One Step Forward, Two Steps Back

Be careful what you wish for sure did apply to this year’s mHealth Summit, which was held last week in Washington D.C. Of the some 4,000 in attendance, I was one of the 10% or was it even 1% of those present that have attended all four events in succession. It is with that perspective that I came away from this year’s mHealth Summit more disappointed than ever.

At previous mHealth Summits, I often bemoaned the lack of organization of the conference, the often bizarre exhibitors one would find (couple of years back one exhibitor, and I kid you not, was marketing herbal aphrodisiacs) and basic necessities one would find at virtually any event, breaks with coffee, maybe a snack here and there. This disorganized, but charming event was mHealth Alliance Summits of years past.

After an initial partnership last year with the NIH Foundation, the original organizers of the mHealth Summit, HIMSS formerly took over the mHealth event this year. The result, a much more well organized registration process, greater focus on the exhibition area and a definite improvement on basic event logistics.

Unfortunately, HIMSS was less successful in improving the content of the numerous sessions that were held. It seemed that anyone with an idea for a topic was given a stage to stand on, or at least a panel to participate on even if what they had to say had very little to do with the session topic.

The exhibit area, while improving, still lacked a core constituency, HIMSS’s bread n’ butter customer base, the traditional HIT companies that one finds at the national HIMSS conference. This struck me as quite surprising as we are now beginning to see EHR vendors finally release solutions that truly enable physicians to use their tablets for bi-directional interaction with a healthcare facility’s core health information system.

But there were two things I found most disturbing about this year’s event. The first was how HIMSS handled the keynote presentations. From this vantage point, it appeared that each and every one of keynote was simply sold to the highest bidder and since they were sold, the winning bidder felt that their keynote provided them the opportunity to sell the audience on their concept, their product, their platform for mHealth. It was horrid to watch and cheapened this event to a level it has never seen in its short history. Seriously HIMSS, today you have enough clout in the market to not stoop this low so why did you?

Another big omission in the main stage was the lack of clinicians discussing the potential use cases for mHealth, the challenges to adoption, the challenges to link into legacy systems and how they see mHealth evolving in the future to meet their care delivery needs. THere could have been some stunning visionary talks on the topic, but none were to be found at this year’s Summit.

The other disturbing issue relates more to the industry itself and those positioning themselves to be the leaders in the mHealth market. Companies such as Aetna, AT&T, Qualcomm, Verizon, et. al., all spoke about an open platform for mHealth applications. Of course each of them was talking about their own proprietary “open platform” that they are hoping will become the de facto standard in this industry sector. Problem is: none of them have the consumer traction, nor a compelling enough vision to gain a critical mass of developers for their specific platform. There are no “Apples” in this bunch.

The need for a common set of standards that will allow mHealth apps to cross-talk to one another is a serious need in this sector, Without such standards, mHealth will never truly blossom into its full potential and remain the sideshow that it is today. Now, if we could get these big players to all agree that mHealth is far more important than any single one of them, that competing via proprietary platforms is a dead-end, then maybe we will finally get somewhere.

Note: As mentioned previously, we are getting ready to switch to a completely new site. THerefore, while you can leave comments here now for discussion, it is unlikely that they’ll be transfered over to the new site.

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The Promise of a Little Blue Button

Yesterday, I was in Washington DC to attend ONC’s Consumer Health IT Summit. While having high hopes for some breathtaking new developments, ultimately walked away disappointed as this event ultimately devolved into a Blue Button promotional event. Now I have nothing wrong with some promotion, after all my background is heavily steeped in marketing. What I do have a problem with, as an analyst, is major hype around any concept, technology, etc. that is not balanced with some serious, thoughtful critique.

There were times when I thought this event felt more like a channeling of a Health 2.0 event with the clarion call of “Give me my damn data” being chanted. At times like that I had to pinch myself to remember, no, I’m in the grand hall of the Hubert Humphrey Building. Of course the multiple, large portraits of past HHS Secretaries hanging from the walls was also a clear reminder of exactly where I was.

But despite some shortcomings, the event was focused around what may be the government’s (VA & CMS) finest contributions to promoting patient engagement – the Blue Button. The Blue Button was first released in 2010 by the VA to allow veterans to gain access and control of their personal health information (PHI). CMS later released their own version of Blue Button that allowed beneficiaries access to their claims data. The VA thought Blue Button would be a success if they saw 25K Vets use this capability. The VA passed that number long ago and now, two short years later, the doors have literally been blown off that original estimate with some one million patients now using Blue Button to gain access and control of their PHI.

That is a phenomenal rate of adoption especially when one considers what they actually have access to.

A Blue Button download does not give one a well formatted easy to read file of their PHI. No a Blue Button download is nothing more than a simple ASCII text file and when you look at such a file dump, it isn’t pretty. Thankfully, ASCII has been around since we were hunting the great wooly mammoth during the ice ages so just about any piece of software (e.g., legacy EHRs and claims data bases) can easily create an ASCII file and developers can likewise take an ASCII file and repurpose that text into something fairly legible.

