Healthcare Unbound – Day 2 Post-Conference Workshop One
This workshop addressed emerging clinical and business models, focusing on digital homes and smart phones. The first speaker, Stan Kachnowski launched into HU oriented trends. Since I was trying to remember what I was going to say, I really don't remember Stan's presentation – the audience did stay awake right after lunch, so it must have been compelling.
Innovation in health care seems to be more difficult that it is in other industries. There are good reasons for this – like the fragmented “cottage industry” nature of health care, the many different stakeholders, and the Byzantine reimbursement and regulatory frameworks. Any new venture requires a strategic view rendered by someone who can put all the pieces together, and identify barriers or detractors to a particular innovation. Only a proper assessment of the health care environment will result in a course of action that eliminates or avoids the problems and leverages the strengths of the business plan. Given these challenges, and the entry of numerous startups and non-medical companies entering the HU market, I presented a framework for evaluating the potential success of innovation in health care. You can read more about the framework here. If you attended Healthcare Unbound, you can download the presentation from the HU website here. If you'd like to know more, drop me a line.
Yacov Geva, CEO of Card Guard, was next. He reviewed their product portfolio. The sensors shown all communicate with back end servers via smart phones. His barriers to adoption included lack of reimbursement, lack of government support, massive consumer marketing costs, providers not keen on ordering or recommending remote monitoring solutions, and unproven business models. Also noted was that patients don't want to pay for remote monitoring. He also mentioned the key potential benefits of remote monitoring – sort of like the golden fleece, glowing attractively just out of reach.
Stephen Intille was up next. He started asking the rhetorical questions, who likes to pay for a new roof, electricity, car insurance, and Stephen's condo's dead steam boiler? No takers. Stephen summarized Mike Barrett's Prospect theory and Don Jones' desired properties of HU applications. Stephen's point is solutions must provide a positive experience – from installation through use. Smart sensors can monitor, help prevent and provide compensation (like help with a mild cognitive impairment). The sweet spot is where these three capabilities intersect. He identified the point of decision as the best time to provide positive reinforcement. Stephen provided some great examples of product concepts that actually provides the just in time positive reinforcement that was his theme.
Mike Barrett broke up the presentations and we broke into discussion. The first question was, “Who will represent the largest buyer of HU solutions in four years?” One limit of smart phones is that they are a poor platform for wireless apps – too many tasks, like starting the app and accessing the internet, have to be manually initiated. Brad Sokol drew parallels between HU solutions and the evolution of the RFID industry – these solutions started vertical and went horizontal.
Darrin Jones, Sr Bus Dev Manager in Intel's Digital Health Group, articulated why Intel decided to enter the HU market space. Darrin spends a lot of time in Europe because he sees different things in the market about “aging in place” and HU solutions. Perhaps because Europe has socialized medicine, they don't have the luxury of putting off decisions about the coming boomer tsunami. He noted GE's recent deals buying 186 nursing homes and $110 million debt financing for long term care providers. (Leveraging opportunities in health care, without mucking up their current medical device business will be a challenge.)
The advent of retail clinics (typically manned by nurse practitioners) will be disruptive in health care. Sample companies include RediClinic, Take Care Health Systems, and MinuteClinic. Consumers who chose not to pay for health care, or have a high deductible health plan, they will vote with their feet and use these retail clinics. Payers will eventually turn to retail clinics for some patient encounters due to the lower cost. Cognitive trending companies include GleeCo and Posit Science – these Darrin's advise is to avoid any business plan based on anticipated reimbursement – VCs aren't funding these kind of businesses.
Lydia Lundberg, owner of Elite Care, talked about the route from independent living to institutional care. Elite Care has developed a HU solution to help people age in place, that also transfers to their own independent living facility. She described their solutions and the business model implications for referrals and community relations with providers. One of her key points was that “data doesn't scale” – you only have some much time to look at so much data. Using knowledge modeling and discovery software, they are building abstracted business models. This will enable Elite Care to move from a reactive mode in caring for their residents, to becoming proactive and anticipatory of patient needs.
