HealthBlawg

Mobile Health Apps: Pass the Secret Sauce

The IMS Institute for Healthcare Informatics released a report on the ecosystem bloody mess of 40,000+ mobile health apps that are available today. Hat tip to Jane Sarasohn-Kahn for writing about it today at Health Populi.

From the executive summary:

Over time, the app maturity model will see apps progress from being recommended on an ad hoc basis by individual physicians, to systematic use in healthcare, and ultimately to an end goal of being a fully integrated component of healthcare management. There are four key steps to move through on this process: recognition by payers and providers of the role that apps can play in healthcare; security and privacy guidelines and assurances being put in place between providers, patients and app developers; systematic curation and evaluation of apps that can provide both physicians and patients with useful summarized content about apps that can aid decision-making regarding their appropriate use; and integration of apps with other aspects of patient care. Underpinning all of this will be the generation of credible evidence of value derived from the use of apps that will demonstrate the nature and magnitude of behavioral changes or improved health outcomes.

(Emphasis supplied.)

We are nowhere near this endpoint -- integration of the use of health apps into health care management -- right now, due to a number of factors.

Engage With Grace

As patients, as family members, as friends, as health care providers, we have all faced end-of-life issues at one time or another, and we will face them again. And again. 

Having been through this process twice in the past year, I can only repeat that it is important to have The Talk, to help ensure that your family members' and friends' wishes about end-of-life care are clear, are documented and, as a result, are followed. If it helps to get the conversation going, use the Five Questions in the slide at the end of this post. 

Download your copies of the Massachusetts health care proxy form or other states' proxy or living will forms -- and add specific instructions about nutrition, hydration, and anything else that is important to you so that everything is crystal clear.  Having the conversation is a starting point; we all need to follow through and make sure that our loved ones' wishes are documented, placed in medical records, discussed with physicians and other caregivers, and honored.

And with that I turn it over to @engagewithgrace for #blogrally12 (the latest edition from a group of us kickstarted by Alexandra Drane, Matthew Holt and Paul Levy.) If you blog, consider copying the rest of this post, and putting it up now through the end of Thanksgiving weekend. 

- O -

One of our favorite things we ever heard Steve Jobs say is… ‘If you live each day as if it was your last, someday you'll most certainly be right.’

We love it for three reasons:

1) It reminds all of us that living with intention is one of the most important things we can do.
2) It reminds all of us that one day will be our last.
3) It’s a great example of how Steve Jobs just made most things (even things about death – even things he was quoting) sound better.

Most of us do pretty well with the living with intention part – but the dying thing? Not so much.

And maybe that doesn’t bother us so much as individuals because heck, we’re not going to die anyway!! That’s one of those things that happens to other people….

Then one day it does – happen to someone else. But it’s someone that we love. And everything about our perspective on end of life changes.

If you haven’t personally had the experience of seeing or helping a loved one navigate the incredible complexities of terminal illness, then just ask someone who has. Chances are nearly 3 out of 4 of those stories will be bad ones – involving actions and decisions that were at odds with that person’s values. And the worst part about it? Most of this mess is unintentional – no one is deliberately trying to make anyone else suffer – it’s just that few of us are taking the time to figure out our own preferences for what we’d like when our time is near, making sure those preferences are known, and appointing someone to advocate on our behalf.

Goodness, you might be wondering, just what are we getting at and why are we keeping you from stretching out on the couch preparing your belly for onslaught?

Thanksgiving is a time for gathering, for communing, and for thinking hard together with friends and family about the things that matter. Here’s the crazy thing - in the wake of one of the most intense political seasons in recent history, one of the safest topics to debate around the table this year might just be that one last taboo: end of life planning. And you know what? It’s also one of the most important.

Here’s one debate nobody wants to have – deciding on behalf of a loved one how to handle tough decisions at the end of their life. And there is no greater gift you can give your loved ones than saving them from that agony. So let’s take that off the table right now, this weekend. Know what you want at the end of your life; know the preferences of your loved ones. Print out this one slide with just these five questions on it.

