Thursday, January 17, 2019

Exploring the Connected Medical Home

Over the past few weeks, I've been exploring the combination of internet of things, artificial intelligence, and ambient listening with a focus on how these technologies might improve care management, patient/family navigation of the health system, and wellness.

Google, Apple, and Amazon all have ecosystems that include the functionality I'm writing about.  Purely because I'm spending January investigating the Android/ChromeOS environment, my first exploration has been with Google products.    I'll explore Apple next.

Here's my test bed:

Unity Farm Sanctuary heating and cooling is controlled by Nest Thermostats.

The animal areas are streamed from Nest Cameras.

In the living room, I've installed a Google Home Hub, a Chromecast Generation 3, and Chromecast audio (now discontinued).

I'm currently carrying a Google Pixel 3 phone running Android Pie.   My personal computing platform this month is a Google Pixelbook.

What does this infrastructure enable me to do?

Here's a sample dialog (Google product responses are in italics)

Ok Google, what is the temperature in the living room?

The farm living room is at 66 degrees.

Ok Google, increase the living room temperature to 68 degrees

The farm living room temperature has been increased to 68 degrees.

Ok Google, show the cows on TV

Showing the Sanctuary Cows on the Farm Living Room TV

Ok Google, play music on the speakers

Playing selections from Google music on the farm kitchen speakers

Ok Google, pause.

Music paused.

Ok Google, call Mom

Calling Mom

This internet of things, artificial intelligence, and ambient listening example illustrates the many possibilities for any internet connected home.    As 5G cell phone technology is deployed in 2020, gigabit internet will exist over the air throughout the country - no wires/fiber needed.   The potential is only limited by our imagination.

What exactly is the potential?   Google Home enables the definition of routines - a kind of macro that links commands together, including "if this, then that" kinds of controls.

For example

Ok Google, Good Morning

Good Morning John

It's 22 degrees outside and today will be dry with a high of 32 degrees.

Your commute to work today will take 47 minutes because traffic is heavy

Increasing the temperature of the kitchen and decreasing the temperature of the bedroom

Playing morning music

Ok Google, Good Night

Turning off the lights

Activating the security system

Reducing the temperature of the kitchen and increasing the temperature of the bedroom

Sleep well

All of this has worked so well, that it makes me believe the future of computing is not limited to phones and apps, but increasingly a voice driven integrated ecosystem that requires very little technical expertise to use.

The artificial intelligence components can be startling.

Ok Google, play NCIS on TV

NCIS is available on CBS All Access and The CW

CBS All Access

Playing NCIS from CBS All Access on the Farm Living Room TV.  I will play from CBS All Access next time you ask for NCIS.

This required identifying that NCIS is a television program, offered by certain vendors, each with a different way to play it.   Notice also that I was vague about which TV to use, but Google Home figured it out.

Fast forward to healthcare. As we think about the integration of wearables and other in home wellness devices, this technology can integrate devices, routines, and voice commands to measure activities of daily living, suggest healthy behaviors, evaluate compliance with care plans, and communicate with care teams.

Today, only those with technological literacy and dexterity can perform these functions with a collection of apps, but it takes diligence, planning, and a steep learning curve.

Assembling all the connected home functions described above was done by me, in a few minutes, by unboxing devices and doing minimal setup - a one time only event.

As we move from fee for service to value-based purchasing, reimbursement reform will align incentives for wellness in the home rather than the treatment of sickness.  I predict that healthcare delivery organizations will restructure themselves for success  by shifting work from building more hospital beds to empowering patients outside of the hospital.  This will require training clinicians in  telemedicine  (let's call the new medical specialty "virtualists"), home support people (both visiting nurses and connected home technicians), and care managers who ensure all services are coordinated to maximize quality while reducing total medical expense.

To me, this tech works so well, and is so affordable (compared to treating sickness), that the future of the connected medical home looks very bright.

Tuesday, January 15, 2019

Dispatch from India

I spent last week in Bihar, an area of Northern India near Nepal.  The best way to describe the journey is in pictures.

