DATA, the Adapting of a New Currency

Todd Gifford, MBA      6/13/2012     tgifford@ermconsultinginc.com

“US warns of cyber-attacks on medical devices”

A man uses a robot to practice surgery in Melle on April 15, 2013. US authorities on Thursday warned makers of medical devices and hospital networks to step up efforts to guard against potential cyber attacks.

http://www.rawstory.com/rs/2013/06/13/u-s-warns-of-cyber-attacks-on-medical-devices/

Can you imagine the next episode of Criminal Minds you encounter, experiencing the plot twist of the often overlooked, angry underling rising up to reach out and commit murder by causing the wireless malfunction of the CEO’s perfectly working internal cardiac device” internal defibulator”.It would prove disarming if a medical device could be manipulated to cease performing it’s incredibly important function being turned into an instrument of murder. The malfeasant would soon be caught by the electronic foot print, for this I am sure but the possibility is frightening none the less in light of the world in which we live .

I am comfortable with the math of Big Data, two plus two can equal 3.9 or 4.1.  We accept these parameters not because we rely on big data for the sole factor in our decision making but as reinforcement for our collective theories toward improvement.

I find it unnerving that Target a massive retailer can send correspondence to a man that causes strong anger and resentment due to the giant retailer sending a congratulations on being pregnant to his home targeting “no pun intended” his teenage daughter barely out of Jr. High ,not even 16 years old yet for Heaven’s Sake . The much upset father called the corporate office and complained at length about the mistake.                                    

He felt all the worst when he had to pick up the phone and call the individual he reamed and apologized because it seems his young daughter was indeed pregnant. Kindly explain how Target can know more about a Fathers Household than the Patriarch himself. How do they have the ability to know so much about us? Data mining big data is the easy answer.

To truly understand the scope is beyond my humble mind , but it does make for a genuinely Scary Story.

AFP - US authorities on Thursday warned makers of medical devices and hospital networks to step up efforts to guard against potential cyber attacks.

The US Food and Drug Administration said implanted devices, which could include pacemakers or defibrillators, could be connected to networks that are vulnerable to hackers.

An FDA warning notice was sent to medical device manufacturers, hospitals, medical device user facilities, health care technical staff and biomedical engineers.

It said the agency has recently "become aware of cybersecurity vulnerabilities and incidents that could directly impact medical devices or hospital network operations."

"The FDA is recommending that medical device manufacturers and health care facilities take steps to assure that appropriate safeguards are in place to reduce the risk of failure due to cyberattack," the warning said.

These devices or systems could be compromised "by the introduction of malware into the medical equipment or unauthorized access to configuration settings in medical devices and hospital networks," the FDA said.

"This may sound like it is out of a science fiction movie, but the threat is conceivably a serious one," said Jon Ogg at 24/7 Wall Street.

"Can you imagine a device being retooled maliciously, like an inserted pacemaker/defibrillator? Or imagine if a robotic surgery system was maliciously recalibrated in even a slight manner for surgeries.

"The list of threats is endless."

The FDA said it was "not aware of any patient injuries or deaths associated with these incidents" nor does it have any specific information on targeted devices.

The FDA said it had been working with other federal agencies as well as manufacturers, which it said are "responsible for remaining vigilant about identifying risks and hazards associated with their medical devices."

Among the measures that should be taken, the FDA said, are limiting unauthorized device access, "particularly for those devices that are life-sustaining or could be directly connected to hospital networks."

 

