From TechCrunch by Sarah Perez:  DrChrono, a startup focused on bringing medical records and more to the iPhone and iPad, is announcing a big update today which introduces mobile payment feature to its platform, as well as a new way for physicians and patients to access their health insurance information from mobile devices.  Continued.

Trish’s Comment:  Ever since the Health Information Technology for Economic and Clinical Health Act (HITECH Act), enacted as part of the American Recovery and Reinvestment Act of 2009, was signed into law to promote the adoption and meaningful use of Health Information Technology (HIT), HIT firms have experienced significant growth.

Particularly, this has been the case for Electronic Health Record (EHR) Companies thanks to the EHR Incentive Programs, which specifies that each physician within a practice can qualify for $44,000 in Medicare Incentives or $63,750 in Medicaid Incentives for adopting a Certified EHR. 

This is the main reason behind the explosive growth experienced by innovative small startups in this area, such as DrChrono and Practice Fusion.  What is DrChrono and why has it caught my attention?

DrChrono is a freemium SaaS solution for doctors that is built on top of Apple’s iOS platform.  It offers an online service and iPad app that doctors can use to schedule patient appointments, write or dictate notes via audio, take pictures, write prescriptions, enable reminders, access lab results or input health records.  It is experiencing strong growth going from 5,000 users during the summer of 2011, to 15,000 at the beginning of 2012 to around 23,000 this month.   The best way to get a feel for DrChrono is to review the following short video.

It has caught my attention for four main reasons:

• Michael Nusimow, DrChrono’s CEO, says:  ‘We’re a non-health care company in health care …  A tech company looking for tech solutions.’  And thus, when defining their business and revenue models, they studied and analyzed other tech companies.  Although they are a big data company, they, at least so far, have not gone down the same path as PatientsLikeMe where aggregate patient information is used – and sold – to look for trends in drug performance, disease evolution or geographical distribution.  This is the revenue model favored by other EHR companies such as Practice Fusion.  
  
  In the case of DrChrono, it has chosen a freemium model, with many features offered for free while others, such as speech-to-text, medical billing and insurance checks, are available as in-app purchases.  And it seems that its users are behaving much like users of other freemium-based technology companies, such as DropBox or Evernote, regarding the split between free and paid customers.  

• Although the company launched its product on the iPad first, it initially had plans to port their software to other platforms, most notably Android.  As of late, it has decided to focus 100% on iPad and other Apple products, betting its future in the iPad being the best suited for doctor’s use.  This is a bold bet!
  

• As far as I know, it is the first EHR company to include Square-based mobile payments into its processing flow – directly connected to its billing system.  It makes perfect sense since DrChrono is targeting the smaller scale doctors’ practices (up to ten doctors), where traditional POS systems can prove to be an expensive solution. 
  
  According to Nusimow, it not only makes sense but it is also something doctors really want to use because it is ‘something sexy …  It makes them feel modern’.  Well, no harm in that!

• Finally, it keeps adding very innovative features, the latest being real-time medical insurance checks, available through an iPad app for the very first time.  It allows doctors to easily find out details of a patients’ current coverage and provides patients with details regarding co-pay, deductibles and procedures covered.
  
  DrChrono is a platform and, as such, the possibilities for new features and solutions to be added are limited only by imagination.

DrChrono has already raised over $4 million from the likes of Yuri Milner, Matt Cutts, Paul Buchheit and Charles River Ventures.  It is sure to continue to raise interest as it adds new features and services.  I will keep you updated!

As I have described in a previous blog, a few months ago I had surgery which led to further surgeries and complications. Although my pancreas was already fully functional, there was a moment in time when I feared that, as result of surgery, I would become diabetic, requiring constant checking of glucose levels and the corresponding insulin shots.  Once I was back home, I wondered:  Had that been the case, what are the available technologies that would have helped me manage this condition? 

The most promising and, potentially, life-changing product I found is called Pancreum, ‘The Wearable Artificial Pancreas’, still under development.  

The inventor, and CEO/CTO & Founder of the company with the same name, is Guilherme de Paula an electrical engineer with extensive software and medical devices experience. 