Our small team visited villages along the Ganges to the east of Patna, tracing the path of patients from seeking care to diagnosis to treatment to compliance to wellness.   We met with patients, providers, field officers (think of them as care managers), chemists (pharmacists), and labs.    Here's what we experienced:

The villages had hand pumped water supplies, electricity and 4G cellular connections.  Cows and goats were a part of many households.


A unique telemedicine program from World Health Partners (WHP) provided access to experts, connecting each village to trained clinicians in urban areas.    We participated in such a consultation.


We visited patients in their homes to hear their stories.  All of us were touched by Pooja, a 25 year old new mother who spent 70,000 rupees (about $1000) on unnecessary medical care due to a misdiagnosis.   She had to sell her land and her cow to pay for healthcare.   We've started a go fund me to help rebuild her life.


We reviewed medical records and imaging studies, which in India are maintained by patients and families.  In this photo, I'm reviewing the records of a TB patient who is feeling better after treatment, but appears to have a negative initial chest X-ray.


We visited a local lab which offered a menu of diagnostic tests ranging in price from $.70 to $14.00. Diagnostics included GeneExpert TB testing and 3D doppler ultrasound.   All lab data is manually recorded on paper and carried by the patient.


Local chemists make available a range of medications at very low cost.


Medical record keeping is done via a brief note which is the property of the patient.  Prescriptions are often abbreviated in a way that can be hard to decipher but a local chemist can understand.   Registry data is entered for tuberculosis and is one of the few electronic workflows, completed on low cost android phones by provider support staff.


I came away with a better understanding of the cultural, political, and clinical workflow in the state of Bihar.   Next steps will be designing the digital health services which are most likely to serve the stakeholders, now that we have experience with their requirements and constraints.  We'll do everything possible to leverage the remarkable national cloud hosted services available in India including identity management via Aadhaar, payments via UPI  and the rest of the "India Stack".

As I wrote last week, the next 30 years of my life will be dedicated to purposeful causes that I hope
will make a difference.    India and China, which comprise more than 1/3 of the humans on this planet,  seem like the right focus for 2019.

Thursday, January 10, 2019

Choosing Effective, Sticky Health Apps (Part 2)

In a blog post last week, I shared an excerpt from the new book that Paul Cerrato and I just completed, The Transformative Power of Mobile Medicine.  Here is a second excerpt from Chapter 3,  “Exploring the Strengths and Weaknesses of Mobile Health Apps.”

Even patients who are fully engaged in their own care still need access to medical apps they can trust. The IQVIA Institute for Human Data Science has performed a detailed analysis of the clinical evidence supporting mobile health apps, rating their maturity and relative quality. Its rating scale places a single observational study near the bottom of the scale, progressing upwards through multiple observational studies, a single randomized controlled trial, multiple RCTs, a single meta-analysis, and several meta-analyses. Using this methodology, it organized mobile apps into several categories. In the category called “Potential disappointments—more study required” are apps for exercise, pain management, dermatology, autism, schizophrenia, multiple sclerosis, and autism.  In the category called “Candidates for [clinical] Adoption” were mobile apps for weight management, asthma, COPD, congestive heart failure, stroke, arthritis, cancer, PTSD, insomnia, smoking cessation, stress management, cardiac rehabilitation, and hypertension. The most important category listed in the IQVIA analysis, which it considered candidates for inclusion in clinical guidelines, were diabetes, depression, and anxiety.

IQVIA has also generated of list of “Top rated apps” for 2017, taking into account their top clinical rating and the fact that they are free and publicly available.  Top rated apps in the free list includes Runkeeper by FitnessKeeper, Inc, Headspace, for stress management, Kwit, for smoking cessation, My Spiritual Toolkit, an AA 12 step program, mySugr, for diabetes management, and SmartBP for hypertension. In the top clinical rating list are Omada, for diabetes prevention, BlusStar Diabetes by WellDoc, Kardia by AliveCor, for atrial fibrillation and dysrhythmias, MoovCare for cancer patients, AiCure for medication management, and Walgreens medication refill app.

