TEDMED 2013: Reactions and Themes

I am just finishing up a packed few days at TEDMED 2013 as a FrontLine Scholar.  There were over 1,800 people there, from a broad spectrum of occupational backgrounds, countries, skills, and areas of interest within healthcare.  This made for an unending cascade of “unexpected connections,” the theme of the conference.  Indeed, though there were many engaging speakers who told stories about turning personal tragedies into discoveries and new passions, to me, the real action at TEDMED was away from the conference stage at “The Hive” (set up with booths showcasing innovators as well as comfortable and open meeting spaces).  I met dozens of amazing people, with whom I had dozens of thought-provoking conversations.  I will follow with another blog post about some of the specific companies that I met and spoke with at The Hive.  There is more to write about from 3 1/2 days at TEDMED than can fit in a “short” blog post.

Here are some of the overall themes that emerged at TEDMED this year:

• Watch your backs! Those entrenched in the current model of the healthcare system need to be innovating and disrupting themselves from within their own organizations, or else risk being out of business in a short number of years.  Lip service to change will not suffice.  There are many, many companies and innovators taking aim at current models of healthcare, and while most of these companies will fail, and while change may be slow and halting, it will happen.
• Bottom-up innovation: Change in healthcare cannot come only from the ivory towers and healthcare professionals.  As a doctor at UCSF, I recognize that this means me.  America Bracho spoke passionately about how innovative ideas should come from within local communities in a bottom-up fashion rather than a top-down manner.  We in the healthcare establishment need not only to listen, but to include the people who are most easily able to identify their actual problems and the potential solutions.
• Interdisciplinary problem-solving: As discussed by Tim Brown in Design Thinking, to creatively and successfully tackle a big problem, an interdisciplinary team is needed.  Five doctors sitting in a room are not going to solve a major healthcare problem.  We need engineers and patients, designers and artists, marketers and people in finance.  We need them to work together.  The cross-disciplinary problems in healthcare require cross-disciplinary attention.  I was encouraged to see how many talented people with backgrounds outside of healthcare are now turning their attention to solving healthcare-related problems.  While some are doing so with a Willie Sutton “that’s where the money is” philosophy, most are truly dedicated to innovating and solving important problems, and we need their energy and their ideas.
• Courage: Have the courage to ask difficult questions that everyone else is afraid to ask, and to pursue the answers in ways that other people are afraid to pursue.

The popular themes among the startup companies at the Hive (or discussed in speeches):

1. Medication adherence.  This was true at the mHealth Summit several months ago and remains true.  There is a lot of attention being paid to trying to track, measure, and improve medication adherence.  Some of the companies at TEDMED: AdhereTx, AdhereTech, GeckoCap, NudgeRx, RxAnte, and others.  There are a number of different approaches being tried, from “smart pill bottles” to reconciling claims data with EHR data.
2. Crowdsourcing.  This concept is being applied across different fronts and in different ways.  Docphin is creating a social experience around reading medical journals, allowing clinicians to see what the most popular articles are in their field or across all fields.  Science Exchange is creating a TaskRabbit for scientific tasks, matching scientists who have a particular skill with those who have a specified task requiring that skill.  UpRise is converging all of the patient education materials that they can into one common platform for distribution to patients.  Crowdmed is applying the wisdom of the crowd to diagnosing diseases.  Roni Zeiger spoke about “networks of microexperts,” allowing patients to share their knowledge and best practices, announcing his company, SmartPatients.  Larry Brilliant spoke about infection monitoring tools for public health, like FluNearYou.
3. Psychosocial and behavioral interventions.  The companies on this list included Empower Interactive, Healthify, Omada Health, and Sense Health.
4. Digitizing the patient. (Slight tangent– Jay Walker made a great point that we don’t really have a word for what to call people in the healthcare context who aren’t sick, ie not “patients” in the traditional sense.  Do we just call them healthcare consumers?)  There is a ton of work being done in terms of capturing physical and biometric data to augment the clinical data available today, both expanding the scope of the type of data we currently collect but also expanding out into the home (shameless plug for my JAMA Internal Medicine commentary).  At MIT, they are developing a portable set of glasses that allow an easier view of the retina as a “window into systemic diseases.”  There are sensors for everything– oxygen, heart rate, falls– you name it, somebody is building it, and the data is most often now able to be transmitted wirelessly to somebody, somewhere (what we’re going to do with all of it workflow-wise is another question for another day!)