Pancreum is made up of several separate components with CoreMD at its heart. CoreMD is a wearable, and not disposable, medical device that works as the brain of the Pancreum system. Other smaller devices, called wedges, can be attached to this core.  CoreMD receives information from some of these wedges (sensors), interprets it and then it can either send orders to other wedges (pumps) or send the data to a PDA or smart phone to be displayed to the user (patient). 

For example, when acting as a wearable pancreas, CoreMD will have three wedges attached: 

1)   GlucoWedge – A wearable, replaceable continuous glucose sensing device.

2)   BetaWedge – A small, wearable, replaceable insulin pump.  It contains micro-mechanisms for automatic insulin delivery via a subcutaneous cannula.

3)   AlphaWedge – A second small, wearable, replaceable pump that can be used to deliver glucagon, cortisol, adrenaline or other substances needed to avoid hypoglycemia.

Basically, CoreMD will receive information from the GlucoWedge on glucose level, it will then analyze it and determine the amount of insulin or other substances that are required to bring glucose up or down to its ideal level.  Using this reading it will either automatically order the Alpha and Beta wedges to release the appropriate amounts of insulin and other substances, or it will send this information to the user’s phone or PDA to receive confirmation on the next step to take (i.e. if the user does not want to be treated without prior knowledge).  

Information from the sensor (GlucoWedge) is registered and analyzed every 4 minutes, 24 hours a day, providing constant monitoring and allowing the user to closely regulate his/her glucose level.  And all of this is achieved by wearing a small device that becomes invisible under your clothes (1/2” thickness and 2 1/8” in diameter when all wedges are present).  It is considerably better – more comfortable and safer – than having to manually check your glucose levels (normally done just a few times a day) and then having to inject yourself when necessary. 

Because of the modular nature of the CoreMD's design the wedges can be used to build up different medical functions.  An artificial pancreas is built with a Gluco, a Beta and an AlphaWedge, however wedges can also be attached to monitor heart activity (for an ECG, for example), monitor fetus activity or that can pump different types of drugs that need to be infused subcutaneously on a regular basis.

As mentioned above, this system is not yet available and it will probably take another two to three years to have it ready to be commercialized (patents are not yet ready) but, given how revolutionary it can be for the treatment of diabetes and other conditions, I will keep looking for updates!

This is the last blog of the HIT series but, rest assured, there will be other blogs on this topic!

The second question that I would like to cover in this HIT series is how technology can improve the lives of patients during and after hospitalization.

These are some examples of situations that I have witnessed in the last couple of months where I believe better use of technology could have improved my personal experience and, maybe even, the medical outcome:

1)   During hospital stay:
a.     Changes in medication or treatment – The doctor would visit me during his daily rounds and we would discuss any treatment changes required.  After he finished his round (and visited over a dozen patients), he would enter all changes into the hospital’s IT system with a clear risk of forgetting some of the necessary changes.  Why not directly enter changes into a connected tablet while doing his round?
b.     Questions to doctor – Unless there was an emergency, I only had access to the doctor during his rounds.  Why not allow me to send him secured messages with questions / requests, that he could check and reply at his convenience? 

2)   During convalescence period:
a.     No communication between hospital and GP – The day after I was released from hospital I went to see my GP.  He had not received any information during the many weeks I spent there.  I had to give him copies of all the medical reports and test results for him to review and enter into his IT system for future reference.  Why not have the hospital communicate directly with him? 
b.     Logging my ‘symptoms’ – I had many things to control the first few weeks out of hospital (blood sugar levels, temperature, heart rate, amount of exercise…).  I logged all the information in an Excel sheet that I would share with all my doctors during visits.   Why not log data into an app directly connected with the doctors’ IT systems?

Are there any industry-wide initiatives to promote the use of technology to cover these issues and the many other experienced by patients every day? There are, indeed, a number of initiatives but the one that seems most promising to me is the SMART program. 

SMART stands for ‘Substitutable Medical Apps, Reusable Technology’ and is backed by the U.S. Department of Health and Human Services (DHHS), the US government principal agency for protecting the health of all Americans and providing essential human services.

