2019 Predictions: M&A, Big Tech, and the Fate of ACOs

The Meaningful Use gravy train finally came to an end in 2018. As the strongest EHR vendors struggle to define new revenue streams, weaker ones faded from view through acquisitions or leveraged buy-out. Meanwhile, funding for ‘digital health’ start-ups continued to increase, though it likely hit the high water mark in 2018. And lest we forget, Amazon, Apple and Google continue their forays into the healthcare sector as the market is simply too big to ignore.

So what’s in store for 2019?

We brought together our analysts’ brain trust and came up with the following baker’s dozen of 2019 predictions. Over the near decade of making these annual predictions, our batting average has consistently been well above .500, so don’t ever say we didn’t give you an advanced warning on the following:  

 

Revenue cycle management M&A picks up; Optum acquires Conifer

Revenue cycle management M&A activity will continue to pick up with the most notable acquisition by Optum as it doubles down on its Optum 360 managed revenue cycle business and acquires Conifer Health Solutions from Tenet.

Alternative primary care clinics remain a side-show

Despite the hype and media attention around alternative primary care clinics (e.g. Oak Street Health, Chen Med, One Medical), the actual number of physical locations serving patients will remain paltry at less than ten percent of the number of retail health clinic locations. 

Humana finds a life partner with Walmart 

Walgreens will likely make the first move to acquire Humana in 2019, but Walmart will outbid Walgreens to win Humana over.

Regulatory approvals for artificial intelligence-based (AI) algorithms accelerate, tripling the number approved in 2019

The number of FDA approvals for algorithms in 2018 was impressive and shows no signs of abating. Additionally, 2020 will see a further tripling of regulatory approvals for AI.

Choose wisely: 2019 sees the first major shake-out of DTC telehealth vendors

Consumers’ use of telehealth will continue to see rapid growth and rising competition leading to significant consolidation among the plethora of vendors. By year-end, a major non-healthcare-specific consumer brand will join the mix, and the market will be down to five direct-to-consumer (DTC) nationwide brands.

Data science services see extraordinary growth, nearly doubling in 2019

By the end of 2019, every major healthcare analytics vendor will provide a cloud-hosted offering with optional data science and report development services.

In 2019, healthcare organizations (HCOs) adopt a cloud-first strategy

Cloud offerings have become far more robust, concurrent with HCOs’ struggles to recruit IT talent and control costs. Amazon’s AWS and Microsoft’s Azure will be clear winners while Google’s own cloud infrastructure services will remain a distant third in 2019.

New rules from ONC about data blocking have little effect because the business case does not change

Laws and regulations to-date have not compelled providers to freely share data with patients. ONC’s information blocking rule, which will be released before the end of 2018, will make it easier to transfer data to other organizations but will do little to open the data floodgates for patients, clinicians, and developers.

Big tech companies’ intentions in healthcare do little to disrupt the delivery of care

  1. Despite high-profile hires, the Amazon/Berkshire/JPM initiative will make no substantive progress.
  2. Amazon will focus only on the DTC supply chain, payer, and employer—staying away from anything substantive in the provider space.
  3. Apple’s Healthkit and sensor-laden smartwatch will remain sideshows in 2019 awaiting a more actively engaged healthcare consumer.
  4. Google [Deepmind] will never break out of clinical research and drug discovery.

Majority of MSSP ACOs stay and take on risk; hospital-led ACOs lead exits

Despite loud protests, the vast majority of provider-led MSSP ACOs will take on downside-risk as CMS shows flexibility in waivers. However, hospital-led ACOs, who continue to struggle with standing up a profitable MSSP ACO, will exit the program in 2019.

Closure of post-acute facilities shows no signs of slowing

Continued changes in post-acute care reimbursement, especially from CMS, combined with the migration to home-based services, puts further economic strain on these facilities. Nearly twenty percent of post-acute care facilities will shutter or merge in 2019.

2019 Health IT IPO market fails to materialize

The warning signs are there over the last couple of months that the stock market has become skittish. This will extend well into 2019 (if not lead to a mild recession). It will hardly be an ideal time to do an IPO, and those planned by Change Healthcare, Health Catalyst and others will wait another year.

Elon Musk reinvents healthcare

Elon Musk will have a nervous breakdown leading him to reinvent the healthcare system from his bed during his two-week recovery at Cedars-Sinai.

Stay up to the minute.

Did You Know?

Revisiting Our 2018 Predictions

As is our custom here, we like to look back on our predictions for the closing year and see just how well we did. Some years we do amazingly well, others we over-reach and miss on quite a few. For 2018, we got seven of our 13 predictions spot-on, two were mixed results and four predictions failed to materialize. If we were a batter in the MLB we would have gotten the MVP award with a .538 batting average. But we are not and have to accept that some years our prediction average may hover just above the midpoint as it did this year.