Life-changing healthcare innovations feature at Made in Brunel 2013

05 Jun 2013

Several young designers and engineers featured in this year’s Made in Brunel showcase have focused on providing healthcare solutions that can make a difference to people’s lives both in the UK and around the world.
Healthcare designs taking centre stage at the highly-acclaimed exhibition include Zen, a watch that can help relieve anxiety, Digit Floss, an innovative device to help clean between the fingers of stroke patients who are unable to unfold their hands, and a new inclusive Easy-Open Deodorant designed to enable independence in personal care.
The exhibition, which showcases the innovations of young designers from Brunel University’s School of Design and Engineering, opens at The Bargehouse on London's South Bank from Thursday 13 - Sunday 16 June 2013.
Zen is a wrist mounted device designed by Johnny Connors that, at the aesthetic level, works as a watch. However there are sensors on the product which detect the biological signs of the user to determine the level of anxiety they are experiencing. Once detected, the watch vibrates to alert the wearer and then displays options to help relieve the stress.
Hand contracture due to a stroke is a heavily underestimated condition with few effective offerings in maintaining hand hygiene and the condition is particularly prevalent among the older population. Young designer Fung Chan has developed Digit Floss, a device which intuitively enables safe hand washing without prying apart the fingers.  The product assist carers to perform their duties safely and efficiently and patients benefit from an improved experience to maintain personal hygiene.
Young designer Ben Clarke’s Otto is a rollator developed through research with many older people, designed to combat problems with current walking aids which lack design acumen, reducing their independence and inhibiting the quality of their lives. Otto’s unique Scandinavian inspired birch plywood construction is optimised to improve posture and provide unobtrusive aid around the home.
Inclusion and disability are also major themes of this year’s showcase. Lynette Smith’s project Easy-Open Deodorant looks at the stigma which is unfortunately still attached to many disability aids despite the growth of inclusive design. Initially, an assistive deodorant product for one person, the design was adapted for a wider variety of users, resulting in an inclusive product that is easier to use by all. The Easy-Open deodorant design enables independence in personal care, accommodating different grip and reach abilities, alongside convenience for fast paced lifestyles
Weixin Jin’s Innovative Spoon Design is a comprehensive and detailed investigation to develop a spoon to help adults who experience reduced muscle strength, poor spatial coordination and decreased motor skill. The design concept improves food serving accuracy and thus reduces the chance of food spillage. It is hoped that using this spoon will help the adult gain confidence and retain personal dignity.
This year’s show focuses on stories of the design and engineering students and how their own personalities and experiences have shaped their innovative products.
Many of the young designers and engineers are set to become industry names of the future and a number of the designs have been developed in collaboration and at the request of leading brands including Coca-Cola, Puma and Rolls-Royce.
Around 300 innovations are expected to catch the eye of consumers, producers and service providers. Previous Made in Brunel exhibitors have landed top jobs at the likes of Jaguar Cars, Porsche Design, Dyson, Burberry and Lastminute.com.
The three day exhibition will include workshops, design forums and talks from leading figures in the design and engineering industry.
For more information about Made in Brunel 2013 please go to the Made in Brunel website or you can follow the show on Twitter: @madeinbrunel13.

NY Digital Health Accelerator Is a Model to Emulate: Startup's Perspective

Zina Moukheiber said the New York Digital Health Accelerator Is a Model to Emulate at the beginning of the program. With the proliferation of accelerators, I thought I’d share an insider’s perspective on what it was like to be in the program now that it is complete. I’ll also share some ideas on how can take it to the next level building off of their already-strong foundation.

Zina described the program as follows:

One of the toughest hurdles for health IT start-ups is getting in front of customers. Doctors are reluctant to pay, and sales cycles at hospitals can take months. Entrepreneurs often inspired by a negative personal experience, and moved to fix the problem, find later that their product doesn’t fit the hospital’s “workflow,” or offers no incentive for doctors to adopt it.

The New York Digital Health Accelerator’s (NYDHA) program was unique in that over 50 CIOs and CMIOs from 23 leading providers were the selection committee — in other words, prospective customers, not investors, made the call. These same executives agreed to mentor the startups during the program. Consequently, despite announcing that 12 companies would be selected, the program only selected 8 out of the 250+ companies that applied. With the executives making that level of commitment, they were only able to find 8 companies that met their high bar.

A major focus of the program was to get us connected to providers. A key responsibility for the provider mentor was convening meetings with their organization’s leadership. Even though they didn’t all become customers, the feedback and perspective was invaluable for our focus going forward. A few of the companies (including mine), were able to close major opportunities that are game-changers. As these were extremely competitive bids, being a part of the NYDHA program was a big help. Why? It took a lot of the perceived risk out of the equation because the providers knew that we’d cleared a high bar (i.e,., 50+ senior executives and investors had agreed that the selected companies were worth investing their time and money).

With the support of investors such as Milestone Venture Partners, Janssen Healthcare Innovation (Johnson & Johnson), United Health Group, Aetna and others, the investment was managed by the Partnership Fund for New York City (PFNYC) led by Maria Gotsch. The investors recognize Healthcare’s Trillion Dollar Disruption provides a great opportunity. The program was co-managed by the New York eHealth Collaborative (NYeC) led by ex Intel veteran Dave Whitlinger. Much of our day-to-day program interactions were conducted by Maria and Dave’s lieutenants — Jahan Ali at the PFNYC and Anuj Desai at NYeC. They teed up many opportunities such as being featured at the Digital Health Conference and getting access to federal healthcare leaders.

One of the distinguishing facets of the NYDHA is providing the most funding per company of any accelerator ($300,000 or more) — roughly 5-15x more than other accelerators while taking significantly less equity. This ensures that the NYDHA will be the most competitive program to enter as the value proposition is strongest for healthtech startups. New York leaders are striving to ensure that New York is the epicenter of healthcare’s reinvention. Increasingly, other communities are organizing themselves with similar ideas such as Tampa Bay. Like New York, they strive to be where healthcare gets revolutionized and understand what was written in Jim Clifton’s The Coming Jobs War – i.e., it’s not just about maximizing short-term equity returns. Todd Park, our nation’s Chief Technology Officer, has said that the NYDHA program is one that other locales should seek to emulate.

As Zina outlined at the outset, the NYDHA has specific focus areas:

The accelerator’s mission is very focused, answering the needs of the state and health care providers. Start-ups need to have a product that addresses care coordination, patient engagement, analytics, or message alerts. New York is moving away from a fee-for-service system for Medicaid patients suffering from chronic illnesses, to one based on patient outcome. That involves coordinating care among different health care providers to prevent the likelihood of hospitalization. NYEC also oversees the state’s health information exchange which allows hospitals and doctors to electronically transmit patient records; it is looking to build applications on top of its network.

