Patients, scientists learn from microbiome data

By: Aditi Pai | Apr 19, 2013        

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Larry_SmarrWhen Larry Smarr started exploring the biochemistry of his body, he turned to his microbiome to find answers. At TEDMED 2013, Smarr talked about the steps he took in the months before he discovered he had Crohn’s disease.

At first, Smarr used apps like Zeo and Fitbit to monitor his sleeping and exercise respectively. Eventually, Smarr delved deeper, turning his attention to blood work and stool analysis. Studying his stool provided Smarr with rich data about his microbiome, the ecosystem inside the human body made up of different organisms such as bacteria.

Graphing his results, he saw a large jump in lactofferin, a protein tested to check for Inflammatory Bowel Disease. Smarr never felt sick, especially not sick enough to have a chronic disease, and yet that’s what the data showed.

“[There’s] this fallacy that you can guess what’s going on inside of you instead of measuring it,” Smarr said.

His experience with self-diagnosis left him with some insight into how technology might assist patients in actively seeking solutions to their medical problems.

“What this allows us to do, if we start thinking about this tracking over time, that’s going to be a very different form of medicine than we’re used to,” Smarr said.

Jessica Richman, cofounder of uBiome, has begun heading down that road already. Her crowdfunding campaign to collect citizen-sourced biome data raised over $350,000 from 40 different countries, according to her press release. Participants paid $80 and sent in a stool sample to have their own microbiome data sequenced. Richman, who also spoke at TEDMED, vouched for uBiome’s business model to spur a new form of scientific research — that of the citizen scientist.

Encouraging scientists to “think outside the current system,” Richman expects her project to democratize research, creating an “open system, so anyone can participate.”

Smarr and Richman agree that the biological data gleaned from the microbiome can help with the exploration of a variety of conditions, including Crohn’s, eczema, autism, and anxiety. The more data Richman receives, the better results and information she can provide those that provided data.

“People are desperately sick and have chronic conditions and there’s no money to fund their research,” Richman said. “We’re all dying waiting for studies to be funded.”

It’s yet to be determined whether uBiome will be an example of a new model for crowdsourced research, but both Richman and Smarr see significant potential in shifting the paradigm. Similar to Smarr’s experience with his microbiome, uBiome offers citizens the opportunity to send in samples of their stool for testing. The success of the uBiome project in terms of what citizens can learn is contingent on how many people decide to participate, according to Richman.

Smarr credits self-tracking technologies for his own discoveries about himself, and believes new technologies will only help more.

“Because of the big data and because of the ability to analyze it, we’ve got hope,” he said.

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Manhattan: 72 percent of physicians have tablets

By: Jonah Comstock | Apr 18, 2013        

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Female Doctor with TabletManhattan Research shared a few more numbers from its annual “Taking the Pulse” online research survey of 2,950 physicians in a webinar this week. The numbers showed that smartphone, desktop and laptop use has leveled out among physicians while tablet adoption has risen to 72 percent, up from 62 percent last year. The 62 percent number was a surprise for Manhattan last year, more than doubling 2011’s 30 percent metric. The firm also asked doctors how they used each of their different devices.

“The smartphone continues to be a quick hit device, many times per day being accessed, but for, of course, a much shorter burst,” said Manhattan Research President Meredith Ressi. “It’s largely used for looking up information, as opposed to content consumption, checking email, etc., whereas the desktop and laptop continue to be the mainstay, especially for EHR access.”

“The tablet one is a lot more interesting,” she went on. “It really kind of defies classification, so we’re calling it a hybrid device. There’s 72 percent who own one but they’re not all using it the same way. Theres a minority who are very active users treating it as a quasi-mobile device, using it throughout the day for both information look-up and content consumption. And then there’s more of a leanback crew, more of an ‘on the couch’ thing, watching video and reading emails.”

The study also looked at the apps and programs doctors are running on their devices.

“It was the first time we’ve seen online textbooks surpass print textbook in terms of weekly use,” Ressi said. She also said physicians were “quite amenable to prescribing apps to patients.”

“We did a little section asking what kinds of apps they had prescribed,” she said. “So it’s really interesting to see that becoming a reality.”