The UK’s National Institute for Health and Care Excellence (NICE), has also made real progress in evaluating mobile health apps. One of its missions is to provide guidelines for the use of health technologies within the NHS. NICE reviews data on drugs, medical devices, diagnostic techniques, surgical procedures, and health promotion activities, basing its recommendations on clinical evidence that demonstrates these treatments and activities are effectives, and on economic evidence that shows they are cost effective. [1]

The Institute has evaluated numerous mHealth services, with very detailed reviews of each service or mobile app.  Among the apps that have been studied: GDm-Health, which is intended for women with gestational diabetes, AliveCor Health Monitor and AliveECG app for monitoring cardiac function, Sleepio, for adults with sleeping problems, VitalPAC, for assessing vital signs in hospital patients, LATITUDE NXT Patient Management System, which allows clinicians to monitor cardiac devices at home, and numerous others. [2]

To illustrate the depth and thoroughness of the NICE reviews, consider its analysis of GDm-Health. The review explains the app’s purpose, which is to download data from a patient’s blood glucose meter and send it to a secure website where it can be monitored by clinicians. The web site also lets clinicians send text messages to patients to help them manage their condition. But NICE does not stop there. It also evaluates the app’s clinical effectiveness, user benefits, and the impact that its use would have on costs and resources. It then puts the mobile app into the context of NICE’s guideline for gestational diabetes, explains several of the app’s features in detail, and goes into an extensive discussion of the evidence supporting the app, including summaries of each of the clinical trials that support its use, the key outcomes, and its strengths and limitations.  

1. NICE. Technology appraisal guidance. https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-technology-appraisal-guidance     Accessed Feb 6, 2018.
2. NICE. Mobile health technology search results. https://www.nice.org.uk/search?q=mobile+health Accessed Feb 6, 2018.

Tuesday, January 8, 2019

The Meaning of Life (as a CIO)

As I approach 60 and reflect on over 40 years in the healthcare IT industry I sometimes feel that I’ve transitioned from a rogue upstart to the leader of the status quo - always about to be disrupted. I’m no longer a trouble maker, I calm the troubled healthcare technology waters.   If I’m not careful, that could mean I’ll become a rate limiting step to radical change since I’ve been shaped by a lifetime of experience that started with punch cards, paper tape, and Fortran.

The themes I’ll write about twice a week in 2019 will be about exploring new technology around the world and in a Boston-based lab, the Healthcare Technology Exploration Center at Beth Israel Deaconess Healthcare System, which I lead.    We’ll evaluate new products, ideas, and workflows.   We’ll pilot innovations and fail fast (if needed) so that we can rapidly converge on the right tools for the business requirements we’re given.

In our first quarter we’ll describe an evaluation of the Google ecosystem and potential healthcare implications for Android, Chrome OS  and sensor devices such as

Google Pixel 3 phone
Pixelbook
Google Home Hub
Google Chromecast 3rd Generation
Google Mini-home
Google Chromecast Audio
Nest Thermostat
Nest Outdoor Camera

We’ll review internet of things devices including the Withings suite of watches, blood pressure cuffs, sleep monitors, thermometers, and scales.

We’ll evaluate telemedicine devices and services that bring cloud hosted, machine learning driven decision support to patients and providers.

And of course, we'll take a deep dive into everything Apple is doing in digital health space.

Why am I starting a new lab as I approach 60?   Simple - the meaning of life  (in my view) is about finding a purpose that serves the world selflessly, while surrounding yourself with people who give you a sense of belonging, enabling you to pursue your passion, and ultimately composing the ongoing narrative of your life.

To me, improving wellness with digital health around the world excites me every day

For example,  today I'm in Patna, India at the corner of Nepal, Bhutan, and India evaluating the potential for cloud services, apps, and devices to be used in resource constrained settlings for the management of tuberculosis.

