Category: e-health

Listen app: ResApp diagnoses respiratory ailments

published date
April 28th, 2016 by

ResApp-Logo-50px

I’m intrigued by an Australian company, ResApp that has developed a smartphone app to diagnose respiratory diseases by analyzing the sound signatures of coughs. The company has just completed an oversubscribed fundraising round, so I guess I’m not the only one who finds it interesting.

I interviewed the CEO, Dr. Tony Keating via email, and his answers are below. Meanwhile, check out the demo for their consumer-facing product.
[vimeo 140138524 w=640 h=360]

What is ResApp? from ResApp Health on Vimeo.

Q1. What unmet need does ResApp serve? How big is the need?

ResApp is developing digital health solutions for the diagnosis and management of respiratory disease (e.g. pneumonia, bronchiolitis, asthma, COPD). We estimate that every year more than 700 million doctor visits result in the diagnosis of a respiratory disease within the OECD, in the US the number is 125 million visits. Pneumonia in particular costs the US hospital system $10.5 billion annually. The World Health Organization estimates that nearly 1 million children die of pneumonia in the developing world every year, with a large portion attributed to the lack of availability of a low cost diagnostic tool. 

Current diagnosis of these disease is costly and time consuming (consider that an x-ray for pneumonia diagnosis in the US costs more than $200 and can take up to an hour in an emergency department), and there are also many areas where current diagnostic tools are unavailable. Our initial focus is to provide an accurate remote diagnostic capability to telehealth where even the stethoscope is not available to physicians. 

Q2. How does the system work?

ResApp’s technology is based on the premise that cough and breathing sounds carry vital information on the state of the respiratory tract. We use machine learning algorithms that analyze the sound of a patient’s cough. Our algorithms are able to match signatures that are within a patient’s cough with a disease diagnosis. An analogy might be how speech recognition algorithms match speech to text, or how Shazam’s algorithms look for signatures in music to identify the artist and title. 

Q3. Who came up with the idea? How?

The technology was developed by Dr Udantha Abeyratne and his team at The University of Queensland. Dr Abeyratne and his team have been engaged in the R&D of the technology since 2009. They were initially funded by a grant from The Bill and Melinda Gates Foundation to investigate if mobile phones could be used to diagnose pneumonia in the developing world. The initial idea was to take the latest advances in speech recognition technology and couple them with physicians’ in-depth knowledge of cough and breathing sounds to develop a diagnostic test that could be delivered at low cost to patients in the developing world. 

Q4. You started as a telehealth app but are now looking to serve physicians for in-person visits, such as in the emergency room. Why?

Our focus remains on providing a remote diagnostic test to be used alongside a telehealth consultation. However we have seen great interest from physicians for use in in-person visits, such as in the ER. The potential of our technology to provide an instant and highly accurate differential diagnosis of respiratory disease is seen as a way to greatly improve the diagnosis and treatment of their patients. In addition, healthcare payers could potentially realize significant cost savings versus traditional diagnostic tests (such as chest x-ray). 

Q5. The app doesn’t require any additional hardware. Is a smartphone really good enough to serve as a medical device?

Our clinical study, run out of two major Australian hospitals, has demonstrated very high levels of accuracy (both sensitivity and specificity) in diagnosis from recordings taken using the microphone on the smartphone. We are simply using the smartphone as an efficient platform for delivering a clinical-quality medical diagnostic device. The FDA has approved over 100 mobile medical apps, including a number that diagnose a disease. 

Q6. Your initial focus is on diagnostics. Do you also plan to offer tools for ongoing management? 

Yes, our recent fundraising allows us to accelerate our plans to develop tools for ongoing management of the chronic respiratory diseases asthma and COPD. We see an opportunity to potentially measure the severity of these conditions on a more regular basis than what is done today. We also see the opportunity to deliver these management tools to all smartphone users who suffer from these conditions, without the need to purchase additional hardware (or perhaps also just as importantly, without the need to carry a second device). 

Q7. What geographic markets are you serving? Are you worried you are spreading yourself to thin?

Our focus is the US telehealth market, although our recent funding extends our US market into the in-person use by a physician. In both of these instances, we are still providing the diagnostic result to the physician, not directly to the patient, so our clinical studies and FDA submissions are essentially unchanged. We have recently seen growth in telehealth, in particular in Europe and Australia and will be working through the regulatory process in those regions in parallel to the US regulatory process.

