This week was the Healthcare Unbound conference. Between the considerable innovation in this market, and the openness with which presenters and attendees share information and ideas, this is always a terrific conference.

The following are some notes from some of the more interesting presentations - be sure to keep scrolling, this is a long post! I'll follow this up with a post on my presentation at this year's conference, "How the Network Effect Impacts Adoption of Healthcare Unbound Technologies," and a wrap-up post.

At 8 am Monday morning, Teri Louden kicked things off. She started her career at Baxter Travenol in the 1970s. Referring to The Graduate, Baxter’s innovative technology of the day was plastic IV bags. Today, things have come a long way from plastics to Healthcare Unbound.

There have been few breakthrough industry segments over time - disease management, home infusion therapy, outpatient surgery - and Healthcare Unbound (HU) is an important pioneering new industry segment.

Teri prognosticated that many of the really breakthrough solutions in health care will come from companies outside of health care - mentioning Intel, Qualcomm, and other electronics and communications companies.

Using CardioNet as an example, Teri described how a new type of solution presents substantive challenges for adoption and effective use. The CardioNet value proposition was unique and required new ways of selling, patient use, and reimbursement.

She introduced Vince Kuraitis and David Kibble, and their topic: The Personal Health Information Network (PHIN): Opportunities and Implications for Healthcare Unbound

The Personal Health Information Network (PHIN): Opportunities and Implications for Healthcare Unbound

Vince introduced the topic with a classic example of the network effect, phones. He asked, what is the value of a single phone? The health care industry is currently the equivalent of two phones representing one to one solutions. The real value comes to the fore when many phones are interconnected, allowing users to contact many other users whenever they want.

Today personal health information is scattered and static. It is not accessible using computing and Internet standards. That data is frozen.

Using a prototypical patient as an example, he introduced the following concepts:

  • Portability (can I take my data with me),
  • Interoperability (can different applications exchange information - can Cerner’s EMR exchange data with Google Health?), and
  • Data liquidity (the degree of freedom with which data from difference sources are permitted to move over networks).

Possible routs to portability/interoper/data liquidity (which can be complementary):

  • Maintain the status quo
  • Legislative mandates
  • PHIN

The PHIN platform companies include Microsoft HealthVault, Google Health, Dossia, and others to follow. Future platform vendors could be affinity ogranizations like AARP, banks, health insurers, large provider organizations and others.

The PHIN could be made up of multiple interoperable platforms. One one side are patients with intermediary applications or direct access to what Vince called “consumer access services.” These “middle” services are currently HealthVault, Google Health and Dossia. Interoperability is assumed between these various middle services (but by no means assured). Without interoperability it is like trying to use your Visa card at a retailer that only takes American Express. Interoperability would be like the phone system, where calls go across all carriers. On the other side are all the various providers in health care: payors, hospitals, physicians, labs, pharmacies, etc.

There are several challenges that PHINs must overcome. These are described as "conventional wisdom" or the status quo, and potential market responses.

Conventional wisdom #1: “It’s our data” where players in health care (payors, providers, etc.) consider their patient’s data as their data. Certainly patients can have a paper copy of data (for a charge), but the liquid flow of that data is purposely restricted. The emerging reality is that patients say, “Its my data, hand it over, now!” This means personally controlled health records. This transformation has no real legal changes. What’s missing is the ability to get that data electronicallly in an interoperable form.

Conventional wisdom #2: Proprietary IT and business models are sources of competitive advantage. This is the traditional proprietary product strategy. Market pressures are causing a small but growing number of vendors to move to common platforms to take advantage of a network effect.

Conventional wisdom #3: Building  NHIN/RHIOs with a “big bang” approach where an entire community or region ties everthing together in one big move. In reality, interoperability and data liquidity can be achieved incrementally, obviating the need for the perfect soluition in a single step. Vince sees business models being built around high value incremental applications.

Conventional wisdom #4: Personal health records (PHRs) done by patients won't work; patients don't understand, don't care. Vince suggested that in fact, patients are getting it. More importantly,  PHR applications can be enabled for patients provided you have the data liquidity, automation and patient permissions.

Conventional wisdom #5, where the media positions this as a zero-sum battle between Google and Microsoft. The reality is that the competition is between electronic means versus the persistence of paper records where competitors like Google and Microsoft cooperate enough to grow the market.

