3. Wireless body monitoring
We need only to listen to the words of FCC chairman Julius Genachowski to get a feel for the potential for wireless body monitoring. Genachowski noted last year that “a monitored hospital patient has a 48% chance of surviving a cardiac arrest,” compared with only 6% for an unmonitored patient.
With the tremendous opportunity for improving health care in mind, the FCC proposed allocating spectrum for Medical Body Area Network, or MBAN, devices. Such devices will record vital signs and other important physical information through sensors attached to a person’s body, with the data transmitted to a local wireless hub. The information can then be monitored remotely by clinical professionals, with alerts sent to let these experts know when medical intervention could be needed.
GE Healthcare (NYSE: GE) is one company already developing MBAN devices. The giant company plans to introduce technology using sensors that monitor heart and breathing rates, temperature, and pulse oximetry within the next few years. Deloitte predicts that the wireless body monitoring market could more than triple in just the next couple of years. Within the next decade, this technology could be key in helping control overall medical costs.
China is expanding its health care system and aiming for universal coverage for its 1.35 billion citizens by 2020. The report estimates that the country alone will make up 34% of the global growth in medication spending over the next five years.
When we look back at contemporary health systems 50 years from now, we will consider them to be an technologically indulgent folly of grand proportions, driven by an imperative to deliver more and more complex care in order to justify higher and higher costs.
In a fee-for-service context, elaborate technologies justify higher costs. An elective angiogram costs $25,000. If this had to be paid by individuals, there would be no interest in conducting them with the frequency that they are performed today.
Perhaps this is why Singapore, with its health savings accounts with health costing around 4% of GDP (achieving the same high outcomes of Australia), lacks the excesses of more universal health systems?
The use of bariatric surgery for obesity is perhaps the most egregious example of this phenomenon. A AU$20,000 – 30,000 procedure is now introducing moral hazard that will undermine attempts to introduce behavioural and lifestyle change i.e. “Why bother changing my lifestyle when I can simply get a lap band to fix me later?”
Pharmaceutical companies are also using this play book with the introduction of their new, highly-specialised, so-called “biologics” to the market, particularly in the cancer area. They are often protein based and extremely difficult to manufacture, but are also very targeted. Funders are responding to this threat with value-based payment schemes where by the drug company only gets paid if the treatment succeeds.
Current health market settings establish this perverse incentive. Moves to value/outcomes-based care will remedy these perversities, providing incentives for activities that reduce care costs. In such an environment, the cheapest interventions also become the most profitable.
Home delivered broccoli instead of lap-bands.
CBT SMS’s instead of SSRIs and psychotherapy.
A rapid learning health system instead of a profit yearning sickness market.
Curing Type 2 Diabetes with Surgery: It Works — Now Let’s Figure Out Why
During my endocrinology training, I was captivated by a phenomenon I’d seen on the wards, and had just started to read about in the literature: type 2 diabetic patients receiving bariatric surgery exhibiting rapid, seemingly instantaneous improvements in their glycemic control, apparently related to profoundly reduced insulin resistance as a consequence of the surgery.
The first teaching seminar I gave as a fellow, at Endocrinology Grand Rounds, asked the distinguished medical faculty who gathered in the Ether Dome, “Is Diabetes a Surgical Disease?”
At the time, the answer was, “Yes?” Now, two recent reports presented today at the ACC, and simultaneously published in the NEJM (here and here), seem to upgrade this answer to “Yes!”
Both reports conclude that bariatric surgery surpasses medical therapy as a treatment for type 2 diabetes, and are fascinating not only because of the immediate clinical implications (as discussed by Matt Herper here, and in anNEJM editorial comment here), but also because there’s some really cool underlying science that nobody seems to understand.
The fundamental paradox is the same mysterious clinical phenomenon that so intrigued me years ago: the drastic improvement in diabetic function that occurs significantly before most of the weight is lost.
