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HIMSS Takeaways: Size Doesn’t (Always) Count, Johnny Appleseed and MomGPT

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By MICHAEL L. MILLENSON

Live and in-person once again, HIMSS 2023 attracted more than 30,000 attendees to the exhibit halls and meeting rooms of Chicago’s sprawling McCormick Place. Although no one person could possibly absorb it all, below are some harbingers of the health care future that stayed with me.

Size Doesn’t Count. Exploring the remote byways of the cavernous exhibition areas, it became clear that it’s not the size of the booth, but the impact of the product that counts. At a pavilion highlighting Turkish companies, for instance, R. Serdar Gemici stood in front of a kiosk that might fit into a walk-in closet.

The display listed an impressive roster of clients for a chronic care management platform, prompting me to stop to learn more. The smartphone user interface for “Albert,” the namesake product of Albert Health, the company Gemici co-founded and leads, immediately impressed me as one of the simplest and yet comprehensive I’d seen. (Indeed, the company website boasts of the “world’s simplest health assistant.”) Albert Health has begun working with England’s National Health Service and large pharmaceutical companies, though I found myself wondering how the name resonates in the Turkish- and Arabic-language versions the company touts.

HIMSSanity 2023! (Photo:HIMSS)

Another far-off cluster of kiosks hosted a company called Dedalus, which promised an interoperable, whole-person care platform. A demo included a graphic showing a breadth of holistic personalization and collaboration capabilities I’d not seen elsewhere. It turns out that while Dedalus only entered the U.S. market in late 2021 – which explains why, as the nice woman showing me the presentation noted, Americans mostly haven’t heard of it – Italy-based Dedalus Global’s software and services are used in more than 40 countries by over 6,700 health care organizations.

Oh.

Size Does Count. When I sat down with Dr. Jackie Gerhart, Epic’s vice president of informatics, and Seth Hain, senior vice president of research and development, at their very large and very busy booth, I had in mind Epic CEO and founder Judy Faulkner’s reputation as a tough, my-way-or-the-highway businesswoman. But Gerhart and Hain were so nice and down-to-earth, earnestly extolling the company’s culture of collaboration, that it was initially as disorienting as watching Elon Musk help a little old lady across the street. (A colleague assured me that, yes, this is actually the way many Epic employees act.)

Nonetheless, Epic remains a 500-pound gorilla, with a third of the hospital electronic health record (EHR) market. Its Cosmos platform, containing records from over 184 million patients and 7 billion encounters in all 50 states, is the largest integrated database of clinical information in the nation. The company is currently working to integrate Microsoft’s ChatGPT generative AI with Cosmos’s data visualization capabilities, which presents fascinating possibilities.

Ask around, though, and you’ll discover that not all hospitals are comfortable with Epic’s control of information. There will certainly be competitors, perhaps including the Mayo Clinic Platform.

A colleague related that many years ago big tech firms marketing their own EHRs warned prospective customers that choosing Epic meant relying on a company that might not be around very long. Instead, those competitors aren’t. Underestimating all those nice (and perhaps some not-so-nice) people at Epic would be a serious mistake.

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Obesity is crippling the US, but there are solutions

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By STEPHANIE TILENIUS

Well over a third of Americans are obese — and the percentage keeps growing at a staggering rate. Over the last twenty years, obesity prevalence grew from 30% to 42% of the US population and rates of severe obesity nearly doubled. If we don’t make serious changes to our healthcare system, it’s scary to think where we’re headed in a few short years.

The fact is, obesity is far from a cosmetic condition. It can be a devastating disease and was classified as such by the American Medical Association in 2013. Obesity is the leading risk factor for deadly diseases like type 2 diabetes, heart disease, stroke, and at least 13 types of cancer.

If we don’t stop the obesity epidemic in its tracks now, we’re in for a world of hurt. People’s lives, the healthcare system, and, by extension, the US economy could be headed for collapse if we continue to ignore it. Cardiometabolic conditions like obesity, heart disease, stroke, and diabetes cost the US healthcare system upwards of $500 billion a year in healthcare costs and another $147 billion in lost workforce productivity for heart disease and stroke alone.

