Monday, March 31, 2014

Follow Your Heart on a Smartphone

Yes, it is possible for you to follow your heart on a smartphone.  And we are not talking about the heart of metaphors and symbolism.  We are talking about the real deal, that vital human organ whose maladies require treatment in the U.S. that runs in excess of $440 billion per year (CDC Heart Disease and Stroke Prevention at a Glance). Monitoring your heart, or at least its electrical activity, is now possible with over-the-counter, FDA approved, EKG devices that work in conjunction with a smartphone.

The humble electrocardiogram (EKG or ECG for short) has long been valued for its ability to measure the electrical activity in the human heart.  From EKG readings a physician can learn a lot about the health of your heart and detect a broad range of coronary health problems.  While best known as a test administered at a medical office or facility by a healthcare professional, portable and hand-held EKG testing devices for at-home use have actually been around a long time.  Some of these at-home devices even provide internet and smartphone connectivity that allow recorded EKG results to be stored electronically and transmitted to a user's physician. 

While EKG devices with internet and smartphone connectivity have actually been available for some time, up until recently consumers could not access these devices without a doctor's prescription.  That barrier has come down.  In recent years two innovative, smartphone compatible EKG products have earned FDA approval for over-the-counter distribution.  One is made by San Francisco based AliveCor.  The AliveCor Health Monitor fits like a phone case and works in conjunction with a mobile app for select iOS and Android smarthphones.  Holding your enabled phone as instructed will yield EKG results that are stored for the user for future reference or can be accessed by a user's physician through the user's AliveCor account dashboard.  The AliveCor Heart Monitor currently costs $199 and the mobile apps are free.  For an additional charge, a user can have his or her EKG results analyzed by experts who are U.S. board certified cardiologists or U.S. based cardiac technicians.

Another FDA approved, mobile-enabled EKG device is ECG Check, a product manufactured by Utah-based Cardiac Designs.   ECG Check works in conjunction with a mobile app on select iPhones.  It too fits like a case on an iPhone and, when held as instructed, will yield EKG results that can be stored and, if desired, shared with your physician.  Currently priced at $99, for an additional charge your EKG results can be submitted for independent review by qualified technicians.  The OTC version of ECG Check takes a full EKG reading, but only displays select parts of it to the user.  It will, however, tell you if you're readings are normal or abnormal.  To have full EKG readings displayed and additional reporting made available, a doctor's prescription is required.  The OTC version of ECG Check can be readily upgraded to a prescription version.  In either OTC or prescription mode, ECG Check stores the results and supports distribution of those results to your physician or submission of EKG results for independent review.

Although available over-the-counter, consumers should understand that these particular products, while clinically accurate at what they do, are not replacements for the EKG one gets at a physicians office or in a hospital.  Some physicians have embraced these over-the-counter EKG devices that integrate with smartphones as they facilitate more efficient monitoring and managing of their patients, even if these devices are not quite on par with conventional EKG equipment.  Many physicians are taking a "wait and see" approach toward these devices.  Over-the-counter, smartphone enabled, EKG devices are a fairly new entrant in the remote heart monitoring arena.  As innovative telemedicine companies continue to refine and enhance the capabilities of these products, patient-administered EKG tests via a smartphone device will likely become an increasingly valuable tool in cardiac care.

Monday, March 24, 2014

Say Wello to My Little Friend

Say Wello to My Little Friend.  Forgive me for the lame title.  I could not resist spinning Tony Montana's famous line as I drafted this commentary about Wello, another new product that aims to be a little friend to American healthcare consumers by melding medical diagnostic and smartphone technologies.

Developed by Azoi, Inc,. Wello is conceptually very similar to the Scanadu Scout in that it is designed to measure and track your key vital signs - temperature, blood pressure, heart rate, blood oxygen levels, heart rate variability and an electrocardiogram reading - in conjunction with a smartphone platform.  Whereas the Scout's sensors are incorporated into a stand-alone, pocket-sized device, Wello's sensors come in a phone case for your iPhone.  By holding your Wello enabled iPhone for a few seconds as instructed, Wello will capture your vital sign data and then record, display and store the data through a mobile app. Wello is compatible with Anroid smartphones, but initially only as a stand-alone unit and not as a phone case. 

Like the Scandu Scout, Wello is seeking Federal Drug Administration (FDA) approval and cannot be shipped in the U.S. until such approval is granted.  It can, however, be pre-ordered, then shipped once FDA approval is received.  Getting FDA approval will be an important step in affirming the quality of Wello's vital sign measurement accuracy and its potential usefulness as a source of clinically reliable information.  From what we can tell, assuming no bumps for Wello in the FDA approval process, it will probably be sometime next year before the product is ready for use by the general U.S. healthcare consumer. 

