TRAVIS GOOD

This is where I post about stuff that I'm interested in. It's mostly pictures, snippets, and quotes that cross my path.

[travisjgood-blog]

At Hops & Hominy

At Hops & Hominy with Mohan – See on Path.

[travisjgood-blog]

At Buffalo Wild Wings Grill & Bar

Takeout – at Buffalo Wild Wings Grill & Bar with Laurie – See on Path.

[travisjgood-blog]

The other HIT

I'm sure I'm not the only one but this is a very frequent part of a conversation for me: "I see, you do health technology. So you work for an electronic records company?". Invariably I have this discussion multiple times at every one of my wife's department functions, or at conferences, or just on the street. I can't be the only one, right? I'm sure lots of readers out there, whether they work at an EMR vendor or not, get this response from people when health technology comes up? The conversation may also include a comment like "what eles is there" or "oh, that's interesting".

If it's a more informed person and I've been talking about mobile health or mobile generally, they might ask "So you mean like MyChart". That was the conversation I had this morning. It's also what triggered me to write this post. I understand the reference to MyChart because I do live in Epic's backyard, but don't we all live in Epic country these days?

It's a bit annoying at times but I totally understand the knee-jerk reaction about working for an EMR. EMRs are the key part of HITECH and a monster part of HIT generally. They are widely used and known by consumers who read about them and also increasingly see them when they go to the doctor. And I also understand MyChart being representative of mobile health for lots of people; there are likely more MyChart users than just about any other mobile health app. Maybe iTriage and WebMD mobile would contest that last statement.

Whatever the reason, I get it. But it's still a barrier, or an extended explanation, I face every day when I try to describe to people what I'm working on or what I write about. This all got me thinking about mobile health success stories, specifically about mobile health success stories and how they relate, or don't relate, to EMRs and EMR workflows.

I'll try to confine myself to true success stories, meaning mobile health apps and services that have been or are widely used, not just those that are very well funded and get a lot of press. And I'll also focus on those that are mobile only or mobile first. I get asked all the time about what I consider the main mobile health success stories. Below is my typical answer, though I put more thought into it now that I'm writing it and not answering live. What's interesting is that none of them were dependent on an EMR for success.

Epocrates. Always the go-to example for mobile health success - big growth and eventual acquisition by Athena. It grew before HITECH and health reform. Still today it's used outside of the EMR for medication reference and decision support. Adding the ability to e-prescribe from within the app would be good I guess but then you'd have to integrate the entire patient panel so docs don't have to re-enter them. But that's not even necessary because it's a reference tool and something to which providers need access.

AirStrip. It is still relatively new but has had a good amount of success selling and with adoption, beyond the huge amounts of financing it has secured. AirStrip didn't launch as complete mobile health platform, with the ability to be a mobile front end for EMRs. It was based on device data initially (fetal monitoring then cardiac monitoring). AirStrip is now more broadly a mobile health platform for clinical content, inclusive of EMR data. I assume working with device data, like data from ECGs and fetal heart monitors, is an easier start than integrating with EMRs.

iTriage. I think this is the only non-provider facing, or consumer-facing, app on my list. iTriage got out quick and offered something that consumers wanted. As consumers downloaded it and used it, enterprises wanted to sponsor listings and enable pre-registration from within the app. None of this really has anything to do with the EMR. It has to do with patient search and entry into the health system, something that has become a very competitive area.

VisualDx. I have a half written post just about this company. It does clinical decision support at the point of care, starting in dermatology but with plans to expand much more broadly. It recently added the ability to email educational content straight from the mobile app to patients, which is again pretty cool. It's widely in use in terms of licensing to medical centers. I've used it and my wife uses it all the time. It's very similar in its utility to Epocrates.

Decision support obviously holds a lot of value because it motivates a user, a clinician user, to open a standalone app, often during a patient encounter. We're seeing decision support integration into EMRs so clinicians can get it all in one place; ideally these integrations will get better and the decision support will be available totally contextual, or based on the med record being viewed. But, hopefully clinicians aren't in apps or any technology during the entire time with patients so standalone decision support still makes sense.

Also, on mobile, assuming good mobile EMR options become the norm or at least available, it doesn't make sense to bloat them with all of these add ons. People will use apps for specific functions at specific times, and I think most people are OK to have multiple apps for common tasks. Clinical decision support or reference is a very common task.

Mobile messaging. As many have written EMRs should be primarily communication tools; but as EMRs have become increasingly bloated, the focus is on documentation without much thought about or focus on communication. I wrote a series of posts way back in 2012 about all the activity in the clinical messaging space, or all the apps that are vying to be pager replacements. This is another great example of a tool that should be integrated with the EMR but is independent today, whether it's pagers or smartphone apps. Messaging from within the EMR makes sense on the web but ideally messaging, or at least inbox, apps would be standalone on mobile to keep them from being too mobile.

One area I'm not listing but I think will see big growth is telemed and virtual visit companies, many of which will be available on mobile. The reason I'm not listing is that I don't think these have really hit the tipping point yet for consumer usage.

While I do think EMRs have the potential to be amazing data platforms, something I've written about before and something that lots of people in DC discussed this week at Datapalooza, I do think we've seen some good examples of mobile health success that have been built, grown, and even been acquired despite being separate and distinct from the EMR. I think tons of opportunities remain to grow apps and services with similar models though it's not easy. It's not easy because you have the non-EMR stigma to get past; but, in certain respects I think that's a good thing because you can clearly start to address some of the shortcomings in current EMR offerings, and help enterprises start to think about answer the question, "Now what?".

What do you think? Have you had similar experiences when you talk to people? What is your take on the EMR / Non-EMR buckets?

[travisjgood-blog]

Agile Care

I love agile development. We use agile with development efforts and I've recently tried to implement aspects of it into parenting. I'm sure most developers reading this know agile. If you want to learn a bit about agile development, wikipedia is probably the best intro to it as it applies to software development.

There are lots of reasons I really like agile. Agile is a wonderful way to turn big projects into very tangible and manageable tasks. It's also a great way to flatten the structure of a group, keep lines of communication open, and increase personal and group accountability. If you look at those benefits, you quickly realize that agile, as a methodology, does lots of things that we should be striving to do in healthcare, especially as it relates to engaging patients.

