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It has not yet been 20 years since the term Digital Healthcare was defined in the year 2000. Yet arguably the most important day in the history of Digital Health occurred on September 24th, 2019, and relatively few in the healthcare sector even took note. On this one single day, five simultaneous, but uncoordinated announcements were made that collectively signaled the beginning of a seismic shift in the healthcare sector.

The first announcement, in Forbes magazine, indicated that analysts at Morgan Stanley are predicting that healthcare may eventually become a bigger business for Best Buy than selling electronics. “Health monitoring services for seniors and other digital health initiatives … could generate anywhere between $11 billion and $46 billion. This study was commissioned because a non-healthcare company wanted to assess its potential ROI in the health sector and they found it to be significant.  The article also sheds light on the electronics giants’ intentions to offer healthcare services, not just sell health related digital electronics. Secondly, Walmart announced its plans to build a healthcare workforce to fill future healthcare jobs at Walmart and Sam’s stores. They will accomplish this by offering 7 health related college degrees and certificate programs for $1 per day. That’s a full bachelor’s degree for $365 per year, to build a healthcare workforce for stores, not hospitals. Thirdly, Humana & Walgreens announced an expansion of their full-service primary care clinics for seniors, some of which are in Walgreens stores.  This partnership, unlike the current versions of the CVS Health efforts located at CVS stores and Minute Clinics, are designed to offer full service primary care. Anything a traditional primary care provider can do in their office or hospital, will now be done in a Walgreens store. Fourth, Amazon launched “Amazon Care”, a 100% virtual health clinic with in-home follow-ups.  Here individuals can see a health provider via a mobile app or website. They can text a nurse on any health topic any time and if follow-up care is needed, a nurse goes to the home. The patient goes nowhere. If medicines are needed Amazon will prescribe medications within a few hours for immediate pick up or in some cases delivery by drone. No hospital involved or needed! And Finally, CVS Health announced the availability of their first purely digital therapy which uses an avatar to provide behavior modification therapy to treat insomnia. No doctor involved. No prescription needed.

Individually, these announcements could appear to be of relatively minor importance.  Collectively they also could be seen as of little importance because they do nothing to fundamentally change the practice of medicine. They do collectively however they do signal an effort, that if ultimately successful, would at scale, represent a seismic shift in the organization and delivery of healthcare. None of these solutions were conceived with the belief that the hospital is a critical or central cornerstone of healthcare service delivery. The fact that all five of these announcements occurred on the same day, by tech companies and payors, suggests the speed and seriousness at which the market is moving, compared to traditional healthcare-initiated practice and policy changes. Finally, the current national and international footprint and consumer reach of the companies involved in these announcements, makes them able to serve large numbers of consumers relatively quickly, should they choose to scale nationally and beyond. Traditional hospital CEO’s, health systems administrators and even astute medical providers should now be able to appreciate the reality that digital technologies will bring significant change to the historic organization and delivery of healthcare in addition to changing the practice of medicine and traditional business models.  Digital Health can no longer be credibly viewed as a fad, an app, or snake oil. In reality, it represents a significant, clear and present threat to the current healthcare system. Only those CEO’s who understand this reality and move aggressively to adapt, stand the best chance of surviving.  The good news is that the end of the story has not yet been written. With the right effort, some traditional healthcare organizations may not only survive, but become health and care leaders in the emerging digital economy.

In our next blog we will discuss the impact of Digital Health on the patient experience and what this will mean for the healthcare sector.

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There is considerable buzz about connected care models these days. It has been said that connected care models are disrupting the healthcare system. However, upon close inspection, the primary use of connected systems in healthcare is to do electronically, what we have been doing live since the beginning of our profession. Connected care (telemedicine and remote monitoring) is a necessary but not sufficient step in the right direction.  This is primarily because it does not change current healthcare delivery at a fundamental level. Rather it enables patients and doctors to “see” each other, without being in the same room. Good? Yes. Game changer? No. On the other hand creating “digital health ecosystems” might be just “what the doctor ordered”. Connecting people, via broadband infrastructure, to healthcare providers AND other resources they need to be healthy (not just data), could for example enable the creation of a “health” system that focuses on all the things patients need to get healthy and stay well. in addition to delivering clinical services it could also help address social determinants of health by also enabling new  educational and employment opportunities.  Because so much of education and business is already shifting to the virtual environment, problems associated with distance and time are rapidly becoming irrelevant. Creating digital health ecosystems could improve health far more than connected healthcare systems could accomplish.