At the kick-off of the NYDHA program, Dr. Nirav Shah, the New York State Commissioner of Health, explained how the NY Health Home program is a key plank of how they are shifting from a hospital-centric view of healthcare to one that extends beyond the hospital walls. A reason why providers need modern cloud-based vendors is captured in the needs of the Health Home. They require systems that can scale from a two-person clinic with no IT infrastructure (other than an Internet connection) to a large urban hospital and everything in between. Not only would it be cost-prohibitive to deploy a traditional client-server model, it’s a highly dynamic time when providers don’t want to be burdened with nightmarish version upgrades typical in a client-server model. It was refreshing during the program to find providers who fully understood this and how it was imperative to move to a cloud-based model. These smart providers recognize how other health systems are spending billions to prepare for the “last battle” rather than looking forward.

NYDHA Recognized for its Results

Since the launch of the program in September 2012, the inaugural class of companies made tremendous strides in a marketplace (healthcare) noted for its slow pace of change and long decision cycles. The following are some of the accomplishments of the program shared by the NYDHA:

• In aggregate, the companies raised approximately $5 million in funding in order to drive growth while significantly expanding their customer base.
• This growth has led to the creation of jobs in New York, with the companies hiring 40 new employees since the program’s inception, with plans to add 41 additional staff by the end of 2013.
• In addition to providing product feedback, the participating healthcare providers facilitated 17 pilots at their organizations. Mount Sinai has adopted Cureatr’s enterprise-grade mobile care-coordination mobile app. Mount Sinai has signed a multi-year contract to roll out the app to Mount Sinai clinicians. The Brooklyn Health Home (an organization of 50+ independent provider organizations) and Maimonides Medical Center (large hospital in Brooklyn) selected Avado as their enterprise-wide standard for a patient portal and engagement platform for multiple years. [Disclosure: Avado is the company where I'm the co-founder, CEO]  By the end of the summer, Aidan will be helping 30,000 patients choose their post-acute care.

The NYDHA has received broad national recognition including the following:

• The California Healthcare Foundation has called the NYDHA one of the most successful accelerator models in the country. In particular, the report noted the financial and strategic ties that have already been forged in the market. These strong market ties are critical because they will determine which accelerators survive and thrive in the long term.
• The Rotman School of Management has ranked the NYDHA the number one Health IT Accelerator in the world, compared to 21 similar accelerators. The ranking was based on 10 different criteria including access to customers, investors, government, and support for innovation.

Raising the Bar on HealthTech Accelerators

There are some terrific healthtech accelerators such as Blueprint Health, Healthbox and Rock Health. They continue to raise the bar as Rock Health has brought in significant new funding and I’ve heard great things about Blueprint’s latest class while Healthbox is expanding their footprint with an accelerator in Florida. The great thing for healthtech entrepreneurs is as each one raises the bar, it gets better for the entrepreneur. In turn, that helps the health ecosystem. The best accelerators will separate themselves from the pack. Until the new accelerators establish a track record, I’m dubious of their value given meager funding (e.g., $20,000 per company) and aggressive asks on the equity front (e.g., 6-8%). I have a hard time imagining how they will get high quality companies with unfriendly terms such as this.

As part of the exit from the NYDHA, they asked for feedback so they can continue to improve. The NYDHA is in the planning stages of the next class. Along with others, I suggested broadening to additional health organizations. I was pleased when the NYDHA indicated they are looking to bring on sponsors and additional mentors from payers, pharma, and tech companies. This is a smart move, particularly as the lines are blurring between various industry segments. Large multi-specialty groups, tech companies, pharma, etc. tend to make decisions faster than traditional hospitals. I’m certain the first class would welcome the opportunity to get in front of these organizations as well. It will be interesting, over time, to see which accelerator programs foster their “alumni” to ensure their long-term success. That would be logical given the equity interest as well as to promote the cache of their alumni companies.

I’ve personally seen payers and pharma, in particular, making major bets (largely behind the scenes today) versus most health systems that are just dipping their toe in the water. My most read piece on Forbes has been IBM’s Reinvention Should Inspire Flat Pharma Businesses which speaks to the imperative pharma has to avoid the fate of the railroad industry. Future NYDHA classes should benefit from the aggressive moves by pharma and payers. I would expect Anuj Desai (NYeC’s VP of Business Development) is going to be busy striking deals with these organizations.

Ultimately, the litmus test for accelerators is how well they fix the market inefficiency of innovative healthcare organizations not being aware of innovative technology companies that could accelerate their market success. With the longest program (9 months) and best funding, the NYDHA has grabbed the pole position. As nimble startups themselves, I’m certain that other accelerators are going to respond and try to leapfrog the NYDHA. Everyone, including the NYDHA, benefits by this healthy competition. It’s never been a better time to be a healthtech startup.

Are You Choosing Privacy Over Healthcare?

