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The Next Fountain of Youth? Rethinking Connected Health for Our Aging Population

August 23, 2017

Last month I shared an update on my upcoming book, The New Mobile Age, and am excited to share a bit more about this work.  We continue to hit our editorial milestones for an end of October launch at the Connected Health Conference, and as I’m reading the manuscript for the final time before sending it to the printer, I’m re-learning some important lessons–and enjoying the content! I’ve been honored to gather input from a long list of esteemed colleagues and wanted to share a few ideas I believe are critical in our thinking about the healthspan.   Below is a sneak peek at two fundamental concepts we discuss in-depth in the book.

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First some context.  We’ve added 25 years to our lifespan in the last century through various public health innovations, but we haven’t provided tools to help us use those additional years in the most productive, fulfilling way. Instead, we’ve put folks in that demographic (those in the latter 25 years of their life) into a category of ‘old.’  They retire, are perceived as no longer adding value or, even worse, become a burden to their ‘sandwich generation’ adult children.  We must turn aging from being a dreaded inevitability into something to be celebrated. My friend Jody Holtzman, who is quoted in the book, coined the term “Longevity Economy,” and defines it as the 100-plus million people in the United States over age 50 who account for $7.1 trillion in annual economic activity.  He quite accurately notes that only in the eyes of the U.S. government would this population be viewed as a burden. Rather, we need to refocus on this group of older adults as an opportunity!

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Now that we’ve extended the lifespan, our first priority should be to enhance the healthspan, by giving people the tools needed to improve their health and inspire them to maintain healthy lifestyle choices.  If we do this right, we will turn this growing cohort of older adults from being seen as a burden to one that is remaining vital, connected and adding value.  And of course, connected health is a big part of the solution.  There are multiple dimensions at play, and I can’t cover it all here, but I want to touch on two areas that became clear to me while researching the book.

The first group of insights comes from another respected friend and colleague who is helping society rethink aging, Charlotte Yeh.  Charlotte has written the Foreword for this book and has taught me several things in the process.  Once I learned of her perspective, I became tuned in to several reproducible findings in patients in my own clinical practice.

We’re used to thinking of predictors of longevity in a very scientific, dry way–measures such as exposure to tobacco, high blood pressure, blood cholesterol level and the like.  Of course, these are valid and important, but Charlotte opened my eyes to a different set of important measures.  One is a sense of purpose.  There is a lot of research on this and we cover it in the book, but anecdotally, as I’ve spoken with my own patients, I’ve seen this come to life.  People who have some purposeful activity they pursue in retirement are healthier.  The second is social connections.  Again, there is a remarkable body of evidence on this, and it turns out that isolation eats away at an individual and has the same effect on health as multiple packs of cigarettes a day!  Finally, physical activity.  This can range from taking the stairs or walking each day to going to the gym or even remaining a competitive athlete.

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None of these measures are unique to aging, but to strip away the traditional, clinical science and break it down into these three simple predictors was liberating for me.  Of course, the bonus is that connected health can play a role in all three, whether it is participating in the gig economy to drive purpose, being active on social media or FaceTime to keep up social connections, or tracking your steps on a Fitbit. All of these challenges are made easier by modern technology.

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The second important insight driving new, increasing opportunities for personal health technologies has to do with managing chronic illness.  As much as we’d all like to stay healthy all our lives and die peacefully at a ripe old age, the fact is we all suffer from system wear and tear and require more illness management as time goes on.  We are at the breakpoint as a society, to provide the resources needed to do this.  Very soon, we won’t have enough healthcare providers and caregivers to tend to the aging population if we only rely on one-to-one care delivery models. We spend a lot of time in The New Mobile Age talking about how to use technology to create one-to-many care delivery models.  Particularly exciting is the work of some of the early stage companies, paving the way for these new models of care, including:

Care.coach, a platform that features an interactive avatar to engage people in their homes—or in the hospital—to promote medication adherence, detect cognitive changes early on and keep an eye on patients who are prone to falls.

