It’s a brilliant niche. MotherKnows will interact with the healthcare system (your physician, hospital, insurer, etc.) on your behalf to procure a copy of the medical record, store it, analyze it and make the information available to you on-demand. Anyone who has tried getting their child’s immunization record will agree that the conventional interaction is a sub-optimal customer service experience at best. So having someone else do it for you is worth paying for.

Once collected, the information is available in a PHR manner – view meds, problems, allergies, immunizations, growth charts in one place; create emergency cards; get reminders; mobile access, etc. But the key to MotherKnows’ viability, in my view, is being the authorized agent for painful extraction of medical records. As long as the pricing is right (which, at $19-$98/year, is in the right range) it will gain traction.

It’s a prudent strategy to market it initially to parents as a way to keep the records straight for their precious progeny. But I don’t see why it can’t be extended to adult healthcare consumers themselves. I’d like to be able to get my medical data all in one place, hopefully showing me trends found in my quasi-annual physical exams and labs. Today in the patient population, the motivated few try to save copies of records; and the enlightened few go one step further and manually key the data into an online PHR like Healthvault. In either case manual labor and discipline is required. Perhaps having a real-world service (of paper record collection) is what really can make a difference to PHR uptake by consumers. Hopefully, MotherKnows will reach beyond just child medical records in future.

The overall idea of patients paying an agency to wrest to their medical records from providers point to the underlying systemic inefficiencies. Theoretically, there are solutions on the horizon. An enterprise EHR used by care providers could pass the relevant info into a PHR accessible by patients. And if they change providers, a community-wide Health Information Exchange (HIE) could still enable patients to be the custodian of thier own information in another system. But we are not there yet.

The unmet need for electronic systems (like PHRs) to interface with the physical world (i.e. bricks and mortar organizations and paper processes) is very real. Till every end-point in healthcare delivery is digitized and interoperability is no longer a pipe dream, we’ll need services that handle real-world complexities. Take companies like eHGT who are already in this ‘record retrieval services‘ niche. By actually having real account managers who can get imaging records from facilities, they elevate the value proposition of an “Image Exchange” to new level. The phenomenon exists outside of healthcare too. The now defunct Random Acts of Genealogical Kindness (RAOGK) site was a volunteer effort to bridge the gap between virtual demand and physical supply of genealogy records.

Turns out that Lifescan apparently did nothing with that concept. Anita Mathew (who gave the demo on Lifescan’s behalf in 2009) decided to take it forward on her own and founded Glooko. The company currently sells MeterSync, a cable that connects your iPhone to five popular glucometers in the market. Users can download the ‘LogBook’ app from iTunes store to document, analyze and share their data.

I’m not an investor (yet), but if I was, I’d put my money in Glooko. This is exactly what the future should start to look like for conventional consumer health devices. Instead of being isolated products that store a limit amount of quarantined information, they need to provide a service that enables longitudinal disease management. For a patient with long-standing diabetes, he/she needs to know how much insulin to inject for covering the meal they are about to have, not what their blood glucose number is. It reminds me of Theodore Levitt’s famous MBA quote “People don’t want to buy a quarter-inch drill. They want a quarter-inch hole.”

For Glooko, the long-term sustainability is directly proportional to how useful and sticky it’s users find the logbook iPhone app. The hardware (Metersync) may be critical at first, but end user experience and market differentiation will come from the software. There is competition, of course. Agamatrix  has been in the market with it’s iPhone compatible glucometer, and last year they announced partnership with Sanofi-Aventis that gives them the much-needed commercialization ability. Instead of augmenting diagnosis, another company Cellnovo takes a similar approach with therapeutic insulin pumps. Perhaps we’ll see a synchronized gluocometer-insulin pump offering or an intelligent, symbiotic ecosystem for diabetes devices in future.

I’ve talked about the ‘last-mile’ of remote patient monitoring in the past. Conventional medical devices produce digital manifestations of physiological parameters, but the information collected hardly goes beyond the device itself.  We need consumer-oriented medical devices to become monitoring services that automate/transform the last mile for consumers. The future is arriving piecemeal, and sadly enough, it’s not being delivered by the incumbent behemoths of the medical device industry. Withings BP Monitor (which I can personally validate since I use it) enhances the value proposition of a regular BP Monitor for hypertensives. Zeo does the same for people with sleep disorders. Granted these offerings are perfect yet, but all vectors are aligned in the right direction. As for Glooko, look out J&J.

While reviewing Zeo and aXbo last year, I found myself wondering what was the need for having a bedside clock hardware, since most of that computing could be done in a smartphone. Seems like the crop of solutions  that followed (e.g. WakeMate, Lark, Zeo Mobile) thought of the same. EASYWAKEme follows the pattern: wearable sensor (on wrist) that monitors movement as a proxy for sleep phase, provides intelligent wake-up alarm and longitudinal insight into your sleeping habits. Their ‘how it works‘ page explains it well.