At this point, David Kibbe took over to ask, "How is all this disruptive?"

If you were interested in being a participatnt in health care over the next 10 or 20 years, what would you need to be thinking about? Here are some key issues:

  •  Health is personal, healthcare is not
  • The PHIN-empowered patient is no longer simply an object for institutional medical process, but the locus of change
  • We can’t expect government to “fix” healthcare (they haven't fixed much of anything else)
  • Consider the power of Wikinomics, community, collaboration, soelf-organization of health information
  • “We’ve tried the experts, and it’s not working. Let’s try the wisdom of crowds.”

Transparency and openness will be key. Most of health care is closed. All along the supply chain, health care is made up of oligopolies and alliances. Outright secrecy about methods, pricing and data is used to gain competitive advantage.

The PHIN creates new opportunities for non-experts to access health data and knowledge, and to use it without (as much) need for experts.

Continuity is control. The patient needs to be the integrating agent in the system, and not the other way around.

We are at the dawn of an era of new tools and capabilities that can link a person’s health experience in time and space.

Coaches, caches, continuity, control are the watchwords. These tools will be expert systems for use by non-experts, and therefore must be designed to be used by patients.

The public benefit matters. There is a common interest, a public interest, in improving the health status of Americans. Kebbe promotes socialized health care.

Vince wrapped things up talking about the migration of multi parameter remote patient monitoring. This transition will be from high costs and proprietary systems (bound by low volumes and unnecessary duplication of capabilities that adds little or no value) to openness that provides the free flow of patient data throughout the health care system.

Next up was Liz Boehm, principal analysist Forrester Research. Her topic, creating a culture of wellness rather than illness.

Healthcare Everywhere - How the New Culture of Wellness Is Opening the Door for Healthcare Unbound

In 2002 Forrester was defining the HU market with focus on technology. In 2004 they sized the market and came up with growth projections. (She noted we’re getting uncomforably close to that hockey stick with little uptick in growth rate.) In 2005 they identified early adopters of HU. The "network" was the focus in 2006 - the ecosystem with Continua, HealthVault and Google. In 2007 Forrester looked at design elements and market requirements for seniors. Today we’re looking at culture versus biology.

We’re up against a culture that in some ways is antithetical to what we’re trying to achieve, i.e., wellness. Boehm went on to paint a pretty negative picture of society in the U.S. today.

In the U.S. our culture is about the here and now. We're about profits rather than ethics, about near term costs versus long term costs - destroying our environment rather than hair shirt environmentalism. Simplicity (e.g., feedlots) compared to the complex (polycomplexity farming). Convenience (food that’s easy to find, tastes good) rather than health (foods that are more challenging to put together). Today’s pressure versus tomorrows consequences - smoking, sedentary lifestyles, etc. Her conclusion: Healthcare Unbound is antithetical to U.S. culture.

If were relying on consumers to suddenly gain an interest in health and wellness, we’re in for a long slog. HU is about prevention, management, outcomes and consequences.

Are there signs that times are changing? Perhaps.

Priorities are shifting in increased consumer interest in whole foods, and hybrid cars (although I would argue that’s only because of short term pain - $4 a gallon gas). In health care, consumers are bombarded with choices - type of coverage, primary care physician or specialist, community or teaching hospital, hospital ED or walk-in clinic, etc. Consumers also wonder if a PHR is safe, and is it worth the effort?
Patients are struggling with what they don’t know. Awareness of the actual impact of behavior is low. Perception: is healthy behavior worth the trade off? Psychology of loss versus gain: why does gaining a pound feel so much worse than losing a pound feels good?

Culture changes occurs at all levels, nationally, ethnic culture, at the family level, and at the corporate level.

Forrester surveyed corporations about HU. The top interests were preventive health, cost sharing with employees and wellness management. Wellness prevention investments have grown the most within corporations. But employers are still struggling with how to measure the impact of their efforts in this area. Employers want to measure things like drug compliance, health outcomes and wellness participation.

Employers are looking for one stop shopping, or to put it another way, they want whole product solutions rather than a few tools.

Consumers are looking for convenience.

HU vendors need to provide solutions rather than tools, and build on existing tech infrastructure (rather than waiting for PHRs). Boehm suggested using Boomers to get to their parents, i.e., drive adoption among seniors.