The authors of the first study note, “Reductions in the use of diabetes medications occurred before achievement of maximal weight loss, which supports the concept that the mechanisms of improvement in diabetes involve physiologic effects in addition to weight loss, probably related to alterations in gut hormones.”
The authors of the second study were also struck by the rapid improvement in glycemic control they observed, reporting that all patients treated surgically were able to discontinue all their diabetes medicines within fifteen days of their operation – a remarkable result (and entirely consistent with my own clinical experience). Almost all of the surgically-treated patients remained free of diabetes after two years, while none of the medically-treated patients were as fortunate.
As the authors write, “there was no correlation between normalization of fasting glucose levels and weight loss after gastric bypass and biliopancreatic diversion, findings that are consistent with results of previous studies, which suggests that such surgeries may exert effects on diabetes that are independent of weight.”
The authors also point out this result is in contrast with gastric banding procedures (which constrict the stomach but don’t otherwise alter the anatomy); the improvement in diabetes seen in those patients does appear to correlate more directly with weight loss.
The intriguing scientific question is how can bariatric surgery result in an almost immediate improvement in the insulin resistance profile of diabetic patients? To my mind, this is among the most important unanswered questions in endocrinology, and medical science more generally. While the effect is generally attributed to “gut hormones” (as the authors of the first study write), the biology beyond that gets a bit murky.
To be sure, some companies are working on it – the example that springs first to mind is NGM Biopharmaceuticals, a small Bay-area biotech (with which I have no personal nor professional connection) founded in 2008 as an ambitious science play by The Column Group, Rho Ventures, and Prospect Venture Partners. I’m sure others are working on this challenge as well.
A final point – as attracted as we are to the view of basic science driving clinical medicine, the experience with gastric bypass surgery arguably exemplifies the reverse, and represents a triumph of empiricism, as well as a reminder of the value of human physiology (see here), and more generally, the importance of studying people (and not just parts of people).
It also would not be the first (nor will it be the last) time that medical sophisticates learned a valuable lessons from those laboring – often, as in the case of many bariatric surgeons, with inadequate respect – on the front lines of patient care.
TRACKED SINCE BIRTH: THE RISE OF EXTREME BABY MONITORING
DOES TRACKING A BABY’S EVERY MOVEMENT, CRY, AND WET DIAPER MEAN HAPPIER PARENTS AND HEALTHIER INFANTS, OR ARE WE TURNING OUR KIDS INTO TAMAGOTCHIS FOR NO REASON?
For the first 10 months of her life, her mother, Yasmin, kept detailed records of Elle’s sleep patterns, feedings, and diaper changes, noting the data points with a pencil and paper on a clipboard. A few months in, she digitized the logs, graphed the data, and became a more knowledgeable parent.
“It helped me feel confident,” she told Fast Company.
Elle wasn’t a very good sleeper, even for a baby. The pediatrician told Yasmin she needed to let her daughter “cry it out” until she fell asleep, but that never worked. For the sake of her sanity (and sleep), Yasmin took problem solving into her own hands. She wanted answers: Did she put Elle to bed too early? Too late? Give her too many naps? Parsing data, she thought, would help her figure it out. “That was the kind of stuff we were looking for,” she said.
Unfortunately for the Lucero family’s sleeping habits, Yasmin never found a definitive answer. Per the data, Elle was just fussy.
The results suggested Yasmin couldn’t engineer better naps, as she’d hoped. Just knowing that, however, made her feel better. “If you come to the conclusion that you have no control, then it’s okay to relax and just do whatever is convenient for you at the moment,” she explained. (Of course, many parents come to this conclusion at the moment of birth, without all that tedious data tracking.) But for Lucero, a conclusion–any conclusion at all–was all she wanted.
Many new and sleep-deprived parents crave that peace of mind and would kill for a data set that helped them determine if putting little Emma down an hour earlier would mean a restful night for the whole family. But unlike Yasmin, most people aren’t trained statisticians. Tired moms and dads with no mathematical background aren’t about to write down hundreds of data points, and might not know how to analyze that information anyway. Twenty-two months into Elle’s life, even Yasmin has semi-abandoned the project, and keeps much less rigorous records now.