Quick market analysis shows that price is going to be a very important factor since there is a wide range right now and consumers will tend to favor the cheapest. EASYWAKEme (£118), aXbo (starts at €179), SleepTracker ($149) are at the more expensive end compared to competitors like Lark (starts at $99), Zeo (mobile is $99), FitBit ($99), Jawbone Up ($99). WakeMate has already started the downward spiral at $59.

Activity sensors like FitBit, and more recently Jawbone Up are also chomping at the bit to include sleep monitoring as their value proposition. Cheaper solutions that are just smartphone apps are competition too. I actually bought the $0.99 SleepCycle iphone app out of curiosity (it had >20,000 reviews, most were positive) and ended up forgetting about it after a week. I now put it in the same category as placebo: it’ll work only if you already believe it does.

So the real question is whether body movement tracking and analysis is really a dependable way for extrapolating sleep phases. I still believe (based on scientific persuasion like this, and this) that it is. The ultimate hope is that these low-cost innovations can make their way back to help with serious issues like sleep disorders and psychiatric disorders. Current solutions like polysomnography are too cumbersome to be done outside of a clinical setting.

Disclosure: the generous folks at EASYWAKEme offered to send me a review unit, so I’ll be testing that hypothesis over the next few weeks. Look out for an update to this review in near future.

HealthLoop was founded by Jordan Shlain, MD to address outpatient transition to home-based care. The service is in very early stages, and the site explains little about exactly what it provides. All I could find was “… (it) enables medical practices to efficiently monitor signs and symptoms, and communicate with patients during the recovery process“. So I’m guessing the core is case management and communication functionality, with perhaps some way for patient to input their vitals (hopefully it’s not manual data entry). Healthloop is in the embryonic stages, so I won’t attempt to read the tealeaves any further.

Potential issues for HealthLoop are low barrier to entry and powerful incumbents. If they choose to pursue, big EHR vendors can potentially create a much more comprehensive and integrated solution for care transition management. Today the inpatient/outpatient care is digitally captured in EHRs anyway, and theoretically comes coupled with PHRs. So care transition becomes one of the natural value propositions of the EHR-PHR continuum. Besides EHRs, HIEs are the other upcoming intermediary that may find this space relevant. It makes business sense for HIEs to offer care transition management as a paid-service.

The underlying space of care transition is valid enough that startups in this space have a chance to be viable. Especially given that currently very few EHRs or HIEs are explicitly and completely tackling it.

PS: Read more about care transitions on the National Transitions of Care Coalition (NTOCC) website.

Today, clinical professionals have tools (like Ovid, ScienceDirect, UpToDate, Trip) that help answer complex questions and are connected to validated knowledge bases derived off of sources like PubMed. But how does a patient, with no access or expertise in the domain find and leverage this information? Medify tries to solve that.

The value proposition of Medify is not easy to describe. In fact, the ‘What is Medify‘ description on the site was banal enough to be dismissed, just like most other online social health startup marketing. They do a better (albeit prolix) job on the ‘How it works‘ page. Medify will appeal to the well-informed patients who are not afraid to sift through piles of academic articles burdened with medical jargon to understand and manage their own disease. Medify gives them a dashboard of existing literature – with it they can monitor things like which treatments are gaining traction in the provider community, which institutions are on the forefront of relevant research, etc. Affiliated web 2.0 functionality like faceted search, social sharing, tracking, annotating are bundled in to make it more personal.

Under the hood, it is smartly leveraging what public knowledge bases are already out there. The citation and abstract are free from PubMed. Interstitial phrases and terms in the content are further linked to sources like Wikipedia and MeSH. Brief outcomes or summaries are synthetically constructed from the article text.

Medify is not alone. There are other sites that try to help patients navigate the vast sea of research literature. PubMed’s parent NLM runs MedLinePlus,  UpToDate has a patient-oriented version, and niche startups like MyDailyApple, PatientsLikeMe are also tackling this to some extent.

In 2001 Brian Haynes, MD, PhD wrote an article describing the landscape of such ‘pre-appraised’ resources through a hierarchical structure that had four layers (called “4S” Model):

• Original ‘Studies’ (what PubMed provides) at the base
• ‘Syntheses’ (systematic reviews sources like The Chochrane Library) of evidence just above that
• ‘Synopses’ (like EBM, EBN Online) of studies and syntheses next up, and
• the most evolved evidence-based information ‘Decision Support Systems’ at the top.

He later expanded the model to 2 more layers (read about the “6S” paper here), but the basic argument remained same – Information seekers should begin looking at the highest level resource available for the problem that prompted their search. That is a good framework to understand why services like Medify are needed.

The skeptics would argue that offerings like Medify will do little more than empower hypochondriacs. But I believe that well-served health information only makes outcomes better. The lag time between published research being implemented in real-world medical practice can be in the order of decades. As consumers, we are entrusted to make choices about other important topics like money, and the market provides personal finance tools/services to help. Same can apply to healthcare, without diminishing the role of experts.