I looked around for stuff on agile healthcare and didn't really find much. A couple of population health tools, predictive analysis stuff, and then some organizational tools (lean mostly). I didn't see anything related to using agile as a methodology, or framework, for working with patients. That surprised me. If there is more that I'm not seeing, please send along any info as I'd love to see anything related to this.

Below I've take some liberties and broken out areas of agile thinking and tried to map them specifically patient care.

Flattened structure. I think I read the phrase "share decision making" every day. It's in almost every story or post about the future of healthcare, and is seen as an essential part of effective patient engagement. Agile does a great job of flattening an operational structure and improving decision making. Patient care is the domain of PCPs, specialists, nurses, care navigators/managers, caregivers, and of course patients. That's a broad group. Historically it was very hierarchical with doctors at the top and patients at the bottom. Our goal should be to flatten this structure to give everyone a voice and increase understanding at all levels of interaction with the patient. PCPs can remain coordinators, especially if a part of a patient centered medical home model, but integrate more data points from those directly providing regular care, as well as the patients themselves.

Discrete goals (closing the feedback loop). Long term targets, while necessary, aren't very tangible. Losing 25 pounds over 12 months is a great goal but it's not really tangible on a daily or weekly basis. Breaking goals down into weekly objectives, which ideally translate into daily targets, helps patients more easily see and work towards the finish line. It also closes the feedback loop with patients to be able to have them accomplish goals on a daily or weekly basis. One added benefit, if applied to the care team, is to create a better understanding of the roles and action items for each member.

Daily scrum (regular communication). We should strive to give patients and all of the care team a voice. With agile development, daily meetings are held to discuss progress and road blocks. In agile parenting, the standard seems to be weekly meetings. The point is to have regular checkins that are short and very structured. Agile meetings typically ask 3 questions. In healthcare, those could be: "What healthy thing did you do this week?"; "What problems did you encounter with your health this week?"; and "What are your health goals for this upcoming week". I'm sure there are some other questions that might be relevant but keep it simple and let patients elaborate so you can discover what is important to them.

Accountability. Discrete goals and regular communication ideally create accountability, not just for the patient but for all of those in the care team. Everybody makes mistakes and acknowledging those mistakes helps everybody learn. Agile is a great way to facilitate this learning and continually improve.

Beyond what is laid out above, each of the areas needs to be integrated into a formalized process, or workflow, if it is going to be effective. There is a very big technical component to this because lots of agile is about contact and communication, something that would have to be done virtually if agile is applied to healthcare. There are tools that we use for agile development because we are not all co-located. These include things like IM and Google Hangouts. In healthcare there need to be more solutions to facilitate what I described above.

But the first step is not the cool tools or the great UI, it's defining a process that works for everybody. This is hard with providers because it's a major shift in the approach to care. I'd love to hear some ideas on how to accomplish this or learn about examples of pilots testing processes similar to agile? Maybe with a targeted approach to something very specific like discharge and readmission prevention?

This post was originally published on HIStalkConnect

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HIPAA Box

The big HIPAA news last week was that Box (formerly Box.net then Box.com and now Box seems to be acceptable) is now HIPAA-compliant. In the world of HIPAA news this is a nice break in the steady stream of stories about laptops being stolen of patients suing over breaches. Mr. HIStalk covered the Box story briefly earlier this week in a news post. This is potentially interesting news for consumers and providers.

If you search for "Box.com HIPAA" you find a Box support page that says the company actually was deemed HIPAA-compliant, presumably from an audit, back in November of last year. I assume this was delayed for Box to integrate several key health app launch partners and secure an investment in iPad EMR drcrhono. I use MediCam, one of the apps that was listed in the Box release, and noticed Box was added as a storage option in the last update of the MediCam, so I figured this announcement was in the works.

One point I wanted to clarify, and I'm hoping somebody can help with this. The article references lots of different healthcare organizations that are currently using Box. My bet, and this seemed to be the consensus with several friends I asked about it, was that Box at most healthcare organizations today is more of a tool for admin and business functions, nothing clinical or HIPAA-related. I have friends that use Box to share and comment journal articles, but not for patient records. Anybody out there at a healthcare org that uses Box that can tell me specifically how it's used?

In all the press about Box and HIPAA, there's another article by Missy Krasner (formerly Google Health and not helping Box) about Box taking over where Google left off. I don't think comparison's to Google's PHR is very strong positioning for Box but the article makes some good points about Box and how it could be used in healthcare, especially by patients.

The use case goes something like this. Box can become a trusted partner, through something like DirectTrust or some other trust anchor to systems that produce CCDA data, enabling it to both receive and transmit clinical summary data. Patients can then have records pushed directly to and from Box (I'm still a bit confused if the "from Box" part is real or will ever be). Presumably, people that store records on Box can then use secure sharing features of Box to share those records with selected individuals. Since the data would be standardized, or mostly standardized and hopefully CCDA, Box could integrate technology to make it interactive, like the soon-to-be-open-sourced health record viewers from the recent HHS challenge.

That's very cool. It's not exactly easy, in fact it's extremely hard. Box needs to either work directly with all of the systems to access data or it needs enough partner apps to do it. But I see what Box is pushing for with the HIPAA announcement and the press about sharing medical records on Box. The piece that Box doesn't talk about is just how valuable it would be to be the repository of aggregate patient data, even if that data is just clinical summaries and CCDAs (not full EMR data). There is obviously the very clear individual value from the extreme pain most people experience sharing medical records; I, for example, wish I could do what I described in the last paragraph. But if Box allows users to grant access to different apps or researchers or whomever to access data, sometimes anonymized and sometimes not, that's extremely valuable. As long as Box isn't making money off directly off of these relationships and just adding value to it's place as a place to store records, I think it gets around the issues in the new HIPAA rule related to marketing; read this about CVS and pharma-sponsored refill notices for more on that.