Q8. What’s to prevent someone else from copying what you are doing?

The university has filed a patent application (which ResApp has a worldwide exclusive license to) describing the method and apparatus of respiratory disease diagnosis using sound. The machine learning algorithms that we use also require a significant amount of high quality clinical data, which we have generated from our multiple clinical studies. 

Q9. Anything else to add?

ResApp’s technology, originally developed by a world-class team at one of the world’s leading universities, provides an opportunity to deliver a clinical-quality medical diagnostic test for respiratory disease to everybody who has a smartphone in their pocket. While we’ve talked a lot about the opportunities in the US, Europe and Australia, we must remember that there are also billions of people in the developing world who do not have access to quality healthcare. We have recently partnered with a leading global humanitarian organization to help bring a high accuracy, low cost diagnostic test for pneumonia to those people and to try to reduce the number of children who die from pneumonia and other respiratory diseases every year in the developing world. 

By healthcare business consultant David E. Williams, president of Health Business Group.

Free market for surgery: interview with Allevion CEO Arnon Krongrad, MD

published date
January 6th, 2016 by

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Surgery can be expensive, scary, dangerous and even deadly. Yet it’s hard for patients and even for referring physicians to navigate the system. So I was intrigued when I was contacted by Dr. Arnon Krongrad , CEO of Allevion, Inc., a healthcare logistics company that markets surgery packages. The company’s Surgeo online marketplace let’s patients shop for the surgeon of their choice.

I explored the topic in depth with Dr. Krongrad in this email interview.

What are the limitations of referrals to surgeons by primary doctors?

Conventional surgeon referrals by other doctors, such as primary physicians, rely upon limited knowledge about a limited number of surgeons. For example, primary physicians tend to know a relatively small handful of surgeons for specific procedures, such as vision correction. The simple reality is that in today’s environment, when primary doctors are pressured to churn patients, type into EMRs, and speak ICD-10, they have little time to sort through choices of surgeons. They will reflexively refer to the familiar, which may or may not be optimal. Primary physicians, like the rest of us, might welcome systematic, easy access to knowledge about choice of surgeons.

It looks like your surgeons are selected based on the opinions of their peers. Are there more objective, quantitative ways to rate surgeons?

Surgeo’s purpose is to simplify access to quality care. In surgery, quality comes from the surgeon. The question, then, is how to qualify surgeons. This is an urgent question as our increasingly consumerist ecosystem demands transparency regarding cost and quality. It is a question with obvious and easy answer but a conceptual framework will help us to manage and make progress.

First of all, no, there are no objective, quantitative ways to rate surgeons. We should be clear. We are not talking here about waiting room times or adequacy of parking. We are talking here about clinical quality: blood loss, rectal perforation, positive margins, and the like. A system that has not produced an objective, quantitative way to transparently, uniformly, and broadly present cost – a much more cleanly quantifiable dimension of care – has only just begun to think about objective, quantitative ways to present surgeon quality.

As we think about surgeon quality, we should recognize that surgeons do not operate in a vacuum. Most critically, they operate on patients, who are varied, and produce outcomes that are varied. Let us use prostate cancer surgery as an example. The factors other than surgeon skill that affect various outcomes vary. For example, cure is affected by cancer grade and preservation of erections is affected by diabetes. So which outcome – cure, erections – are we looking at when we ask about surgeon quality? Once we decide, have we collected patient data in a way that would permit us to explain variation in outcomes between surgeon A and surgeon B? No, we’re just not there yet.

Secondly, formulaic objectivity, laudable as it might be, is not the only way to go. The other way is subjectivity, the argument for which was previously laid out in this article. In brief, the principle relates to the instantaneous ability of subject experts to detect artistry when they see it. It argues that surgeons know quality surgery when they see it. As one very senior surgeon who has taught surgery all around the world said it: “I can tell within a minute of skin incision if a surgeon is good.”

There are data, most notably in bariatric surgery, to show that subject expert peer credentialing correlates with objectively measured outcomes, such as hospital readmission. In other words, we think we can do well by patients and payers by applying the collective, subjective wisdom of surgeons.

Do other factors affect surgeon qualification? Any surprises?