The study also looked at many different ways doctors communicate with each other and with their patients. She said doctors’ usage of closed online physician-only communities has remained stagnant overall, although particular communities, including Doximity and QuantiaMD, have grown.

Physician communication with patients by video was stagnant after growing a lot from 2009 to 2011, she said. Overall, digital communication between doctors and patients was up.

“Close to half of physicians had done some sort of email or electronic consultation with their patients,” Ressi said. “That could be email, secure message, video, or text message. I will say that what’s driven that metric is patient-facing portals in EHRs and Meaningful Use criteria. One of the best ways to ensure that patients actually engage with a patient portal is to have the physicians send some kind of outbound message.”

Last week, Manhattan released a press release with one of their most interesting findings: that seven in ten physicians have had a patient share self-tracking data with them.

Mobile health startups talk innovation, acquisition

By: Jonah Comstock | Apr 18, 2013        

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TED talk

Left to right: Michael Weintraub, Giovanni Colello, Josh Stein, Nina Nashif, and Juan Enriquez.

The TEDMED organizers tried something new this year: they dedicated Thursday morning to some unscripted meetings of the minds about innovation in healthcare. The first discussion (which TEDMED maintained was not a panel) centered on the topic “From Start to Scale to Exit, the Trajectory of Innovation.” Juan Enriquez, managing director of Excel Venture Management, moderated a group of entrepreneurs at various stages in the launch process. Nina Nashif, CEO of Healthbox, a startup incubator, and Josh Stein, founder and CEO of AdhereTech, represented early stage companies, while Giovanni Colella, founder of Castlight Health, and Micheal Weintraub, founder and CEO of Humedica, spoke as experienced founders.

The speakers had a lot of opinions on the question of what drives — and what should drive innovation.

“It’s really important for entrepreneurs to understand industry,” said Nashif. “In healthcare, the buyer and the user are not always the same individual, so figuring out who you’re going to approach is actually really hard.”

Several of the speakers stressed the importance of researching the market, identifying the need, and “skating toward the puck” (in Weintraub’s words.) Colella emphasized not research and preparation, however, but passion and risk-taking.

“You need that free spirit, free market mentality, and you need a few people who are unemployable, who just want to do something big,” he said. “The guys I can guarantee you will succeed are the ones who say ‘I don’t know what I want to do, but I want to do something big, I want to change the world.’ Once you have the right social structure and the unemployable entrepreneur who wants to do something big, make sure they marry with the right investor. When those three things come together, innovation will happen.”

Weintraub also said there’s a sweet spot where the best startup ideas fall.

“If there’s too many people doing it, you’re too late,” he said. “And if it seems too simple and no one’s done it for a decade, it’s probably a bad idea.”

Enriquez asked Weintraub, whose company was recently acquired by UnitedHealth Group, and Colella, whose old company Relay Health was acquired by McKesson, about the realities of acquisition.

Weintraub advised founders to never build a company to sell it. He said acquisitions work best when a startup does research well ahead of time on any companies that might make an offer, so founders don’t feel pressured to make a decision quickly. Weintraub also offered advice for companies looking to make acquisitions. He mentioned two extremes companies should avoid.

“On one extreme, I call it the ‘smash and crash,’ which is just smash it all in, merge everything in functionally, and hope — and hope is never a good strategy. It will not work because the DNA, the culture, the ecosystem will evaporate overnight, and that’s not what we’re doing,” he said. “The other extreme is just leave it alone, leave it as a separate business and do nothing, but then why’d you buy it? So how do you thread the needle and truly have a plan that is not casual, about really finding those leverage points and doing them thoughtfully, not too fast, not too slow? There’s an art or a science to that.”

Collela said that it’s a hard choice, whether to try to push through alone or be acquired.

“There’s a point in the life of a company when an entrepreneur has to ask the hard question: can we build a company to last, or are we better off as a feature of a bigger product?” he said. But he warned that being acquired does make a difference. “For a big company, any new dollar is marginal revenue. For you, any new dollar is real revenue. So, your life is going to change.”

Colella also talked about IPOs, a notable topic since Castlight has been floated by many in the space as headed in that direction.

“Just look at it as a financing effort. I mean there’s nothing different — well its different because it’s a public market, but that’s how you should look at it, its just one more tool to grow your company,” he said.

