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.

Touch Diagnostics is a small startup that has created four iPhone applications that provide a new way to administer some of the neurologic exams:

1. Nystagmus is a  disorder with periodic rhythmic, involuntary movement of the eyes. One of the ways to test for it is by using a ‘Optokinetic Drum‘, which relies on the response of the eye to continuously moving pattern that has contrasting elements. Now the drum can be expensive and comes with real-world problems (storage, disinfection etc.). OKN+™ is a simple app that replaces the drum for $2.99.
2. In Finger Oscillation Test, individuals are instructed to tap their index finger as quickly as possible for few seconds, keeping the hand and arm stationary. It measures motor speed and helps determine particular areas of the brain that may be damaged. $2.99 DigiTap™ is replacement of older devices for this test.
3. Reaction time is a simple measurement (in milliseconds) between the presentation of a stimulus and the elicited response. The results can be used to assess fatigue, concussion, sobriety, etc. ReAct™ does that for $2.99.
4. Tremors are unintentional movements, and sometime these micro-vibrations are too small to notice with naked eye. For $3.99, TremorTracer™ provides a way to perform some subjective tremor tests (like Archimedes Spirals in which patient tries to trace a line inside a spiral space)

Okay, so these apps are not exactly cut for the top 25 list on iTunes. And they may never gain traction amongst the myriad of health-related apps out there. The clinical value of doing these tests, although foundational, is also no match for a CT scan. A neurologist I spoke with was quick to point out that doing these test the old-fashioned way doesn’t take much time, and the results are not that crucial anyway (for clinical course of action).

Regardless, I like the way these apps cleverly digitize a small subset of real clinical tests even when the hardware (i.e. the iPhone) was never intended for clinical applications. There will be a time in future when these smart computing devices open up to third-party hardware add-ons like scopes or sensors- temperature, pulse oximeter, etc. Then this would be a valid and viable genre of applications. Till then, we need to ‘fit the test to the device’ rather than the other way around.

Rochester, NY based Logical Images is the company behind VisualDx. Understandably enough, it was founded by two dermatologists from University of Rochester in 1999. At its core lies a pretty big repository of clinical images (they claim > 60K) that are tagged with clinical metadata like symptoms, location, history etc. A user can browse through diagnosis domains or input findings to reach a relevant set of images.

There is a 15-day trial for non-enterprise users, and individual subscription pricing ranges from $49.99 (Pediatric) to $99.99 (Adult) for a year. Student discounts brings it down to a very reasonable level ($29.99 and $49.99 respectively) in my view. The company has leveraged their content to create an online consumer health resource called Skinsight. Besides the clever name, I really liked their slick ‘Skin Condition Finder‘ tool. Overall, it’s a smart approach for gaining market recognition and expanding services.

The concept of Diagnostic Decision Support (DDS) often comes with the implicit notion of text-based query, so I really like the ‘visual’ DDS approach. Dermatology, Pathology are obvious choices to implement such an approach and situations like ER, bioterrorism, infectious diseases are prime contexts since there is not enough time to engage a pure text-based knowledge base. Also, some conditions are rare enough that most practicing physicians and non-specialists haven’t actually seen one in real life. Other factors like dark skin, atypical presentation can be confounding. It’s handy to have a this as a medical education tool and as a care delivery aid in facilities where specialists are not available all the time.

I’m bit surprised why it’s not a widely subscribed resource in hospitals, public health entities, medical education and general EMR vendor products. Anyway, it’d be interesting to see this visual content embedded in other consumer tools (like iTriage, FreeMD) and enterprise offerings (Isabel Healthcare, SimulConsult, Curbside.MD etc.). Wonder which firms are competitors for VisualDx today…

With that background, Corventis becomes an interesting entrant to the MCOT space. Their technology platform consists of a bandaid-size wireless sensor patch called (“PiiX”) that detects, records and transmits physiological data to a portable hub (called “zLink”). zLink is a cellphone-size device that sends the data over wireless network to ‘Corventis Monitoring Center’, which is a staffed to do preliminary interpretation and urgent physician notification. They offer these capabilities in two forms: NUVANT (ECG based continuous arrhythmia monitoring) and AVIVO (non-ECG physiological paramters monitoring). Corventis has some big venture names behind it: KPCB, Mohr Davidow, DAG ventures. They recently got FDA clearance for NUVANT in January 2010.