Digital health ecosystems enhance engagement with healthcare services providers and data but also enable opportunities to help improve personal/family financial resources, which itself could in turn facilitate healthy behaviors (i.e. improving dietary options via grocery/meal delivery services, enhancing medication access through online prescription access programs, increased physical activity through connected services like Peleton, improving education via online resources like Coursera, MOOCS and Kahn Academy and improved social support through resources like FaceTime, WhatsApp and Zoom based community meetings etc.) Are these perfect? No. Can they be abused? Yes. Should they totally replace in person interactions? No. But can they be helpful, particularly for underserved populations where nothing else exists or is feasible? Could a digital health ecosystem provide invaluable support and assistance to patients and caregivers “anytime, anywhere, at the point of need” not just at the point of care, wherever the doctor or hospital is located? Absolutely!! Do they add anything helpful to how we currently construct our healthcare systems, connected or not? I think history will one day show the answer is a resounding yes!  We must think differently if we are ever going to achieve different results in Health and healthcare.

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Telehealth is the use of telecommunications equipment and infrastructure to enable or facilitate health related activities. The use of Telehealth is growing rapidly in the US. As this occurs the types of technologies and the ways in which they are used in healthcare is also rapidly changing. Today, telehealth services are delivered in 4 basic ways. These include a) live video-based interactions between two individuals b) the transmission of prerecorded digital pictures and images c) remote patient monitoring which is the collection and wireless transmission of health information from an individual in one location to someone in another location and d) mHealth which involves the use of mobile hardware (phones, tablets etc.) and software (apps) to enable or facilitate health activities.

The delivery of telehealth services is often organized in one of three ways or models. When a large healthcare system is the primary provider of telehealth services to smaller often rural hospitals, this is called the hub and spoke model of telehealth organization and delivery. Alternatively, telehealth services can be delivered through a network model. In this model health care facilities are connected to each other, creating large networks and smaller subnetworks which work at times, independently and at other times together, to provide a range of telehealth services to patients and caregivers. Thirdly, due in large part to advances in broadband network availability and reliability, telehealth is increasingly being deployed in a “direct to consumer” model where consumers using their own devices can directly connect with health personnel and services anytime, anyplace.

So, what impact will telehealth have on the health sector in the future? Over the next decade we will continue to see tremendous innovation and evolution in the telehealth space. This will continue until most patients and most providers will be delivering health services using some form of telecommunications technology and or infrastructure. Consumer telehealth devices will go far beyond cell phones, tablets and apps to include voice activated systems like Amazon Alexa or Google Home, automobiles and even homes and buildings themselves. There will be tremendous growth in the types of data that can and will be collected from patients.  There will also be rapid growth in the number of ways in which this data can be collected. Many everyday consumer devices will not only capture data and send it somewhere to be analyzed, but these devices will also, in the future, be able to appropriately act of the collected information, in real time without the direct involvement of a healthcare professional or family caregiver.  This is the basis of what are known as “smart devices”.  They are smart because computing power will have advanced to the point where it can be put not only into desktop computers and cell phones but into devices as small as dust or blood cells.  They will not need batteries, because they will be able to run using the electricity generated by our bodies. Finally, they will in many cases, transfer information using low power medical body area networks which will enable the automatic capture and transmission of information from multiple body worn sensors simultaneously and wirelessly. The introduction of 5G networks will enable an era of continuous connectivity (or pervasive computing as it is also known). This will allow patients, caregivers and providers alike to monitor important health information continuously. (in real time, at all times, no matter where a patient, consumer or provider is located). Finally, there will be further evolution in the models of care delivery. Current models of telehealth all require an individual to decide to provide or receive a telehealth-based service. These models of Telehealth can be said to be “active” models because they require a person to do something in order to receive the or deliver the service. In the future, telehealth services will be delivered, in many cases, automatically, as the need arises. At times, patients will not even realize they are receiving health services at all, because delivery or receipt of the services will not require any active action and the spaces in which will live, work and play, will all be connected and smart. In this future, health care providers will oversee the development of the “brains” of these systems but will not always need to be involved in deciding or implementing the appropriate action to address the health concern. Broadband based technologies like telehealth are changing the world in exciting ways that are sometimes hard to imagine. They also have the potential to make the possibility of health a reality, for all.