Rendever, an MIT spin-off offering a virtual reality (VR) experience for nursing home patients, as way to connect to the outside world.

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OhmniLabs, a startup with a telepresence robot for elder care that enables an older person to stay in touch with his or her family or healthcare provider in real time.

Sonde Health, another MIT spin-off that uses voice-based technology to analyze health and the user’s emotional state in real life, real time.

Hasbro’s Joy for All Companion Pet, a dog or cat interactive companion pet with built-in sensors and speakers. For ages five and up, it is used for Alzheimer’s patients and as a tool to relieve loneliness, a prime example of intergenerational thinking.

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Catalia Health’s Mabu, a kitchen counter robot designed to improve medication adherence that makes eye contact and tracks the emotional state of the user.

Affectiva, a leader in “emotion AI,” the new science of training computers to read and understand human emotion.

Omada Health, which offers a digital curriculum based in part on the National Institutes of Health (NIH) groundbreaking National Diabetes Prevention Program (National DPP).

Iora Health, a “whole new operating system for healthcare” that is focusing on the needs of Medicare patients.

Each of these companies has an innovative approach to helping address the challenges of keeping older adults engaged, vital and independent, and opportunities to provide technology-enabled care for this rapidly growing population.

I’ve enjoyed putting this book together and look forward to sharing it with you, to continue the discussion, gain your feedback and, together, advance our learning and care delivery in this New Mobile Age.

Coming Soon… The New Mobile Age

July 24, 2017

I have fallen behind on blogging over the last few months.  When I started the cHealth Blog, in 2008, I posted every other week, but over the years, the frequency has fluctuated somewhat.  My main excuse is that I’ve had the opportunity to publish in other places, such as NEJM Catalyst, Harvard Business Review, and Nature Biotechnology. This is gratifying personally, but also brings in new audience members and broadens the discussion about connected health.

Given the warm reception The Internet of Healthy Things received, I have also been working on a new book which we’ll release this fall at the Connected Health Conference.  This time around, with the same coauthors, Carol Colman and Gina Cella, we’ve taken a long, hard look at the role technology will play in helping us live longer, healthier, more productive lives.  At this point, the manuscript is almost complete and The New Mobile Age will soon be in the hands of the printers.  This has been an exciting endeavor for me, as we’ve managed to get many of the top minds in aging to lend us their thoughts. Those insights, combined with my own twist, should make for informative, fun reading about this very important topic.  It is no coincidence that the theme of the book marries well with an important initiative that our friends at Personal Connected Health Alliance are leading on Healthy Longevity.

Here’s a quick preview of The New Mobile Age: In the 20th century, we added 25 years to our lifespan. In the 21st century, the challenge is to employ new tools and strategies to enable us to live healthier during those years–adding to our healthspan.  We have already crossed the threshold where the demand for healthcare services is outstripping the supply of providers. And, by 2050, there will be more older adults needing care than younger individuals to provide care for them.

Aging Baby Boomers want control of their health and want to grow old on their own terms. Digital technologies are creating a new kind of old, enabling individuals to remain vital, engaged and independent through their later years. But it has to be the right technology, designed for an aging population, not just what technologists and app developers think people want. Social robots, artificial intelligence, vocal biomarkers and facial decoding will analyze emotion, anticipate health problems, improve quality of life and enable better relationships with healthcare providers. It’s also about using data to better understand the ‘soft science’ of wellbeing and address the neglected crisis of caregiving. It’s a business model but, more so, it’s a new way of life.

The New Mobile Age will explore what needs to be done to bring the healthspan into line with the ever-increasing lifespan. At a time when digital and connected health solutions are needed more than ever to stem this ‘Silver Tsunami,’ health tech innovations will not just improve healthcare for older adults, but will create a better and more responsive healthcare system for everyone.

The time is now to galvanize our efforts on this important topic.  If we continue to insist that the only way to receive healthcare services is one-to-one in a physical location, we will drown in service demand.  Technology, properly designed and implemented, can allow us to live a long, healthy life.