The concept was initially described by Kenneth D. Mandi, MD, MPH, and Isaac S. Kohane, MD, PhD in an article published in The New England Journal of Medicine in 2009.  They envisioned a ‘flexible information infrastructure that facilitates innovation in wellness, health care, and public health.’  To achieve this vision, they advocated a platform approach to software design that would support an extensive ecosystem of apps similar to those developed on the iPhone or Android platforms.   Such an easy-to-use, flexible and robust platform could certainly support an ecosystem that would solve all the issues I described above and many more. 

The key characteristic of such platform would be:

1)   Liquidity of data – Clear APIs that would allow apps to easily access all available data across systems.

2)   Substitutability of apps – A primary care provider should be able to readily use a billing system from one vendor and a prescription-writing program from another.  Furthermore, he/she should be able to change from one billing system to another with minimal effort to ensure the creation of a competitive and vibrant marketplace for apps.

3)   Open standards – The platform should be built to open standards, accommodating both open-source and closed-source software.

Mandi and Kohane also envisioned the DHHS having a key role, particularly in the following areas:

1)   Regulation – Although the platform would support a free marketplace of products and ideas, the DHHS should ensure that the dominant driving force is the maximization of health and that adequate privacy protection is in place.

2)   Incentives – The DHHS should offer incentives to providers to make use of HIT to improve quality of care.

This idea was picked up by the DHHS and it is being implemented through its SHARP Program (Strategic Health IT Advanced Research Projects).

Although the platform, data models and API are not yet finalized, app developers can start to experiment with a preliminary API and data model that have been made public, along with sample code and development tools and support.    In fact, in order to motivate developers to collaborate, the Office of the National Coordinator for Health Information Technology lead by Dr. Farzad Mostashari has launched a number of challenges targeting the development of specific apps that are viewed as key starting points to build a proof of concept of the ecosystem.

Furthermore, as proof that this approach could be applied not just across the US but across the world,  one of the entries into the UK’s National Health Service first NHS Hack Day on May 26th-27th was an app implementing a portion of the SMART API to expose the HES dataset showing a data grid and radar chart for patient problems.  More important than the app itself are the strategic implications of this development.  Co-developer Rob Tweed explained that ‘The technology clearly works and is applicable to use in the UK just as in the US.  This is a set of wheels that the NHS can avoid re-inventing.’  Indeed, it is a set of wheels that many countries around the world could re-use.  Could this mean global interoperability in health care?

Although I asked many questions and did on-line research before deciding to go ahead with surgery, I was utterly unprepared for the seriousness of some of the complications I suffered which, it must be said, are relatively common.  What should I have done to be better prepared?  How could I have been more thorough with my research?

I backtracked my steps and reviewed the websites I had used to help me learn more about pancreatic laparoscopy or distal pancreatectomy.   Some examples of pages I used are:

1)   eHealth Forum – This site, and other similar forums, give you a good sample of individual experiences.  Although you do learn about the types of possible complications and some specific treatments, it is difficult to get an idea of the probability, seriousness and most likely outcome of the possible complications.  

2)   Georgetown University – I found this site, and other university and hospital web pages, very helpful since the information is well organized and very structured.  At the same time, although there was a thorough list of possible complications, neither the probability nor the seriousness or the consequences, were specified.  

3)   Annals of Surgery – I have listed this website to represent the large number of medical papers available online.  I found this to be a good source of statistics regarding types of surgeries performed, types of complications and likely outcomes.  However, the intended audience for these papers is doctors and researchers, which makes it difficult for the average person to follow.

I had used all these different resources and then tried to piece all the bits of data together to make an informed decision.  I know that undergoing surgery was the right decision – there seems to be a general consensus regarding the importance of removing any pancreatic tumor, whether benign or malignant – but I had not managed to piece the information together to prepare me for what happened as a result of it.  Is there a website that could have helped me further?

