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Internet Turns 25 – Looking Back And Forward

happy birthday

Wow!  The Internet turned 25.  Do you remember when you started using computers and technology?  I can.

I think my first computer was the Commodore 64 which we plugged into our home TV for a monitor and used a tape recorder to store files and access programs.

commodore 64

I can remember when we got 3 Macintosh computers to use at school.

first Mac

I can remember when we got our IBM PC Jr.

IBM PC Jr

After that, computers started being a little more common where we had them in high school for typing, but at the same time, people were using electric typewriters more than computers.  (I can’t believe that they still sell electric typewriters – see Wal-Mart ad.)

I can then remember being at the University of Michigan with massive computer labs of Apple computers.  At that time, I still remember using the Gopher technology that had been developed out of the University of Minnesota and pre-dated today’s Internet and HTML.

gopher

This eventually led to all the excitement about physical companies having websites and being able to do amazing things like order pizza online…the rise of e-commerce and eventually the dotcom bubble.

I still smile when I think that one of my first assignments in healthcare was to convince managed care companies to build a website.  I flew all around the country as a consultant with Ernst & Young LLP meeting with teams to convince them of what the Internet could do, why they should build a website, what functionality to put on it, and how to drive members to the website.

And, now, our kids grow up with this as normal.  Everything can be “googled”.  There is no card catalog to look things up or waiting to figure out why someone is late.  Things are instantly available.  (If you’ve never seen the list of what graduates will never remember, here’s a link to their 2017 graduate list.  Always interesting.)

So, I’ll wrap this up with a look at the future from a new report by PEW.  Here’s 15 predictions from their report:

1) Information sharing over the Internet will be so effortlessly interwoven into daily life that it will become invisible, flowing like electricity, often through machine intermediaries.

2) The spread of the Internet will enhance global connectivity that fosters more planetary relationships and less ignorance.

3) The Internet of Things, artificial intelligence, and big data will make people more aware of their world and their own behavior.

4) Augmented reality and wearable devices will be implemented to monitor and give quick feedback on daily life, especially tied to personal health.

5) Political awareness and action will be facilitated and more peaceful change and public uprisings like the Arab Spring will emerge.

6) The spread of the ‘Ubernet’ will diminish the meaning of borders, and new ‘nations’ of those with shared interests may emerge and exist beyond the capacity of current nation-states to control.

7) The Internet will become ‘the Internets’ as access, systems, and principles are renegotiated

8) An Internet-enabled revolution in education will spread more opportunities, with less money spent on real estate and teachers.

9) Dangerous divides between haves and have-nots may expand, resulting in resentment and possible violence.

10) Abuses and abusers will ‘evolve and scale.’ Human nature isn’t changing; there’s laziness, bullying, stalking, stupidity, pornography, dirty tricks, crime, and those who practice them have new capacity to make life miserable for others.

11) Pressured by these changes, governments and corporations will try to assert power — and at times succeed — as they invoke security and cultural norms.

12) People will continue — sometimes grudgingly — to make tradeoffs favoring convenience and perceived immediate gains over privacy; and privacy will be something only the upscale will enjoy.

13) Humans and their current organizations may not respond quickly enough to challenges presented by complex networks.

14) Most people are not yet noticing the profound changes today’s communications networks are already bringing about; these networks will be even more disruptive in the future.

15) Foresight and accurate predictions can make a difference; ‘The best way to predict the future is to invent it.’

 

Healthcare Gamification

If you believe all the hype about digital health, you might think gamification was a natural solution.  Of course, if you’ve never heard of gamification, let me provide a basic definition from Wikipedia.

Gamification is the use of game thinking and game mechanics in non-game contexts to engage users in solving problems.

Here’s several articles for more information:

  1. Four Factors Driving Gamification in Healthcare
  2. From FitBit to Fitocracy
  3. The Wellness Game
  4. Gamification: Drugmakers And Health Campaigners Turn To Games To Promote Health

I think this quote from the Perficient white paper on this topic is a good one.

Gabe Zichermann, the author of Game-Based Marketing, speaks of balancing the fun and frivolity of gamification with the task of making life easier for cancer patients. He says, “I don’t presume to think that we can make having cancer into a purely fun experience. But, we have data to show that when we give cancer patients gamified experiences to help them manage their drug
prescriptions and manage chemotherapy, they improve their emotional state and also their adherence to their protocol.”

You can also look at a post by Jane Sarasohn-Kahn (one of my favorite bloggers) on this topic where she highlights several trends from a recent paper on gamification in healthcare.

Now, why should you care?

  1. Gamification should improve engagement which is critical to changing behavior.
  2. Gamification creates opportunities to make healthcare fun which can be difficult.
  3. People are different and respond to different “incentives”.  Competition and leader boards are concepts that excite lots of people to take action.

The forecasts for the gamification market are huge.  They show a nice hockey stick which gets every investor excited.

1

Of course, the important question is who uses games.  Is it just teenage boys?  It’s not.  Here’s a good report which shows you breakdown by age, gender, and many other stats.

Gaming

Another quick article about gamification is from TEDMED.  The video is below, but it reminds me of some of my personal perspectives.  The sites also lists out several vendors and solutions in the obesity gamification space.

While one “easy” opportunity in my mind is to use gamification to address the rising number of kids with chronic diseases and to help address childhood obesity, there are many other opportunities like adherence.  A few examples of games out there include:

Companies like Ayogo, Mango Health, and Akili are ones that I’ve heard about, but I know there are a lot more out there.

One example I think of from watching my kids play games is from Webkinz which was a blend of real stuffed animals with online digital personas.  The animals could get sick if you didn’t nurture them and visit them.  It made me think of how an avatar could get fatter or slower based on their pedometer or eating habits.

Forbes “Most Promising” Companies – Healthcare

Whenever I see lists like the Forbes list of America’s Most Promising Companies, I like to look through the list and pull out the healthcare companies.  They say these are private companies that standout because of their growth and outstanding management.

#4 – Evolent

#24 – 24HR HomeCare

#28 – CareCloud

#39 – Intersect ENT

#41 – Therapearl

#95 – Boston Heart Diagnostics

If healthcare is 20% of the GDP and with all the mHealth and HIT spending, I was hoping to see a few more companies on this list.

Dossia: Not Just a Personal Health Record Anymore

Image

I had a chance to see a product demo of Dossia the other day.  I was really impressed which I don’t easily say.  I was expecting to hear a pitch on Personal Health Records (PHRs) and why they were different.  Instead, I got to see a robust patient engagement portal which did some really interesting things. (see image above from the Health 2.0 demo they gave)

From their website, here’s the “about” description which lists some very influential players…

Dossia is an organization dedicated to improving health and healthcare in America by empowering individuals to make good health decisions and become more discerning healthcare consumers. Backed by some of the largest, most respected brands in the world – Applied Materials, AT&T, BP, Cardinal Health, Intel, Pitney Bowes, Vanguard Health Systems, NantWorks and Walmart – Dossia’s founding member companies have united under the common vision of changing healthcare.

Having these companies involved over the past 6 years has been really important for them to accomplish what they’ve done.  As someone that’s worked on a lot of the same population health challenges, they’ve accomplished things that not even Google Health could do.

So what were the features and functions that really impressed me:

  1. They’ve built integration to health plans, PBMs, pharmacies, lab companies, and even EMR companies.  This creates a data rich longitudinal view of the patient for the patient.  (I like the expression on their website where they say “Dossia is the connective tissue that powers healthy change.”)
  2. They’ve incorporated health content which by itself isn’t impressive, but the content is tailored to the individual based on their medical data.  Not hard, but not something that many people do well.
  3. They’ve built out a series of partnerships and integrations with over 50 apps where you can navigate that turn them on as widgets within the portal.  This is very similar to some of the cool things that CarePass is doing.
  4. They’ve built the system out using open APIs (application programming interfaces) which allows other companies to easily integrate with them.
  5. And, probably one of the cooler things from my consumer engagement lens was their ability to do WYSIWYG rules creation to trigger outbound communications based on clinical data.  The idea of a rules engine isn’t difficult, but the ease of their solution with the integrated data makes it very powerful.

And, they’ve expanded their reporting.  They’ve pulled in ways to manage those family members for which you’re a caregiver.  They’re doing lots of interesting things.  They are definitely worth talking to if you haven’t seen them in a few years.

Interview With David Tripi – Janssen Healthcare Innovation

A few weeks ago, as a follow-up to my discussion with Aetna about CarePass, I had a chance to talk with David Tripi from Janssen Healthcare Innovation about their new solution.

David is a founding partner at Janssen Healthcare Innovation where he is part of a multi-disciplinary group working toward the goal of propelling the company to become the leader in the healthcare solution business. Prior to the launch of the JHI team, David was with Johnson & Johnson for over 15 years.

“Janssen Healthcare Innovation (JHI), an entrepreneurial group within Janssen Research & Development, LLC, develops cutting-edge health solutions designed to modernize healthcare delivery, improve patient outcomes, and create a healthier world.”  This is a 3-year old effort by Johnson & Johnson focused on integrated care businesses and enabling technologies.  To support those, medication adherence and mobile are key areas.