While there can be no assurances about Wello's specific impact on healthcare delivery, much less its success at getting FDA approval, Wello nevertheless is another example of an innovative health delivery solution from companies that are integrating diagnostic and increasingly powerful smartphone technologies.  These innovative companies, some of whom are also integrating web technologies into their solutions, have been and will continue to bring forth products and services that are changing healthcare delivery. It is a fact that for many years now we have already seen significant advances in telemedicine, where the successful integration of testing and monitoring technologies with telecommunication platforms have made possible remote healthcare delivery that was difficult to imagine just twenty years ago.  While "traditional" telemedicine platforms have been provider oriented, some of today's telemedicine innovators are looking to expand the scope of remote healthcare delivery.  These new breed innovators, like those behind Scout and Wello, want to provide solutions that empower consumers more in the remote healthcare delivery process.

The internet and mobile technologies have significantly advanced the ability of consumers to access information about almost every kind of medical condition or treatment over the past fifteen years.  More recently, these same technologies have made it possible for consumers to seek out and receive treatment, even prescriptions, for minor health conditions from board certified Online Doctors.  And sooner than some might imagine, we expect consumers to have access to a wide range of mobile and web enabled solutions that will provide clinically relevant data to physicians and other members of the consumer's healthcare delivery team.

Tuesday, March 18, 2014

Is Scanadu the Future of Consumer Driven Healthcare?

Is Scanadu the Future of Consumer Driven Healthcare?  Unless you are a healthcare techie who stays on top of such things, we imagine your most likely response to this question is: Who or what is a Scanadu?  Let's start with some basics. Scanadu is a young technology company, based in Silicon Valley, with a vision for consumer driven healthcare that integrates medical diagnostic and smartphone technologies.  It is developing a suite of medical devices based on this vision that could profoundly alter the consumer healthcare landscape in the not too distant future.  We say "could" because the company technically does not have a product on the market just yet.  It's initial product, called the Scanadu Scout, is about to roll out on a clinical trial basis as the company seeks Federal Drug Administration (FDA) approval before making the Scout available to the general public.  If all goes well, Scout could be on the market next year

The Scanadu Scout is a pocket-sized device that, by just holding it against your forehead for a few seconds, facilitates measuring, tracking and analyzing your key vital signs - temperature, blood pressure, heart rate, blood oxygen levels, heart rate variability and an electrocardiogram reading.  The device can then transmit your vital sign information via Bluetooth to your smartphone for tracking over time and, if some vital sign readings are out of the ordinary, Scout will let you know about it.  Moreover, the vital sign history you compile via Scout can be readily shared with your doctor, making those office visits more productive.

What is noteworthy about the company's approach is that it is investing extra time and money to subject the Scout to clinical trials required by the FDA approval process.  Getting FDA approval would attest to the Scout's clinical-grade accuracy and position it with the physician community as a viable source of clinically reliable information. 

Scanadu's vision goes beyond the Scout.  Also in development is a disposable urine testing kit that will link to a smartphone app that will walk the user through the testing procedure, then process, store and explain the test results. And as with Scout, a user will be able to electronically transmit their test information to their doctor. In addition, the company is purportedly working on a flu test that presumably will integrate with a user's smartphone.

So is Scanadu the future of consumer driven healthcare?  The company has an impressive vision for consumer driven healthcare, some strong financial backers and a stellar group of medical advisors, so they have the potential to be a profound force one day.  Yet getting from development stage company to a major player in the healthcare market is a herculean task and there is no telling if Scanadu, the company, can travel that path.  That said, Scandu's vision of enabling consumers to measure and monitor their own health through the integration of medical diagnostic and smartphone technologies, and then to electronically share that information with healthcare providers, is a powerful one that is shared by other healthcare innovators.  It is just a matter of time, and we think that time will be sooner than one might think, before innovative healthcare companies like Scanadu will be empowering consumers in ways that would have been hard to imagine just a few years ago. 

Wednesday, March 12, 2014

Online Doctor Visits for the Webcam Challenged

As discussed in our last post, someone with a minor health condition can now arrange, at their own volition, webcam consultations with licensed medical practitioners.  More importantly, that online doctor visit will typically yield a personalized treatment plan and, if medically necessary, e-prescriptions to be fulfilled at a local pharmacy.  So what if you could benefit from an online doctor visit but don't have a webcam or you are otherwise webcam challenged?  Fear not, because at least one innovative healthcare company lets you arrange an online doctor visit without a webcam.  

