting in the change of focus to “address the demand for support and practical tools to commission, procure, implement and evaluate technology enabled care services” according to Sir Bruce’s letter as reported on the NHS England website.

The TECS Stakeholder Forum‘s views and proposals now form the TECS Improvement Plan for 2014-17. This is a broader group following the failure of the 3ML Stakeholder Forum, which consisted mainly big industry organisations, to achieve anything of substance.

According to the NHS England website posting, Sir Bruce explains: “To ensure continued progress, we have brought together a TECS Implementation Group consisting of experts and leaders from across these sectors whose remit is to support the strategic development and delivery of the proposals within the Improvement Plan. In addition, we have formed the TECS Executive Steering Group which meets regularly to provide clinical, technological and strategic leadership for the programme at a director level in NHS England.”

This all sounds like a lot of bureaucracy and a drawn out attempt to rescue what remains of the 3ML programme. I started thinking of the Titanic and deck chairs.

Insomnia Apps: A replacement for sleeping pills?

sleepstation

For those of us suffering from insomnia there’s no denying it can be a real pain! For some it means wakening up a number of times throughout the night, while others are unable to get back to sleep after only a few hours rest. In my case it means drifting off into a peaceful slumber before inevitably waking just minutes later with a jolt, looking like Frankenstein’s monster and wondering if someone just hit me up the face with a bolt of lightning!

The latest NHS approved sleep app is Sleepstation. It’s one of three listed on the NHS Choices Health Apps website, the others are Sleepio and Sleep Diary. (more…)

The ‘grey’ market is where it’s at for ‘quantified selfing’

Surprisingly in the tech-addicted (and young-skewing, based on subject matter) Gigaom is this short piece on how health tech companies are missing the boat by targeting the young, healthy fitness addict or plain addicted-to-the-data Quantified Self (QS) market, rather than those over 50 and their families. ‘Simple’ and unobtrusive are the keywords, especially for what the late and much missed MetLife Mature Market Institute termed the ‘old-old’–those over 80. Mentioned are home activity monitoring systems such as Lively, BeClose and GrandCare Systems supplanting the PERS pendant (Lifeline) and the additional alert capabilities offered by GreatCall/Jitterbug. (This Editor will also mention a new telecare system entering the European and Americas markets, Essence Care@Home, which premiered at Mobile World Congress 2014. More on this in the next few days.) What’s notable about the article is the emphasis on the market size (via expert Laurie Orlov): $2 billion now, ten times that in 2020. What’s incomplete about the article is no ‘look-ahead’ to how devices like smartwatches (and watch-like forms such as AFrame), sensor-based wearables which connect to smartphones–and sensor-equipped smartphones, tablets and even Glass-type devices with simple apps which can help with self-or group-monitoring, prompts for those with cognitive difficulties, and more. Worldwide, we are also running out of carers [TTA 24 April]. Who will crack the code on tech for seniors?

Apple patents built in emergency alert for iPhone

Apple have filed a patent for a “Mobile emergency attack and failsafe detection” which uses the iPhone’s inbuilt sensors to detect a probable emergency situation, such as a physical attack against the user.  When the device is in ‘attack detection mode’, certain events can cause it to request help automatically, by calling a defined emergency contact or the emergency services. The GPS co-ordinates can also be transmitted. Apple Insider