One thing that David stressed is that they are platform agnostic and that their Care4Today Mobile Health Manager works as both an app and via SMS.  Therefore, the 50% of the US that doesn’t have a smartphone can still use it.  Additionally, it’s not a product or drug specific solution.  You can use this even if you don’t use a J&J product.

Care4Today Care4Family

Adherence is a huge challenge that everyone is aligned around, and everyone is trying to find solutions – plan design, incentives, apps, consumer engagement, framing, behavioral economics, and smart pill bottles (to name a few).  So, what’s part of the Care4Today solution?

  • It has reminders for Rx and OTC products.
  • It has a refill reminder process which they hope to automate in the future.
  • It has a two way secure messaging platform.
  • It has images of over 20,000 pills.
  • And, they also included a caregiver strategy and an incentive option.

The idea of social health is important.  We’ve talked about this for weight loss and smoking.  But, with the expanded role of caregivers, can they play a key role in improving adherence?  For example, if you respond that you didn’t take your pill and the response goes to your caregiver, will they call you?  Will that follow-up motivate you?  (Care4Family)  Some prior research says yes.

A broader question might be about how to pick a caregiver or how to define it.  Should it just be your family?  Should it include your physician?  What if you don’t have a support system?  Could the healthcare companies or advocacy companies give you a “professional caregiver”?  What about an avatar as a caregiver?

I asked about the incentive program that they included (Care4Charity).  David pointed out that using apps isn’t fun (at least for most people) so they wanted to give a slight motivation.  I questioned him on why $0.05 (which is the daily donation if you check in and take your meds).  They did lots of research which showed that the amount didn’t really matter.  So, this is an experiment to see if this extra feature of the program will nudge people to be more adherent.  Or ultimately, it would be great to segment the population to understand who it was motivating for and for whom it didn’t matter.

One of the things I wondered about was how they were going to promote the app.  Obviously, relationships with companies like Aetna and their CarePass program are one way, but with the tens of thousands of apps out there, how will people find it?  David told me that they were going to initially focus on social media – Facebook, Twitter, and mommy blogs – to drive awareness.  Next, they’re going to use pharma reps to discuss the app with physicians and pilot this strategy in HIV.

At the time, they’d had over 55,000 consumer downloads, and they’ve already gotten some initial feedback from physicians that like the fact that they’re offering solutions that aren’t branded to a specific pharmaceutical product.  Some of those physicians are already offering it to patients.  They expect this will be a big driver.  They are now starting to talk with retail pharmacies about how to encourage consumer use.  While my initial reaction was that this would be “competitive” with the Walgreens and CVS Caremark mobile solutions, they see collaboration opportunities especially with Walgreens and their open API.

Of course, I wondered about how the app was being used, but they don’t collect PII (personally identifiable information).  In the future, they plan to offer an option for patients to opt-in to share information and create a clinic dashboard for physicians to see which patients are using it and providing them with data.  And, with a new collaboration with HealthNet, consumers will be logging into the app with their HealthNet ID which will allow them to link up PII and PHI (protected health information).

So, what’s next…

  • They’ve launched in the US and France.  They’re expanding into the UK and other countries next.
  • They’re adding Spanish in Q1-2014.
  • They’ve just completed some human factor testing which will drive some UI and UX changes.
  • They’re going to do some testing and look at results with whatever data is available.
  • They’re going to try to partner with as many people as possible.

Will it move the needle around adherence?  It’s still too early to tell.  But, it’s great to see pharma testing new strategies and working in new ways with payers to try to address this challenge.

CarePass Updates – Medication Adherence and Stress

A few weeks ago, I had a chance to follow-up with Martha Wofford, the VP of CarePass about their latest press release.  This was a quick follow-up interview to our original discussion.  As a reminder, CarePass is Aetna’s consumer facing solution (not just for individuals who they insure) which integrates mHealth tools and data to help consumers improve their engagement and ultimately health outcomes.

“Many Americans have a lower quality of life and experience preventable health issues, adding billions of dollars to the health care system, because people do not take their prescribed medications. There are a myriad of reasons why medication adherence is low and we believe removing barriers and making it easier for consumers to take their medications is important,” said Martha L. Wofford, vice president and head of CarePass from Aetna. “As we continue to add new areas to CarePass around medication adherence and stress, we seek to provide people tools to manage their whole health and hopefully help people shift from thinking about health care to taking care of their health.”   (from press release)

As part of this update, we talked about one of my favorite topics – medication adherence.  Obviously, this is a global problem with lots of people trying to move the needle.  In this case, they’ve included the Care4Today app from Janssen.  This tool does include some functionality for the caregiver which is important.  It also links in charitable contributions as a form of motivation.  We talked about the reality that adherence is really complex, and people are different.  This may work for some, but adherence can vary by individual, by condition, and by medication.  But, they hope that this is a tool that may work to nudge some people.

I was also glad to see them taking on the issue of stress by adding the meQ app.  This is a key struggle, and Martha pointed out to me that 1/4 of adults are either stressed or highly stressed.

“When people are under chronic stress, they tend to smoke, drink, use drugs and overeat to help cope.  These behaviors trigger a biological cascade that helps prevent depression, but they also contribute to a host of physical problems that eventually contribute to early death…” – Rick Nauert, PhD for National Institute of Mental Health, 5/2010

She mentioned that they’ve gotten a great reception to this program, but they have a lot more to learn.  They’re still in the early period of getting insights and interconnecting all of their efforts.  We also talked about some of the upcoming opportunities with the caregivers (or the sandwhich generation).  I personally think the opportunity to improve aging in place through a smart home strategy with remote monitoring is going to be huge of the next 10 years.

I did interview the Janssen people as a follow-up which I’ll post separately, but I also thought I’d include this video interview of Martha that I found.

Verizon As A Healthcare Company? – Converged Health Management

You know that something has become mainstream when the large Fortune 500 companies (not already in healthcare) begin to jump into the space.  So while some people in healthcare are still trying to figure out what to do about remote monitoring, Verizon has jumped into the pool with their Converged Health Management solution. 

Now, don’t forget, people have been forecasting huge growth in this space while at the same time some of the start-ups in this space haven’t taken off as fast as expected.

I was hoping to talk with Verizon about this new effort, but they declined.  Since I had already prepared to interview them, I’m sharing my thoughts here.

What is Verizon doing in healthcare?

Verizon appears to be doing several things in healthcare.  While a lot of it is critical but less exciting back-office technology, they are starting to move into more of a consumer strategy (I think).

  • Networking
  • Cloud connectivity
  • Mobile
  • Security

What is Converged Health Management?

Converged Health Management is a “remote patient-monitoring medical platform designed to help clinicians and patients manage patients’ health in between doctor visits.”  This sounds really intriguing.  I was hoping to find out more about the device, the apps, the data, the platform, and how this is being integrated into the provider workflow.  But, for now, I’ll have to live with this video.

Why is this important?

This is important because about 50% of consumers have a chronic disease, and there’s no cost effective way to manage and monitor these consumers without using technology.  Remote monitoring of patients to provide a “bridge” between physician visits and nurse consultations is critical.  But, there are several key issues to be addressed:

  • How does the device get “prescribed” to the patient?
  • How does the patient learn to use the device?
  • How easy is it to set up the device?
  • What is the cost of the device?
  • What data is captured by the device?
  • How is this data transmitted and to whom?
  • How is the data used by the patient?
  • How is the data used by the clinician?
  • How does the solution change patient behavior?
  • What rules are written to monitor the data to create escalations to the physician, their care manager, or their caregivers?
  • How are outcomes demonstrated?
  • What is the ROI?

What I learned from the Press Release…And More Questions

I was able to learn some things from the latest press release on this solution, but it also drove lots of questions:

  • “The Converged Health Management solution enables patients to use biometric devices to take health information such as blood pressure, oxygen saturation levels, glucose levels and weight from home or on the go.” [Who provides the devices?  Are these additional costs?  How are they coordinated?]
  • “Patient data is then automatically transmitted through a wireless connection to a secure server that resides in Verizon’s HIPAA-ready cloud for analysis and intervention by the patient’s clinician, including a reward system that incents patients to make healthier lifestyle choices.” [Does the MD have to log-in to a portal?  Can the data be pushed to their EMR?  What is the reward system?  Who’s running that?  Are the rewards financial?]
  • “Patients can access this information and find personalized health-enhancing suggestions via the Converged Health Management smartphone app or Web portal.  [Is this free?  Can I use it or does my plan / employer have to sign up for it?  Who provides technology and member support for this?  How many people are using it?  What’s their response been?]
  • “As part of their health program, patients can take advantage of related health information, including videos and webinars.”  [Who provides the health information?  Is it URAC or NCQA accredited?  How does this integrate with the information from their health plan?  Does the nurse and physician have access to see the same information?  Can they see what information the consumer has accessed?]
  • “In addition, patients can connect anonymously with other patients in a secure “social networking” environment, where they can ask questions, and share ideas and experiences.”  [Is this like PatientsLikeMe?  Is the data sold to pharma?  Is the environment monitored?  Does Verizon provide experts to share opinions here?]

