Microsoft HealthVault: Device Connectivity
The HealthVault (HV) beta was launched October 4, 2007. Between the confusion surrounding the launch and work, I've tried to gather some thoughts and get some questions answered.
The launch was a classic Microsoft launch: big, dramatic, expensive, and well executed, right down to the goody bags (you had to be there to get one, so I missed out). Typical with such events, naysayers were out in force, and there was a bit of confusion. You can also find some good information on the big picture of HV from Vince Kuraitis and Enoch Choi.
Perhaps the most confusion around HV is whether or not it is a personal health record (PHR). Many of the “news stories” that recycled the HV press release referred to HV as a PHR. A few, Vince and Enoch among them, noted that HV is in fact not a PHR. From what I and others can see, there is very little in the way of a user interface that would allow patients to maintain and manage a PHR.
According to one Microsoft executive I talked with, HV is a “platform” that's intended to be used by other applications, and is not a PHR. He reported that Microsoft's taken a more consumer focused approach, surrounding them with their information so they can share their health data with whom they wish. So, the absence of a robust PHR user interface is apparently a conscience
decision on Microsoft's part. Nor would it be to awfully difficult to
provide one should they move in that direction.
The published API, data interoperability via numerous standards, data storage, security, authentication, and the patient's ability to control their data creates a veritable Swiss Army knife for health data. Microsoft has tried to create a new kind of platform that's ideal for health information. They certainly have some ideas about how it can be used (and currently monetized – by ad revenue), but my contact acknowledged that they expect partners and consumers to take the platform in unforeseen directions. As a beta product, there are many unknowns beyond the mid term horizon.
Device Connectivity
Microsoft sees devices for health and fitness and chronic disease management as a big piece of HV. Medical devices are integrated into HV via the Connection Center (CC). The HV CC includes a device driver (specified by Microsoft and developed by the device vendor) that integrates a remote monitoring device into a Windows PC, and the CC application that runs on the PC and integrates with the HV web site. Microsoft has an SDK for creating a serial device driver for connecting these devices to Windows PCs, along with the HV CC sync program that allows consumers to capture, review and share data via HV. There do not seem to be any data editing capabilities in HV CC – more on this in an upcoming post.
My contact used the digital camera analogy when describing what this might mean for remote monitoring devices. In the early days, digital cameras came with their own proprietary software that allowed you to connect your camera to a computer and download pictures. As the technology matured, cameras adopted the USB standard and now plug and play with PCs.
This ubiquitous connectivity sounds great, but Microsoft is not anything like the USB Implementers Forum. While their device to PC SDK is open, the software on the PC is not. In fact, one wonders how HV will play out against another medical device group, the Continua Health Alliance.
Remote monitoring systems have 4 components: the medical device, a gateway device for aggregating data from multiple devices and moving that data over a network to an application, the application that manages the patient data (which usually runs on a server on the Internet), and some sort of integration with EMR/billing system(s). Continua is working to provide multi vendor plug and play interoperability between each of these components. Microsoft is not a member of Continua and is providing an open, but proprietary means to link devices with server applications – turning the Windows PC into a virtual gateway.
The HV CC turns your Windows PC into a remote monitoring gateway. The application can aggregate data from multiple devices and push that data into your HV account. To then get the data into the remote monitoring application it is transferred (automatically?) from HV to a compatible application.
Most remote monitoring gateway devices pull data from remote monitoring devices and push it directly into the target application. In fact the data may not be “ready” for third party applications until it is processed by the target application – more on this issue in an upcoming post. Certainly Internet-based remote monitoring server applications can leverage HV to provide interoperable data between other applications like physician EMRs.
Will vendors implement both Continua and HV connectivity? The fact that Continua validated interoperable products won't be available until the end of 2008 is an issue than you might think. Any vendor starting development now will take at least that long to finish their product. So they must make the decision whether to base their new product on Continua, HV, or both. (Hint: this is not a “o brainer” question.)