Zipnosis, a healthcare start-up that was recently named an innovation award winner by The Minnesota Heath Action Group, a healthcare purchasers association, can fill the void for you webcam challenged types in need of online doctoring.  Like other online doctor services, Zipnosis hones in on about about two dozen minor health conditions that can be safely diagnosed and treated online.  Among these conditions are colds, influenza, sinusitis, strep throat, allergies, urinary tract infections, yeast infections, cold sores and mild acne.  And as you would expect, the diagnostic question and answer session is at the heart of the process.  While other online doctor service providers push the patient into a webcam consultation for the diagnostic Q&A, Zipnosis handles it through an interactive, online questionnaire using its adaptive software technology.

The diagnostic Q&A is naturally an adaptive data gathering exercise.  You tell your doctor what hurts, she asks a few questions about your ailment, you give some answers, depending on the answers you give she asks more questions.  And so it goes until your doctor has enough information to diagnose your condition and recommend a treatment plan.  The Zipnosis technology semi-automates this diagnostic Q&A data collection process.  

Using an adaptive approach, the Zipnosis software leads the user through a series of diagnostic questions to capture the patient's medical history and pertinent symptom information, just as a clinician would do. According to the company, their typical diagnostic interview lasts less than 5 minutes.

Once the Q&A process is complete, the user ends the interview session and awaits a response.  Behind the scenes the user's diagnostic Q&A results are  reviewed by a board-certified clinician who sets a treatment plan for the user, then submits it to the user's account .  During business hours, a clinician will respond back to a user within an hour according to Zipnosis literature.  When medically necessary, a clinician will include in the treatment plan prescription drugs (excluding pain medications and narcotics).  When prescriptions are part of the treatment plan, users can have their prescriptions sent electronically to one of 80,000 pharmacies nationwide for fulfillment.   

If a user has a condition that cannot be treated virtually, Zipnosis will direct the user to an appropriate healthcare provider.  The Zipnosis service is available 24/7 and can be accessed through any device with an internet connection, including mobile phones and tablets.

Zipnosis does not provide pharmacy services, so any prescription costs are the user's responsibility.  However, at its current cost of just $25 per diagnostic session it is even less expensive than other  online doctor services we have found.  Faster, less expensive and more convenient than an office visit sounds like a potential winning recipe to us.

Zipnosis is still in its early stages and is not yet available in all States.  However, this innovative, cost-effective online platform has drawn interest from the broader healthcare community.  Most notably, Fairview Health Services, a major Minneapolis based health system and one of just 32 Pioneer Accountable Care Organizations nationwide, has incorporated the Zipnosis platform into their web presence.  In addition, reports indicate that the company is working with the University of Alabama and UCLA Medical Center on initiatives set to be rolled out later in 2014.

While it is still too early to predict the future of the Zipnosis service itself, you can rest assured that there other many other companies working on innovative ways to use the internet to deliver healthcare more efficiently and cost effectively. 

Monday, March 10, 2014

Your Online Doctor Will See You Now

Various healthcare entrepreneurs hope to make the online doctor visit an integral part of the healthcare delivery system, particularly when it comes to treating common, minor health conditions.

The basis for online doctoring comes from telemedicine, which has been practiced for over 20 years.  According to the American Telemedicine Association, over 50% of U.S. hospitals use some form of telemedicine and that within the U.S. one can find about 3,500 telemedicine service sites and close to 200 telemedicine networks.  Through these telemedicine networks, physicians and other healthcare providers have been providing medical consultations and remote monitoring services for many years now.

While virtual doctoring has actually been around for more than a decade, patient access to any such service was basically dependent on (a) the patient's doctor or healthcare provider participating in a telemedicine service and (b) that provider agreeing to work with the patient on a telemedicine basis.  A consumer driven process, where a patient can get a medical consultation and a real treatment plan over the internet, rather than a private network, is a more recent development.   Today one can find a number of entrepreneurial companies pushing the envelope on the online doctoring front.  MeMD and American Well, for example, are among a number of young companies offering medical consultations and treatment plans through the internet.

The basic model for these companies is to facilitate an online webcam consultation between a user and a licensed, certified healthcare practitioner in the user's state of residence.  Practitioners are typically a physician, but some companies may also use physician assistants or nurse practitioners who are licensed in the user's state of residence to provide primary care medical services.

By design, these online doctor models restrict their service to common, minor health conditions that can be safely diagnosed and treated in a virtual environment.  The common cold, the flu, allergies, bronchitis, earaches, sinus infections, urinary tract infections, pink eye, and sore throats are among the many minor health conditions treated by these online doctor organizations.  These online doctor visits normally run 5 to 15 minutes, after which the patient is issued a treatment plan.  If the treatment plan requires prescription medications, e-prescriptions are transmitted to the user's local pharmacy where they can be picked up and paid for by the user.  While prescriptions are issued when needed, most online doctor services typically will not issue a prescription for any drug on the DEA Controlled Substances list and may not issue scripts for certain elective medications, like those used to treat erectile dysfunction, hair loss and obesity.