And yet private and government-sponsored health plans are dragging their feet to address obesity head on. They know most people jump from health plan to health plan every few years, so they’re willing to take the chance that their members with obesity won’t develop high-cost complications soon enough to justify treatment now. And yet treatment could reverse the effects of obesity and downstream chronic disease, saving lives and billions of dollars in the long run.

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Can we trust ChatGPT to get the basics right?

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by MATTHEW HOLT

Eric Topol has a piece in his excellent newsletter Ground Truth‘s today about AI in medicine. He refers to the paper he and colleagues wrote in Nature about Generalist Medical Artificial Intelligence (the medical version of GAI). It’s more on the latest in LLM (Large Language Models). They differ from previous AI which was essentially focused on one problem, and in medicine that mostly meant radiology. Now, you can feed different types of information in and get lots of different answers.

Eric & colleagues concluded their paper with this statement: “Ultimately, GMAI promises unprecedented possibilities for healthcare, supporting clinicians amid a range of essential tasks, overcoming communication barriers, making high-quality care more widely accessible, and reducing the administrative burden on clinicians to allow them to spend more time with patients.” But he does note that “there are striking liabilities and challenges that have to be dealt with. The “hallucinations” (aka fabrications or BS) are a major issue, along with bias, misinformation, lack of validation in prospective clinical trials, privacy and security and deep concerns about regulatory issues.”

What he’s saying is that there are unexplained errors in LLMs and therefore we need a human in the loop to make sure the AI isn’t getting stuff wrong. I myself had a striking example of this on a topic that was purely simple calculation about a well published set of facts. I asked ChatGPT (3 not 4) about the historical performance of the stock market. Apparently ChatGPT can pass the medical exams to become a doctor. But had it responded with the same level of accuracy about a clinical issue I would be extremely concerned!

The brief video of my use of ChatGPT for stock market “research” is below:

Implementation May Be a Science, But, Alas, Medicine Remains an Art

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By KIM BELLARD

I’ve been working in healthcare for over forty (!) years now, in one form or another, but it wasn’t until this past week that I heard of implementation science.  Which, in a way, is sort of the problem healthcare has. 

Granted, I’m not a doctor or other clinician, but everyone working in healthcare should be aware of, and thinking a lot about, “the scientific study of methods to promote the systematic uptake of research findings and other EBPs into routine practice, and, hence, to improve the quality and effectiveness of health services” (Bauer, et. al). 

It took a JAMA article, by Rita Rubin, to alert me to this intriguing science: It Takes an Average of 17 Years for Evidence to Change Practice—the Burgeoning Field of Implementation Science Seeks to Speed Things Up.

It turns out that implementation science is nothing new. There has been a journal devoted to it (cleverly named Implementation Science) since 2006, along with the relatively newer Implementation Science Communications. Both focus on articles that illustrate “methods to promote the uptake of research findings into routine healthcare in clinical, organizational, or policy contexts.” 

Brian Mittman, Ph.D., has stated that the aims of implementation science are:

  • “To generate reliable strategies for improving health-related processes and outcomes and to facilitate the widespread adoption of these strategies.
  • To produce insights and generalizable knowledge regarding implementation processes, barriers, facilitators, and strategies.
  • To develop, test, and refine implementation theories and hypotheses, methods, and measures.”

Dr. Mittman distinguished it from quality improvement largely because QI focuses primarily on local problems, whereas “the goal of implementation science is to develop generalizable knowledge.” 

Ms. Rubin’s headline highlights the problem healthcare has: it can take an alarmingly long time for empirical research findings to be incorporated into standard medical practice.  There is some dispute about whether 17 years is actually true or not, but it is widely accepted that, whatever the actual number is, it is much too long.  Even then, Ms. Rubin reminds us, it is further estimated that only 1 in 5 interventions make it to routine clinical care.  

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THCB Spotlight: Glen Tullman, Transcarent & Aneesh Chopra, Carejourney

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No THCB Gang today because my kid is in the hospital (minor planned surgery) So instead I am reposting this great interview from last week.

I just got to interview Glen Tullman, CEO Transcarent (and formerly CEO of Livongo & Allscripts) & Aneesh Chopra, CEO Carejourney (and formerly CTO of the US). The trigger for the interview is a new partnership between the two companies, but the conversation was really about what’s happening with health care in the US, including how the customer experience needs to change, what level of data and information is available about providers and how that is changing, how AI is going to change data analytics, and what is actually happening with Medicare Advantage. This is a fascinating discussion with two real leaders in health and health tech — Matthew Holt

AI: Not Ready, Not Set – Go!