Yes. Surgeo’s surgeons are qualified using a published, multi-factorial surgeon credentialing process that includes but is not limited to peer input. The idea is to try to get as close as possible to surgeons who know what they are doing and who exemplify the high standards of service and mission.

The additional steps have yielded some surprises. For example, Surgeo recently rejected the application of a very well known, very high volume, well published surgical specialist whose peers think highly of him. We rejected the application upon discovering what his peers did not know: that he has a history of numerous high-dollar malpractice payouts, including one incomprehensible loss at jury trial. This example relates to the opening comments: doctors do not investigate surgeon qualifications as fully as they might if given motivation and time. Surgeon qualification takes time, effort, and more than one criterion.

What do surgeons think of your approach?

Doctors generally are under siege. They are all looking for simplicity, fairness, and respect for their abilities and integrity. Surgeo delivers those and surgeons love the surgeon driven, clinically rational product design and administrative approach. The model works because it satisfies patients and providers. It has also satisfied payers, as when we used it in a previous chapter to satisfy Blue Cross and develop surgery bundles for the network.

What has been the most surprising reaction of your surgeons?

Surgeons are often paralyzed by the freedom that Surgeo offers. They have no idea how much to charge for their services because nobody has ever asked them before. Surgeo does not negotiate prices with its downstream vendors. Surgeo does not set allowed amounts or ask for discounts. This is unfamiliar to most doctors. This seems bizarre. Have you ever met a lawyer who has no idea what his hourly rate is?

What’s the history of Surgeo? What is its future?

One day, two things happened: Congress said everyone was getting healthcare and a man with cancer told me he could not get healthcare: surgery for his newly diagnosed cancer.

I tried to help him and ran into inflexibility and apathy. The solution ultimately involving sending him from Oregon, my surgical team from Florida, and a surgical robot spot purchased on eBay for 1% of retail from Colorado to an operating room in Trinidad. The exercise delivered a flat-fee surgery package at a price he could afford and worked for all involved. We then developed the model domestically and sold surgery packages to individuals and large payers. You can see a presentation of that case here.

Surgeo is a public, interactive, online face of surgery packaging and pricing software engine that was designed in-house under the direction of Kimberly Langer, our Chief Product Officer. Kim was formerly with a large payer, where she designed large enterprise claims related software. She built Surgeo to scale in a way that can work with payer EDI streams for easier network integration and for presentation to members of service choices and out-of-pocket costs. Kim also built it to accommodate our customers who want privately labeled software by which to market their own surgery packages. We’re seeing demand for that from financial and provider organizations.

You cover a variety of surgeries. Are there any surgeries that have been more popular than expected?

Penile implant surgery. We did not even think about this when we first set out. It turns out that there are huge problems related to this procedure. First of all, authentic conversation about male sexuality and erectile function is in very short supply and men with diabetes, cancer, and other conditions associated with erectile dysfunction have very few places to turn for substantive learning. Secondly, the pharmaceuticals for erectile dysfunction have taken over the airwaves and displaced much of the conversation about other, very effective treatments. We were amazed, for example, that one national network of diabetes activists, whose constituents have up to 70% prevalence of erectile dysfunction, has not discussed erectile dysfunction in 10 years!

What makes the challenges even greater is that penile implant surgery is often not covered by payers. We hear regularly from patients who thought they had what they call “really good insurance” that penile implant surgery is not covered. The way things are going, with CMS having dropped covered for vacuum erection devices, it won’t surprise us if penile implant surgery is just uniformly dropped.

We are getting sad, pleading calls from men with diabetes, obesity, cancer, and others who would like to restore their erections, relationships, marriages, and mood. These men are finding a delivery system that is broadly opaque and unhelpful. In response, we built in response is a national penile implant surgery package network. It features peer credentialed surgeons, comprehensive flat-fee packages, finance navigation, and financial protection in the event of complications. It offers plenty of choice.

The risk protected, flat-fee penile implant surgery package network is a model for efficient delivery of non-covered services. It can help payers to help direct members who do need those services.

What do you mean by financial protection in the event of complications?

Surgeo packages protect surgical patients against financial surprises by bringing in qualified surgeons. This is not a guarantee of elimination of complications but it helps. The second protection is inclusion in the flat-fee package of ancillary procedures. For example, gastric sleeve surgery includes hiatus hernia repair if it is needed: no surprise bill. In some cases, such as penile implant and laparoscopic hysterectomy, we are able to also include third-party products that take financial responsibility in the event of surgical complications. Think of it like getting collision insurance when renting a car.