There are some big risks associated with Box doing this. Just because Box is HIPAA-compliant, or was as of November, doesn't mean that vendors and apps that use Box for storage are HIPAA-compliant. I think Box should be careful about partners making claims based solely on integration with Box.

Overall I think this is great news. I think we're going to see other similar offerings from other new and old vendors but Box has such a strong presence on the enterprise side it's going to be interesting to see how quickly it can get traction as a place to store records. Personal storage is all well and good but it's the linkage and integration with existing systems that will determine if this is really valuable.

This post was originally published on HIStalkConnect.

[travisjgood-blog]

One App to Rule them All!

I find I use the "One BLANK to rule them all" expression a lot. I love Lord of the Rings. I'm waiting impatiently for my kids to be old enough to start reading the books to them. Any suggestions on what age is appropriate for that series? Our kids started watching Star Wars at age 4 and the level of obsession with it is very satisfying to me. We've also got Narnia and Harry Potter standing by while we work through more appropriate classics like Indian in the Cupboard and Tale of Despereaux.

This post, about the one or many app argument, is motivated by recent discussions I've been having. First, I've been talking to lots of physicians lately about apps for healthcare. The majority of the ideas are mobile but web makes sense, at least as another point of access, for most concepts. The apps vary from internal practice-based apps to virtual care apps to some consumer direct wellness apps. I find it fascinating and very positive that I'm having these conversations and that there seems to be a lot of interest.

What's also interesting is many of the app ideas aren't terribly original. They are original to the docs that I'm speaking with but that doesn't mean similar apps don't already exist that do the same thing. A good example is an OB friend that called me a few weeks ago telling me how great it'd be if she could monitor her laboring patients using her iPhone; I pointed her to AirStrip but her hospital doesn't have a contract with them and she'd never heard of it. The potential conclusions I draw from these discussions are 1) there is way too much noise to find what you're looking for with health apps, 2) docs just don't know what's happening with health apps or where to start looking (could be a result of #1 or just because they don't even know to be looking), and 3) docs put a premium value on their own ideas. #3 is the most intriguing conclusion to me.

Also in the last few weeks I've had two related conversations, one with a health system exec and the other with an investor, about doctor-built apps. The response I got in these discussions is that doctor-built apps are a bad idea because they just creates more fragmentation, silos, and noise. It's a very logical argument, especially with the current state of health apps. Creating more apps, especially if distributed to the app store, does create more noise for those searching for apps. Also, building apps that don't communicate with other systems or apps also creates more data silos.

When I think about doctor-built apps, I come to a different conclusion, and it in part is based on my belief in conclusion #3 above, that docs put a premium on their own ideas, as well as how and why patients will eventually find and use apps.

First, I think doctors are used to leading. Yes, team-based care is a big part of training and care; but, ultimately physicians are used to being in charge - directing care decisions and leading medical teams. There's nothing wrong with this and it doesn't run counter to current Pit Crew thinking. It makes sense that docs would think their idea for a diabetes app or a whatever app is better because it's their idea; this really isn't a unique quality of physicians at all. Everybody does this.

The main difference is that docs are a huge part of app success so getting them to buy-in, even if that means having lots and lots of different, but very similar apps, is not really a bad thing. That last sentence reminds me of the expression my wife and I heard countless times when we were backpacking through SE Asia, "Same Same, but different" (they even have shirts with this expression on them). From what we gathered, the expression means "similar" but "Same Same, but different" definitely fits better in this situation than just "similar".

I agree there is way to much app noise but that's only relevant if people are having to search for apps themselves. If the app has a physician name associated with it, or the doc distributes links to the apps, then it doesn't matter that the rest of the app store has another 100,000 diabetes apps. People will still find and use the app recommended by the doc. No noise issue. In fact, I think it solves some of the noise issue for patients and docs. Even better, my hypothesis is that docs will be more vested in patients using these apps and incorporate them into standard care.

The other problem with all of these different doctor-driven apps is the data silo problem. This one is hard to solve. Let's start with what we have now. Today we already have silos with health apps, so I'm not sure adding more silos is necessarily making things worse. If data is stuck in silos then it's stuck in silos, right? It doesn't matter if it's 10 silos or 100,000 silos. Fixing 10 silos is probably easier than fixing 100,000 silos, but you still need to fix silos regardless. I'm just not sure adding more silos is bad enough to offset what I think is the gain.

At least we have some emerging patient standards in CCDA and BlueButton Plus. Hopefully more and more apps will support these standards, solving some of the silo problems in the process.

I'm curious what readers think? I've gotten a few blank stares when I've discussed this with people. Do physicians want their own apps and should we encourage them to build them? Is it a net negative or positive?

This post was originally published on HIStalkConnect.

[travisjgood-blog]

I find I use the "One BLANK to rule them all" expression a lot. I love Lord of the Rings. I'm waiting impatiently for my kids to be old enough to start reading the books to them. Any suggestions on what age is appropriate for that series? Our kids started watching Star Wars at age 4 and the level of obsession with it is very satisfying to me. We've also got Narnia and Harry Potter standing by while we work through more appropriate classics like Indian in the Cupboard and Tale of Despereaux.

This post, about the one or many app argument, is motivated by recent discussions I've been having. First, I've been talking to lots of physicians lately about apps for healthcare. The majority of the ideas are mobile but web makes sense, at least as another point of access, for most concepts. The apps vary from internal practice-based apps to virtual care apps to some consumer direct wellness apps. I find it fascinating and very positive that I'm having these conversations and that there seems to be a lot of interest.

What's also interesting is many of the app ideas aren't terribly original. They are original to the docs that I'm speaking with but that doesn't mean similar apps don't already exist that do the same thing. A good example is an OB friend that called me a few weeks ago telling me how great it'd be if she could monitor her laboring patients using her iPhone; I pointed her to AirStrip but her hospital doesn't have a contract with them and she'd never heard of it. The potential conclusions I draw from these discussions are 1) there is way too much noise to find what you're looking for with health apps, 2) docs just don't know what's happening with health apps or where to start looking (could be a result of #1 or just because they don't even know to be looking), and 3) docs put a premium value on their own ideas. #3 is the most intriguing conclusion to me.

