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Trade-Off or Turn-Off? The Privacy Dilemma

October 6, 2016

I recently had the opportunity to join Boston news media veteran, Dan Rea, on his AM radio program, Nightside with Dan Rea. It was a one-hour call in program, and an eye opening experience for me. Dan and I chatted about connected health and how it can truly disrupt care delivery and put the individual at the center of their own health. Then Dan opened the lines to the fine citizens of New England for questions, and the phones started ringing off the hook.

The overwhelming concern – actual fear — among callers was maintaining their privacy in an increasingly connected world, especially their personal health data. This is a topic I touched upon in my recent book, The Internet of Healthy Things, and one which I will explore further in my upcoming talk at our Connected Health Symposium in a few weeks. But I was so struck by the extent of concern, I thought I’d present a few theories I’ve been contemplating on the subject.

When it comes to privacy issues, the cyber world is typically characterized as a sinister place, where consumers are duped and exploited, their data leaked or stolen. What we unfortunately don’t talk about is what consumers have to gain by sharing their data. For instance, the same information that can be used to create highly personalized programs to help people stay healthier and happier, can also be a key factor in improving efficiencies and reducing healthcare costs.  Further, it’s been shown that sharing data with providers, friends or social media groups can actually help people stay on track with their health and wellness goals.

Yes, there is always some risk sharing personal data – whether online banking or communicating with your healthcare provider. But there are also rewards. In my view, it’s a trade-off, and one that I personally am willing to make with my own health data.

As I see it, there are two main problems when it comes to privacy. First, many companies have not been forthright regarding their privacy policies, leaving consumers unaware of when and how their data is being used, sometimes in ways they may not approve of. Second, we are all too aware of some alarming data breaches that make consumers wary of posting or sharing their personal data.

Cyber security concept on virtual screen, consultant presentation

We can combat much of consumers’ fear by making privacy policies transparent; putting a halt to spying on people without their consent and creating systems to keep data confidential. Bottom line, the rights of individuals must be protected, and organizations – healthcare providers included – need to do a better job explaining privacy issues and safeguards.

As my friend and colleague Rob Havasy pointed out to me, HIPAA doesn’t directly apply to most connected health interventions, and certainly not to those things that don’t directly connect to a hospital. Therefore, the consumer’s protections are covered by the privacy policy of the company that provides the equipment or service.

In my mind, privacy is not a complicated issue. In fact, it’s pretty straightforward.

So how do we increase consumers’ comfort levels and create more transparency around the red-hot issue of privacy? Here are two simple ideas:

For anyone who is in the healthcare space, whether you’re a payer, provider, business or entrepreneur developing connected health devices or programs for consumers, you should be very forthcoming about your data collection and privacy policies. And, by all means, provide this information in simple, easy to understand language and skip the legal jargon.

And, consumers need to understand that there’s no such thing as a free app. If it’s a free service, more than likely the business model will sell advertising – or data – including subscriber lists, to marketers. In most cases, without this revenue stream, there would be a fee attached to the service. This is a concept most consumers will understand. Some will opt for the free service with the understanding that they give up some privacy. Others will want a fee-based service that will preserve their privacy. Either way, it should be the consumer’s choice.

Is the privacy fear such a turn-off that consumers will never agree to share their health data? Or can we help individuals understand the trade-off?

Why not just text them?

September 8, 2016

I want to acknowledge the contributions my colleague Kamal Jethwani and his team made to this post.

The business value of medication adherence tools is coming into focus.  For years, I remarked that, while we could create a case for why adherence was the right thing to do, we had great difficulty creating the right financial incentives to move these programs from curiosity to scale.  That is changing now with the collision in the marketplace of new payment models and exorbitantly priced pharmaceutical products.

The poster child for this phenomenon is the drug Sovaldi, which represents a miracle cure for Hepatitis C infection but costs $84,000 for a course of therapy.  But if the patient doesn’t finish the entire course, the money is largely wasted.  In that context, the price of any adherence solution is small compared to the cost of a failed treatment.

Today, there are a large number of adherence solutions on the market.  Two years ago, we found more than 100 companies offering products in the space.  A more recent report lists 5 categories for addressing adherence:  predictive modeling solutions, communication and education, smart pill bottles, smart tablets and apps.