There is no better way to solve a problem than to immerse yourself in the lives of the people you are trying to help, which is what I’m doing this week in homes, clinics, pharmacies, and hospitals.

However, a sense of purpose needs a group of like minded people who give you a sense of belonging. People you can talk to - sharing your successes/failures, and asking for feedback on your ideas.   Throughout my life I’ve been lucky enough to surround myself with people smarter than me, who are a constant source inspiration and energy.    At the moment my sense of belonging comes from extraordinary collaborators in international governments, academia, industry, foundations, and non-governmental organizations (NGOs).       I have a special respect for people in their 20 and 30’s who have far fewer biases and battle scars than me.

Although my passions have changed over the years, there is a common theme.  I’ve always worked at the edges of disciplines.   I'm a physician but my academic work has been at the intersection of medicine and digital health.  In my youth I was the first student at Stanford to have a computer in my dorm room (I built it).   I was the first young journalist to review a portable (25  pound) computer from a new company called Compaq.     I was the first person in Wellesley, Massachusetts to get broadband.   All of my experiences have been at the margins of the possible before the ideas were even considered reasonable.

And I’ll continue to tell my story via the evolving narrative of my life.    In an upcoming post, I’ll explain that my biography should start with the sentence  “He was the Forrest Gump of healthcare information technology” purely because by random chance I’ve been present at every major health related IT innovation of my generation.    And over the next 30 years (I’m vegan, so I should last that long), I’m hoping to be present for the amazing things my friends, students and collaborators do to change the world.

So my meaning of life is about making a difference in digital health around the globe, surrounded by inspirational people, investigating new ideas at the edges of the possible, while creating a story filled with impactful events.    

And that’s what I’ll write about over the next year.

Thursday, January 3, 2019

Choosing Effective, Sticky Health Apps

In a recent blog post, I talked about the new book that Paul Cerrato and I just completed, The Transformative Power of Mobile Medicine.  In that post, we shared the Preface to the book in the hope that it might pique readers’ interest in mobile health.  What follows is an excerpt from Chapter 3, “Exploring the Strengths and Weaknesses of Mobile Health Apps.” 
Choosing Effective, Sticky Health Apps
Even healthcare providers who see the need for innovative mobile apps still face numerous obstacles. Given the human tendency to seek the path of least resistance, identifying the most effective, “stickiest” mobile apps becomes a real challenge. In Realizing the Promise of Precision Medicine, we discussed the need to individualize medical care and the importance of improving patient engagement. When choosing mobile health apps to meet patients’ needs, it is critical to keep both goals in mind. Each patient is at a different stage in their journey, with some lacking basic knowledge about their disorder and others almost as well informed as their providers. With that in mind, the prescription of health apps should be geared to an individual’s level of patient engagement. 
Mobile apps can be divided into several broad categories based on the level of engagement that each patient has reached. Patients will likely lose interest in a health app if it is not consistent with their level of engagement. [1] Among the categories that can meet patients’ needs are apps that:
'Provide educational information
Alert patients to take some specific action
Track their health or medical data
Present patients with data that they have put into their mobile device
Offer advice based on the data that patients input into their device
Allow patients to send information to their family or healthcare provider
Provide social network support
Reward patients for changing their behavior.’ [1]
An activated, fully engaged patient will likely know most of the basics that would be provided in a mobile app that only offers educational information and will lose interest in the digital tool quickly. Conversely, a patient who is only modestly interested in managing a chronic condition may not benefit from a more in-depth app that tracks their medical data or physiological parameters. They must learn to “crawl before they walk.” 
The second category on the list, namely alerting patients to take some action, requires a closer look as well. No doubt many patients have benefited from mobile apps that remind them to take their medication on time or to make an appointment for their periodic mammogram or colonoscopy. Forgetfulness is a normal human failing and these apps can address that. But to be realistic, most non-adherence is not driven by poor memory. It’s driven by far more complex and entrenched motives, and the reason many patients fail to heed their provider’s advice is because it is just not that important to them, or because in their minds the risks outweigh the benefits, or because they can’t afford the prescribed intervention, or because they didn’t fully understand the advice offered or….  The list is long.
Addressing the first issue, Ira Wilson, an authority on patient adherence, points out that ‘we don’t forget to pick up our kids from day care or to make dinner or anything else that’s really important.’ [2] With that reality in mind, it’s not surprising that reminder apps that send patients alerts frequently fall short. This once again emphasizes the point we have made elsewhere in this book: Mobile tools can only supplement medical care, not replace it. And for clinicians to motivate such uncooperative patients will require time, a precious commodity in today’s healthcare environment.
Time is required to ask patients about why they don’t want to follow a prescribed course of action. Time is required to query patients about possible obstacles to adherence: “Can you afford this medication?”  “Does it cause unbearable GI reactions?” “Do you have a way to get to your next appointment or would it mean losing a day’s pay and possibly termination?”  “Do you think your hypertension requires medication even though it’s not causing you any pain or discomfort?”  We obviously can’t solve all our patients’ problems, but knowing what’s behind their noncompliance is the first step toward resolving it.   
Ira Wilson takes this type of deeper probing to heart when he works with patients:
Wilson doesn’t push reluctant patients to take their medications. During a visit with a man with poorly controlled hypertension, for example, Wilson began by asking, “What does hypertension mean to you?” The man replied, “I’m kind of a hyper guy. And sometimes I get tense.” He explained that he takes his medications only when he feels both hyper and tense. In such situations, I [the author of a New England Journal of Medicine editorial] would probably reply, “That’s not how it works,” but Wilson gently asks, “May I share a different perspective?” And patients usually say, “Of course, that’s why I’m here.” 
People like Wilson don’t need a digital reminder to have these conversations or to abandon the “doctor knows best” dynamic. For those of us who struggle, the most effective adherence booster may be giving doctors and patients the time to explore the beliefs and attributions informing medication behaviors. These conversations can’t happen in a 15-minute visit. [2]

