We're very glad we got to the Partners' Connected Health Symposium in late October. Although we've covered connected health since 2003, the last conference we attended was Healthcare Unbound in July 2007. At that time, we were disappointed in the lack of progress on significant implementations. In the two and a half years since, there has been noticeable progress, including within the U.S. healthcare reform agenda.
Past conferences have focused more heavily on some of the changes that must happen to the system in order to improve quality while controlling costs. One example is the need to change the traditional "fee for service" model into value-based payments. Although suppositions about necessary changes were part of this year's agenda, we came away feeling that we are closer to reaching the tipping point in which people will come to take connected health for granted in the same way that email and blogs have become part of our social fabric.
Broadband connectivity is pervasive. Most consumers own mobile devices. Connected health device standards are being set. Certified devices and services are starting to reach the market, with many more coming. Many types of health data platforms are available to healthcare practitioners and consumers.
With the national focus on improving the cost-effectiveness of healthcare, it's clear that connected health will play a major role.
Some Take-Away "Nuggets"
At any conference, there are some quotes that you take away with you. Before we delve into some areas that deserve more focus, here is a brief summary of some of these nuggets.
Enabling Everyone to Participate
Connected Health enables people to become active participants in their health care. It's important for people recovering from a serious illness, suffering from a chronic disease, or just interested in improving wellness. Connected health provides the key tools for both the patient and healthcare practitioners.
These tools start with simple mechanisms such as email exchanges between patients and their doctors, and online access to health records and test results. They progress through home monitoring systems which measure blood pressure, pulse rate, weight and other vital signs, and upload them to a system where health professionals can view them. Ultimately the patient and the professionals become collaborators.
Dr. Joseph Kvedar, Director of the Center for Connected Health at Partners Healthcare, expressed this progression in his keynote presentation at the conference. His opening slide titled "Where We’ve Been And Where We’re Going…" shows four stages. We're currently at "Clinician and Patient Collaborate and Share Info" and heading towards "Patient Self-Mgmt...Clinician as Coach...Employer as Enabler".
Tools exist today to enable clinician/patient collaboration. Several companies offer email systems specifically for doctors, and medical practices are signing up for these services. As an example, RelayHealth provides a comprehensive system for medical practices, including email communications and email-based "Web visits", prescription renewal, lab results, online personal health records, and more. (Our primary care physician recently signed up with RelayHealth, and we're now using it ourselves.) Other companies offer similar systems for group practices and hospitals.
Standards and Devices
The most important change in the past three years has been in establishing standards for connected medical devices intended for personal use in the home. When we first started attending these conferences, every device had a proprietary interface, with the entire end-to-end system provided by a single company. Many of these products had price tags of $1000 or more.
Today there are IEEE standards for device communications. Many companies are developing products to meet the standards. Certification mechanisms are in place, and the first certified devices are now on the market. Prices are falling.
Continua Health Alliance and IEEE 11073
The Continua Health Alliance is playing a leading role in driving the standards. Formed in mid-2006, Continua is an open industry group comprised of more than 200 companies involved with connected personal health and fitness products and services. In addition to providing products and services to healthcare providers and consumers, some Continua member companies are actively using them with their own employees.
Continua efforts are focused on three "use cases": Disease Management, Aging Independently, and Health & Wellness. For each, it envisions devices in the home communicating with an "Application Hosting Device" such as a mobile phone or a PC, which can in turn communicate over the Internet to care givers, healthcare professionals, and services.
Communication standards are required for all these use cases. An IEEE group P1073 has been working on protocols for interoperable medical devices for more than 20 years. Its efforts moved into high gear with the formation of the ISO/IEEE 11073 Personal Health Devices Work Group in July of 2006 with active participation from Continua members. The first set of new 11073 standards was published in October 2008, with 24 more under way. These cover many kinds of devices, including thermometers, scales, pulse oximeters, cardiovascular fitness and activity monitors, and an "Independent Living Activity Hub."