In conversation with an influential senior executive at my organization — who I’d consider to be a connected health enthusiast but a realist — we debated the pros and cons of a simple text messaging solution versus one or more of these other approaches.  I thought I’d share the highlights of our discussion in this post.

Text messaging has become easy to scale.  We can now do it directly through our EMR, so the incremental cost of sending a reminder message is nil.  We can reach hundreds of thousands of people easily using this approach.

The downsides are important to mention as well.

  1. Onboarding: The FCC mandates two levels of consent from patients. First, when patients share their cell phone number, they are required to consent to receiving text messages from our organization; and second, the first text message sent should always be an ‘opt-in’ message that the patient has to reply to, in order to initiate the messaging campaign. In previous studies, we have seen a 30% drop off rate at this second step.
  1. Regulatory considerations: Text messages need to be ‘HIPAA compliant,’ which means we cannot send anything that could possibly reveal personal health information, including the patients’ condition, should others have access to their phone/messages.
  1. Reminders only: Text messages are usually prompts that ask a patient to remember something, or take a certain action. In several cases, the barrier to taking action is a patient’s lack of information/knowledge/understanding, making it difficult to predict which individuals will fall into this category. The limited number of characters (140) can also render the text prompt futile.
  1. Message Fatigue: It is well documented that, over time, people will pay less and less attention to timed, similar messages.
  1. Other considerations include the cost an individual may incur per message received, as well as oft-changing phone numbers, common in certain patient demographics.

Mobile apps overcome most of these problems.  Once you download the app, it is much easier to manage communication with you via notifications, and it’s also easier to secure the transmission of personal health information.  Engagement is multifactorial in the app environment: we can remind but also educate and interact with the patient. Finally, apps can be free to download.

Of course apps are not a panacea.  Patients sometimes have difficulty with the download process itself.  Just as messages can cost users, use of apps can affect data plan expenses.  Estimates of smart phone ownership vary, with most urban markets coming in around 80%.  That leaves 20% of any given sample as unable to use an app.

So what is the best course of action?

Based on our experience and research with both texting and mobile apps, we recommend texting for simple, one-time interventions such as medical appointments, annual screenings, medication refills and flu shots. Text reminders can also be good for short-term campaigns for patients taking infrequent meds, de-addiction or rehabilitation programs, or for patients who do not own a smart phone.

However, for more complex treatment regimens or challenging patient populations, we believe, and have proven the effectiveness of mobile apps when sustained, long term patient engagement is required.  There are a few examples that come immediately to mind, including programs that use sensors or collect patient reported outcome measures (PROMs), highly dynamic medical conditions that require just-in-time care, or programs targeting sensitive conditions such as HIV or STIs. Further, mobile apps can play an important role in patient education, improving patient-provider communication and passive data collection.

There is also a place for mobile apps in medication adherence, in cases when poor adherence is the result of factors other than forgetfulness. This may seem to be impractical advice, but I’m hopeful that as we continue to develop predictive algorithms, we will be able to better segment individuals to create more robust and effective engagement.

But for healthcare providers and executives, like my colleague, who are in need of immediate, cost-effective solutions to address critical healthcare needs, text messaging appears to be the answer. Our research and experience tells us that is not always the case.

What are your thoughts?

Is Chronic Disease Management Beyond Our Reach?

August 25, 2016

Hand touching pill reminder app on screen

People are living longer, but not necessarily healthier. It’s unsettling to think about it in these terms but, in our lifetime, it’s unlikely that any of the lifestyle related diseases—like obesity, diabetes and heart disease—will be cured by a pill. Yet the most effective weapons we have to battle chronic disease include more daily activity and exercise, a healthier diet and weight management, and lower stress — behaviors that are seemingly the most difficult to sustain.

Healthcare providers are at a distinct disadvantage in this battle against chronic conditions. Patients need intervention far before symptoms of a disease start to become evident. And then they need sustained, consistent support if we are to achieve true behavior change. While interventions such as mobile and digital health solutions have the potential to improve management of and even prevent some disease, our reimbursement system is better suited for acute care, and reimbursement for preventative care is sorely lacking. Health plans have tried, mostly without success, to cajole us to a healthier state.  Let’s face it:  the burden of chronic illness prevention is on the patient.