Stay tuned, 2019 predictions will be released in about one week and it is our hope that they will inspire both rumination and conversation.

(Note: the bigger and plain text are the original predictions we made in 2017, while the italic text is our review of 2018). 

Merger & acquisition activity continues; Humana or Cigna acquired.

Major mergers and acquisitions that mark the end of 2017 (CVS-Aetna, Dignity Health-CHI and rumored Ascension-Providence) will spill over into 2018. Both Humana and Cigna will be in play, and one of them will be acquired or merged in 2018.

MISS – neither happened. However, Cigna did pick-up PBM service Express Scripts and rumors continue to swirl about a possible Humana-Walmart deal or more recently, even a Walgreens-Humana deal.

 

Retail health clinics grow rapidly, accounting for 5 percent of primary care encounters.

Hot on the health heels of CVS’ acquisition of Aetna, growth in retail health reignites, albeit off a low overall footprint. By end of 2018, retail health clinic locations will exceed 3,000 and account for ~5% of all primary care encounters; up from 1,800 and ~2%, respectively, in 2015.

MISS – Modest growth in 2018 for retail health clinics with an estimate of around ~2,100 by year’s end. Telehealth, which is seeing rapid growth and on-site clinics may be partially to blame.

 

Apple buys a telehealth vendor.

In a bid to one-up Samsung’s partnership with American Well, and in a bid to establish itself as the first tech giant to disrupt healthcare delivery, Apple will acquire a DTC telehealth vendor in 2018.

MISS – Apple continues to work on the periphery of care with a focus on driving adoption of its Health Records service in the near-term with a long-term goal of patient-directed and curated longitudinal health records.

 

Sixty percent of ACOs struggle to break even.

Despite investments in population health management (PHM) solutions, payers still struggle with legacy back-end systems that hinder timely delivery of actionable claims data to provider organizations. The best intentions for value-based care will flounder and 60% of ACOs will struggle to break even. ACO formation will continue to grow, albeit more slowly, to mid-single digits in 2018 to just under 1,100 nationwide (up from 923 as of March 2017).

HIT – MSSP performance data showed only 34% earned shared savings in 2017 (up from 31% in 2016) and by year’s end it is estimated there will be ~1,025 ACOs in operation.

 

Every major EHR vendor delivers some level of FHIR support, but write access has to wait until 2019.

While some of the major EHR vendors have announced support for write access sometime this year and will definitely deliver this support to their most sophisticated customers, broad-based use of write APIs will happen after 2018. HCOs will be wary about willy-nilly changes to the patient record until they see how the pioneers fare.

HIT FHIR-based read APIs are available from all of the major EHR vendors. Write APIs are still hard to find. To be fair, HCOs as a group are not loudly demanding write APIs.

 

Cloud deployment chips away at on-premises and vendor-hosted analytics.

True cloud-based deployments from name brand vendors such as AWS and Azure are in the minority today. But their price-performance advantages are undeniable to HIT vendors. Cerner will begin to incent its HealtheIntent customers to cloud host on AWS. Even Epic will dip its toes in the public cloud sometime in 2018, probably with some combination of Healthy Planet, Caboodle, and/or Kit.

HIT – adoption of cloud computing platforms is accelerating quickly across the healthcare landscape for virtually all applications. Cloud-hosted analytics is seeing particularly robust growth.

 

True condition management remains outside providers’ orbit.

Providers will continue to lag behind payers and self-insured employers in adopting condition management solutions. There are two key reasons why: In particular, CMS’s reluctance to reimburse virtual Diabetes Prevention Programs, and in general, the less than 5% uptake for the CMS chronic care management billing code. In doing so, providers risk further isolation from value-based efforts to improve outcomes while controlling costs.

HIT – Awareness of the CCM billing code (CPT code 99490) remains moderate among providers and adoption is still estimated at a paltry less than 15%.

 

Mobile-first becomes the dominant platform for over 75% of care management solutions.

Mobile accessibility is critical for dynamic care management, especially across the ambulatory sector. More than 75% of provider-focused care management vendors will have an integrated, proprietary mobile application for patients and caregivers by end of 2018. These mobile-enabled solutions will also facilitate collection of patient-reported outcome measures, with 50% of solutions offering this capability in 2018.

MIXED – While the majority of provider-focused care management vendors do have an integrated mobile application (proprietary or partnership), collecting PROMs is still a functionality that remains limited through an integrated mobile solution.

 

Solutions continue to document SDoH but don’t yet account for them.

A wide range of engagement, PHM, EHR, and care management solutions will make progress on documenting social determinants of health, but no more than 15% of solutions in 2018 will be able to automatically alter care plan interventions based on SDoH in 2018.