Interview With IMS Health About AppScript – #mHealth13

“Today, there is growing recognition of mobile health’s potential to transform healthcare – to advance doctor/patient engagement and empower consumers to better monitor and manage their own health,” said Stefan Linn, senior vice president, Strategy & Global Pharma Solutions, IMS Health. “That potential can only be realized through a systematic evaluation of the clinical benefits of healthcare apps, clear professional guidelines around their use, and effective integration of apps with other aspects of patient care. With these game-changing solutions, IMS Health is establishing an intelligent, secure infrastructure for mobile health, backed by our market-leading real-world evidence capabilities and the most advanced technology platform in healthcare.”

Most of you that read the blog on a regular basis know that I was really intrigued by the idea of “prescribing information and technology” early on.  With 90,000 different health related applications, the question is which ones should you use and how should you find out about them.  Happtique started to get into this space earlier in the year, and I spoke with them at length about integrating this into a care management platform.

I was really surprised to learn that IMS Health which I think of as a healthcare data company was jumping into this space.

IMS Health is the world’s leading information, services and technology company dedicated to making healthcare perform better.

By applying cutting-edge analytics and proprietary application suites hosted on the IMS One intelligent cloud, the company connects more than 10 petabytes of complex healthcare data on diseases, treatments, costs and outcomes to enable our clients to run their operations more efficiently.

Drawing on information from 100,000 suppliers, and on insights from more than 40 billion healthcare transactions processed annually, IMS Health’s 9,000+ expert resources drive results for over 5,000 healthcare clients globally.

Customers include pharmaceutical, medical device and consumer health manufacturers and distributors, providers, payers, government agencies, policymakers, researchers and the financial community.

I talked with Matt Tindall who’s their Director of Consumer Solutions about this a few days ago (but was waiting for their press release to be out and their presentation at the mHealth Summit – which I am very disappointed to be missing for the second year in a row.)

I also read their press release about their new solutions.

IMS Health today announced the immediate availability of AppScriptTM, an mHealth app prescribing solution designed to help healthcare providers and health plans create proprietary formularies based on an objective assessment of healthcare app functionality and value. The company also announced the launch of AppNucleusTM, its customizable, cloud-based hosting platform that will enable developers to build secure, industry-compliant healthcare apps at very low cost. Both new products will leverage IMS Health’s comprehensive data on diseases, treatments, costs and outcomes.

The AppScript Software-as-a-Service solution classifies and evaluates more than 40,000 mobile healthcare apps currently available for download on iOS and Android platforms, categorized by stage of the patient journey. Each app is assessed using the company’s proprietary IMS Health AppScore, which ranks apps based on functionality, peer and patient reviews, certifications, and their potential to improve outcomes and lower the cost of care. As part of wellness, prevention and treatment regimens, physicians can organize these apps into formularies based on their specific patient population and practice preferences. In addition, AppScript enables them to securely prescribe, reconcile and track app use by patients from any mobile interface.

AppNucleus is the company’s innovative healthcare app development and hosting platform that makes it easier for app developers to offer HIPAA- and HITECH-compliant solutions. The platform, compatible with all mobile operating systems, uniquely integrates IMS Health information and analytics at every stage of app development to support design and performance evaluation decisions. AppNucleus features a suite of plug-and-play solutions, enabling patients and physicians to exchange health information on mobile devices via a secure, encrypted channel to protect patient information. It also offers app developers a highly economical way to build security into their apps and protect patient information.

Here’s my notes and key observations:

First off, I quickly learned that I missed a very interesting report that they put out in October.  This report titled “Patient Apps for Improved Healthcare: From Novelty to Mainstream” has lots of great information which I share below.  It also is essentially the business case for these new solutions.

In talking with Matt, he shared with me how IMS Health, a 60 year old company, is using their consumer solutions group to transform how people learn and manage their health.  He talked about how they want to make mobile safer, more effective, and easier.

I really wanted to understand how they determined where to look given all the apps out there.  A lot of it is in the report, but he shared how they looked at 40,000 apps and used over 25 different criteria (such as type of information, functionality, communication process used) and peer reviews to determine a shorter list to focus on.

We discussion how the short-term success of mobile is engagement, but the long-term success will have to be tied to clinical outcomes.

He walked me through the process for getting the app prescribed:

  • The physician would be using a white labeled platform (provided by their health plan, provider group, others).
  • They would select an app based on a curated formulary.
  • The patient would get a secure e-mail or a text message with a link to the app.
  • The patient would follow the link and enter a proprietary passcode.
  • This would take them into the app store.
  • They can then download the app.

This process will allow them to track “intent to download” and then whether they did download.  The key next step will be partnering with the apps and getting the patient consent to pull data back to know not only if it was downloaded but whether it was used and how often.  And, ultimately, this will have to be integrated with the provider platform.

We talked a little bit about why IMS and he talked about their knowledge of the prescriber and ability to recommend apps for their formulary based on their patterns of prescribing.

Ultimately, I think they may be in a good position to succeed here.  I think there are several key questions:

  • How are the apps evaluated?  Do clinicians evaluate the clinical algorithms?
  • How do you determine the financial viability of the apps?  Are they one-hit wonders or shiny objects or will they be around for years.
  • How do you modify the “formulary” based on user and prescriber feedback?
  • How do you integrate the tools into the physician’s workflow?
  • How comfortable will the physicians have to be with each app?  (Won’t the users have questions for them and will that be a barrier?)

From their report on healthcare apps:

  • Only about ½ of the 40,000 apps they looked at justified a deeper dive.

IMS Consumer App Functionality

  • They categorized the apps by:
    • Inform: Provide information in a variety of formats (text, photo, video)
    • Instruct: Provide instructions to the user
    • Record: Capture user entered data
    • Display: Graphically display user entered data/output user entered data
    • Guide: Provide guidance based on user entered information, and may further offer a diagnosis, or recommend a consultation with a physician/a course of treatment
    • Remind/Alert: Provide reminders to the user
    • Communicate: Provide communication with HCP/patients and/or provide links to social networks

They also looked at apps by therapy area and by which part of the patient journey they focus on.

IMS Apps By Patient Journey

“There’s a group [of patients] who each have several medical problems and often they have several specialists, all making recommendations. It’s often overwhelming for the patient and for the caregiver. They get overwhelmed by the number of pills and the number of recommendations that they have been given, so I feel that if everybody starts prescribing apps it could quickly lead to app overload”

Leslie Kernisan – Geriatrician and caregiver educator

IMS MD Hurdles To Apps IMS App Maturity Model

 

If E-Prescribing Doesn’t Have All The Data…Is It Helpful?

This is an interesting dilemma.  At this point, I think everyone is pro e-prescribing even if it’s simply for the benefit of reducing errors.  But, I think the original intent of the solutions were to do a lot more than reduce errors.

The hope was to improve adherence (which I think may have been too lofty).  The idea was that e-prescribing would reduce the abandonment rate at the pharmacy.  I’m not sure picking up a prescription is the same as taking a prescription.  And, taking a prescription once isn’t the same as staying adherent over time.

Another hope was that the use of e-prescribing would drive formulary compliance and increase generic utilization.  The idea was that putting this information in the hands of the prescriber would allow them to make more real-time decisions that were aligned with the consumer’s interests (i.e., lower out-of-pocket spend).  The latest report doesn’t seem to support this at all.  It also echos my prior posts about whether e-prescribing was aligned with pharma at all.

Fewer than half (47.5%) of the 200 PCPs polled said they have access to formulary information when e-prescribing, and fewer than a third said they have access to prior authorization (31.0%) or co-pay (29.5%) information. Among physicians with formulary information access, that information was available 61.1% of the time and was said to be accurate 68.6% of the time.

Physicians with an EMR (54.1%) were more likely to have access to formulary information than physicians without an EMR (29.6%). And differences were seen depending on the EHR vendor: Allscripts physicians (32.2%) were less likely to have access to this information than “All Other” software suppliers (60.5%), Epic physicians (62.5%) and eClinicalWorks (68.8%). 

Another big effort that e-prescribing and integration with EMR was going to have was to push utilization management (UM) to the POP (point of prescribing) rather than having the pharmacy and the PBM dealing with it.  I never really thought this would work.  If the information isn’t there or they don’t trust the information, the prescriber isn’t going to want to deal with this.  It’s already work that they let their staff handle and isn’t something they want to deal with during the patient encounter.

While e-prescribing is definitely here to stay and becoming the norm, the question is whether it’s creating simply a typed “clean” Rx to transmit electronically or whether it’s actually an intelligent process which will enable better care.

Given multiple studies and surveys recently about transparency in healthcare billing and the general push with Health Reform to drive to outcomes, I’m not sure the “dumb” system process can be a sustainable value proposition.

Aetna’s Metabolic Syndrome Innovation Program

I’ve been closely following Aetna’s innovation for the past few years (see post on CarePass and Healthagen).  I had the chance last week to speak with Adam Scott who is the Managing Director of the Aetna Innovation Labs.

Here’s Adam’s bio:

Adam Scott is a Managing Director within Aetna’s Innovation Labs, a group developing novel clinical, platform, and engagement solutions for the next generation of healthcare.  Mr. Scott specializes in clinical innovation, with a focus on oncology, genetics, and metabolic syndrome, as well as “big data” analysis.  His work is aimed at conceptualizing and developing products and services that better predict illness, enable evidence-based care and lengthen healthy lives.  Prior to joining Aetna, Mr. Scott’s 15-year healthcare career has included management roles in consulting, hospital administration, and most recently health information technology.  Mr. Scott holds a bachelor’s degree from Washington University in St. Louis and a Masters in Business Administration from Northwestern University’s Kellogg School of Management.  Mr. Scott resides with his family in Needham, MA, where he actively serves as a director on community boards.