So, are we doomed? Is it time to throw in the towel and declare these chronic conditions the victor? I say not so fast.

goldfish jumping out of the water

Digital therapeutics can help people make positive and sustainable behavior change that can be as effective as taking a medication. It’s time to break free of the traditional paradigms of disease management and embrace the future by leveraging technology to fully realize the benefits of therapeutics. Let’s create a new cocktail, mixing connected health technologies with proven medicines to create effective therapies that truly do go beyond the pill.

Specifically, for diseases that are largely related to lifestyle choices — including obesity, diabetes and hypertension — we must think of all the tools in our bag, including interventions such as behavioral therapy, coaching and support groups. Add to that mobile technologies, apps, sensors and the Internet of Things, along with the new push for value-based care, and we may be onto something.

These technologies make it possible to reach entire populations on a large scale — before, during and after a chronic condition is detected. Effective interventions to motivate and sustain positive behavior change can be delivered continuously. All this and the patient doesn’t have to set foot in a hospital or doctor’s office, which fits nicely into the construct noted above – that consumers/patients must own this.

In my recently published book, The Internet of Healthy Things, I devote an entire chapter to what I’m calling ‘digital therapeutics,’ which I define as therapeutics as an intervention delivered by digital means that, independently of any medications changes, has a positive effect on clinical outcomes. I also site three very interesting examples of successful programs that are improving the care, and the outcomes for treating diabetes.

We have also pioneered a number of similar initiatives right here at Partners Connected Health.

Planet Earth sourrounded by a global computer network, sun rising

It’s fascinating and inspiring to think that a digital tool, mobile app or wearable device can compete with chemical therapeutics. This is the dawn of a new era. Digital offerings are now providing physical and occupational therapy at home for patients undergoing rehabilitation for stroke and other conditions, cognitive behavioral therapy to treat depression, anxiety and the like, and blood pressure and heart monitoring to detect debilitating events such as stroke and atrial fibrillation.

A number of innovative companies are taking an exciting new direction, creating ‘no-burden’ monitoring, passively collecting data via compatible devices and smartphones that a patient already uses regularly. Once the program or app is downloaded, the patient doesn’t need to do a thing, hence the no-burden. Interestingly, we’ve found that even the seemingly simple act of putting on a wearable or opening an app every day can prove to be too much for some individuals, causing health and activity tracking to fall to the wayside over time.

Young woman talking on cellphone

I’m encouraged to report that there are already several no-burden monitoring programs that are showing promise. One example is Sonde, a Boston-based company, developing technology that can monitor speech and other sounds — without storing or analyzing the content of their speech — enabling long-term monitoring of mental, emotional and physical health conditions. This technology works in the background of devices that most people already use every day, and could be very useful for patients chronic conditions requiring challenging treatment regimens.

We need more evidence that these digital interventions have the staying power to truly change behavior in the long term, in order to get large populations of people to stop smoking, lose weight or otherwise improve their health. Reimbursement and regulation also need to catch up with what appears to be low-risk technology, and address the ever-present concerns about privacy and security.

I say it’s time to pull out all the stops and put in the work to create the preventative and treatment strategies needed to affect behavior change that will, in turn, change the course of chronic disease on a population-level scale. Our healthcare system, as it stands now, cannot sustain the high cost and resource utilization that characterizes today’s chronic disease management protocols. We can — and must — make chronic disease management an efficient part of care delivery. I believe digital medicine is the way forward.

Are you with me?

Symposium Attendees Have the Opportunity to StressLess!

July 12, 2016


Sometimes we can find synergies and opportunities in unlikely places. On the one hand, we’ve all been seeing research pour in, showing how critical stress is to our well-being. Stress is the new fat! On the other hand, our team has been hard at work planning this year’s Connected Health Symposium, always looking for new ways to entice, inspire and educate attendees. So I got to thinking…. Wouldn’t it be interesting to evaluate a couple of new connected health devices and offer Symposium registrants an opportunity to participate in the study.