Behavioral Economics Goes Pop

Mike Barrett's talk was, Behavioral Economics Goes Pop, is based on research that goes in sharply divergent directions. Behavioral economics was founded by psychologists and is now dominated by economists. Current research continues to use insights from psychology to challenge traditional “rational actor” assumptions. Two years ago, Mike introduced behavioral economics to HU. Last year, Mike dug into loss-aversion and associated negative information, with heightened risk of loss.

In the last 12 months, behavioral economists have pushed for a popular audience. Two books have come out, Predictably Irrational and Nudge, targeting the mass audience. Both books have done well. These behavioral economists are also getting proscriptive, suggesting solutions to the problems they’ve identified.

The focus of behavioral economics looks at the decision-making that departs from rational actor expectations. The focus is on heuristics and biases: framing effects, excessive optimism, status quo bias, lose aversion, anchoring, conformity effects, etc.

“Dual personality” conflicts like the id versus the super ego, becomes an exploration of the doer versus the planner, the human versus the economist and reflexive responses versus reflective responses.

Incentive effects are being explored, focused on monetary versus non monetary incentives.

The bottom line is that we are far less rational than standard economic theory assumes. The good news is that the irrational behaviors are predictable.

In the book Nudge, the author developes a construct called "choice architectures." Anyone responsible for organizing the context in which people make decisions are “choice architects.” And this context is never neutral.

These behavior economists have developed a political frame work and justification for consciously creating choice architectures that they call "libertarian paternalism." The libertarian part is leaving the ultimate choice up to the individual. The paternalism comes in how the economist creates the choice architecture.

A key concept in choice architectures how the question is framed. Humans are wired for context and this is where choices are framed.

Behavior economists recommend “social engineering” to correct for the distortions caused by heuristics and biases by putting those heuristics and biases to work in a good cause. Because there is no such thing as neutral design, defaults need to be tweaked to produce better choice architectures and outcomes.

Some interesting questions:

  • Can payors be trusted as choice architects? Can politicians?
  • Who plays the role of choice architect in social networks and patient communities?
  • What is the right role for financial incentives?
  • Who organizes the context in which people make decisions at home?

Mike provided the example of personal care robots and their ability to greatly influence choice architectures.

The notion of a PHIN is based on the assumption that patients reliably do the right thing - something that behavior economists show does not happen.

How Can Healthcare Unbound Avoid the "DM ROI Trap"

After the break, Gordon Norman of Alere Medical, presented “How Can HU Avoid the “DM ROI Trap.” Gordon admitted that he came today, not with answers, but with a series of questions.

The DM (disease management) ROI trap refers to the question, “does DM work?” Proving the value of DM once it is generally accepted and nearly ubiquitous becomes very challenging. And proof hurdles differ between academics, government and corporations.

In the early days, DM referred to the minority of the population that drives the highest levels of health expenditures. Employers who come into DM on the buyer side have an additional issue, presenteeism - employees who are present but not fully productive. Many employers are looking for someone to effectively address this much larger segment of the population. This extension of DM now includes wellness programs and health coaching, in addition to the traditional acute chronic disease management.

Now, DM means population health improvement to virtually the entire population.

The implied question is, does DM always work for every condition in every population? “Working” typically means short term savings and ROI. This assumes that DM is some monolithic invention, unlike the specific medical interventions applied to more acute chronic disease management.

Some better questions to ask:

  • Does DM ever work for any condition in any population?
  • Which outcomes are impact and in what sequence, over what time frame?
  • How important is personalization of DM?

Due to different apporaches, policy wonks reach the conclusion that there is no proof that DM works, while employers and the health care industry concludes that DM does indeed have compelling justification.

In spite of this “absence of proof” DM is used in over 90% of health plans. Yet CMS remains skeptical. This issue continues to be worked out between CMS, industry and the DMAA.

Gordon ask if the medical home model and DM will converge. He suggested that the two are very complimentary. Since three fourths of patient practices have inadequate resources to implement the medical home model, DM firms could compliment those smaller practices.

Researcher Don Berwick once observed that, “the RCT is an impoverished way to learn.” A better model might be the CMO model (context + mechanism = outcome).

From Mainframe to Personal Healthcare:  A Progress Report on Addressing Technology, Policy, and Cultural Challenges

Eric Dishman, of Intel Digital Health, talked about the transition from mainframe to personal health care. The medical mainframe borrows from the concept of the mainframe computer. This highly centralized form of computing shifted to personal computers and smart phones.