The Path to Scale for Digital Therapeutics

June 16, 2017

Thanks to our friends at Omada and other companies in this space, the term ‘digital therapeutics’ is working its way into our lexicon. There are now many examples of how a digital intervention can have the same or better clinical outcome as a chemical therapeutic, demonstrating the power of connected health, particularly in the realm of lifestyle-related chronic illness.

For the sake of argument during this post, let’s assume that digital interventions can be effective as tools to combat illnesses like type II diabetes, hypertension, asthma and others. With that premise in mind, consider this….

I recently had to complete a clinical research safety training program and the learning module went into some detail about how new drugs and devices get into widespread use. I couldn’t help but compare this to digital therapeutics, and quickly came to the conclusion that we need a better strategy for getting digital therapeutics into the mainstream. Here are some thoughts.

1. Discovery phase: This is where large pharma and/or med device companies work in the lab to create new interventions. This is probably the development phase when digital
therapeutics are most similar to new therapeutics and devices. Innovators and scientists tinker, try new things and publish papers in academic journals. If the research is internal, the path to commercialization is straight forward. If it comes from an academic lab, there is a need to license intellectual property. One way that digital interventions may be different is that the software and/or hardware tested in this early phase is rarely product-ready. There is a commercialization step in software that I believe is not part of the process of pharmaceutical development. It may be part of device development.

2. Preclinical studies: There really isn’t an analogous phase for digital interventions (except perhaps ingestibles or implantables). Since digital interventions are mostly intended to work based on their interaction with our psyche, they have to be tested, from the start, in humans. There is also less worry about safety. Yes, these interventions need validation and patient safety is always important, but this is very different from introducing a new molecule into the bloodstream or a new implanted device.

There are a lot of individuals and organizations weighing in on this issue, including groups like WLSA and others, and I expect that there will be some important debate, and even consensus, building in the near future.

The U.S. Food and Drug Administration (FDA) approach to digital interventions deserves separate attention. For this post, I’ll just mention that, more and more, digital interventions are being approved as class II medical devices, especially if there is a decision support function. The fact that digital interventions can largely leap frog this stage should be attractive to investors, as these products can reach the market that much sooner; and inevitably, these companies are more capital efficient.

3. Clinical validation: Increasingly, companies that wish to have their digital interventions as part of the healthcare delivery armamentarium are spending time and money to do proper clinical validation of their products. As potential consumers of these tools, we should be comforted by this trend. But, from a business perspective, there are challenges here. It takes a long time to do high quality clinical research. Technologies change rapidly and it is common for the software or hardware being studied to go through several upgrades/improvements during the time of the trial.

In addition, there are some research methods that can help move trials faster, but the randomized controlled trial is still industry standard. Because digital interventions can’t be studied in a double-blind manner (the investigator always knows which subjects are in a control group vs the intervention), there is less likelihood that a trial can be stopped early. There is also a fear of investigator bias while looking at data prior to the conclusion of the trial. And while there is a high degree of regulation in the pharma and medical device industries, due to the interactions with the FDA and the need for clinical trials of new interventions, we don’t yet have that for digital therapeutics. I am sure some individuals pray we don’t get to that point, as it adds costs and time to market. I only bring it up because it will be hard to legitimize digital therapeutics without a regulatory framework.

4. Negotiating with payers: Both device manufacturers and pharma companies devote tremendous resources setting prices with pharmacy benefit managers and large insurers. There is nothing like this in the land of digital therapeutics. Each entrepreneur toils in the quicksand of these negotiations, starting with pilots and eventually getting contracts with either employers or health plans. The work is tedious and resource intensive. It is fun to imagine what the world would be like if there were a handful of negotiation points for digital intervention pricing. It seems like this would be necessary to achieve scale.

