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October 25, 2010

Connected Health Symposium 2010

I attended the Connected Health Symposium last week in Boston. I enjoyed many of the sessions (sometimes wished I could have attended two simultaneously, though the livetweeting helped on that front), and as usual enjoyed the hallway and exhibit floor conversations too.  As is often the case at conferences these days, I had the opportunity to meet several on-line connections in real life for the first time. 

(I will not attempt to give a comprehensive report of the symposium here; please see the livetweeting archive linked to above and other reports to get a sense of the rest of the event.)

This year's exhibit floor included a diverse mix of distance health tools.  Most striking from my perspective was the fact that most of these tools do one of two things: Enable patient-clinician videoconferencing, or upload data from in-home monitoring devices.  The best of the second category also trigger alerts resulting in emails or PHR/EHR alerts to clinicians if vital signs are out of whack, or phone calls to consumers or their caregivers if, for example, meds aren't taken on time (one company had a pill bottle with a transmitter in the cap that signals when it's opened; another had a Pyxis-like auto-dispenser, that looked like you'd need an engineer -- or a teenager -- to program it).  One tool -- Intel's -- seemed to combine most of these functions, and more, into one platform, but it's barely in beta, with only about 1,000 units out in the real world.

The speakers this year seemed to return again and again to several major themes: (1) Is any particular connected health solution scalable? (2) Who will pay for connected health, or mobile health (mHealth)? and (3) Does it work?

These issues are, of course, interconnected.  With the current ACO (Accountable Care Organization) feeding frenzy, and expectations of health reform's full implementation as background, there was a palpable sense, or hope, that all this health-tech-geeky goodness will be snapped up by the ultimate payors for health care. 

Who the ultimate payors are depends on your vision of the future.  Is it health care providers, who will be squeezed by bundled payment demos and mainstream Medicare payment changes coming down the pike under the Affordable Care Act?  Providers have an incentive to save more money than they'll be losing through payment reform under the ACA (and perhaps even the implementation of the SGR [link is to a post on the subject from over a year ago; Congress still hasn't faced the music]-- the latest "doc fix" is slated to expire after the election and fall in the laps of the lame duck Congress).  Is it health care insurers, who are being squeezed by state regulators?  Consider, for example, the recent Massachusetts experience with the Connector -- the model for state insurance exchanges -- and the governor insisting on limited rate increases, with the dispute ending up in court.  Is it premium-paying or self-insured employers?  Is it consumers, or patients?

In addition, the future of ACOs and the rest of health reform implementation is a little unssettled, to say the least.  The law has been thrown to the courts in a series of constitutional challenges, and will be thrown to a new Congress in January.  So even if an investment in some of these systems could eliminate a significant chunk of a physician practice's overhead expense, who's going to invest those up-front dollars right now?

Some of the pricey hi-tech solutions raise my perennial question as well: How many childhood vaccines could we buy with that money?  Roni Zeiger of Google Health tweeted a similar comment attributed to Bill Gates during a presentation on genome sequencing: "I'll get my genome sequenced after we cure the top 20 infectious diseases."

In short, there is recognition that some connected health tools can have a positive impact on health status of individuals and populations, but the key questions center on the cost-effectiveness of those interventions.

One speaker, B.J. Fogg, of the Standford Persuasive Technology Lab, said: "Many crummy trials beat deep thinking," encouraging folks to continue to throw stuff against the wall and see what sticks.  I would take issue with this approach.  For example, the home monitoring devices I described above only upload data to their own proprietary software.  Only one vendor (Intel) seemed to be close to designing an interoperable interface to standard PHRs.  It seems to me that this is a key feature of any such system, and the sooner the vendors adopt this thinking, the sooner they will be able to demonstrate the utility of their products and grow their markets.

On the "Does it work?" front, many speakers addressed the issue of behavior change.  All of the tools discussed at the symposium are, in essence, intended to make change in personal behaviors easier to accomplish.  While much of the behavior change discussion was laced with paternalism, it had, at its core, a remarkable patient-centered orientation.  This orientation was emphasized by a discussion on process and outcome measures of the future, to be used as a means for calculating incentive payments to health care providers.  One speaker insisted that the most useful measures will be patient-centric measures: patient satisfaction, patient compliance, etc.  The difficulty lies in reaching the point where patient and consumer behavior is being changed appropriately. 

This raises the question: How do we reach consumers?  What incentives will people resond to?  What options do we need to present to individuals, and how?

Sheena Iyengar delivered a terrific keynote on choice, making the point that in our society we have too many choices -- about everything: breakfast cereal to jam to mutual funds in our retirement plans to Medicare Part D plans.  Research shows that the optimal number of choices to lay out before human beings is 7+2, and that more choice results in no choice at all being made -- no mutual funds selected for retirement, no Medicare drug supplement plan selected to help with prescription medication costs.

Kevin Volpp, from the UPenn Leonard Davis Institute Center for Health Incentives, spoke about how we do, and can, incentivize healthy behaviors, noting that many accepted approaches are shown through research to be ineffective -- e.g., posting calorie counts on menus, CDHPs, reducing copays.  One interesting positive note: lotteries can improve compliance with healthy behaviors in a cost-effective manner.  Volpp gave a compelling example of a medication compliance study that increased compliance by giving compliant patients the chance to win money in a lottery if they took their meds.

Overall, there was consensus that the reason we don't have all the latest tech available in service of health care is that the economic model for health care in this country is broken, thanks to skewed incentives based on the fee for service model.

To me that seems to be too facile an excuse, explaining only the failure of health care providers to adopt these tools on their own initiative.  Gary Gottlieb, CEO of Partners Healthcare addressed one plenary session and emphasized that the work of the folks in the room was critical to the success of Partners -- precisely because of the cost-saving potential of the solutions at various stages of development.  This is of critical importance to Partners as it seeks to prepare for success as an ACO and, more broadly, for success in a market less willing to see things its way than in the past.

Ultimate payors have always had the incnetive to improve health care processes and outcomes, and they are getting more and more sophisticated about it.  ACO's may be the latest (provider-centric) frame for the discussion, but the (ultimate payor-centric) patient-centered medical home frame has been around for a while, and may even prove to be a key engine for ACO success.

Back to patients. The key to success in transforming health care in this country is patient engagement, so patient-centered care, delivery of information to patients, and the enabling of patient community are the goals that health care providers and their connected health vendors need to focus on.

The concluding presentation from Joe Kvedar demonstrated that patients are more likely than we may expect to prefer interacting with computers vs. people in certain circumstances.  As symposium participants struggled with the challenge of scaling their solutions, this insight provided some comfort.  In an earlier session, Adam Bosworth described his goal for Keas as broader than scaling an individual solution.  He hopes to have his company's service act as a platform for other developers' applications -- creating an ecosystem for health apps benefiting individuals and underwritten by the ultimate payors for health care (in Keas' case, employers).

Scaling, payment, utility -- several of the challenges lined up opposite the connected health community.

All in all, this year's Connected Health Symposium showed that the potential exists for (lower case) meaningful use of a whole heck of a lot of tools and toys.  The challenge is to execute on this potential.   

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

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