HIT – despite all the hoopla in the market about the need to address SDoH in care delivery, little has been done to date to directly affect dynamic care plans.

 

ONC defines enforcement rules for “data blocking,” but potential fines do little to change business dynamics that inhibit data liquidity.

The hard, iron core of this issue is uncertainty about its real impact. No one knows what percentage of patients or encounters are impacted when available data is rendered unavailable – intentionally or unintentionally. Data blocking definitely happens but most HCOs will rightly wonder about the federal government’s willingness to go after the blockers. The Office of the National Coordinator might actually make some rules, but there will be zero enforcement in 2018.

MIXED – Last December we said, “The hard iron core of this issue is uncertainty about its real impact.” Still true. Supposedly, rulemaking on information blocking is complete but held up in the OMB. The current administration does not believe in regulation. So “data blocking” may be defined but there was and will be no enforcement or fines this year.

 

PHM solution market sees modest growth of 5-7%.

Providers will pull back on aggressive plans to broadly adopt and deploy PHM solution suites, leading to lackluster growth in the PHM market of 5% to 7% in 2018. Instead, the focus will be on more narrow, specific, business-driven use cases, such as standing up an ACO. In response, provider-centric vendors will pivot to the payer market, which has a ready appetite for PHM solutions, especially those with robust clinical data management capabilities.

HIT – PHM remains a challenging market from both payment (at-risk value-based care still represents less than 5% of payments nationwide) and value (lack of clear metrics for return on investment) perspectives. All PHM vendors are now pursuing opportunities in the payer market, including EHR vendors.

 

In-workflow care gap reminders replace reports and dashboards as the primary way to help clinicians meet quality and utilization goals.

This is a case where the threat of alert fatigue is preferable to the reality of report fatigue. Gaps are important, and most clinicians want to address them, but not at the cost of voluminous dashboards or reports. A single care gap that is obvious to the clinician opening a chart is worth a thousand reports or dashboards. By the end of 2018, reports and dashboards will no longer be delivered to front-line clinicians except upon request.

MISS – Reports and dashboards are alive and well across the industry and remain the primary way to inform front-line clinicians about care gaps.

 

At least two dozen companies gain FDA-approval of products using machine learning in clinical decision support, up from half a dozen in 2017.

Arterys, Quantitative Insights, Butterfly Network, Zebra Medical Vision, EnsoData, and iCAD all received FDA approval for their AI-based solutions in 2017. This is just the start of AI’s future impact in radiology. Pioneer approvals in 2017 — such as Quantitative Insights’ QuantX Advanced breast CADx software and Arterys’s medical imaging platform — will be joined by many more in 2018 as vendors look to leverage the powerful abilities of AI/ML to reduce labor costs and improve outcomes dependent on digital image analysis.

HIT – With about a month left in 2018 the count of FDA approved algorithms year to date is approaching 30 and could potentially hit three dozen by year end. This is a significant ramp up in the regulatory pipeline, but more is needed in the way of clear guidance on how they plan to review continuously learning systems and best practices for leveraging real-world evidence in algorithm training and validation.

 

What do you think of 2018 for health IT?

What’s All the Fuss – Some Thoughts on Recent News

At times it can be challenging to draft commentary on all that is happening across this industry sector. Rather than write short posts for each, I have created an amalgamation of commentary to some of the more newsworthy announcements.

Roche Acquires Flatiron

Wow, whoever knew that data could be such a valuable resource? Roche’s total spend to acquire Flatiron Health, a company focusing on the oncology space, was an eye-popping $2.1B. At first, I just could not fathom why anyone would spend that much for a relatively young company, that despite receiving a lot of VC funding early on, had little to show other than acquiring a modest oncology EHR.

Digging deeper however I learned that Flatiron was taking all that oncology data being collected in their EHR at physician offices across the country and cleansing and normalizing the data for clinical research purposes. Clean, normalized data is hard to come by in this industry and near impossible in oncology. Upon reflection, it now appears that Roche made an incredibly savvy move, one that will reap a handsome, long-term return on investment for the company.

Veritas Capital Acquires GE Healthcare’s IT Assets

This acquisition by Veritas is a tough one to understand. Over one billion dollars cash for assets that are dated and fading from the market? Granted, there is that installed base, there is that maintenance revenue to leverage and if you strip out virtually all SG&A costs you can make some money here, but is it really worth the trouble?

Veritas’s acquisition of Thomson-Reuters healthcare business that became Truven and later sold to IBM for roughly 2x what they paid shows that Veritas may know what they are doing. Maybe combining these GE assets with Verscend (formerly Verisk Health), also under Veritas, creates a 1+1=3 scenario but right now, just don’t see it.

