Posts Tagged ‘iTriage’

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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In Monday’s post, Chilmark reflected upon a piece that Peter Hudson, co-founder of Healthagen, the developers of mHealth app iTriage wrote for mobihealthnews. In that article, Peter talked about the utility of an mHealth-based PHR (iTriage recently launched such capabilities), but in our post, we countered that today, it is still far too difficult for a consumer to pull together their personal health information (PHI) to create a truly longitudinal record. This will likely stunt the efforts of companies such as Healthagen who are trying to offer consumers a PHR – the hassle factor is still far too great to overcome.

Now we will look at the red hot space of Health Information Exchanges (HIEs).

As local, regional or even statewide aggregators and distributors of health data to facilitate care coordination, HIEs have the potential to play a pivotal role in helping a consumer create and manage their PHI. Now that does not mean that the HIE has to offer the consumer a PHR per se, but what an HIE may be able to do is offer the consumer an ability to have a portal view into their PHI that resides within the context of a given HIE. Better yet, why not have as a condition of receiving some of that federal largesse of $564M for state HIE programs that these HIEs support “Blue Button” functionality allowing a consumer to readily download or export their PHI to wherever the consumer desires.

Ah, but we digress.

The purpose of this post is to extract a couple of data points from our forthcoming HIE report as they pertain to consumer engagement. Unfortunately, it is not a pretty picture.

As part of our market survey of twenty HIE vendors, we asked them a number of questions with regards to what consumer-centric capabilities did their HIE solution support. Fully eighty percent of those interviewed had either modest (15%) or weak (65%) consumer offerings.

The following table provides a brief snapshot of those HIE vendors that have what Chilmark considers strong consumer engagement tools. Two of those vendors, Kryptiq and MEDSEEK are somewhat difficult to classify as an HIE in the traditional sense, thus you will not find them running under the covers at your local RHIO. Microsoft is still new to the HIE market with one HIE live in Milwaukee and another in D.C.. While Microsoft’s platform offers these HIEs the potential for bi-directional communication with HealthVault, that capability, to the best of our knowledge has not been tested at either of these HIEs. Also, it is important to note that the Microsoft HIE solution offers little with regards to support for transactional processes (appointment scheduling, Rx refill, eVisit, etc.). RelayHealth is the remaining HIE vendor that actually has some of the more robust consumer tools in the market (they received fairly high ratings in our previous iPHR Market Report), so this is not too much of a surprise.

Now it is not necessarily the fault of laggard HIE vendors that today, their solutions offer weak consumer tools. Frankly, the market has not asked for them. Even as recently as last year when the various HIT policy committees were meeting in Washington to set policies for the HITECH Act and the funding to come, the committee on HIEs, in one of their seminal meetings, completely ignored the consumer role in an HIE. Shameful.

But this will change in due time. MEDecision and Carefx are building out their consumer-facing capabilities and we are sure others will add consumer functionality in time, most likely via partnerships or an occassional acquisition as market is moving too fast for an internal build-out. in the meantime, those vendors that have this capability bring to market competitive differentiation.

While this is all well and good, another development is also taking place, NHIN Direct – something that Microsoft’s chief architect, Sean Nolan mentioned in his comment to our Monday post. What role might a secure, lightweight communication system play within the broader context of HIEs, aggregated PHI, consumer access and potentially control of their PHI? A lot of questions to ponder that we will be looking into further over the next few days

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iTriage is a slick iPhone app that we first took a look at back in April.  A couple of weeks back we had a chance to meet with the CEO, Dr. Peter Hudson (yes, he’s an ER doc who still practices medicine) who was in Boston to attend a conference.  During that meeting, Peter gave us a brief update on progress to date, including their recent announcement with HCA to become a premier listing service for South Florida.  Following is what we learned.

Since its launch in April 2009, iTriage has maintained an enviable position as one of the top downloaded apps in the iPhone AppStore, currently in the top 10% of all apps downloaded.  When one thinks about all the 35,000+ apps currently available and some 1 billion apps downloaded to date, that is pretty impressive for a small company.  Clearly, they must be doing something right.  That being said though, if they are such a popular app, why don’t they at least show up on the AppStore Health & Wellness or Medical sections in the list of top paid apps? Curious.

The parent company’s (Healthagen) business model is to solicit providers, mostly large integrated delivery networks (IDNs) to become premier sponsors who pay an annual subscription fee (based on number of hospitals & clinics) to Healthagen to have their facility listed along with some brief marketing content, including the ability to upload videos, as to why one would want to go to their facility (typically ER) versus others. Thus, Healthagen is tapping into the marketing budgets of IDNs. With home offices in Colorado, Healthagen has done a good job of landing the big IDNs in Colorado including Centura Health.