Brad Sokol of FastTrack Technologies, talked about building ROIs for HU solutions. Using models from other industries, he laid out how to create compelling return on investment analysis value propositions. He also suggested a number of nascent HU solutions like meal delivery and operational software for remote monitoring service providers. Brad also presented Near Field Communications technology combined with cell phones as an enabling technology for HU solutions (more here). He ended his presentation describing what he called a natural birth adoption curve: users born in 1975, will adopt in 2015 and the market will be saturated in 2040. The big money will be made between 2015 and 2040.
Bill kicked off another Q&A session with his usual panache. He painted a rosey scenario where governments are broke and can't pay more for HU solutions, and payors are facing catastrophic loss in risk management with aging baby boomers. He posits that the sole long term market will be based on consumer self-pay and self-insured employers. A Canadian researcher suggested that people's sense of entitlement won't let them self-pay for health care. It was noted that socialized medicine in a number of countries is running out of money and moving to self-pay. Another audience member suggested we not count out payors, who he thinks will manage risk and survive.
The discussion then transitioned to Elite Care and the social and emotional dynamics between residents, family, and staff that are the consequence of the technology they use and how the manage their business. After a question about sensor costs (they're falling rapidly) the conversation transitioned to the importance of how the resulting sensor data is used – much like the lifestyle DNA that Astro Teller talked about yesterday. In general, the more sensors you can layer on analysis algorithms, the better the data. Installation is a major cost component, and how the sensors are installed is critical to the sucess of the installation. Stephen's suggestion was to take what Elite Care's already doing and make it fun – like putting sensors in family members homes and using them to mediate free communications (like Skype) that does not exist now.
Mike brought us back to the backend intelligence. One to one mapping of sensors to behaviors is easy, but detecting more sophisticated behaviors like eating. Stephen posited that by getting enough sensors in enough homes, researchers expect to discover new biomarkers that will impact health. IBM has a product called Home Director that is not far from what we're talking about.
UPDATE: Here's a press release on a study from the California Healthcare Foundation on the “Minute Clinic” movement that Darrin Jones of Intel's Digital Health Group discussed.
The retail clinics concept has also gotten play in the blogs – Matthew Holt has a post, as do the guys at Hospital Impact.
UPDATE: If you're returning to this post, you might notice that I provides some additional background about my presentation on Innovation in Healthcare.
Pictured right is a view from the presenter's table.
Healthcare Unbound – Day 2 Plenary Panel Discussion
Well, I missed a couple sessions due to internet access issues – Hyatt is too cheap to provide free and easy Wi-Fi coverage (one reason I stayed at a different hotel).
Joe Ternullo, telemedicine guru at Partners Healthcare, opened the closing session. After the obligatory overview of needs and market trends, Joe launched into the agenda.
The first question was, is there a shift to wellness management? The CMS response was they're all about quality and cost effectiveness. The potential for patients to seek out providers with EMRs and a focus on wellness was proposed a s a key factor in the shift to wellness management – no data was provided. There's been a leap of faith that the government will drive EHR adoption and standardization, and that the result will be higher quality and lower cost. The home health care industry's financial decisions are driven by reimbursement. Remote monitoring was adopted when changes in reimbursement created the incentives. The importance of buyer's internal change agents or HU champions is currently critical to adoption in early innovator accounts. There was recognition of the resistance of providers (especially non-acute care providers) to invest capital to reduce operating costs and improve quality. Reimbursement seems to drive a disparate extent. It was suggested that publicly available quality data for physicians, home health agencies and hospitals will shift investment decisions to look at more than reimbursement – an example of this is the current push by CMS on prevention and transparency in quality outcomes.
Eric Handler, of CMS regional office in Boston, spoke about a new provider reporting program that started last January. Participants submit procedure and outcomes data to CMS who calculates quality measures, providing feed back on how the provider compares with their peers. This program will be expanded into a full pay for performance program. The quality results will be available to the public. Eric reinforced that this is happening now, and will become pervasive.