Eric drew the analogy to health care, and posited that the current acute care delivery system - the mainframe - can’t effectively provide things like chronic disease management, wellness and prevention. Demographics and a constrained acute care delivery system will force the adoption of personal health care.

How do we create a vibrant personal health industry in response to and in order to prepare for the age wave? His solutions:

  • Look beyond the acute care setting
  • Enable care networks to drive healthy life styles, improved detection, etc.
  • Focus on behavior markers (diet, exercise, weight, etc.)

The medical mainframe is all about biology, but behavior and how care is delivered are just as important.

His case study, fall detection, was based on the 3 Es: ethnography, evidence, and ecosystem.

  • Ethnographic - Understanding falls, fall risks, and fear of falls in elderly homes;
  • Evidence - capture baseline of falls and movement data; deploy to in-home pilots to prove prevention;
  • Ecosystem - share common research platform of hardware, software, and data; collaborate to build 10,000 home testbed.

The emerging competition, oriented towards proprietary solutions, frightens Eric because without a certain common ecosystem underpinning the market, there will be no market for anyone.

Intel is working through the Technology Research for Independent Living to create a broad platform for research. The goal is to take university research to large population studies. Software is made available to researchers for free to facilitate research.

Real Time Incorporated is now the commercial provider for a common platform for wireless sensors called Shimmer.

Another missing piece is the R&D ecosystem for HU.

He asked, "Have you regularly used a PHR for more than 6 months and gotten medical/personal value from it?" Very few in the audience had. Eric's conclusion: there is no market place. You’d have to hire a systems integrator to put all this together.

The good news:

  • Products based on the Continua spec v 1.0 will be released soon
  • More universities are doing work on personal health
  • Conferences are abounding
  • Press coverage is growing
  • The CAST congressional vision video is increasing interest
  • Early products are arriving
  • Bits and pieces of legislation are popping up
  • Some coalitions/non-profits are banding together

The downside:

  • Very few products so far
  • There is no channel or shelf space for these products
  • Not enough value to warrant making a lot of money (and thus motivating entrepreneurs or corporations)
  • Many corporate labs are small, barely hanging on
  • Academic labs at risk; no publications, reviewers, tenure or scale
  • Very little progress on prevention, behavior change
  • Advocacy groups fighting for small bills and members
  • The health care mainframe is fighting back

His advice for the industry:

  • Get real - get out of denial about the thinking there’s no market
  • Get large - create the ecosystem to drive sufficient value to grow the market
  • Get loud - stop battling one another, join voices and work together

Q: How do we get through the mire in methods patents. A: Eric noted this as a huge issue with no obvious or short term solution. It's gotten so bad that he’s finding it harder to negotiate with universities than companies like Microsoft.

The Internet of Bodies

Don Jones with QualComm, presented “the Internet of Bodies,” where he explored potential and actual successful wireless Healthcare Unbound applications.

Don started his talk with an overview of the wireless industry. There are now more than 625 million 3G subscribers world wide. Mobile services are becoming central to modern lives. Don’s group at QualComm is focused heavily on the body area network (BAN).

Don mentioned the Amazon Kindle as a device that’s really a cell phone that’s positioned as something completely different. The potential for non-cell phone looking HU technologies based on cell phone technology is considerable.

His summary of sensor platform requirements:

  • Ultra low power
  • Security
  • Integration with sensors - prcoessing, essy configuration
  • Smart nodes

Once the sensors capture the data and it is sent on by a gateway, you have to have data management.
A discussion of remarkably successful health and wellness products included the Wii Fit and Nike Plus described as the two most successful digital health products. The Wii Fit sold over 1 million units in a month - in Japan alone.

The challenge is the decentralized patient view and the standards for interoperability so products from different vendors all work together in support of the patient.

The Wireless-Life Sciences Alliance was noted as a forum for vendors to come together to build market awareness and create platforms for HU solutions.

The health care market is a very big - wide and deep - black hole. They see  very select rifle shots as having the best chance of success.

When asked about the patent situation, Don noted that the cell phone industry works on a “patent pool” approach to grow the market.

There was also a question about research on running life critical applications on cellular networks. Don’s response was that any product’s design must identify and mitigate all communications risks.