Kameron Gifford, CPC

Medicine is practiced much different today than it was twenty years ago. The delivery of care has been altered and reshaped over and over again in an effort to continually comply with new regulations, changing technology, complicated reimbursement systems and increasing numbers of patients. 

The development of technology has allowed us a greater understanding of the human body and better tools to diagnosis, treat and prevent disease.  Revolutionary ideas such as employer sponsored health care and benefits for low income children have allowed us to extend health coverage to many more Americans. Standardized reimbursement codes have provided researchers the opportunity to study the prevalence of disease and track outcomes of treatment; and most recently we have seen alternative models of care aimed at improving outcomes (and costs) in high risk populations.

How has all of this innovation affected the consumer’s perception of health care and patient provider relationships? There is a growing population of insured Americans that choose not to access our healthcare system. There reason, whatever it may be, has become a barrier to them receiving primary and preventive services.

My aunt is one of these people. In the last twenty years she has sought medical attention only twice… both through the emergency for an acute injury. She will be 63 years old this year and has never had a mammogram or a colonoscopy; not even annual labs in over 25 years. Her decision was not pre-empted by her lack of access or knowledge. My aunt is an attorney who successfully fought to protect patient’s rights and increase accountability in the medical community. Her choice is founded in the dilution of the patient provider relationship and the non-existence of patient privacy. The decision to trade medical care for privacy is a personal one, one that no one can force her to change. She continues to pay her premiums, as she always has, so the deterrence of a tax penalty would not even apply. How do we engage these people?

I have to believe that there is an alternative system that can engage these individuals on their own terms. Perhaps, a one size fits all system shouldn’t be the only way.

I see a growing market developing for “patient directed” care. This idea is not new, but until recent advances in technology we were unable to assess a patient “remotely”. With this innovative technology we can now offer non-conventional solutions directly to the consumer. These disruptive tools will allow us to meet the individual needs of all consumers on their own terms.

If our ultimate goal in healthcare reform is to create a sustainable system, we must work with each individual population to create personal solutions.

So, how do we reach this population of patients that “distrust” the current system, and what type if any, would build enough trust to create access?

ERM is diligently working to create an integrated platform of primary care that can be delivered directly to the patient in a setting of their choice. This network of patient directed care will allow us to close gaps left by traditional systems; and provide “On Demand” care for less than $30 a visit.

On a recent visit, I had the opportunity to pitch this concept to my aunt just as I had hundreds before. But this time, her reaction was different…

After picking her up at the airport I noticed an infected mosquito bite on her left elbow. After the usual back and forth about her refusal to see a doctor, I asked if she would have been more willing with our new system. After determining the cost was $5 less than her copay and she was the gate keeper of her records – she was left without an excuse and to both of our surprise she said, Yes!”

The decision to seek, or not to seek, medical care is a private choice. Personal responsibility can’t be demanded or forced, even with punitive taxes. We must invest in whole system change that is flexible enough for every American. Awareness begins with education and education empowers healthier choices. Choices, after all is the ultimate behavior that we seek to improve if we are ever to create a valuable system.

How Data And Technology Will Write Us A Prescription For Better Health

WRITTEN BY: Gadi Ben-Yehuda

We’re at the cusp of a revolution in personal health, fueled by personal monitoring and better analytics. In the future, will health care be as simple as taking your car for a tune-up?

1 Comments

inShare

EDITOR’S NOTE

This post is part of Co.Exist’s Futurist Forum, a series of articles by some of the world’s leading futurists about what the world will look like in the near and distant future, and how you can improve how you navigate future scenarios through better forecasting. Get more visions of the future here.

Visiting a doctor and visiting a car mechanic have certain aspects in common. For each, we are expected to come in for regular check-ups (our annual physical and our 50,000 mile tune-up) and when we notice that things aren’t operating properly (sore throat, shaking from the engine). Another commonality is that in the past few years, a slew of products have been created to give ordinary citizens real-time information on the inner workings of each of those complex systems.

WHAT WE CAN NOW MEASURE

For less than $100, anyone with a smartphone can monitor and record all the functions of their car’s engine. The idea, of course, is that with information like this, we can be better drivers and better caretakers of our vehicles. For not so much more, we can also begin to track our bodies’ processes.

Though our bodies don’t have OBD-II ports like our cars, we do have other outputs. For example, a consumer device called BodyMedia uses accelerometers, thermometers and a sensor to track our galvanic skin response to help users track calories burned, distance walked (or run), and a host of other information. Another company, FitBit has a number of devices that use both an accelerometer and an altimeter to help track weight, activity, and even sleep.

Changing behavior to improve our health is, after all, the desired outcome.

Both companies, among others, help people track basic data that define the contours of our bodies’ functions. Some people, however, need to monitor specific data, such as blood sugar levels, white and red blood cell count, the oxygen levels in our blood, and other health information that can help manage conditions such as diabetes or certain organ functions.

And of course, we can measure the same things we’ve been keeping track of for more than a century: our weight and height (which we now use to calculate our BMI), our age, gender, and temperature. We also have access to sight and hearing tests on phones now.