This is one of my favorite topics – Metabolic Syndrome (although yes…I still hate the term).

Definition of Metabolic Syndrome from the NIH:

Metabolic (met-ah-BOL-ik) syndrome is the name for a group of risk factors that raises your risk for heart disease and other health problems, such as diabetesand stroke.

The term “metabolic” refers to the biochemical processes involved in the body’s normal functioning. Risk factors are traits, conditions, or habits that increase your chance of developing a disease.

The Aetna Innovation Labs are focused on bringing concepts to scale and staying 2-3 years ahead of the market.  They are looking to rapidly pilot ideas with a focus on collecting evidence.  In general, Adam described their work as focused on clinical, platform, and engagement ideas.  They are trying to collaborate with cutting edge companies that they think they can help to scale quickly.  It’s pretty exciting!

As stated in their press release about this new effort:

“During the course of the last year, Aetna Innovation Labs has successfully piloted an analysis of Metabolic Syndrome and the creation of predictive models for Metabolic Syndrome. This prior work showed significantly increased risk of both diabetes and heart disease for those living with Metabolic Syndrome,” said Michael Palmer, vice president of Innovation at Aetna. “With this new pilot program with Newtopia, we are aiming to help members address Metabolic Syndrome through specific actions, before more serious chronic conditions arise, like diabetes and heart disease.”

Aetna selected Newtopia for this effort for their unique approach toward achieving a healthy weight with an integrative and personalized focus on nutrition, exercise, and behavioral well-being. Newtopia’s program begins with a “genetic reveal,” leveraging a saliva-based genetic test to stratify participants with respect to three genes associated with obesity, appetite, and behavior. Based on the results of this test and an online assessment, Newtopia matches each participant to a plan and coach trained to focus on the member’s specific genetic, personality and motivation profile. Through online coaching sessions, Newtopia will help members achieve results related to maintaining a healthy weight and Metabolic Syndrome risk-reduction, which will be measured by changes from a pre- and post-program biometric screening.

“Newtopia’s mission is to inspire individuals to make the lifestyle choices that can help them build healthy lives,” said Jeffrey Ruby, Founder and CEO of Newtopia.

If you’ve been following the story, this builds upon their project with GNS to develop a predictive algorithm to identify people at risk for Metabolic Syndrome.  As you may or may not know, there are 5 first factors for Metabolic Syndrome (text from NIH):

The five conditions described below are metabolic risk factors. You can have any one of these risk factors by itself, but they tend to occur together. You must have at least three metabolic risk factors to be diagnosed with metabolic syndrome.

  • A large waistline. This also is called abdominal obesity or “having an apple shape.” Excess fat in the stomach area is a greater risk factor for heart disease than excess fat in other parts of the body, such as on the hips.

  • A high triglyceride level (or you’re on medicine to treat high triglycerides). Triglycerides are a type of fat found in the blood.

  • A low HDL cholesterol level (or you’re on medicine to treat low HDL cholesterol). HDL sometimes is called “good” cholesterol. This is because it helps remove cholesterol from your arteries. A low HDL cholesterol level raises your risk for heart disease.

  • High blood pressure (or you’re on medicine to treat high blood pressure). Blood pressure is the force of blood pushing against the walls of your arteries as your heart pumps blood. If this pressure rises and stays high over time, it can damage your heart and lead to plaque buildup.

  • High fasting blood sugar (or you’re on medicine to treat high blood sugar). Mildly high blood sugar may be an early sign of diabetes.

So, what exactly are they doing now.  That was the focus of my discussion with Adam.

  1. They are running data through the GNS predictive model.
  2. They are inviting people to participate in the program.  (initially focusing on 500 Aetna employees for the pilot)
  3. The employees that choose to participate then get a 3 SNP (snip) test done focused on the genes that are associated with body fat, appetite, and eating behavior.  (Maybe they should get a few of us bloggers into the pilot – hint.)  This is done through Newtopia, and the program is GINA compliant since the genetic data is never received by Aetna or the employer.
  4. The genetic analysis puts the consumer into one of eight categories.
  5. Based on the category, the consumer is matched with a personal coach who is going to help them with a care plan, an exercise plan, and a nutrition plan.  The coaching also includes a lifestyle assessment to identify the best ways to engage them and is supported by mobile and web technology.
    newtopia
  6. The Newtopia coaches are then using the Pebble technology to track activity and upload that into a portal and into their system.

We then talked about several of the other activities that are important for this to be successful:

  • Use of Motivational Interviewing or other evidence-based approaches for engagement.  In this case, Newtopia is providing the coaching using a proprietary approach based on the genetic data.
  • Providing offline support.  In this case, Aetna has partnered with Duke to provide the Metabolic Health in Small Bytes program which he described as a virtual coaching program.

Metabolic Health in Small Bytes uses a virtual classroom technology, where participants can interact with each other and the instructor. All of the program instructors have completed a program outlined by lead program developer Ruth Wolever, PhD from Duke Diet and Fitness Center and Duke Integrative Medicine. Using mindfulness techniques from the program, participants learn practices they can use to combat the root causes of obesity. The program’s goal is to help participants better understand their emotional state, enhance their knowledge of how to improve exercise and nutrition, and access internal motivation to do so. (source)

We also talked about employer feedback and willingness to adopt solutions like this.  From my conversations, I think employers are hesitant to go down this path.  Metabolic Syndrome affects about 23.7% of the population.  That is a large group of consumers to engage, and pending final ROI analysis will likely scare some employers off.

Adam told me that they’ve talked with 30 of their large clients, consultants, and mid-market clients.  While we didn’t get into specifics, we talked about all the reasons they should do this:

  • People with Metabolic Syndrome are 1.6x more expensive
  • People with Metabolic Syndrome are 5x more likely to get diabetes
  • Absenteeism
  • Presenteeism

This ties well with my argument that wellness programs aren’t just about ROI.

Obviously, one of the next steps will be figuring out how this integrates into their other existing programs to address the overall consumer experience so that it’s not just another cool (but disconnected) program.  And, of course, to demonstrate the effectiveness of the program to get clients and consumers to participate.

Two quotes I’ll leave you with on why this is difficult (but yet exciting to try to solve):

“The harsh reality is that scientists know as much about curing obesity as they do about curing the common cold: not much. But at least they admit their limitations in treating the cold. Many doctors seem to think the cure for obesity exists, but obese patients just don’t comply. Doctors often have less respect for obese patients, believing if they would just diet and exercise they’d be slim and healthy.” (source)

Thirty percent of those in the “overweight” class believed they were actually normal size, while 70% of those classified as obese felt they were simply overweight. Among the heaviest group, the morbidly obese, almost 60% pegged themselves as obese, while another 39% considered themselves merely overweight. (source)

10 Healthcare Projects I’d Like To Solve

I always tend to see the glass half full so when I see a problem then I often want to rush in and try to fix it. With that said, here are 10 things that I’ve thought about that I’d like to fix or see as big opportunities:

1. The healthcare experience. While this is the third leg of the Triple Aim, it often seems like the one that is so hard for healthcare companies to get. The system is so fragmented that the patient often is forgotten.

2. Device integration. While devices are better and integration is possible, there is still a huge lift to integrate my data into the typical clinical workflow. This is only going to get much worse with ubiquitous use of sensors and will be the limiting factor in the growth of the Quantified Self movement. (See my post on FitBit)

3. Intelligent phones. This is something that people carry everywhere. They often live life through the phone sometimes missing out on reality. The phone has tons of data as I’ve described before. We have to figure out how to tap into this in a less disruptive way.

4. Consumer preferences. I’m a big believer in preference-based marketing. But the question is how do I disclose my preferences, to whom, and are my preferences really the best way to get me to engage. What would be ideal is if we could find a way to scale down fMRI technology and allow us to disclose this information to key companies so they could get us to take actions that were in our best interest. (see old post on Buyology)

5. Benefits selection. I’ve picked the wrong benefits a few times. This drives me crazy. As I mentioned the other day, the technology to help with this exists and all the data which sits in EMRs and PHRs should allow us to fix this problem.

6. The role of retail pharmacy. This is one of my favorite topics. With more retail pharmacies than McDonalds and a huge problem of access, pharmacies could be the key turning point in influencing change in this country.

7. Caregiver empowerment. Anyone who cares for an adult and/or child knows how hard it is to be a caregiver and take care of their own needs. This becomes even harder with the people being geographically apart. With all the sensors and remote technology out there, I see this being a hot space in the next decade.

8. The smart house. As an architect, I’ve always dreamed of helping create the intelligent house where it knows what food you have. It manages your heat and light. It tracks your movements and could call for help if you fall. I see this being an opportunity to empower seniors to live at home longer.

9. Helping the disenfranchised. For years, we’ve all seen data showing that income can affect health. The question is how will we fix this. Coverage for all is certainly a critical step but that won’t fix it. We have a huge health literacy issue also. Ultimately, public health needs a program like we had to get people to wear seat belts. We need yo own our fate and change it before we end up like the humans in the movie Wall-e.