ACHE Congress

Attended my first American College of Healthcare Executives (ACHE) Congress two weeks ago. This is a very collegial event – warm and welcoming. Everyone is there to learn from one another through various educational sessions and seminars. It is also an event where I was a bit floored and probably under-dressed as virtually everyone was in suits and ties.

I attended several sessions, mostly on IT and innovation, to get a feel for how these senior-level executives think about these issues. Came away with a feeling that most really do not see what is coming. Along with all of those suits, one walks away with the impression that there is a certain level of calcification across this audience. Sadly, many will likely become the detritus of the digital train that will run right over them.

Apple & the Elusive Consumer-controlled Health Record

Have been taken aback by all the fuss being made about Apple’s recent announcements regarding its Health Record app. From the Twitterverse, to a wide range of trade mags, to blog posts, folks are making this app seem like the second coming – that this signals Apple’s ability to disrupt the industry.

Hold on folks.

While I certainly applaud Apple’s efforts and for that minority of the population using an Apple iOS device, this may be just what they are looking for, I can’t help but feel a deja vu moment.

Were not Google Health and MSFT’s Healthvault going to do the same thing – revolutionize healthcare, put patient’s health records into their control. We all know where that ended – in the dustbin of history.

I’ll stay cautiously optimistic, but will reserve excitement until that day when Android devices also have the same capability with both clinicians and citizens warmly embracing and using this functionality for their care and the care of loved ones.

What We’ve Been Commenting On

Lately, there have been quite a few big developments in healthcare, including Allscripts acquiring Practice Fusion, Apple’s PHR, and the mysterious Amazon-JP Morgan Chase-Berkshire Hathaway healthcare company. Not all of these developments have enough detail yet for Chilmark to analyze the impact on the future of the health IT market in-depth, but we are commenting elsewhere on the wider possibilities for the healthcare industry.

 

Blockbuster digital health funding to spill to 2018
Brian Eastwood in HealthcareDive
“’We think next year is when we’ll begin to see [predictive analytics] go beyond simply accounting for and noting social determinants of health and barriers to care and start to use that information to inform care plan decisions,’ Eastwood said. Vendors able to adequately take this on will emerge as key players in the care management and population health markets as the year progresses, he added.”

Health IT eyes M&A as market grows up
Ken Kleinberg in HealthcareDive
The EHR market is saturated [and] consolidation is very clear…The movement to analytics and population care, that’s where the action is now,” Kleinberg said. “There’s a tremendous amount of innovation still possible.”

Apple debuts medical records on iPhone
Brian Eastwood in HealthcareDive
“Apple is widely accepted as understanding the user experience,” Eastwood said. “If all of the sudden, a substantial chunk of the population has the capability to tap into a patient portal in a way they haven’t before, then it could be a gamechanger.

Why AI tools are critical to enabling a Learning Health System
Ken Kleinberg in HealthcareIT News
The Learning Health Systems continually improve by collecting data and processing it to inform better decision making. As the amount and complexity of big data continues to increase, organizations are challenged to fully take advantage of it,” said Kleinberg. “AI systems are particularly suited to analyze huge data sets to discover meaningful and actionable insights, and even to carry out actions.”

Apple steps into Epic System’s arena with medical records iPhone app
Brian Eastwood in The Capital Times
“(Health record companies) will still be building their core products,” said Eastwood. “They’ll still be maintaining the records…[Regarding rumors of Apple or Amazon creating EHRs], right now, it’s still a little bit in the realm of fantasy.”

How Amazon, JPM and Berkshire could disrupt healthcare (or not)Health IT eyes M&A as market grows up
John Moore in HealthcareDive
“‘I’m not holding my breath for big changes,’ Moore said. Instead, he expects incremental change are more likely over the next three to five years.”

Will Amazon’s push into health care impact Epic Systems’ future?
Ken Kleinberg in The Capital Times
“Software to power the applications for health care providers come predominantly from a few large players like Epic and Cerner,” Kleinberg wrote. “It’s a great question to ask to what degree they can take their provider and software application expertise and apply it to the needs of payers.”

Back to the Crystal Ball: Our 2018 Healthcare IT Market Predictions

couple looks into a crystal ballOur favorite post of the year is this one. As analysts, we come together with our propeller hats on to collectively look ahead at the key trends in the year to come in the healthcare sector. While there are any number of predictions one might make for this dynamic market, we will stick to what we know best: Healthcare IT and the broader issues that influence this sector. 

Following is our annual Baker’s Dozen. As always, love getting your feedback in the comment section. Let the dialog begin.

 

Merger & acquisition activity continues; Humana or Cigna acquired.
Major mergers and acquisitions that mark the end of 2017 (CVS-Aetna, Dignity Health-CHI and rumored Ascension-Providence) will spill over into 2018. Both Humana and Cigna will be in play, and one of them will be acquired or merged in 2018.