One company doing just that is Humetrix who I first met at the HDI Forum in June. They were also present at this event where they gave me a quick demo of their latest version of iBlueButton – a nice piece of mHealth software that takes the ASCII file from a Blue Button download and reformats it into a very easy to read and decipher file that a consumer can share with their care team. There is even an iPad version designed specifically for physicians, which gets to my next point.

Whenever I am in the company of physicians, I often ask them how they are coping with the changes taking place and specifically adoption of HIT. Had one such conversation Sunday while I was doing the charity Jimmy Fund Marathon walk for cancer research. On this walk there are always quite a few oncologists and nurses and seeing as you’re walking for a good many miles, plenty of time to talk.

I asked one oncologist about HIT adoption at Dana Farber and meaningful use to which he quickly replied: “Meaningful use is the bane of our existence right now.” So I asked further: What problem could HIT really solve for him? He had a ready answer: “Rather than a new patient showing up with a mound of paper records that I must laboriously review, I want a digital version of a new patient’s record with labs, pathology, images, meds, etc. all readily laid out so I can make a more rapid assessment to define a treatment plan for that patient.”

Now we could wait until all the HIEs are in place, all DURSAs are signed resulting in frictionless data flows between healthcare institutions. We could wait until every certified EHR for Stage Two is deployed and physicians start using Direct messaging. We could also wait for patients to request under Stage Two that their provider transmit records to another (still not sure how complete those records need to be to meet Stage Two). Or we could enable Blue Button, educate the public and let them take direct control of their PHI and share it with whom they see fit. Plenty of options but if we really want to change healthcare, the last one is the most impactful, the most viable, but unfortunately like the others, it will take some time, though likely less than getting those DURSAs signed.

Getting back to yesterday’s event and my disappointment, following is what I would like to see in the future:

Honest and frank discussion on giving patients access to their records. The American Hospital Association was in vehement opposition to the Stage Two rules on patient access to their records. Let’s put them on stage to explain why, to give that contrarian viewpoint, to provide balance.

Enlist providers to discuss the benefits and challenges of giving patients access to their records. How does patient access to records change the conversation of care? How does it impact the workflow of a practice? What fears may physicians have and how do we address them?

Fewer panels of talking heads and more real world perspectives. The event had a wonderful moment when a Vietnam veteran talk about his healthcare challenges and how Blue Button contributed significantly to his self-management. Let see more of that, e.g. a Medicare patient using Blue Button.

And my biggest disappointment of all had nothing to do with this event – it had to do with Stage Two.

If indeed the feds really believe in the Blue Button the same way they believe in Direct then why the h*ll did they not directly put it into the certification criteria for EHRs. Clearly something went amiss and it is unfortunate.

Thankfully, many vendors have stated they will support Blue Button in a forthcoming release including Allscripts, athenahealth, Cerner, Greenway, and many others. Our last HIE report also found just over 25% of vendors profiled intend to support Blue Button in 2012. There is momentum here already, now we just need to on-board physicians to talk to their patients about the value of having access to and control of their PHI for as we move to more capitated models of care, the engaged patient may indeed be the miracle drug to rescue our healthcare system from financial collapse.

Addendum: Have received feedback regarding Stage Two and patient access to their records so let me clarify. Stage Two does indeed grant a patient the ability to access, view and transmit their records. This is incredibly powerful, especially with the push towards standards and the transmitted file being in a CDA standard format. As Keith Boone so clearly articulates, the content package that is transmitted under Stage Two is a fairly complete, summary document of care received and an individual’s health status. But Stage Two does not support an ability to transmit a full and complete longitudinal record. It is my understanding that the Blue Button, at least the instance at the VA, allows a patient to download their complete record thus why I took the argument down the path I did. 

In time it is my hope that the Blue Button becomes a symbol, as Keith puts it, “a verb,” that all will understand instinctively – click this, get your data and move on. Other services will take that data dump, transpose it the way you want it for the purposes you intend. The technology and standards behind it will simply become irrelevant to the user. It just works. Getting there will be the task of the S&I Framework workgroups. I wish them God’s speed in accomplishing that task for the benefit of all citizens.

Many in both the private and public sectors are working hard on that vision – keep up the good work!

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Implications: Supreme Court Gives Thumbs Up to ACA

This morning, as most of you already know, the Supreme Court ruled that the Privacy Protection and Affordable Care Act (commonly known as ACA) is constitutional and basically left the entire law intact. While it was no surprise that this was a close 5-4 decision, it was surprising that rather than rule that certain sections of the law were unconstitutional (e.g., the individual mandate), it was either an all-in or all-out dividing line (those in dissent would have thrown the entire law out the window). In fact, among our esteemed and we like to think highly knowledgeable readers, two-thirds voted in our prediction poll that ACA would be circumscribed by the Supreme Court while 17% felt the law would be upheld in its entirety.