In the imminent future, though, any curious parent with an iPhone will have access to helpful analytics, thanks to the rise of wearable gadgets for babies. Following the success of self-trackers for grown-ups, like Jawbone and Fitbit, companies likeSproutling, Owlet, and Mimo want to quantify your infants.
Mimo Onesie
These devices connect to a baby via boot, anklet, or onesie, and record his or her heart rate, breathing patterns, temperature, body position, as well as the ambient conditions of the room. They aim to replace baby monitors, which give an incomplete picture of a sleeping child. There’s also the nascent “smart diaper” market, led by Pixie Scientific, which scans dirty diapers for signs of infection.
In addition to alerting parents of any concerning findings, these companies encourage a big-data approach to parenting. By gathering information on your kid’s poop, sleep, and eating schedules, the idea goes, you can engineer a happier, healthier baby. The accompanying app for the Sproutling monitor, for example, looks at patterns specific to your child and its environment to offer insights–the kind that Yasmin craved–that might help the child sleep better. It might find that little Jake naps better in complete dark, for example.
The Sproutling monitor
In theory, all this data will lead to more rested, relaxed parents and healthier kids. As of now, parents do a lot of this in the dark. “There’s no owner’s manual,” Sproutling CEO Chris Bruce told Fast Company. His company hopes to change that. “It’s smart technology that helps raise the parenting IQ.”
When Bruce talks about “parenting IQ,” he doesn’t just mean his customers. Sproutling and its cohorts want to use their arsenals of data to better inform research. “The promise of big data is that we can monitor every single environmental parameter and we can find correlations and detect patterns,” added Bruce, calling big data the “holy grail” of his business. Both Owlet and Sproutling indicated that they will offer up their intel–anonymously!–to researchers so that all future parents can better understand babies.
Parents like Yasmin, who haven’t had a full night of sleep in months, are desperate to have that information. She didn’t want to know average sleep patterns–information available in baby books–she wanted bell curves. Yasmin knew her baby wasn’t normal, but she didn’t know how abnormal and her own analyses couldn’t clarify that, either. “I wasn’t finding the exact data I wanted to see,” Yasmin said, after scouring the Internet for answers.
An aggregation of Yasmins, however, can provide those insights. At least that’s the hope.
What sounds like a lot of progress for parenting also means handing a digital record of your baby over to an iPhone app. Are the benefits worth that?
While these apps could improve infant health by telling a parent the exact right nap or changing time, the app in large part benefits parents. Anxious first time moms and dads who worry about every little movement (or non-movement) can monitor their children more closely than ever. “You see your baby lying there and you don’t see them moving,” Bruce, who has two young daughters, said of his experience with old-school video monitors. “You can’t see them breathing; your first thought is: ‘Oh my God, something is wrong.'”
Unlike a basic $35 baby-monitor, the $250 Owlet bootie and accompanying app can alert parents if anything serious has gone wrong, like if a kid stops breathing, or if his heart stops beating. That means no more unnecessary freakouts for the over-protective and inexperienced dad like Bruce, which leaves more time for him to do other dad things.
But, to an extent, these apps take advantage of parent anxieties. “SIDS is the number one cause of infant death. That’s really scary to parents,” Jordan Monroe, a cofounder of Owlet, told Fast Company. Monroe has no kids, but while talking to friends and friends of friends with babies, he found that to be a common worry.
Those fears don’t come from a place of reality, though. According to the Center for Disease Control, 4,000 infants die each year from Sudden Unexpected Infant Death. Only a fraction of those deaths occur because of “accidental suffocation and strangulation in bed,” according to the CDC report. And even SIDS–which causes about 2,000 deaths a year–might stem from underlying brain issues, according to recent research. Monitoring a child’s breathing with a high-tech bootie won’t cure SIDS.