I asked my friend and colleague, Rob Havasy, HIMSS subject matter expert in connected health, his opinion on this topic. He clearly articulated that, if our goal is to secure reimbursement, our thinking needs to embrace digital therapeutics as a replacement for traditional therapeutics, rather than as an add-on to traditional care, which is often perceived as being an additive cost. In addition, he suggests that we need to focus on comparative effectiveness trials to demonstrate that digital therapeutics can achieve the same or better outcomes as traditional treatments.


5. Distribution: This may be the area where pharma and medical device products have the strongest divergence with digital therapeutics. In both the pharma and device
industries, there are well-worn paths to achieve distribution. In the case of a drug, once the price is set and the drug is in the supply chain, there is a marketing blitz by the manufacturer and folks like me start to write prescriptions. I simply go to the ‘order’ section of my EHR, type in an order for the drug, the software allows me to prescribe it and the patient goes to a pharmacy to pick it up (or has it mailed to their home). In the case of digital therapeutics, there is no pharmacy and no uniform way of prescribing. This may be one reason why so many entrepreneurs are going to employee health plans with these interventions.


It is time we begin to think of digital therapeutics as a legitimate tool in the battle against chronic illness. We need to:

a. Hone the clinical trial process; b. Establish a uniform regulatory process; c. Engage payers in high level negotiations for these products, and; d. Create a distribution network that includes the ability to prescribe and a mechanism for filling prescriptions.

Developers, providers, regulators, payers, consumers. We all have some skin in this game. What’s your take?

Physician Adoption of Connected Health: The Multichannel Paradox

April 19, 2017

One of my advisors has a great perspective on healthcare delivery from the large system perspective.  He served as the chief of staff to our last CEO.  Recently, he posed an incisive question to me.  “Joe, when are we going to take all of these digital health concepts from the 30,000 foot level and get them into that 10 minute window that the doctor has with the patient?”  It is not hyperbole to say that this put the last 20+ years of my career in a whole different perspective.

I remember in the early 1990s, when it seemed we were just getting used to a new tool called voicemail.  Fax machines had become popular in the late 1980s, and we’d all had answering machines that tape recorded messages, but voicemail seemed like a brand new concept with the potential to be a very robust messaging channel.  It seemed like we were just getting used to voicemail when we got another new channel for communication–email.  All the talk in the executive suite was about how we were being inundated with multiple communications channels which, for a while, were overwhelming.

I can’t recall exactly when things changed, but I have to ask: when was the last time you got a meaningful fax?  How about voicemail?  My children chide me, saying nobody uses voicemail any more.  With caller ID, you can quickly decide if you wish to return the call.  Our communications channels have narrowed considerably in the past 20 years, to voice and asynchronous text-based messaging.

There is a parallel with the adoption of connected health into mainstream healthcare delivery.  I visited my own primary care physician the other day and at the end of the appointment had one or two follow up items, so he suggested we do our follow up by evisit.  The evisit is an asynchronous exchange of information for exactly this type of brief follow up encounter.  It is probably more efficient for the doctor and since we’ve already developed an internal payment structure and integrated the workflow into our electronic record, it all goes pretty seamlessly.  I would call this phase one of physician adoption of connected health.  That is, we’ve taken a task that previously required an in-person interaction and transferred it online, making it a bit more efficient for all parties.  Adding an evisit to follow our in-person appointment (which was more like 30 minutes, not 10) was natural and easy, because there was need for some sort of follow up anyway. A perfect example of moving from 30,000 feet to that doctor-patient window!

Phase two will be the integration of tools like remote monitoring of diabetes and blood pressure.  This is more tricky.  The front-end work of monitoring remotely-derived values is done by either a non-physician clinician or, in some cases, a software algorithm.  The doctor gets involved only when there is a complex medical judgment required.  When deployed at scale, this approach extends the doctor across many more patients due to the one-to-many nature of the intervention.

Taking the recent interaction with my PCP as an example, remote monitoring would be considered a whole new channel of work, which doesn’t easily fit in to his workflow like an evisit does.  It is hard to estimate its value, hard to predict how much impact it will have and hard to envision how to integrate it into clinical practice.