Implications of Decision:
We are an analyst firm that is focused on the adoption and use of healthcare IT. Thus the implications of the Supreme Court decision which follow are focused on just that:

Healthcare systems will continue to aggressively move forward to form comprehensive care delivery systems (acquiring practices, long-term care facilities, etc.) to more effectively manage their patient populations across care settings. This will in turn require greater clinical connectivity and integration across these care settings. Expect to see very strong demand for health information exchanges.

Payers will continue to struggle with improving their operating margins. Some, such as United Health Group and Aetna, have ventured into the more lucrative and higher margin HIT market via acquisitions. Expect to see other payers make a move here as well jumping into the HIT market via acquisition(s).

Payers will also venture directly into care delivery via partnerships with large providers to stand-up ACO-like entities (e.g., Blue Cross of CA & Dignity Health) or acquire (e.g., Highmark and West Allegheny). We may also see some payers be quite innovative and begin providing more state-of-the-art, low cost concierge care services such as One Medical to serve the vast pool of some 30M+ new members nationwide.

To effectively and efficiently survive under future bundled care reimbursement models, hospital systems will finally have to get truly serious about patient engagement. No longer can they view this as just something for the marketing department to deal with (listen to yesterday’s podcast) but will need to actively engage with patients and aggressively encourage self-management of chronic diseases. This need will lead to a blossoming of innovation in new solutions, be they mobile, telehealth, whatever you want to call it to improve patient adherence outside of the clinical setting.

Got Analytics? Yes, analytics is going to be huge but today, most analytics solutions are not up to the task of serving all healthcare provider needs, or at least no single solution/vendor is. Providers will need to accept the fact that for the foreseeable future they’ll be purchasing best-of-breed solutions. But providers also need to do their homework as we predict that there will be a significant amount of consolidation, via acquisition, in this market over the next five years. And one last word of advice to providers, don’t count on your EHR vendor to deliver these solutions anytime soon.

Of course there is far more that we could delve into on the implications of this ruling to the HIT market but for now believe we have provided enough to get your collective  juices flowing. Is there anything we missed that you believe is screaming out loud in the HIT market due to this decision? If so, please let us know via a comment – we love comments!

In closing, hope all have a great July 4th week ahead and…

God Bless America

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Podcast on mHealth Report Findings

For those of you who do not have the resources to purchase our latest mHealth Report (mHealth Adoption for Patient Engagement)  here’s something that you may find of interest.

At the Health Datapalooza earlier this month, I sat down with Don Fluckinger of SearchHealthIT who interviewed me about the report’s findings. SearchHealthIT recently posted the interview, via podcast which provides some highlights of the report’s findings. If you want to learn even more, well just dig deep and buy the report, it really is quite good (yes, I’m biased).

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Some Areas We Covered in May Monthly

Earlier this year Chilmark Research launched its latest service, the Chilmark Advisory Service (CAS). One of the benefits of CAS is that subscribers receive a continuous feed of our research, from major annual reports such as the recently released 2012 HIE Market Report, to Quarterly Reports (e.g., mHealth Adoption for Patient Engagement) and exclusive to subscribers, the Monthly Update. Of course, subscribers also get unfettered access to our analysts to answer any specific questions they may have.

For the merry month of May, the Monthly Report touched upon four topics that are abstracted below:

Social Games for Wellbeing, Courtesy of Your Health Insurer
Much of this story was pulled from the forthcoming report that Cora is authoring that takes a close look at how payers are adopting consumer technologies (social media, gamification, mobile apps, etc.) to more effectively engage their members in healthy behaviors. This story looked at the current initiatives of Aetna, Blue Cross of California, Cigna, and Humana, each of which is taking a slightly different approach to more actively engage their members.

When Behavioral Health Goes Mainstream Will Technology be Ready?
This year, five states received grants of $600K each to explore how they would integrate behavioral health data into their statewide HIEs.  Analyst Naveen interviewed several stakeholders about how they would actually address the technology and policy hurdles to incorporate such data into an HIE. One of his findings, which he details in this story, is that current technology offerings from HIE vendors are ill-prepared to address this growing need to fold in behavioral health data into the HIE. Secondly, there remain significant policy issues that need to be addressed as behavioral health data is some of the most sensitive and protected health data.

Filling Gaps Separating Behavioral Health from the Healthcare Continuum
We had another story on the relative state of technology adoption within the behavioral health community. Our interviews with several stakeholders uncovered a market that is even further behind (at least 10-15 years) the rest of the medical community in IT adoption and use. As public health officials, healthcare organizations and others come to the realization that a significant proportion of chronic disease patients have a co-morbidity with a behavioral health issue, they are also coming to the realization that more effective care coordination must also occur with behavioral health specialists. John (the younger) takes a close look at what may develop in this market to fill the current gap.

Feds Look to Tighten Privacy & Security of HIEs
This last story took provided subscribers an assessment of the current Request for Information (RFI) for the Nationwide Health Information Network (NwHIN). The RFI was released on May 10, 2012 and is the an attempt by the U.S. government to establish a clear set of governance rules for the sharing and use of patient data within an HIE, and of course more broadly across the U.S., via the NwHIN. While the objectives are noble and to some extent needed, our assessment is that in several areas the RFI goes too far and will significantly hinder HIE innovation, deployment and adoption.