Have the conversation with your family. Now. Not a year from now, not when you or a loved one are diagnosed with something, not at the bedside of a mother or a father or a sibling or a life-long partner…but NOW. Have it this Thanksgiving when you are gathered together as a family, with your loved ones. Why? Because now is when it matters. This is the conversation to have when you don’t need to have it. And, believe it or not, when it’s a hypothetical conversation – you might even find it fascinating. We find sharing almost everything else about ourselves fascinating – why not this, too? And then, one day, when the real stuff happens? You’ll be ready.

Doing end of life better is important for all of us. And the good news is that for all the squeamishness we think people have around this issue, the tide is changing, and more and more people are realizing that as a country dedicated to living with great intention – we need to apply that same sense of purpose and honor to how we die.

One day, Rosa Parks refused to move her seat on a bus in Montgomery County, Alabama. Others had before. Why was this day different? Because her story tapped into a million other stories that together sparked a revolution that changed the course of history.

Each of us has a story – it has a beginning, a middle, and an end. We work so hard to design a beautiful life – spend the time to design a beautiful end, too. Know the answers to just these five questions for yourself, and for your loved ones. Commit to advocating for each other. Then pass it on. Let’s start a revolution.

Engage with Grace.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Pan Mass Challenge 2012 Enters the History Books

Massachusetts has 351 cities and towns. Last weekend, the 352nd Massachusetts municipality came together for a brief, shining moment, and then disappeared again, gone for another year. It was, of course, the Pan-Massachusetts Challenge, the annual bicycle fundraiser for the Dana Farber Cancer Institute's Jimmy Fund. If it's the first weekend in August, that's where you'll find me. This year, there were 5500 riders and 3100 volunteers -- not to mention untold numbers of friends, family members, neighbors and strangers -- who formed this remarkable village on wheels.

Every year from 2004 through 2011, I've biked 200 miles in two days, from Sturbridge to Provincetown, to raise money for the cause, and each year I've experienced it in a different way -- as a novice cyclist, I was just focused on finishing the ride; another year, I was focused on my own good fortune in being diagnosed and successfully treated for cancer in the heart of Boston's Longwood Medical Area, home of the Harvard teaching hospitals, ten years before I started riding the PMC; in yet another year, I remember reveling in the delight of doing nothing but bike for two days, with the luxury of having all my needs attended to by volunteers who serve up peanut-butter-and-banana sandwiches, "Gatorade-a-tinis" and more, and being cheered at every turn by some of the hundreds, or thousands, of people lined up along the PMC's route. Every year, though, the bottom line is the singular focus that this village on wheels brings to the fight against cancer; the villagers greet each other: "Thanks for riding," "Thanks for coming out," "Thanks for volunteering."  In 2012, our little village is on track to raise $36 million for the Dana Farber Cancer Center.

This year I wasn't able to ride, due to a back injury. It's been a real loss for me, not just on the PMC weekend, but all season: cycling has become more than exercise for me: it's a meditative retreat, a therapeutic source of mental health achieved through pedaling and camaraderie. Nevertheless, I've done my part on the fundraising front, and I thank all of you who have contributed to support my ride -- or, rather, virtual ride -- this time around. (Every year, I give the PMC my credit card in January, and then it's up to me to raise, or pay, the minimum ....) For the first time, my 15-year-old son (known to my Twitter followers as Son No. 2) registered to ride; and I was disappointed that I couldn't ride with him on his first PMC.  I've enjoyed hearing his stories from the road over the past couple of days, though (he recognizes his need for more adjectives, since he just keeps saying everything about the PMC was incredible or awesome), and I've really enjoyed seeing the PMC through the eyes of someone who's just moved into the village. He rode one day this year, Wellesley to Bourne, 85 miles, with no training (15-year-olds can do anything for one day, I suppose); next year, we plan to ride from Sturbridge to Provincetown together.

The PMC had special meaning for my family this year. My mother-in-law, who lived with -- and battled -- melanoma for the past year, died in late July. She did her best to continue living her life, on her terms, for most of the past year -- despite being dealt a bleak prognosis. She was fully engaged with friends and family, remained just about as active as ever, continued piano lessons and pursued her other interests -- including offering emotional and other support to friends, family and her counseling clients -- until just shortly before her death. In the face of this devastation, we are trying to regroup, and we are remembering the good times. And there were plenty of good times.