Cardiac diseases are certainly the prime target for any wireless remote monitoring startup. Corventis is not alone. iRhythm’s Zio Patch is designed to diagnose cardiac arrhythmia by providing  up to 14 days of continuous recording. Once done, the Zio Patch can be mailed back to the company for analysis. Unfortunately, the Achilles heel for all of these companies is reimbursement. So far, private insurance companies and CMS are not convinced that such services are worth paying for. MobiHealthNews has an interesting post about this trend here.

I’ve written about a number of consumer-oriented ‘wellness’ services by startups that are using wireless sensors to detect simple metrics like activity and help you achieve a healthy lifestyle. Corventis, iRhythm are good examples of medical-grade services utilizing the same basic technical framework and abilities for managing life-threatening conditions. Once we get over the barrier for reimbursement, you can bet on the remote monitoring market for serious medical conditions exploding. We can wait for that to happen, but I’m personally convinced that as consumers take more charge in managing their conditions (and health insurance continues to spiral the drain from a cost and outcome perspective), there is a growing scope for remote monitoring services that consumers will pay for themselves.

PS: I had a discussion with Corventis founder, Darryl Drinan a few weeks ago. He had three insightful comments for anyone thinking about getting into the remote monitoring space:

• If you have a choice, focus on therapeutic service, not diagnostic
• Product alone is not enough, always tie it to a service
• Patient education is a big problem (if you need to do it for them to use your device, you are hosed)

At the core is a symptom-checker that lets users do a high-level categorization of what could be wrong with them, and how serious/not can it be. That functionality is nothing special, since there are multiple services that do that both online and mobile. Also included is a nationwide directory of care facilities (including urgent care, retail clinics, pharmacies and physician offices) and nurse advice phonelines (sorted by insurance provider). Your smartphone knows where you are, so the neat service is to be able to find directions to the nearest facility with few clicks. It may not sound like much; but when you are away from home, it’s pretty useful to be able to quickly figure out the nearest urgent care or retail clinic. iTriage is also trying to take this service to another level with the addition of ‘ER wait times‘ functionality in select cities. That way a user can further filter out the facilities based on wait times. Even if this is not really present/reliable in your area today, I think it’s a brilliant extension of a service like iTriage. Because its not a question of if this will be useful, but when. Once there is a critical mass of hospitals in an area submitting their ER-time feed to iTriage, the rest will find it hard not to do the same. There is a need for public to have a near real-time pulse on ER utilization, and services like iTriage provide a good platform for it.

The other interesting aspect is their partner service integration. Healthgrades provides the physician/hospital quality reports within iTriage, although users need to pay to get info beyond minimal basic report. Teladoc provides the 24×7 physician advise service (its phone consultations are for under 40$ mostly). They also partner with a claims adjudication organization (name?) that helps consumers negotiate thier medical bills. One can argue that a lot of the above functionality can be accomplished with a mobile browser or search app. But the value-add of a dedicated app is to provide fast, context-relevant info and be a steady companion as the user traverses the acute healthcare system.

I heard Paul Hudson, MD (co-founder) speak at the Mobile Health 2010 conference last month. He used an intriguing term to describe their technology: “symptom-to-provider technology”. Guess that is one way to think about a IT service that holds your hand from beginning to end of an acute care episode. He placed iTriage in the “multi-billion $ self-referral market”, and gave couple of interesting factoids about it’s current utilization:

• Around 89% iTraige members are commercially insured
• It’s use has gone beyond Emergency care in some cases- people have used the Healthgrades info to switch providers

Both of those underscore the fact that consumers need a trusted guide in handling how they interact with the acute care system. ERs, Urgent Care centers are the way most people experience care delivery most of the time, and having insurance doesn’t really help in making a good choice. With mobile phones getting smarter, the ‘self-referral’ market is ripe for innovative services.

FreeMD is the free online version of the same underlying triage application. It  uses video to conduct the interview, ask questions and then generates a custom web page that contains care instructions and suggested next steps. I tested it with a few hypothetical cases (from benign nose bleed to serious UTI) and it seemed to do fine for basic diagnosis. With vague complaints like diffuse abdominal pain and vomiting, it stayed roughly in the right categories at a high-level (appendicitis, pancreatitis, kidney stones, gallbladder disease, intestinal obstruction).

Is the underlying logic based on hierarchical structured programming or a more sophisticated expert system with forward and backward chaining algorithms? I don’t know. My interest in FreeMD spiked when I saw the 100K+ unique visitors/month statistic. They are consistently generating a lot of traffic, so there’s got to be fairly comprehensive content and at least some utility in the service. My personal impression is that as a patient-oriented triage tool, it does well. Of course, provider-oriented decision support is tougher and I don’t expect it to hold up like Mcyin or DXplain.