Closing Thoughts
Regardless of those that claim Microsoft “won round one” against Google, there is no first mover advantage in any of this. In fact, follow on solutions will likely benefit greatly from Microsoft's very public experience. Other big vendors or efforts mentioned in the press include Google, Cisco, and Dossia (which includes Intel, Wal-Mart and other big employers). I talked about non health care companies entering the health care market before. This is not an easy transition; it will take longer and cost a whole lot more that most anticipate.
Check back throughout the week; I'll have some follow on posts on adoption, network effect and other topics.
Pictured right is Bill Gates, from a PhotoShop contest on Gizmodo, that tickled my fancy.
GE and Sprint Announce Some Kind of Wireless Stuff
Yesterday I came across an eWeek.com story about GE Healthcare and Sprint. There were lots of what marketing folks call “glamor words” but little in the way of substance. After reading another 4 stories here’s what I’ve figured out.
GE Healthcare is taking their proprietary WMTS wireless telemetry, the MobileAccess in-building distributed antenna system (what GE calls CARESCAPE Enterprise Acess), Sprint’s CDMA and iDEN cellular phone services, combined with the customer’s WiFi network, and is providing integrated wireless connectivity engineered (I think) by Sprint’s Custom Network Solutions group. (Here’s the GE press release – by far the most informative source on this announcement.) From the press release:
Uninterrupted communication within a hospital is a requirement for physicians, patients and visitors and is essential to quality care. Sprint (NYSE: S) and GE Healthcare announced today their collaboration to provide in-building wireless communications services to hospitals in North America. Patients, clinicians and hospital visitors will benefit from secure, reliable voice and data communications, supporting an environment conducive to higher levels of patient care. Historically, the use of mobile phones in hospitals has been limited due to unreliable wireless support and the risk of interference between wireless phones and medical equipment. Using the new combined offering, physicians and caregivers will be able to communicate amongst each other and securely access patient information from almost anywhere in the facility.
Motherhood and apple pie. But what’s the announcement?
The new in-building cellular communications network from GE Healthcare and Sprint’s Custom Network Solution (CNS) team leverages GE’s CARESCAPE Enterprise Access, a single, universal wireless platform powered by MobileAccess, and includes Sprint handsets. This solution will provide hospitals with a comprehensive platform for voice and data communications over secure cellular, Wi-Fi and telemetry infrastructure that requires only one installation. Using the combined offering, clinicians, patients and hospital visitors can communicate more efficiently and with ease.
“Sprint CNS provides scalable coverage and a high-capacity platform for wireless voice and data services on the Sprint National Network and Nextel National Network, enhancing the mobility and productivity of staff at hospitals and other businesses,” says Darlene Braunschweig, vice president of CNS at Sprint. “We are very excited to partner with GE Healthcare to provide differentiated and innovative mobile solutions that are critical for every business. This new solution facilitates constant communication of secure information amongst hospital staff; an aspect very critical to patient care.”
So it seems that Sprint will pipe their cellular network into hospitals to run on the MobileAccess DAS. This is something that MobileAccess can already to – with any carrier. It is not clear how (or if) Sprint’s offering will be differentiated from other carriers. Nor is it clear if CDMA, iDEN or both networks will be supported. For that matter, what about the new WiMax wireless network that Sprint’s building? The fact that a Sprint handset is required is also confusing. Since US carriers lock their phones to their networks, of course you must use a Sprint phone on their network. Or does the Sprint handset provide some special features? Oh, and the bit about “secure cellular” – all cellular networks are secure, especially the air link which is encrypted.
Does the announcement also include WAN networking on Sprint’s backbone? This is also not clear, though it could be a nice feature if there was a nice bundled (i.e., reduced) price, or there were other hospital trading partners on the WAN.
The downside of this announcement is that Sprint is a second tier mobile carrier at best (52 million subscribers), behind both AT&T (58.7 million subscribers) and Verizon (54 million subscribers). They are also the only carrier with the iDEN network (they bought Nextel). Hospitals that only offer Sprint in building coverage will meet the needs of less than a third of potential users. Hospitals need carrier agnostic solutions that allow users to connect, regardless of carrier. Maybe GE is working on announcements with AT&T and Verizon too.