Retail health clinics grow rapidly, accounting for 5 percent of primary care encounters.
Hot on the health heels of CVS’ acquisition of Aetna, growth in retail health reignites, albeit off a low overall footprint. By end of 2018, retail health clinic locations will exceed 3,000 and account for ~5% of all primary care encounters; up from 1,800 and ~2%, respectively, in 2015.

Apple buys a telehealth vendor.
In a bid to one-up Samsung’s partnership with American Well, and in a bid to establish itself as the first tech giant to disrupt healthcare delivery, Apple will acquire a DTC telehealth vendor in 2018.

Sixty percent of ACOs struggle to break even.
Despite investments in population health management (PHM) solutions, payers still struggle with legacy back-end systems that hinder timely delivery of actionable claims data to provider organizations. The best intentions for value-based care will flounder, and 60% of ACOs will struggle to break even. ACO formation will continue to grow, albeit more slowly, to mid-single digits in 2018 to just under 1,100 nationwide (up from 923 as of March 2017).

Every major EHR vendor delivers some level of FHIR support, but write access has to wait until 2019.
While some of the major EHR vendors have announced support for write access sometime this year and will definitely deliver this support to their most sophisticated customers, broad-based use of write APIs will happen after 2018. HCOs will be wary about willy-nilly changes to the patient record until they see how the pioneers fare.

Cloud deployment chips away at on-premises and vendor-hosted analytics.
True cloud-based deployments from name brand vendors such as AWS and Azure are in the minority today. But their price-performance advantages are undeniable to HIT vendors. Cerner will begin to incent its HealtheIntent customers to cloud host on AWS. Even Epic will dip its toes in the public cloud sometime in 2018, probably with some combination of Healthy Planet, Caboodle, and/or Kit.

True condition management remains outside providers’ orbit.
Providers will continue to lag behind payers and self-insured employers in adopting condition management solutions. There are two key reasons why: In particular, CMS reluctance to reimburse virtual Diabetes Prevention Programs, and in general, the less than 5% uptake for the CMS chronic care management billing code. In doing so, providers risk further isolation from value-based efforts to improve outcomes while controlling costs.

Mobile-first becomes dominant platform for over 75% of care management solutions.
Mobile accessibility is critical for dynamic care management, especially across the ambulatory sector. More than 75% of provider-focused care management vendors will have an integrated, proprietary mobile application for patients and caregivers by end of 2018. These mobile-enabled solutions will also facilitate collection of patient-reported outcome measures, with 50% of solutions offering this capability in 2018.

Solutions continue to document SDoH but don’t yet account for them.
A wide range of engagement, PHM, EHR, and care management solutions will make progress on documenting social determinants of health, but no more than 15% of solutions in 2018 will be able to automatically alter care plan interventions based on SDoH in 2018.

ONC defines enforcement rules for “data blocking,” but potential fines do little to change business dynamics that inhibit data liquidity.
The hard iron core of this issue is uncertainty about its real impact. No one know what percentage of patients or encounters are impacted when available data is rendered unavailable – intentionally or unintentionally. Data blocking definitely happen,s but most HCOs will rightly wonder about feds willingness to go after the blockers. The Office of the National Coordinator might actually make some rules, but there will be zero enforcement in 2018.

PHM solution market see modest growth of 5-7%.
Providers will pull back on aggressive plans to broadly adopt and deploy PHM solution suites, leading to lackluster growth in the PHM market of 5%to 7% in 2018. Instead, the focus will be on more narrow, specific, business-driven use cases, such as standing up an ACO. In response, provider-centric vendors will pivot to the payer market, which has a ready appetite for PHM solutions, especially those with robust clinical data management capabilities.

In-workflow care gap reminders replace reports and dashboards as the primary way to help clinicians meet quality and utilization goals.
This is a case where the threat of alert fatigue is preferable to the reality of report fatigue. Gaps are important, and most clinicians want to address them, but not at the cost of voluminous dashboards or reports. A single care gap that is obvious to the clinician opening a chart is worth a thousand reports or dashboards. By the end of 2018, reports and dashboards will no longer be delivered to front-line clinicians except upon request.

At least two dozen companies gain FDA-approval of products using Machine Learning in clinical decision support, up from half a dozen in 2017.
Arterys, Quantitative Insights, Butterfly Network, Zebra Medical Vision, EnsoData, and iCAD all received FDA approval for their AI-based solutions in 2017. This is just the start of AI’s future impact in radiology. Pioneer approvals in 2017 — such as Quantitative Insights’ QuantX Advanced breast CADx software and Arterys’s medical imaging platform — will be joined by many more in 2018 as vendors look to leverage the powerful abilities of AI/ML to reduce labor costs and improve outcomes dependent on digital image analysis.