If you wish to learn more about CAS, please head on over to the Research Services page and towards the bottom there is a slide deck that provides a prospectus on CAS. If that piques your interest, drop us a line and we’ll be more than happy to answer any further questions you may have regarding the service.

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Latest Report: mHealth Adoption for Provider–Patient Engagement

The market is abuzz about all things mHealth. Press coverage on provider-patient mHealth solutions is ramping up with a recent example being the point–counterpoint piece in Forbes following the press waterfall about Happtique’s app-prescribing platform. We even wrote a piece recently about a personal experience using the iTriage app to self-diagnose E. Coli poisoning.

Here at Chilmark Research we have been following the adoption of mHealth solutions for some time and in addition to several private contracted studies for clients, published the report, mHealth in the Enterprise in late 2010.

We are now releasing our newest report, mHealth Adoption for Patient Engagement, Status, Trends and Forecast. This report takes a close look at adoption trends for mHealth apps that will facilitate provider-patient engagement. Our research uncovered a market with an enormous future ahead, (market will exceed $1.1B by 2017) but significant hurdles continue to stand in its way, at least for the near-term.

The report is both heartening and saddening. Heartening for the market will accelerate quickly in about three years time, a fairly short window for the healthcare sector. Saddened, because it means a lot of the current hype will overinflate expectations of impatient technology investors foraying into this unfamiliar space, greatly increasing the potential for high rates of failure as these investors pull the plug on their young prospects.

For the report, we started with the definition of mHealth from the WHO report mHealth, New Horizons for Health Through Mobile Technologies, published in 2011:

“…mHealth or mobile health is medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants and other wireless devices.

We then narrowed the scope to those offerings that went beyond mere monitoring and are truly engaging care providers in more continuous, patient-centered care. What we found should surprise no one that follows this market: there is almost no current market demand for such solutions, and offerings today remain in perpetual pilot stage.

The market won’t really be one to speak of until 2014 comes around. This is when CMS begins basing quality payments on a competitive scale. The advantage for these payments will go to provider groups that have already starting internal testing of first line innovations such as two-way patient messaging services.

The current mobile priority for progressive healthcare organizations (HCOs) is simple transactional systems that allow a patient to view their records via a mobile optimized PHR portal, and perform simple transactions such as appointment scheduling and prescription refill requests. These initiatives are largely being driven by the marketing department of HCOs to increase member/patient loyalty.

Adoption of these services is still incentivized by current payment models, where fee-for-service reigns supreme. Scheduling tools have repeatedly been shown to decrease patient no-shows and are hugely popular among users. Increasing the opportunity to provide billable services in the short term will equate to greater access to care in the long term as patients have the opportunity to adjust appointments according to their schedule, reducing issues around last minute cancellations, which happen with approximately half of all primary care visits.

The true revolution is in its earliest stages as more innovative organizations start to adopt patient-physician messaging tools. Over the past few years, a number of doctors were already starting to do this to improve their connection with patients, but standard email is often not secure enough to meet the requirements of HIPAA compliance. This has led to a number of companies developing solutions specifically for the sake of enabling more secure communication, some of which are just starting to be worked into the mPHRs previously discussed.

These ad hoc messaging systems are the first generation of what will later become true patient engagement solutions that focus on specific chronic diseases driven in part with patient-derived data. This will result in fundamentally different models of care provision, as patient-generated data factors into proactive, near real-time decision-making.

Over the ensuing years we predict convergence of disease specific care provisioning mHealth apps with an mPHR, secure messaging and various transactional tools. Today, no HIT vendor, whether from the mHealth, PHR, EHR or other has publically articulated such a solution suite though many look to be heading in that direction. The recent announcement by Aetna of its win at Banner Healthcare may be a very early indicator of what is to come.

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mHealth: There When You Need It

A couple of weeks back, Neil Versal wrote an interesting article for mobihealthnews on mHealth App development and adoption trends. While agreeing with some of the thesis of his argument, that many Apps have little relevance to the broader populace and seem to be more focused on the Quantified Self geeks, there are a couple of points he made that give a false impression of what our research and personal experience have found in this emerging market.

First, there was the argument that those who may be in the greatest need of using an mHealth App to manage a chronic condition may not have the wherewithal to identify and use an App. This is true for pretty much the entire population and not only those with a chronic disease. Our research for the upcoming report, mHealth for Provider-Patient Engagement, found a market where most mHealth App developers struggle to get users, particularly those with chronic illnesses, to continuously use an App.

Where an mHealth App has seen success is when it becomes a critical component of a care management process and a patient receives periodic feedback from a clinician. Such was the case in an urban, predominantly poor neighborhood in Washington D.C. wherein diabetic patients actively engaged in the use of an App to record their glucose readings for they were getting feedback from clinicians. Therefore, our thesis is that the issue is not whether the App has been designed for a given populace but its potential use (success) rests more with how and more importantly who deploys the App. The vast majority of the populace needs that clinician guidance and support in use of an App to manage a chronic condition – it will not work in a vacuum, it must become a part of the care management process.