To read more about why we ride, to read vignettes from earlier rides, and to see photos and videos from the PMC in past years, please see my PMC profile and my son's PMC profile. Thanks again to all for the support we've gotten to date -- and it's not too late to support the cause before the books close on PMC 2012.

Thanks, and see you on the road.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Let's Talk Health Care

Harvard Pilgrim Health Care is re-launching Let's Talk Health Care, which started life as former CEO Charlie Baker's blog. There's a series of related discussions going on now in the Let's Talk Health Care Linked In group, sponsored by Harvard Pilgrim.  I've been participating (at the request of the group organizer; disclosure: client) and would like to invite you to do the same.

A salient characteristic of the site and of the group is the focus on three broad categories of care and cost: fostering health and wellness, balancing quality and cost, and redefining care coordination -- all of which are informed by a focus on chronic health care issues.

One of the great successes of modern medicine is the conquest of most infectious disease.  (Equitable global distribution of the tools necessary for eradication is another story -- and some of the more compelling chapters of that story are being told these days by The Bill and Melinda Gates Foundation.) One of the great failures of the modern consumer state is the development of the contemporary couch potato, inactive and over-laden with processed foods, e.g., government-subsidized high fructose corn syrup.  Let's Talk Health Care, like most contemporary health-focused web properties and their sponsors, is laser-focused on wellness (well, OK, everyone has an agenda, and Harvard Pilgrim is an insurance company, so the focus spreads from wellness to encompass a broader focus on affordability of care as well). Targeting prevention and management of chronic diseases that sap health from people, productivity from their employers, and cold, hard cash from all of us is critical; employees, employers, and buyers of goods and services are all called upon to pay the piper, so we have a community of interest here.

As an example of the conversations going on in the group, take a current thread that I kicked off, regarding employers partnering with employees around health care and wellness.  I invite you to join in and offer your perspectives -- what works, what doesn't work, what would you do if you were king or queen of the world, etc.  In my humble opinion, a ton of resources are spent on wellness programs in an unscientific manner -- meaning they are not necessarily spent addressing issues that are, or should be, of great concern to the employee population targeted, and they are not necessarily spent on interventions that work, or that work on a long-term basis. For example, the health reform law is throwing additional money in this direction: $200 million in grants will be available to small employers kicking off wellness programs since the law was passed, and the law also provides the opportunity for employers to subsidize health insurance premiums in exchange for wellness program participation (the maximum premium discount has been raised from 20% to 30%).  Unfortunately, observations of some participants in this on-line conversation support my understanding of the situation here -- incentives to participate in wellness programs in the form of cash (or insurance premium discounts) do not seem to motivate folks sufficiently.  

Collectively, we need to get a bigger bang for the buck in this arena -- and to do that, we need to spend our money more wisely.  Some people are focused on figuring out just how to do that, including, for example, BJ Fogg ("Persuasive Technology"), who I was glad to see present at a conference here in Boston a year or so ago, and entrepreneurs behind such online offerings as HealthMonth and StickK (as well as numerous folks behind stealth and beta sites in this space, some of whom I'm working with now) -- which seek to encourage healthy behavior modification in part by keying into the social levers that affect human behavior.

The goal here is to get the conversation going, and to surface ideas that can benefit all of us --employers, employees, payors and providers.  

The days of couch potatoes saying "I'll take a pill for that" are over.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

David Harlow presents two webinars this week: one on health care social media, the other on accountable care organizations

I am presenting two webinars this week, one on health care social media and the other on accountable care organizations, or ACOs.

Details:

Health Care Social Media: An Introduction to Engaging Intelligently and Legally

(Title links to registration information)

Webinar: Tuesday, October 25, 2011 

Time: 12:00 p.m. to 1:30 p.m. ET

Health care organizations, professionals and patients alike are embracing the social media movement with vigor as online tools like blogs, Facebook, Twitter and YouTube grow in popularity. It is no longer a question of whether you should be using social media tools to promote your practice and institution and connect – effectively, legally and ethically -- with patients and referral sources; it is a question of when, and how.  