I would love to hear from others who were at TEDMED or following via Twitter or TEDMEDLive to hear your thoughts and opinions.  I’ll be blogging more later about other aspects of TEDMED…

 

Asthmapolis: Why Can’t Inhaler Sensor Be Adapted For Diabetes and Insulin Pens?

Asthmapolis, which launched in 2010, has been in the news the last few days after announcing a $5 million series A venture capital round of funding.  They are an innovative mHealth company that is focused on improving care of asthma through a combination of hardware and software.  They developed a small sensor that attaches to the top of an asthma inhaler and wirelessly synchs with your smartphone.  The data can then be tracked, viewed, analyzed, sent to a physician, used for clinical research, etc.  Anything you can imagine.  The frequency with which someone uses their inhaler is often directly tied to how severe their asthma is, and can predict which people are headed for trouble.  So, rather than each squirt of an inhaler being an invisible act lost to history, it can now be tracked and used to generate meaningful data to help patients (and for research).  This is exactly what mHealth is all about.  The innovators at Asthmapolis have developed a relatively simple and straightforward intervention that should add no additional hassle to a patient’s life but might be life-saving if it can serve as an early-warning system for worsening asthma.

Taking this one step further, we need to have such an add-on piece of hardware for insulin pens for use by people with diabetes. It is obviously not exactly the same: with an asthma inhaler, one press is one dose, whereas with an insulin pen, it would have to be able to capture the exact amount given; with asthma, an increasing use of an inhaler could be a sign of impending trouble, whereas with diabetes, daily fluctuations in insulin dose can often be a normal pattern.  However, there are enough important parallels that make this an invention that we need in the diabetes world.  We are always asking our patients to keep track of how much insulin they use, but it is an extra task for them in their already busy lives, one which could relatively easily be automated.  I’ve still yet to see a prototype of such a device for an insulin pen outside of the GluBalloon project from MIT about a year ago.  I hope that there is more to come in the near future for us in the world of diabetes.

Best of luck to Asthmapolis… they look to be poised to make a major difference in the lives of people with asthma.

 

The Future of Diabetes Management: Social Networking and New Technologies

I gave a talk yesterday to a great crowd at the annual UCSF CME conference, Diabetes Update.  The slides from my presentation, “The Future of Diabetes Management: Social Networking and New Technologies,” can be viewed on Slideshare.

mHealth is “so hot right now”… Ten themes from the 2012 mHealth Summit

To quote Mugatu, Will Farrell’s character in Zoolander, mHealth is “so hot right now.”  In this spirit, nearly 4,000 people came together for the past several days outside of Washington DC for the 2012 mHealth Summit organized by mHIMSS.

For anyone who was sitting at home and playing buzzword bingo during the conference, here are the words that would have comprised the winning row: interoperability, gamification, wellness, big data, social, consumer, adherence, re-admission.

 

My Top Ten Takeaways From the 2012 mHealth Summit

1) mHealth adoption will be consumer-driven.

At this point, I think few people question this.

2) User interface and user experience are lacking.

Because of point 1 above, user experience and user interface are critical.  For something to have durability (or “stickiness”) with consumers, it is going to have to be simple, engaging, intuitive, and heck, maybe even delightful.  Most of the current crop of products has work to do here.  One up-and-comer in the StartUp Health class that I really enjoyed seeing was designed by a RISD graduate and is called Thryve.  I have also yet to see a person interact with the ECG-in-an-iPhone-case, AliveCor, and not get excited.  More products need to generate these enthusiastic reactions.

3) We need to use mHealth to solve real problems, and do so in thoughtful ways.

Sometimes the trouble with an mHealth app is simply that it wasn’t designed based on a real clinical problem or need.  No amount of snazzy UI can fix this.  I was encouraged to meet many very intelligent and thoughtful people at the conference who are working hard on big problems and using rigorous, scientific approaches, for example Ginger.io and the team at University of Toronto, among many others.