These new online doctor services are usually available on a 24/7 basis.  And the cost for an online doctor visit and a personalized treatment plan?  In the case of both MeMD and American Well, less than $50 per consultation, excluding prescription costs billed by that users local pharmacy .  No taking time off from work to have your minor health condition treated.  No insufferable waits at a doctor's office.  Prescriptions, if needed, are sent electronically to your local pharmacy for fulfillment.  Compared to a regular office visit, an online doctor visit is way faster, way more convenient and, in many cases, less expensive too.

Right now we are in the early stages of the online doctor visit.  From experience with telemedicine, it is known that many minor health conditions can be effectively treated in a virtual environment.  Considering ongoing advances in internet, mobile and diagnostic technologies, the types of conditions that can be effectively treated in a virtual environment will undoubtedly grow in the future.

In our next post we will take a look at another company that is pushing the online doctor visit envelope a bit further.

Thursday, March 6, 2014

Are Accountable Care Organizations a Silver Lining to Obamacare?

For critics, Obamacare has no silver linings. Yet silver linings may indeed exist with the Affordable Care Act (aka Obamacare) and one development that merits watching is the Accountable Care Organization. Within the context of Obamacare, ACO’s are collaborations of healthcare providers who provide high quality care to Medicare populations. The goal of the ACO is ensuring that patients, especially the chronically ill, get the right care at the right time, while preventing medical errors and avoiding unnecessary duplication of service. For decades now, health experts have recognized that the traditional healthcare system can foster uncoordinated care that, at a minimum, leads to costly unnecessary medical care and, at its worst, can lead to medical errors that adversely affect outcomes for patients.

The idea of coordinating care that underlies ACO’s is hardly new. Kaiser Permanente, Group Health Cooperative (Seattle), and Kelsey-Seybold Clinic (Houston) and dozens of other organizations around the country have been successfully operating coordinated health delivery models for decades, some as far back as the 1940s. By design, Obamacare is attempting to expand the presence of coordinated delivery care models in the marketplace through financial incentives. For ACOs who succeed in both delivering high-quality care and spending health care dollars more wisely, the Federal government will allow them to share in the savings they achieve for the Medicare program. There are 3 incentive programs available to interested ACO’s: (1) the Medicare Shared Savings Program - a program that helps a Medicare fee-for-service program providers become an ACO; (2) the Advance Payment ACO Model - a supplementary incentive program for selected participants in the Shared Savings Program; and (3) the Pioneer ACO Model - a program (which is no longer accepting applications) designed for early adopters of coordinated care.

Provider interest in these incentive programs is self-evident. Since becoming operational in 2012, enrollment in these programs has grown to more than 360 Accountable Care Organizations serving almost 5.3 million Medicare beneficiaries. Moreover, in January the Centers for Medicare & Medicaid Services (CMS) released findings on a number of its initiatives and the interim results for its ACO initiatives were encouraging. Savings from both the Medicare ACOs and Pioneer ACOs topped $380 million. To be sure, it is still too early to judge if these programs will continue to yield positive results much less improve upon them. Savings of $380 million is better than nothing, but it amounts to a tiny drop in the $600 billion per year spending bucket that is Medicare. And that spending bucket is on a trajectory to grow to $1.1 trillion in 2023 with continued growth in the Medicare population and sustained health cost inflation.

The advancement of ACO’s is a good thing for patients in our estimation. Research on integrated healthcare delivery systems does indicate that coordinating care has a positive effect on the quality of care provided to patients. That same research does not, however, show solid evidence that costs are materially reduced through better coordination of care. Nevertheless, we expect that as time goes by cost advantages from coordinating care will become more apparent and broader trends in the healthcare marketplace will increasingly benefit the coordinated care principles of ACO’s. Even before the passage of Obamacare, there has been a discernible trend toward shifting more of the healthcare cost burden to individuals. Obamacare has only accelerated this trend. As this cost shifting trend continues to evolve, we expect healthcare consumers to become increasingly price sensitive. In this very possible future healthcare marketplace, market forces will likely favor more efficient providers who are better positioned for price competition. Accountable Care Organizations, most of whom are investing heavily in the information systems infrastructure needed to support coordinating care, could win big in the future healthcare marketplace. That same information systems infrastructure will give ACOs a leg up on the efficiency front and put them in a strong position from which to compete on price in the future healthcare marketplace.

So are ACO’s a silver lining to Obamacare? We are not inclined to jump to that conclusion just yet. However, we do think that certain market trends being accelerated by Obamacare could mean that Obamacare has a silver lining in it for ACO’s.