10. A Hispanic healthcare company in the US. With 16% of the US that speak Spanish, I’m shocked that I haven’t seen someone come out with a health and wellness company that is Hispanic centric in terms of the approach to improving care, engaging consumers, and providing support.

So, what would you like to solve?

The 15 Year Old Technology Missing From Healthcare.gov

I talked about my experience trying to use the site day one. I honestly hoped it was an anomaly but it doesn’t seem to be.

But, as I think about Healthcare.gov and the general benefits selection process, I see two huge gaps.

Back in 1999, I was working with a company called Firepond. The had what was called a product configurator. At the time, I was at E&Y and Empire BCBS and several other Blues hired them to build a tool for brokers. The tool sat behind a really slick web interface which allowed the broker to ask a consumer less than 10 questions. They would move a sliding bar across the screen and it would dynamically rank their plan options to tell them what was the best option for them to buy. It seems like that wold be great for Medicare.gov and Healthcare.gov.

What we were missing then which Big Data might actually help us solve now is individual claims data. This is what drives me crazy when you have to pick your benefits at work. Why can’t I upload my benefits information and have a tool actually tell me what to buy? If I had my claims history plus a predictive model, I could make smarter decisions about how to select my benefits.

Retail Pharmacy As The Digital Medical Home

I’m excited to deliver my presentation on the topic about the retail pharmacy as the digital medical home tomorrow at the intersection of three CBI conferences – Point of Care Summit, Retail Strategy Summit, and Strategic Distribution Planning for Specialty Products.  As always, I’m sharing my slides below via SlideShare, and I’ll set up some tweets to give you the cliff note version.

The key here IMHO is that retailers are best positioned to take advantage of this, but the key points are:

  1. Why retail pharmacy?
    • Retail pharmacies have trust from consumers.
    • Easily accessible.
    • Pharmacy is the most used benefit.
  2. What’s the challenge?
    • Successfully engaging the consumer.
    • Integration with the provider so there are process oriented care gaps.
    • Data.
  3. What needs to happen?
    • Focus on the golden moments for engagement.
    • Systemic model for engagement – e.g., Prochaska.
    • Tools and skills to motivate the consumer – e.g., Motivational Interviewing, Incentives.

Blue Button And United Healthcare – Disappointing

Ever since I interviewed the CEO of Humetrix about iBlueButton, I’ve been excited about the prospects for using Blue Button myself.

Now that I’ve moved to Charlotte, I figured I would download my data to take to my new PCP.  I knew that United Healthcare was participating with Blue Button so I started there.  What a disappointment!

After finding it on the United Healthcare site, it offered me two options – a PDF file or a data file.  I quickly went to iBlueButton to look at uploading and connecting, but United doesn’t work with them (although Aetna does).

So, I figured I would settle for a boring PDF that I could print and bring to my physician.  My understanding of the Blue Button project was that you could get your medical record digitally to share with your physician.

Here’s what the PDF contains:

  • A few things from my HRA
  • The name of my physician
  • The fact that I went to a clinic
  • The dosage of a medication that I take
  • A listing of blood work done (under surgery not labs)

But, it didn’t include:

  • The fact that I had a flu shot at the clinic
  • The name of the medication that I take
  • Any diagnosis from my physician
  • Any values from the blood work
  • No list of providers that I’d seen even though there’s a section for this

And, before I printed it, I completed my HRA.  The printout picked up much of this information but not all of it.  Some of it was still a year plus old from the last time I completed it.

Maybe it’s just me, but this seems a lot more disappointing than what I’d been led to believe.

Why Use RunKeeper?

I’ve been a longtime user of Garmin for my running.  They provide easy to use GPS watches that provide you with all the details and history you want.  I also now have my FitBit as another tracking device when I run.

So, while several people encouraged me to try RunKeeper, I was hesitant.  How many trackers for the same activity do I need?  But, I started carrying my iPhone for music while I ran so I decided to give it a try.

I like it.

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So, the question is why?

  1. It talks to you.  While looking at my Garmin is pretty easy, the RunKeeper app speaks into my headphones while I’m running to tell me when I’ve completed a half-mile, what my total time is, what my average mile pace is, and what my last split was.  I can certainly calculate all that and see it on my Garmin, but this is very easy.
  2. It gives you reinforcement and now some badges (through Foursquare which I don’t use).  But, I do like the reinforcement – i.e., that was your longest run, that was your fastest run.  Simple but positive.
  3. It has a nice GUI (graphical user interface) or app.  It tracks my data.  It’s easy to read.

images

So, if you’re like I was, I’d recommend trying it.

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CarePass, Another Aetna Innovation – What’s Your Healthy?

Have you seen the new “What’s Your Healthy?” campaign?  Here’s a few shots.

BTW – My healthy is keeping up with my kids in sports and moving down a belt notch.

Image

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As many of you know, I consider Walgreens and Aetna to be two of the most innovative healthcare companies today (out of the big, established players).  [And, full disclosure, I own stock in both.]  I’ve talked about Walgreens (see Walgreens post on innovation) several times along with Aetna (see Healthagen post).

That being said, the new campaign along with the press caught my attention.  I was glad that I was able to get some time with Martha Wofford who is the VP and head of CarePass.

“We want to make it easier for everyone to engage in their health and hopefully shift from thinking about health care to taking care of their health,” said Martha L. Wofford, vice president and head of CarePass from Aetna. “CarePass helps consumers connect different pieces of health data to create a fuller, more personalized picture of their health.”

I spent some time talking with Martha and team about their initiative.  Here’s some highlights that stuck out to me.

  • There use of goals was really easy and intuitive.  If you log-in to the CarePass site and get started, you have 3 options or you can create your own (see below).  We spent some time talking about the importance of making these relevant to the individual not focusing on “healthcare goals” like adherence or lowering you blood sugar.  Most of us don’t think that way.  As they described them, they picked “motivation centric goals”.
    Aetna Carepass goals
  • I was also really interested in how they picked which apps to recommend.  There are so many out there, and many of you know that I’ve been fascinated by the concept of curating apps or prescribing apps to people.  They had a nice, simple process:
    • Which apps are most popular?
    • Does the app have “breadth”?  (i.e., national applicability)
    • They also spent more time pre-screening apps which collect PHI to understand them before listing them on the site.
    • They’re using the consumers goals to recommend apps to them.
  • The other big question I had is why do this.  It certain helps build the Aetna brand over time, but there’s not direct path to revenue (that I see).  They described their efforts as “supporting the healthcare journey” through connected data.  Ultimately, it’s about making Aetna a preferred consumer brand which may be very relevant in the individual market and exchange world in the not too distant future.
  • I like the idea of companies being “app agnostic” as I call it.  Walgreens is doing this.  Aetna is doing this.  I plan on doing this in my day job.  This allows the consumer to pick the app that works for them and as long as the data is normalized (or can be normalized) and the app provides some type of open API (application programming interface) it’s much easier to integrate with.
  • We talked a little about what’s next.  Metabolic syndrome is something they brought up.  This is something that Aetna’s been talking about in several forums for a while now.  They launched a new offering earlier this year.  (I still hate the term metabolic syndrome from a consumer perspective, but it seems to be sticking in the healthcare community.)
  • We also talked about new goals to come around smoking cessation, medication, and stress.
  • Another discussion I have with lots of people is how this data gets used.  (see a good article about what’s next for QuantifiedSelf)  I personally really want to see my data pushed to the care management team to monitor and send me information.  (Eat this not that type of suggestions)  Martha talked about how the data belongs to the member and they have to choose to push it to the coach.  She also talked about how they’re integrating with their PHR (Personal Health Record) first and then looking at others.  (see old interview with ActiveHealth)

In summary, CarePass is a nice additional to your #QuantifiedSelf toolkit.  As you can see from the screenshots below, the GUI (graphic user interface) is simple.  It’s well designed.  Integration with your apps is easy.  It provides you with goals and motivation.  They help you navigate the app world.  And, it helps you bring together data from multiple sources.  Once it can pull in all my Rx, medical and lab data along with my HRA data and my device data, it will be really cool!  But, I know that I’m a minority in that effort.  I’m really intrigued by the lifestyle questions they ask and wonder how those will ultimately personalize my experience.

Carepass lifestyle questions Carepass dashboard

So, what apps do they share?  Here’s a screenshot, but you really should log-in and try the site and see the full list.  It’s simple and worth the effort.

Carepass apps

As an added bonus, I’m adding a presentation I gave with Aetna at the Care Continuum Alliance two years ago.  I was searching for my past interviews with Aetna people and found this online so I added it to SlideShare and put it here.

Prescribing An App vs. An Rx – Why Are People Surprised?

A staggering 90 percent of chronic patients in the US would accept a mobile app prescription from their physician, as opposed to only 66 percent willing to accept a prescription of medication, according to a recent survey from health communications firm Digitas Health.  (source)

Is this surprising to anyone?