Also in the last few weeks I've had two related conversations, one with a health system exec and the other with an investor, about doctor-built apps. The response I got in these discussions is that doctor-built apps are a bad idea because they just creates more fragmentation, silos, and noise. It's a very logical argument, especially with the current state of health apps. Creating more apps, especially if distributed to the app store, does create more noise for those searching for apps. Also, building apps that don't communicate with other systems or apps also creates more data silos.

When I think about doctor-built apps, I come to a different conclusion, and it in part is based on my belief in conclusion #3 above, that docs put a premium on their own ideas, as well as how and why patients will eventually find and use apps.

First, I think doctors are used to leading. Yes, team-based care is a big part of training and care; but, ultimately physicians are used to being in charge - directing care decisions and leading medical teams. There's nothing wrong with this and it doesn't run counter to current Pit Crew thinking. It makes sense that docs would think their idea for a diabetes app or a whatever app is better because it's their idea; this really isn't a unique quality of physicians at all. Everybody does this.

The main difference is that docs are a huge part of app success so getting them to buy-in, even if that means having lots and lots of different, but very similar apps, is not really a bad thing. That last sentence reminds me of the expression my wife and I heard countless times when we were backpacking through SE Asia, "Same Same, but different" (they even have shirts with this expression on them). From what we gathered, the expression means "similar" but "Same Same, but different" definitely fits better in this situation than just "similar".

I agree there is way to much app noise but that's only relevant if people are having to search for apps themselves. If the app has a physician name associated with it, or the doc distributes links to the apps, then it doesn't matter that the rest of the app store has another 100,000 diabetes apps. People will still find and use the app recommended by the doc. No noise issue. In fact, I think it solves some of the noise issue for patients and docs. Even better, my hypothesis is that docs will be more vested in patients using these apps and incorporate them into standard care.

The other problem with all of these different doctor-driven apps is the data silo problem. This one is hard to solve. Let's start with what we have now. Today we already have silos with health apps, so I'm not sure adding more silos is necessarily making things worse. If data is stuck in silos then it's stuck in silos, right? It doesn't matter if it's 10 silos or 100,000 silos. Fixing 10 silos is probably easier than fixing 100,000 silos, but you still need to fix silos regardless. I'm just not sure adding more silos is bad enough to offset what I think is the gain.

At least we have some emerging patient standards in CCDA and BlueButton Plus. Hopefully more and more apps will support these standards, solving some of the silo problems in the process.

I'm curious what readers think? I've gotten a few blank stares when I've discussed this with people. Do physicians want their own apps and should we encourage them to build them? Is it a net negative or positive?

This post was originally published on HIStalkConnect.

[travisjgood-blog]

What will patients pay for?

Or put differently, what do patients value when it comes to health-related services?

This is a question I've discussed a lot lately. It's one that fascinates me, because of the implications for both providers and patients. Cost is a very big and hot button issue, but hopefully the question I'm looking to answer can be broken down to make a discussion meaningful, and it's not really about cost the way most are discussing it.

Patients in healthcare, as many have written about, are largely insulated from the cost of the services they get. It's not surprising that patients would not know costs given many providers don't have a clue what services or visits or tests cost. The costs are so variable based on payer or geography or a number of other factors that it's really hard to keep track. But even if it's not absolute or exact costs, it'd be nice to know relative costs, imaging being the obvious example (MRI vs CT vs XRay). Lack of transparency is a problem, one lots of people are trying to fix.

Providers, at least the ones I know, aren't used to charging patients or collecting money directly from them. Bills are sent or collections are done by somebody other than the provider. There are some very unique practice models where this isn't the case buy by and large the days of a checkup being paid for in eggs or milk are gone. I've talked to probably 5 different youngish docs recently that have all told they'd feel uncomfortable charging patients for services like secure messaging because, even though they realize they aren't paid for fielding phone calls today, their patients have come to expect it. Maybe my perspective is based on too much exposure to big, academic medicine?

My question ultimately is what services would patients be willing to pay for out of pocket and next, would providers be willing to offer and charge for them? I don't want to bring in some massive disruption here by talking about payers or anything, just what services, driven mainly by convenience, are patients willing to pay for out of pocket? And then are docs willing to market those to their patients.

HelloHealth is probably the best example to look at, as their model allows providers to charge patients $3/month for PHR access, online scheduling, and secure Q&A with staff. More recent examples, what I think are the beginnings of a trend, that piqued my interest was Me-Visit and DoctorBase, both of which enable physicians to offer virtual services, charging patients out of pocket in the process. The premise of all these offerings (HelloHealth and DoctorBase do more than just the convenient, out of pocket services) is that convenience is worth something to patients and they are willing to pay for it. Do you think that's true? I do. But first we need to figure out what patients actually want.

First, some recent news about what patients don't want - simple portals. There was a pretty good article I read last week on the failings of the Mayo Clinic in engaging patients with its patient portal. It's very sad but also telling that Mayo put so much into this and is still struggling to engage 5% of portal users on a regular basis. It's good learning for the industry. So a simple portal with access to records, and likely some static associated education based on those records, is not something patients use, even if it is free.

I'm not knocking giving patients access to records, because I think this is extremely important, but you need to add context and connectivity to those records to make them really valuable. As the article above, there are other good example success stories of patient portals.

Enough about portals. I think what people really want is convenient access to things, like providers or services. It's really all about convenience and this is what people will pay for, at least I think they will. Convenience is what is pushing Walgreens further and further into healthcare delivery. Convenient, affordable care is not always easy. Putting in a retail pharmacy makes sense for people. Enabling access via technology also makes sense.

What specific services do I think people will pay for out of pocket from their PCPs? First, I think it's asynchronous virtual visits for non-emergent acute care and follow-up. If providers can offer these services for close to or slightly higher than the cost of deductible, I think patients will pay for it, or at least a decent number of them will.

Similarly, I think patients will pay for synchronous virtual visits (telemed) as well. These can be kept short, less than 5 minutes, and paid for out of pocket predominately now.