Dire predictions were made that early innovators adopting HU solutions will be in a position to buy up technology laggards. Companies that are in Leap Frog Group could be valuable HU adoption drivers. Bridges to Exellence is another program driving quality improvements in health care delivery.
The closing comments included predictions and exhortations. Looking at a consumer or retail model there are huge opportunities for consumer paid HU solutions. Five to ten years was the range noted as the horizon for real HU adoption. Informaiton tech adoption, remote monitoring connectivity, and changes in health insurance design will help consumers vote with their feet. Lastly the quality movement will be an accellerator to HU adoption. For the foreseeable Americans will continue to eat fast food, watch TV and smoke cigarettes. There is a need for behavior modification and education. Most home health agencies first bought their first IBM PC was when Medicare refused to accept paper claims. Interoperability will provide the flexibility and affordability (along with private pay) to drive HU adoption. It was also suggested that elder care benefits (like remote monitoring) would be attractive to large self insured employers. Research must be timed to ocur when technology is sufficiently mature. One panelist challenged the group to use HU solutions to delivery needed care to the uninsured, and those who can't afford HU themselves. Don't forget Medicaid as a source for HU adoption – quality measures are coming to bear in this market as well.
Pictured right, the plenary panel holding forth.
Healthcare Unbound – Day 2 Wireless Vital Signs Monitoring
Matt Banet, President/CTO of Triage Wireless (previous posts here and here), and Paul Hedtke, with Qualcomm, presented a case study on wireless and cuffless vital signs monitoring. Triage targets the long existing weaknesses with current vital signs monitoring solutions; ECG electrodes and cables along with the blood pressure cuffs both hinder patient movement, come undone, and are sources for hospital acquired infections. Current vital signs monitors are also rather large and unwieldy, having to be pushed around on pole stands or COWs (computers on wheels). Triage is targeting a number of use cases:
- One time measurements – office visits, spot vital signs monitoring
- Ambulatory continuous monitoring
- Acute care continuous monitoring
Ambulatory blood pressure can be important for patients with hypertension, “white coat” hypertension, and non-dipper diabetic patients. In the acute care setting, the monitor supports
conventional alarm limits and management, with an associated text based
alarm at a remote software client and audible alarms on the device. Matt noted the challenge of dealing with hospital's wireless LANs that frequently are not up to snuff for supporting continuous life-critical wireless applications.
The Triage solution is small (handheld), flexible, easy to use, and monitors blood pressure without a cuff – just a disposable inexpensive sensor, one cable and a PDA-like hand held monitor display. Triage has developed their own vital sign monitor that serves as a gateway that supports CDMA, Wi-Fi and Bluetooth radios.
Monitored parameters include: blood pressure, ECG, PPG, PCG, heart rate, beat to beat variability, SpO2, respiration, temp, PEP, LVET and other STIs, pulse wave velocity, and atrial stiffness/compliance. That's quite a diagnostic armamentarium.
Initial focus on hospital market, with consumer product in the works.
The patch cost is just a few dollars each. The monitor will probably be
under $2,000. The consumer product will be a replacement for the $99
blood pressure cuff sold in pharmacies.
Issues: central station client, alarm notification, motion artifact, hospital wireless LANs are problematic
Pictured right is Matt, because I didn't think to ask if I could get a photo of his sensor when he showed it to me.
Healthcare Unbound – Day 2 HU in the Home
The first part of this breakout was a panel discussion. Alzheimer's disease was discussed as a key need where HU solutions can help those patients remain independent longer, delaying the inevitable transition to institutional care. Assisted living and congregant homes can make better solutions than home care, for seniors who would otherwise be isolated.
Health plans have a number of incentives for adopting HU solutions. The payer's key motivation is to provide the best care at the best cost. Payers look for evidence of cost savings and improved quality of life. Insurers are motivated when they are at risk. In capitated environments, payers and providers look for cost savings and/or improved outcomes. One speaker noted that HU solutions are not new, they've been around for more than 10 years. The challenge is to scale up to broad industry adoption. There are also different motivations between payers who see high turnover, and self insured employers who have longer term relationships with employees and retirees. For new studies, randomized controlled studies are the gold standard.