So it is with great excitement that I announce enrollment in our StressLess trial, evaluating the effectiveness of Muse and Spire, two personal health devices, on stress management. Folks who register for the 2016 Connected Health Symposium will be eligible.  A total of 126 participants will be enrolled in this nine-week randomized, controlled study; devices will be provided to participants. In addition, all study procedures — including consent, eligibility screening and the enrollment questionnaire — will be completed using Compass, the mobile application we developed for secure online data collection.


Muse and Spire are recent technologies that could improve understanding of stress management and enhance quality of healthcare. The Spire points out when you are stressed and the Muse is an aid to meditation/mindfulness. Conventional wisdom would tell us that those who are using these devices will show reduced levels of stress episodes.


This is what we’re testing:  Those who enroll will have access to the Spire to collect baseline data on current stress levels, as measured by breathing rates. After the two week baseline period, half of the participants will use the Spire device for stress management and the other half will get a Muse device, for mindfulness meditation.  If the Spire and Muse devices are effective in improving stress management, study participants will have fewer episodes of stress for the duration of the study.


It’s an important study and a unique opportunity for Symposium participants to get a birds-eye view of how we conduct clinical research, its impact and, importantly, the role of study participants.

There will be a panel session at the 2016 Connected Health Symposium to discuss the lessons learned.

This is but one example of how we are always innovating at Partners Connected Health. Our thanks to Muse and Spire for supporting this study.

I hope you will register for the Symposium and take part in this exciting trial.  I’m sure you’ll learn a lot!

Direct to Consumer Telehealth: Throwing The Baby Out With The Bathwater

June 10, 2016

I would like to acknowledge the contributions of Catherine Schuster Bruce in this post. Catherine is a University of Bristol Medical Graduate who recently spent two months on placement with Partners Connected Health prior to starting work at the Royal London Hospital, London.

Missed diagnosis. No Diagnosis. Dodgy Clinicians… There’s been a lot of hand wringing around direct-to-consumer (DTC) telehealth. Recently, more alarms went off in the wake of a Wall Street Journal article, outlining the results of a study posted online in JAMA Dermatology that assessed the quality of DTC teledermatology.

Specifically, this study aimed to test the quality of 16 DTC teledermatology services in California. They created surrogate ‘personas’ that presented as potential real-life patients seeking a teledermatology consult. Factors assessed included clinician choice; clinician location; type of data the clinic requested; the diagnoses given; the treatment prescribed or recommended; whether adverse medication effects were discussed; and whether the care was coordinated with the patient’s own physician.

Although the study did not use real patients, it raised some legitimate concerns about these online services. For example, the researchers were not able to verify American Board of Medical Specialities (ABMS) certification for all listed domestic physicians, and some websites did not even offer a consultation with a licensed, board-certified dermatologist. In addition, only 11% offered to send records to a current member of the patient’s clinical team, highlighting growing concern over lack of communication between primary care providers and DTC telemedicine services.  This issue was raised in a survey by Fogel et al that was published in the Journal of Telemedicine and Telecare, and in policy documents from the American Medical Association.

The study also raised concern with respect to diagnostic accuracy. However, these claims may be overstated, as the study authors were unable to assess whether clinicians seeing these patients in traditional face-to-face encounters would have performed better. Arguably, we should aim for a standard of care that is the same, whether you are seen in person or via telehealth. Although there is robust literature showing comparable agreement between face-to-face clinicians and tele-clinicians, the studies have not been extended to DTC services.  This line of research needs to be pursued because, in the DTC environment, a clinician is dealing with less information than either face-to-face encounters or traditional telehealth encounters.  The empiric question is how much information is enough to render an accurate diagnosis and prompt an effective therapeutic strategy.

But, let’s pause and try to put all of this in perspective. Today there are a number of mobile and web-based DTC teledermatology services — some linking  volunteer physicians to underserved clinics and organizations, and other dermatology websites and independent providers that offer consumers a dermatologist’s opinion without ever meeting in person. At the same time, there are also numerous companies, such as American Well and Teledoc, that offer telehealth consultations to employer groups and insurers as a member benefit. For a defined list of non-acute conditions, you can tune in and get a consult from a provider you’ve never met before.  Walgreens and CVS offer these services too.

