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:
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.”)
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.
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.
They’ve built the system out using open APIs (application programming interfaces) which allows other companies to easily integrate with them.
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.
Google Health was a personal health information centralization service (sometimes known as personal health record services) by Google introduced in 2008 and cancelled in 2011. The service allowed Google users to volunteer their health records – either manually or by logging into their accounts at partnered health services providers – into the Google Health system, thereby merging potentially separate health records into one centralized Google Health profile.
And, I would also point to the intelligent home (per their acquisition of Nest) as a venture which will lead them down the path of health at some point.
You could also look at the companies that Google Ventures is investing in from the health space:
I could have easily seen them investing in something like Theranos which stands to change the biometrics space.
So…it’s not like they’re ignoring the space which isn’t unusual for many companies outside of healthcare. Healthcare is hard. Healthcare has lots of regulatory constraints. In general, many companies want to avoid having to deal with some of those issues which can constrain the rest of their businesses.
But, let’s look at the critical and hot topics in healthcare right now:
BigData – how to use data; how to build predictive models
Engagement – how to personalize communications and engage consumers to take action from mass customization to segmentation to even gamification
Social – how to use social pressures and peers to create better health
Connectivity – how to connect devices, caregivers, pharmacies, providers, and others into a shared platform for care
Security – how to securely manage data
Transparency – collecting and aggregating pricing data to help consumers make intelligent decisions
User experience – creating user journeys and user interfaces to improve the overall consumer experience (perhaps changing the model like Uber (a Google Ventures investment))
Do those things sound like the competencies of any one company? To me, they all sound like things that Google is good maybe even great at. Additionally, the founders of Google have the big, picture and long-term vision that’s critical in healthcare. Driving change in healthcare isn’t about meeting specific quarterly numbers. It’s about seeing the world in a new light where you want to drive change and improve things like childhood obesity. It doesn’t happen overnight.
I wish I knew more about Google. Someday, I’d love to work with them on some of these opportunities. If so, I could see this being a perfect fit in the Google X world. I could see them making a change as a core focus, as investors, or simply by creating enabling tools. But, at the end of the day, this is why I think health needs Google to have a focus here. It’s almost 20% of our GDP and something that impacts most people on a daily basis.
It’s been a few years since I’ve worked on medication adherence solutions. It seems to have become a big focus again in the industry both with the Medicare Star Ratings program and with all the emphasis on waste.
As I started thinking about adherence, I thought it would be good to create a list of solutions and vendors. I couldn’t find one anywhere on the web. So, here’s my initial list of almost 100 companies.
I’ll make this a dynamic list so please comment or send me suggestions to add.
Here’s some old posts on adherence that I think are still relevant here:
I’ve divided the list of solutions and vendors into the following:
Devices
Adherence Solutions LLC – develop programs to create alliances between different players, sell Dose-Alert which is a smart pill bottle cap, and provide a mobile tool
By now, the idea of a PBM and who they are is much more of a household item than it was a decade ago. We’ve seen massive consolidation in the industry. We’ve seen PBMs grow in the specialty PBM space. The question I often ponder is what’s next. Here’s some of my thoughts.
Do Nothing. Obviously, there’s a lot to be said for ongoing momentum. The PBMs have shown growth for many years. While the generic opportunity and the mail opportunity has slowed down, there are still opportunities in the specialty space.
Distribution. This seems like an obvious possibility. Why not buy Cardinal, AmerisourceBergen, or someone else? Procurement and distribution are core competencies so I think this makes some sense. But, will that create issues in the current client list and retail pharmacies and PBMs haven’t always had the best relationships. (E.g., Express Scripts GPO with Kroger)
Pharma. This has been debated by a few PBMs, but getting into the R&D space is risky and doesn’t build on their core competencies. What could be more interesting would be them getting into the services space by acquiring a company like IMS or Quintiles.
International. Several PBMs have tried this model. In general, it hasn’t gone anywhere. I think the international collaboration of Walgreens and Boots is really interesting and other retailers have gone international. I don’t see this happening anytime soon with any material impact.
