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The August 15, 2004 Issue Provided by System Dynamics Inc.
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Transforming Disease Care Into Health Care: Can Broadband Help?

We've talked for years about applying broadband in ways that help make people's lives better. At the recent Healthcare Unbound Conference in Boston, hearing about how broadband contributes to keeping people alive and functioning longer and better was pretty exciting stuff. Speakers included those on the front lines of health care, who have conducted studies about how broadband, along with several other key technologies, is producing measurable results.

Eric Dishman speaking at Heathcare Unbound --> Click for larger pictureWe usually write about broadband access, home networking and consumer electronics. How did we find ourselves speaking at a healthcare conference? After we ran Eric Dishman's article Repurposing Broadband: Home Health Technologies for the Worldwide Age Wave, we got an email from Vince Kuraitis of Better Health Technologies. He was helping to select speakers for the Healthcare Unbound Conference and asked us to join in a workshop on "Smart Homes and Smart Phones." We were delighted to participate, since the intent was to begin a dialog between us plus others from the technology side and a wonderful collection of healthcare experts. More about the workshop below.

The title of the conference derives from a study by Forrester in 2002. Its basic premise is that we can improve access to, the quality of and the cost effectiveness of healthcare by moving it away from institutions and doctor's offices and into wherever people live and work. Telemedicine is a related term and concept. One succinct definition of healthcare unbound is "technology in, on, and around the body that frees care from formal institutions".


Framing the Problem: It's More Than Technology

We suspect that many of our readers who have dealt with the US healthcare system for themselves or their aging relatives have come away, as we did, shaking our heads. It's tragic but true that the US spends so much money on "healthcare," has such great technologies that could be applied, and yet has so fundamentally broken a system--see a recent Washington Post article on this. A line we heard repeatedly at the conference is that ours is not really a "healthcare" system, but rather a "sickness care" system.

Vince Kuraitis speaking at Healthcare Unbound --> Click for larger pictureAs the opening speaker, Vince Kuraitis summarized the current situation:

  • People prefer to live in their homes and communities
  • They prefer to avoid institutional care as long as possible
  • The population in the developed world is aging
  • The opportunity for healthcare unbound technologies is huge
  • Healthcare unbound is disruptive to the existing players--and therefore they will fight it
  • But it is the right thing to do.

He described healthcare as being in the early stages of a sea change, during which the human body will become the focus of technology applications for the next decade. The raw ingredients are mostly in place. These include pervasive computing, non-invasive measurements and communications technologies to create the "body area network" or BAN. Those familiar with the hierarchy of networking, starting from the wide area and working toward the person, will understand this is the next step in the logical progression from wide area network (WAN) to metropolitan area network (MAN) to local area network (LAN) to personal area network (PAN).

Joseph Kvedar speaking at Healthcare Unbound --> Click for larger pictureTechnology is only one ingredient in fixing the situation. Dr. Joseph Kvedar, Director of Partners Telemedicine and President of the American Telemedicine Association, and others made clear that in some ways it is the simplest. The prerequisites for getting from today's world to the one we want for the future include:

  • Health-conscious consumer behavior: all those things you've heard about giving up Big Macs, stopping smoking, exercising more, etc.
  • A sustainable economic model: the current economic model pays for sick patients that show up at a doctor's office or hospital emergency room, but not for keeping people out of these places. A quote from Dr. Moore's presentation (referenced below) was "You must not understand…I get paid to take care of sick patients who show up on my doorstep, not to keep them out.”
  • Enabling policy: this is the thorny issue Hillary Clinton and others tried (unsuccessfully) to resolve during her husband's US presidency.

Technology still has some challenges in getting to really "usable technologies", which Dr. Kvedar defined as reliable, "wear and forget" (fully integrated so there is no user interface) and disposable.

Other speakers noted that at least two more things would have to change to make healthcare unbound a reality. First, people need to learn how to do things differently--and people's behavior does not change easily. Second, the economics for a sustainable economic model need to look at the total costs of patient care--not just looking in "silos" as many health organizations do now. For example, the ROI of homecare taken by itself may not look that good, but if you count the cost savings from reducing emergency room visits and hospital readmissions, the ROI looks great. The talk by Drs. Moore and Woodbridge (see below) clearly illustrated this point.

Michael Barrett speaking at Healthcare Unbound --> Click for larger pictureMichael Barrett of Critical Mass Consulting gave an interesting keynote in which he observed that the aging of the population in the developed world plus the availability of new technologies can cause disease and disability trends go off in different directions. He believes that "healthcare unbound" can re-order the links between age and dependence. As an example, he spoke about the following translations which occur today:

  • “I am 75.” (Age)
  • “I have arthritis.” (Disease/condition)
  • “I have trouble walking long distances.” (Disability)
  • “I can’t shop for myself.” (Dependence)

He pointed out that new technology products and services can negate these equations:

  • Age ≠ disease: Products and services promote prevention, wellness, risk reduction, and behavioral change
  • Disease ≠ disability: Products and services neutralize disease’s impact on physical activity, mental alertness, and emotional balance
  • Disability ≠ dependence: Products and services enable independent living despite disabilities


Case Studies

Dr. Kvedar observed that a study of his own organization's healthcare costs showed that 3% of the patients account for 40% of the costs and 1/2% account for 20%; this is similar to what other organizations have found. Kuraitis and others focused on the understanding that if you can determine which diseases and chronic conditions account for most of the illness, disability and cost, there is a logical path to attacking the problem: identify which value propositions most effectively address them, which technologies we need to create those value propositions, and which environments they work in. This is the path that much of today's work is focused on.