Will we see a future where physicians spend hours on end reviewing dashboards of population-level data from myriad of home monitoring devices?  If so, how will we reward them for time spent? How will they find the time to do this work? This is hard to imagine, given today’s crowded schedules and pressure to see more patients face-to-face.  It seems to me, this is analogous to the transition we went through from voice+fax+email+voicemail to voice+email.  There was no guide. It just naturally happened.

How can we smooth this transition?

One way will be to find ways to quantify the work involved in reviewing remote monitoring data sets and taking appropriate action based on high-level clinical judgment.  There is progress on this front and I’m pleased to be co-chairing a panel at the American Medical Association (AMA) that will look carefully at a number of alternative reimbursement models, including remote monitoring.  Of course this is only one component.  Workflow and EMR integration are the others.  A number of creative individuals both at our institution and across the country are working on these important factors.

Phase III is even farther out and includes things like the prescription of mobile apps. Another consortium that includes AMA, called Xcertia, will be attacking that one.  I am watching closely as this develops and hope for a successful launch.

What are your thoughts on taking connected health from 30,000 feet of the theoretical and land it in that well-defined and coveted care delivery window to achieve provider adoption?

When Will Healthcare Get Digital and Analog Integration Right?

March 9, 2017

I did a second stint on evening AM talk radio a few weeks ago for a program called Nightside with Dan Rea, which I really enjoyed.  Dan’s callers represent a genuine, down-to-earth view of the reality of connected health adoption.  The first time around, most callers were cautionary, raising concerns about data security and wondering about physician endorsement.  This time the theme that spontaneously emerged was one of people telling stories from the heart, about loved ones who have benefited from connected health. That was uplifting for me.

As the hour came to a close, the last caller, a physician, voiced a concern I’ve heard from the medical community before.  He suggested digital technologies could negatively affect the doctor-patient relationship.  He argued that digital tools merely get in the way of cultivated, face-to-face relationship building. Because of time constraints, the only comment I could make was, ‘If we implement it that way, then we will have failed.”

After the show, my friend, colleague and coauthor Carol Colman asked me to expound upon what I had meant.

The question was a timely one.  Lately, I’ve been thinking more about how to move the needle on physician adoption, and came up with a framework for general discussion. This is a topic of concern and of great interest.

As I often do, I turned to non-healthcare services to look at the integration of digital tools into previously analog service offerings.  I can think of three types of resulting consumer experiences.

The first is what I’ll call complete replacement of analog with digital. One easy example is the ubiquitous phone tree you get when you call an organization for customer support or problem solving.  These days, everyone wants you to solve your problems online, often with FAQs and chatbots first, then with an email.  This makes human contact difficult, especially when the question you have can’t be plugged into this phone tree formula.  For example, I recently forgot to renew my driver’s license before it expired.  Although the Registry of Motor Vehicles was closed on Saturday, there was another company that could perform the renewal. I could not use their online option, because a new photo was required.  So I called and went through about 10 minutes of the dreaded phone tree but could still not find someone to answer my questions about renewing an expired license.  Exasperated, I got in the car and drove there.  This is exactly the kind of experience the doctor who called into the radio show was worried about.  Unfortunately, it is a very common one. As stewards of the implementation of connected health, we must do everything we can to avoid this experience for our patients.

By contrast, we now have several examples of optimized integration of digital and analog services.  One of my colleagues had a recent experience with the online retailer Amazon that required changing an order.  He was effusive in his praise for Amazon.  Not only did he get to a person right away, the service representative knew him, his profile and his order history.  His problem was resolved quickly and effortlessly.  It may not be surprising that a company like Amazon, built on the idea of making it easy to do business on a new platform, is the model example here. Starbucks and Uber, like many other companies, also design their mobile apps to enhance our experience of what is ultimately an analog interaction.   My doctor caller may not have had this type of experience, or perhaps he had yet to realize we could indeed provide healthcare this way.