Another service is simply the ability to ask your doctor a question. This is different from an asynchronous virtual visit from above in that it is unstructured and not meant to be used for acute problems (though I'm sure some patients would). Examples I can think of are "can I drink alcohol while on this medication" or "is it safe for me to eat sushi while pregnant". I have no clue what you'd charge for this, since most people could use Google to find the answer; but, I do think some people would pay for this because the answer is from their doc.

What about medication refills? I've seen services that charge $1-3 for a patient to request a medication refill. This seems wrong to me but I can't really put my finger on why. If a patient called in for this, it'd be done without reimbursement, but turning a healthcare service into something that could be resold at Dollar Tree seems off somehow. Maybe that's just my strange perception and isn't real at all? This post was supposed to be about services I thought people would pay for out of pocket and, honestly, I'd pay $3 if it meant I didn't have to call or wait on hold or anything else.

Requesting medical records or vaccination records? I have kids and I'd pay for med records or for vaccinations if it was easy to do. I know our pediatrician so I know he'd never charge for that but, if he has a change of heart and makes it simple, I'd happily pay for it.

What about scheduling? Scheduling appointments is different, it's not transactional. I wouldn't pay to do it but I might pay for a services that included it, along with some other services like med refills or immunization records.

Obviously not everybody would pay for these services, just like everybody doesn't pay to fly first class or to join concierge practices. I do think there is a market for it, and it is largely offering convenience to patients using technology. It's also offering potential additional revenue to providers, especially to PCPs, a group that could use it.

So what do you think? I've asked more questions than I've answered but this is an area that really interests me and one that does have potential benefits for both providers and patients, as well as the system as whole, through increased efficiencies and cheaper care delivery.

This post was originally published on HISTalkConnect

[travisjgood-blog]

Blueprint Health Winter 2013 Class

Blueprint Health had it's demo day earlier this week. Lt. Dan covered this class back in January, and I wasn't at Demo Day in NY this week, so hopefully this post isn't repetitive. I did go to a different demo day (not health focused) last night so I am in the right mindset at least.

I really like Blueprint for a few reasons. First, it seems very focused on helping companies accomplish two things - raise money and get pilots / customers. Money is great but I think customers and pilots, which to me serve as validation, are much more valuable. With pilots and customers come an easier route to financing.

Second, Blueprint has a health-tech focused co-working space in NYC. The space is now used by 25 health startups. I love co-working space in general but really love this concept of bringing together health-focused startups in one place. Are there other health-tech co-working spaces out there? I know the guys at healthfinch and Moxe Health, along with a few other local startups, are looking to create a space in Madison, WI.

Below are my impressions of the 11 "graduating" startups in Blueprint's most recent class.

DocASAP. Being a service that helps consumers book appointments with doctors, you can't help but compare it to ZocDoc. What I definitely respect about DocASAP is that is launched right in ZocDoc's backyard of New York. The focus for DocASAP, or what I see as differentiating from ZocDoc, is 1) it is focusing a lot of marketing energy on trying to help docs boost online profiles, 2) it is partnering with payers, and 3) it is partnering with companies like Vitals.com so it won't be competing on search engine optimization (SEO). This last point is important because I think ZocDoc is putting a ton of resources into being very high on Google search results. Vitals.com, and Health Grades and a few others, are already pretty high on Google search results, so partnering with them seems like a great way to boost consumer bookings, which in turn will help sell practices for DocASAP.

Evoncea. Evoncea provides data and analytics to health delivery organizations so they can better market more profitable services to patients. It seems a little like Network Insights (I heard its CEO speak last night) in that it analyzes data, presumable consumer-generated data on the web (Twitter, etc), and then helps organizations understand what people are actually looking for and how they are looking for it. If you know that, it's easier to tailor marketing. It'd be really cool if a startup was using public data to proactively engage patients around care, and not profitable services, but you really need a business case for that, and that's a harder sell than marketing profitable services.

For[MD]. It's a different take on doctors networks, though there are definitely comparisons that could be made to Doximity. The unique angle is they are marketing to medical associations, presumably to replace Listservs and ideally more actively engage members. The service is free to medical associations. The company makes money by charging hospitals to use the platform to find and recruit new physicians. It makes a lot of sense but the biggest risk is probably when docs learn the association is essentially selling their profiles, through for[MD}, to recruiters. Maybe the associations already do this and docs don't know or don't care.

HealthyOut. This company is still in stealth mode but from what I can gather on the website it has a mobile app that makes it easy for users to find healthy dishes at local restaurants. It provides filters like heart health and gluten free. I definitely see this working with the same people that buy Fitbits and Fuelbands, meaning the people that are already concerned about their health.

iMedicare. Nice name. The company works with pharmacies to help seniors choose a Medicare Part D plan. From my parents experience and what I've read, the process of wading through plan info and making a choice is a nightmare. I thought others were doing this as well but the angle of working through pharmacies may be the differentiator for them.

IntelligentM. The company makes a wrist-worn device that detects hand washing by identifying hand washing motion. It's funny how much the hand hygiene space is heating up; I guess the word is out that hospital acquired infections are on the radar for hospitals. I'm not sure what else to say about IntelligentM. The concept seems like a good one, and I actually see clinicians more willing (I still don't think they'll like wearing something to track their compliance) to wear a band than a waist-worn hand washer like the one from SwipeSense.

Keona Health. The platform is meant to move nurse calls to online forms, saving nurse time by allowing them to respond using a few clicks. The saved time by nurses can then be used for other billable tasks, making offices more efficient. Seems like a good idea and it already has 6 paying clients.

Luminate Health. This platform helps clinical labs engage and educate patients. By doing so the logic is that labs are differentiated and form stronger ties to both docs and patients. I really don't know much about this area at all. Can you drive additional lab orders from docs with something like this?

Nurep. Nurep is a virtual medical device support platform for device companies. By providing virtual access, sales and support reps can be in more places at one time, increasing the number of physicians and locations they can support. The device market is big and growing with new devices in development or testing all the time. In related news, have readers been following the recent lawsuit against the makers of the Da Vinci robot? Pretty scary stuff. Remember to ask how many procedures your doctor has done when it comes to these new devices. The process of credentialing and determining competency with these new devices and technologies has to be improved.