Google Health Overview

Jerry Lin, product manager at Google, presented Google’s perspective on personal health technologies. He suggested that the patient may be in the best position to manage information on things like redundant lab test results - or actually pointing to the previous lab test, precluding the need to have that duplicative test.

Semantic interoperability was noted as a major requirement. Alignment of incentives has a big impact on the adoption of semantic standards.

Jerry noted “long tail” applications, and providing their service for free (foregoing transaction fees) to drive adoption. They do see opportunities for third parties to provide valuable services from which they could generate revenue.

He went on to demo Google Health, showing the importation of data from third parties (Beth Israel Deaconness) and how patients could view and manage that data.

Q: What’s your strategy for driving adoption? A: By creating more value for the user.

Q: Issues were raised regarding Google’s current business model and whether that’s a fit for a service like this. Specifically, an account break in to Gmail and Google’s lack of the means to respond to individual situations, security, and normalizing data in the front end. A: Jerry had a rather unfulfilling boiler plate answer for this question.

Q: What’s Google Health revenue model? A: There is no revenue right now. They have yet to figure out how to monitize it.

Q: How doe they limit access to the data from internal Google employees. A: Patient data is encrypted and a limited number of employees have access.

Continua Health Alliance Update

Next up, Dave Whitlinger, director of healthcare device standards at Intel, with an update on Continua’s activities. Dave is also the president and board chair of the Continua Health Alliance.

Continua’s mission is to establish an ecosystem of interoperable personal health systems - as opposed to the usual proprietary end-to-end solutions. The three categories of personal tele health targeted by Continua are health and wellness, disease management, and aging independently. Continua aims to provide interoperability between sensors, gateway devices and the back end information systems. He noted the WiFi Alliance as an example of the desired cooperation between competitors with the goal of increasing market growth.

Version one of Continua’s device connectivity standards includes 11073 standards (just finishing up) running on Bluetooth and USB. The standard for connectivity to providers is HL7. Starting late this year and early next year, we’ll start to see new products with Continua logos.

Continua has about 500 modules of member written source code that can be downloaded by member companies. They’re paying contractors almost $1 million to finish up a common software library for connectivity. The code is “reference” only, and written for a generic reference platform, rather than optimized for a specific device. The reference is Windows XP, X86-based hardware, written in C/C++. The library will implement all the mandated features. The library modules include a common API. They estimate member companies can save $500k to $600k in R&D costs.

Use case voting for version 2 occurred earlier this year - a total of 16 use cases. It takes roughly 18 months to 2 years to go from use case selection to commercially available product.

Work is progressing on a project plan for companies to use Continua certified solutions in trials of remote monitoring products. There is also a global policy working group and regulatory user group working in their respective areas.

Continua has also pushed strong internal involvement, with meetings in Europe, Asia and elsewhere.

Dave sees the IHE as the key entity focused on interoperability in acute care.

Emerging Technologies Help Consumers Enjoy Higher Healthcare Standards

David Cerino is general manager, consumer engineering, health solutions group, at Microsoft. His presentation was titled, “Emerging Technologies Help Consumers Enjoy Higher Healthcare Standards.” David applied his experience in the market’s adoption of electronic banking and travel. He had some great suggestions about how consumers will shape HU, and similarities with electronic baking and travel.

He showed geographically based health care communities calling them silos, where providers take their best educated guess based on the knowledge they have. They want to put the patient in the middle to connect all their information together.

Microsoft took the platform approach. Health care is so big and complex, automating this industry is beyond any one vendor - collaboration is a requirement. Health care is always changing as science advances.

Microsoft’s position is that HealthVault is not a competitor to Google Health’s PHR, and that they should be interoperable.

A key differentiator of HealthVault is the Connection Center where device vendors can create interfaces so data from their devices automatically flows into HealthVault.

David compared and contrasted HealthVault with PayPal to illustrate how HealthVault is a platform. Both are data exchange platforms where the user experience is driven by partners. (The HealthVault team is not even marketing to consumers yet.)

HealthVault is not a PHR. A PHR’s end point is to store data. HealthVault stores data so that it can be shared with other entities in the health care delivery system.

The revenue model for HealthVault is based on search engine ads and lifting other Microsoft business.