In 2015, visits to DTC telemedicine websites reached 1.25 million individuals, and more than one million visits are expected this year, according the American Telemedicine Association (ATA).  As these web-based services proliferate, there is apprehension over a lack of regulation, quality control and clinical standards. In fact, in a recent JAMA Viewpoint, my colleagues Stephen Agboola and David Bates and I raised concerns about telehealth and patient safety.

Medicine is a profession, and various forms of regulation – licensing, credentialing, granting of privileges — are in place to assure that those providing services to patients are legitimate professionals who will, as Hippocrates put forth, ‘above all do no harm.’ While most advocates have long agreed that state licensing of providers creates artificial barriers for telehealth, most also agree that unfettered, unregulated growth of DTC telehealth is probably not a good idea.

Some efforts are underway.  For instance, the ATA offers an accreditation process for direct-to-consumer telehealth.  This is an important start, but probably not enough.

The illustrative case from the JAMA Dermatology study is a teledermatology ‘patient’ feigning symptoms of secondary syphilis. This condition looks a lot like other more common, benign skin rashes and is rare, so I suspect it gets missed in many healthcare settings. That said, if the doctor thinks of it, s/he should order the test.  Of course, ordering a test requires sending the patient to some brick-and-mortar facility, all but negating the value of the online consultation.  When the online provider is faced with a patient with what appears to be a common condition easily treated with a prescription cream, the temptation could be too great to treat without recommending the blood test, thus supporting the business model of online consultation.

There are some things to work out, but there is good to be had by encouraging the thoughtful growth of DTC telehealth. For example, we need more patient-focused regulation and further study. We should also determine which symptoms are properly suited to online diagnosis versus the need for in-person care.

It is time that medical professionals tackle direct-to-consumer telehealth in a thoughtful way.  Today, virtually every other service is delivered online these days.  Do we really think healthcare is so different?  Although it is a threat to traditional brick-and mortar healthcare, to dismiss telemedicine without further study is short-sighted. Those offering DTC telehealth services have an obligation here as well.  It seems apparent that these online services are faced with a dilemma: provide the sort of convenient care that consumers demand or admit defeat.

What other challenges — and opportunities — do you see in advancing telehealth services?

The Quality of Virtual Visits

April 28, 2016

Virtual visits are increasingly the rage amongst forward-thinking healthcare providers that want to jump on the telehealth band wagon.  Extending the office visit across distance, using the same technology we use to keep in touch with loved ones (videoconferencing such as Skype and FaceTime), is a safe and logical way for providers to venture into a new tech-enabled world that may still be scary for some.

One way to think of this trend is to consider virtual visits an extension of the brick and mortar care model made famous a decade ago by companies like Minute Clinic.  Offer convenient access to a care provider for a limited number of conditions.

Virtual visits can take place by either video or voice connection.  These interactions are most often for indications that are non-life threatening, acute problems such as sore throat, ear ache, urinary tract infection and the like.  There is also a role for this technology in follow up care for conditions such as diabetes and hypertension, but for this post we’ll focus on acute care.

Employers and health plans are interested in this mode of care delivery too.  In a relatively short period of time, virtual visits have gone from a curiosity to a ‘table stakes’ offering in the world of employee health.  Several companies now offer services in the space, most notably Teladoc (now publically traded) and American Well.  These companies are interesting in that they can offer a complete service (i.e., software platform for access and a network of physicians who are waiting by the (video)phone for your call) or pieces of the service (for instance, just the software platform).  This has led to some confusion in the marketplace.  A consumer can now get a virtual visit from Walgreens or CVS (using the complete approach noted above).  Blue Cross of MA offers its fully insured members access to virtual visits through American Well’s software and network.


You can see why provider organizations would sit up and take notice, with concerns about loss of revenue in the very important segment of primary care, as well as fragmented care. Hence, providers are looking very carefully at how they can offer these services themselves, before they are disrupted by the likes of CVS, Walgreens and their local health plan.