PadInMotion. The idea is pretty simple - give patients a tablet they can use for entertainment as well as targeted education, subjective monitoring, and feedback. I debated this concept with friends about 3 years ago and still think it's a great idea. I even predicted it in my "Prediction for 2012" post. I'm happy the company is having success with 10 customers already.

Touch Surgery. Touch is creating mobile apps to help educate physicians with virtual surgery simulations. I imagine this would be very agreeable to medical device companies, and Touch has started working with a larger device company already. It does seem like a good way to stay up to date, and maybe tracking surgeon performance on the simulator patients could be one data point to assess competency with new devices and techniques.

This post was originally published on HIStalkConnect.

[travisjgood-blog]

The Evidence for Health Tech

I think everyone can agree type 2 diabetes is a big problem, both in the US and worldwide. It's big from a social standpoint. It's big from a financial standpoint. I guess that means it has a tremendous potential for financial and social ROI if effectively targeted.

I can't even remember when it was that I first wrote about diabetes and life-style decisions in health and how technology has such an incredible potential in this area. I may have lumped diabetes in with metabolic syndrome in this post from 2011; it's fun to go back and skim some of these old posts to see how the industry, and my own perspective, have changed over time. I've also written countless times about how hard it is to target type 2 diabetics as a patient population. Most recently I've written about Omada Health, which as a mission seems to be targeting pre-disease patients, starting with pre-diabetes.

With that background, I thought it was interesting to see this recent Cochrane Review article about the effectiveness of HIT-enabled interventions on diabetes self management. Cochrane Reviews are pretty fantastic because they filter and sum up evidence for specific topic areas. In the review linked above, the authors reviewed studies on the effectiveness of technological interventions for diabetes.

The review, which ultimately combined results from 16 studies and more than 3,500 patients, found that HIT-enabled interventions were only marginally beneficial to patients with type 2 diabetics, and only when it came to glucose control. There was no evidence that the tech-driven interventions helped with weight or other health-related issues.

I'll pause for the collective "damn it!". It does sucks. It really does, mostly because it would've been great if the review had found that tech-based interventions were overwhelmingly cost effective, clinically efficacious, and both patients and providers loved them. If those were the findings, then we would've seen 20 more health startups peddling diabetes self-management platforms, but more importantly, we would've seen more providers and payers interested these types of offerings.

The silver lining in the findings, to me at least, is that the review found mobile interventions to be more effective than web-based interventions. Web and mobile are converging and in time will be one; but, in the meantime, mobile has to be a key component of any self-management platform, period. Self-management is about ongoing, always on, closed feedback loop, in-your-pocket support, and mobile is essential for those.

Here's my overall impression of this review. It's basically that yes, we don't have great evidence from randomized controlled trials (RCTs) that technology-enabled self management is hugely effective for diabetes; but, that's because we're still so early in the market and product stage where things are evolving extremely rapidly. Technologies and products available today were not even possible a few years ago, so we're still pretty light on the data. I also think it shows that a one size approach doesn't work. Charlene Quinn, who's research was part of what the Cochrane team reviewed, said "In our studies we learned people needed an individualized approach to manage their diabetes, feedback and communication with a trusted source (health provider, diabetes educator, trained lay person or peer)". I had the pleasure of meeting Charlene last year at an event and I'd trust her judgement.

This post isn't all about diabetes, it's about evidence and research for new technologies and new forms of care delivery. Evidence is king in medicine these days, with good reason. When I was a med student, I had to do countless EBM (evidence-based medicine) projects and write-ups on patients. We'd even get chastised by more intense attendings and chiefs for quoting things like Cochrane Reviews or UpToDate articles instead of reading and citing the primary source. The need for evidence in support of medical decisions runs pretty deep.

But evidence shouldn't hold back health technology integration into medicine, and the Cochrane diabetes review, while informative, shouldn't be too discouraging. I'm not saying we ignore it, it's pretty helpful from an informational and educational perspective. Quite the opposite, I think we use it to dig deeper into not just the results but the reasons behind the results. We then tailor and test new tech-based interventions. In this new testing, will the app owners and champions please collect data, even if it's not part of a RCT.

The main thing that keeps me optimistic, in spite of these Cochrane findings, is the clear evidence that we need changes in the way we deliver care and interact with patients. To me the evidence clearly shows our current systems (both health and social) don't work when it comes to preventing or effectively managing diabetes. If evidence is king, we should be running from what we do now in search of a better alternative. Apps and technology are not a panacea but, in time, we will have evidence that shows intelligent tech-enabled or tech-augmented interventions are cost effective, clinically efficacious, and both patients and providers loved them.

This post was originally published on HIStalkConnect.

[travisjgood-blog]

Open Source Health Teach

When I think of open source and healthcare, I always think of Vista from the VA. I'm not sure how viable Vista is as a production EMR, but Oroville Hospital certainly got a good amount of press when it announced it had customized and rolled out an EMR based on Vista.

I also think of OpenMRS, which is extremely popular internationally and in public health, with a very active open source development community. I'm still a bit surprised that nobody has written any systems or apps in the US based on OpenMRS. I'm not quite as thrilled with the UI of OpenMRS but the backend seems pretty powerful, especially for population health stuff. Are there US-based software tools developed using OpenMRS? I'd really be interested to see them.

I've been thinking a lot about open source licensing and technology recently. In the process, I've been researching open source tools in healthcare, something that has taken me beyond Vista and OpenMRS. There are some really great open source stuff out there for developers of health and wellness. Some of the more interesting things on GitHub are under Children's Hospital of Boston. It's where all the Indivo and SMART Program code resides. If you haven't taken a look at it then you should, it's interesting to see what's out there and freely available. There's other Blue Button code and a bunch of EMR platforms and modules on GitHub as well.

The interesting part is that, despite these tools being available and ready to use for commercial or any other use (licenses vary but the ones I've seen for SMART and Blue Button are pretty flexible), none of the open source tools I find on Git are that popular, judging by the number of stars and forks, compared to other open source tools I come across. I imagine most health app developers are just building from scratch or don't want to bother integrating larger open source libraries with tons of functionality the developer won't be using, or doesn't think they'll be using or needing.