Finally, the speakers were asked about their strategies for risk management. Stein said risk mitigation meant focusing on your minimum viable product. Nashif said it was about starting small and being realistic. Colella said he was a person who took a lot of risks, so risk management for him was “know your limits and pick the right team.”

“I think that managing risk is an oximoron for an entrepreneur. We sort of jump in headfirst and think later,” said Weintraub. “If something doesn’t feel right, move, because big risks start out as small risks.”

MIT Media Lab demos wearable fundus camera

By: Jonah Comstock | Apr 18, 2013        

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eyeMITRA

This image from TEDMED shows a closeup on an MIT student wearing an eyeMITRA prototype.

The MIT Media Lab’s Camera Culture Group, led by Dr. Ramesh Raskar, has innovated the smartphone eye diagnostic space before. Their NETRA software for smartphone-enabled eye exams spun off into EyeNetra, which raised $1 million in first round funding last year. Prior to that, they developed CATRA, a cheap smartphone connected device for diagnosing cataracts.

At TEDMED, Raskar announced (and demoed) the lab’s newest project, eyeMITRA. A demo of an earlier prototype, under the name RetiCue, has been online since last year. The new device isn’t a snap-on camera lens like the lab’s last two inventions, but instead a pair of smart glasses that displays a realtime image of the wearer’s fundus.

Raskar said the technology could be useful as a cheaper, smaller diagnostic tool for early diagnosis of diabetic retinopathy, a complication of diabetes which can lead to blindness. This is the same basic use case as Welch Allyn’s iExaminer system, a recently FDA-cleared smartphone-enabled fundus camera. But while Welch Allyn’s device, which was also featured at TEDMED’s Smartphone Physical demonstration, is only for clinical use, Raskar said eyeMITRA could also be used at home.

“Imagine you wake up in the morning, brush your teeth, take our eyeMITRA glasses, put them on.” he said. With all that data, the company could “do a longitudinal and a cross-sectional analysis, and then of course create algorithms, and really get to the world of predictive analytics. The eyes are not just windows into your health, but into the heatlh of society.”

Although diabetic retinopathy is the beginning, Raskar said that reliable realtime pictures of the eye open the gates for all kinds of preventative diagnoses. The eye is the only part of the body that offers noninvasive imaging access to both blood vessels and nerves. Because of this, many chronic conditions have early warning systems that can be detected via the eyes. Raskar listed AIDS, rheumatoid arthritis, hyper-cholestrolemia, tumors, Wilson’s disease, and neurological conditions like Parkinson’s and Alzheimer’s as just a few possibilities.

With such a wide potential for noninvasive diagnosis, one wonders if Raskar and his team are considering entering the race for the Tricorder X Prize. It’s certainly clear that their vision for the technology extends far beyond eye care.

Mayo Clinic, Geoff Clapp launch mobile health startup, Better

By: Brian Dolan | Apr 18, 2013        

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Better health appHealth Hero co-founder and Rock Health mentor Geoffrey Clapp announced this week the launch of his new startup, Better, which is backed by The Mayo Clinic and The Social+Capital Fund, according to the demo he gave onstage at the Wall Street Journal’s D:Mobile event in New York City. (Social+Capital has also funded Asthmapolis, Simplee, and Glooko.)

Clapp described Better as “the best way for you to get healthcare wherever you are directly on your mobile device.” He also said that while there have been promising developments with healthcare legislation, new medical sensors, and big data, “there isn’t a great mobile experience for healthcare yet” and that’s what Better aims to bring.

The user experience of the Better app begins with “Siri for healthcare”, Clapp said. The app asks: “What can we help you with?” (in writing) and the user types in their question or issue. Arguably, the core offering of the app is a symptom navigator, similar to iTriage. Better, however, is stocked with medical content from the Mayo Clinic. If a user enters certain symptoms, Better might suggest a user consider seeking emergency care or calling their physician, but for those users who have a paid subscription to Better, the app can connect them — when appropriate — with a lifestyle coach, registered nurse, or physician at the Mayo Clinic.

