07 February 2017

Some industry experts say that without a doubt, the healthcare system in America is broken. Many reasons are given. Some say it’s a result of long-running, compounding fractures of competing interests, disconnected payment schemes, rival financial motives, poor visibility to costs, massive amounts of regulatory rules and requirements, complex layering of protocol and training, and the list sadly goes on and on… And all of this mess is in the context of high-stakes, literal life-and-death nature of some illnesses.

While technology is generally a wonderful and useful tool in most all aspects and applications, in healthcare and medicine it’s a bit of a different story. Just throwing technology at healthcare is not a strategy for success, but that does not dissuade many from trying. For example, at last count there were more than 165,000 healthcare and wellness apps available. Of course, Darwinian market forces will cull that herd, but on the other hand some Luddite approaches are alive and well, such as using paper medical records, pagers and faxes. Honest.

I do not want to shame those who prefer the quaint (and actually pretty un-hackable) “technologies” of ink, paper, and phone warbles. I also do not want to blindly evangelize a techno-panacea-utopia that always seems forever unreachable—just 15 minutes into the future. Instead, I thought it may be more helpful and of interest to do a review of some of the current technological approaches that actually seem to be working and have surfaced above the din of the next-latest-thing. And, because I cannot help myself, I’ll also opine about a few things that are indeed promising, but not fully baked. Forgive me. I’ll then set them in a context of integrated case examples that I think are fun and cool, er, I mean, clever and smart.

The Empowered Patient

Big pharma may have inadvertently spurred on patient self-efficacy by making them aware, via advertisements, that there exist medications for symptoms they may have, and then recommending such meds to their physicians. Of course, “Dr. Google” has also augmented this phenomena as well for both good and bad. But now, the empowered patient can make provider selections based on clinical performance, cost, insurance coverage, satisfaction, availability, and proximity.

I have met with the nice folks from Castlight and I was impressed with their platform and what they note to be a “… unique and comprehensive data set (that) powers (their) health benefits platform. They are the only company to combine patient claims from all major carriers, employee search and engagement data with the industry’s most robust quality, cost, and clinical data. This drives our healthcare transparency, predictive analytics, and highly personalized experience.”

Another form of the empowered patient is demonstrated in the concept of “The Hospital at Home.” The initial idea driving this was born at Johns Hopkins two decades ago, in that patients didn’t like being at the hospital and they may actually fare better with care delivered at home. This course of treatment is not for everyone, but for those befitting the option, the outcomes are good and the program is scalable. In fact, a recent report in the Harvard Business Review found “…Early experiences showed that, compared with usual hospital care, Hospital at Home resulted in fewer complications (e.g., drastic reductions in delirium), greater satisfaction with care for patients and family members, less caregiver stress, better functional outcomes, and lower costs. Since then, Hospital at Home has been one of the most studied innovations in healthcare. A 2012 meta-analysis of randomized controlled trials of Hospital at Home showed a 38% lower six-month mortality rate for Hospital at Home patients than hospitalized patients. Clearly, if Hospital at Home were a drug, it would be a blockbuster!”

But what if the Hospital at Home model could be augmented with patient-friendly tech? Well, at last year’s SXSW I had the fortunate timing to meet Jeroen Tas, CEO Connected Care & Health Informatics and Member of the Executive Committee at Philips and see the demo of Phillips HealthCare’s ambulatory telehealth program called “eIAC,” and while I was really impressed with its design and functionality, what really knocked my socks off was that it is “… is built upon a population management software platform designed for monitoring and delivering care to the most complex patients at home. Care systems develop the organizational capability to deliver integrated, coordinated care across specialties and services at scale. The eIAC program enables all stakeholders in the clinical and social management of a patient to identify and address the root causes of the patient’s frequent admissions, creating a cohesive system of care that helps reduce hospital admissions while providing the highest level of care to patients with complex, chronic conditions.” That level of integration and fundamental platform seemed like an elegant but powerful engine to scale between various providers as well as their complex patients. 

Most of my work focuses on orthopedic rehabilitation and sports medicine. In this world, clinical outcomes are optimized by patent compliance to home exercise programs (HEPs). As a way to both empower patients and measure compliance, Kiio may have one of the best solutions currently available (disclosure, I am an advisor). Their software is operating system agnostic and plays well with mobile or desktop. It allows for video capture of a patient doing a physical therapy exercise and can then be later replayed in the exact range of motion as will spur recovery and avoid re-injury. The fact that the image is of the patient him/herself is a very cool feature and I cannot help but think also aids in understanding proper technique and compliance. If the patient uses their resistant tubing with a Kiio hand-held force sensor handle, then precise, objective assessment data and complex metrics are automatically calculated and recorded, and progress is tracked over time. The sensors transmit the data via Wi-Fi or Bluetooth to the patient’s device for their therapist to review at the next in-clinic visit. As the patient progresses, the therapist can likewise tweak the subsequent exercises for both force and range of motion.