How can providers be encouraged to recommend or order telehealth solutions. The disruptive issue for providers is the transition from patient encounters measured in months, to data that is provided daily or round the clock. This interaction with data between office visits is something that's new for providers. This change requires a big shift in how physicians think and practice medicine. (I've seen ICD implantable vendors sow fear, uncertainty and doubt by telling physicians looking at a competitor's wireless ICD remote monitoring solution by suggesting that the additional data will increase the physician's malpractice risk.) This is a huge barrier to adoption, with no “best” solution.
A barrier to adoption for home health providers is the different protocols required by payors. Medicare reimbursement is a problem, a third of home care agencies lose money on Medicare patients. Changes required to effectively utilize HU solutions for nursing is as significant as it is for physicians. Many home health agencies won't invest in cost saving technology unless it is reimbursed.
On the political front, members of congress still are not interested in changing the status quo in health care by supporting HU solutions. MedPac has a huge impact on Congress' perception of health care issues. MedPac's position is that “there is not conclusive evidence” that HU solutions lower costs and improve outcomes. There also seems to be an absence of constituent issues revolving around HU solutions. The federal level is slower than movement at the state levels – Colorado has adopted HU solutions to lower Medicaid costs (so has Indiana). There exists a lot of data showing the efficacy of HU solutions, but the industry needs to do a better job of packaging and publicizing these data. Data must also look “academic” – a study with bold “Research Paid For By XZY, Inc.” is a turn-off for politicians and staffers. Vendor data is assumed to be biased, the NIH or NSF are the premier sources regarding credibility. The need for mult-site randomized controlled studies is a challenge for NIH and NSF, a partnership with industry would be beneficial – could this be a role for Continua?
Visit reduction protocols is knowledge that is not widely available. This is another area needing education and research. Other barriers include things as mundane as union contracts that stipulate hospital admissions in situations that could be avoided using HU solutions. The flip side of avoided hospital admissions include an increase in ambulatory visits and additional communications between patient and caregivers.
The “production” cycle between doing research and product development was also noted. It can take a year or more to write a grant, get funding and complete the research – even longer to get published (which many pubs won't take if the content has been publicized). In this time products can be eclipsed by next generation products. Keeping research and products in synch is an important yet difficult task. This is an important consideration because payors look at not just the application, like telehealth, but also the technology required for the implementation – is video conferencing required, would simple telephone interaction be sufficient – payors want data on the minimum technology required.
Pictured right is one of ViTel Net's home monitoring solutions.
Healthcare Unbound – Day 2 Opening Remarks
Jeff Kidder (Hanover Health Services) and Mitch Work (The Work Group) opened the second day. Jeff observed the common lack of realistic expectations on the part of large corporations from outside of health care who decide to go after the health care market. He talked about a number of companies that eventually pulled back, and one that reset their expectations and came back. He also plugged a book, Home Telehealth: Connecting Care Within the Community.
Mitch Work introduced the content scheduled for today, contrasting yesterday's insightful analysis of the HU market today dives into case studies of what folks are doing in the market. He also plugged the post-conference workshops (where I'll be presenting).
This is the third year of the Healthcare Unbound conference. Each year attendees and exhibitors have grown. Mitch also noted new publications targeting the HU market. There is a great growth opportunity for this market, but what can be done to facilitate growth?
- The market needs a broadly accepted descriptive name
- Need to market and publicize to the general health care community
- Need to continue “missionary sales”
- Seek affiliations with other health care associations like HIMSS, HFMA, AHIMA, AHIP and physician specialty associations.
More advice included:
- Keep an eye on federal initiatives
- National health record and RHIOs
- CMS and disease management
- HIPAA enforcement
The need for proofs (a consistent theme during the conference) was emphasized.
Pictured right is InforMedix's Med-eMonitor medication adherence solution.