So whether we visit our mechanic or our doctor, we can now give very detailed answers to that first question “what brings you in today?”

HOW DATA CAN CHANGE BEHAVIORS

Of course, gathering information into databases and presenting it as a spreadsheet is helpful for very few people. Far more informative are graphics or dashboards, and even better are visualizations formatted for mobile devices. This is another similarity between car- and body-monitoring apps. Whether using bar graphs, pie charts, or moving graphics resembling tachometers, dashboards and visualizations are powerful representations that help people monitor and then respond to changing metrics.

Another possibility is to remove raw numbers entirely and simply focus on goals. Instead of showing calories consumed or number of minutes spent in exercise, some companies are simply telling people “it’s 1:00 PM and you’ve walked only 20% of your goal today,” or “It’s only 1:00 PM and you’ve already walked 120% of your goal today!” For many people, this is a more effective way to help them change their behavior.

Changing behavior to improve our health is, after all, the desired outcome. The goal is to live a healthier life and data can help us do that. The difference between a sedentary day at the office and an active day outside may be more than a thousand calories. Yet, in that sedentary day, do we think to eat a thousand fewer calories? If the data were presented to us, we could adjust either our intake or our output--and now more people are able to see that data in real time.

Further, many applications gamify healthy living, giving badges for healthy choices and setting up friendly competitions among groups of people to meet their health goals. Employers, too, can offer incentives (like cash) for establishing good eating and exercise habits. Bit by bit, and byte by byte, it adds up to healthier individuals and a healthier nation.

THREE WAYS DATA CAN CHANGE HEALTH CARE

There are three ways in which people’s having access to their own health data plays a critical part in the health care transformation. Here again, it’s useful to think of think of how access to our cars’ data changes our relationship to mechanics. Here are three examples of how increasing individuals’ access to their own data can change health care:

1: Reducing costs through data transparency.

Data opens a door to transparency that helps consumers understand in advance what they need and better anticipate the costs of care. To go back to the car example, if someone knows they need a new oxygen sensor, they don’t have to pay for a diagnostic first to figure out what the problem is; they can simply call a few garages and ask “how much do you charge to replace an oxygen sensor.” Likewise, patients should be able to call their health care providers and see how much they’ll be charged for the care they need. This has recently started happening, as the government has forced hospitals to reveal some of their prices, but there is still a long way to go.

2: Reducing costs and increasing effectiveness through streamlining health care delivery.

Data enables us to do more diagnostics ourselves and, thus, when we visit our doctor we now have the ability to give them very detailed information. For example, with a $20 kit (and a smartphone), we’ll be able to say “here are all the numbers for my levels of glucose, bilirubin, proteins, specific gravity, ketones, leukocytes, nitrites, urobilinogen, and hematuria.” This knowledge of our own personal health helps streamline the process for health care providers, lowering costs. Diagnosing problems earlier also means treating them more quickly, which reduces costs.

3: Reducing costs and increasing effectiveness through coordinated health care activities.

If the private companies who are developing devices include a way to anonymize the data, and the people who use the devices allow their anonymized data to be shared with government agencies, like the CDC and HHS, it will allow for a profound shift in real-time health preparedness. Already the CDC has partnered with private companies to help people prepare for flu epidemics. If open government could meet big health data, and if everyone who was tracking their own health allowed for non-identifying information to enter into large public databases, this public health data could be used to reduce illness, decrease health care costs and improve individual and community health.

If more individuals begin to track and record their own health data, not only are they likely to improve their own health, but they will all contribute to a health care system that delivers higher quality care at a lower cost. Health care can be more personalized to each individual, and can focus more on maintaining wellness rather than on treating sickness. The implications for telemedicine and for data-driven health care are also significant. And with more devices and applications entering the market each quarter, the trend lines are encouraging.

The Hot Spotters Sequel: Population Health Heroes

Dave Chase, Contributor

CEO of Avado: Powering the disruptive innovators reinventing healthcare

Frail elderly and polychronic patients are a special challenge for our healthcare system. Many have tried and failed to get these two tough cohorts of patients on track to better health. Atul Gawande’s refers to them in his New Yorker piece as The Hot Spotters. Just as law enforcement in community policing identifies crime hotspots, the most challenging (and expensive) patients in a community are identified and become a part of a model that is very proactive about reaching out to them.

The primary focus of Gawande’s article was on a program put in place in Camden, New Jersey by Dr. Jeff Brenner that has received much acclaim. Dr. Brenner has justifiably been lauded for his work and is on the speaking circuit. Less noticed was another physician featured in that article — Dr. Rushika Fernandopulle — who has gone on to aggressively expand on the model that was written about. Dr. Fernandopulle is one of the examples of DIY Health Reform that is providing guideposts to government-driven health reform.