I’m also intrigued why DSHI systems chose to make their application available for free, when the revenue model seems to be based on licensing/co-branding with partners. I was half-expecting to see a feedback loop on FreeMD (like “Was this the right diagnosis? Let us know”) since one of the major reasons for open-sourcing anything is to leverage wisdom of crowds. But there isn’t anything like that, so maybe its all about gaining awareness and marketing the application.

Feb’10 Update: Connected with Dr. Steven Schueler after writing this post. He correctly identified that FreeMD is a triage system, so its a bit unfair to compare it with diagnostic decision support systems like Mycin/DXplain.

Dec’10 Update: FreeMD has a new look now. The user interface is much better and the interaction is much more easy (handy pain scale, descriptive pictures for example). Some interesting new functionality has been added too:

• Triage results now provide more information: FAQ, video explanations, and images
• Best options for care included in results, like ER, Urgent Care. Especially interesting are newer venues like eVisit and Retail Clinics. Hovering over each option gives some useful information like average charge expected at that venue. Very cool.
• The final ‘Triage Report’ can be printed or copied to clipboard.

These are all steps in the right direction. A more integrated future (like export capability to Google Health Record, or ER wait times from iTriage, or provider rankings from Vitals) would definitely establish FreeMD as a viable online triage destination.

Healthline was founded in 1999 as YourDoctor.com and was re-launched as Healthline Networks in 2005. It’s got some deep-pocket investors behind it (Aetna, NBCU, Kaiser Permanente, Reed Elsevier, US News & World Report to name a few) so I’m not surprised that they have managed to create (what they call as) ‘Consumer Healthcare Taxonomy’ of >1 million terms and 250K medical concepts. That is what powers their proprietary ability to organize and present contextually-relevant health information to a viewer. Personally I don’t think of it as novel, given that there are plenty of precursors in the medical ontology area (SNOMED, UMLS…) that match this feat.

So Healthline can power health search in multiple ways (symptom, treatment, doctor, drug) and help consumers navigate to the right information. They have also branched out into health-specific ad network, PHR etc. Regardless, I’m interested in mentioning Healthline because of their excellent 3D Body Maps. They have a neat library of 3D animations that lets you partially control and understand body structure and function. Much like CareFlash. Development of these consumer-oriented educational health content repositories is a positive trend, although it’d be much nicer if all these individual attempts were cataloged in one place, giving a complete guide to educational 3D health and wellness content on the web. Like what Clicker does for Internet television.

SimulConsult has an interesting logic behind it. Roughly speaking, its knowledge is derived from a ‘computational wiki’ that is restricted to physician users only. So its database is not only open for viewing, but users can submit modifications to the database. The system performs bayesian pattern matching and also considers temporal information like the age of onset and disappearance of each finding for each disease under consideration.

According to Dr.Segal, there are about 33,000 data points (disease findings) in the system and the future expansion plans are to include more of metabolism and genetic diseases. Interestingly, the wiki approach for knowledge gathering in healthcare is becoming more common (AskDrWiki, WikiDoc, wikiMD to note a few- more on them later).

Feb 20, 2009 Update: Got an email today announcing that those who contribute information to SimulConsult database will now get paid for their contributions. As they are adding sponsored links in the software, I guess it makes sense to share the wealth. More info here.

The navigation is pretty simple and straightforward. MEDgle’s output is a probabilistic list of disease/conditions based on the user input. The content is authored by their 3-physician team and is based on publicly available information available such as the Center for Disease Control and National Institutes of Health. Where probability estimates were not available, they have used their own practice experience to fill in the gaps.

The need for a healthcare vertical search engine is widely realized, and like everything else, it opens up the ability for potential (ab)use with self-diagnosing hypochondriacs. Skepticism aside, I did a search using a common symptom (difficulty in walking, heel pain) and found it easy to navigate to a list of links and information around bone spur and plantar fasciitis. The “Related Local Doctors” section for finding local providers relevant for your symptoms is a neat idea too.

There is an obvious limit to the utility of such tools- Alexia Estabrook’s blogpost talks about MEDgle’s performance for a more complex query. Although that points to the Achilles heel of any diagnostic decision support system today; it’s hard to model the entire spectrum of disease-symptom relationship in an all-inclusive, 100% accurate way. It has more to do with the ever-expanding body of medical knowledge than the lack of technical prowess. That why medicine is a science and an art.

PS: You can read the interviews of some of MEDgle team members here and here.