“His treatment was fragmented rather than integrated. Each of his myriad maladies was being treated by different specialists – oncologists, pain specialists, nutritionists, hepatologists, and hematologists – but they were not being coordinated in a cohesive approach.”

– Steve Jobs, by Walter Isaacson (p. 549)

As you’ve undoubtedly heard, Apple made a big splash last week by announcing “official” involvement in healthcare through a new app and accompanying SDK. In the past week much fanfare has been made and many speculations have been raised. As an industry that is built on the notion of looking forward, the obvious question right now is, “Will Apple Succeed?” An important precursor however is, “What is Apple trying to do?”

The announcement at WWDC was scant on details, comprising just three minutes of the broader two-hour session. More detail is available elsewhere, but the basics are that this fall, Apple will release an app called “Health” to track and store multiple health data, mostly from devices, of around 60 parameters upon release with iOS 8. The app will enable selective sharing of data, across other apps or with other individuals. The app’s release coincides with the pre-release of an SDK called “HealthKit”, designed to allow third party apps built with HealthKit to be able to have common data structures for data management, sharing, and privacy control. Two early partners were announced in Mayo Clinic and Epic, though details of those partnerships are still TBD.

So the vision here appears to be that patients and healthcare providers can use multiple apps written on Healthkit, all through a consumer-controlled, portable hub (that also makes calls!) to help fill the healthcare void when patients are away from a health facility.  Sound familiar? So much for “Think Different” – Apple is not trying out anything new here. Rather, they are betting that this particular formula of consumer-friendly hardware, new software, brand strength and market clout can result in a win. But they are also, finally, addressing a problem that has plagued health apps for years: an inability to aggregate data into one spot for a more complete view of one’s health.

Over the long term, the web-dominant approach to the above vision is slowly dying; the notion of sitting down at a computer to upload workouts or blood sugar readings into a website already seems antiquated compared to automated tracking on a device. So if mobile truly is the future, then Apple seems better positioned then others to capitalize on that trend, save Samsung.

With Samsung’s recent announcement of the SAMI platform, their S-Health app on the S4 and S5, and other recent activity in health IT, they too have arrived to the party. We will cover both tech titans’ varying approaches more deeply as part of the CAS as details around them emerge. For now, looking at ghosts of PHRs past as well as the current mHealth environment, we can point to several issues that will define the success or failure of Apple and their contemporaries.

Timing: Compared to predecessors, Apple has the benefit of timing on their side. Consumer-friendly hardware is now ubiquitous in the market (much of it Apple’s) and growing in sophistication. Healthcare software has decidedly shifted in a mobile-friendly direction, from a wellspring of APIs from major HIT vendors to emergence of standards like HL7’s FHIR. With the MU3 PGHD provision set to roll out this fall, the timing here could work out in Apple’s favor.

Wellness vs. Health: Many from Aetna to Microsoft have struggled trying to straddle the fence between wellness and medical care. We suspect Apple will be no different. Despite the umbrella of “health”, fitness tracking and condition management are two different marketplaces. Apple’s best bet for success may be to drive Wellness growth through B2C efforts, and drive clinical adoption through healthcare partnerships and clinical evangelists. For now, it is Apple’s best interest (and the broader industry’s collectively) to keep these lines blurred.

Quality and Curation:  With regards to adoption, the biggest healthcare complaint about mHealth is that there is too much going on. With over 43,000 apps available in some flavor of health, Healthkit adding more may not necessarily be better. It remains unclear what Apple’s involvement at this level will look like, but if they really want to get a foothold in the marketplace, they are best served by addressing this issue on some level.

Data: Apple is essentially the Epic of their industry: They’re big and well-fed and they don’t play well with their peers. Apple may take the same approach that Epic took before being regulated into interoperability by the ONC; they are big enough and far enough outside of healthcare that the NPRM for Stage 3 PGHD might not matter to them.

Closing Thoughts: Potential vs. Reality

At this early stage, questions can go on forever. Speculation aside, one thing we can safely say is that Apple is not all of a sudden a healthcare company. With this recent announcement they have simply provided some new tools to a broken industry, tools that appear to be arriving at the right place, at the right time.