Alliance Health offers services to create health-related social networks. So it’s like Ning (Marc Andreessen‘s online platform for custom social networks) for healthcare, except that users can’t self-service and start a health-related network on Alliance Health.

They currently operate separate networks on over 40 physical and mental health issues (see screenshot below). Each community offers the standard fare expected in a online social networking site- discussion forums, videos, posts, reviews, etc. The star performer in their portfolio is DiabeticConnect, which is reportedly the largest diabetic community online with around a million unique visitors monthly.

If you look at the top most active social networking websites today, there are hardly any entries related to health (DXY.cn, DailyStrength, CaringBridge are the only ones). Yet health information is one of the most commonly sought-after content online. So there is definitely scope and need for leveraging social features of internet for health. Doing so on a combined platform increases viability, since the mainstay of revenue for social networking is still advertising. Cumulative audience across all networks is a better sell to potential advertisers.

I have high hopes for Alliance Health. Once the user base is there (like in DiabeticConnect), there are significant revenue opportunities in data analytics and mining. Beyond niche topic-based networks, I think they can extend services to private organizations like large care delivery organizations, insurers to create white-label social networks.

Apixio is one of the few startups tackling this issue. Their analytics engine indexes the underlying data, processes queries and provides context-relevant results. The core technology is supposedly based on Apache’s Pig (a data-flow language and execution framework for parallel computation), Hadoop (a framework that allows for the distributed processing of large data sets across clusters of computers) and Cassandra (a scalable multi-master database).

There are a number of terminologies (read ontologies) in healthcare, trying to specify the concepts and relationships from a particular perspective. LOINC, ICD, SNOMED, CPT are common examples, but see a pretty comprehensive list of all human-related ontologies at BioPortal (filter by category ‘Health’).

So a medical-grade search service offering would need to traverse such terminologies and surface all relevant, normalized data related to the query. For example, a search for keyword “breathlessness” in a patient with long, complicated medical history would bring up documents and encounters that mention items like wheezing, PEFR, smoking, asthma management. It’s no short order to do all that analytical crunching.

Sophisticated data transformation and abstraction offerings are certainly needed for making sense of complex healthcare data. Niche efforts like Apixio, 360Fresh, are signs of growing market realization that the era of just trying to digitize healthcare data is getting over. Now we start figuring out what the heck to do with all the incoming bytes.

PS: Advanced analytics offerings in healthcare are an interesting topic. See this wiki page for a living list of relevant companies in this space.

Voxiva provides the technology platform, professional services and support needed for designing and deploying a mobile-based health solution for consumers. When you read that, think beyond the now-hip smartphone app market. Less than a fifth of mobile handsets out there are smartphones. So to reach the remainder, the solution has to encompass relatively simpler mechanisms like feature-phone data entry, SMS and IVR.

There are a number of unique design challenges for creating an engaging public health solution that can work across any/most devices and be delivered through multiple channels to a varied set of end-users. It needs to work synchronously across web, mobile, email. It should support data entry across all kinds of user interfaces (feature phones, smartphones, different mobile operating systems, multiple-languages, etc). It needs to deliver real-time alerts (SMS, voice, email, web portal) and provide real-time analysis for decision-makers. And obviously be scalable and dependable with near-100% uptime. What appears to be a simplistic low-end IT solution on the surface is really a huge undertaking to communicate with an end-user population that is as diverse as it can be.

Voxiva’s real impressive achievement is doing a lot of what they do in international market- specially developing countries. They have created a HIV/AIDS mHealth solution for Rwanda Ministry of Health, disease surveillance solution for Peruvian military, diabetes management program in Mexico, and plenty of others. In US, their most famous offering was Text4Baby (see Multiplyd’s previous review on it), an SMS-based maternal health education service launched in early 2010. Since then, they have diversified into Text2Quit (smoking cessation) and Care4Life (diabetes management). Simple interventions, but designed for massive implementation and adoption. Which is why Voxiva continues to stand out.

Alzheimer’s Association created Comfort Zone service to provide location updates for family members through a device worn or carried by the affected individual. The hardware form factor ranges from a regular smartphone to a device that can be carried in pocket or installed in car. Each comes with a monthly service plan that is priced according to the frequency of location updates. For example: the once-a-day location update plan (for sprint phone) costs $9.99/month vs. every-15-minute update (for a qualcomm pocket device) is $64.99/month. The underlying LBS platform technology is from Omnilink.

Some of these devices come integrated with Comfort Zone Check-in – a website where a family member or caregiver can log in online to setup geographical ‘zones’ and customize the recipients and frequency of email/text alerts if patient exits their zone. It’s a great example of how healthcare IT should be used: focused solution with integrated hardware, serving a specific need. The service is augmented by a couple of valuable additions. In case internet is not accessible, there is a 24-hour call center available. Monthly plans also include the MedicAlert® + Alzheimer’s Association’s Safe Return® program, which is a 24-hour nationwide emergency response service for missing Alzheimer’s patients.