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GreystonevectorSocietal forces are pushing healthcare out of hospitals and into the home.  Healthcare professionals have new incentives to care about the behavior of their patients, in between hospital visits. Many patients are taking more ownership of their health and healthcare.  Soon one in three Americans will be over the age of 65 and almost 90 million people will be over the age of 85. Approximately 11,000 baby boomers are turning 65 every single day. Most of these people want to continue living independently in their homes as long as possible. These consumers will demand a paradigm shift in which they can receive healthcare services, use educational content and respond to employment opportunities “On Demand”, when they need/want them, not just when the store, office or clinic is open.

In the future, our homes and cars will identify us and unlock the doors by reading our heartbeats. These homes will diagnose health issues and instantly deliver treatments, sometimes before we even know there is an issue. They will use cloud based artificial intelligence, machine learning and smart devices in the home, to prevent serious health problems from ever even occurring.  Residents, caregivers and homeowners will have unprecedented ability to engage, monitor and manage their health and the care of loved ones anytime, anywhere.

Smartcare Communities are about reimagining living spaces into residential networked community dwellings that are optimized for health.

SmartCare community residents who need health services could receive televisits through flat screen TV’s located in the privacy of their apartments. Alternatively, they could walk down to the community urgent care center if they like. Also, residents could even receive in person, robot or avatar based house calls if necessary. Health sensors in the homes along with information from wearable devices like smart watches and other wearables would be collected and insights delivered to residents each morning, by their preferred method, email, text, voice (Alexa), video (TV), to help patients manage their health concerns. This is just the beginning.

The question is though, will the poor and middle class ever benefit from these advances or will they remain in the hands of the wealthy? How will people from underserved populations (rural, inner city, elderly, homeless, substance abusers etc.) be able to purchase these homes? Join us for a special discussion on “Smart Cities and Smart Care at HIMSS18 at the Sands Expo and Convention Center in Las Vegas March 5-8, 2018. Here we, along with 40,000+ others will discuss this and many other important topics in Health and technology. Join us for a fascinating discussion as we create the future of health and care!

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Face A lot has been said about the disruptive effects of emerging technologies on diagnostics, clinical decision making, therapy and patient engagement. However a new report from the health technology research, innovation and consulting company suggests emerging technologies will have a profound impact on the organization and composition of future health care systems. The report details eight national trends that will drastically reduce the need for hospitals, radically change insurance practices, provide disruptive new business models in health care. The resulting systems will not be located in one centralized area but more virtual and located in consumers connected smart homes and communities that automatically treat the environment not just the patient, sometimes before they or family members recognize they are even sick.

If the authors are right, the healthcare systems of tomorrow will look nothing like the healthcare systems of today, yet these future systems will provide better care, when consumers need it, at lower cost and with higher patient satisfaction and better outcomes. At this point, it is probably reasonable to drop the mic!

To read the full report click here.

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fiber-optic-cable-serivcesWhile technology based innovation in healthcare is not new, the growing diversity of US (and Global) populations combined with the significant lack of diversity in the tech sector, represent both a problem with potentially far reaching consequences and an opportunity with transformative potential.

One critical key to improving health in America, is to provide consumers with much better “user experiences” in healthcare. It does not matter whether healthcare happens in hospitals and is provided by professionals or at home and is provided by parents, loved ones or other caregivers, the experiences of patients and consumers who are struggling with health concerns can and should be significantly improved. “Who continues to engage in activities that are unappealing, boring and inconvenient”, they ask. “In our current system, you only need a hospital when you hurt or there is a problem”. “When you go there, they are cold places where doctors always wear white coats, there are long waiting periods, odd odors and yet the healthcare system want us to get more engaged?!” While there are some good reasons for the way things are currently being done in the healthcare system, there is much room for improvement.