The 11073 standards form the core of Continua's "Version One Device Connectivity Standards". The device standards are transport independent; in Version One, they can communicate with the "Application Hosting Device" over USB or Bluetooth.
Continua has established a formal certification process. The first certified device was a Nonin pulse oximeter. Continua has announced five more certified devices, including a blood pressure monitor, scale, and blood glucose meter.
Every major medical device maker is a Promoter Member of Continua. All of these companies prominently displayed the Continua logo in their booths at the Partners conference. Although few of their devices have been certified, it's reasonable to expect many more now that certification is under way.
Connected Health Services
Several companies provide services which accept and store clinical data from medical devices, and provide analysis and information for patients and clinicians. The simplest services run on a PC in the home, with data uploaded from the devices by USB or Bluetooth. An example of these is the Omron Health Management Software which works with Omron's USB-enabled HEM-790IT blood pressure monitor and HJ-720ITC pedometer.
Partners' Center for Connected Health takes this a step further with its SmartBeat program. SmartBeat couples remote blood pressure monitoring, Internet-based feedback, and personalized coaching for hypertension self-management. After trialing SmartBeat for six months with EMC Corporation between 2007-2008, Partners launched SmartBeat for its own employees in Spring 2009. It is now offering it to large employers in New England.
Personal Health Data Platforms
In addition to platforms like RelayHealth for healthcare providers, and those such as SmartBeat for employers, several personal health data platforms are offered directly to consumers. The leaders of three of these platforms -- WebMD, Microsoft's HealthVault and Google Health -- participated in a panel at the Partners conference. While WebMD is primarily focused on providing health-related information to patients, HealthVault and Google Health are focused on collecting and storing patient data, making it available--with the patient's permission--to caregivers and healthcare professionals.
HealthVault and Google Health both include tools to maintain an online personal health record showing conditions, family history, prescriptions, and the ability to share those with providers. HealthVault includes logging measurements of blood pressure, weight, etc. The measurements can be entered manually through a Web interface.
Even better, HealthVault includes the capability to upload measurements directly from a connected device by installing a PC program called HealthVault Connection Center. Many connected medical devices are already supported by HealthVault; some are also Continua certified.
A session on behavioral health provided the opportunity to hear about a success story in using telehealth for mental health in areas such as post traumatic stress and depression treatment. Dr. Linda Godleski who is the lead for Telemental Health at the Veteran's Administration spoke about how they have an extensive program in place for mental health issues of veterans. Their focus is remote access into the clients' residence.
One of the key values of the program is privacy--no one except the client needs to be aware of their use of mental health support. Patients with certain diagnoses such as schizophrenia seem to prefer to be remote from the therapist.
The VA has studies that document that this program really works. The same quality measures are used for teletherapy as for face-to-face. The VA is now looking at effectiveness measures compared with more traditional modes of therapy.
Is Disruption Necessary?
In a keynote speech, Dr. Jason Hwang of Innosight Institute summarized his recent book, The Innovator’s Prescription: A Disruptive Solution for Health Care, co-authored with Clayton Christensen of Harvard Business School. The book applies Christensen's well-known "disruptive technology" model to the healthcare system.
"Disruption is facilitated when historically valuable and expensive expertise becomes commoditized." In the move to "connected health" new technologies like expert databases and videoconferencing are a lever toward that commoditization. The problem is that cramming new technologies into an old business model is futile.
Huang observed that although most service businesses are decentralized, the healthcare delivery system is highly centralized around large general hospitals. He said that the traditional general hospital is not a viable business model and that decentralizing the system would open the way for investment in new business propositions.
We saw some signs of this disruption at the conference. Although Partners Healthcare is the parent of Massachusetts General Hospital and Brigham and Women's Hospital in Boston, its "connected health" initiative is encouraging a movement toward a more decentralized approach, with patients, employees and data platforms all playing a role.