Comfort Zone is not entirely unique though; there are other places to get such location-aware services for healthcare use. Project Lifesaver, LoJack SafetyNet provide the technology and the real-world service to locate missing individuals. Some low-end solutions are also available in popular electronics stores.  But the online Check-in service is a differentiator for Comfort Zone. Keep in mind that Alzheimer’s is the only cause of death among the top 10 in the United States that cannot be prevented, cured or even slowed. For a concerned caregiver, it is paramount to have a continuous, remote ability to know if the patient is safe. It enables more than one person to lead a normal, independent lifestyle.

Disease organizations are great resources, no doubt. They provide reliable helplines, confidential counseling, referrals, education and support for the affected individuals. Services like Comfort Zone are a perfect example of the technology-based evolution of such organizations.

According to the National Association for Home Care, about 12 million people in this country receive care from more than 33,000 home health care providers. The market is made up of few large, publicly traded companies (see LHCG, AFAM, AMED stocks for example) and many small/mid-size players. The challenges faced by these companies are typical of those with field-based employees: scheduling the visits, then figuring out if their employee actually visited the patient, if they did then what was the real time and mileage, ensuring the data collected during visit is archived and accurate, etc.

Which brings me to CellTrak. It was founded in 2006 and delivers mobile-based automation to Home Healthcare agencies. I think it’s a brilliant application of healthcare information technology for alleviating self-reported information issues and paper-processes in a niche market. Given that everyone carries a phone today, using mobile modules to increase compliance and productivity makes a lot of sense for a field-based business. Some examples of the modules available:

• Care Plan Management
• GPS and Directions
• Time and Attendance
• Travel Time and Mileage
• Supply Management
• Alerting and Messaging
• Scheduling
• Nurse Care
• Wound Care

Solving logistical issues like location, time capture, attendance, inventory etc. is pragmatic. But providing modules around clinical care is the more interesting strategy from my perspective. Usually, software solutions that enable care documentation and collaboration are associated with either care-delivery enterprises (e.g. fixed location hospitals using EHRs) or with patients themselves (e.g. PHRs). Neither of those have a particularly critical need to be consumable in a mobile form-factor- that is just a nice-to-have functionality. CellTrak has found a special need where the inherent care delivery workflow necessitates even the clinical Healthcare IT solution to be exclusively mobile. It is a good example of the hidden corners within the complex maze of healthcare system which require thinking outside the traditional bounds.

Other examples of using exclusively mobile-based electronic health records are mostly restricted to public health context in developing countries (see ChildCount for example). That skew is mostly due to the field-based nature of public health and mobile being the primary means of connectivity in emerging economies. With CellTrak, we see the same technology paradigm tackling the problems of a conventional health industry segment in a developed country.

CellTrak partners with some EHR (Cerner, Allscripts) and wireless providers (AT&T, T-Mobile, Sprint, Verizon) currently. I expect that the future iterations of most enterprise EHRs would include incorporating a solution like CellTrak which enables running operations in the field and  seamlessly connects health information to/from a mobile workforce.

I first heard about MyBasis during a talk given by Bharat Vasan (founder?) at Bay Area Quantified Self gathering in June 2010. He referred to it as PulseTracer back then, and described its use for pulse monitoring. Based on the current description on their website, the product concept seems to have matured. Similar to BodyMedia, it now has 4 Sensors: Pulse, Temperature, Accelerometer, Skin Conductance (i.e. moisture). It is USB and bluetooth enabled; and comes with integrated social functionality (gaming, sharing, rewards, etc.). There seem to be smartphone, iPad and online applications that help provide analysis and understanding of the collected data.

MyBasis certainly has the concept nailed: A smart device with multiple sensors and long battery life in a familiar form-factor + Always-on and connected to desktop, mobile and online dashboards that simplify analysis of the aggregated raw data + Integrated social features that help make it sticky and viral. If they play it right, this can be a hit. Mainstream competition from products (like the lackluster Polar offerings) is uninteresting and hardly addictive.

But critics can say that there are always technophile early-adopters (like me) who crave anything that is novel and web-enabled. So before we get over-optimistic about the impending success of such devices, consider two important caveats.

First, it’s not about sophisticated monitoring or granular data. Whether they realize it or not, the key value proposition for an average end-customer is the personalized insight that results from it. Gathering 24X7 data from multiple sensors is great, but it’s all pointless if the user doesn’t understand the ultimate picture that results from all that data. Most users are interested in revelations into their health and lifestyle, not numbers. So the way MyBasis handles analysis is going to be critical. I was disappointed with MyZeo and FitBit for the very same reason. An interesting approach that MyBasis seems to have is the creation of a virtual pet that gives a quick proxy of your overall status. It may sound silly, but abstractions like these have shown promise in encouraging self-monitoring and positive behavior change in users (e.g. see UbiFit project at University of Washington).