There is also a middle of the road, which is increasingly common in today’s healthcare delivery model.  I’ll call it side by side execution of both analog and digital.  The best example is the current buzz around virtual visits.  The offerings include video communication with an individual (patient/consumer) and, on occasion, a more email-like communication.  When thoughtfully implemented, this type of service can increase both access and convenience for patients.  Although it is possible, the overall care delivery experience (including virtual and the face-to-face interactions) may be a bit more efficient than our purely face-to-face process, most experts agree there is little gain.  It really is an extension of the usual way we do business into the digital realm. The analogy would be if Uber was simply a way of speed-dialing your cab company.  I want to underscore that virtual visits are an important advance, but we should think of this as only the beginning.

For years at Partners HealthCare, we’ve been remotely monitoring patients with congestive heart failure, using a combination of vital signs, patient-reported symptoms (the digital component) and a nurse call center run through Partners HealthCare at Home (analog component).  These features work very synergistically.  Our patients report feeling more cared for and more reassured than they did prior to being on this program.  Interestingly, their comments belie how important the nursing component is.  “They call me before I get short of breath,” and “I can’t cheat on my diet because my nurse knows right away,” are phrases commonly heard from patients.

These patients receive very efficient care. One nurse can oversee 100 or so patients at a time.  Hospital readmissions are down and there is an improvement in mortality and lower total medical expenses in the monitored cohort.  This is an example of successful integration of digital and analog. We still have improvements to make, so I can’t say ‘optimized,’ but it is an early success story.

Can we move healthcare into the realm where we optimize for the integration of digital and analog experiences?  I think we can.  We have a ways to go and healthcare delivery is slow to change.

I appreciated my caller’s concern.  When connected health is correctly implemented, digital tools will not stand in the way of the doctor-patient relationship, but will strengthen and support it. Are you seeing evidence of that?

More Predictions: When Smart Food is Smarter Than You

February 6, 2017

In 2011, my friend Andy Donner, then with Physic Ventures, and I both started noticing something exciting and puzzling was happening in the connected health industry. Non-standard entrants were coming into the field of connected health. The likes of Walgreens, CVS, Walmart, Avery Dennison and others were entering the field.  Up until then, we had acknowledged the traditional participants (providers, payers and supply-chain vendors), but it was a new phenomenon for predominantly consumer companies to gain interest in the space.

Some progeny programs of that wave of non-standard entrants were Walgreen’s program to connect wearables to their app and give rewards points for healthy behavior. And of course, today’s myriad of virtual health offerings comes from all over the industry these days. My friend Andy’s vision inspired us to gather, semiannually, a group of these non-standard entrants so we could learn from them and they from us. Among the first to look at membership was PepsiCo.

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You’d not be faulted for asking why a company known for sugary drinks and salty snacks was interested in connected health. It was for two reasons. First, a sincere interest in moving beyond this product set to a healthier product portfolio.  Second, an interest in exploiting their sports drink franchise.

We talked about how to possibly put sensors in a Gatorade cap, whether there could be some way of checking in to a store display with one’s mobile phone, and many other scenarios. Although our imaginations were ample, nothing really came out of our ideas. The technology was unreliable and complicated. The sensors were too costly to be able to blend into the background.  We abandoned our quest (and decided to remain friends).

In what seems like the blink of an eye, fast forward 5+ years and here we are.

Now, sensors in a Gatorade cap exist. Chips within the bottle cap can share real-time hydration information with World Cup soccer athletes and even analyze sweat type to determine fluid intake needs.

(PepsiCo/Frito-Lay)

(PepsiCo/Frito-Lay)

Here’s something similar that caught my eye recently. If you have not seen the hype around the smart Tostito’s bag released for Super Bowl Sunday, please do check it out.  It is a brilliant marketing statement and a clever internet of things app – that even promotes good health.

