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The September 16, 2007 Issue Provided by System Dynamics Inc.
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Healthcare Unbound: A Progress Report

We have been covering the application of broadband and wireless technologies to healthcare for more than four years. We attended the Fourth Annual Healthcare Unbound Conference in San Francisco this summer to see how much progress has been made in "healthcare unbound" over the last two years.

A study published by Forrester in 2002 defined "healthcare unbound" as "technology in, on, and around the body that frees care from formal institutions". The basic premise is that information technology can improve access to heathcare, and its quality and cost effectiveness, by moving some aspects of healthcare away from institutions and doctor's offices and into wherever people live, work, and play.

Everything related to healthcare changes at a glacial pace, but we did see some signs of progress in addressing the major issues. We also started to see the beginnings of a sorting out of the different market opportunities for healthcare information technology.

Why Health Care Delivery Must Change

The underlying situation remains much as we described it in our article on a symposium at Harvard Medical School two years ago. The population is aging. Growth in chronic diseases will put increased pressure on ALL healthcare systems. Health care delivery must change because patient demand is increasing and resources are shrinking. People would like to take better care of themselves, but the reimbursement systems are designed to reward doctors and medical institutions to treat people when they're sick, not for keeping them well.

Although there have been anecdotal successes and activity over the last two years--especially in personal health records and remote patient monitoring, the picture of progress overall is that we still have a long way to go. Jay Srini, VP Emerging Technologies, University of Pittsburgh Medical Center, in her opening address, pointed to the following facts:

  • The U.S. government spends $1390 per person per year to treat disease and $1.21 to prevent it.
  • Unhealthy lifestyle is the primary contributor to the six leading causes of death in the U.S.
  • Despite spending more on health care per capita, the United States trails other developed countries on access, safety, efficiency, and equity measures.

Rising healthcare costs are not just a US issue. The lifestyle, health and demographic trends that are contributing to skyrocketing health care costs are worldwide. According to the World Health Organization:

  • Over 1 billion people in the world are overweight, and at least 300 million of those are clinically obese.
  • Over 600 million people worldwide have chronic diseases, and the spending on chronic diseases is expected to increase.
  • Globally, the number of persons 60 and older was 600 million in 2000. It is expected to double to 1.2 billion by 2025.

Market Segmentation

While we were at the conference, we started thinking that the "healthcare unbound" market has several segments, including:

  • Wellness care and prevention: helping people stay well
  • Chronic disease management: taking care of people with long-term chronic diseases such as diabetes, congestive heart failure, and high blood pressure
  • Post-acute care: monitoring people who have recently been released from the hospital
  • Aging in place: Helping older people to continue living at home as long as possible

Each of these segments addresses somewhat different customers and willingness to pay, and we found it helpful to think about them when looking at the issues and opportunities discussed at the conference.

These segments are not independent. Older people often suffer from chronic diseases, and they represent a substantial percentage of hospital stays. But many younger people also have--or are at risk for--chronic diseases, and spend time in the hospital. People of all ages would rather be well than sick, and many are willing to pay for help.

Addressing An Aging Population

Liz Boehm, Principal Analyst at Forrester presented a talk amusingly titled "Designing Experiences For An Aging Population: Are Old People Getting Wired, or Are Young People Just Getting Old?" By exploring what drives technology adoption among seniors and what obstacles affect seniors' technology adoption, her work concluded that the key is to design for ability, aptitude, and attitude -– not for age. As with populations of any age, all seniors can't be treated the same.

Majd Alwan, Director, Center for Aging Services Technologies (CAST) reminded us that US seniors are expected to double over the next 25 years and 75% of people over 65 have one or more chronic conditions. At the current rate of growth, health care costs in the US will rise to 20% of GDP or $4 trillion in 8 years. He pointed out that home healthcare costs several orders of magnitude less than hospital care. He said the conclusion is simple: "The way we care for seniors today cannot scale to meet the looming global 'age wave'."

CAST--a coalition of over 400 technology companies, universities, and aging service providers--is "working on a future paradigm for senior care". CAST is taking an active role in launching pilot projects which evaluate the various outcomes of technologies on the stakeholders in different care settings. It is also exploring and evaluating eldercare service delivery models suited for technology-enabled care. The bigger technology challenge is "no ecosystem is yet in place".

Who Pays the Bills?

Dr. Jeremy Nobel, Harvard School of Public Health --> Click for larger pictureThe key issue of reimbursement--who pays for care?--is still the biggest hurdle. Dr. Jeremy Nobel, Harvard School of Public Health, believes that employers, who are a significant portion of healthcare purchasers in the US, are moving healthcare plans toward those that are information technology rich. They will provide real-time information and decision support for providers, payors, patients, and pay for performance.