I’ll highlight a few examples of DIY Health Reform that kicked in before Obamacare, yet provide a road-map to programs such as a major program in New York that are building off of these DIY Health Reform approaches. To the extent that the evolving landscape follows models such as the pioneers outlined here, I’m optimistic about the future of healthcare. On the other hand, if Medicare squashes proven models, we’ll be doomed to a continuation of a healthcare system not realizing its full potential. Each of the examples here stand in stark contrast to the common problems outlined in the recent Kaiser Health News/Washington Post article Health Care’s ‘Dirty Little Secret’: No One May Be Coordinating Care.

I have outlined three overarching themes followed by a few examples of providers who have adopted a Hot Spotters type model. Kaiser Permanente is often held up as the future of healthcare in the U.S.  However, I would argue that the models pioneered by Iora Health, the Nuka Model, CareMore, and the New York Health Home program offer a more replicable set of models. Read on for more on each program.

Overarching Theme # 1: Population Health Management
Population Health Management (PHM) has been defined as “the technical field of endeavor which utilizes a variety of individual, organizational and cultural interventions to help improve the morbidity patterns (i.e., the illness and injury burden) and the health care use behavior of defined populations.” Though they take different approaches, they all recognize that the most important medical instrument is communications – something that is woefully under-prioritized in our expensive and inefficient healthcare system.

Brenner describes it vividly. “There is a bias in medicine against talking to people and for cutting, scanning and chopping into them. If this was a pill or or a machine with these results it would be front-page news in the Wall Street Journal. If we could get these results for your grandmother, you’d say, ‘Of course I want that.’ But then you’d say, what are the risks? Does she need to have chemotherapy? Does she need to be put in a scanner? Is it a surgery? And you’d say, no, you just have to have a nurse come visit her every week.” In other words, yet again, patient engagement is the blockbuster “drug” of the century.

A recent past president of the American Academy of Family Physicians, Dr. Ted Epperly, described to me the failing of our present model during a tour through his clinic (disclosure: Dr. Epperly is an advisor to my patient relationship management software company). We stopped at the waiting room in one of the clinics he runs and he simply stated “this is a failure.” When I asked why, he described how they were essentially sitting there waiting for patients to present themselves. Instead, he outlined a vision of a dashboard that proactively manages which patients should be seen if they haven’t heard from them and one that is tracking other patients looking for signals where they should intervene before some issue flares up. The metaphor is less catcher’s mitt and more NASA control center (astronauts were, after all, the original Quantified Self crowd).

Last week, as part of the Oliver Wyman Health Innovation Center advisory board (see Healthcare’s Trillion Dollar Disruption for more), we had a half-day site visit to one of the most successful Medicare Advantage programs in the country (read about CareMore below). Core to their PHM approach is they state that primary care should be an outbound activity, not an inbound activity.

Overarching Theme # 2: Primary Care isn’t Milk in the Back of the Store

As Leeba Lessin (CareMore President) stated ”Primary care has become a specialty referring mechanism, not care driven.” Said differently, our flawed reimbursement model has effectively turned primary care physicians (PCP) into “milk in the back of the store” — i.e., a low margin service intended to direct people to high margin products/services. If a PCP can only make a good living by averaging 7-minute visits with patients, there is little choice but to rapidly figure out whether the presenting symptom is best addressed by a pill, test, or procedure. It’s no wonder that the most unsatisfied physicians are PCPs operating in that broken model. In contrast, the most satisfied physicians I know are operating in one of the models described below that get them off of the 7-minute-per-patient hamster wheel.

All of the models outlined below have rethought their primary care focused models from the ground up. Dr. Fernandopulle stated “What everyone else is trying to do is improve existing practices, making incremental improvements. We figured out that maybe what we need to do is start from scratch.” In one conversation we had, he put it more colorfully as “others are putting wings on cars and calling them airplanes” when I asked him about a popular new model called patient centered medical homes (PCMH). While he agreed with many of the PCMH principles, he believed that simply layering on some new payment structure on top of a severely flawed model was doomed to under-perform.

Team-based primary care is central. For example, Maimonides Medical Center is a pioneer in New York running the “Health Home” program for Brooklyn. [Disclosure: Maimonides Medical Center is a customer of my patient relationship management software company.]  In New York, the Department of Health led by Dr. Nirav Shah is deploying a Health Home program Maimonides is helping to pioneer. The Health Home program has many care team members coordinating care that contrasts sharply with the uncoordinated model of care that is a defining element of today’s healthcare system.

Overarching Theme # 3: Highly Patient-centric Providers

Despite far outperforming their peers, the health organizations highlighted here are tough on themselves. When asked how they’d improve, their comments universally mapped to addressing The 7 Habits of Highly Patient Centric Providers listed below (follow link for more detail on each of the habits).

1. Multi-provider patient portal/tools
2. Medical information is made relevant
3. Patient-generated data is sought out
4. Portable and on the patient’s terms
5. Collaborative care process with shared decision making tools
6. Patient-facing tools that are inviting to use
7. Recognize the importance of caregivers and the Family proxy

While they are far ahead of their competition, even the organizations outlined here don’t have all of these items. They all recognize that in order to maintain their leadership, they will relentlessly improve in these areas.