A skilled user of social media has the opportunity to become a trusted source, a convener, an influencer; and can effectively and efficiently utilize these tools for reputation enhancement and building strong relationships with existing patients and referral sources while “expanding the sales funnel” to attract new patients and referral sources.  However, the use of these tools requires interaction and engagement at a level that many health care organizations find uncomfortable. Balancing the inherent tension between transparency and privacy, openness and control, can be difficult. While the legal land mines are there, you can make your way through and emerge unscathed if you have a clear understanding of HIPAA and other relevant rules – and how they apply to social media initiatives.  

Learn more during this interactive 90-minute webinar about the value of social media tools, the range of issues they present, and some key strategies for using these tools effectively while steering clear of trouble by social media expert and charter member of the Advisory Board of the Mayo Clinic Center for Social Media, David Harlow.  Become comfortable with social media for your facility!

Learning Objectives:

• Gain greater familiarity with social media tools and tactics and their value to the health care enterprise.
• Achieve understanding of legal, regulatory and risk management issues related to the use of social media in health care.
• High-level introduction to best practices.

Accountable Care Organizations, Bundled Payments, and the Future of Health Care

(Title links to free registration information)

Webinar: Thursday, October 27, 2011

Time:  1:00 p.m. to 2:00 p.m. ET

David Harlow previews HCPLive Webinar on ACOs

In the future (starting tomorrow!) health care providers will have to do more with less. Total reimbursement by both public and private sector payors is dropping, and the metrics for success are changing. Instead of thinking about this as a zero-sum game, payors and providers are moving away from fee-for-service payment systems to bundled payment systems. The health reform law spells out one such program in detail -- the ACO, or shared savings, program -- and created the CMS Center for Innovation, and funded it with $25 billion. The Center for Innovation’s mandate is to run experiments on how to do more with less, and to scale up successful experiments quickly.  

In this webinar, noted attorney, consultant, blogger and speaker David Harlow will describe the future contours of the health care market, defined by emerging federal and private sector programs in a post-fee-for-service environment, and identify ways in which provider organizations should be preparing themselves in order to succeed in this brave new world.

Join the simultaneous tweetchat at #ACOchat.

See you later this week.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting 

Health 2.0 Fall 2011

I attended Health 2.0 in San Francisco this week, and participated in the new Health Law 2.0 pre-conference, moderating a lively panel discussion about reviews posted on listings and ratings websites, featuring attorneys and an entrepreneur.

Please take a look at the posts I've written about the conference, here at HealthBlawg, and on HealthWorks Collective:

Health 2.0 San Francisco, September 2011, "Son et Lumiere"

"This post comes to you from the Health 2.0 conference in San Francisco.  The main conference kicks off today, but it has been preceded by a week of code-a-thons and a variety of other events, including HealthCamp and the four-track pre-conference yesterday (Health Law 2.0, Patients 2.0, Doctors 2.0, Employers 2.0).  I moderated one of the Health Law 2.0 panels, and shook up some of my brothers and sisters at the bar by wearing my new Regina Holliday jacket -- I've joined the Walking Gallery.  (Follow the links, including the walking gallery back story, to learn more about who Regina is, and what this means.) ..."  (Read more on the Health 2.0 pre-conferences.)

Health 2.0 Kicks Off in San Francisco

"Todd Park, the HHS CTO, is a vigorous champion of data liberation.  He has moved the government to open its vast repositories of data (e.g. Medicare claims data) to sharing with the public to solve health care problems.  Data liberation is one of the watchwords of the participatory medicine movement, and is a goal that will be reached more easily through the proliferation of online tools that will facilitate health information exchange.  While we would hope that, in the future, this would be a core functionality of interoperable EHRs, It seems we just aren’t there yet.  Meanwhile, however, there are Health 2.0 companies ready to bridge the gap, and ensure that data from whatever source regarding an individual patient will be available to her clinicians...."  (Read even more on the Health 2.0 pre-conferences.)