He said that leading health plans are moving quickly toward "member facing" systems and applications, like benefit accounts and reward programs, which will enable more consumer-directed healthcare. For a reality check, he pointed to the Aetna Website, which already embodies some of these attributes, including a comprehensive online Personal Health Record.

Another Disruption From the Web

Over the past year, the term "healthcare 2.0" has come into use for describing a disruptive movement which brings together Web-based technologies and a personalized approach to health, wellness, and medical care. In his talk, Dr. David Kibbe explained that Health 2.0 "is about reuseable, repurposable, and reconnectable health data, and tools consumers can use to live healthier and longer lives." The end result will be a consumer's ability to access their own health information in electronic format and the disintermediation of some groups in the healthcare industry. Or as Gordon Norman, EVP of Alere, pointed out: "one person’s cost savings is someone else’s revenue reduction."

Ecosystems Need Standards

Standardized heath care records and system interoperability are needed to establish a broad health care ecosystem. Right now, our health records are distributed across doctors, hospitals, healthcare plans, pharmacies and labs. "We have not had an MP3 format for health information" said Dr. Kibbe. What we need is portable and compatible electronic medical health record formats.

However, that is starting to change. The Continuity of Care Record (CCR) was developed jointly by a number of leading medical associations and Dr. Kibbe said "the CCR standard will be the format for personal health information in the future."

Promoting interoperability of personal telehealth systems is central to the mission of the Continua Health Alliance, an open industry group comprised of 125 companies involved with connected personal health and fitness products and services. David Whittlinger of Intel, Continua's President and Board Chairman, talked about Continua's recent progress in establishing a market of personal health and fitness products and services to aid patients, caregivers and healthcare providers more proactively manage ongoing healthcare and wellness needs.

Whittlinger's presentation described Continua's approach to developing standards, starting with formal definition and document ion of use cases and requirements, and then selecting standards to meet these requirements. Continua's planned path from Guidelines to Certification to Logo is based on that used by industry marketing organizations such as the Digital Home Working Group and the Wi-Fi Alliance, and Whittlinger's presentation used the highly-successful Wi-Fi Alliance process as a template.

Continua's Version one standards create a baseline from selected connectivity standards, with gaps identified. They include elements derived from the Bluetooth SIG, the USB Forum, IEEE and the Health Level 7 Electronic Health Records (EHR). The goal, according to Continua's press release of September 12, 2007, is for consumer devices to be able to "share information through common communications channels such as telephones, cell phones, PCs, TV set top boxes and dedicated health devices".

The Version One guidelines are scheduled for completion by the end of 2007 and a test, certification, and logo program is under way. Continua plans a pavilion at CES in January to showcase the logoed products, and we look forward to seeing them there.

The Role of Information in Compliance

Many programs for healthcare unbound depend upon individual compliance with the prescribed regimen. The World Health Organization promotes the idea that information is necessary to build motivation and guide behavior, leading to compliance. But sometimes people don't want to know the information.

Michael Barrett of Critical Mass Consulting --> Click for larger pictureMichael Barrett of Critical Mass Consulting--who co-authored the 2002 Forrester report that coined the phrase "Healthcare Unbound"--gave an amusing and thought-provoking presentation on why individuals are likely to sabotage their own compliance. Barrett bases his view on a concept from economics called "loss aversion": as individuals evaluate the uncertain prospects of potential losses and gains, they dislike losses much more than they like gains. His thesis is that "information aversion"--a form of loss aversion--undermines self-management of chronic disease.

Barrett explained that asking a person to self-manage their health--for example, by going on a diet and weighing themselves daily--asks them to give up ignorance ("I eat too much and gain weight") and gratification (the joy of that wonderful cake and ice cream). If you dislike bad news more than you like good news, you will avoid stepping on the scale. Loss aversion leads to patient self-mismanagement.

Barrett said that behavioral economics suggests some effective responses once we are aware of people's predictable information aversion. Pointing to the effectiveness of alarm clocks, we said automation and shifting from self-management to device management are two of the keys here. Successful solutions will use technology and social forces to encourage "the right behavior."

Wireless Is Critical

Since people are by nature mobile, rather than tethered to any particular place, the role of wireless in health care is a given. With its huge interest in the wireless world, Qualcomm, represented by Don Jones, Vice President Health & Life Sciences, has been a continuing presence at each Healthcare Unbound conference.