I don’t think it should be…and here’s why:

  1. In general, most apps don’t cost anything while prescriptions generally do.
  2. I don’t know of any apps with side effects.
  3. It’s unlikely that your app will have a negative interaction with another app (like a drug-drug interaction).  It may give you conflicting information, but that’s about it.
  4. You don’t have to wait to get your app.  You can probably download it while you’re at the physician’s office.  A prescription can take time to get either waiting in line, waiting for it to get filled, or sending it in through the mail.
  5. You don’t have to refill your app.  You may have to update it every once in a while, but it tells you when and all you have to do is press a button.

Of course, most (all) apps won’t have the same likelihood as Rxs in improving your health.  Of course, Rxs only work if people take them…which they don’t.

Still surprised?

The Role Of Healthcare Technology Curator

When I worked as an IT consultant, you had two clear choices – an enterprise system (e.g., SAP) or a best-of-breed (BOB) strategy.  People liked the simplicity of an enterprise system, but you may have sub-optimized reporting or some flexibility in your solution.  On the other hand, the BOB strategy required more maintenance, effort, and coordination to pull it off in a coordinated fashion.

In today’s healthcare world, I look at and meet with a ton of technology companies.  The struggle is how to keep up with all the change in the industry and be nimble enough to engage the new start-up, but flexible enough to evolve with the market without impacting the consumer experience.

Maybe it draws on my training as an architect, but I was describing my technology vision as one of a general contractor.  The buyer (client) wants a BOB solution.  They want everything optimized – data, reporting, workflow, content, mobile, clinical algorithms, etc.  At the same time, they often underestimate what it takes to manage all of these vendors, integrate the data on the backend, and create an integrated consumer experience across multiple vendors and technology platforms.

That’s where I see some real value add as a “technology curator”.  I see one of my roles in helping manage an evolving ecosystem of healthcare companies and working with a flexible technology platform that can quickly plug and play with different solutions.  This also allows me to have pre-built integrations with certain solutions, but I can also offer consumers the ability to choose their device (for example) and with the right API set up just be device agnostic in my solution.

Over time, this offers clients a lot of flexibility.  The get the BOB approach within an enterprise system environment.  They don’t have to keep issuing RFPs and evaluating vendors (since we’re doing that).  They don’t have to stitch together multiple data sets to create the integrated, longitudinal view of the consumer (since we’re doing that).  They don’t have to pretend that they’re offering a cohesive consumer experience (since we’re doing that).  And, most importantly, they are flexible over time to jump from solution to solution within the architecture without disrupting everyone since it’s behind the “presentation layer” that the consumer experiences.

How Walgreens Became One Of The More Innovative Healthcare Companies

While we are generally a society focused on innovation from start-ups (and now all the incubators like Rock Health), there are a few big companies that are able to innovate while growing.  That’s not always easy and companies often need some catalyst to make this happen.  Right now, there are four established healthcare companies that I’m watching closely to track their innovation – Kaiser, United/Optum, Aetna, and Walgreens.  (Walgreens has made the Fast Company innovation list 3 of the past 4 years.)

I think Walgreens is really interesting, and they did have a great catalyst to force them to really dig deep to think about how do we survive in a big PBM world.  It seems like the answer has been to become a healthcare company not just a pharmacy (as they say “at the corner of Happy and Healthy”) while simultaneously continuing to grow in the specialty pharmacy and store area.

Let’s look at some of the changes they’ve made over the past 5 years.  Looking back, I would have described them as an organic growth company with a “not-invented-here” attitude.  Now, I think they have leapfrogged the marketplace to become a model for innovation.

  1. They sold their PBM.
  2. They re-designed their stores.
  3. They got the pharmacist out talking to people.
  4. They got more involved with medication therapy management.
  5. They increased their focus on immunizations increasing the pharmacists role.
  6. They formed an innovation team.
  7. They invested heavily in digital and drove out several mobile solutions including innovations like using the QR code and scanning technology to order refills.
  8. They’ve reached out to partner with companies like Johns Hopkins and the Joslin Diabetes Centers.
  9. They increased their focus on publications out of their research group to showcase what they could do.
  10. They started looking at the role the pharmacy could play and the medications played in readmissions.
  11. They partnered with Boots to become a much more global company.
  12. They offered daily testing for key numbers people should know like A1c and blood pressure even at stores without a clinic.
  13. They created an incentive program and opened it up to link to devices like FitBit.
  14. They partnered with The Biggest Loser.
  15. They increased their focus on the employer including getting into the on-site clinic space.
  16. They created 3 Accountable Care Organizations.
  17. They partnered with Novartis to get into the clinical trials space.
  18. They developed APIs to open their system up to developers and other health IT companies.
  19. They formed a big collaboration with AmerisourceBergen which if you read the quote from Greg Wasson isn’t just about supply chain.

    “Today’s announcement marks another step forward in establishing an unprecedented and efficient global pharmacy-led, health and wellbeing network, and achieving our vision of becoming the first choice in health and daily living for everyone in America and beyond,” said Gregory Wasson, President and Chief Executive Officer of Walgreens. “We are excited to be expanding our existing relationship with AmerisourceBergen to a 10-year strategic long-term contract, representing another transformational step in the pharmaceutical supply chain. We believe this relationship will create a wide range of opportunities and innovations in the rapidly changing U.S. and global health care environment that we expect will benefit all of our stakeholders.”

  20. They jumped into the retail clinic space and have continued to grow that footprint physically and around the services they offer with the latest jump being to really address the access issue and help with chronic conditions not just acute problems.

With this service expansion, Take Care Clinics now provide the most comprehensive service offering within the retail clinic industry, and can play an even more valuable role in helping patients get, stay and live well,” said Dr. Jeffrey Kang, senior vice president of health and wellness services and solutions, Walgreens. “Through greater access to services and a broader focus on disease prevention and chronic condition management, our clinics can connect and work with physicians and other providers to better help support the increasing demands on our health care system today.” (from Press Release)

This is something for the whole pharmacy (PBM, pharma, retail, mail, specialty) industry to watch and model as I talked about in my PBMI presentation (which I’m giving again tomorrow in Chicago).  It reminds me of some of the discussions by pharma leaders about the need to go “beyond the pill”.

 

How Aetna’s Pivoting With Healthagen – #whcc13

Do you know the term “pivot“? It’s all the rage now in terms of describing how companies continue to evolve their models with this rapidly changing business environment.

Of course, Aetna is one of the big healthcare players in the US. They’re not going to abandon a model that’s been working for well over 100 years. But, thanks to some great leadership from people like Mark Bertolini, CEO of Aetna, they’ve created a new business unit called Healthagen (building on the company they bought known mostly for iTriage). The screen shot says it all.

I got the privilege to sit down with Dr. Charles Saunders who runs Healthagen at the World Healthcare Congress in DC (#whcc13).

Charles E. Saunders, M.D., is responsible for leading the strategic diversification of Healthagen’s products, services and global opportunities. He focuses on identifying new growth opportunities and developing market strategies that can help Healthagen and Aetna profitably manage quality and cost for its customers.

Prior to joining Healthagen, Dr. Saunders served as executive in residence at Warburg Pincus, one of the world’s largest and oldest private equity firms. He has held a number of other significant leadership positions during his career, including CEO of Broadlane, Inc., President of EDS Healthcare Global Industry Solutions; Chief Medical Officer of Healtheon / WebMD; Principal of A.T. Kearney; and Executive Director of San Francisco General Hospital Managed Care Programs.

Dr. Saunders received a B.S. in biological sciences from the University of Southern California and an M.D. from Johns Hopkins University. He is board certified in Internal Medicine and Emergency Medicine and has served on the faculty of several universities, including the University of California, San Francisco; Vanderbilt University; and University of Colorado.

I also got to hear him speak right before I talked to him. (As a side note, he is a great presenter which is something that I really respect in a world of people who present too many slides, use notes, talk to the screen, and can lose you quickly.)

He hit on several key themes in his presentation that we then discussed further face-to-face:

  1. Social Caregiver Model
  2. Game Theory
  3. Digital / Mobile

One of my first questions was to really understand Healthagen and what it was set up to do. (As you can see from the screen shot below, they’re doing lots of things in this group.)

He boiled it down nicely to three things:

  1. Physician (provider) enablement
  2. Patient engagement
  3. Population Health Management IT

Our next discussion was really around why and how to create and innovate within a large company like Aetna. He reiterated what I believed that Mark Bertolini championed this new vision along with several of the other senior leaders. But, I think the key was that they recognized that issue of trying to do that internally and were willing to form a group to be different. To minimize bureaucracy for this group. And, to leverage their capital and assets to support this group. Not many big companies do this well. My impression is that Aetna is and will continue to be successful here. (Full disclosure – I own a minor number of Aetna shares and have believed this since I bought them about a year ago.)

Of course, in today’s market, there’s an explosion of innovation with questions on the short-term and long-term ROI of many initiatives and start-ups. With that in mind, Dr. Saunders pointed out that they don’t want to own everything. They want to create a plug and play platform of enablement. iTriage is a great example of this where they brought in a mobile technology with 2M downloads in 2011 and now have over 9.5M downloads of the tool (on top of massive increases in functionality and integration). You can download it here – https://itunes.apple.com/app/itriage-health-doctor-symptoms/id304696939?mt=8.