Unfortunately, stating one is “patient-centric” has become an overused and abused term. Here is how the leader’s of the Nuka Model described what they do in Family Practice Management (PDF) in contrast to the platitudinal use of “patient-centric.”

There’s a lot of talk about being “patient-centered.” Unfortunately what that usually means is that the patient is put in the middle and then all “really smart professional people” stand around and try to decide what’s best for that person.

In the Nuka model, they use “customer-driven”. This means that everything the customer-owner defines as needs, goals and values become the system’s focus. The doctor and clinical team provide expertise, keep track of preventive matters, explain options and make recommendations. But the customer-owner is in control and makes decisions, rather than the providers trying to decide what is best.

It turns out that when given this kind of control and partnership over time, customers make knowledgeable, informed decisions about their health care treatment and generally choose less aggressive treatments than medical professionals would choose for them.

For the Nuka Model and the programs outlined below, being “patient-centric” isn’t a market platitude — it’s a central design point of their programs and technology. In all of the examples below, the most important enabling software was homegrown or came from a startup. Naturally, the incumbent vendors are profiting and optimizing from the old models. Like any market shift, newer vendors have an advantage as they can nimbly address the nascent market segments that aren’t big enough to get the full focus of the incumbent vendors. Rather than simplistic and silo’ed patient portals that are merely a marketing checkbox, as leading healthIT thinker Shahid Shah has stated, “sophisticated patient relationship management software is the #1 requirement of new accountable models.”

Example # 1: Medicare Advantage Program Wildly Outperforming Its Peers
If you want to get both excited and depressed at the same time, study CareMore. It’s exciting that they have achieved such impressive results within a federally-funded program (Medicare Advantage). On the other hand, it’s somewhat depressing that it hasn’t expanded faster and doesn’t have greater market presence. While it’s a great validation that Wellpoint acquired CareMore for $800 million, it doesn’t appear Wellpoint has done much to embrace and aggressively expand upon this successful model beyond the organic growth CareMore leaders continue to drive.

Oliver Wyman’s head of their Health Innovation Center, Tom Main, co-wrote a piece outlining CareMore’s success entitled The Quiet Health-Care Revolution for The Atlantic. Take a moment to read it. As you’ll see, CareMore is dramatically outperforming their peers with much better health outcomes, lowered costs, and highly satisfied patients. During the site visit, I took notes on what stood out. Here’s a summary:

• Early intervention is central to their model. CareMore has proprietary resources and predictive modeling allowing for early intervention to prevent acute episodes. See The Atlantic article for an example of how they repeatedly save 98% off of what is typically spent for a common scenario. They’ve learned that many patients fare better with less complex healthcare interventions.
• At every turn, CareMore challenges the status quo. In their experience, they believe 50% of healthcare costs for chronically ill can be avoided. Though they were founded by a physician they state “A high percentage of physician services can be delivered by non-physicians.”
• They believe prepayment (capitation) is freedom, not risk.
• In their experience, a patient can go from being in the Easy chair to ICU in 12 hours so they must rapidly intervene. They talk about “Speedy Delivery” — i.e., services and programs that can be delivered within minutes.
• CareMore has a “Longitudinal Patient Record” that collects information from several sources — the EHR is only one of 8-10 sources. See Health Systems Spending Billions to Prepare for the “Last Battle” for a contrast with what typical organizations are doing. CareMore’s Longitudinal Patient Record approach is the future. A silo’ed EHR is the past. While I prefer the term Collaborative Health Record to Longitudinal Patient Record, CareMore’s approach is visionary.
• CareMore states that “Education is a large part of what a patient needs.” See Khan Academy Approach Poised to Solve a “Wicked Problem” in Healthcare for more on one approach to addressing this issue (besides face-to-face encounters).

Example # 2: Direct Primary Care: Secret Weapon Hidden in Obamacare
The simplest way to explain Direct Primary Care (DPC) is “concierge medicine for the masses.” Because it’s a small portion of the Obamacare bill and it has bipartisan support, I’ve called DPC the “David Clause” in Obamacare Ready to Slay the Healthcare Cost Beast. Recognizing its significance, the California Health Care Foundation commissioned a paper to be written about DPC. As they did several years ago when retail clinics emerged, the CHCF analyzes emerging trends on the cusp of high growth.  The release of the paper couldn’t be more timely as the biggest obstacle to DPC exploding more broadly has been the lack of a national insurance player getting behind it — that will change in the next month. On a related note, a regional Blue Shield recently invested in the pioneer of DPC, Qliance. It’s not hard to imagine that they’ll also develop a DPC wraparound policy.

The other obstacle to DPC gaining a big footprint is a national player on the provider side getting behind it. The closest so far is DaVita’s Paladina Health division. With DaVita’s national footprint with their dialysis clinics and their recent $4.4 billion purchase of HealthCare Partners, it’s clear they have their sites set on something larger. It is only a matter of time before a national player that has retail and/or onsite clinics such as Walgreen’s or Walmart will partner with a national insurance carrier. It’s notable that the national insurance carrier isn’t a traditional health insurer. In other words, they have nothing to lose.