On October 5th, HCA announced that they would become a premier sponsor as well for their facilities in South Florida.  What is particularly cool about this announcement is that in addition to the standard promotional marketing content that one may find in iTriage on a given HCA facility, HCA will also be providing real-time information on expected wait-times in ER, right there in the palm of your hand on your iPhone and in a recent upgrade of the software, a Blackberry as well.  (In November, they’ll release versions for Android and PalmPre.) This is all part of a larger push by HCA, which includes posting wait-times on billboards in this region to drive consumers seeking medical attention to their facilities as a significant percentage of those admitted to ER wind up being admitted for more extensive care.

Granted, someone having a heart attack will dial 911 and go to the nearest facility, or as in my recent case, choose a hospital known for excellent care based on a recommendation (the EMT that treated triaged me suggested I go to Brigham & Women’s as they have the physicians to treat nasty cuts, in my case a plastic surgeon stitched me up). But there may be other cases where someone who is feeling ill and cannot get an appointment with their primary care physician or are on travel, may find this feature useful.

Now, if I can only get something like a change:healthcare feature embedded into iTriage for costing information, a medication checker like PharmaSURVEYOR or DoubleCheckMD (who knows, maybe that new med I was prescribed is causing all the grief) to evaluate current meds I am on and while we are at it, a more user friendly mobile interface (yes, they do have an avatar on the Web) then we really would have one powerful app to support consumer-driven healthcare.

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img_0002Couple of weeks back had the opportunity to talk to the CEO and CMO of Healthagen, developers of the iPhone app, iTriage a new, consumer-facing app with some interesting twists, including partnerships with Coalition America, HealthGrades and TelaDoc.  iTriage can be found on the Apple iTunes store for less than a dollar.

The co-creators of iTriage, who happen to be ER docs, developed the app to address a very real issue they saw everyday in their day jobs: The huge information gap that consumers have in choosing what level of care is appropriate for a given symptom.  In developing iTriage, they wanted to marry “symptomitology” with diagnosis and from there recommended best care procedures/treatment plans and who is most appropriate to conduct those procedures for that given diagnosis.

How it works:

iTriage always launches with the question: Is this an emergency? If one answers yes, app automatically calls 911.

Once one gets past the “emergency question,” iTriage presents a very long list of symptoms alphabetically with search bar at top. Search on say chest pain, viola, there it is.

img_0003After clicking on given symptom  (we’ll use chest pain) one is provided an extensive list of possible causes (33 popped up for chest pain) which are often highly technical terms e.g., costochondritis, hiatal hernia, etc. and some more basic terms such as lung cancer. Within “Possible Causes” iTriage does offer a filter to limit selection to common, pediatric and life threatening causes.

Click on a Possible Cause and you are provided a number of fields to further drill down and understand the disease including standard work-up and treatment which may prove very useful in a clinical encounter.  Standard work-up and treatment guidance is based on best practices (the developers of iTriage set-up a review board to oversee and approve work-up & treatment write-ups found in the app).

To some extent, much of the above can be found in other iPhone apps such as A.D.A.M., SymptomMD and WebMD, though none of those apps do it as extensively and comprehensively as iTriage.

img_0004But where iTriage really gets interesting is assisting the user in the next step, where do I go to get treatment.  Once one goes through the above self-triage steps, you can click to “Advice Line” which takes you to an embedded TelaDoc page where one can initiate a call to TelaDoc to get fee for service advice on your symptom(s)/condition.

In addition to geting advice, one can also click “Find a Facility” and based on the disease you have self-identified, iTriage suggests which facility is most appropriate (see figure) and then leveraging the GPS capabilities of the iPhone locates the facilities within a given radius and provides directions from current location to the one chosen. Currently, iTriage has over 67,000 facilities listed within its proprietary directory.  iTriage also has established a partnership with physician/hospital rating service, HealthGrades allowing the user to access information (like TelaDoc, for a fee) on specific facilities listed.

Nice features, especially for someone who travels as frequently as I do.

The Business Model:

Certainly the company will make some money selling the app, but at $0.99, they’ll need to sell a lot.  They’ll also have some revenue sharing with their partners Coalition America, TelaDoc and HealthGrades.  But what they are really banking on is listing services, much like the Yellow Pages, but in this case listing healthcare provider services, probably geo-located, within the app. Company emphatically stated that they will not rely on referral fees.

The Good, Innovative Aspects of iTriage:

1) Comprehensive list of symptoms and diseases with vetted work-ups and treatment options.

2) Unlike most iPhone apps, which are siloed.  iTriage founders have done a mash-up of sorts leveraging partners to create a richer, more complete experience and of course, service.

3) Puts a lot of power into the hands of the consumer.

4) Low cost to end user to promote adoption, this could easily get viral.

5) Full HIPAA compliance to appease the privacy and security community.

And the Not So Good, Needs Improvement Category:

1) Interface is challenging and does not appear to be designed with the average consumer in mind.  Far too many of the diseases listed for a given symptom are in obscure medical terminology that is difficult to decipher.  This may be fine once a medical professional has confirmed a diagnosis and one wishes to know standard work-up and treatment, but as an entry point into self-triage, not so sure this is the best approach.  The filter feature helps to simplify searching on diseases, but while his may shoprten the list, there remains the technical jargon.  More graphical capabilities are needed – A.D.A.M. & WebMD have done a good job here that iTriage would be wise to emulate.