Health goals will not likely be realized without creating a healthcare delivery system that is more patient and consumer centered and therefore more responsive to cultural differences that exist in an increasingly diverse US population.  The Institute of Medicine has highlighted this need by calling for initiatives to enhance the cultural appropriateness of the healthcare delivery system. In addition, noted anthropologist Diana Forsythe has done studies which show that computer based solutions are embedded with “hidden cultural assumptions,” that are inevitably made by innovators and designers. Designers often believe their creations to be culturally neutral. In reality though, the cultural assumptions that have been made, may not be appropriate for all consumers or patients. Other authors have called, for deeper understanding of how health information should be tailored for diverse cultural groups, how cultural factors affect the use of health technologies, and how health technology may be used to mitigate intractable health gaps. Finally, computer engineers have long understood that designers must design for the physical, cognitive and cultural realities in which consumers live, in order for digital solutions to be valued, usable and provide patients and consumers the best user experiences. Cultural difference manifest in a range of technological system elements – from keyboard layout to attitudes toward privacy – each of which have important design implications. Indeed some experts suggest that design factors such as culture can no longer be dismissed nor can a design be considered truly user-centered if it does not address cultural factors.

The lack of diversity will inevitably lead to the development of health solutions that are most appropriate for users whose demographics, behaviors, mental models and cultural norms are similar to those of the creators. As these solutions proliferate and the US population continues to become increasingly diverse, it is inevitable that usability and utilization gaps will appear across users from different backgrounds. In the healthcare sector, these gaps may translate into poor health outcomes for certain users and may eventually lead to widening health disparities between patient groups.

It is possible though, to close health technology usability and utilization gaps and in turn reduce or eliminate intractable health problems. The first step is to disrupt the traditional innovation process itself. In the traditional design thinking processes of innovation, ethnographic studies support innovation for a particular market. However we propose an alternate  “Collaborative innovation” model which is not about innovation for a market, but innovation with a market.” While traditional innovation formulates a ‘user’ who must be studied and for whom innovation is done. Collaborative innovation, involves the community that is the target of innovation, in every aspect of the design, innovation, and startup processes. It’s about empowering communities to articulate their own problems and innovate for themselves, in collaboration with stakeholders who bring needed expertise to the development process. Shifting the traditional innovation model will not be easy nor will it come quickly.  This is primarily because most people are reluctant to embrace change, especially in areas they don’t understand or in which they have little knowledge, experience or expertise. This is completely reasonable, logical and safe they say.  But is also precisely the reason that most diversity strategies will continue to yield very slow progress.

It is really imperative that we go beyond creating more “traditional” incubators & accelerators. This is because new entrepreneurs from multicultural backgrounds often (though not always) need more mentorship than more traditional innovators and entrepreneurs. Because in general, they lack the exposures and informal mentoring that is often available to more traditional innovators, it becomes difficult for many of them to even believe that an opportunity, is a possibility, if no one that they know, or that looks like them, has ever done it before.

In closing, most children are taught in preschool, the Arnold Munk story entitled The Little Engine that Could. In the story, a long train needed to be pulled over a high mountain. Large train engines, were asked to pull the train, but for various reasons they refused. The request is sent to a small engine, who agrees to try. Ultimately, the engine succeeds in pulling the train over the mountain while repeating the phrase “I-think-I-can”, “I-think-I-can.  While most children, in the US have heard the story, for some children it becomes a metaphor for hard work and success, while for others it remains a cute children’s story. The reason this happens has little to do with intelligence or aptitude but everything to do with early life experiences, opportunity and societal norms. Can these things ever be changed? If the little engine could do it, why can’t we!