4) Business models are still being worked-out.

There are still not a lot of success stories to guide the industry and everyone seems to be feeling their way around in the dark.

5) Corporate wellness is “so hot right now.”

One of the proposed business models that seems to be popular is to market a product to large employers as a method for improving employee wellness.

6) Scott Peterson (Verizon): “We cannot allow walls around data to continue.”  We need real interoperability.  

Although the term “interoperability” falls into the “so hot right now” category, this often seems to mean, “I want everyone else to interoperate with me.”  I participated with Open mHealth at the conference, who is trying to foster a community towards the goal of true interoperability.  Open mHealth recognizes that patients should be the ones to control access to their own data.  I hope the rest of the industry catches up to this idea.

7) Physicians need to change.  Now.

Vinod Khosla famously and provocatively predicts that “80% of the work that physicians do today can be done in the future by computers.”  Everyone can waste their time arguing the details, but would be better off realizing that the spirit of this comment is accurate, and instead focus on how to facilitate and shape this transition.  This does not mean that 80% of doctors will not be needed.  It means that what we do will change.  Big data, analytics, and artificial intelligence will be able to do many tasks better than physicians.  I, for one, am happy about this… I believe that these tools, when built properly, will make me a far more effective and efficient physician.  My colleague at UCSF, Dr. Seth Bokser, told me that he focuses training his pediatric residents on empathy and decision-analytic skills, worrying less about rote memorization and knowledge.  He’s right, and medical education should reinforce this.

8) Research techniques are needed that better fit mHealth.

There was an excellent panel at the conference where this was discussed by Dr. Joe Caffazzo from the University of Toronto and Dr. Bonnie Spring from Northwestern.  The general consensus was that traditional randomized controlled trials (RCTs) are too slow and too expensive, and that by the time they are completed, the technology they are studying may often be obsolete (Dr. Spring gave the example of a recently-completed RCT using a Palm Pilot!).  Usability testing and other qualitative methods are important for building a good, user-centered product, but may not provide high-quality evidence for clinical effectiveness.  Newer models are needed.

9) Despite being a buzzword, “wellness” actually is important. 

The current healthcare paradigm focuses too much on treatment of end-stage diseases.  In so many cases today, these diseases are all linked by stemming from the milieu of obesity, insulin resistance, and inflammation… heart attacks, strokes, sleep apnea, diabetes, kidney disease…  I think that “wellness” as a buzzword grates on people when it is used in the context of the “worried well” obsessing over minor details.  But as a US and world population, where the above health problems are becoming overwhelmingly expensive, we really do need to figure out (and soon!) how to promote healthy eating, exercise, and other good lifestyle choices for those who are not yet on board.

10) Take the stairs.

There was a lot of high-tech, whizz-bang, cutting-edge stuff on display at the conference.  And yet every time I looked, at least 90% of the people seemed to be taking the escalators instead of the stairs between conference sessions (reminding me of the below photo).  If the 4,000 people in the US who are the most gamified, FitBit’ed, and social networked won’t take the stairs, we must still have our work cut out for us.

 

 

New diabetes social app, Diabesties

Story at DiabetesMine about Diabesties.

MedX 2012 Conference at Stanford

I spent a few hours this morning watching the livestream of the MedX conference at Stanford organized by Dr. Larry Chu.  From the portions I have been able to watch, this looks so far to be a really great conference.  The speakers this morning included a panel of self-trackers, Dr Paul Abramson (a physician who uses self-tracking in his office), Anne Wright of BodyTrack, and Sean Ahrens of Crohnology.  As I’ve always found with the mhealth and quantself communities, even from my office on the other end of the peninsula watching the video via livestream, the energy, excitement, and passion are phenomenal.  A few themes and ideas stand out from MedX itself and from the Twitter feed #medx, meriting some discussion.

1) Self-tracking is about the process, not the data.