Personally, I really like that big non-health tech companies are actively building open source tools. Some of the best examples are Google (tons of open source developer tools like Angular.js and Yeoman), Twitter (does anybody build website without Bootstrap anymore?), and Learnboost (if you develop with Node, you likely use tools created and open sourced by Learnboost). The main open source example I can think of in health, and this is sort of a stretch, is Font Awesome (if you go to the site you'll likely recognize the icons from apps you use everyday). The guy behind Font Awesome is product lead a Kyruus, a health tech company (big physician data), so Font Awesome has been adding more and more health specific icons.

The extreme example of open source for companies are those companies that open source everything, and typically try to make money on enterprise support and services. The most recent example is Meteor, which has raised a bunch of money towards it's mission of making it really, really easy for developers to build apps using 100% JavaScript. The Meteor library is freely available to download and use, though it's still probably a bit early to use it for anything meant for production. I'm not sure how this model would work in healthcare and don't think any open source EMR models have had much success with this approach. The healthcare market seems more than big enough for something like this, but I guess the healthcare enterprise may not be ready today or may not ever be the right target, especially if it isn't building many of its own apps.

Open source can be a polarizing subject for discussion. I'm a big believer in the power of open source, in using open source tools in development, and in contributing back to the community in the process. I don't think every line of code that companies write is differentiating for them or is intellectual property (IP), and sharing that code back with the open source community, either by allowing individuals to share it or to open source it as a company, is a powerful thing; I also think it helps with recruiting developers, if that's a sell for you.

To some extent, it comes down to what you want to compete on. As an example, I don't think competing, or creating barriers to entry, on interfaces is sustainable in the long term, though there are some billionaires out there that may not agree with me or may not be too overly concerned with the long term. As another example, I also don't like competing on a data model; I'd rather see companies and products compete on how they add value to the data, such as through analytics or value add services on top of the data.

For me, the Health Design Challenge is a really great move to leverage crowd-design to create open source tools. If you haven't looked at the challenge, it's worth it to see some of the winning designs. Entries were just images, essentially mockups, but the ONC will be converting those designs into working code (presumably HTML, CSS, and JS) that anybody can use as a starting point, or ending point, for display of CCD data. As the challenge page states, "This will be like Bootstrap for health records...", and it's true, at least for personal health records.

For companies and investors, it comes down to protecting IP and minimizing risk. I think historically, and I'd vote many enterprise companies (especially in health) are operating in a historical tech context, most companies protected themselves and didn't release any code as open source. This has been changing with younger companies and generations, mainly outside of health and I think mainly in the consumer tech space. Also, Twitter's new IP policy for employee inventions is particularly interesting. I personally hope we start to see more of a change in healthcare as well.

What do you think of open source tools in health and the role companies should play in it?

This post was originally published on HIStalkConnect

[travisjgood-blog]

Orange, lemon, ginger, wheatgrass, honey. Very good. – View on Path.

[travisjgood-blog]

Our weekend project in first day that really felt like spring.

[travisjgood-blog]

Regulating Mobile Health Apps

Do you ever get the sense that this whole FDA-regulating-mobile-health is a bit of a circus? I've spent time trying to read up on what happened last week at the FDA meetings in Washington and I'm still pretty confused about the whole thing. I understand it became, or maybe it always was, a political debate pitting those that supposedly support business and innovation against those that supposedly support safety, using regulation as the vehicle.

As an aside, I recently got into a debate with friends about mobile devices and apps for young child education, and the parallels to healthcare were eerie; both healthcare and education have lots of technology money, products, and policies being thrown at them by people that don't really understand the problems because they aren't clinicians, teachers, patients, caregivers, parents, or students (actually seems hard not be any of those roles). I don't think innovation has to come from within the industry but some understanding of the key stakeholders is required. In healthcare, having a deep understanding of patients, and their social structure and motivations, is required if we're going to enable patients to lead us.

Back to mobile health regulation and the FDA. I'm really confused about why this is taking so long? Either regulate or don't regulate. Make rules and let's start interpreting them. Or was the draft FDA guidance meant to generate discussion and ultimately a decision on whether to really regulate or not? See, I'm confused.

I wrote a while back, after the initial draft guidance, about regulating mobile health apps and devices. I believe now, as I did then, that certain apps and devices should be regulated. The problem is deciding what needs to be regulated. I think certain things definitely need to be regulated, but even these can quickly move into gray areas.

Devices that integrate with mobile apps to measure biometric data (mobile health accessories). Good examples of devices in this category are connected glucometers like Glooko and iBGStar, pulse oximeters, and blood pressure cuffs. But even this gets a bit blurry to me when I start thinking about wireless scales. If scales are going to really be used in health and remote monitoring, and the use case I'm thinking of is a heart failure patient discharged from the hospital with a wireless scale (Withings or Fitbit lets say), then those scales need to be FDA cleared. The reason is that changes in weight would be a part of identifying and targeting interventions to avoid a readmission or an acute decompensation (not sure you can use "decompensation" in place of "decompensated" but I am anyway).

Clinical decision support apps for providers. I did some reading on this a while back and remember something to the effect of having a learned intermediary (clinician) between the app and the actual decision (dosing a med, for example) means that FDA clearance is not necessarily required. I'm not really sure if this was ever the case, or if it is still the case today? The app also needs to provide the intermediary with access to the algorithm that reached the decision. If this really is the case, I think this is ludicrous. Anything that advises a clinician about a treatment for a specific patient needs should be regulated. Yes, doctors are some of the most learned intermediaries out there but they 1) can't keep up with all the science and 2) don't have the time to review and assess app algorithms for accuracy. Yes, they will catch ludicrous suggestions, but hopefully so will other systems like pharmacies and dispensing machines. This is a category that definitely might be stifled by innovation but I'm not sure how you can avoid regulating in this area. It's pretty easy to create simple apps that help providers with calculations, like certain risk assessment or treatment apps, but there really needs to be some way to verify the accuracy of the apps themselves. Who else is going to take on the liability of "approving" these apps?