As anyone who has ever had any contact with a hypochondriac knows, those facts don’t really matter. Parents will continue to worry. And, as we saw with Yasmin, certainty has a lot of value. A certain type of parent, like TechCrunch’s Leean Rao, thinks that $250 for Owlet or $200 for Mimo’s version–Sproutling hasn’t yet announced pricing–is a reasonable price to pay to worry about one less thing. In her review of Sproutling, she writes:
As a relatively new parent myself, I would have loved to be able to use some of the data from a wearable to help determine optimal sleep patterns for my child. I’m not sure if it would have helped my daughter sleep through the night earlier in her development, but to me as a fledgling parent, knowledge is power.
Of course, the dollar amount is only a part of the price parents pay with these apps. They give up their children’s data and possibly privacy. “We’re creating the largest data set of infant health data,” Monroe said–a chilling statement in certain contexts. Trackers could turn around and sell their troves to insurers or be forced to hand them over to the government. The information is also vulnerable to hackers.
These companies say they take security issues seriously. “Security encryption has been designed in our system from the get-go,” said Bruce. Anonymous sharing with researchers is both opt-in and anonymous for Sproutling users. But, even Bruce admits that our cultural acceptance of privacy changes every day. What seems innocuous today might feel invasive tomorrow (or vice versa).
Is that risk worth the stated benefits? At this point, it’s not clear these monitors offer many health solutions. The breathing and sleeping alerts will calm (and draw) a lot of parents. But, none of these companies see that as the “holy grail.” The main sell is the tracking. And what does that do for parents and babies?
Arguably, it means finding those little tweaks that make life easier. But, as Yasmin discovered, sometimes babies fuss just because. Numbers don’t always offer solutions, as technical theorist and staunch critic of the self-quantified movement Evgeny Morozov wrote in his book To Save Everything, Click Here: The Folly of Technological Solutionism. “Self-trackers gain too much respect for the numbers and forget that other ways of telling the story–and generating action out of it–are possible.”
While pediatricians typically ask new parents to chart and report feedings and bowel movements for a few weeks after bringing babies home to make sure all systems are go, obsessive tracking beyond that could get in the way of parenting, some doctors say. “Often, when babies have regained their birthweight and are 10-14 days old, I instruct families to dial the tracking down,” Dr. Wendy Sue Swanson wrote on her blog. She adds:
I want new parents to gain confidence and appreciate the homeostasis with following a baby’s natural routine. Relying only on the numbers may cause parents to miss out on the nearly unspeakable experience of parenting a new baby and all that a baby intimately communicates from the beginning. It’s better to look up at the sky to know if it’s raining than to consult the weather report on your iPhone.
After all, do you really want to treat your child like a Tamagotchi?
despite the noise regarding safety, quality and health reform, and in particular payment reform from fee-for-service to value-based-payment, the truth is that practically all providers and provider organisations are simply focused on one thing: MAXIMIZING REVENUE
It’s fun to read about cool technology, big data, and innovation incentives, but the reality is that in the trenches, many (I’d say most) providers and provider groups feel that they are locked in a deadly battle with payors (and increasingly, other providers) for their livelihoods; many feel they are having to work harder and harder to bring in the same (or less) money then doctors a generation ago.
Many feel that the profession has lost the autonomy and respect it used to enjoy, and that providers are now viewed as mechanized assembly line workers, held to strict quantitative “quality” metrics that rarely capture the complexity, or essence, of the patient experience.
Health policy discussion these days focuses extensively on the idea that medicine is changing, moving (maybe slowly, maybe rapidly) from a fee-for-service to a fee-for-value world, where providers and hospitals own risk, and are incentivized to reduce costs and improve care, a win-win situation for all.