However, in our conversations with a number of physicians we found a common theme that most are struggling to figure out how enabling their chronic disease patients with such tools and follow-on monitoring will fit into their existing workflow. We see this as code for: “How will I be reimbursed for this effort?”

Good question. The impending changes in reimbursement and subsequent move towards capitation may provide the path forward without the requisite CPT codes. There remains the challenge of how EHRs may accept such patient entered data from an mHealth App as today we do not know of any that can support this capability but that is a topic for another post. The important point we wish to make is that mHealth can play a role an important role in the care process, it just needs a advocate to drive its use, that advocate being a clinician/care management leader to help guide and support he patient.

The other issue we wish to raise is the oft-cited numbers that are thrown about of how people download various mHealth Apps and then rarely, if ever use them.

All of us who have a smartphone likely have a few Apps that we have maybe used once or twice and have forgotten about or tossed them for they did not appeal to us. But that does not necessarily mean lack of use equates to lack of value. Some Apps are not meant to be used frequently, iTriage is one of them, but I sure am glad I have it on my phone.

Now I have been a fan of iTriage from its early founding and was happy to hear that they found a willing suitor in Aetna when they were acquired last year. Their solution, while a little intimidating at times, is one of the better mHealth Apps out there in doing self-diagnosis, which is what I had the opportunity to do last month when visitng my parents.

Late one evening (actually about 3am) I awoke not feeling quite right. Next day I learned that I was not the only one as both my sister-in-law and father where also feeling under the weather. After a couple of days, my sister-in-law and I began to feel better. Such was not the case for my father. After some exploratory questions, came to the conclusion that we all suffered from some form of food poisoning. As my father’s health declined I asked him more specific questions about his symptoms. He was suffering from loose stools, weakness, fever and painful urination (sure sign of UTI). Using the iTriage App I triaged my father eventually settling on the likely culprit: E. Coli poisoning.

Knowing this was a very nasty disease (yes, it kills), you don’t waste time getting treatment. Took father to the local ER where they immediately put him on an intravenous feed of some pretty strong antibiotics and to hydrate him. The attending physician took a culture and stated they would have an answer  in some 36 hrs as to what was at the root of his symptoms. Sure enough, when the physician got back to us he confirmed that it was indeed E. Coli poisoning.

Prior to this event, when was the last time I opened up the iTriage App? Really can’t recall but it was likely to demo it to someone and probably more than six months prior. But this is not an App designed to be opened and used frequently, it is designed to be used when you need it. And that is part of the problem with a lot of these broad pronouncements about the use, or lack thereof, of mHealth Apps: some of these Apps simply aren’t meant to be used frequently but you’re sure glad you have them when you need them. The mHealth App market is far more nuanced and most do not dig deep enough prior to making broad pronouncements instead painting the whole sector with one stroke of the brush which is a disservice to this emerging sector.

As to my father, he has made a full recovery and one of the first things he asked me when he got home from the hospital was: What was that App you used? Can I put it on our iPad? Done. Now if only iTriage would make an iPad version of their App then my father, and maybe others would be even more delighted.

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mHealth Apps & Patient Engagement – Moving Beyond Transactions

Despite a constant buzz around the idea of using mobile technologies for patient engagement, the depth and breadth of these solutions has remained consistently thin and frankly dated. Today, healthcare organizations who are adopting and deploying engagement solutions are focusing these efforts on marketing/patient retention (e.g., simplifying transactional processes such as appointment scheduling, prescription refills, etc., online access to lab results & records) and accelerating payments (online bill-pay). Despite all the talk about using mHealth for care provisioning, our research for the upcoming report that will be released later this month, mHealth Adoption Trends for Provider-Patient Engagement, finds a market that is still in an early, embryonic stage of development.

So why the disconnect between the hype of mHealth for care provisioning and reality? Of the many potential reasons, there are two that are dominant: a lack of solutions with proven clinical efficacy and few financial incentives to drive adoption.

While there is little argument that increasing the interaction between a care team and their patients is a good thing, the best means for accomplishing this feat are still unclear. A year ago, Group Health published results from an internal study testing just what impact this increased communication may have on outcomes and patient satisfaction. What they found comes as no surprise to us as trusting advocates of patient engagement. In this study, Group Health provided patients suffering from depression a relatively simplistic form of engagement wherein patients were able to communicate with their care team through the EMR portal. The results, impressive: antidepressant medication adherence increased 33%, overall depression scores decreased, and satisfaction with treatment improved 61%.

While this study fostered communication via a computer/portal, it is not too big a stretch to see such communication readily migrate to a smartphone modality wherein a patient would not be tethered to a computer and could communicate from virtually any location. But that is part of the problem. This study, which was published only last year, uses a relatively old model of communication (portal), which has been used to varying degrees in the healthcare sector for years. And if there is a paucity of clinical evidence for the efficacy of portals, for mHealth Apps it will approximate a vacuum. Sure, basic logic tells you that increasing patient-provider communication should lead to better outcomes, but the healthcare community can be a bit odd at times in its demands for stacks and stacks of clear evidence before it is willing to take the plunge, either providers adopting such models of care and more importantly, payers will to reimburse for such models of care.