Health 2.0 - Focus on High Quality, Low Cost & Connectivity

"The health care payor and provider worlds are concerned with access, cost and quality.  The federal government adds a population health gloss, and calls it the Triple Aim – better care for individuals, better health for populations, at reduced per-capita costs.  Those fundamental drivers are now having a clearer effect on the Health 2.0 ecosystem.  The demos and discussions I’ve observed thus far at this year’s conference are more consistently focused on addressing these issues than they have been in the past.  Early-stage, and more established, companies’ products are also notable in that they are focused on connectivity in a broader sense than before – whether that’s connectivity for data, so that sensors can share data with your personal tracking software, your doctor or your community, or connectivity for individuals, who can use online social tools to improve their own health status through online interactions in a number of different ways...." (Read more on Health 2.0 Day 1.) 

       Health 2.0 Conference: Data Liquidity Can Improve Care and Reduce Cost

"On the last day of Health 2.0, the key takeaway was this: data liquidity can improve health care and health status, and reduce cost.  Hey, we knew this already; the cool thing about hearing this message at Health 2.0 is that you get to hear it (1) while seeing the tools that will actually create that data liquidity that are ready for prime time, or almost ready for prime time and (2) from federal officials who are visibly excited about this stuff...." (Read more on Health 2.0 Day 2.)

In addition, please take a look at the Health 2.0 Fall 2011 vlog with David Harlow, featuring 18 mini-interviews on Health 2.0 and "data liberation" with some of your favorite Health 2.0 and ONC figures -- including Matthew Holt, Jane Sarasohn-Kahn, Farzad Mostashari and Lygeia Ricciardi -- and some new faces as well.

The conference was jam-packed, and of course there were many more worthwhile demos and presentations that I was not able to include in these brief collections of highlights.  I hope to see more of you at the next conference.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting 

Healthcare Associated Infections: What is the Message, and What Can We Do About Them?

 

The good people at GE and JESS3 have come up with an HAI infographic.  It's pretty, and it conveys the horrible information that many of us already know -- healthcare associated infections kill about 100,000 people a year, and add $35 billion a year to our collective health care bill (here in the US of A); 5% of hospital inpatients end up with an HAI.

So what do we expect the world to do with this infographic?  The FDA has rolled out new cigarette package warnings, including graphic photos, that are presumably intended to so sicken potential purchasers of cigarettes that they drop the pack of cigarettes and run screaming from the counter.  In more measured terms, the FDA says:

The introduction of these warnings is expected to have a significant public health impact by decreasing the number of smokers, resulting in lives saved, increased life expectancy, and lower medical costs.

But what is the expected public health impact of publishing this infographic?  I would like to see GE, and/or others, fund the public health campaigns that are needed to accompany the release of such information.  GE is already doing some of that, to be sure, but a staggeringly large problem like the one identified here needs more attention.  The federales are trying to move the needle by refusing to pay for the cost of providing health care services required due to HAIs.  The government and providers are likely to be spending a lot of time and resources in line-drawing and finger-pointing, fighting over the dollars at stake, without pulling back and addressing root causes of HAIs in a systematic manner.

And what sort of campaign do we need in this circumstance?  A consciousness-raising campaign, so that (1) the empowered patient can insist on provider transparency, and create additional market forces pulling or pushing providers away from the marketplace that has allowed the preventable HAI count to swell, and (2) engaged providers can work to prevent the preventable HAIs and communicate the value and quality of care that they can deliver to patients and potential patients.

One possible meeting ground for like-minded patients and providers on this issue is the Society for Participatory Medicine (yes, another shameless plug for the Society and its journal, blog and listserv -- full disclosure: I am chair of its public policy committee).  Join us! 

Participatory Medicine is a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners.

Again, the infographic may introduce the problem to folks who may not be aware of it, but the real work lies in solving the problem, not just realizing that there is one.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Regina Herzlinger speaks with David Harlow about health care reform and other health care innovations

I spoke with Harvard Business School professor Regina Herzlinger this week about health reform – the good, the bad and the ugly – touching on ACOs and demonstration projects under the Affordable Care Act; innovations coming down the pike in the private sector either because of the law or because of market forces; social media in health care; and two key fixes to the ACA that she believes are absolutely necessary in order to make it work, or work as best it can.