Several of the case studies showed credible and convincing outcomes focused on leading diseases and conditions. Let's look at three to see what actually happened.

Diabetes

The essence of a talk by Dr. Larry Gottlieb, Chief Medical Officer of Intermed Advisors was the need to transform the management of chronic diseases such as diabetes from "episodic" (providing treatment when something goes wrong or happens to get caught) to "continuous". The work he reported on involved people with diabetes and was done in conjunction with Joslin Diabetes Center in Boston. The statistics indicate that there were 15 million people in the US with diabetes (in 2002) and 177 million worldwide (in 2000).

His technique involves the use of home monitoring devices (for diabetes it includes measuring blood pressure, glucose, oxygen saturation and weight) and the automatic transmission of biometric data from those devices to physicians and care managers. A key in this work has been sophisticated mathematical time-series analysis to characterize each patient's individual pattern. The mathematics plus the continuous monitoring can quickly and accurately discover trends by looking at the stability of results and the variance. The key is to decrease the cycle time between evaluations and interventions and use the information to make behavioral changes which prevent future adverse events.

The second part of making such a program successful is to make it self-care oriented. Intermed has developed a simple personal interface using a Web pad, or a PC for users who already have one and are comfortable with it. A "virtual nurse" provides frequent positive feedback to the subject--in the form of a human sounding voice, pictures and animation, and simple progress charts to encourage improvements and make suggestions.

The keys to the success of this program are that it is frequent, personalized, self-care oriented and affordable. The subjects generally see participation as an excellent way to avoid the complications of diabetes which can include stroke, eye disease and amputations.

Chronic Heart Failure

Dr. Robert Scott of Ochsner Clinic --> Click for larger pictureThe second study was reported by Dr. Robert Scott from the Department of Cardiovascular Medicine at Ochsner Clinic Foundation of New Orleans. In this case, the subjects were those with unstable chronic heart failure (CHF). Again, home-based electronic patient monitoring was employed -- in this case using the HomMed telemonitoring system (see below). The work involved a group of 115 adult patients with CHF who participated in home monitoring and a control population of 158 people with similar conditions who did not take part. Because of the more serious condition of these patients, their daily results were monitored by trained healthcare professionals. The frequency of all hospital and emergency room visits was reduced by 41% in the program participants, reducing overall costs and improving their quality of life.

Veterans Administration

A third study was described by Doctors Randall Moore of American Telecare and Peter Woodbridge of the Roudebush Veterans Affairs Medical Center. It involved care coordination and telehealth for the US Veterans Administration (VA). Although US Veterans Hospitals were at one time at the trailing edge of technology and innovation, they are currently a bright example of its success. By re-engineering their clinical and operational processes, and employing video (systems and phones) plus monitoring and messaging devices, they saw improvement in diabetic control and chronic heart failure.

Dr. Moore and Dr. Woodbridge showed a dramatic reduction in hospital and ER admits --> Click for larger pictureTheir presentation included a chart showing the dramatic reduction in hospital and ER admissions before and after Telehealth. They reported that the ROI of Home Care alone was good but not compelling; however at a systemwide level it was >400%.


"Smart Homes and Smart Phones"

Connecting Consumers To Create Healthcare Unbound

We spoke in a post-conference workshop moderated by Michael Barrett of Critical Mass Consulting that also included presenters from the University of Virginia Health Sciences Center, MIT and Qualcomm. Our only concern about speaking in this session was its title, which talked about "smart homes"--a phrase we generally try to avoid. Steven Intille, Technology Director of Changing Places/House_n at MIT was on the same wavelength, saying in his talk that there is no such thing as a "smart home", only "smarter people" who are properly enabled.

Stephen's talk focused on the difference between teaching and controlling. He believes that technologies that people will appreciate are those which are fundamentally useful and/or provide the user with lots of benefits. He distinguished between four levels at which technology might operate in a home setting:

  • to control or automate--the user has no choice
  • passive alerts
  • active teacher--alerts that provide information as to why the alert has been given
  • "just in time" active teacher--which adds to the above a level of immediacy at the "teachable moment"

Stephen is testing his premise in an electronically-mediated house at MIT, where volunteer subjects move in for a 10 day stay. The idea behind what happens in the house is that user empowerment is very important. This is quite different than the "smart" home which acts automatically. We hope to see the outcomes of these studies to understand the results and implications. We wonder if the application of this theory may be quite appropriate in some circumstances--such as diabetes control--and inappropriate in others--such as dementia care.