Unless someone can explain it to us, this seems this is a non event.
In other news, the Chair, President and CEO of Sprint, Gary Forsee, beat a hasty retreat. It seems that, “Sprint decided it was time to put new leadership in place to move the
company forward in improving its performance and realizing corporate
objectives.”
VC Firm Takes New Approach to Life Sciences
According to this story on CNNMoney.com, “During the first half of 2007 VCs invested $4.8 billion in biotechnology and medical devices.” This is not just a blip on the radar.
first quarter, setting a single-quarter record. In the second quarter
VCs set a record for the number of deals signed with 223.
With all that competition for top rate investment opportunities, VCs need to either take a different approach to the market, or look beyond the conventional template for life science startups. Third Rock Ventures is doing both. The large venture firms, with their billion-dollar funds, have moved their investment focus to late-stage, near-approval products leaving a big gap at the early stage.With their just announced
$378 million fund Third Rock is going after early stage technology,
and moving the VC business model from investment-centric to a company-creation model.
According to partner Kevin Starr, “We're looking for great ideas we can turn into what we call product
engines. We take those kernels of ideas and innovation, then we turn
that into what we call a product engine company.” Third Rock wants to create a broad
scientific, biological, medical, intellectual platform can target multiple markets, disease areas or product segments.
The big untapped investment opportunity that I see in the medical device market is disruptive. Other high tech markets – banking, telecommunications, aviation – have experienced several waves of disruptive technologies that have increased product capabilities, reduced price, and greatly enlarged markets. The bastions of embedded system medical devices have thus far held off such transformations, but there are a number of such products working their way to market.
There could be a lot more disruptive medical devices transforming the medical device industry, but there are 2 principal barriers. Few entrepreneurs embody the deep understanding of the health care market with the knowledge and skills to create truly disruptive new medical devices. And if anything, potential investors are more conservative and conventional in their evaluation of investment opportunities than medical device execs.
The result is everyone seeking intellectual property (IP) that creates a long term competitive advantage – fully locked-in with air-tight patents. Very little of the disruptive technologies that have transformed other industries were based on “secret sauce” – in fact, usually the opposite has been true as new industry standards lowered costs and complexity for everyone and made a lot of new millionaires. Just look around Silicon Valley.
There will always be a few new “block buster” drugs, or novel medical devices that are dependent on IP for their long term success. An even bigger opportunity is the transformation of entire product categories by disruptive technologies that are based on industry standards or open source. This is where the conventional life sciences guys scratch and shake their heads. This disruption is creeping in around the margins of more conventional companies as a way to reduce costs and time to market. I've yet to see anyone (especially investors) visionary enough to tackle disruption head on.
Some day, some day…
Wall St Analyst Touts McKesson's HIT Portfolio
Goldman Sachs analyst Randall Stanicky, “pointed out that no rival has health care IT offerings as comprehensive as McKesson’s.”
“Based on our mapping of McKesson’s current health care information technology offerings and the competitive landscape, we have concluded that the company has one of the most comprehensive portfolios across market participants who range from hospitals, physicians, payors and pharmacies to functions including business management, clinical and automation,” he said in a note to clients.
McKesson increased its growth and capabilities in the health care IT space with the acquisitions of HealthCom Partners, RelayHealth, Per-Se, Practice Partner, and Awarix over the past 18 months, Stanicky noted.
Two thoughts come to mind. First, don’t think that Cardinal Health, AmerisourceBergen and other competitors aren’t leveraging software (and other things) to create their own unique value proposition. I don’t see HIT as some inherently superior differentiator relative to all the other market segments and differentiators available to vendors.
The second thought is that McKesson’s strength could also be its weakness. Hospitals love single vendor solutions. At the very least, they get “one throat to choke” when it comes to product and service issues. In the best case, you have a broad well integrated product line that provides one solution that takes the place of multiple vendor’s systems.