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By KIM BELLARD

I feel like I’ve written about AI a lot lately, but there’s so much happening in the field. I can’t keep up with the various leading entrants or their impressive successes, but three essays on the implications of what we’re seeing struck me: Bill Gates’ The Age of AI Has Begun, Thomas Friedman’s Our New Promethean Moment, and You Can Have the Blue Pill or the Red Pill, and We’re Out of Blue Pills by Yuval Harari, Tristan Harris, and Aza Raskin.  All three essays speculate that we’re at one of the big technological turning points in human history.

We’re not ready.

The subtitle of Mr. Gates’ piece states: “Artificial intelligence is as revolutionary as mobile phones and the Internet.” Similarly, Mr. Friedman recounts what former Microsoft executive Craig Mundie recently told him: “You need to understand, this is going to change everything about how we do everything. I think that it represents mankind’s greatest invention to date. It is qualitatively different — and it will be transformational.”    

Mr. Gates elaborates:

The development of AI is as fundamental as the creation of the microprocessor, the personal computer, the Internet, and the mobile phone. It will change the way people work, learn, travel, get health care, and communicate with each other. Entire industries will reorient around it. Businesses will distinguish themselves by how well they use it.

Mr. Friedman is similarly awed:

This is a Promethean moment we’ve entered — one of those moments in history when certain new tools, ways of thinking or energy sources are introduced that are such a departure and advance on what existed before that you can’t just change one thing, you have to change everything. That is, how you create, how you compete, how you collaborate, how you work, how you learn, how you govern and, yes, how you cheat, commit crimes and fight wars.

Professor Harari and colleagues are more worried than awed, warning: “A.I. could rapidly eat the whole of human culture — everything we have produced over thousands of years — digest it and begin to gush out a flood of new cultural artifacts.”  Transformational isn’t always beneficial.

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Matthew’s health care tidbits: The drug model for DTx was wrong

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Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

If you were to look at pharmaceuticals in the US you might make three observations. 1) They are the most important way health conditions are helped, cured or eradicated. 2) The way they are delivered to patients (via pharmacies) is very badly integrated with the health care delivery system. 3) They are way too expensive.

OK, so those are my observations not yours but I think you’ll agree they’re all true.

Now I am going to tell you that we’ve developed a technology that lives in your phone that has the same impact as a drug, if not better. It will cure your depression, insomnia, pain, even maybe Alzheimer’s. And because it is a software product, not a drug you ingest, it has no (or at least few) dangerous side effects. And because it’s software and easy to distribute to millions of people, it can be cheap. Wouldn’t it be a great idea for the people managing health conditions—a patient’s clinical care team—to directly integrate this technology into the care they are delivering?

Some of the people building these technologies agreed, but most of them decided that they liked the current model of prescription pharmaceuticals. They built these cool technologies and decided to distribute them via physician prescriptions and charge for them like pharmaceuticals. To do that, they had to get FDA approval for their “Prescription Digital Therapeutics” (DTx) via expensive clinical trials. Additionally, of course, they hoped to get government-backed monopoly status–called patents in the pharma business.

In general in health care, the FDA regulates things that go into the body and may cause damage. The rest of clinical medicine has great latitude for experimentation, technique and technology development, and allows others to copy what works.

The companies heading down the Prescription DTx route also used the business model of regular pharma and biotech companies. They raised large amounts of money up front, applied for patents, went through the FDA clinical trial process, and hoped to charge significant amounts per patient once their DTx were approved and prescribed.

None of them seemed to care that if they succeeded, their DTx would necessarily only be accessed by a small population at great cost. None of them seemed to notice that their DTx were usually an electronic distillment of teaching, patient advice, coaching therapy or other activities that look more like extensions of traditional clinical care, as opposed to ingested pharmaceuticals.

Many of these companies are now in deep trouble. They raised money when it was cheap or even, like Pear and Better Therapeutics, took advantage of the SPAC vehicles to IPO. Now they have found that they cant get their DTx through the FDA process quickly enough or aren’t seeing the prescribing numbers they needed to make their products a success. Since the digital health stock crash, it’s very hard for them to raise more money. Pear Tx this week announced it was trying to sell itself.