Physician. Having a greater impact in the prescribing process could make a lot of sense. I could see some interesting targets in terms of Allscripts, Cerner, or athenahealth. This has been a challenge for years with a few ventures into the space. (e.g., CVS Caremark and iScribe)
Technology. At the end of the day, the PBMs are large technology companies. Could they see their way into the mHealth space? This space is growing like crazy, and you’re seeing established players get into the remote patient monitoring space (e.g., AT&T and Qualcomm). I could see an acquisition in this area of a telehealth company (e.g., Teladoc) or a device company (e.g., Welldoc). Or, they could build something more organically. On the flipside, they could look at technology platforms to open doors to care management or ACOs (e.g., Lumeris). Alternative, I could see SoloHealth as a really interesting asset.
Retail. With a few exceptions, I think this strategy is off the table. I’ve loved the CVS Caremark integration for years, and I think it’s showing dividends. Rite-Aid is probably the only big acquisition target out there. In this space, you probably have to look at it the other way. Would any retailers (e.g., Walmart, Walgreens, Target) buy a PBM? Walgreens got rid of their PBM, and Walmart has said they don’t want to be in that market so I’m not sure that would go anywhere.
Insurer. I think this one has some interesting opportunities from a Medicare perspective and from a commercial perspective. Could PBMs create an underwritten product and take on risk? I think yes, BUT I think that could impact their need for reserves and the way the market sees them. That makes me think this is less likely, but possible.
Device Benefit Management. I think several ex-PBM executives have gone out to try to build the “benefit management” concept into the healthcare marketplace in other areas (e.g., IPG). Could an existing PBM do it and cross-sell into their base? Perhaps. But, a stretch. They’re getting big so they want to buy meaningful revenue, create synergies, and then grow it.
Navigation. The most used benefit is pharmacy. Today, consumers touch the healthcare system most frequently through retail and their daily prescriptions. With the ongoing complication of the health benefits, there is a huge need for navigators (and not just in the healthcare.gov use of the term). Think about companies like Health Advocate or Accolade.
Data. With the RxAnte acquisition, it has to make you wonder about PBMs and their data assets. How can they use them differently? Can they create apps? Can they create algorithms to license? What would this look like? What about companies like Proteus? Perhaps, a PBM could consolidate several unique assets along the device, smart bottle, data path.
Condition specific. I could see some PBMs going deep on particular areas like oncology to really build out an oncology practice that did everything from second opinions to case management to end-of-life counseling. Those could all wrap around the drugs. Or, imagine them going into the chronic kidney care space by acquiring a company like DaVita.
Providers. While there could be some interesting synergies here with a large hospital group (e.g., HCA) or some ACO/PCMH players, I see that more of a managed care play for rolling up companies. The ROIC (Return on Invested Capital) is too different in these physical operations that I see that being a struggle. And, I think there’s lots of concerns about the hospital needs over time.
Which path plays out…I don’t know, but I think it’s getting close to time that you’ll see another shift in the market as they try to secure their next 10 years of growth by expanding into something that builds on their core competencies.
I think the other question would be if they focus on differentiation by really showing material differences in outcomes and engagement rates and look at how they show an overall health ROI not just Rx specific. That would be where I would place my bets and look at which of these options support that. Maybe we’ll see a PBM X (like Google X) doing some strategic long-term deals to change the overall healthcare roadmap.
It got me thinking about other mash-ups to get into this space.
What about Pulte Homes working with BCBS of MI, the UAW, Ford, and the Henry Ford Health System to create a long-term retirement community built around an ACO with Medicare included? This could be a great offset for the UAW and Ford to their healthcare liabilities. It could create new provider models for Henry Ford. It would create new building opportunities for Pulte, and it would provide new underwriting opportunities for BCBS.
The other question that this brings up is who else will they acquire…or will others in this space get acquired by Cisco or AT&T or others that want to create this.
I’ve reached out to the Nest founder and some people at Google and Google X. (I don’t know any of them.) This seems really exciting and similar to some of my thoughts. I’d love to learn more.
And, perhaps with the news that some of the Google X people met with the FDA, maybe Google is figuring out a way to get back into healthcare. Hopefully, they don’t overlook the opportunity for patient remote monitoring in the smart home.