With this backdrop, I read two interesting journal articles this month.  The first, published in JAMA Internal Medicine, employed individuals trained to act as patients with the following acute illnesses:  ankle pain, strep throat, common cold, low back pain and urinary tract infection.  These were chosen because there are recognized quality measures (which go by the acronym HEDIS) for how they are to be handled in an outpatient setting.

These fake patients performed 599 virtual visits across a number of different vendor scenarios.  The findings revealed that quality of care delivered by this method is variable.  For instance, the correct diagnosis was arrived at in 458/599 visits.  Rates of guideline-adherent care ranged from 206 visits to 396 across eight different vendors.  The big challenge with this —  and something we have trouble talking about — is lack of comparison to the face-to-face office visit.  For example, in traditional office-based circumstances, doctors misdiagnose and sometimes do not follow established guidelines.

Senior Patient Having Medical Exam With Doctor In Office

The second paper was published in the Journal of Telemedicine and eHealth.  The authors specifically targeted virtual visits from Teladoc and they did the comparison with office visits.  The approach was different, however, in that it involved a retrospective insurance claims analysis from a specific organization, the California Public Employees Retirement System.

The first interesting data point is that of 233,000 eligible individuals, 3,000 took advantage of virtual visits, accounting for just over 4,600 visits.  Utilization of just 1.3% is worth noting for those of us preparing to offer these services in the near future.  We probably don’t need to anticipate an avalanche of demand.

The punch line from this study: Teladoc doctors performed worse on a number of indicators than office-based practitioners.  Specifically, they did not order strep tests as much as office providers and they ordered antibiotics for bronchitis more often.  This makes some intuitive sense, as it is additional work and bother for the virtual doctor to insist the patient get a strep test. (The patient will also be thinking, “Why did I bother to do this virtually and why do they offer this service if I have to travel for a strep test?”)  In the case of antibiotics, the virtual provider may be more cautious without the person in the same room and err on the side of treating with antibiotics.

Both of these papers highlight how early we still are in the widespread adoption of virtual visits.  Though there is lots of pressure to move, and we should do so, we have some time to get it right.  We can take comfort in the low utilization, and work on educating providers on the pitfalls of the virtual environment.  We can also educate our patients up front that even though their entry into the healthcare system will be virtual, they may need to travel to get additional diagnostic services, etc.


It seems that anytime a new tool or technology is introduced, we inevitably apply it broadly, learning as we go that the tool has ideal applications.  Think about how we reflexively use text messaging, email, voice calls and in-person meetings in the context of our work lives.  With time and a thoughtful approach, we’ll get there with virtual visits as well.

Of course there will come a time when that strep test can be done in-home, at the time of the virtual visit (or even before).  We’ll have better tools for determining which cases of bronchitis should be treated with antibiotics.  Who knows, we might even be able to do some sort of portable imaging for your low back pain.

Until then, we’ll be well served to educate both providers and consumers regarding both the excitement and the limitations of virtual visits.

Headlines, Heuristics and Subtlety in Interpreting Connected Health Studies

March 28, 2016


We live in a headline/hyperlinked world.  A couple of years back, I learned through happenstance that my most popular blog posts all had catchy titles.  I’m pretty confident that people who read this blog do more than scan the titles, but there is so much information coming at us these days, it’s often difficult to get much beyond the headline.  Another phenomenon of information overload is that we naturally apply heuristics or short cuts in our thinking to avoid dealing with a high degree of complexity.  Let’s face it: it’s work to think!

In this context, I thought it would be worth talking about two recent headlines that seem to be set backs for the inexorable forward march of connected health.  These come in the form of peer reviewed studies, so our instinct is to pay close attention.

In fact, one comes from an undisputed leader in the field, Dr. Eric Topol.  His group recently published a paper where they examined the utility of a series of medical/health tracking devices as tools for health improvement in a cohort of folks with chronic illness.  In our parlance, they put a feedback loop into these patients’ lives.  It’s hard to say for sure from the study description, but it sounds like the intervention was mostly about giving patients insights from their own data.  I don’t see much in the paper about coaching, motivation, etc.