Certainly, one concern others have historically had in this space was how to own solutions and sell them to their peers (competitors). Dr. Saunders talked about their ability to do this with ActiveHealth and a perception that the industry is over that issue as long as Aetna can continue to demonstrate that they are good stewards of the data and are keeping the appropriate firewalls in place.

We wrapped up the conversation talking about the social caregiver and game theory. I think both are important in our mHealth / digital world. With the sandwhich generation, this is increasingly important. That is where Aetna is focusing…enablement of the caregiver for infants and seniors leveraging a social approach. This reminds me of their recent announcement of a pilot with PatientsLikeMe. We also talked about game theory and the role of that in healthcare which is a common theme from my discussion with Keas this morning and a theme from the overall conference.

It should be interesting to watch Dr. Saunders and his team and how Aetna continues to pivot.

#WHCC13 Interview: Content + Community + Competition = Keas

I had the opportunity to sit down this morning with Josh Stevens who is the CEO of Keas.

“Keas is the most engaging wellness program in the workplace. Keas promotes healthy behavior and teamwork with interactive media that delivers relevant, individualized content to hundreds of thousands of employees. Keas has a proven track record of supporting corporate HR in increasing retention, productivity, teamwork, collaboration, and competitiveness. By rewarding people for achieving simple exercise and nutrition goals, employee health is improved and overall healthcare costs are decreased.”

He is a passionate believer in using fun and social to drive change in healthcare with a focus initially on wellness and then moving upstream to other challenges like disease management.

As CEO of Keas, the market leader in corporate wellness, Stevens is responsible for leading the development and market adoption of the company’s breakthrough wellness platform and applications.

Stevens has over 20 years of experience in product, sales, marketing, and is a recognized leader in driving high-value product experiences that deliver customer delight and investor’s valuation growth.

Prior to Keas, Stevens was Vice President of e-commerce at YouSendIt, Senior Vice President of strategy and business development at TicketsNow, and General Manager of e-commerce at AOL. Prior to his GM role at AOL, Stevens held a variety of leadership positions in business development, product marketing, product management, and corporate strategy.

Some of you may have seen Keas over the years. They were founded by Adam Bosworth who was responsible for Google Health at one point. They’ve gone through a few evolutions, but it seems like they’ve hit on a working model leveraging several principles that we discussed:

  1. Being intellectually nimble
  2. Developing holistic and integrated solutions
  3. Using content, community, and competition to drive engagement
  4. Building social networks around health
  5. Integrating into the consumer’s experience to be seamless (e.g., single sign on)
  6. Recognizing that change is dependent upon corporate culture changing also
  7. BYOD (bring your own device) meaning that they can integrate with anyone with an open API
  8. Realizing that while some people (like me) might want to focus on data in a Quantified Self manner, we’re only 15% of the population

While Josh isn’t a healthcare native, that seems like a good thing. I’ve seen a lot of people try to come into healthcare from the outside. Most of them fail because they get overwhelmed by the regulation or frustrated by the challenges or stick too much to what they personally think should work. In the hour we spent together, I didn’t get that sense.

I’m looking forward to learning more about Keas and trying out the tools myself. One of the most fascinating points was that they get people to engage 15 times per month. I told him that that was a ridiculous number in healthcare. We went on to talk about his hiring a team from the gaming industry and that they were used to being tied to repeat visits not simply getting people to download the tool.

IMHO – if you could get 50% of people to engage twice a month with a tool (and sustain that engagement rate), you would be a hero.

As I’ve talked about in my posts about CVS and as I tweeted earlier today from the conference, companies need to engage the worker at the workplace to transform healthcare. Josh gets that key point.

“Today’s employees spend most of their daily lives at work and companies can have a huge impact on improving overall health by creating a culture of wellness at work. That culture starts with Keas’ fun, engaging platform, which helps employees become healthier, more productive and more engaged at work, and in life.” (press release)

Life Through #QuantifiedSelf Glasses

No…this is not about how Google Glass can impact healthcare although I do believe it can and will (something many are talking about). 

This is about how the QuantifiedSelf movement can change your view of the world.  Ever since I’ve been using the FitBit (see my review) and focusing on getting 10,000 plus steps per day, I’ve noticed a change in how I view the world. 

Here’s some examples:

  1. We got 12″ of snow yesterday.  I was immediately thinking about how great of exercise it would be to shovel the snow.  I was excited to go out several times and shovel.
  2. When I was flying today, I was thinking “hopefully we’ll get dropped off at a far gate so I can get in some extra steps.”
  3. I’ve been excited to clean the house and get in the steps from cleaning.
  4. I look forward to grocery shopping.
  5. I park farther away in the parking lot.
  6. I’m sometimes intentionally less productive at home to get a few extra sets of stairs in for the day.
  7. When I’m cutting brownies, I’m calculating out how many brownies are supposed to be in the recipe and making sure I cut them to the right size.
  8. When I eat something, I think about how many steps I’ll have to walk (or run) to burn off that food. 
  9. When I pick meals at a restaurant, I’m always looking for their nutritional menu or going online before ordering.

It’s a totally different way of thinking about life when you look through these “quantified self glasses” to see the world through a “health lense” about calories, exercise, sleep, stress, and other dimensions.

Two Surveys On #mHealth #healthapps

The data from these two surveys just passed my desk so I thought I would post them.

Mobile survey
mHealth survey MCOL

A Web Strategy Is NOT A Digital Strategy

I was monitoring a pharma conference over in Europe this morning.  I found a few of the dialogues really interesting.  One of them was about a company creating all these websites to allow consumers to engage with them.  There was then some debate.

On the on hand, I can agree that you can do some creative things with the channel, and therefore, I should be too down on someone who is very web centric.  (i.e., focus on the strategy)  On the other hand, digital is much bigger than web.

I’m sure there’s a lot of views here, but let me share mine in terms of what to consider from a digital strategy:

  • A website or series of sites along with a mobile web optimization for devices
  • Search engine optimization
  • Social (e.g., Facebook, Google+)
  • Communities
  • Video
  • Mobile apps
  • Device integration (e.g., BodyMedia)
  • Software integration (e.g., EMRs, PHRs)
  • Blogging
  • Twitter
  • Gamification
  • Telehealth
  • Remote monitoring
  • Big Data
  • Predictive algorithms
  • Location based services (e.g., FourSquare)
  • Use of SMS

While there are a lot of complicated images out there trying to show everything around digital strategy, I found this one pretty simple and concise.

Digital Strategy

2013 PBMI Presentation On Pharmacy Need To Shift To Value Focus

Today, I’m giving my presentation at the PBMI conference in Las Vegas.  This year, I choose to focus on the idea of shifting from fee-for-service to value-based contracting.  People talk about this relative to ACOs (Accountable Care Organizations) and PCMHs (Patient Centered Medical Homes) from a provider perspective.  There have been several groups such as the Center For Health Value Innovation and others thinking about this for year, but in general, this is mostly a concept.  That being said, I think it’s time for the industry to grab the bull by the horns and force change.

If the PBM industry doesn’t disintermediate itself (to be extreme) then someone will come in and do it for them but per an older post, this ability to adapt is key for the industry.  While the industry may feel “too big to fail”, I’m not sure I agree.  If you listened the to the Walgreens / Boots investor call last week or saw some of things that captive PBMs and other data companies are trying to do, there are lots of bites at the apple.  That being said, I’m not selling my PBM stocks yet.

So, today I’m giving the attached presentation to facilitate this discussion.  I’ve also pre-scheduled some of my tweets to highlight key points (see summary below).

 

Planned PBMI Tweets

59% Of MDs Want To Know About Employer Care Mgmt Efforts

I just came across this survey data from January of 2010 where the Midwest Business Group on Health (MBGH) did a survey of physicians. I found it really interesting. Let me pull out a few points with some comments…

  • 72% of physicians agree that employers should have a role in improving and maintaining the health of their employees with chronic disease. [Since they ultimately are the one paying the bill, this seems like a reasonable expectation in today's world.]
  • 59% believe that they should be informed about employer efforts to help their patients manage chronic conditions. [This is increasingly becoming important as we move from a Fee-For-Service (FFS) world to a value-based or outcomes-based healthcare environment.]
  • 46% agree that employers should have a role in helping employees adhere to their medication and treatment regimes. [Since MDs generally don't view this as their task, if it's not someone acting on behalf of the employer, I wonder who they think should be doing this.]
  • 32% agree that employers should play no role in the health of patients. [With healthcare impacting productivity and global competitiveness, I think this is an unreasonable expectation.]
  • 61% want the employer to provide physicians with information on what is available to patients so they can counsel them on the value of participation. [How would they want this information and what would they do with it?]
  • 49% would like to receive workplace clinical screening results to reduce redundancies in testing. [Do the other 51% want duplicative testing?]
  • 48% want to receive actionable reports (e.g., screening results, health coaching reports) to support them in treating patients. [I would hope so. If the employer (or really their proxy) is managing the patient in a chronic program, why wouldn't the physician want this data?]
The study went on to say that physician’s want employers to provide support around weight loss, smoking cessation, flu shots, and other broad programs. They also want the employer to focus on lifestyle change and health improvement not the chronic disease itself. This makes sense, but in general employees are more focused on trusted information coming from their physician not their employer so there’s a clear gap here. (See graph from Aon Hewitt’s 2011 Health Care Survey, New Paths. New Approaches.)