In 1998, I wrote my first business plan which was about technology and architecture. At the time, I had graduated from Architecture school and was working with Sprint on a data warehousing implementation. It got me thinking about how to create a series of connected devices and link them to an enterprise system to manage that data for a smart home. At the time, I think people thought I was crazy.
Jump forward 15 years and it all seems to make more sense. For example:
You have remote patient monitoring solutions like Healthsense working on smart beds, toilets, and other sensors that track motion and other activities in the home.
You have smart pill bottles. You have smart pills with companies like Proteus Digital Health.
“The Internet of Things (or IoT for short) refers to uniquely identifiable objects and their virtual representations in an Internet-like structure. The term Internet of Things was proposed by Kevin Ashton in 2009.[1] The concept of the Internet of Things first became popular through the Auto-ID Center at MIT and related market analysis publications.[2] Radio-frequency identification (RFID) was seen as a prerequisite for the Internet of Things in the early days. If all objects and people in daily life were equipped with identifiers, they could be managed and inventoried by computers.[3][4] Besides using RFID, the tagging of things may be achieved through such technologies as near field communication, barcodes, QR codes and digital watermarking.[5][6]
Equipping all objects in the world with minuscule identifying devices or machine-readable identifiers could transform daily life.[7][8] For instance, business may no longer run out of stock or generate waste products, as involved parties would know which products are required and consumed.[8] A person’s ability to interact with objects could be altered remotely based on immediate or present needs, in accordance with existing end-user agreements.[3]
According to Gartner there will be nearly 26 billion devices on the Internet of Things by 2020.[9] According to ABI Research more than 30 billion devices will be wirelessly connected to the Internet of Things (Internet of Everything) by 2020.[10] Cisco created a dynamic “connections counter” to track the estimated number of connected things from July 2013 until July 2020 (methodology included).[11] This concept, where devices connect to the internet/web via low power radio is the most active research area in IoT.”
“More objects are becoming embedded with sensors and gaining the ability to communicate. The resulting information networks promise to create new business models, improve business processes, and reduce costs and risks.”
Of course, the key is a core infrastructure that manages all of this data and starts to create algorithms for how to use it. Image being able to log in and get information about your house, your kids, your community, and your health. Some things are already out there and being developed.
Mother is a technology that summarizes all of this data and pulls it together for people to use and monitor.
Twine monitors your home and provides you with information such as your garage door is left open.
Ninja Sphere is another solution for controlling your home devices.
Thing Worx is another solution focused on this connected house.
Qualcomm and Verizon and others are getting into the health space, and you have companies like ADT or Time Warner that are already in the home and could expand into the health space.
The other thing that all this data drives is the need for insights. It’s no good to have data without the ability to turn it into knowledge. This is again something that Google knows a lot about. Imagine having a connected team of physicians that monitor your health based on your sleep patterns, your adherence, your exercise, and other key metrics such as blood pressure. Imagine a dietician that monitored your food and gave you ideas about how to eat better. There are lots of ways for the data to be used in an obviously Big Brother way, but if that could be turned on and off, then we could gain the insights without having to give up all our privacy.
But, in general, many people are willing to trade privacy for insights. That’s what we do every day.
This idea of the Smart Home or Connected Home or Intelligent Home got me thinking over the holidays. I even emailed Pulte Homes and Lennar Homes to see if they were doing anything in this space. (They didn’t respond.) I did stumble upon Home For Life Solutions which seems to be thinking about some of this and was talking about this back in 2009 in an article about Smart Homes and Aging in Place. I was talking to a friend on Friday, and he shared with me some very cool things that The Villages in Florida is doing to incorporate health into their community.
I can see so many opportunities here especially around the concept of Aging in Place. Imagine all the Baby Boomers getting older and wanting to stay in their homes. I’m not sure what Calico is going to do, but this could be an opportunity for them.
In a recent issue of TIME, Page discussed how Calico will treat aging and related diseases. He didn’t reveal much about the methodology, but stressed that Calico’s team will “shoot for the things that are really, really important.” The goal for Calico’s research according to Page, is to help prevent many diseases and have a greater impact on public health than drugs that target individual diseases. (from MedCity News)
Imagine if this community existed. You would be able to create your own insurance company. You could offer discounts. You could do the same with life insurance. It could be like the Snapshot from Progressive.