While pondering this question, I stumbled upon PatientsLikeMe.  This company, (5) co-founded in 2004 by three MIT engineers (brothers Benjamin and James Heywood and longtime friend Jeff Cole).  It has been recognized in Fast Company’s 2010 50 Most Innovative Companies in the World and again featured as a new MIT Technology Review 50 Company in 2012,  only two of the many awards and mentions PatienstLikeMe has received since its inception.

It covers over 500 chronic conditions from depression and epilepsy to ALS and MS.    It does not cover the type of issue I was researching (i.e. surgery of a benign pancreatic tumor) since it is not a chronic condition but I wanted to test the concept.  What can you do in this website?

1)   Members report their personal experiences over time both from a qualitative and quantitative perspective.  For example, you can log your condition, when it developed, current and past symptoms and their evolution, medicines used (including amount and cost) and many other useful bits of info.  This allows for somebody with a similar condition and evolution to directly learn from another person’s experience over time and even contact him / her to exchange ideas. 

2)   Users are also asked to numerically describe the severity of their symptoms, along with the benefits and side-effects from the medicines they are taking.  This allows the website to build ‘statistics’ on symptoms, medicines and any other relevant piece of information.  This information is displayed in a very friendly, usable and easy to understand manner. 

As an example of the power of this information gathering process, PatientsLikeMe has published a patient driven study – based on data contributed by 596 patients it refuts a previous paper suggesting that lithium could help people with amyotrophic lateral sclerosis (also known as Lou Gehrig’s disease).  The findings, published online in the journal 'Nature Biotechnology', highlight how social networking could play a role in clinical trials and enable patients to explore medical questions most relevant to them.  Jamie Heywood the PatientsLikeMe Co-Founder Stated, “While not a replacement for the gold standard double bind clinical trial, the platform can provide supplementary data to support effective decision-making in medicine and discovery.  Patients win when reliable data is made available sooner.”  Many in the scientific community, such as Lee Hartwell (Nobel Prize in 'Physiology or Medicine' 2001), have praised this initiative and believe “the approach has tremendous potential.”

Just as impressive is the fact that the founders, as part of this study and using the wealth of information shared by the site’s members, have built models that predict disease progression in individuals with certain characteristics, incorporating variables like age, gender, disease severity and time since diagnosis.  Although this is still being debated, the company defends that these models allow researchers to predict the course of an individual’s disease more accurately than the standard prognostic tools.  “We can predict when a patient will die 16 months ahead of time, compared to the typical doctor report of ‘you have two to five years to live’”, stated Heywood.

Obviously, PatientsLikeMe is only possible because of user commitment to the site, which is likely to be highest among chronic patients who, over time, need to develop into expert patients to best manage their condition.  It will be difficult to motivate ‘transitory patients’ (i.e. those that, after a few months of convalescence, will make a full recovery) to become as involved in data gathering and analysis but, at the same time, it would be just as helpful and relevant.  

The next few posts will be focused on Health Information Technology (HIT), a newly found interest of mine brought on by a recent personal experience.

Two months ago I was admitted to hospital to have a small benign tumor removed from my pancreas. Due to a number of complications, what was supposed to be a 4-day hospital stay with a 2 to 4 week recovery time turned into a 5 week hospital stay with a 2- to 3-month recovery time.  Happily I am on my way to making a full recovery and that this experience will soon just be a distant memory.

I have found myself thinking about the role that technology played in my experience – before, during and after hospitalization – and how it could have been used better.  I started researching this topic with the objective of answering three main questions:

1) Before hospitalization, what resources should I have used to better understand and gauge the risks associated with pancreatic surgery?  Furthermore, could I build a list of reliable and thorough on-line resources that would help me make more informed decision in the future?

2) During and after hospitalization, how are hospitals, pharmaceutical and health-care companies using technology to improve the lives of patients?  And, just as importantly, how are the U.S. Federal Government and its Department of Health promoting innovation in this field?

3) Thinking specifically about pancreatic issues, what technologies are available to make everyday life easier for those with a non-fully-functional pancreas?

I will devote one blog to answer each of these questions and will post them in the coming days. This is the first time that I cover Health IT here but I believe it will not be the last!