Hopes seem to be higher within the healthcare industry and across the blogosphere that this is just a first step for Apple. With its beloved brand, vast resources, design-driven thinking, and technological expertise, many are rooting for Apple to be the one to rewrite the chapter on enterprise mHealth strategy. Realistically however, Apple’s goals here are likely more simple: to sell more phones, tap directly into a booming mHealth market (Remember, Apple keeps 30% of all app revenue), and grease the wheels of their widely rumored iWatch rollout.

Having taken a hiatus from last year’s Health 2.0 event, was looking forward to this year’s event to see what may be new and upcoming among those looking to disrupt the status quo. Unfortunately, surprisingly little.

Health 2.0 a couple of weeks back had your usually cheery crowd of those who are looking to transform healthcare. As with past Health 2.0 events we have attended, hype was far out in front of market reality but that does not seem to deter the cheerleaders, which were again present with abundance among the some 1,700+ attendees.

Show Me Your Big Data – That’s what I thought, not so big after all
There was plenty (i.e., too much) talk about Big Data when in reality, presentations focused on relatively small datasets with little thematic similarity in any one session. For example, the Risk Assessment & Big Data session had Dell talking about genomics, Sutter Health talking predictive analytics for CHF, another about mashing up claims and clinical data and the last looking at risk assessment. At the conclusion of this session, nary a question was asked – audience confused. Another session on Big Data tools for Population Health Management (PHM) was cut short, thankfully, when the power died. Hard to say if it is the industry drinking the hype, this particular event (though experienced similar at HIMSS’13), or what but this silliness has to stop – we really need clarity, not smoke n’mirrors =- and don’t even get me started on PHM…

Track Me – Track You and no, I probably don’t want your data, at least not yet
In addition to riding the Big Data hype, the event also jumped on the hype surrounding the rapid proliferation of self-tracking, biometric devices now entering the market and all the great things that will come as a result of consumer adoption and use of such devices to monitor health. Not all are jumping on this band-wagon and for good reasons. There is no doubt that in time, such devices will be used by clinicians and patients together which will be the focus of a forthcoming Insight Report from Chilmark but our early research points to a number of challenges in the adoption and use of such devices in the context healthcare delivery.

There was again a plethora of solutions for price transparency. Some odd partnerships that are more opportunistic, for the partners, than providing value for the end users, e.g., the Dr Chrono-Box.net demo was so laborious I can’t imagine any clinician actually doing it. On the patient engagement front, plenty of new solutions on display and was particularly impressed with what Mana Health had build for the NYeHC patient portal contest. Simple, clean, straight-forward and intuitive to use refreshing.

Of course no Health 2.0 event would be complete without one of the large commercial payers taking the stage to announce their latest and greatest member outreach initiative. Two years ago it was Aetna with CarePass. This year it looked like it would be Humana until they were a no show – but Cigna was there with GO YOU Hub. First impressions of GO YOU: a fairly shallow pool in the health & wellness domain with lots of catchy phrases and colors – something your pre-pubescent daughter may like – but this adult quickly lost interest after four clicks

Health & Wellness Redux, Redux, Redux
And again, no Health 2.0 event would be complete without a gaggle of health & wellness solutions, the majority of which won’t be around by 2016.

There are now far more health and wellness solutions in the market than what the market can absorb. This situation is not likely to get better anytime soon as the numerous incubator/start-up accelerators continue to spew more of these solutions into the market every year. The only thing I can think of is that the barriers to entry must be exceedingly low, yet few of these companies realize that the barriers to adoption are exceedingly high and the market is on the verge of contraction.

The Big Squeeze
We are now projecting a significant level of contraction in the health and wellness arena as the broader market comes to grips with a shift in risk from payers to providers with providers ill prepared to accept that responsibility and the migration of many employees off of their employer plans and onto Health Insurance Exchanges (HIX).

This will create two challenges:

Providers are not accustomed to providing such solutions to their patients. While risk may shift to providers, provider adoption and use of such solutions to manage their patient populations is limited. When one adds in self-tracking devices, well…

…providers are struggling with the data dumps from their recently install EHR. The last thing they are seeking is another data source. Healthrageous is one example. A self-tracking wellness solution that was developed by provider Partners Healthcare, adopted in pilots by some big providers, failed to gain traction and was quietly sold to Humana. Not a pleasant outcome. If a provider organization can’t make a go of it through a spin-out, to the multitude of these health & wellness solutions think they can?