If it is true that the interactivity/coaching/motivation component was light, that may explain the lackluster results.  We find that the feedback loops alone are relatively weak motivators.  It is also possible that, because the sample included a mix of chronic illnesses, it would be harder to see a positive effect.  One principle of clinical trial design is to try to minimize all variables between the comparison groups, except the intervention.  Having a group with varying diseases makes it harder to say for sure that any effects (or lack of effects) were due to the intervention itself.


Dr. Topol is an experienced researcher and academician.  When they designed the study, I am confident they had the right intentions in mind.  My guess is they felt like they were studying the effect of mobile health and wearable technology on health (more on that at the end of the post). But you can see that, in retrospect, the likelihood of teasing out a positive effect was relatively low.

The other paper, from JAMA Internal Medicine, reported on a high profile trial for congestive heart failure, which involved using telemonitoring and a nurse call center intervention after discharge.  This trial included a large sample size and was published in a well-respected and well-read journal.  On initial reading, it was less clear to me why they did not see an effect.  I had to read thoroughly – way beyond the headline — to get an idea.  The authors, in the discussion section, provide several thoughtful possibilities.

One that jumps out to me is that the intervention was not integrated into the physician practices caring for the patients.  In our experience with CHF telemonitoring, it is crucial that the telemonitoring nurses have both access to the physician practices and the trust of the patients’ MDs.  Sometimes a simple medication change can prevent a readmission if administered in a timely manner. This requires speedy communication between the telemonitoring nurse and the prescribing physician.  If that connection can’t be made, the patient may wind up in the emergency room and the telemonitoring is for naught.

It is also fascinating that the authors point out that adherence to the intervention was only about 60%.  This reminds me of another high profile paper from 2010 that came to the conclusion that telemonitoring for CHF ‘doesn’t work.’  I blogged on that at the time, pointing out that their adherence rate was 50%.  In both cases, with such low adherence, it is not surprising that the effect was not noted.

In our heart failure program, adherence is close to 100%.  As a result, our readmission rate is consistently about 50% (both all cause and CHF related) and we showed that our intervention is correlated with a 40% improvement in mortality over six months.  The telemonitoring nurses from Partners HealthCare at Home cajole the patients in the most caring way and patients are therefore quite good at sending in their daily vitals.  If they don’t, the nurses call to find out why.  Our program is also tightly aligned with the patients’ referring practitioners.  I suspect these two features are important in explaining our outcomes.

A prime example of how these study headlines can derail the advancement of connected health, was captured in an email I received the other day from my good friend Chris Wasden.  Referring to the JAMA Internal Medicine study he said, “Our docs are using this research to indicate they should not waste their time on digital health.”

Perhaps a spirited discussion over some of these nuances may change some minds.


And that leads me again to the concept of headlines and heuristics.  How could ‘telemonitoring’ in CHF lead to such disparate results?  Is our work wrong? Spurious?  I don’t believe so.  Rather, I think we’ve collectively fallen into a trap of treating ‘mobile health’ and ‘telemonitoring’ as monolithic things when, as you can see, these interventions are designed quite differently.

I believe we are susceptible to this sort of confusion because of applying a heuristic. We are used to reading about clinical trials for new therapeutics or devices.  A chemical is a chemical and a device is a device.  In a pure setting, when applied to a uniform population of individuals, a chemical either has an effect or not.  Connected health interventions are multifaceted and complex. Thus the apparent contradiction that telemonitoring works in our hands but not in the recent JAMA Internal Medicine paper.

My conclusion is that the next phase of research in this area should move away from testing technologies. Instead, we should focus on teasing out those design aspects of interventions that predict intervention success. Now I think that’s a good headline!

I’ll start out by offering two hypotheses:

  1. 1. mHealth interventions that are separate and distinct from the patient’s ongoing care process are less likely to be successful than those that are integrated.
  2. If adherence to a program is low, it will not be successful. Early phase, pre-clinical trial testing of interventions should include work to fine tune design features that promote adherence. Chapter 8 of The Internet of Healthy Things offers some ideas on this.

As I said five years ago, I’m not sure intention to treat analysis is the right way to evaluate connected health interventions. If patients are non-adherent to the intervention, is it any surprise that they don’t respond? I’m having trouble wrapping my head around that one.