Jones sees wireless devices acting as "dashboards, controllers and communication gateways for health." One example is LG's cell phone with a blood glucose monitor, which acts as a blood test for diabetics in Korea. A wireless device helps individuals with their health by providing access to the right information to know what to do next--especially in addressing the biggest question people have in any health-related situation: "Do I need to see a health care professional?"

We have long thought that broadband connectivity and home networking would play a major role in personal healthcare, and have increasingly come around to the view that wireless broadband and personal area networking will play a critical role. Cellphones are not only for making phone calls, but for providing local connectivity to monitoring devices, local processing, and remote connectivity to systems and people. Bluetooth and its successors provide standardized local connections, and cellular wireless permits connectivity virtually anywhere.

Wireless devices are especially suited to encouraging compliance. Behavior change (like monitoring our glucose level, or remembering to take the right medication at the right time) requires that we always have something at hand that keeps us on track.

Foodphone and Babyphone

The products shown in the exhibit area by Myca, based in Quebec City, Canada, provide concrete examples of these concepts. Myca provides "mobile health applications" to consumers using standard smart phones with cameras and video screens. Unlike most other applications at Healthcare Unbound, Myca's products and services are not targeted to health care providers, but rather to consumers interested in their own health and wellness.

Myca's mobile health applications --> Click for larger picture

Foodphone, Myca's first product, helps people who are on a diet. Unlike conventional approaches, which require dieters to keep a written journal of what they eat, FoodPhone uses the camera on the smart phone to create "a visual 'photo album' of every one of your meals". It captures biometric data such as weight, blood pressure and exercise level into an electronic health profile, and provides video feedback from a nutritionist acting as "personal nutrition coach." Launched in 2006, Foodphone was recently reported to have 5,000 customers each paying $10 a month.

Babyphone will provide support for "expecting and new moms and their children." It captures and saves relevant biometric data, and provides consultation with medical professionals. Doctorphone will provide similar support for adults. Myca says it will handle reimbursement for those few health plans that reimburse for video visits.

Myca's concept--"bringing healthcare consumers face-to-face with experts - anywhere"--seems very appealing. We'll watch to see if they can turn this into a successful business.

The Bottom Line

In the four years we have been covering healthcare, technology has become more capable and less expensive. Companies like Myca can go directly to the consumer market, and other companies are developing products whose lower cost promises a much larger market. Good progress is being made in defining standards for health care records, system interoperability, and device connectivity. But technology is no longer the limiting factor in Healthcare Unbound -- business models and reimbursement are.

Continua is likely to play a key role in accelerating the pace. Its 125 members include leading technology organizations such as Cisco, Dell, IBM, Intel, Nokia, Oracle, Panasonic, Philips, Samsung and Siemens. In addition to working together on standardization, Continua is now working on reimbursements. A working group is developing reimbursement mechanisms, including plans to "eat our own dog food" by deploying personal telehealth systems to their own employees.

Early successes from individual organizations are encouraging, but we have to agree with the opening remarks by Vince Kuraitis of Better Health Technologies; we are still some way from sighting the tipping point for Healthcare Unbound.

A Personal Postscript

[Sandy]Healthcare is personal. We all have stories about our dealings with the medical system and its shortcomings. Here's one of ours.

In March, our adult daughter Allison had open-heart surgery to correct a congenital heart condition at Mayo Clinic in Rochester, Minnesota. We can't say enough good things about the hospital, the staff, and the quality of care and attention she received there.

"Healthcare unbound" technologies could have aided in Allison's recovery process, reduced the anxiety for both Allison and her family, and reduced the number of trips to the doctors and the emergency room. But during the months of recovery after Allison's return home, we did not encounter a single example of any of this technology being used to provide remote care.

Allison (left) with her physical therapist --> Click for larger picturePerhaps if we hadn't been attending conferences on health care technologies and been aware of the kinds of things that are becoming feasible, we wouldn't have identified the interventions that could have greatly reduced Allison's stress during the early stages of recuperation. They could include some of the following, all using Allison's webcam and broadband connection:

  • periodic measurement of blood pressure and pulse rates, and a video link with a remote specialist to provide reassurance that elevated levels are typical and should start coming down over time;
  • a video hot line answered by a cardiac nursing specialist to discuss whether certain new symptoms were normal or a source of sufficient concern to necessitate a fast trip for emergency care;
  • a video link with a physical therapist to save some of the home visits;
  • video coaching to help speed the recovery process.

We would gladly have paid for some of these touchpoints out of our own pockets in return for the peace of mind they could have delivered.

The bottom line: lots of possibility but still no reality.

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