Clinical decision support for consumers. This is really gray because wellness and disease care are really gray. Apps that take an image of a skin lesion and tell whether it is cancerous should be regulated, but this is the obvious one. Legally is it permissible for an app developer to say "for entertainment purposes only" and get around regulation? I think this area is going to be the hardest category of apps to regulate and I'm not sure we're any closer today than we were two years ago to understanding what apps need to go through the FDA and which do not. I'm also not sure more congressional meetings are going to help us along.

One other thing about all of this that really baffles me. Speaking specifically about mobile apps and software, I'm not sure why there is a distinction between mobile and everything else, especially as it all converges, both in terms of hardware (big phones and small tablets) and software (responsive web, hybrid apps). What about health accessories that connected desktop computers for data display?

I'm curious what you would do if you were an app developer creating apps for healthcare? If you were new, low on cash, and needing to get to market as fast as possible, would you err on the side of caution and go through the FDA or would you go to market and wait for final rules to decide? Or follow both paths concurrently, which is what I'd do at this point I think? The problem is that even the final rules are going to leave a good amount to interpretation, something that will make for a nice environment for consulting and legal gigs.

The post was originally published on HIStalkConnect.

[travisjgood-blog]

Pre-juice. Plus some grapefruit. Rather tasty, though these golden beets were not terribly juicy. with Laurie – View on Path.

[travisjgood-blog]

What is to practice medicine today and what is it going to be in 10 or 20 years? Would you tell your kids to go to medical school? I've heard this question a lot, not directed at me but at practicing docs, my wife included. I remember talking to docs when I was in medical school, both academic physicians and community docs, and hearing over and over how the glory days of medicine were over. I also get asked by a doc, on almost a weekly basis, about career options outside of clinical medicine. I also get asked a lot if I regret going to medical school. For the record, I don't. I wouldn't change anything, other than to maybe have some of my debt forgiven.

Then I came across this article by a gastroenterologist. The author brilliantly lays out the nightmarish process required to become a physician today, including issues related to time commitments, career alternatives, reimbursement, and debt. For those that are unfamiliar, it's worth reading to see the black box from the inside. For those physicians or those close to physicians, it's worth reading to give voice to your own process and to read something that makes you nod just about every paragraph. It also may come off as whiny and might even piss off a few lawyers, so heads up.

Older docs may be wondering why the younger ones are whining so much, after all work hours rules continue to evolve and reduce the max hours residents are allowed to spend at the hospital. I think overall work hours have helped but I still know fellows that bust 80 hours almost every week (amongst other blatant violations) and other residents that are not-so-subtly told to make sure they report hours within the work hours limits to avoid getting programs in trouble. That's crap, and people I know at those programs know it, but rocking the boat is not considered worth it. And that's also not universal. I have several resident friends that are strongly encouraged to be honest about work hours because the programs truly want to stay in compliance. These topics tend to dominate our social outings.

And then readers may be wondering where the hell I'm going with all this and if it has anything to do with connected health or startups or patient engagement. Well, that KevinMD post above got me thinking. It's written as an attempt to give docs a voice. Why do docs need a voice? As my father-in-law loves to tell me (he manages specialty and concierge practices), "doctors have given away the farm". I think it's been a while since they even managed the farm, let alone owned it.

As clinical medicine, from a scientific (biopharma, genetics, our understanding of physiology and pathology) and evidence-based perpective, has grown in complexity, so have the other aspects of practice. The other aspects I'm talking about are things like practice management (billing/coding), documenting (EMRs), malpractice (legal), marketing (consumerization), and probably a bunch of others I don't even think about. This is forcing lots of docs (the word on the street in med school and training is solo and largely independent practice are dead or dying) to become employed. Being employed makes sense. It allows docs to focus on seeing patients without worrying about lots of the other stuff, or at least spending less time thinking about it. I've also been thinking about this a lot lately as my wife is going through the job search process and interviewing.

The downside of more employed physicians is that medical doctors are becoming trade workers, and my cynical perspective tells me they are being employed solely so that somebody else can resell their license. It goes beyond reselling and starts to become dictating how docs even use their licences or are paid for their licences.

Then I remembered this article from a couple months back. The article was based on a survey that found that 10% of docs would change to concierge practices, or direct primary care, in the next 1-3 years. I've always loved the concept of concierge medicine, at least I've loved the concept if it was affordable to more people. Direct primary care, the cheaper west coast version of concierge that has One Medical Group as its cheerleader, involves docs directly contracting with patients to offer most primary care services. Patients get same day appointments and docs typically spend more time with patients. Lots of the middlemen, the people that take a piece of the transaction, are cut out. It's pretty cool stuff if you can find a practice like it.

Well, 10% of doctors is a pretty solid number. It's not anywhere close to a majority but concierge never will be the majority. Most importantly for this post is that's 10% of doctors, in the next 3 years, that could definitely benefit from technologies that connect patients to practices, provide access to records, provide medical education, and extend the convenience that concierge practices offer to members. For developers this should be a huge target to solve distribution problems.

While 10% is great, I think some of what holds doctors back is the large commitment when you convert a practice to concierge. Is anybody doing partial-concierge today? My point is that maybe technology can help bump up that 10% to an even higher percentage, making it easier for providers to move to a more direct-to-patient model, powered by connected health technologies. Sherpaa Health is doing this for employers without sophisticated technology, providing employees with direct access to specialist physicians 24/7 via telephone.

It's exciting to see technology as enabling more direct connectivity between provider and patient. It enables providers to practice their trade directly with patients, instead of through lot and lots of layers. It opens doors to transparency and more direct accountability. It also has the potential of significantly lowering costs. Concierge has a clear incentive to make the connection between provider and patient but maybe the lessons learned can be leveraged beyond concierge. Even if not, healthcare is huge, and there is never going to a one-size-fits-all solution, but any double digit percent is significant. So let's keep watching concierge and start building, or adapting, technologies to it.

This post originally appeared on HIStalkConnect

[travisjgood-blog]

Golden beet juice (with lime, ginger, grapefruit, and carrot). Very pretty. Never heard of a golden beet before finding them yesterday. Similar but more mild tasting than red beet. – View on Path.