Second, the technology and device needs to be so well-integrated with a user’s lifestyle that they essentially ‘disappear’. If someone needs to put a headband one (like for Zeo) or remember to find a USB cable and synchronize every week to prevent data loss, you can be assured that it’s not going to work out long term. As a species, we humans have remarkable lack of discipline even when it comes to things/habits that are good for us. So the offering needs to add minimal extra work and be seamless with your daily life. Neil Versel at MobiHealthNews calls it “passivity”. Example: FitBit gets a better grade than Zeo in this regard. I clip it onto my belt (almost sub-consciously now) every day and plop it on to the USB hub (always connected to my desktop) once in a couple of weeks. That’s it.

MyBasis is still in early beta, so my impression is based on what their website claims and not actual usage. I’ve signed up for preorder and will update this review when I get my hands on one. Seems like the cost is a one-time $199 for now. It would make a lot of sense to have  a subscription-based model of some sort though. Also, it’d be great to see such solutions go beyond just wellness and be tailored for medical-grade serious conditions like diabetes, hypertension, etc. All clues indicate that such applications are not very far in the future.

Established in 1995, the Center for Connected Health is another such example within Partners HealthCare in Boston. They’ve dabbled in a number of remote monitoring pilots- diabetes, dermatology, heart failure, etc. Healthrageous is their first spin-off. It started as a pilot project conducted in 2006 with EMC Corp. to give employees self-management tools for blood pressure. In June 2010, Healthrageous raised $6 million in a Series A funding led by North Bridge Venture Partners of Boston.

Having read enough of them, I think the marketing message around the concept of continuous care through remote monitoring has now been perfected from multiple angles. Read the descriptions from Welldoc, HealthBuddy, Telcare, iMetrikus, Hommed, Cardiocom, Gentag, BL Healthcare for example. Healthrageous also does a good job at describing the high-level value proposition.

But it seems that the transition from online paragraphs to a generally available, well-known and affordable solution has not happened. I searched for what product/service I could buy through Healthrageous to help a close friend manage her hypertension, but couldn’t find anything. There are some encouraging success stories on the website, but no explanation as to where can one sign up for becoming a success like that. I wish these websites were more transparent and lucid, maybe even at the risk of being less enchanting.

PS: Found two candidate consumer-oriented solutions for remotely managing hypertension. One is not available yet (Withings BP Monitor), and other needs an Apple iOS device to work (iHealth Lab’s BP3) and didn’t get great reviews. If anyone knows of other products/services, please share through comments below.

Companies like Cellnovo represent the key role IT is playing in the evolution of medical devices. UK-based Cellnovo began in 2002 as Starbridge Systems Ltd. to develop a novel micropump with only one moving part that made it smaller, more accurate and less expensive. Somewhere along the line, their conventional medical device transformed into a mobile health offering. It now consists of:

1. Pump: A small, waterproof device that can be easily applied, removed, and repositioned on the body. Also includes a built-in accelerometer that registers and stores user activity data.

2. Handset: A hand-held device that communicates wirelessly to control the pump and sends data to a secure website. User can manage dosage, schedule, log supplemental data like food intake, activities, emotions, etc. through this device. The look-and-feel has been compared to today’s appealing smartphones with icon-driven intuitive graphical display and touch screen ability.

3. Online: Websites customized for various participants that are usually involved in managing diabetes- provider, patient, caregivers, etc. Given the variety of people that can be involved in the care team (primary doctor, dietitian, diabetes nurse educator, eye doctor, foot doctor, endocrinologist, exercise trainer…), communication and coordination is an often under-served part of diabetes management. Seems like Cellnovo Online is an attempt to improve just that.

The overall concept is not new. OmniPod by Insulet Corporation (a public company) has a pump and handset. Big players like Medtronic, Sanofi-Aventis, J&J have shown signs of moving in similar direction. With the February 2011 series B financing round of $48.4 million, Cellnovo also seems to have enough runway in this space. As an interesting aside, combining insulin pumps with Continuous Glucose Monitoring System (CGMS) makes a terrific combo- uninterrupted sensing and coordinated, intelligent drug delivery. OmniPod does this.

Solutions like Cellnovo provide not just a way to deliver therapy, but a novel way to collect detailed data about given patient population. Analyzing aggregate data like that can lead to insights at multiple levels- clinical evidence (EBM), provider performance, population health, etc. An interesting decision fork in this evolution would be whether manufacturers leverage commercial computing hardware like smartphones or create their own (like Cellnovo). The former gives wider reach, while latter provides better, medical-grade control (something that FDA probably mandates).