A 2012 meta-analysis of randomized controlled trials of Hospital at Home showed a 38% lower six-month mortality rate for Hospital at Home patients than hospitalized patients.
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While Kiio is certainly a bespoke, custom rig, others are creating and some gamifying the in-home exercise experience with video. Here are at least 7 startups using Microsoft Kinect for online physical therapy and not to be left out, Nintendo’s console is being repurposed, for, yes, wait for it, “Wii-hab.” 

Additive Manufacturing, 3-D Printing, Mass Customization, Just in Time Delivery: It’s Not Just for Your New Car Anymore

As an orthopedic rehabilitation researcher, I found a 3-D printable device for finger pip joint stabilization or arthritic joints. Then I found 3-D printed wrist splints for rheumatoid arthritis sufferers that enable clinicians (or patients) with no experience in Computer Aided Design (CAD) to design and make custom-made 3-D printed wrist splints. These splints are not only more comfortable, but they look really cool, too. This is yet another new advancement in patient empowerment.

Taking this to the next level is a bespoke, 3-D printed, just in time delivered via additive manufacturing… a new knee, just for you. Yup, ConforMIS has developed what they call the Image-to-Implant® Process, and can provide your surgeon with a “…customized patient-specific knee implant designed to accommodate all stages of osteoarthritis of the knee.” Via their “iFit® Design process, ConforMIS implants and instruments are designed based on the patient’s CT scan. An automated design process uses proprietary algorithms to map the articular surface of the joint in three dimensions. The software uses that information to design the implants and instrumentation that will match precisely to the 3D model of the knee, correcting the data for any underlying arthritic deformity such as bone spurs, cysts or flattening of the joint.” The result is believed to be faster recovery and improved functional outcomes over “off-the-shelf” knees.

Surgical Help

No matter the age or skill of one’s surgeon, a tremor is present when operating. Researchers and engineers have developed Tremor Suppression for instruments used in laparoscopic procedures.

At this year’s Exponential Medicine Conference, I was able to play with, er, demo a da Vinci Surgical System. It was amazing! What looked like a doughnut sized ring that was in a model, once removed and handed to me, I was amazed to learn that the actual size was more like that of a bead due to magnified 3D high-definition vision system. Such machines allow for minimal number and size of incisions—thus less iatrogenic trauma and mitigation of infection risk.

When you combine surgical education with virtual reality you get The Virtual Surgeon™.

The Brainiacs at The Virtual Surgeon™ have mashed up 360 video, 3-D virtual reality and interactive content/experience to put remote viewers anywhere in the world in the operating room. Virtually experiencing an operation through the point of view of the surgeon. The rig runs on the Oculus Rift or Samsung Gear VR. This could be revolutionary in medical training, especially in resource-poor areas.

3-D printed, just in time delivered via additive manufacturing makes a new knee, just for you.
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What do orthopedic surgeons think of such techno-doo-dads in the OR? In an article published last year in Becker’s Orthopedic Review, a number of sawbones were asked just that. Here is a sampling of responses:

“With regard to robotics in surgery, Computer Assisted Orthopedic Surgery (CAOS) is prevalent. For the most part computers used in surgery are TOOLS to help the surgeon navigate position of implants, confirm implant orientation and give real time information while the surgery is being performed. 

“Computers and robotics are becoming more integrated with surgery every day. Image-guided surgery, or surgery in which a computer helps outline trajectories or helps in the visualization of anatomy, is already common place in the operating room. Robots that actually perform surgery already have established roles in urology. These technologies are now more frequently being employed in orthopedic and neurosurgical spine cases. Image guidance for example allows surgeons to more accurately placed pedicle screws in the Operating Room…. 

“As a consequence, these surgeries can not only be more accurate but shorter with better outcomes. Our patients have benefited from spinal surgery that has been more precise than ever before. Typically these have been done in a hospital setting, we are now attempting to bring image guidance to outpatient surgeries which will hopefully allow our patients to benefit from these technologies in a manner that gets them back on their feet quickly.

“As a diversified clinical and academic orthopedic surgeon I am comprehensively dependent on computerizations and apps. These include EMR such as EPIC, injury surveillance for teams and athletes using the Healthe Athlete by Cerner, Outcome Systems such as SOS by Arthrex, Digital Imaging using the Synapse System and patient education using the Ready Set Med YouTube channel.”

Caveats

Some promising (or promised in the case of Theranos gee-whiz technologies) may wind-up not working, not coming to market, or not being as world-changing as originally hoped. Yes, sadly, not all unicorns survive the hype cycle. It was a good day for UniQure, a Dutch biotech company at work on gene therapies for rare diseases. A big pharma company had just made a billion-dollar investment in its future. What could go wrong…?  Well, eighteen months and two CEOs later, UniQure started laying off about a quarter of its staff, abandoning some of its hoped for cures.

The moral is to not expect that the wave of a tech-empowered magi want will cure what ails a broken healthcare system, always being product to market as promised, and never have any unintended consequences of side effects.

 
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