This is absolutely true.  Using diabetes as a reference point, just looking at data for the sake of data is a waste of time.  People with diabetes make decisions all day, every day, most of which are minor and subtle decisions driven by habit.  Looking at data might help them make changes, but it’s not very likely.  More important is that they actively engage with the data and learn from it.  This process leads to crucial education about the self and personal habits that might help lead to different behavior the next time they are faced with a decision.  The act of gathering the data itself also enables personal exploration and revelations that would not be otherwise possible.  Self-care behaviors and self-awareness have no choice but to improve if someone is actively engaged in self-tracking.  Data should include not just numbers but life stories and context for what was going on at the time the numbers were collected.

2) Patients want doctors who believe them.

We heard this from many of the self-trackers and e-patients at MedX.  There are many patients who have found our current healthcare system too impersonal and uncaring.  I’ve heard this over and over, seen it happen in places where I work, and experienced it with family members.  There are a million reasons why this has happened and changes have to be made to medical education and healthcare economics in order to start making patients feel cared for again.  Regardless, we have no excuse.  No matter what pressures exist on doctors, we must retain compassion for the person sitting in front of us.  Everything else follows from this simple rule.

Sometimes, the problem can be that our current body of medical knowledge and experience is inadequate and only scratches the surface of the true pathophysiology of human disease and suffering.  All physicians have had experiences with patients where we listen to the patient describe their symptoms and we know something is wrong, but we have no diagnosis, no terminology with which to describe their particular situation.  This is always an incredibly frustrating experience for patient and physician alike.  As physicians, we are left not quite sure what to do, which frustrates us, because we are trained to do (though we should more often be like jazz musicians and place more focus on the empty space, ie what not to do).  Despite our frustration, physicians still have a choice in these situations.  The patient’s symptoms can be believed and empathy given, or the patient can be told, “I don’t know what you have, but at least you don’t have ______.”  I’d imagine patients prefer seeing physicians who do the former.

3) Patients want doctors who are willing to engage with their self-tracking data.

Even as a self-tracker and innovator in diabetes data and tracking, I find this leads me to some internal philosophical conflict.  Do I believe that self-tracking will help many patients improve their health?  Yes.  Do I believe that gathering self-tracked data will play a major role in the future of healthcare?  Yes.  Do I want my patients to self-track and to share their data and their experiences with me?  Absolutely!  Does the healthcare system have the resources and ability to handle this?  No.  Not right now.

First: We’re not ready yet for self-tracking data from a technical standpoint.

The simple fact is that most healthcare organizations are still trying to get an electronic health record implemented.  Getting self-tracked data into EHRs may be on the radar, but it is not imminent.  Once we have self-tracked data in the EHR, then what?  At least the patient’s medical record then becomes more whole, but EHRs have already left physicians in the position of having information overload, and this is in a situation where physicians already lack sufficient time to spend with each patient.  New piles of data will only exacerbate the situation.  Smarter ways of organizing and filtering the information are going to be absolutely necessary to make this manageable and to allow physicians to use the data with patients in the way it should be used.  (As a slight aside, having a single, unified patient-centered record is also a precondition for a functional system.  None of this works if each patient has their data fractured over ten different healthcare organizations, PHRs, and websites.)

Second: We need to find the proper place for self-tracking tools and data within healthcare, which requires a better understanding of their effect on healthcare quality and costs. 

There was a Twitter comment in the #medx stream expressing outrage, saying, “Cannot believe that some diabetes tracking tools are not covered by some insurers. Absolutely nonsense!! give them the tools!!!”

This was in reference to a panelist with type 2 diabetes who used a Dexcom CGM and had to pay for it out of pocket.  This Twitter comment shocked me.  It is not news to anyone that the resources of our healthcare system and entire economy are strained by rising costs.  There is just no way it is sustainable, acceptable, fair, ethical, or you-choose-the-word-to-put-here for everyone to expect that their healthcare insurance should cover every device they want.  Our country has to stop expecting this.  While there have been many new devices in healthcare that have achieved better health at a reasonable cost, history is littered with examples of new devices that have either been overwhelmingly expensive for minimal health benefit or have flat-out had negative impacts on health.  So, there simply HAS to be research done (hopefully efficiently and effectively) showing that a new device has health benefit, and at some reasonable cost, before we expect insurers to cover the device.  Using the specific example of a CGM for a type 2 diabetes patients, there are too many people in the country who don’t even get basic, proven care for type 2 diabetes, like eye and foot exams, blood pressure control, or metformin, for us to be claiming that all insurers should be covering this device for all type 2 patients.  If a patient wants to pay for an unproven device or treatment out of pocket, I have no qualms, but we cannot expect society to pay.