But the key point in all this is about the future of traditional consumer medical devices. The next-generation devices seem to be less conspicuous, continuously connected, more personalized and come with an integrated online component that becomes the window to interaction with multiple parties (caregivers, friends, insurers…like an evolved, niche form of social networking). The new value proposition doesn’t stop at just a hardware device, but becomes a continuous service for managing chronic disease.

One can argue that managing all chronic diseases requires understanding an ever-changing constellation of information continuously generated by a whole ecosystem of participants. This ever-connected disease management approach that removes the burden of keeping journals and pushes information to healthcare professionals can to be applied to many diseases besides diabetes. I’m sure a number of those are already underway.

Docmein is an online appointment scheduling service focused on private practices. The value proposition is that providers and patients can both use this online service to request and confirm appointments without any software to install. Side benefits are timely email reminders and custom pages for patients and practices.

It’s a bit surprising that healthcare continues to get the onslaught of simple web ideas repackaged from elsewhere. Perhaps its due to the relative ease of executing on internet-based ideas today. More importantly, it underscores how poor is the public perception of healthcare IT. Those who have observed the disruptive force of information technology elsewhere wonder why it hasn’t penetrated healthcare effectively. Hence the constant idea and technology arbitrage.

Most internet users are probably aware that online group scheduling services are free. Choices are plenty (Google Calendar, Tungle, TimeBridge, Jiffle, Doodle to name a few) and they are all very good. So what does healthcare need that can’t be fulfilled by these companies? Consider it from two perspectives: inpatient and outpatient.

Outpatient scheduling is more aligned with the services described above. The need is for patients and providers to coordinate a mutually convenient appointment time. But usually patients already know their provider by the time they are trying to find an appointment (e.g. they’ve called the insurance company or the doctor’s office). So finding an appointment time is just a short conversation away. The real value proposition is when patients are still open to picking a provider. That’s when such consumer-oriented outpatient scheduling services are really worth using. ZocDoc does this.

On the inpatient side the need is for a enterprise-grade, rules-based scalable system that integrates with various existing healthcare information systems. To figure out what is the most suitable appointment time for a patient coming in for knee replacement, the scheduling department needs to know the status of radiology/lab reports, clinical resource availability, OR schedule etc. Even just scheduling in-house clinical staff is often an insurmountable and complicated task. For example, YourNurseIsOn is s start-up specifically focused on the nurse scheduling and communication.

Docmein may not be there yet, but scheduling in healthcare delivery systems is definitely a problem waiting to be solved.

There are exceptions though, perhaps due to changes like Orphan Drug Act of 1983. Take Genzyme‘s wonder drug cerezyme for example. It’s target population (worldwide) are the roughly 10,000 patients affected with Gaucher’s Disease. For each patient, the drug treatment costs $200,000 annually and is needed for life. No wonder that even with that small target market, cerezyme accounts for about 30% of Genzyme’s revenues, netting close to a billion dollars every year ($1.24B in 2008, for example).

Such exceptional, near-magical stories are not limited to pharma wonderland. Patients with some rare conditions have found exceptional support through dedicated online communities started by inspired individuals who are often patients themselves. PatiensLikeMe was started for ALS, for example. Ben’s Friends was started by Ben Munoz in 2006 for AVM. There are many more niche online destinations for rare conditions, and that fact is hardly surprising.

The really interesting trend, though, is the emergence of companies/organizations that offer something at a higher level; beyond just a focused online destination for an uncommon disease. CureTogether is a good example. By aggregating self-reported data from patients, it aims to create an open-source research database for uncommon conditions. Similarly, Bens’s Friends acts as an incubator and clearinghouse of online communities focused on the long tail of rare medical conditions. They claim to have around 25 networks and over 7,000 patients in their family of ad-supported communities. The sites don’t have huge number of visitors, but that is perhaps due to the implicit rarity of target audience. See the quantcast chart below, for example, where I compare couple of their communities that are supposedly the most popular.

Regardless of visitor numbers, Ben’s Friends points to an interesting evolution phenomenon for healthcare information online. Building communities is now old-school. The new set of ideas are at a higher level of abstraction.

Seems like the new crop of ‘medication management services’ are purely software applications using the increasingly-ubiquitous mobile phone as the hardware companion. The space is getting crowded: PillBoxApp, PillBoxer, RememberItNow, ZumeLife, PharmaSurveyor, MedWatcher and Jitterbug. PillPhone joins the lineup with a few mildly notable differences.

Pillphone is made by Vocel, a mobile messaging platform developer. It’s based on ‘The Pill Book‘: consumer guide to the most prescribed drugs in america. The book has been around for decades; now in it’s 14th edition. The app is available on AT&T, Sprint and Verizon networks and the company claims it can work with most handsets and costs around $4/month. The features are pretty standard: visual/audible alerts and reminders, a mobile MAR, visual identification (i.e pill pictures), and side-effects information. Bit surprisingly, they have managed to get an FDA 510(k) clearance, handful of patents and some big investors.