At the D:Life conference Clapp showed how a user with abdominal pains can use the symptom navigator to get to a potential cause of celiac disease and connect to a registered nurse at the Mayo Clinic via a phone call. The RN, named Linda, knew that Clapp had just used the symptom navigator and that it had suggested celiac as a potential cause. After a two-minute call she offered him a few tips for over the counter meds, emailed some home remedies, and set up an appointment for him at a lab by him near Stanford University.

When pushed, Clapp shared the general price points for the paid services that Better plans to offer. Users who sign up for a monthly plan that includes access to a lifestyle coach will pay about $150 a month. Access to a nurse scales up to about $400 a month, Clapp said, while real-time access to a doctor will end up running between $400 and $1,000. There’s also a very high end option that includes flying out what Clapp called a “healthcare SEAL team” to wherever the user was to pick them up and fly them back to the Mayo Clinic. Clapp said this “black card” option will cost in the thousands of dollars per month.

Clapp told attendees at D:Live that the Better app and services are set to launch at the end of the summer and it seemed clear that prices were not yet finalized.

Besides the curated content, symptom navigator, and premium telephone consultation services, Better also integrates with various fitness tracking devices. While Clapp didn’t specifically name which devices his app would pull data from, he was wearing both a Basis Band and (what appeared to be) a Jawbone UP on either wrist and did reference both of them during the demo. Basis might be providing heart rate data, while the other wrist-worn device was for tracking steps, he said.

Following his demo on-stage, Clapp wrote a post on his personal blog about Better’s launch. An interesting passage was this explanation for why the business model is (initially, anyway) focused on direct-to-consumer:

“I believe empowering consumers to be engaged in their health starts with choice. Mobile and consumer choice has changed every market, and healthcare is not an exception to this force,” Clapp wrote. “We will work to drive healthcare prices down and to expand options to as much of the population as we can. This starts by providing choice, and exceeding expectations of what “quality care” really means. At Better we’ve already taken services you simply can’t get today, made many of them free, and cut the cost of most of them by 30% or more. We will also offer more premium services at a higher price point, and if you want a jet to come pick you up in a foreign country and fly you back to the best care in the world (yes, we offer this), it costs money and is not for everyone. But the very engine of a market economy is empowering customers and growing a market is giving them the choice, and we’re very sure this will have a net-positive effect on the market costs, overall.”

The whole post is worth a read for more perspective on Better. There’s also a video of Clapp’s demo over WSJ here.

CDC proposes smartphone surveys for quicker reads on public health

By: Brian Dolan | Apr 18, 2013        

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CDC Mobile AppsThe National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) at the Centers for Disease Control and Prevention (CDC) has proposed a project that would use smartphones to collect information on health behaviors, especially with an eye on smoking habits and cessation. The project, which was outlined in the Federal Register this week, is for a feasibility study set to last one year to determine whether mobile-friendly websites targeting smartphone users and text message-based questionnaires for other mobile users would help it collect public health data faster.

“New mobile communications technologies provide a unique opportunity for innovation in public health surveillance,” the CDC writes in the Register. “Text messaging and smartphone Web access are immediate, accessible, and anonymous, a combination of features that could make smartphones ideal for the ongoing research, surveillance, and evaluation of risk behaviors and health conditions, as well as targeted dissemination of information.”

The groups aim to first send the surveys to US residents aged 18 to 65 nationwide with questions related to smoking habits and alcohol consumption. Following the survey, the smartphone users will be asked to participate via text message in the feasibility study, which includes a survey immediately following the first and then another one a week later. The texts will include links to the survey on a mobile-friendly site.

Some of those who participate in the initial outreach that are non-smartphone users will be asked to participate in another study, the text message pilot, which will conduct the surveys one question at a time via text.

The study aims to evaluate, among other things, the response bias of data collected from the smartphone users on the mobile site to those responses collected via text. The study could help the CDC to make a case for using smartphone surveys in other contexts or for other uses like diary studies to track activities or events, it wrote.

The CDC has recognized the potential for mobile health for many years:

“Mobile communications is absolutely going to revolutionize not just health communications, not just public health, but, I believe, health in general,” the CDC’s former Director of the National Center for Health Marketing Dr. Jay M. Bernhardt said in 2009. “We can put [health-related information] on television, on billboards, or your doctor can tell you… but one of the big problems with mass communications is that it’s hit or miss… [while] mobile technology is always within an arm’s reach.”