Only 50% Of Healthcare Companies Respond To Twitter Messages – Test Results

12 Of 23 Companies

As I mentioned a few weeks ago (2/2/13), I wanted to test and see if healthcare companies would respond to consumers via Twitter. To test this, I posted a fairly general question or message on Twitter to see the response (see below). Of the 23 companies that I sent a message to, only 12 of them ever responded even after 6 of them received a 2nd message. Those results are shared below. What I also wanted to look at was the average time to respond along with which group was more likely to respond.

  • PBMs – All of the 3 PBMs that I reached out to responded. (This could be biased by my involvement in this space since two of them e-mailed me directly once I posted a comment.)
  • Pharmacies – Only 2 of the 4 retail pharmacies that I reached out to responded.
  • Disease Management Companies – Only 1 of the 3 that I reached out to responded. (I was surprised since Alere often thanks me for RT (re-tweeting) them, but didn’t respond to my inquiry.)
  • Managed Care – 5 of the 7 companies that I reached out to responded. (For Kaiser, they responded once I changed from @KPNewscenter to @KPThrive.)
  • Health Apps or Devices – Only 1 of the 5 companies that I reached out to responded. (This continues to surprise me. I’ve mentioned @FitBit on my blog and in Twitter numerous times without any response or comment.)
  • Pharmaceutical Manufacturers – Only 1 of the 3 companies that I reached out to responded. (This doesn’t surprise me since they are very careful about social media. @SanofiUS seems to be part of the team that has been pushing the envelope, and they were the ones to respond. I thought about Tweeting the brands thinking that those might be monitored more closely, but I didn’t.)

I will admit to being surprised. I’m sure all of these companies monitor social media so I’m not sure what leads to the lack of response. [I guess I could give them the out that I clearly indicated it was a test and provided a link to my blog so they could have chosen not to respond.]

Regardless, I learned several things:

  1. Some companies have a different Twitter handle for managing customer service.
    1. @ExpressRxHelp
    2. @AetnaHelp
    3. @KPMemberService
  2. Some companies ask you to e-mail them and provide an e-mail.
  3. Some companies tell you to DM (direct message) them to start a dialogue.

From a time perspective, I have to give kudos to the Prime Therapeutics team that responded in a record 2 minutes. Otherwise, here’s a breakout of the times by company with clusters in the first day and approximately 2 days later.

Company

Response Time (Hrs:Min)

Prime Therapeutics

0:02

Aetna

1:12

LoseIt

1:19

Healthways

2:07

Walmart

3:01

Express Scripts

8:35

Kaiser

29:22

BCBSIL

47:32

OptumRx

47:39

BCBSLA

48:18

Sanofi

53:30

I guess one could ask the question of whether to engage consumers via Twitter or simply use the channel more as a push messaging strategy. The reality is that consumers want to engage where they are, and there are a lot of people using Twitter. While it might not be the best way to have a personal discussion around PHI (Protected Health Information) given HIPAA, it certainly seems like a channel that you want to monitor and respond to. It gives you a way to route people to a particular phone number, e-mail, or support process.

As Dave Chase said in his Forbes article “Patient engagement is the blockbuster drug of the century”, this is critical for healthcare companies to figure out.

The CVS Caremark team told me that they actively monitor these channels and engage with people directly. I also talked with one of the people on the Express Scripts social monitoring team who told me that they primarily use social media to disseminate thought leadership and research, but that they actively try to engage with any member who has an actionable complaint. They want to be where the audience is and to quickly take the discussion offline.

If you want to see the questions I asked along with the responses, I’ve posted them below…

The Prescribing Apps ERA – Will Clinicians Be Ready? #mHealth

Dr. Kraft (@daniel_kraft) recently spoke at FutureMed and talked about the prescribing apps era.  I’ve talked about this concept many times, and I agree that we are rapidly moving in that direction.  And, there’s lots of buzz about whether apps will change behavior and how soon we’ll see “clinical trials” or published data to prove this.

From this site, you can get a recap, but here are the key points that he made:

1) Mobile Phones (quantified self) are becoming constant monitoring devices that create feedback loops which help individuals lead a healthy lifestyle.  Examples include; monitoring glucose levels, blood pressure levels, stress levels, temperature, calories burned, heart rate, arrythmias. Gathering all this information can potentially help the patient make lifestyle changes to avoid a complication, decrease progression of a particular disease, and have quality information regarding his physical emotional state for their physician to tailor his treatment in a more efficient manner.

2) The App prescription ERA:  Just as we prescribe medications prescribing apps to patients will be the future. The reason why this is important is that apps created for particular cases can help the patients understand their disease better and empower them to take better control.

3) Gamification: using games in order to change lifestyle, habits, have been mentioned before. A very interesting concept was that created in the Hope Labs of Stanford. The labs created a game in which children would receive points after there therapeutic regiment, once points were optioned they could shoot and attack the tumor. Helping with the compliance rate of the treatments

4) Lab on a chip and point of care testing

5) Artificial Intelligence like Watson and its application in medicine.

6) Procedure Simulation: Several procedures done by medical professionals follow (not 100%) a see one, do one teach one scenario.  Probably very few people agree with this concept and that is why simulation has great potential. In this case residents, fellows in training can see one, simulate many and then when comfortable do one.

7) Social Networks and Augmented Reality

At the same time, a recent ePocrates study hammered home the point that while this is taking off physicians don’t have a mechanism for which ones to recommend and why.

According to the Epocrates survey, more than 40 percent of physicians are recommending apps to their patients. In terms of the apps being recommended, 72 percent are for patient education, 57 percent are lifestyle change tools, 37 percent are for drug information, 37 percent are for chronic disease management, 24 percent are for medical adherence and 11 percent are to connect the patient to an electronic health record portal.

Physicians also have several different sources for identifying which apps to recommend to their patients. According to the survey, 41 percent get advice from a friend or colleague, while 38 percent use an app store, another 38 percent use an Internet search engine, 23 percent learn of an app from another patient or patients, and 21 percent use the app themselves.

That said, the survey also notes that more than half of the physicians contacted said they don’t know which apps are “good to share.”

As I’ve discussed before, this is somewhat of the Wild West.  Patients are buying and downloading apps based on what they learn about.  They’d love for physicians, nurses, pharmacists, and other trusted sources to help them.  But, those clinicians are often not technology savvy (or at least many of the ones who are actively practicing).  There are exceptions to the norm and those are the ones in the news and speaking at conferences.

IMHO…consumers want to know the following:

  1. Which apps make sense for me based on my condition?
  2. Will that app be relevant as I move from newly diagnosed to maintenance?
  3. Should I pay for an app or stick with the free version?
  4. Is my data secure?
  5. Will this app allow me to share data with my caregiver or case manager?
  6. Will this app have an open API for integration with my other apps or devices?
  7. Is it intuitive to use?
  8. Will this company be around or will I be able to port my data to another app if the company goes away?
  9. Is the information clinically sound?
  10. Is the content consumer friendly?
  11. Is it easy to use?
  12. Is there an escalation path if I need help with clinical information?
  13. Will my employer or health plan pay for it for me?
  14. Is my data secure?

And, employers and payers also have lots of questions (on top of many of the ones above):

  1. Is this tool effective in changing behavior?
  2. Should I promote any apps to my members?
  3. Should I pay for the apps?
  4. How should I integrate them into my care system?
  5. Do my staff need to have them, use them, and be able to discuss them with the patient?  (Do they do that today with their member portal?)

mhealth_infographic_large

Would A Robot Therapist Solve Your Problem?

Wired had an article recently about how robots are replacing people over time.  The article talked about TUG which is a robot used in hospitals.  It also mentioned MindMentor.com which it called the site of the world’s first robot therapist.  Interestingly, it says that after a 1-2 hour session, that 47% of patients said that their problems were solved.  From the 2008 article, it sounds like there’s some opportunities for improvement in terms of NLP, avatars, and other technologies.

That seems high.  I would think it would take more sessions.  Additionally, I would think that people don’t get their problems solved that easily.

While this solution is on sabatical (due to lack of funding), the article went on to talk about USC’s Bandit robot for kids with autism.

Google Glass Plus The Checklist Manifesto

I continue to think about all the cool ways that Google Glass could be used to change healthcare.  Here’s my thought from today.

You could combine The Checklist Manifesto concept with Google Glass to allow surgeons to be reminded of the things they need to do with a patient while they were during the encounter or during the procedure.

In complex situations – such as those which arise in almost every profession and industry today – the solutions to problems are technical and demanding. There are often a variety of different ways to solve a problem. It’s all too easy to get so caught up dealing with all these complexities that the most obvious and common sense immediate solutions are not tried first. To overcome this problem, take a leaf from the commercial aviation industry and develop checklists people can use to make sure every base is covered quickly and concisely. Checklists are a forgotten or ignored business tool. It’s time for them to come in from the cold. 

“Here, then, is our situation at the start of the twenty-first century:We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And with it, they have accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields – from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us. That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our human inadequacies. And there is such a strategy – though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies. It is a checklist.”

(This is from this PDF on The Checklist Manifesto.)

Here’s an example of a checklist from the WHO.

 

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