How so? Each of these limited edition bags (not available in stores, but collector’s items) has a sensor that will register if your breath has any alcohol on it. If so, the bag lights up with a message: Don’t drink and drive.  The next step is that you can tap your phone on the bag and via near-field communications, have an Uber summoned to your exact location.  Each bag of Tostidos even has a unique bar code on the bag linked to a $10 Uber discount code, courtesy of Mothers Against Drunk Driving (MADD).

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An ad featured on Tostido’s Twitter account even features Tennessee Titans football star Delanie Walker. “You should get a safe ride home. That’s the best bite,” he says. Walker’s aunt and uncle were both killed by a drunk driver after the 2013 Super Bowl.

It’s definitely a successful appeal for emotions. But what are the greater implications of its effectiveness and usefulness? The product may be gimmicky, but what a stroke of genius and a great example of the Internet of Healthy Things!  Nonetheless, there are some caveats.  Here is a look at both the positives and the cautions.

Pros:

  1. In Chapter 8 of The Internet of Healthy Things, we talk about 3 strategies for engagement and 3 tactics.  This gimmick takes advantage of them.
    • Make it about life: Tostidos uses the opportunity of the Super Bowl to educate consumers about drunk driving. The ad campaign claims it will allow 25,000 fans to get a safe ride home the day of the big game.
    • Make it social: If you are at a party and breathe into the sensor, all will see the result. Peer support and peer pressure come into play.
    • Subliminal messaging – Although the novelty of the experience really has nothing to do with chips, the branding is indeed around chips.
    • Unpredictable rewards – when you breathe on the bag you are not sure if it will turn green or red. Perhaps as the evening wears on it is more predictable.
    • Sentinel effect – also maybe a bit of a stretch, but does it matter that MADD knows you’ve had too much to drink?
  1. The use of IOT and near-field communications is brilliant. None of this would have been possible in 2011 when we were still dreaming.

Cons:

  1. The actual bag is in very short supply – being given away as a promotion we’re told. I went to several local grocery stores during the days leading up to 2/5 and though there were lots of Tostitos in evidence, none of the bags matched this description. This tells me that the cost of the technology (sensors, batteries, etc.) is still not low enough to be buried in the cost of a bag of chips.
  2. The whole campaign to promote better health is merely a novelty. The bag is technically not really a breathalyzer, but just an entertainment sensor. It cannot accurately measure blood alcohol level content. Will a hearty swig of mouthwash cause the sensor to change color?
  3. You already have your phone available to you to call an Uber. The bag just gives you a discount on a ride (minus the cost of the bag).
  4. Says one blogger who reviewed the product, Napier Lopez, the bag itself hardly contains any chips.

Predictions for Connected Health, Data-Sharing, and Business Model Disruption

January 17, 2017

Predictions are something I make often in my line of work. As someone who has been making healthcare predictions for more than 2 decades – and keeping score of how often they come true – I admit it is a humbling pursuit. Some predictions end up being flat out wrong. Others turn out to be right, sometimes with a significant twist. For example, although many of us predicted in the mid 90s that video communication with patients would someday become ubiquitous, I daresay missed the power of the smart phone as a game changing device. I just re-watched the early 80s film Blade Runner (the action takes place in 2019) and chuckled at the scene where Harrison Ford’s character does a video conference with another character, but through a device that looks suspiciously like a pay phone!

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When a prediction comes true, it is worth writing about. For several years now we’ve talked about the power of wearables to generate feedback loops. In some cases, those feedback loops can induce behavior change (the individual must be self-motivated and will use the feedback loop to measure progress). Often, some other motivational force must be applied to induce behavior change. For instance, many people will set up competitions with a friend or loved one. In any event, the sine qua non for a wearable is the feedback loop.

Another important principle is that shared data provides a window into the tracked individual’s habits and lifestyle, particularly about their technological engagement level and their ability to achieve personalized tracking goals. Humans apply filters and biases when they estimate about themselves. I’m no different. When my doctor asks me each year how much I exercise, I always reply, “Twice a week.” What I neglect to add is “…on a good week.” I’m not trying to deceive him, but that’s just how the answer always comes out. Now imagine how different that conversation would be if the dialogue were about total active minutes and he had access to my Fitbit data.