Contact me via LinkedIn at http://www.linkedin.com/in/chasedave if you’d like a copy of the seminal study of Direct Primary Care

Perhaps the best demonstration of applying the hot spotting approach in DPC is Iora Health (click link for a previous profile with a slideshow of their outcomes). Dr. Fernandopulle founded Iora Health which just received another round of funding bringing its total to over $20 million raised including funding from Zappos founder, Tony Hsieh. We now have Tony Hsieh, Jeff Bezos, Michael Dell, and Rich Barton (Expedia & Zillow founder) having backed DPC practices.

Two concerns have been raised about DPC. Most recently, I was speaking with Tom Main, the head of Oliver Wyman’s Health Innovation Center who raised these same concerns.

1. The movement towards DPC could exacerbate the shortage of primary care physicians. As I outlined in WSJ Underestimates the Power of the Market and Healthcare Entrepreneurs, our flawed healthcare reimbursement system has done a masterful job of making primary care increasingly a miserable existence. The most unsatisfied physicians I meet are in fee-for-service-based primary care. In contrast, the most satisfied physicians (of any kind) are those in DPC models. The comment of one who had made the shift was striking when I asked him why he opened a DPC practice. He stated that he found that in order to meet his “productivity” requirements, he was only using 40% of his medical training and felt that it was borderline unethical to continue practicing in a fee-for-service model. While it is true DPC practices have smaller patient panels (typically 500-1000 patients), so do the Extensivists (intensive primary care) in models such as CareMore. They typically have 250 patients.
2. DPC isn’t supportive of population health management. As mentioned above, DPC providers such as Iora Health are some of the most effective population health managers around. In contrast to the myth that DPC skims the cream, it’s actually the opposite of that. For example, unions have been among the early adopters of DPC models. They work with organizations such has Iora Health and Qliance to identify their highest cost members and put them into team-based care models strikingly similar to CareMore. I would argue that DPC care teams are more prepared than traditional primary care teams who have been operating in fee-for-service models. In fee-for-service, they do the opposite of what CareMore discussed. That is, fee-for-service primary care providers are referral machines.

Example # 3: Indian Health Service Funded Organization Wins Baldrige Award

Read more about the Nuka Model in DIY Health Reform from Massachusetts to Alaska. Following the link will get you to videos from the leaders of the Nuka model describing their approach. You can also read more about the Nuka Model in Family Practice Management (PDF) and Indian Country. The following are excerpts from those articles.

The system’s results—measured from Nuka’s start to today—speak for its strength: 50 percent decrease in visits to specialists, 40 percent decline in urgent care and emergency visits, 30 percent drop in hospital days and admissions, 20 percent decline in primary care visits, and 92 percent employee and customer satisfaction rates.

“Prior to our redesign, the SCF medical system suffered from one of the key problems in health care today. The system misunderstood the core product as being tests, diagnoses, pills and procedures,” she said. “When individuals sought health care services, providers would take their signs and symptoms, perform a physical examination, and produce a different diagnosis. Then, providers would do what health care does really well: order a bunch of tests,” she said.

How Models Can Scale or be Replicated
The following is a summary of how models referenced above should scale or be replicated by others:

• Nuka Model: The SouthCentral Foundation has regular events in Alaska to teach other organizations how to replicate their model.
• CareMore: Wellpoint can use its massive scale and customer base to expand upon CareMore. In addition, the past president of CareMore (John Kao) has founded Alignment Healthcare which is designed to scale many of the successes CareMore achieved in tandem with other healthcare organizations seeking to replicate the CareMore model. A recurring theme I hear from forward-looking healthcare organizations is they are using the Obamacare funded programs such as the Pioneer ACO or Medicare Shared Savings programs to build their competency on the federal nickel and then are going all-in on full capitation with Medicare Advantage and other similar programs. As Dr. Jim Bonnette (Chief Medical Officer of Oliver Wyman) stated, “the government is going to be surprised by how fast Medicare Advantage programs grow.”
• Direct Primary Care: Both Iora Health and Qliance have gotten large funding rounds to expand their footprint. DaVita’s Paladina Health division is quietly expanding their footprint. In the near future, a national health insurer will team with a national player in primary care such as Walgreen’s to offer DPC at scale to consumers via a gym-like monthly membership fee taking DPC from a niche offering to a new model consumers begin to understand. Increasingly health-literate consumers will recognize the waste associated with doing the equivalent of using one’s auto insurance policy for getting oil changed, new tires and other day-to-day needs. As satisfied DPC customers have learned, their monthly membership fee is lower than the co-pays one pay in insurance-burdened primary care.

In a follow-on piece, The Hot Spotters Sequel: New York Health Home, the New York program referenced above targeting the high cost, complex Medicaid population (1 million citizens) is highlighted. It will go into detail on the challenges they face and how they will overcome them. Already they are applying lessons from Camden, NJ and other areas that have had success. At the same time, given the unique challenges of Brooklyn, they’ll have new challenges to face.