Singh K, Drounin K, Newmark LP et al. Many Mobile Health Apps Target High-Need, High-Cost Populations, But Gaps Remain. Health Affairs. 2016; 35:2310-2318. 
Rosenbaum L. Swallowing a spy—The potential uses of digital adherence monitoring. N Engl J Med. 2018;378:101-103.

Tuesday, January 1, 2019

Embracing Android

Happy New Year!   I'll be posting blog entries twice a week in 2019, describing my experiences in the healthcare IT innovation economy and international digital health.

Throughout my history in the industry, I’ve tested many emerging technologies and tried to predict future winners.   Here's a CIO magazine article from 2007 in which I replaced my computing platforms each month to rigorously test Windows vs. Linux vs. OSX

In the late 2000's, I felt that Microsoft had lost its agility and focused on adding features that few people wanted at the expense of usability.   I switched to Apple products because the software felt more utilitarian, secure and stable.

Now, I'm asking if Android and Chrome OS has the balance of features and usability that best meet my requirements for 2019.

I've moved to my phone to a Google Pixel 3 to help answer that question.

Thus far, my experience has been remarkable - a good mixture of speed, stability and usability.   I think of it as a toolbox that doesn't prompt me to adopt functions that I don't want.  

One of the best features is a simple consolidated notifications display that enables me to scroll down from the top of the screen and see every change that has occurred since I last picked up the phone - email, texts, app messages, reminders, and calls.

The gestures are intuitive.    The browser is Chrome (works everywhere with everything) and the email client is the highly usable and stable Gmail client

I've been so impressed with the functionality of my Android phone that I decided to move my computing environment to Chrome OS and Android as well.   My Google Pixelbook arrives on Friday and I'll travel with it in India next week.

I'm writing this using Gsuite.    My data is stored on Google Drive.  I'm making my purchases with Google Pay.

All of this will be an interesting experiment, but thus far, it seems to me that the future of healthcare IT looks belongs to cloud hosted applications/services accessed from thin browser-based and mobile clients.   Android/Chrome OS might very well be those thin clients.