Robin Felder described the Sleep Monitor --> Click for larger pictureRobin Felder, Director of the Medical Automation Research Center at the University of Virginia, spoke about Eldercare Technologies at MARC and how they are aiming at personalized care enabled by technology. In this work, they have created technologies which allow vital signs to be monitored passively. A gait monitor is one example; it distinguishes between normal, limping and shuffling gaits, detects falls and detects changes in pace and gait mode over time. A sleep monitor uses sensors to passively measure sleep quality, sleep depth and vital signs. The technology, which they have named Home Guardian, was deployed for 24 subjects at a Volunteers of America assisted-living facility and ran for three months. Those with the lowest pre-monitoring quality of life showed increases of 66%, 90%, 12%, 54%, 40% and 8% respectively. Robin is continuing work on "the three p's" -- Predictive, Preventive, and Personalized Medicine.

Our talk focused on the broadband home and how healthcare ready it is. We described the infrastructure—-to and in the home-—that home healthcare products can assume in the future. We discussed how this infrastructure was used in some current home healthcare applications, and referred to the work by Telefonica in Spain we looked at last year.

In looking at today's healthcare technology prototypes and products, we observed that most fail to assume the future will include a persistent connection to the home (broadband) or a home networking infrastructure, both of which are becoming more widespread.

Comparing what exists in healthcare today with other applications/products that have reached mass market proportions (such as PCs, cellular telephony and Wi-Fi), it appears that the prerequisites for mass deployments are still some time in the future. In our experience, these prerequisites include both an appropriate target architecture and the development of a technology ecosystem. Each of the home healthcare systems we’ve seen appear to be complete end-to-end solutions. In the absence of an appropriate "home healthcare ecosystem" this is probably "the only way to do it today".

We suggested the audience think about what will it take to get there from here and what efforts are underway to facilitate the development of a successful technology ecosystem for home healthcare.


Exhibits

Like most conferences, Healthcare Unbound had a good-sized exhibit floor, demonstrating a variety of products and services. Many of these contained some variety of monitoring devices, communications capabilities, and processing; these facilitate interactivity between those who have some type of illness or condition requiring medical oversight and the health professionals who care for them. Products from HomMed and FitSense illustrated the range of products and services in the exhibit area.

HomMed Genesis Monitor --> Click for larger pictureThe HomMed Sentry Monitor is used for those who have had recent hospitalization or emergency room visits; those with conditions requiring frequent monitoring or trending of their health status to assist in their clinical management; and those who are trying to avoid admission to alternative living facilities or are having a poor record of compliance with medications, diet or self-monitoring. Basic units contain such devices as a digital scale, blood pressure cuff, and finger sensors for obtaining heart rate and oxygen saturation; other medical peripherals--such as a glucose meter or peakflow meter--can also be attached. They include communications capabilities (usually POTS and a digital 2-way pager) plus an interactive capability--in this case voice and text prompts and a simple interface which guides the user through the process.

JD Ginty showed us the FitSense Pacer --> Click for larger pictureThe FitSense technology is quite different: it is applicable not only for medical conditions but also for fitness, sports and life-safety. These products use miniature, wearable bio-sensors with wireless data links to track physiological variables such as activity, heart rate, blood pressure, weight, core body temperature and skin temperature. Their BodyLAN (TM) enabled systems use a proprietary two-way radio protocol, networking intelligent sensors that process, collect and transmit data. The data can be viewed in real-time on a watch, cell phone or PDA or moved off the body through a gateway to a local or remote database. One example is their Pacer, an activity monitor/pedometer which measures the user's step count, distance traveled, speed and calorie burn. It can be used along with their Pulser heart rate monitor to record associated heart rate data. Although these can be used to monitor a patient's exercise compliance at home, it is equally applicable for healthy physical fitness buffs who want to track the progress of their training programs.

Reflecting back on all that we learned during Healthcare Unbound, we're unclear as to how fast what is possible via technology will be translated into what will be available and affordable. As with many significant changes in how people live and work, home healthcare requires some very basic changes in consumer expectations, government policies, and business and personal incentives. These fundamentally influence the rate of progress and vary from country to country. There is no question that "healthcare unbound" will come to pass in the next 10 to 15 years, but many of the keys to change lie in government policies regarding healthcare and the associated reimbursement systems.

( www.tcbi.org/hu2004 ) ( www.bhtinfo.com ) ( www.forrester.com ) ( telemedicine.partners.org ) ( www.atmeda.org ) ( www.intermedinc.net ) ( www.ochsner.org ) ( www.americantelecare.com ) ( www1.va.gov/directory/guide/facility.asp?ID=62&divisionId=ALL&map=1 ) ( architecture.mit.edu/house_n/ ) ( marc.med.virginia.edu ) ( www.hommed.com ) ( www.bodylan.com )