In reality, there are very few broad well integrated product lines – and it seems the broader you get, the less well integrated the overall solution. Consequently, the best case promise of single vendor solutions is rarely realized. And many hospitals forgo operational or clinical performance as a consequence of the conscious decision to remain faithful to one strategic vendor.
The breadth of the McKesson portfolio makes me nervous. If I was a CIO, I’d want to know how much is being budgeted to actually integrate those recent acquisitions to create a truly superior solution. Few things in life are black and white; so too with single vendor versus best of breed solutions. An enterprise architecture made up of a combination of a few key vendors rounded out by best of breed solutions should provide greater performance and value than either extreme.
Pictured above is a photo from McKesson’s 2006 national sales meeting.
Devices for Diabetics Improve
Business Week has an interesting story about recent advances in glucose meters and insulin delivery systems for diabetics. Many of the devices in the story aim to improve usability in various ways to improve patient compliance and outcomes. Proper control of blood glucose levels has a tremendous impact on a diabetic's health, quality of life and susceptibility to complications.
The market for glucose management has not escaped medical device vendors or entrepreneurs:
The audience for diabetes-management tools is large–and growing. The Centers for Disease Control & Prevention estimates that there are 20.8 million American diabetics, about 7% of
the U.S. population. According to the International Diabetes
Federation's latest statistics, nearly 194 million adults around the
world are diabetic; by 2025, according to estimates, this figure will
reach 333 million. Palo Alto (Calif.) research and consulting firm Frost & Sullivan estimates that the U.S. market for traditional diabetes monitoring
(blood testing equipment and strips that diabetics use to measure their
glucose levels) tallied $3.53 billion last year, up 12% from 2005.
“In the last several years, we've seen low double-digit growth,”
says Mona Patel, director of Frost & Sullivan's medical research
department. “Yes, there will be a saturation factor, but the number of
diabetics keeps increasing–even among children.” So, Patel says, the
market for pediatric devices will grow, too.
The market is slowly growing, but the real opportunity is the poor design of conventional products made for diabetics. They are hard to use, make funny noises, inconvenient, have a medical device look that makes patients look and feel “sick”, have poor battery life, and can be big and clunky.
Blogger Amy Tendrich posted an open letter to Steve Jobs on her blog Diabetes Mine, challenging Apple to bring the same design excellence they bring to consumer electronics to devices for diabetics. The Business Week story describes a design created in response to Tendrich's plea, and touches on a number of other products. (Surprisingly, no mention of DexCom's continuous glucose monitoring system.)
The (glacial) transformation taking place in diabetic devices highlights a structural problem in the medical device industry. Due to barriers to market entry, established vendors feel little pressure to create the equivalent of an iPod for diabetics. Some vendors like Medtronic have created innovative systems like the MiniMed insulin pump with real time glucose monitoring. But in order not to cannibalize sales from their conventional products line, they price the new solution at a significant premium. (Medtronic has taken a similar approach to their relatively new wireless ICDs, charging a $6,000 premium for the wireless models over products that still use induction wands that must be placed over the pacemaker. I know cardiologists that refuse to implant the wireless models because they feel it is unfair to burden the patient/payor for such a high premium.)
Payors only reimburse for technology that has a clear return on investment. They won't reimburse for a fancy (read “expensive”) MiniMed pump for a patient whose condition does not require continuous monitoring and administration of insulin. Sure payors will pay more for a product with better outcomes (i.e., lower costs to the payor resulting from a healthier patient). But proving those improved outcomes – and lower costs of care – is an expensive and time consuming proposition.
It appears that Medtronic – and vendors who pursue a similar strategy – are stuck with a small subsection of the diabetic market, unless they're willing to reduce the price of the MiniMed where patients are willing to pay the difference over what their payor will reimburse for a conventional glucose management system.