What are your healthcare market predictions for 2018?

3 Real-World Reasons the Scripps Study Failed

CH Infographic

Remote Monitoring CAN work – but that doesn’t mean it WILL. (Figure from Chilmark’s Connected Health Report)

The results of a six-month study on the impact of connected devices on chronically ill patients are in – and they’re not good.

The Scripps Translational Science Institute found that in a randomized control trial (RCT) comparing chronic care using connected devices against standard disease management models, the devices had no discernible impact on healthcare utilization, and little impact on health self-management.

Brian at Mobihealthnews has compiled a nice summary of the reaction from industry leaders on Twitter – equal parts defensive, dismissive, and even some smug satisfaction given today’s hype around these devices. Several pundits, including study author Dr. Eric Topol himself, have offered up insights (and excuses) as to what’s happening here: the study wasn’t long enough, data are inconclusive, technology has evolved since 2012, etc.

We’ll offer another explanation.

Simply put, what works for clinical whitecoats and industry whitepapers won’t always work amidst the vivid colors of the real world. Digital Hypemen take note: Just strapping technology onto a patient will not make them healthier. Our new connected health report finds there have been several successful studies (see the infographic to the right)– but few successfully scaled programs. The single most salient insight for me personally was that vendors and their customers play hot potato when it comes to taking a leadership role in onboarding patients and customizing remote patient monitoring (RPM) “kits” to fit into patients’ lives. The dismal outcomes of the Scripps study is a confirmation that this may be the lynchpin to successful deployment of remote patient monitoring programs moving forward. We looked at the Scripps study in more detail and uncovered a few specific areas where the study design came up short.

The Limitations of Claims Data
Claims data reminds us of the old joke about the man on the street looking for his keys under a streetlamp. A second person passing by offers assistance, asking if he’s dropped them nearby. The first man responds that no, he didn’t – but it’s well-lit on this side of the street so he’s looking for them here.

People choose to see a doctor based on a multitude of reasons, many of which have nothing to do with their health status: time, schedules, costs, locations, and a growing list of convenient alternatives. How many of us simply ask a doctor in the family instead (or these days, the IT geek or insurance wonk)? Even if we put aside about the growing financial disincentive to use health insurance, we’ve moved into an era of invisible, ubiquitous utilization, of Minute Clinics, telehealth, YouTube, WebMD, and Dr. Oz. Health, illness, and the rest of life happens outside of the facility –isn’t that the whole point of remote patient monitoring? That researchers limited themselves to measuring only in-facility utilization is a head-scratching oversight.

What was the impact on study participants’ grocery store purchases, or what they bought for lunch at work? On what else they bought at the pharmacy when they renewed their prescriptions? On visits to the gym? On their behavior on a rainy day? On what they searched or bought online, or shared on social media? In 2016, researchers deserve a SMAC the next time they propose studying patient engagement using claims data.

Ignoring Patient Workflow
Participants were provided study phones, rather than allowed to use their own phones. A smartphone is not the same as YOUR smartphone. Our phones are an extension of ourselves, inextricably linked with our behavior, moods, and decisions for hours and hours every day. The baseline for impact on “real” patient behavior is already off. If you were in a study and you wanted to Google something health-related, would you use the phone they gave you, or your own phone? Were disease management staff contacting people on their study phone, or on their regular mobile? While this may be a small issue considering what the study was assessing, to us it seems a missed opportunity to understand real world behavior. We’re thrilled to see companies like Sherbit partnering with Harvard Medical School researchers to explore how real world smartphone data can play a role in improving chronic disease care outcomes.

Requiring patients to set up and log into a third party portal (QualComm’s Healthy Circles) on a third-party phone was another left turn. Remote monitoring is not about the devices– it’s about stitching them seamlessly into the fabric of patients’ everyday lives. Put differently, this is a workflow problem exacerbated by software. We suspect patients had two (or more) additional portals to the one designed for the study – one from their insurer, and one from their doctor. In the context of a digital health study, it’s safe to say the petri dish was probably contaminated. It’s only the occasional vendor, like DatStat, who’s trying to bring a seamless, mobile approach to patient data collection from the world of research into clinical care.

Pushing educational content to patients through a designated online portal is a mediocre, outdated approach. A better move might have been to obtain consent to track their smartphone or web searches that contained certain keywords (e.g. diet, sleep, carbs, salt, blood pressure, etc.) and combining this with automated push of relevant content. This hypothetical opportunity is the type of unique advantage that researchers should aim to leverage in studies like this one. When will vendors and doctors start meeting patients where we are (location, but also era)? We’re hoping Apple’s current hiring spree bodes well for these challenges.

Completely Missing the Point of Sharing Data with Patients

If we want to educate and activate patients, why do data still look like this?