It’s possible such change is happening – somewhere, or in some parts of some organizations.Yet, most providers with whom I’ve been speaking tell a starkly different story. The view from the front lines suggests that hospitals and care delivery systems are obsessing like never before on doing whatever they possibly can to maximize their revenue. They are consumed, utterly consumed, by this objective.
It’s touching to read accounts from Ashish Jha and others describing benevolent CEOs concerned about patient care and safety; the hospital executives I’ve been hearing about tend to talk a good game about safety, and may even genuinely care about quality, but they are focused on, driven by, and hired for their skill at maximizing revenue – a prime directive that quickly percolates its way through the entire care system.
I know of examples at non-academic centers where doctors are refusing to see patients who don’t carry “good” insurance, citing miserable rates of reimbursement – rates they point out can be lower (sometime much lower) than what professional trainers often make.
At academic centers, publishing papers is certainly encouraged, but making your “RVUs” (i.e. seeing enough patients) is prioritized – and failing to do so can get you canned.
Hospital records are routinely reviewed in detail to ensure every opportunity for “revenue capture” has been identified.
The reason to highlight what seems to me the current state of medicine (and yes, this is anecdotal, but I suspect that if anything, this description understates the magnitude of the situation) isn’t so much to critique it as to surface it, and remind readers what healthcare actually looks like today — a reality that seems far more Hobbesian than what’s often imagined, presented, and discussed.
It’s fun to read about cool technology, big data, and innovation incentives, but the reality is that in the trenches, many (I’d say most) providers and provider groups feel that they are locked in a deadly battle with payors (and increasingly, other providers) for their livelihoods; many feel they are having to work harder and harder to bring in the same (or less) money then doctors a generation ago. Many feel that the profession has lost the autonomy and respect it used to enjoy, and that providers are now viewed as mechanized assembly line workers, held to strict quantitative “quality” metrics that rarely capture the complexity, or essence, of the patient experience.
It’s hard to envision this is sustainable – you can only increase the speed of the treadmill so much.
Rather, the question is what comes next for medicine – how will care be delivered, and who will be delivering it?
PATIENTS with type 2 diabetes spend an extra hour a year with their GP compared to other patients, according to new data which has prompted renewed calls for an improved approach to funding for management of the condition.
The findings, from the latest Bettering the Evaluation and Care of Health (BEACH) study, published this week, showed the average patient spent 1.6 hours a year with their GP, while those with diabetes spent an average of 2.6 hours.
The report, General practice activity in Australia 2012–13, noted those with diabetes also spent time with a range of allied health professionals as well as practice nurses.
With the management rate of the condition increasing by 33% over the past decade, the authors said type 2 diabetes was “very resource intensive” and was “bound to increase in future”.
BEACH director Associate Professor Helena Britt said type 2 diabetes now accounted for 8% of GPs’ workload and that patients with the condition visited their doctor an average of eight times a year compared to the national average of 5.6 annual visits.
Patients with diabetes had their condition managed at half of their GP consultations, according to the report.?
Brisbane GP Dr Gary Deed said the data confirmed the need to improve funding models for the management of diabetes in general practice.
Dr Deed, who is a director of Diabetes Australia’s Queensland arm and chairs the RACGP’s National Faculty of Special Interests Diabetes Network, said he hoped the Coalition government would undertake a consultation with GPs “at the coalface” as part of efforts to develop a long-term approach to diabetes management. ?
With the majority of patients also having at least two other comorbidities, he said a block funded model, such as the one being trialled under the Diabetes Care Project, created problems with regard to funding of the patient’s whole care.?
Meanwhile, the report found GPs made 7.6 million more referrals in 2012–13 than they did a decade ago with the increase split almost evenly between referrals to medical specialists and allied health services. A total of 126.7 million GP services were claimed through Medicare in 2012-13.?
The report also stated that despite spending on average three hours less per week providing direct clinical care than a decade ago, GPs were dealing with an increasing number of health problems during each consultation.
“Dementia is our most-feared illness, more than heart disease or cancer,” Perlmutter says. “When you let Type 2 diabetics know they’re doubling their risk for Alzheimer’s disease, they suddenly open their eyes and take notice.