No doubt that mobile computing platforms (not just phones, maybe dedicated health devices in future) are going to play a crucial role in providing medication adherence services of tomorrow. One of the key gaps though, is in integrating such personal MARs data with institutional EHRs. If we continue to be unable to reliably involve patients in the medication reconciliation process, then such mobile applications are just another isolated island of data – incapable of making the overall healthcare system more efficient. See Joint Commission‘s take on this topic here. Lets hope that in future everyone who checks into ER can hand over their detailed medication history on a dumb (or smart) phone to the staff and providers can use that information right away.

The underlying concept is nothing new in medical device industry, with it’s origins perhaps in holter monitoring fifty years ago. But true at-home remote monitoring began gaining traction in early 1990s; and today some major names are in the race: Honeywell Hommed, Philips, Health Hero, Cardiocom, Corventis. All of these companies have had an actual device as a part of the overall offering-  some piece of electronic hardware that enables capture and transmission of given physiological parameter(s). LifeStream, Motiva, HealthBuddy, Commander, PIIX are the respective names of the hardware from companies mentioned before. Even the recent consumer-oriented solutions like GlowCaps, Zeo, Fitbit etc. have a proprietary piece of electronics central to them.

And that, is what makes Welldoc is interesting. They have a disease management solutions that are entirely mobile and web-based. No proprietary hardware. It’s an interesting approach that points to an underlying need as well as an overall weakness of such models.

The unmet need here is for solutions that help engage patients at home and provide round-the-clock assistance in chronic disease management (e.g. what insulin dose to take, when to see your physician, etc.). That doesn’t require a device hooked to patient necessarily- it can be accomplished by manual data entry, easy-to-use software and intelligent algorithms. The value proposition is across many soft (as in, hard to quantify ROI on) aspects: enabling patient self-management, promoting health education, improving compliance, effecting positive behavior change etc. Of course, all these lead to some hard benefits that can be quantified (like improved Hb A1C values over time), but the cause-effect relationship can never be established beyond doubt.

The weakness in this approach is that all this depends on manual data entry by the patient or caregiver. It assumes that the affected individual is capable and disciplined enough to interact with the software consistently and reliably. Offering mobile applications is one way to start making that assumption partially valid. As a constant companion with computing power and internet connection, mobile phone makes it easier to use such software. But not enough to cover what I call the ‘last mile‘ of remote patient monitoring- from the patient’s body to an electronic data capture device. No matter how sophisticated the software is, it’s no good if there is not enough data to run its logic on. And our fundamental human behavior tends to revert back to lazy, undisciplined ways sooner or later. So yes, there is a role for pure disease management software but its a stretch to assume that it’ll suffice on its own.

WellDoc was founded by endocrinologist Suzanne Sysko Clough, MD in 2005. Their first solution, focused on Diabetes managment, was piloted in Baltimore in early 2006. Digging through their news it seems they have been fortunate enough to find substantial angel and grant funding, starting with $5M in 2007 and totaling nearly $17M to date. Recent years have also brought some big milestones for WellDoc: deal with Jitterbug (April 2009), FDA clearance (August 2010), deal with AT&T (October 2010), and integration with AllScripts EHR (December 2010). WellDoc website is skimpy on the actual details of their product, but there is a high-level demo. They seem to be expanding beyond diabetes into cardiovascular, wellness, medication adherence and clinical trials data management areas. That is a smart move. Also smart is their attempt at a business model. As their CEO explains in this article, they are aiming to get paid by large employers, plans and payers for making chronic disease management programs more effective.

The whole RPM industry has been praying for national direct reimbursement for decades now. Its been a tough journey so far- positive studies keep trickling out, and every year seems to be the one that will finally see payers admitting the cost-savings from RPM and starting reimbursement. WellDoc has also invested heavily in clinical trials to convince the industry. It’ll be worthwhile to see how successful a purely software-based company would be at making a living in the RPM market.

February 2011 Update: WellDoc announced that they have acquired Oncology Care Home Health, LLC, a education and consulting company helping home health providers implement specialized oncology home care programs. Probably the idea is to use that specialized knowledge to augment the logic behind their oncology offering (maybe get that FDA certified?).

Pharma, Media, Government organizations sometimes find themselves in dire need for a quick survey of licensed physicians. They are happy to pay honorariums for a response, but how does one quickly assemble a large enough group of physicians based on a specific criteria (like specialty, location, etc.)? TruthOnCall aims to serve that need. Physicians, verified through their provider ID (NPI), sign-up on TruthOnCall to receive text questions through SMS. If they respond within 24 hours, they earn $10 per question. Once the amount reaches $100 or above, TruthOnCall mails a check to the physician.

Granted that there is a need here. Big companies often find it hard to get any objective granular data on strategic issues- surprise move by a competitor, drug recall in same class, end-of-the-year justification for a marketing campaign, etc. The usual source are industry analyst firms like Frost or Gartner, but the facts in those reports are often too generalized. So getting feedback from a thousand physicians in a few hours can be worth a lot.