Disruptive Healthcare Innovation - Changing the Rules of Diabetes Management by Marrying Wireless and Clinical Innovation in the Healthcare Ecosystem

Anand Iyer, president and COO of WellDoc, presented on “Diabetes Management and Emergin Wireless Solutions.” Technology as an enabler can make two key contributions in improved outcomes and lower costs.

Anand used an imaginary diabetic, Frank, to illustrate how WellDoc’s technologies can improve chronic disease management.

Traditional healthcare levels include disease management, pharma innovation, device innovation, and healthcare plan design. These levers have resulted in the status quo. Emerging innovation levers include health and wellness management, pharmokinetic innovation, solution innovation, and value chain design. The heart of this innovation is real time information distributed across a common network.

WellDoc's solution is chronic disease management and welness coaching over cell phones using simple text messages. How interactions are designed and implemented has allowed a ubiquitous technology - cell phones and text messaging - to be used in a new and very effective manner.

How Health Plans Leveraging Active Biometrics Can Drive Member and Provider Engagement to Help Improve Health Outcomes and Lower Costs

Larry Leisure, North American president for iMetrikus talked about “How Health Plans Leveraging Active Biometrics Can Drive Member and Provider Engagement to Help Improve Health Outcomes and Lower Costs.” Employers impact plan design and health plans influence behavior.

Larry did a great job of laying out an approach to improving HU’s traction in the market to grow the industry.

Anand Iyer asked a question that showed a clear understanding for MVAs (multi vendor alliances, like Continua). Larry thinks the best trends will be driven by large employers.

Wireless Technology - Direct Connect to Influencing Consumer Behavior

Sherri Dorfman with Stepping Stone Parnters chaired this panel discussion. Richard Adler, Institute for the Future, lead things off starting with key mobile health trends:

  • Evolution of wireless networks (3G networks currently, WiMax coming)
  • More powerful handsets (multi modal radios)
  • Smaller, more capable sensors
  • Longer lasting batteries/lower power consumption
  • Eventual adoption of EHR/PHR
  • Development of effective behavior change algorithms.

Vince McNeil, Product Line Manager, Wireless Connectivity, Medical Business Unit, Texas Instruments, reviewed the “usual subjects” in wireless HU technologies - Zigbee, Bluetooth, GSM/GPRS, etc. The first proposed TI corporate pilot is a weight management wellness project. They’re going to use Body Media to monitor activity to track effectiveness in behavior modification. Next they will do a chronic disease pilot.

Aaron Goldmuntz, director of business development at Cardionet, described their mobile cardiac outpatient telemetry. Beyond their existing diagnostic service, Cardionet presented a atrial fibrillation disease and therapy management application. This would include correlation of HR trend and AF burden graph. This application can also be used to evaluate AF therapy efficacy by monitoring the patient be fore and after ablation.

Beyond patient management and self care, Cardionet has been successful in providing tools to cardiologists.

Silviu Chiricescu, principal engineer at Motorola Labs, talked about a planned trial. Targeting an independent living facility, a variety of sensors (glucometer, weight scales, NOBP, SpO2) will be used to manage a variety of chronic diseases. The study will have use a control group and will last a total of 2 years.

Paul Hedtke, from QualComm, talked about consumer perceptions on a diabetic self-management application. The solution aimed to be convenient (data logging, data capture), personalized (data driven, tailored assistance) and persistent (always there, integrated with phone). Solutions from t+Medical and WellDoc have shown to be effective - if you can get patients to use them.

Half of diabetics in the study expressed significant interest in a personal diabetics management service delivered via their cell phone. Interest levels were higher among newly diagnosed and those newly on insulin therapy.

Key features by level of interest:

  • Converged devices (phone and measurement device)
  • Auto logging of measurements
  • On demand emergency assistance
  • On demand live diabetes management advice
  • Automatic medication management
  • Automatic electronic diabetes management advice
  • Integrated PHR
  • Physician access to measurement data (QualComm was surprised that consumers ranked this so low)

Q: Wireless sensor band-aids, are those real today? A: Vincent noted that there are presently no released product like this. Paul suggested that adhesives may be the biggest R&D challenge to this application.

Q: Cellphones are quickly becoming the de facto ambulatory gateway; what do you see as the standard gateway for home use - will it also be the cell phone?  A: Aaron notes that cell phone coverage, especially in the home is still problematic. Cardionet has a home based gateway that plugs into the land line to complement wireless carrier networks. Silviu suggested that WiFi and set top boxes provide alternative gateways at home.