Scripps Data

Actual patient data screengrabs from the Study’s Supplemental Methods (https://peerj.com/articles/1554/#supp-2)

This is an old soapbox for us at Chilmark Research; I’ve complained about my useless lab test results at length before. To his credit, Dr. Topol has acknowledged that data visualization could have been better. But over the course of the last five or six years, we are frustrated to see that the typical clinical portal – EMR, Remote Monitoring, Care Management, or other –  has hardly changed how it presents data. We must stop throwing low-value data in patients’ faces without making them easy to understand – and medical decorum be damned, even stimulating and fun. The approach taken by industry, and by Scripps researchers, is tantamount to leaving the patient out of the equation rather than bringing them on board the care team. Worst of all – this is the lowest hanging fruit. There are high school web developers who can juice up these visuals to make them slick and compelling, and college pre-meds who can translate these graphs into English. We simply must get better.

For this research, the failure to get this small, simple piece right may have been the study’s biggest flaw. Of course, we openly acknowledge the whole point of research – to learn, and nudge the industry forward step by step, making one mistake at a time in order to improve. This was a groundbreaking study if for no other reason than it pointed out that we have a lot of work left to do.

But when are we going to do it? As long as we insist on measuring data without leveraging its potential to augment patient behavior – and monitor patients without engaging them – we’re buzzing about wireless with one hand wired behind our back.

Editor’s Note: Naveen makes some excellent points but one other I would add is how does the use of RPM enhance patient satisfaction? This is one area where the use of RPM has shown some positive results in past studies. Rather than going to a doctor’s office to have their biometrics recorded, patients do it from home. For many, this is a huge benefit that is often overlooked. -J. Moore

 

IBM in Healthcare: Deja Vu or Something New?

IBMwatsonIBM has been making a lot of noise as of late. First, it made a series of announcements at the HIMSS confab about its intentions to go deep into the healthcare vertical. Then last week it announced a partnership with Apple and Japan Post to provide Japan’s elderly population with an iPad enabled care platform. Clearly, IBM wants to make a mark in healthcare.

The question is, however, will it matter?

The healthcare industry has seen this play before, many times over. Big company with infinite resources makes claim that they will come in and solve many of healthcare’s ills. Big company goes on to state they are fully aware of the challenges, but they are in this for the long-term. Big company makes acquisitions, forms strategic partnerships, has big booth at HIMSS. Big company’s ambitions far exceed healthcare’s willingness to change. Investors get antsy, wanting results. Big company ultimately concedes defeat and exits.

IBM’s actions have the appearance that they will make a big play for the healthcare market. Leveraging their already copious analytic capabilities, IBM has further strengthened its healthcare hand acquiring both Explorys and Phytel. These two companies have leading mind-share (though not huge revenue streams) in the burgeoning healthcare analytics market and were profiled in our 2014 Analytics for Pop Health Report.

But when one looks more closely at all these announcements there is a distinct pattern – these announcements are not so much about building out an industry vertical as they are about a huge data grab.

Watson, Watson, Watson
Almost the day after IBM’s cognitive computing engine, Watson, won Jeopardy, IBM has been flogging the healthcare industry with all the great things Watson might be able to do in this sector. To date, IBM has had little to show for these efforts as frankly, Watson is a hard sell. Thus it was curious that for a brand that has gained little traction in healthcare, IBM would name its whole new healthcare division Watson Health.

Hope seemingly springs eternal at IBM for its Watson.

But this move also signals what IBM’s real intentions are.

Explorys and Phytel bring over 50M patient records to Watson, which as a learning system, can be used to further train its models. Medtronic and J&J partnerships likewise signal a data grab, this time biometric data from these companies’ devices. And the Japan Post partnership gives IBM access to a huge store of elderly patient data, which again just contributes to further train and strengthen Watson’s capabilities (see Figure 1).

watson

In a recent post-HIMSS industry analyst call in which IBM was to delve into the details of what their intentions are in the healthcare sector, or at least that is what I assumed, the briefing was surprisingly devoid of anything substantive. Instead, just more of the same old, now getting tired song that Watson’s cognitive computing capabilities were going to do great things in healthcare.

Don’t get me wrong. I actually believe that the unique capabilities that Watson possesses has the potential to do some pretty incredible things in healthcare. It’s just time to move beyond the talk and get on with the execution and show us some real use cases that deliver at scale.

Deja vu or Something New
Getting back to the main question: Will IBM be in this for the long-haul?

One of the factors that has stumped many other big players entering the healthcare sector is this sector’s glacial pace of change. In many respects, healthcare has operated like an ancient guild hanging on to its traditions as seemingly every other part of the economy sheds them.