This realization sparks debate about both privacy and consternation about being held accountable for targets – and punishment for missing them.  “Will my employer fire me for not walking enough?” “Will my insurer charge me more?” “This all sounds very creepy.” These are some oft repeated refrains.

A few years ago, I suggested people would be given wearables by their insurers and there would be some contract with the insurer around the monetary value of achieving certain health targets. At that time, Progressive Auto was already doing this in the auto insurance industry. I thought, “Why not?” This vision is even vividly laid out in the first chapter of The Internet of Healthy Things, where Sam the virtual assistant guides me toward better health in exchange for lower health insurance premiums.

The debate has become one about carrots versus sticks. Will we ever reach the time when an individual who ignores healthy lifestyle cues as measured by one or more of these devices is penalized in terms of covering his or her healthcare costs?  I’m not sure. But what I am sure about is the world of rewards is here. Here are two exciting examples of this phenomenon – one from the health plan world and one from the retail pharmacy world. (There is a third from a company called Vitality whose services are embedded in Humana’s portfolio. I don’t know as much about them so I am not reporting on their work here.)

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In 2014, Walgreens introduced a program called Balance Rewards for Healthy Choices. Members earn points, redeemable for store purchases, by making healthy choices like tracking exercise, body weight, blood pressure and glucose, connecting health devices and apps, quitting tobacco, and setting and achieving goals for behavioral health risks modification and chronic conditions management. If you own a tracker relevant to any of these goals, you can connect that device to your Walgreens app and accrue points for improved health.  In 2016, at the Academy of Managed Care Pharmacy annual meeting, data on the program from nearly 7,000 participants showed participating individuals significantly improved adherence to anti-hypertensives, anti-diabetic meds, and cholesterol medications. Pretty impressive achievement with no directed involvement from the patient’s doctors!

United Health Group recently launched a program called Motion. They released their own proprietary wearable and challenged enrollees to meet three types of daily activity goals (as measured by the tracker). They are: frequency (300 steps in 5 minutes at least 6 times/day), intensity (one 30-minute walk of 3,000 steps/day), and tenacity (10,000 steps per day).  Enrollees who meet these goals receive up to $4/day deposited into their health savings account. As with any health insurer model, this is done in collaboration with the enrollee’s employer. Employers can achieve a goal of a 6% premium cap if they achieve 60% compliance across all three goals among their employees. (Which reminds me of another prediction. In 2008 I visited a number of Boston-based large employers pitching the idea of using wearables to track various fitness parameters. Although there was a mix of enthusiasm and skepticism, one of the skeptics said, “If this is so great, why doesn’t my health insurer offer it to me?” Eight years hence, we are there!) Although the program is new enough that they don’t have outcomes just yet, some of the plan sponsors are quoting engagement rates of 85%.

The lessons here are not about who makes the most accurate predictions or whether or not they ever end up coming true.  For me, three insights stand out.

  1. Wearables offer the opportunity to quantify important health-related information and mobile connectivity makes it easy to share that information. First we shared with ourselves, then with friends and loved ones. The next phase seems to be sharing with commercial entities in exchange for some value (not unlike when a retail outlet exchanges a coupon for your feedback on a new product). Many would like to share with their doctor, but doctors are befuddled right now, worried about liability and data overload. Let’s work together to build that future.
  2. With heightened fear and loathing surrounding things like data breaches and identity theft, people will share personal information when they see value in exchange. Most of us have been sharing intimate details for years with Google, because we get so much “for free” in return. Health information is different, yes, but perhaps the old adage, “Everyone has their price,” directly applies here.
  3. The world of connected health offers great opportunity for new ways of providing healthcare. Would you have predicted that a retail pharmacy chain would be competing with a health plan to encourage you to increase your activity level? That is a prediction I did not make! And we will nonetheless only continue making new healthcare predictions together in the years to come.