Second, we are at the very beginning of a massive shift of employers directing employees to HIX. Despite a fitful start, the use of HIX will grow overtime as a wide range of employers, but especially those in the retail and hospitality industries, direct their employees to these exchanges. Shifting employees to HIX reduces employer exposure (risk shifting) and will lead to decreasing interest and adoption of health and wellness solutions by employers.

Yet despite these challenges, the cheerleading at all Health 2.0 events and a questionable future, one thing that comes through every year is that there are a significant number of people that truly want to do something good, something meaningful to improve the sorry state that is our dysfunctional healthcare system, which we all struggle with at times. These are the people that attend Health 2.0, the ones willing to talk about the “Unmentionables”, the ones to project a vision of a better future for us all, the ones willing to take a risk. For that they should be applauded. But be wary as most will not be around three years hence.

But next time, can we actually have some front line providers in greater abundance to give us their take on all of this. Unfortunately, this event was sorely lacking in such, though it did have its fair share of various healthcare representatives – they just weren’t the ones from the front lines which is who we all need to be hearing from today.

Special thanks to Graham Watson for the image. Graham is easily the best cycling photographer in the world today.

And an extra special thanks to Cora who was there with me and provided a few tidbits of her own to this post.

We Americans are on a very terrifying path, health-wise, based on the latest obesity projections from RWJF.

Medical “innovations” around the obesity epidemic are unsettling, to say the least. Most recently, Dean Kamen (of Segway fame) filed a patent for a self-serve Stomach-Pumping Machine.

Disturbing medical devices aside, what does the obesity crisis mean to healthcare IT (HIT)?  Yes, increasing obesity rates means more metabolic syndrome, more intervention, more biometric data,more data stored in EHRs, more HIE to share that data, more clinical analytics and care coordination software, …

Does this sound interesting to you?  In my research I am more focused on how technological innovation can function as a solution to the obesity crisis. First let’s consider the payers — the large, innovative ones who continue to rally for behavior change.

Payer-Sponsored Wellness & Patient Engagement Soldier On

Payer-sponsored behavior change programs have never sustained results in the long term, but this doesn’t stop the early adopters from soldiering on.   For our 2012 Payer Benchmark Report, we profiled several large, innovative payers working to engage their members and the public through low-cost consumer technologies.

Some interesting new developments in this space include:

• Aetna is looking to make running on a treadmill bearable. Its new ‘Passage’ app (storing data in CarePass), promises to make exercisers feel as if they are travelling within a city of their choosing.
• Cigna has just released a ‘Healthy Living App Pack’, bundling the extremely popular FoodEducate app with 3 less-popular ones.  (Cigna didn’t develop FoodEducate, but licensed it from founder Hemi Weingarten).
• Humana has begun offering the HumanaVitality rewards system to a group of Medicare Advantage members. Let’s hope that seniors will take more kindly to this program than to HumanaVille, Humana’s failed attempt at creating an online senior health education community.

Consumer Health Companies Need to Move Beyond Fanatics

If payer apps can’t motivate widespread weight loss, then maybe the consumer space can? Consumer companies are currently busy developing software and testing out motivational models on the fly.  This is not exactly the scientific method but it works for small agile environments…and is definitely something that large payers are less adept at.

There is a belief among many of the quantified-self set that just the act of presenting health data to the consumer affects behavior change.  I seriously doubt this, and believe that consumer health startups have played a miniscule role in affecting real behavior change.  So far, they have provided diet and exercise fanatics better tools to fuel their obsession.

In order to reach the ‘bottom of the pyramid’, must we then dole out dollars for weight loss? I recently spoke with Gregory Coleman, one of the founders of nExercise, which offers a gamified “rewards program” where users randomly accumulate points, similar to a lottery, which can be applied towards real world discounts.

(nExercise is also the driving force behind the recently formed FITco, or ‘Founders In Technology Combating Obesity’. FITco functions as a place for founders to form data sharing/interoperability partnerships, and aggregate marketing dollars).

Talking with Gregory, I found myself better understanding the challenges these consumer companies are up against as they seek to move beyond their core base.  In offering financial incentives, they must spark interest without destroying intrinsic motivation. Framing financial incentives in term of ‘rewards’ and ‘discounts’ helps, but the real goal is to wean users off of them.