But that is also changing and at a fairly rapid pace. One macro vector is the move from volume-based reimbursement models to ones based on value. A second vector, and possibly larger, is the growing role of consumerism in healthcare. Third, of course, is the digitization of patient data which will provide new insights into what actually is providing demonstrable benefits to a patient. There are a multiple of other vectors as well, but these are arguably the largest.

These vectors are forcing the healthcare guild to shed those time-worn beliefs that are no longer relevant. It is forcing the healthcare sector to change and change quickly. That in turn will create opportunities for the likes of companies such as IBM, something that those who treaded down this path before them, were not afforded. It is now up to IBM to capitalize on that opportunity.

Addendum:
IBM isn’t done yet in forming partnerships to scoop up even more data. Today, IBM announced a partnership with Epic to use open standards to pull patient data out of Epic to feed Watson. IBM will work with Mayo Clinic as the first trial of such an approach. This could be potentially huge as Epic claims that roughly half of the US population has a health record stored in Epic. IBM also announced today that it is partnering with a dozen cancer research centers to further personalized medicine in the treatment of cancer.

3 Quick Thoughts on Apple Watch

As expected, Apple announced the latest addition to their product lineup, the AppleWatch. We will leave the hardcore dissection to others, but in watching the event (or trying to watch what was an absolutely awful livestream, complete with annoying Chinese translator, and random recurring muting/video freezes), we came away with a few first impressions:

1) Are Smartwatches Really Mainstream Now?

Apple’s announcement will bring digital health closer into the mainstream, but by how much remains to be seen. Samsung has been relentless in pushing their Gear smartwatches out to consumers over the last two years, selling half a million units in Q1 of this 2014 alone. Now that Apple has gotten involved, they are aiming to differentiate based on quality, UX, and design (as we know, the core Apple strengths). The video demos showed off what seems like a very well designed, elegant product. With an array of wristbands and designs (including a gold-plated model), it was shown to us as *the* watch to have, smart or otherwise.

Using their one-of-a-kind design expertise, Apple today positioned their next product not just as a device for tech geeks or fitness buffs, but for anyone who uses GPS for directions, texts with friends, needs business meeting reminders, shops with credit cards, and so on. However that being said, the introductory, base-model cost of $350 is an inordinate price point for what amounts to a new toy. In spite of the gloss and the Jony Ive voiceover, it’s still tough to imagine these things as indispensable. Looking at the videos Apple showed of AppleWatch in action, the target audience for this product is clearly the rich, young, and healthy elite (who own an iPhone).

2) Viable Healthcare Market: Employers and Payers

A good amount of the demo was spent discussing the two wellness use cases, named Fitness and Workouts. Fitness tracks three different metrics (sitting vs standing, movement, exercise), while Workout enables setting specific goals for exercise. Data are passively sent to the Health App in the iPhone, enabling users to keep a log of their health activity. The low hanging fruit for healthcare here is in the employer market. Because data is passively sent to the iOS8 Health App, which is accessible to 3rd party apps via Healthkit, it is easy to envision an employer or payer sponsoring an app for office challenges, to mete out rewards for those who hit health targets, send reminders to people to stand up at their desk or take the stairs, etc. Again, this is not new technology, but now that Apple’s entered the market, thereby ‘legitimizing’ it, it’s exciting. If Apple hits the mark, their Watch may attract both employee end users who want to be rewarded for their healthy lifestyles (how many times did “Whole Foods” show up in the demos?), as well as CEO’s who want to be seen as “innovators,” ROI data be damned.

3) Nonviable Healthcare Market: Clinical End Users

Once again, Apple managed to leave the dedicated health care folks out there tantalized but somewhat frustrated. My head was spinning with potential ideas for clinical use cases. A medication buzzer app that sends haptic feedback as reminders. A patient-patient or patient-nurse messaging app using the digital touch medium, or a new set of clinically oriented emoji’s to check in between visits. However, Apple chose to leave this side of the market out altogether – whether because of FDA concerns about consumer marketing of tech products as clinical tools (ala 23andMe’s earlier debacle), or because they know at this point their target audience out of the gate is not a type 2 diabetic who’s at a high risk of getting sent to the hospital. Likely, they will focus on the DTC side themselves, and use their ability to attract alpha caliber partners – as with Epic and Mayo earlier this summer, and potentially with payers and employers later this fall – to serve as channels for healthcare end users.

As always, questions remain – around privacy, battery life, extent of interdependence on the iPhone, etc.  We’ll look forward to tracking what was undeniably an exciting announcement today and continue our coverage when these devices actually enter the market in 2015.

Did you watch the event, or at least try to watch it? What did you think – will iPhone6, iOS8, and now AppleWatch be able to change healthcare? Or is this just more fodder for the hypemen who are taking over and bloating the digital health frontier?

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