The poor comparison between conventional glucose management products and consumer electronics has not been lost on medical device entrepreneurs. Vendors like Medicom, DexCom, Health Pia, and Insulet (pictured right) are bringing better designs and technology to market. These new players will need more of a consumer electronics product strategy, rather than Medtronic's strategy for the MiniMed, if they are to succeed.
More here in a iHealthBeat story about a recent FDA continuous glucose monitoring approval for children that highlights cost and potential savings in reduced health care costs.
of their blood sugar through the devices, although other studies have
found minimal impact. Irl Hirsch of the University of Washington said
the discrepancy can be attributed to a lack of effort from diabetics,
not the sensor technology.
The glucose sensors can cost up to
$1,000, with at least $350 in monthly fees for supplies. Although some
insurers pay for them, many refuse to reimburse patients for the
devices until there is more proof that they improve health, the AP/Star reports.
UPDATE: Reader Bernard Farrell has an excellent point in the comments:
present. They don't adequately cover treatments for chronic diseases, and then
later they pay for the outcomes of poor management. There is an argument that
better designed devices will lead to better medical outcomes AND lower support
costs for the device makers. As far as I'm concerned good device design is a
win-win-win situation for patients, device makers, AND insurance companies.
Unfortunately it feels mostly like I'm shouting into the wind about this.
There are two problems I think. The first is demonstrating the hard dollar savings from well designed devices. This naturally falls on the device vendor, and is neither a quick or inexpensive task. The other problem is the tendency of device vendors to want to get a significant premium for their better designed product. A major price increase requires justification before payors will reimburse for a new “class” of device. If a vendor introduced a better designed device (with some additional features) at a slight premium, patients might be willing to pay the difference themselves – think the iPod.
Perhaps what's needed is more of a consumer electronics mindset applied to these kinds of products, rather than the conventional medical device paradigm.
More Physician Disintermediation
On of the changes roiling health care is the disintermediation of primary care physicians. The advent and continued growth of retail clinics and concierge medicine are examples of a new business model chipping away at physician's traditional business. This New York Times story describes a company called Inn-House Doctor.
A new kind of medical practice is flourishing nationwide that offers
to go to where the patients are – whether a home, an office or a hotel – to treat ailments as diverse as a sprained ankle or a bad case of bronchitis. Some services may even wheel in a mobile X-ray machine or an ultrasound machine, depending on the ailment, or perhaps pull out kits to test for strep throat or to draw blood. They may dole out medication on the spot or arrange for pharmacies to deliver prescriptions.
“When
you call, you can speak to a doctor in five minutes, and that doctor
can be there with you within the hour. Where else do you get that kind
of delivery?” said Walter Krause, founder of Inn-House Doctor. The
company says it has 40 physicians on call in Boston, Chicago, Dallas,
Houston, Las Vegas, Phoenix, Philadelphia and Washington; some of the
doctors are in private practice or work in hospitals, and they make house calls during their time off.
This firm charges $250 to $450 per appointment, compared to $80 for a typical office appointment. So what's the problem driving these new services? In some markets where there is a shortage of primary care physicians, patients can wait weeks for an appointment. The office experience itself can be marginal when you get all of 10 minutes with your physician, some times after a lengthy wait to be seen.
Conventional practitioners complain that such interlopers interrupt and fragment the delivery of care to a patient. In reality the office-bound primary care physician with their paper charts and network of specialists they refer to typically don't offer any better coordination of care across a patient's physicians.
The enabler for many of these new services is health care IT. Improving access, convenience, and better coordination of care requires things like open scheduling systems (where patients or referring physicians can book appointments), e-prescribing, EMRs and PHRs. All of this must provide some level of interoperability so that appropriate information can be easily shared with the patient and among providers.
UPDATE: iHealthBeat reports on a radio story about an NYC physician, Jay Parkinson, “who founded a solo practice that treats young, healthy uninsured patients over e-mail, instant message or video chat.” You can check his cool web site here.
If there were more practices like Parkinson's, you could make a case for getting less expensive catastrophic health insurance and paying everything else out of pocket.