Cash, Friends, and Coaching: A Pipe Dream?

Several academic studies have shown that a combination of financial incentives, social support, and coaching from a trusted ally, produced significant behavior change, at least in the short term.

I can imagine a day when I seamlessly upload exercise and diet related data into a CarePass-type platform, where:

• my insurance carrier’s app notices that I have been working out, maintaining my BMI, and applies discounts to my premium.
• my doctor’s app (motivated by value-based reimbursement), suggests that I keep my maximum heart rate below 160 BPM
• I display achievement badges to my friends, and make my data available to health companies in order to receive discounts/free samples

Hmmm, what is that distant feeling of unease, the feeling like I am a pawn in someone else’s Grand Plan?  It might have something to do with the complete loss of privacy around my data.  However, if those premium discounts are steep enough, I can live with that.

Whether we get people sharing their health data or tempt them with financial incentives for weight loss, the systematic nature of the obesity problem remains a force to contend with. In the end it will be up to all of us to push back against the institutions that make us fat. Seeking out motivational consumer solutions is a low cost place to start.

Awhile back, a large health insurer (payer) commissioned Chilmark Research to do a market scan on how payers across the country were using emerging consumer technologies to engage their members. We found this project to be quite interesting and rather than have much of that research sit on the shelves forevermore, we decided to build upon it.

Today we are releasing the results of that effort.

Our latest report: Benchmark Report: Payer Adoption of Emerging Consumer Technologies takes a close look at over 40 payer (health insurers) initiatives that are using a wide variety of consumer technologies (apps, social media, games, etc.) for member engagement. Here’s the PR announcing the report’s release.

Now it is well-known that payers have had a very mixed record in engaging their members. Part of the problem has been trust as members are justified in taking a cautious approach when sharing their health information with payers for fear of future denials. Secondly, many payer initiatives have been half-baked wherein payers have not been fully engaged themselves in the concept of member engagement.

But as we pointed out in a post earlier this summer, this is all beginning to change. Numerous market forces are now pressing down upon payers and payers are increasingly coming to the realization that they need to deploy member engagement solutions that work. Payers are now going to where consumers already are seeking to engage their members via a variety of consumer-based technologies. This report is our initial effort to gain a greater understanding of what payers are doing today and provide some guidance as to how their efforts will evolve overtime.

One thing we have learned in the course of our research is that despite all the talk, the majority of these efforts are in their infancy and that the vast majority of payers have not even begun to venture down this path. Therefore, we intend to update this report on a periodic basis to benchmark payer adoption of consumer tech in support of member engagement and gain an even deeper understanding of what works and just as importantly, what does not.

Thanks to the many that we have interviewed over the course of the last several months to compile this report as your inputs have been invaluable.

It is now nail-biting time, as we here at Chilmark Research brace ourselves for the upcoming Supreme Court decision on the legitimacy of the Affordable Care Act.  We as a nation are indeed living in very interesting times and I am again reminded why I find healthcare markets endlessly fascinating (and perplexing). (Editor’s note: This post was written by senior analyst Cora Sharma and highlights some of her latest research that looks at payer strategies for patient/member engagement.)

Of interest is just how many of the ~30 million uninsured US citizens will land on insurers’ doorsteps in 2014. Even if the Individual Mandate is upheld, it is still uncertain just how many of these uninsured individuals will opt to pay penalties rather than purchase health insurance.

For my patient engagement research, I have spent the past several months speaking with executives at large payers about their consumer-focused strategies.  Just how are payers planning on using relevant consumer technologies to keep new individual customers engaged and healthy?  After such a dismal track record over the years around health/wellness/DM initiatives, is it worth another go-around? (Cora’s research will culminate in a forthcoming report to be released within the next couple of weeks.)

Payer Initiatives in Consumer Technologies
Kaiser Permanente and Humana actually began experimenting in this area circa 2008, creating flash-based, online health games for children. In 2010, UHG released the first version of the OptumizeMe social game App, Anthem released its Grocery Guide App (now EOL), and Aetna partnered with OneRecovery.com to provide a social network for members in recovery.