This serves as a clear reminder to those of us innovating in healthcare that successful innovation will be mindful of the value equation, ie either better healthcare quality or lower cost, or ideally both.  I’m incredibly optimistic and excited about what lies ahead in healthcare innovation, because I think we will create things that improve healthcare value.  I believe that self-tracking will be a major component of this, and will be especially important in empowering patients, bringing new and critical data into the doctor’s office, and creating a new paradigm for the doctor-patient relationship.

What a great conference!  Thank you to Dr. Chu and all of the speakers, panelists, attendees, and other remote attendees!

GreenDot website now live…

As our team gears up for Demo Day on May 16, our GreenDot website is now live.

There was also a very nice article written about us in MedCityNews by Stephanie Baum:

Two clinical trials ongoing with diabetes mhealth

There are two ongoing clinical trials to be aware of.

One is at the Univ of Maryland and is using the forementioned Telcare meter.  This study is a 6-month pilot study taking 100 patients with diabetes (both types 1 and 2) and randomizing them to either typical glucose meter or the Telcare meter.  The outcome measures will be to see if connecting the patients via the Telcare meter will improve self-monitoring of blood glucose (SMBG) compliance, to see if A1c is affected, and to see if patient satisfaction is improved.

The other is being sponsored by a company called Diabetech with a link to the trial information here.  This study is using an investigational device designed by Diabetech that attaches a self-contained wireless accessory to a glucose meter, and then transmits data to a centralized data management system.  The system then analyzes the data and either sends educational materials to the patient or alerts or reports to the healthcare team.  The primary outcome measures in this study are glucose control and patient satisfaction.  The secondary outcome measures are HbA1c, self-test frequency of glucoses, and standard deviation of HbA1c and SMBG.

Two quick links: Telemedicine at the Joslin and iPhone app reviews

1) The Joslin Diabetes Center at Harvard is creating a telemedicine platform so that they can start doing long-distance diabetes consultations.

I’ve been doing a lot of “VTel” (VA slang for videoconferencing) at the VA this past year for diabetes consultations.  While they aren’t a perfect substitution for a face-to-face conversation, they do generally seem to get the job done and save our remote patients a lot of travel time.

2) Reviews by Marisa Moore of 10 iPhone diabetes apps.

I have not yet tried most of these applications, but my overall feeling is that the current generation of smartphone apps for diabetes are not going to take us very far.  There are several reasons for this.  The main reason, as I’ve discussed in previous posts about Glooko and the iBGStar, is that asking patients to manually enter blood sugars after doing a fingerstick is an unworkable workflow.  Also, with the way data is currently displayed, the iPhone screen is too small to glean anything useful.  A lot of apps have education modules, which may be useful, but I think to really gain traction, education will have to be personally targeted to the right patient at the right point in time.

iBGStar turns your iPhone into a glucose meter… on sale in UK now

Still not available in US (though finally FDA approved), but now available in the UK, is the iBGStar from Sanofi.  This device is similar in spirit to the Glooko iPhone connector dongle that I recently wrote about here.

This is a very exciting device because it will allow patients to electronically capture their blood sugars without any extra work.  No more transcribing numbers into a logbook, either a paper one or even a digital logbook.  As soon as you check your blood sugar, the number is already captured into a digital logbook with no extra work.  This device clearly has an advantage over the Glooko solution in that the data is collected in real-time, rather than needing a connection and download the way the Glooko does.  The introduction of real-time data upload brings the possibility of shorter and faster feedback loops between patient and clinician.  There is also no extra hardware to potentially lose, since the extra hardware is your glucometer.  Glooko’s advantage is that it works with many existing glucose meters, so you can get the one covered by your insurance, and still easily digitize the data.  So, they each bring a unique new capability to glucose monitoring that should be welcome.