Another sign of disruption was the introduction of a new medical publication, the Journal of Participatory Medicine (JoPM). A free online journal, JoPM says its mission "is to transform the culture of medicine to be more participatory". Its advisory board includes IT visionaries such as Esther Dyson, Kevin Kelly of Wired Magazine, and Howard Rheingold, and its editorial board includes many doctors and healthcare administrators.
The founders or JoPM believe passionately in patient participation, and aim to provide the evidence to demonstrate its value to all parties. They view themselves as disruptors of the traditional "doctor knows best" approach to medicine.
What About Broadband?
What role does residential broadband play in connected health? In principle, data can be moved between the home and healthcare platforms over any type of transport. When we first started attending these conferences, most medical devices communicated over dial-up modems. Now high-speed connectivity is taken for granted as one of the key enabling technologies.
As healthcare delivery systems embrace connected health as a key element in improving healthcare while managing costs, it will be a major opportunity for wireless and wireline service providers.
Led by Qualcomm, the wireless industry has long promoted the use of the cellphone as the primary tool for connecting medical devices to healthcare platforms. Since many medical devices connect with Bluetooth, and most patients have cellphones, wireless carriers and their vendors view it as natural to carry data through the cellphone to the healthcare platform -- without using PCs and fixed-line broadband links. Wireless carriers and vendors were very visible at the conference, promoting their views.
Wireline carriers have started to see the opportunity. Cox Communications -- the third-largest cable television company in the US -- recently said that it would be focusing on healthcare opportunities. Speaking at a recent conference in New York City, Cox Business vice president Phil Meeks said that Cox already generates nearly $1 billion selling its services to commercial customers, and expects that to double within six years. Meeks said Cox sees the healthcare vertical as the largest component of its future commercial services revenue. He said Cox would provide services to hospitals, doctor's offices and consumer homes: “We're creating this ecosystem where we're tying together the hospital, tying it to the doctor’s office, and tying it to the home."
Influencing Consumer Behavior
One of the most fascinating elements of the Connected Health Conference was influences on consumer behavior and its relationship to health. Nicholas Christakis, Professor of Medical Sociology at Harvard Medical School, gave a talk on "The Spread of Health Phenomena in Social Networks". Christakis is the co-author (along with James Fowler) of "Connected: The Surprising Power of our Social Networks and How They Shape Our Lives."
Based on a variety of scientifically conducted tests and mathematical analyses of data regarding social connections and other characteristics, the authors concluded that a key factor in determining our health is the health and behaviors of not only our partners and friends but also the health and behavior of people in our extended social network. This theme was echoed by Dr. Mark Carroll, Director Telehealth Program U.S. Indian Health Service. He said "The social determinants of health are more important than your cholesterol level." If you don't believe this, we suggest you read "Connected".
Two other books that were discussed at the conference bear mentioning here. The first is "Nudge: Improving Decisions About Health, Wealth, and Happiness" by Thaler and Sunstein and "Free Market Madness: Why Human Nature is at Odds with Economics--and Why it Matters" by Peter Ubel. Although these books are not directly about health care, both bear on how personal decisions about health care can be influenced toward harmful or beneficial outcomes. The ideas in "Nudge" are particularly useful for corporations which are trying to reduce their healthcare costs by improving the health of their employees.
We give the sponsors and speakers in this symposium an "A" for depth of content and intellectual stimulation!
For More Information
We have been covering connected health for more than six years. We have visited with companies and attended many conferences (and spoken at a few). Our Topical Index: Connected Health provides access to our articles on connected health standards, devices and platforms.
( www.connected-health.org ) ( www.partners.org ) ( www.relayhealth.com ) ( www.continuaalliance.org ) ( www.nonin.com ) ( omronhealthcare.com ) ( www.va.gov ) ( www.innosightinstitute.org ) ( www.hbs.edu ) ( www.jopm.org ) ( www.coxbusiness.com ) ( hms.harvard.edu ) ( www.intel.com )