Now all of the major payers have ongoing products, partnerships, and pilots around consumer-focused health and wellness and disease management — though with varying respective strategies (the upcoming report explores these 35 ongoing payer initiatives in detail).

The figure below shows an interesting slice of data around social games, in that the majority of these initiatives are becoming social and ‘gamified’:

Note: Data point positions do not represent degree of gamification/ social-ification. These are just meant to illustrate number of initiatives in each category

Another trend our research has found is the willingness of payers to look beyond health and wellness and towards the complex FDA-regulated space of chronic disease management solutions (partnering with Healthrageous and Welldoc), as well as seeking to improve member ‘Wellbeing’.  Aetna’s partnership with Mindbloom to offer members the premium version of the Life Game™ is one of the few efforts we found among payers that looks to engage the full spectrum of health of a member with a focus on Wellbeing.

Growing market in payers that can transition to a post-FFS world.
In the future, we predict that this market will continue growing along two distinct tracks:

1. In payers that successfully transition their businesses to risk-sharing, care coordinating models (ACO/PCMH) looking to proactively engage members/patients in self-managing their health; and
2. As pure marketing-plays, e.g. releasing cool mobile Apps that generate a nice press release, some market buzz, but little else.

As many readers may know, the health insurance industry is going through a period of rapid transformation.  Payers with the means and the wherewithal to innovate their business models are purchasing providers, as well as partnering with them for data-sharing agreements and ACO-like payment contracts.  Some large payers are also getting into the ACO-enablement business through acquisition of software companies.

Insurers who do not innovate their business models towards a post-FFS (fee for service) world (be they pure insurance providers or mostly claims processors) will find little incentive to experiment heavily with emerging consumer technologies.  The crux of the matter is that they will never have the long-term incentives (nor the culture) to shift gears away from their actuarial focus and will remain low margin businesses, if they manage to survive at all.

Affecting behavior change towards health and wellness has proven incredibly difficult over the long haul. There is scant evidence that these new payer initiatives that seek to adopt common consumer engagement technologies and strategies are meeting objectives. As the entire healthcare industry pivots towards new bundled care reimbursement models though, there may be a glimmer of hope. I remain cautiously optimistic to see payers experimenting with and adopting emerging consumer technologies, knowing that there is still a long road to travel.

Earlier this year Chilmark Research launched its latest service, the Chilmark Advisory Service (CAS). One of the benefits of CAS is that subscribers receive a continuous feed of our research, from major annual reports such as the recently released 2012 HIE Market Report, to Quarterly Reports (e.g., mHealth Adoption for Patient Engagement) and exclusive to subscribers, the Monthly Update. Of course, subscribers also get unfettered access to our analysts to answer any specific questions they may have.

For the merry month of May, the Monthly Report touched upon four topics that are abstracted below:

Social Games for Wellbeing, Courtesy of Your Health Insurer
Much of this story was pulled from the forthcoming report that Cora is authoring that takes a close look at how payers are adopting consumer technologies (social media, gamification, mobile apps, etc.) to more effectively engage their members in healthy behaviors. This story looked at the current initiatives of Aetna, Blue Cross of California, Cigna, and Humana, each of which is taking a slightly different approach to more actively engage their members.

When Behavioral Health Goes Mainstream Will Technology be Ready?
This year, five states received grants of $600K each to explore how they would integrate behavioral health data into their statewide HIEs.  Analyst Naveen interviewed several stakeholders about how they would actually address the technology and policy hurdles to incorporate such data into an HIE. One of his findings, which he details in this story, is that current technology offerings from HIE vendors are ill-prepared to address this growing need to fold in behavioral health data into the HIE. Secondly, there remain significant policy issues that need to be addressed as behavioral health data is some of the most sensitive and protected health data.

Filling Gaps Separating Behavioral Health from the Healthcare Continuum
We had another story on the relative state of technology adoption within the behavioral health community. Our interviews with several stakeholders uncovered a market that is even further behind (at least 10-15 years) the rest of the medical community in IT adoption and use. As public health officials, healthcare organizations and others come to the realization that a significant proportion of chronic disease patients have a co-morbidity with a behavioral health issue, they are also coming to the realization that more effective care coordination must also occur with behavioral health specialists. John (the younger) takes a close look at what may develop in this market to fill the current gap.