Gluten is addictive – it takes a couple of weeks to escape withdrawal
MIT’s Hacking Medicine program believes that entrepreneurship is best suited to tackle health’s largest problems
he best healthcare solutions alleviate suffering at scale, often via technology to de-skill medicine, increase quality and lower costs, thus broadening access
Clinicians often get in habits and practices that are hard to change
Be a missionary, not a mercenary. Find a mission and customer with whom you truly empathize. The rest will come if you use that as your compass.
Entrepreneurship is not academic, though one should try to be strategic you don’t need an MBA.
The most important aspect of entrepreneurship is the entrepreneur’s mindset: to have a mission, clear use case and the persistence to solve it creatively.
Broad realization that technology can be used to scale medicine at a broader systems + population health
Changing healthcare reformsin the US is aligning incentives for better systemic healthcare
Large entrenched healthcare institutions are having a tough time adapting versus more agile startups
Start up costs have plummeted, so it’s more capital efficient than ever
The ubiquity of mobile computing and low cost diagnostics and sensors make health data liquidity and tracking easier than ever
Rising middle classes and health infrastructure in emerging economies are expanding access and demand globally
Why it’s the best time to be a healthcare entrepreneur
We caught up with Zen Chu, the founder of HackingMedicine and the current Entrepreneur in Residence at MIT to ask him some burning questions about digital health and entrepreneurship. Hear more from Chu at our sold out Healthcare Bootcamp in Boston tomorrow, along with thought leaders from athenahealth, MC10, IDEO and others.
What was the impetus for starting HackingMedicine?
We started MIT’s HackingMedicine program to push a philosophy that entrepreneurship is best suited to tackle healthcare’s largest problems. Housed within the Trust Center for MIT Entrepreneurship, it serves as a place to welcome non-healthcare engineers and entrepreneurs and connect them to Harvard Medical School and connect them to Harvard Medical School, the Health Sciences & Technology joint graduate program between MIT and Harvard, and Boston’s wonderful teaching hospitals. Our content and most programs are open to everyone and the mission is to infect more entrepreneurs to tackle healthcare problems.
How do we better engage clinicians in technology innovation in healthcare?
The best healthcare solutions alleviate suffering at scale, often via technology to de-skill medicine, increase quality and lower costs, thus broadening access for more people around the world. Clinicians often get in habits and practices that are hard to change. Our Healthcare Hackathons have brought hundreds of clinicians and health professionals together with entrepreneurs, engineers and hackers. We have now moved over 1500 participants through hackathons on 4 continents and we believe the process we have developed and freely teach is one of the best ways to identify unmet healthcare needs and bring diverse perspectives together to create high impact and creative solutions.
What is the number one piece advice you have for entrepreneurs?
Be a missionary, not a mercenary. Find a mission and customer with whom you truly empathize. The rest will come if you use that as your compass.
How do you ‘teach’ entrepreneurship?
Learn through doing. Entrepreneurship is not academic, though one should try to be strategic you don’t need an MBA. Classes and books can only go so far and every startup or technology is it’s own beast depending on the team and challenge. I think the most important aspect of entrepreneurship is the entrepreneur’s mindset: to have a mission, clear use case and the persistence to solve it creatively.
You’ve said it’s the most exciting time to be an entrepreneur? Why now?
This is truly the best time in the history of the world to be a healthcare entrepreneur:
Broad realization that technology can be used to scale medicine at a broader systems + population health
Changing healthcare reforms in the US is aligning incentives for better systemic healthcare
Large entrenched healthcare institutions are having a tough time adapting versus more agile startups
Start up costs have plummeted, so it’s more capital efficient than ever
The ubiquity of mobile computing and low cost diagnostics and sensors make health data liquidity and tracking easier than ever
Rising middle classes and health infrastructure in emerging economies are expanding access and demand globally
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