And, there is so much more opportunity:
When you drive into your driveway, why can’t your garage door recognize you. Why do you have to press a button to open the garage?
Why can’t my purchases at the store be tracked online so I always know what I have and what I need?
Why can’t a smart cookbook recommend a recipe for tonight based on what food is at home, what food’s about to expire, and what I ate for lunch to create a balanced menu and caloric mix?
Why can’t my devices order my prescriptions for me when I’m low?
Why can’t my calendar automatically reschedule my doctor’s appointment when something else comes up?
Why can’t my running shoes automatically order a new pair of shoes when the cushioning gets low due to too many miles?
One day, this will all happen where our house will be smart. It will understand what I like in terms of lighting, shows, and music. It will tap into my devices. And, I’ll be able to get monitored and insights that improve my life. And, best of all, this will be done in a sustainable way that improves the environment and our quality of life.
So…maybe I can get Google or someone else excited about this idea! It will take someone with a big vision to change the world, but I think it’s a huge opportunity!
I was watching this video of Tim Brown (CEO of IDEO) earlier this morning, and it immediately clicked with me. The idea of design thinking is very similar to the architecture training that I had. Perhaps that is why I’m so fascinated by the opportunity to use technology and data driven insights to improve the consumer experience in healthcare.
I like this definition of design thinking from an HBR article on it.
“it is a discipline that uses the designer’s sensibility and methods to match people’s needs with what is technologically feasible and what a viable business strategy can convert into customer value and market opportunity.”
In general, the user experience in healthcare is horrible. People don’t understand the system. They don’t understand their benefits. Data is only now beginning to be transparent (but it’s still confusing). People can’t read and understand the information. Their providers don’t speak in plain language.
It’s frustrating because all of us know this is a problem, but it’s so massive to change. I always use the Triple Aim framework to make the point that the consumer experience is critical. Think about evaluating prescription drugs or chemotherapy. Quality of life is really important but often overlooked. This leads to patients getting too much care as physicians try to cure them only to perhaps make their life miserable in their last few weeks of life.
I’m going to have to continue to learn more about design thinking and reflect on how to use it more systemically in my approach to problem solving.
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.
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.
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.
I’ll admit that several people have asked me about this over the years. If a picture is really worth a thousand words, would it be better to send someone a picture than a text message. Perhaps a picture of me in my skinny jeans if I’m trying to lose weight. Perhaps a picture of my grandkid if I’m trying to get healthy to run around the yard with them. Perhaps a picture of my favorite vacation location to motivate me to stick with a health goal. It’s an interesting question.
So, let’s start with tex messaging in healthcare. When I think of using SMS (or texting) in healthcare, my first example is always Text4Baby which was a unique coalition of companies that worked with Voxiva to get this launched.
Of course, Voxiva has since expanded to offer other programs:
And, I think there are some business cases out there around using SMS to interact and change behavior in healthcare. The Center For Connected Health in Boston with Dr. Joseph Kvedar has been studying this in several settings. Here’s one poster from them on a pilot. Here’s a good summary of what had happened as of 2012 from MobiHealth News.
I could go on, but I think you get the point. Lots of people have tried using text messaging as a low-cost but potentially effective way to get messages to consumers about a specific health behavior. Especially in other countries, this can be the preferred method.
I was thinking about my interview with Aetna about CarePass and what CarePass was doing, and it seemed to create a good example. Would I rather a text that reminded me about my goal or the picture on the right?
Additionally, I know in discussions with Vic Strecher, co-founder of HealthMedia, that we’re talked about the value of customizing imagery on letters to personalize and engage consumers. I just can’t find anything published by them right now to show that they studied that.
So, as we think about motivating people and sending them reminders, I think it would be really interesting to see the results of a picture driven process versus a written communication. Is it the same effect? Does it vary? By age, gender, type of action? Of course, the one thing I would recommend is letting the consumer upload and pick their picture not picking from some general list of canned photos.
NOTE: The opinions expressed here are those of the author and are not reviewed in advance by anyone but the individual author. They represent personal opinions not the opinions of any employer.
January 27, 2014 
Enabling Healthy Decisions 