Therein lies the crux of the problem – reimbursement.

Now we don’t mean to be crass but physicians are like the rest of us. We are dedicated to our work, we work hard and at the end of the day we receive compensation for those efforts. For physicians, who seem to be perpetually overbooked, their time is particularly precious and adding another activity (patient communication outside of the exam room) without compensation, is a non-starter. There is also the issue of how does one bring mHealth data into an existing HIS let alone into the daily workflow of a physician is not without costs. Who will shoulder those costs when there are few if any reimbursement models in place to support such? This idea scares away investors and many innovators.

And that creates a Catch-22. Without clear reimbursement models there is little incentive to support the adoption of mHealth for care provisioning and therefore, little financial upside for innovators and subsequently creating an unstable market. To date, no mHealth engagement solution for care provisioning has been able to gain enough traction (relates back to financial) in the market to make a significant impact and thus are perceived as risky partners by healthcare organizations. There is ample proof for such concern as there remains a tremendous amount of churn in the mHealth market. For example, two startups in the space were recently ‘acquired’ by other startups: Pipette by Ginger.io and WellApps by Medivo (both in the same week no less!), yet far more start-ups simply fold-up their tents and move on. But without having healthcare organizations willing to take a chance, how are these young companies going to demonstrate clinical efficacy. Yes, Catch-22 indeed.

But all is not lost.

As we’ve written before, reimbursement models are migrating away from the traditional fee for service model and one that is structured around value-based outcomes. These new reimbursement models will in-turn lead to more capitated models of care where healthcare organizations will take on greater responsibility for managing patient risk. To effectively and efficiently do so, these organizations will need to create new models and processes of care delivery that extend beyond the confines of the exam room and actively engage the patient as a critical member of the care team (where they are capable of course). This has the potential to create a “Golden Age” for such new technologies as mHealth. But like all new market opportunities, a big question is timing – just when will the inflection point occur that will truly launch this market. In that forthcoming report we mentioned previously, we intend to provide some insight into that question as well.

Stay Tuned.

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300 Million Asthmatics and the Future of Respiratory Monitoring

A few years ago my daughter began developing asthma-like symptoms brought on by reactions to pollen, cat dander, and other triggers.  I can still remember the panic I felt in my chest the first time she ran to me wheezing and crying that she couldn’t breathe.  Thankfully, her wheezing episodes are mild, have decreased over time, and she never received the ‘Asthma’ diagnosis.

Serious health events such as a severe asthma attack produce such a strong, albeit negative demand for health care that the patient often winds up in the ER.  In this respect, asthma is unlike other chronic conditions with more deferred consequences (e.g. ‘diabesity’).

Clay Christensen wrote about this phenomenon in his book, “The Innovator’s Prescription”. Despite the significant behavioral change required (carrying inhalers, taking medication, tracking symptoms, following Asthma Action Plans), asthmatics and their caregivers have good reason to be engaged and compliant with treatment – immediate consequences (relief) to severe attack drive behavioral change (see figure).

A Growing Problem [a Growing Market]

In the US, the CDC reports that 1 in 12 people have asthma. There has also been an unexplained increase in rates among African American children – an almost 50% increase in the past decade.

[Note: Why are asthma rates soaring? Possible causes are not fully understood within the scientific community.  The ‘hygiene hypothesis’ blames ultra-clean western societies that suppress the natural development of the immune system. Other research refutes the hygiene hypothesis and points to western lifestyles/obesity as culprits. There have also been more Asthma diagnoses due to improvement in diagnostic methods over the last few decades.  Further reading on possible causes can be found at Scientific American.]

Given that asthma is a severe, chronic disease affecting a large percentage of the population, it is easy to make the case for investment in asthma-related products.  The American Academy of Allergy Asthma and Immunology (AAAAI) estimates 300 million people worldwide are currently affected – almost 5% of the population, with incidence rates on the rise.

Segmenting the US asthma market by age provides a model to understand key engagement models:

• Asthma Moms are continually engaged in their child’s care.  They oftentimes take information, tips, and questions to the blogosphere.
•  Adolescents manage their condition with Mom’s guidance, though they are not as vigilant in adhering to treatment plans.
• Adult Asthmatics no longer have Mom looking over their shoulder, but are nonetheless motivated to keep symptoms at bay.

Devices to Monitor & Prevent Asthma Attacks

When my daughter was having frequent wheezing episodes, I would have found piece of mind in a technology that could detect and predict when she was going to have an attack… or at least warn of nearby environmental triggers.

Taking a quick look at the Apple App Store, there are almost 100 asthma-related Apps available.  These range from free educational Apps to diary-style Apps that require data entry to track peak flow and symptoms. Do Asthma Moms, especially those whose children have low-severity asthma, really have the time and motivation to write asthma diaries? Not to mention adolescents and adult asthmatics?