What explains the variations in package prices?

We are just now starting to see a geographically distributed free market of uniformly defined surgery packages. Surgeons in Houston are looking and seeing prices in Birmingham and adjusting accordingly. So some of the variation is explained by the absence of a transparent market. Variation will probably shrink as price transparency sets in as it has on Surgeo. We see surgeons routinely not wanting to the most expensive.

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

DocChat puts ER docs online (podcast)

published date
November 19th, 2015 by

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Dr. Steve Okhravi and his son Michael decided to do something about overuse of the emergency room. They founded DocChat to leverage telemedicine for triage and to counteract the forces of defensive medicine that send many patients to the ED that don’t belong there. Early results are strong and they are looking to scale.

I asked the Okhravi’s about their service in this podcast interview.

  1. (0:14) What unmet need are you addressing?
  2. (1:33) Are patients to blame for unnecessary visits to the ED, or do physicians deserve some of the blame?
  3. (4:26) DocChat uses emergency room physicians instead of primary care. Why?
  4. (7:00) Is DocChat appropriate for geriatric patients?
  5. (10:08) Your service is not covered by insurance. Who is the paying customer now and what do you expect in the future?
  6. (12:23) You offer a subscription service as well as charging per call. Is this the type of business where a subscription makes sense?

By healthcare business consultant David E. Williams, president of Health Business Group.

Are privileged people wasting their time using healthcare portals?

published date
October 27th, 2015 by
Should I enter the portal or not?
Should I enter the portal or not?

A new study on use of electronic health portals by patients with chronic kidney disease is another example of telling us something we already know: people with lower socioeconomic status don’t adopt healthcare innovations to the same extent as those with higher status. In this case, white, young, married, commercially insured, higher income patients used the portal more.

Here’s what the lead author told NPR about the study:

“Despite the increasing availability of smartphones and other technologies to access the Internet, the adoption of e-health technologies does not appear to be equitable,” Abdel-Kader says. “As we feel we are advancing, we may actually perversely be reinforcing disparities that we had been making progress on.”

Presumably the portal users expected to receive some sort of benefit as a result of logging in. However, from what I can understand from the NPR story and study abstract, the researchers were unable to document the clinical benefit (better blood pressure control) that they were expecting to find.

So maybe a better conclusion is that relatively privileged people with the luxury of time and bandwidth on their hands tend to waste time and resources on a portal that doesn’t provide benefits, while those with lower status focus on more important and productive pursuits.

Ok, that conclusion may not be correct either, but I have real doubts about the usefulness of this research.

It’s ironic that the authors –while bemoaning barriers to access and arguing passionately for policies to address it– published their study and accompanying editorial behind a paywall in the Clinical Journal of the American Society of Nephrology rather than with an open access publisher such as PLOS. I’m curious about the details of the study but not enough to pay $27 for the article and another $27 to read the editorial. I’m going to spend my $54 on something better.

Image courtesy of basketman at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

Mercy Virtual’s Randy Moore: ROI isn’t good enough (Podcast)

published date
September 25th, 2015 by
Randall Moore, MD. President of Mercy Virtual
Randall Moore, MD. President of Mercy Virtual

Mercy Health has been doing big things in digital health. Last year I interviewed EVP Shannon Sock after he spoke in Boston. And recently I met Mercy Virtual’s president, Randall Moore, MD at Qualcomm Life’s Connect2015 conference to ask him some follow-up questions after his talk.

  1. (0:10) You came out on stage and said ROI isn’t a high enough bar to cross. You really have to consider cash flow. Say more about that.
  2. (1:16) You showed a compelling video of a patient’s experience. How much of that is vision and how much is real? For example, do you really have ‘warm handoffs’ to the ER when someone arrives after calling ahead?
  3. (3:34) Many people at the conference have been sanguine about the new ‘value based’ models. But you said hospital-based ACOs are likely to fail. Why?
  4. (6:07) You discussed radically reducing length of stay and increasing market share to stay viable. Does your business model rely on putting your competitors out of business?

By healthcare business consultant David E. Williams, president of Health Business Group.