But all that depends on the critical assumption of consistent demand and supply. There needs to be enough supply of physicians (in a given specialty) signed up, and there needs to be a demand from an organization willing to pay. Getting the former is the hardest. Metcalfe’s Law from telecom applies here. It’s clear that the value of such a network grows exponentially with the number of connected users in the network. But niche social networks don’t crystallize by themselves overnight. To reach that critical mass (where networks start having “value”), they need significant money or marketing or both. No good way to tell how TruthOnCall is doing with respect to incoming demand and supply.

Some side-notes: There are a few physician twitter celebrities- (@KevinMD, @DeanOrnishMD, @jhalamka, @tedeytan…). Maybe a viable alternative for rapid physician feedback is getting these guys to tweet the question. Generic networks aside, Epocrates is one good example of a viable physician network. Incidentally, this sort of honorarium service is a good fit for Doximity, which is another physician networking startup by the co-founder of Epocrates.

Isabel’s solution is based on sophisticated pattern-recognition technology from Autonomy, a huge pure software company based in UK. The powerful Autonomy engine is unleashed on a database built from medical textbooks and journal content, and claimed to have >100,000 documents covering >10,000 diseases. Think of it as a web crawler, that indexes authoritative medical text instead. The software’s strength lies in identification of the patterns that naturally occur in text, based on the usage and frequency of words or terms that correspond to specific medical concepts. Each diagnosis is assigned clinical weighting scores derived from expert opinions reflecting prevalence effects based on factors like age, gender, geography etc. The user interface incorporates Natural Language Processing to make the interaction more intuitive and easy for the clinician.

I’ve known about Isabel since 2007, and used it for a few months with very positive results. Was specially impressed with the software’s ability to handle free text, and the company’s openness to a peer-reviewed validation process in an effort to convince the medical community. It seems they have done a serious corporate make-over in 2010: renewed website, cleared pricing and changed management (Interesting fact- ex-CEO Joseph Britto now works for Autonomy).

Autonomy announced a clear healthcare-focused initiative this month, called Meaning-Based Healthcare platform (perhaps trying to capitalize the current buzz around Healthcare IT Meaningful Use regulation). Strangely, there is no clear cut mention of Isabel on the AutonomyHealth website. Regardless, with the vast amount of unstructured data being generated in healthcare, technologies like Autonomy have a bright future.

The free app is currently only available for iPhone platform. It offers a staple of standard social networking functionality- creating profile pages, looking up colleagues based on certain criteria, finding med-school classmates, sharing private contact info, sending messages etc. Being mobile-focused gives it some amount of differentiation from other online physician networking sites, I guess. Users can also look up phone numbers and location maps of healthcare facilities like pharmacies but I dont quite see what is the unique selling point in that. Below is a short video demo of some of the functionality.

On to more important things.

Their about page hints at their possible revenue models – “We have a number of fee-based products in the works, including a service for hospitals and clinics to better manage their scheduling and on-call lists“. In an online interview with iMedicalApps, their CEO gave more details. First, they plan to sell a premium version (base version will always be free) to hospitals as a real-time ‘enhanced communication tool’ for physicians so they can get quick consults, updates etc. from each other. That may work, but only if the hospitals or physician groups foot the complete bill for such an ‘enhancement’ tool. I doubt individuals would pay anything for it- enlightened physicians may already have effective substitutes through enterprise EMR messaging functionality or Linkedin/Twitter.

Second one was honorariums given for occasional survey participation. Hmm…don’t think practicing physicians would find that lucrative enough to join, since the time spent on doing such things is almost never worth the money that can be offered in return.

Third one was mediation fee for physician recruiting. Now that may work, but it depends on how they structure the job-exchange functionality. Because there is a real risk of physician recruiters short-circuiting Doximity and approach the candidate physicians directly if they can identify them for free on the network.

Irrespective of the vague details on the revenue model, I’m a supporter of niche social networks. I think the Facebooks and Linkedins of the world are eventually going to be victims of their own success. Beyond a certain size, generic networks risk imploding under their own weight. Just like MySpace did. Professional networks (especially for highly paid professions like doctors, lawyers) need to serve very specific purpose and be fine-tuned to that. One specific aspect that may be served well by a real-time physician social network is scheduling. Enterprise-wide, rules-based smart scheduling that enables physicians to manage their availability in a group setting is a tough problem to solve. There is some analogy to be found in the nurse scheduling space- a startup called YourNurseIsOn. This page explains what they do. That kind of service, I think, is something that large healthcare establishments can find convincing enough to pay for.

By the way, those who know Joomla (the popular open-source content management system) would notice the uncanny resemblance of Doximity logo to Joomla’s logo. Hopefully they will realize it at some point and get a new logo made.

Dec 2011 Update: Doximity changed their logo..