One company, iSonea, is building technologies to avoid this tedious (and possibly erroneous) data entry.  iSonea is currently making a big bet that consumer and provider appetite for asthma monitoring technologies will grow in the coming years.

iSonea

iSonea is a recently restructured and re-branded company that has been developing proprietary acoustic respiratory monitoring (ARM) devices for years. These devices are equipped with sensors and software that detect acoustic markers such as wheezes, rhonchi and cough.

Note: iSonea was formerly KarmelSonix, a medical device company consisting of a joint partnership between Israel and Australia.

I had the opportunity to speak with the new CEO of iSonea, Michael Thomas, who sees iSonea transitioning from a device-centric company to one that is software-based (guarding the castle with already-acquired IP).  In a future filled with Smartphones,   iSonea will try to reach those 300 million asthma patients through mobile Apps rather than through proprietary, expensive devices.

Imaging breathing into your Smartphone, which will analyze and quantify your wheezing in the audio.   Or, imagine your Smartphone setting off an alarm as it detects nearby environmental triggers, crowd-sourced in almost real time by nearby asthmatics.

iSonea is looking at the following revenue streams:

• App downloads and upgrades. The first version of their AsthmaSense™ App will be released in 2012 with a subscription service.
• Data. Anonymized patient data will be up for sale (iSonea is partnering with Qualcomm Life to get data out of devices and into the cloud). If a statistically significant number of asthmatics use the iSonea App, this data becomes valuable to a host of buyers.
• Ads. Products and services could be marketed to the user based on usage patterns.  For example, coupons for therapy drugs could be displayed, etc. (This remains a sensitive area – iSonea needs to find the right amount and types of ads, if any)

Emerging Technologies to Engage Consumers

Another topic I discussed with Mr. Thomas and his VP of Marketing, Michael Cheney,  was the issue of how to make the Smartphone App ‘sticky’, or compelling to use.  All of us mobile-addicted folks know the feeling –  when out of the blue your brain sends you a signal to take your phone out of your pocket and start slinging angry birds.

Will the healthcare space tolerate consumer engagement strategies that have shown success elsewhere?   For example, can we social-ify and game-ify healthcare apps and expect higher user engagement?  I remain hopeful that, treading carefully, healthcare apps that use social media and gamification strategies can indeed achieve higher engagement rates, especially among  digital natives (youths).   App developers are already starting to wade into these waters. One interesting example is the DiaPETic App, where users are rewarded via their pet avatar for sticking to a glucose testing plan, much like the popular children’s online game, webkinz.

Who knows, maybe iSonea’s App will indeed spread virally as users encourage their friends to start “playing along” with them as they manage their symptoms and avoid attacks. Engaging adolescents in this manner would especially be appealing to Asthma Moms, who could do with a little less stress in their lives. But iSonea will need to take their existing mHealth App a bit farther than they have to date to enable such viral attraction among adolescents.

Anyone Else Out There?

There is a surprising dearth of competitors to iSonea, which means that either iSonea is particularly early and/or the space is an especially risky one – with no worn paths to tread.

One company that may morph into a company more like iSonea is Asthmapolis.

Asthmapolis is based out of Madison, Wisconsin and founded by Dr David Van Sickle, formerly of the CDC. They manufacture GPS-enabled devices that attach to inhalers, tracking when and where an asthma puff was needed. Recently, Asthmapolis announced a partnership with Dignity Health (formerly Catholic Healthcare West) where doctors will monitor patients’ inhaler use via a mobile App.

Like iSonea,  Asthmapolis will make asthma data available to patients and clinicians, and sell it to public health agencies and scientists.  Asthmapolis is also developing mobile Apps to receive and display this data, but is not currently (or publicly mentioning) any intent to move beyond GPS-inhalers and towards Smartphone-based asthma monitoring, which is a little surprising in this day and age when just about anyone that is considering a mobile App, typically ahas a smartphone strategy associated with it.

Market Analysis

How will iSonea (and Asthmapolis) defend their strategic positions if the market revs up and new competitors race to the honeypot? Will iSonea’s IP be strong enough? Will they have enough cash to hire good patent infringement lawyers?

Or, maybe this market will really be about the data and network effects.  The service to garner the most momentum early on will become exponentially more valuable until the market tips.  I wonder if Dr Van Sickle’s relationships with the CDC and medical researchers are strong enough so he has first dibs on selling data for population health management.

It will also be interesting to see when and where pharma will step in here (GlaxoSmithKline comes to mind).  Better daily monitoring leads to improved medication compliance, which will help fill pharma coffers.  I’m sure iSonea/Asthmapolis are already entertaining numerous solicitations for partnerships from Big Pharma.