Q: Silviu was asked what vendors offer standards protocols for their wireless sensors. A: Silviu noted that the protocols are standard transport protocols, but they are going to be using products coming out of Continua’s version 1 work.

Doug McClure, transtioned the panel to consider business models.

Paul Hedtke noted that chronic conditions require a continuum of care that cannot be cost effectively delivered by the taditional health care delivery model. Potential models include:

  • Provide tools that allow traditional health care providers to extend the “point of care”
  • Provide tools that allow traditional disease management providers to provide more robust services
  • Leverage technology to provide chronic condition management tools and services directly to consumers at consumer price points

The business model has to be more than instrumenting patients, with data now flowing into the physician’s office. For example, Cardionet built the platform to sell a service in order to relieve the cardiologist with a burden that they really weren’t able to cover.

LifeCOMM (QualComm's announced MVNO) is a direct to consumer model experiment. They plan to bundle health services with typical cell phone services, employing a subscription business model. These services will be tailored for specific chronic diseases. They will build these services through collaboration with “brand authority” partners and market direct to consumers. They plan to sell through health product and services relevant channel partners

Richard explored the pros and cons of mobile as a health platform. It’s personal, portable, ubiquitous, connected and intelligent. The downside is that it is a heterogeneous environment (multiple operating systems), networks operate as walled gardens, its a rapidly changing environment, there appears to be a mismatch between the mobile and health care industry.

The most promising applications include: remote monitoring, reminders (appointments and medications), clinical trial communications, patient behavior change, and remote consultations.

In the long run, a very interesting HU platform is SMS texting. Over 95% of phones are text-capable. More than 100 million of 253 million U.S. subs use SMS. 41 mil Americans text “almost every day,” generating about 1 billion text messages are sent daily. At least 3 of the above 5 applications are well supported by SMS texting. There are even some provocative trials showing the ability to change behavior using texting. An evolution in the technology is MMS, multi media messaging service, for texting messages with still and motion pictures. (Richard also mentioned a low cost SMS application intended for NGOs.)

The future of mobile health care 5 key trends:

  • Continuous monitoring (MD Keeper, RFID band-aid with temp, Body Bug, free swimming nano tech sensor)
  • Continuous support - personal coaches for asthma, I Buy Right that reads packaged goods barcodes that provides additional neutritional and ecological footprint data, and an advanced pattern matching application that identifies your location and provides warnings.
  • Remote consultations - the service shown is in the UK; patient competes an intake form on the Internet and then
  • Mobile personal health record
  • Merging of mobile and social media - Qwitter instead of Twitter to help stop smoking, Daily Strength and Patients Like Me patient support web sites.

Nowadays, patients show up for an office visit with research from the Internet, in the future they may come with their own support group with whom they will filter physician therapies.

Silviu is confident appropriate models will emerge - there is no one single model for everything.

Vince sees consumer electronics and preferences having a growing influence. The key will be not the what, but how best to use it.

Aaron noted that there’s tremendous enthusiasm about the consumer electronics market, but we’re in an environment where patients aren’t used to paying for health care and business models that better fit into the current health care market will be more successful in the near term. While some potential business models have huge long term potential, fitting them into the current health care industry is important.

Paul believes that new technologies will drive new business models. He suggested that if we let the health care providers dictate how to use new technology, only a small fraction of the potential of this new tech will be realized. Doug, who works for a large provider organization, agreed.

Twenty years ago, the thought of doing all your banking without ever facing a bank teller was inconceivable. Today most bank customers rarely interact with tellers.

Q: Is any one working on the meta analysis medical device? A: Aaron reported that there’s lots of interest, but there is an incremental approach being taken.  Paul referred to advances in automobiles; 10 to 15 years ago RPM was about the only thing continuously sensed on your car, now there are many parameters being continuously monitored and recorded. HU technologies are moving in the same direction. Vince sees the same requirements, but because these capabilities are new the market’s working out to use the new data (e.g., combining ECG and auscultatory data or gait data).

Q: What about the challenge in getting buy-in from physicians? For Cardionet, what challenges and success have you had in that area? A: Aaron noted that there are several things. First, they offer a service that takes a lot of the load off the physician. In terms of convincing payors, there is some intuitive persuasion but the heavy lifting comes from clinical trials.