First of all, she expressed her delight at the passage of a federal law nudging us ever closer to universal coverage, combined with dismay at its failure to address rising costs (noting that we're looking at policies yielding an accumulated Medicare deficit of $90 trillion, as compared to an annual GDP of $12-14 trillion) and at the paltry fines to be leveled at noncompliant employers that do not offer health insurance as required. As rational actors, she expects that more and more employers will simply opt out of the health care insurance market one way or another: gaming the system to avoid coverage requirements, paying fines that are less costly than insurance, and/or handing employees cash to put towards their own health insurance rather than arranging for a group plan, leaving the range of future health plans to be hammered out by insurers, state health insurance exchanges, and individuals. This outcome will be to the detriment of the insurers, who will be selling policies to individuals rather than groups (and, I must point out, whose underwriting practices will be constrained in the face of community rating mandates in the ACA); some of these individuals will be given the cash needed for insurance premiums by their employers. Herzlinger cited a recent McKinsey survey of employers (though its methodology and conclusions have been roundly criticized by some), endorsing its prediction of a widespread flight by employers from the field of employment-based health insurance.  Some see health insurance exchanges as a market opportunity; consider Bloom Health, which has launched what it calls the nation's first private health insurance exchange.

Herzlinger said that she sees the Medicare shared savings program (aka the ACO program) as a wholesale failure, unworkable because of the assumption build into the model that a single organization can effectively and efficiently manage all care for a population of patients. Her preferred approach (as outlined in her 2007 book, Who Killed Health Care?) is the development of specialty care organizations ("focused factories," anyone? She came up with the term a while back) focusing, say, on CHF – including all key CHF comorbidities. I am not convinced that this is a complete solution, since patients arrive as bundles of symptoms, not labeled with diagnoses, so there is a significant role to be played by primary care providers and others who do not necessarily fit into the focused factory model. However, there is merit to the notion that a system of providers and payments may be cobbled together in a manner different from the approach laid out in the proposed shared savings program regulations. (See my earlier post on Jeff Goldsmith's critique of the ACO concept, in which I suggest that his ideas should be welcome in the world of commercial ACOs; in addition, given the tremendous felxibility shown by CMS in promulgating the proposed ACO regulations -- for example, downside risk added to the mix despite being left out of the statute -- perhaps there will be a place for Goldsmith's proposed differential payment schemes for PCPs, EDs and focused factories.)  Despite the narrowing of patient choice due to the development of commercial proto-ACOs and other payor-provider alliances, Herzlinger has yet to throw in the towel on her vision of consumer-driven healthcare. She is focused on the notion that, as employers move in the direction of providing additional cash compensation to employees in lieu of group insurance plans, consumer-driven healthcare will thrive, since consumers – not employers – will be the purchasers of services, and providers, despite being squeezed by payors, will need to be more responsive to consumer demands.  Wearing my Society for Participatory Medicine hat, and as a patient myself from time to time, I like this line of thinking.

I also tended to agree with Herzlinger's take on health care social media as a critical tool in the armamentarium, to be used by providers and patients in order to improve health care for all.  (If interested in further reading I commend to you a recent piece of mine on issues surrounding the use of social media by health care providers.)

Finally, in response to my inquiry about what aspects of the ACA she expects to see amended in the near future, Herzlinger shied away from some of the issues being debated today (e.g., significant changes to the Medicaid program in order to forestall budgetary disaster at the state level, or waivers of the federales' state-level health insurance exchange structure, otherwise not obtainable for the first three years under the law, to assist early adopters like Massachusetts) and focused on two specific issues:

(1) The need for an amendment to the tax code so that cash payments by employers to employees, intended to be spent on health insurance premiums, will not be taxable as income to the employee (in order to mirror the economic effect of the tax treatment of health care benefits); and

(2) The need for better transparency in health care, so that patients/consumers can have as much information available to them as they would when it comes to making a purchasing decision about any big-ticket consumer item (car, refrigerator, etc.), including, for example, outcomes quality data.  We closed by agreeing that Todd Park has been doing a bang-up job in granting access to the tremendous store of data held by HHS, and hoping that his office would continue to expand its offerings.