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Much has been said about the impact of emerging technology on modern healthcare. Many entrepreneurs and investors alike are intent on developing disruptive innovations that significantly improve clinical workflows, enable predictive analytics or enable widescale interoperability. While any of these would represent a significant medical advancement, several factors suggest that an even more far reaching disruption may be coming to healthcare for which these advances cannot prevent. I refer to the ultimate demise of hospitals themselves. Consider for example the following facts. First economic factors, policy and regulatory forces are already leading to less care being provided in the hospital and more care provision in the home and community.  Secondly, retail healthcare outlets are rapidly growing in popularity. They exhibit high levels of patient satisfaction, shorter waiting times, lower costs and care quality that is on par or better than similar care provided in hospital emergency departments. Thirdly, hospitals are dangerous places! It has been well documented in the medical literature that many people who go to the hospital, get sick from illnesses they did not bring to the hospital.  In fact, a recent study found that such hospital acquired problems are so common that they are actually the third leading cause of death! Fourth, advances in the computer sciences and broadband networks are fueling a revolution in medical device innovation that is enabling once large bedside and hospital confined medical devices to become miniaturized, handheld, ingestible, wearable, mobile and operable anywhere there is a broadband connection. In fact, some people who 20 years ago required stays in the Intensive Care Unit followed by lengthy hospitalizations prior to discharge are now are able to go home with small portable devices that do the work the ICU based machines did just 2 decades ago! Fifth, advances in robotics are now enabling surgeons located in one place to operate on patients located across town or across the globe. The spectrum of surgeries performed this way will likely increase in the future. Sixth, advances in telemedicine and telehealth are enabling physicians to see, talk to, examine and monitor their patients remotely, lowering the need for inconvenient visits to the doctor’s office or unnecessary visits to the ER or hospital. Seventh, hospitals were in part developed to centralize resources thereby reducing financial costs or improving opportunity costs. In the future, it may do neither. Finally, the emergence of artificial intelligence, and cognitive computing is providing unprecedented levels of data tracking and analytic capacity enabling the generation of insights that are instantly available to medical providers, patients and caregivers alike.

Given these realities then, why would patients, in the future, ever choose, to stay in a hospital? Why would payors insist that covered beneficiaries obtain care in high risk hospitals when lower risk and lower cost options with comparable outcomes are available? Obviously, they wouldn’t. While we are not there yet, it will not likely take 20 years for us to get there. It may not even take 10 years. There is a coming bloodbath for hospitals, as we currently know them. Only those systems that proactively embrace the opportunities these realities portend and innovate on the very notion of what a hospital is and does, will ultimately be able to survive.

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Recently a group of researchers from Microsoft and the University of Cambridge announced the development of a program called DeepCoder. Deep Coder is a combination of an Artificial Intelligence System and machine learning system that can write its own code. Currently, the system is only able to write relatively simple programs, but the developers envision a day when anyone can simply tell DeepCoder what they want and it will then write the code to accomplish the requested task within seconds and without error!

The implications of this technology are simply profound and absolutely disruptive!

Today, much has been said about the potential of using IBM’s Watson supercomputer to solve challenging societal problems across diverse sectors such as security, finance and healthcare. However, to get the benefit of Watson, you have to be able to pay IBM to use the platform. According to recent reports, you will likely have to be able to pay a huge amount of money! (See MD Anderson benches IBM Watson…) Microsoft’s DeepCoder on the other hand, offers the potential, if placed in the hands of consumers, for almost anyone, anywhere and at anytime, to recognize a need or problem and have a working solution developed for it “On Demand”. As the authors point out, this is not meant to replace current infrastructure or personnel, but to augment and enhance current abilities.

In the health sector, the opportunities are almost endless, particularly if we think across the entire care continuum from wellness, to diagnostics and therapeutics, through recovery, chronic disease management and end of life care. Through this system, every problem essentially becomes a “Big Data” problem for which the appropriate code can be written to address the problem!

For busy clinicians trying to understand the potential implications of a new drug for a patient in the office, rather than scheduling a second visit with the patient, prior to which he/she would review a number of textbooks and other digital/print resources in order to make an evidence based opinion, DeepCoder could, write a program that searches the over 26 million research studies available in the National Library of Medicine’s PubMed database, determine which studies apply most closely to the current patient, synthesize the findings from the most relevant studies and print a one page synopsis and recommendations for the patient regarding the best initial dose, on the desktop printer sitting next to the doctor, for his review, faster than the patient can get undressed.

For the aging senior who is diabetic, hypertensive and lives alone, her adult son, who lives in another state, could tell DeepCoder to find the highest quality senior care day program, that offers door to door transportation, meals and is willing to dispense medications, that has an immediate opening and fits within his budget. Since both he and his mother have an Amazon Echo, he could simply tell Alexa what he needs and she then tells DeeepCoder.  A few seconds later, once the program is written, Alexa could then use it as a new personalized “skill”, execute the task, complete the online application after her son’s approval, schedule the in-person interview and send the required down payment to the Senior Care center in advance of the meeting.

While these examples are exciting, they are not yet possible. However it is also true, that is likely only a matter of time before these or something even better become reality in healthcare!