I’ll report on my experiences as they evolve.

Friday, December 14, 2018

The Power of Mobile Health

2018 was a very busy year, requiring extensive international travel—I racked up more than 400,000 miles this fall.   But now that my schedule is a bit more manageable, I plan to start posting again to “Life as a Healthcare CIO”. In addition to my travels to China, Japan, Australia and a long list of other countries, I managed to find the time to work with my esteemed co-author Paul Cerrato on our third book, The Transformative Power of Mobile Medicine. We wanted to share the Preface with readers and have included it below, along with a link to Elsevier’s web site for those interested in reading the entire book.

Cynicism, Optimism, and Transformation

Words are powerful tools, weapons even. They can persuade skeptics, overcome bigotry, injure colleagues, disrupt the status quo, ruin reputations, shatter misconceptions, deceive the uninformed, endear us to loved ones, comfort the grief stricken. The list is almost endless. The three words that are most relevant to our discussion of mobile medicine—cynicism, optimism, and transformation—are no less potent.

Many stakeholders in healthcare have become cynical about the value of information technology in improving patient care, some of which is justified. Clinicians have valid concerns about the ability of the current crop of electronic health record systems to deliver cost effective care. Others doubt whether patient-facing mobile apps can effectively engage patients in their own care or lighten the load of practitioners already burdened with too many responsibilities. And many grouse about the seemingly endless list of IT-dependent government regulations that slow them down.
But for many, cynicism has become more than just a reaction to legitimate concerns. It’s become a national religion, coloring their view of emerging innovations and potentially transformative technologies. John and I are not members of that sect. While we are both optimists by nature, our enthusiasm for mobile technology is not naivete. Call it evidence-driven optimism. Our combined 60 plus years of work on the clinical and IT sides of medicine have convinced us of the value of clinician-facing and patient-facing mobile apps, telemedicine, remote sensors, and numerous other digital tools.

The comedian Stephen Colbert, in one of his more serious moments, once said: “Cynicism masquerades as wisdom, but it is the farthest thing from it. Because cynics don’t learn anything. Because cynicism is a self-imposed blindness, a rejection of the world because we are afraid it will hurt us or disappoint us. Cynics always say no. But saying “yes” begins things. Saying “yes” is how things grow.”

Like Colbert, our goal in this book is to reject the cynic’s view of healthcare. We are interested in growth. And as our subtitle suggests, that growth entails leveraging emerging innovations, seizing opportunities, and overcoming obstacles to mHealth.

In our previous book, Realizing the Promise of Precision Medicine, we demonstrated that mobile medical apps have both “potential and kinetic energy,” i.e., there’s evidence to show that several mHealth initiatives will improve patient care in the near future, and several initiatives have shown mobile medicine is improving patients’ lives now. The Transformative Power of Mobile Medicine will take this theme into deeper waters, exploring the latest developments in mobile health, including the value of blockchain, the emerging growth of remote sensors in chronic patient care, the potential use of Amazon Alexa and Google Assistant as patient bedside assistants, machine learning, the latest mobile apps being developed in Beth Israel Deaconess Medical Center (BIDMC) and elsewhere, and much more. These innovations and opportunities, however, also need to be put into the context of clinical medicine as it is practiced today, which will pose challenges in terms of validation and implementation. With these concerns in mind, we address criticisms and skepticism in the medical community and take a critical look at the published literature on mobile apps in diabetes, heart disease, asthma, cancer, and other common disorders.

Equally important, we discuss the design process for creating new mobile medicine products, exploring successes and failures, the regulatory environment, and the importance of involving clinicians in the designed process at every stage.

mHealth initiatives are certainly no panacea, but they represent a new path for clinical medicine and for patient self-care that will have a profound impact for many decades. We hope our words will accomplish all the positive things words have the ability to accomplish, persuading skeptics, disrupting the status quo, shattering misconceptions, and demonstrating the power of evidence-driven optimism.

Paul Cerrato, MA
John Halamka, MD, MS