Please have a listen to part of our conversation -- after extending a health insurance supermarket analogy just a little too far, technology struck back and deep-sixed part of the recording.

The audio file of my interview with Regina Herzlinger is available for download/podcast (the first 10 minutes or so, anyway; the rest was eaten by gremlins).

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

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

mHealth, markets and cold, hard cash

Last month, PricewaterhouseCoopers issued a report, Healthcare Unwired, examining the market for mobile health monitoring devices, reminder services, etc. among both health care providers and the general public.  One of the big take-away points seems to be that 40% of the general public would be willing to pay for mobile health, or mHealth, devices or services ranging from reminders to data uploads; and the reaction by insiders is either joy (40% is good) or dismay (40% is not enough).  PwC estimated the mHealth market to be worth somewhere between $7.7 billion and $43 billion per year, based on consumers' expressed willingness to pay. Deloitte recently issued a report on mPHRs, as well -- and there is tremendous interest in this space, as discussed in John Moore's recent post over at Chilmark Research.  I agree with John's wariness with respect to the mHealth hype; there is certainly something happening out there, but significant questions remain: What exactly is going on?  Is there reason to be interested in this stuff or is it just something shiny and new?  Can mHealth improve health care status and/or health care quality and/or reduce health care costs?

As a society, across generational divides, we are continuing to move in the direction of greater comfort with electronic communication and mobile devices, and we have the desire and readiness to use these tools in managing our health care -- there are numerous studies and reports out there supporting these conclusions beyond the latest from PwC and Deloitte.  The infrastructure is moving in the right direction, though there are still significant bumps in the road, e.g., lack of a universally-accepted data set for PHR data (the CCD/CCR divide, epitomized by the Microsoft HealthVault/Google Health adoption of these different health data standards).  In a growing effort to overcome some of the interoperability issues in this space, HealthVault recently announced that it will be joining forces with the Continua Health Alliance, thus making a large number of mHealth devices capable of uploading data directly into individuals' HealthVault PHRs.  This is -- potentially -- a huge development; we have yet to see how it will play out.  As HealthVault continues to grow its "white-label" PHR market among health care providers (growth goosed in part by the meaningful use regulations), its ubiquity, paired with the utility of the Continua standards, and the growing adoption of these tools both by health care providers and the general public, will turn mHealth from a geek-fest into a tool, or set of tools, used by all.

Clearly, this is the wave of the future, and the interest in mHealth is not just as a plaything for the early adopter.  Eventually, we will stop calling it mHealth -- it will simply be part of "health." (See Susannah Fox's post on a similar sea change in thinking about the term "e-patient" -- if we are all educated, empowered and engaged in our own health care, then we are all patients, and perhaps need the appellation "e-patient" no longer.) 

As mHealth edges into the mainstream, it must continue to demonstrate its utility.  As it does so, its potential for success should not be measured by the dollars individuals are willing to shell out, but by the savings to the health care system that it enables.  There should be no market for mobile health devices and apps that cannot be counted on to increase health care quality and/or reduce health care cost.  If they don't do one or both of thoise two things, then they could still be sold -- but as toys, not as meaningful health care tools.

The value of SMS messaging (text messages) is highlighted by Jane Sarasohn-Kahn in her review of the PwC report, and has been studied by Kaiser Permanente in as mundane an application as appointment reminders, where the potential for significant savings was identified. 

Savings should be created by those efficiencies, and the price for the tools should be paid by the beneficiaries of those savings -- the health care payors: public and private sector insurers (i.e., Medicare, Medicaid and commerical insurers), self-insured employers and self-paying individuals, and health care provider organizations paid on some basis other than fee-for-service (and we hope this last group will be growing, thanks to the growing emphasis on sharing fiscal responsibility for health care quality with provider organizations).  

David Harlow
The Harlow Group LLC
Health Care Law and Consulting