2) iTraige would also benefit from a built-in Natural Language Processor (NLP) allowing a consumer to enter common terms to search for a disease rather than a very long pick list.

3) Invoking the services of partners, particularly HealthGrades and medical bill negotiation service Coalition America is less than ideal. Right now, it is basically a punch-out to the Home Pages of these partners’ websites.

The Wrap:

A lot of utility in a small, cheap app that one can have with them wherever they go and tons of promise for the future as they expand partnerships and functionality to include such things as average costs of procedures, medication checking, etc.  In its current form, it is certainly a good app to have when traveling, and if having fallen ill with no idea where to turn – iTriage can be a great resource.

But this app, in its current version, requires a sophisticated user and takes some practice (too much in our book) to navigate effectively.  The developers have many plans in store for the app and will be releasing at least two more updates prior to Apple’s launch of the new iPhone OS 3.0, which is expected this summer. Let’s hope those versions focus on usability, the GUI and better embedding of partner services, rather than adding anymore features of which they have plenty for now.


Just as we were geting ready to publish this, came across a presss release from Healthagen sent out today, 4/16/2009 announcing that iTriage will now have a cost estimator to assist the user in identifying potential cost of care.  Another nice feature Healthagen, but please, let’s get that interface cleaned-up.

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img_0112Got back late last night after a relaxing (at least mentally) trip out West, first to give a Keynote presentation at LabInfoTech, and then onto Aspen, Colorado for some downhill skiing escapades and general romping in my old stomping grounds. (Spent most of my teenage years in Colorado Springs.)

Beautiful sunny days with temperatures on the mountain reaching 50+ degrees, that is scary warm for the mountains. Luckily, there was plenty of base so the rocks only appeared on the steepest and most skied runs. I managed to avoid all the rocks – my skis were thankful.

While I skied the three major mountains of Aspen Mountain, Snowmass and Highlands, it was Highlands where I spent the majority of my time.  A great mountain with breathtaking views that no camera can do justice and plenty of challenging runs.  The highlight of the whole trip was the 35min+ hike (in ski boots and skis on shoulder) up the ridge to the top of Highland Peak (~12,400ft) to ski the Highland Bowl.  Picture above is view from the top. Did the amazing drop down the face of the bowl.  One of those super steep runs where if you lose a ski, you’ll be walking a long time down to retrieve it.  What a thrill!

On to the Healthcare Front & Some Quick Notes

The Obama administration appointed Harvard Professor and policy wonk, David Blumenthal as the new head of ONC.  Had heard rumor back in November that like his Harvard compatriot, David Cutler, Blumenthal was destined for a high-ranking position in HHS.  This is a great appointment as the new responsibilities of ONC, as defined in the ARRA require a more visionary leader – Blumenthal fits that need.

A Modern HealthcareIT article incorrectly mentioned that the Mayo Clinic had put on-hold any movement of consumer health data into HealthVault pending further interpretation of new HIPAA guidelines in the ARRA.  As it turns out (direct communication with Microsoft) no such thing has occurred and all is proceeding ahead, as planned.  While the author may have mis-quoted Mayo spokesperson, there is broader concern in the industry regarding the extension of HIPAA to “business associates” and what exactly defines a business associate.  The legislative language is unclear leaving many to wonder how the new HHS administration will ultimately define this term.  This could get tricky.

The small innovative EMR company, MIE (they are also parent of the PHR, NoMoreClipBoard) won a modest size deal with the Internet giant, Google to provide the EMR that will go into Google’s on-site clinics. Assume a big selling point was NMC’s existing relationship with Google Health.  Will be talking to NMC later and have the full story tomorrow.

There is also a new iPhone app, iTriage which looks interesting.  Developed by a couple of ER docs, iTriage resembles a mash-up, combining a symptom checker with doc finder and even has a relationship with Teladoc for immediate, on the phone assistance.  So far, the app is getting good reviews on the iTunes App Store and for a mere $0.99 for the app, looks like a good deal.  Hope to talk to the founders within and week and have more to report.

In closing…

No matter where my travels take me, there is always someone ( or many) I meet with a healthcare story of their own.  Aspen was no exception.

It continues to surprise me just how many struggle with the current, archaic method that we use to currently interact with the healthcare system and receive care.  When I tell them the type of research perform by Chilmark Research and the companies followed, there is almost universal awe and desire to use these new tools that are designed to assist consumers in managing their own health.  Rarely does the issue of privacy and security come up. Far more often is the desire to facilitate communication and manage simple transactional processes with the healthcare system.  There is a pressing demand for such solutions among those I come in contact with, but few know of the existance of these new applications and services, outside of WebMD.  Which raises the question: How will the small companies in the consumer HIT market gain the significant traction to become a truly global brand?

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