My hope is that we get a reset. I want digital therapies that are extensions of clinical care to be widely used and widely available as part of the care process, and for their care to be integrated into clinical care –rather than to be prescribed and then delivered by some third-party. And, because they are software and because software scales, I want them to be cheap. Hopefully that is the future of DTx.

On second thoughts, that wouldn’t be a bad future for regular pharmaceuticals either!

Nils Bottler, Angelini Ventures

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I’ve been friends with Roberto Ascione for many years. Roberto is a keen Napoli fan who on the side runs the Healthware Group and also the Frontiers Health Conference that I’ve been going to for many years (and where Jess DaMassa is co-MC). Recently Healthware acquired the media company pharmaphorum and hired star reporter (and another friend) Jonah Comstock, ex MobiHealthNews and HIMSS Media. This is THCB’s second cross-posting with pharmaphorum.—Matthew Holt

Nils Bottler, who recently joined Angelini Ventures as Principal, is an avid skier, surfer, and digital health investor based in Berlin. In a new podcast, he spoke with Paul Tunnah, pharmaphorum founder, about his career, the German start-up landscape, and where Angelini Ventures aims to have an impact.

Throw Away That Phone

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By KIM BELLARD

If I were a smarter person, I’d write something insightful about the collapse of Silicon Valley Bank. If I were a better person, I’d write about the dire new UN report on climate change. But, nope, I’m too intrigued about Google announcing it was (again) killing off Glass. 

It’s not that I’ve ever used them, or any AR (augmented reality) device for that matter. It’s just that I’m really interested in what comes after smartphones, and these seemed like a potential path. We all love our smartphones, but 16 years after Steve Jobs introduced the iPhone we should realize that we’re closer to the end of the smartphone era than we are to the beginning. 

It’s time to be getting ready for the next big thing.  

—————

Google Glass was introduced ten years ago, but after some harsh feedback soon pivoted from a would-be consumer product to an Enterprise product, including for healthcare. It was followed by Apple, Meta, and Snap, among others, but none have quite made the concept work. Google is still putting on a brave face, vowing: “We’ll continue to look at ways to bring new, innovative AR experiences across our product portfolio.”  Sure, whatever.

It may be that none of the companies have found the right use case, hit the right price point, adequately addressed privacy concerns, or made something that didn’t still seem…dorky. Or it may simply be that, with tech layoffs hitting everywhere, resources devoted to smart glasses were early on the chopping block. They may be a product whose time has not quite come…or may never.   

That’s not to say that we aren’t going to use headsets (like Microsoft’s Hololens) to access the metaverse (whatever that turns our to be) or other deeply immersive experiences, but my question is what’s going to replace the smartphone as our go-to, all-the-time way to access information and interact with others? 

We’ve gotten used to lugging around our smartphones – in our hands, our purses, our pants, even in our watches – and it is a marvel the computing power that has been packed into them and the uses we’ve found for them. But, at the end of the day, we’re still carrying around this device, whose presence we have to be mindful of, whose battery level we have to worry about, and whose screen we have to periodically use. 

Transistor radios – for any of you old enough to remember them – brought about a similar sense of mobility, but the Walkman (and its descendants) made them obsolete, just as the smartphone rendered them superfluous.  Something will do that to smartphones too.

What we want is all the computing power, all that access to information and transactions, all that mobility, but without, you know, having to carry around the actual device. Google Glass seemed like a potential road, but right now that looks like a road less taken (unless Apple pulls another proverbial rabbit out of its product hat if and when it comes out with its AR glasses). 

—————-

There are two fields I’m looking to when I think about what comes after the smartphone: virtual displays and ambient computing. 

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Interview with Ogi Kavazovic, CEO of House Rx

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Ogi Kavazovic, CEO of House Rx joined Matthew Holt to explain how his company is trying to ungum the specialty pharmacy market. Its a huge market with a few huge oligopolies in charge of it, and Ogi thinks there is room to work directly with the clinics responsible for most patients using injectables and provide them a better and cheaper experience. Last year they raised $30m in a round led by Bessemer, but as Ogi says there’s along way to go!

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