Feds Look to Tighten Privacy & Security of HIEs
This last story took provided subscribers an assessment of the current Request for Information (RFI) for the Nationwide Health Information Network (NwHIN). The RFI was released on May 10, 2012 and is the an attempt by the U.S. government to establish a clear set of governance rules for the sharing and use of patient data within an HIE, and of course more broadly across the U.S., via the NwHIN. While the objectives are noble and to some extent needed, our assessment is that in several areas the RFI goes too far and will significantly hinder HIE innovation, deployment and adoption.

If you wish to learn more about CAS, please head on over to the Research Services page and towards the bottom there is a slide deck that provides a prospectus on CAS. If that piques your interest, drop us a line and we’ll be more than happy to answer any further questions you may have regarding the service.

Slowly getting the hang of Twitter and while cruising around the TwitterSphere yesterday looking for updates from the WHIT’08 conference in DC came across a guy providing live tweets from the event.  Looking more closely at his profile, it turns out he works in a “skunk-like” innovations group at Humana, called Humana Innovations.

Like a dog on the scent of something interesting followed the trail to their idea factory, CrumpleItUp.  Very nicely done and gives one a sense of what may be possible, from a Web presentation stand point, if you start thinking beyond columns of text and smatterings of graphics.  Honestly, one of the best sites I’ve come across in sometime.

But I really fell in love with this little group and what they are trying to do when I learned that they are the brainchild behind Freewheel!n.  Freewheel!n is all about providing bicycles to consumers to encourage them to get around via bikes, thus contributing to health (big objective for Humana), goodwill (another Humana win – great PR), eco-friendly, (we all win) and the list goes on.

Freewheel!n made its grand intro at the Republican and Democratic conventions.  Following are some stats off of the Freewheel!n site (stats were cumulative over the 8 days of these conventions).
• 7,523 bike rides
• 41,724 miles ridden
• 1,293,429 calories burned
• 14.6 metric tons of carbon footprint reduction
What’s not to like?

Maybe that Freewheel!n is not in Boston yet, that is still in prototype mode, that we will have to wait to see it arrive in our own fair cities and towns.

Plenty has been written here and elsewhere about various initiatives of payers to encourage healthy behaviors.  Sorry Aetna, CIGNA, United Health, WellPoint, all of the BCBS plans, none of your initiatives have captured my imagination like CrumpleItUp. Humana has broken the mold in reaching out to consumers.

Take a look and learn.

CIGNA has appeared asleep at the wheel for sometime now as competitors Wellpoint and the more aggressive Aetna look to engage the end consumer.

Not any more.

Today’s Washington Post had a brief article on CIGNA’s introduction of the new website, itstimetofeelbetter. Along with the new website, which has a wide ranging and somewhat confusing mix of material, CIGNA is also leveraging social media, ala facebook, and the ubiquitous iPod via podcasts at “CIGNA University” on iTunes.

Checked out the site and it is worth a drive-by just to see how CIGNA perceives the market and what it seeks to offer the consumer.

What I liked:

• The interactive tools (most provided by Healthwise) are fun, though tough to read. Did a quick one on calories burned during my 2hr bike ride this morning (plenty, I get a big desert tonight – did I tell you I ride to eat?). Did another on heart health – looking good.
• Some informative, albeit common content, that one would find just about anywhere via Google search. Nicely presented.
• A “game” to test one’s health knowledge. Taking the test results in CIGNA contributing clean water to children in India.

What I was less impressed with:

• The content/information provided was all over the map. Sure, much of it was consumer facing, but if this is truly a site to educate the consumer, why have a white paper targeting employers?
• If one is going to do something on iTunes, why not get creative and develop a couple of innovative apps for the iPhone/iTouch. A podcast is just so 2002ish.
• Where is the information on PHRs? Absolutely nothing on the subject and a real missed opportunity to educate the consumer.
• How about quality and transparency in healthcare – nothing! How can CIGNA be promoting CDHP to employers while at the same time not educating the consumer on healthcare buying decisions is beyond me.

Bottomline:

Happy to see health plans get out there and try to educate the consumer and in time sites such as this should improve. Question is, will they actually dedicate the resources to do it?

Encourage CIGNA and others to rip a page out of the Google play-book and consider such activities as this as a continual work in progress – iterate, iterate, iterate – it will always be in Beta.