Towards the Utopia of ACOs

The improved monitoring and prediction of asthma attacks definitely has a role to play in a post fee-for-service, ACO/PCMH world.  No doubt these technologies will help shift the patient’s perceived role from passive recipient of care to a more empowered consumer of health, resulting in less ER visits, less readmissions, and ultimately lowered healthcare costs. The social/crowd sourcing component may prove to be especially valuable – with asthma sufferers steering clear of various dangerous locales where several “attacks” occurred. There is, of course the whole privacy debate and clearly, patients should be given an option as to whether or not they wish to have their data shared. More than likely, most will choose to share their anonymized data, but that should be their choice and not that of the vendor of such solutions.

Of course there is no guarantee that consumers will adopt these technologies en masse. Will this be a technology that consumers ‘pull’ rather than it being pushed on them by providers? Will they adopt without a physician’s order or feedback and without FDA approval? One remaining issue is how to monitor children who can’t be trusted to carry a smartphone – either they need to wear some form of (expensive) proprietary device or then again mobile platforms such as the Apple iTouch with a simple data plan may fill this gap.

On a personal level, I would nevertheless like to see asthma monitoring stand out as a poster child for remote monitoring success.  If we can figure out a way to engage Asthma Moms, adolescents (with Social/Gamification strategies), and adult sufferers, then moving on to other chronic conditions on Dr. Christenson’s 2×2 matrix will begin to look more achievable.

Just this morning my daughter told me that she had trouble breathing last night. I look forward to the day when instead of me learning of her symptoms after-the-fact, a phone can wake me up in the middle of the night to warn me to check on her immediately.

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HIMSS’12 Take-away: Follow the Money

Last week we attended the big healthcare IT confab HIMSS in that grand city of sin, Las Vegas. While many spoke of how HIMSS hit an all time record of over 37K attendees (an impressive number), HIMSS is still dwarfed by what is arguably the largest US-based healthcare trade show, RSNA, which had a 2011 attendance of just over 57K, (roughly 54% greater than HIMSS). Why such a radical difference you ask? As one colleague put it:

RSNA is where providers come to make money and HIMSS is where they go to lose money.

While that may be the case today, it is unlikely to be so in the future. The healthcare industry is undergoing a massive transformation that will likely take a decade to complete as we transition from a reimbursement model largely based on fee for service to one based on outcomes. Under this new model, providers will be taking on a greater portion of risk. In reward, these providers have an opportunity to receive a significantly higher net reimbursement. This transition is making for some interesting bedfellows as payers and providers join together to create new care delivery models such as Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs). These new models will be increasingly dependent on a robust HIT infrastructure to effectively measure quality, risk and performance, something that simply cannot be done effectively with the antiquated systems that are in place today in many healthcare organizations (HCOs).

Nearly every vendor we met with at HIMSS had a story to tell about how they had the solution the market was seeking for ACO enablement. This was not entirely unexpected for last year we thought that would be the year of ACO. Obviously, we were a little ahead of ourselves and the industry with that prediction but alas it has come to pass. Small problem though: HIT vendors have had plenty of time to prepare their solutions for ACO enablement but to our surprise, most solutions were still far from mature. Frankly, we are not too worried about this right now for Chilmark is forecasting significant evolution, innovation, and in short-time maturity in these solutions as customers (HCOs) further define what they truly need to succeed in this new world order of reimbursement for healthcare delivery in the US.

This raises what our research team found to be the most significant learning from HIMSS’12.

As most of you already know, ONC made quite a splash at HIMSS by announcing the release of Stage 2 meaningful use (MU) requirements (we’ll have a future post on the implications of these requirements later this week). But honestly, we did not see a wild wrangling of commentary and discussion in the halls of HIMSS’12 regarding these new requirements. Maybe this was because most attendees were simply addressing the needs of today and did not have time to thoroughly review these new requirements. But we believe something else may be at work here.

Our Thesis:
The MU requirements have become little more than a “spec-sheet” for vendors, consultants and IT shops and departments. These requirements have nothing to do with innovation and have little to do with the dramatic changes that will occur in this industry in the next decade. Quoting that oft-used phrase, “follow the money” one can quickly see that the billions in funding for incentivizing providers to adopt EHRs under the HITECH Act is relative chump change to the dramatic fortunes that may be won or lost under the new value-based payment models that are proliferating throughout the industry – payment models that commonly fall under the rubric of ACO or PCMH. In each of these models, EHRs are important to a degree, they are part of the basic infrastructure. But it is what one does with the data that matters (collect, communicate, collaborate, synthesize, analyze, measure and improve). Therefore, if you want to see innovation look beyond today and the tactical push to effectively adopt and meaningfully use EHRs and towards the future of how that data will be used to drive quality improvements, better outcomes and lowering risk exposure.

And speaking of risks…

What was clearly lacking at this year’s HIMSS was patient engagement. Yes, there was a seminar on the topic and sure, everyone speaks of patient-centric care but there was little evidence among exhibitors at this year’s HIMSS (with a few exceptions, e.g., Cerner, MEDSEEK, RelayHealth) that spoke to the need to engage patients as part of the care team. Get a clue folks, one will never get to that nirvana of a truly effective ACO or PCMH without active, effective engagement of the patient. Not having an engaged patient is your greatest risk.

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