OTHERS

#AI in Healthcare by @deveshrajadhyax


There are some subjects that invoke sharp and contrasting emotions in the society. In present day India, the GST tops the list of such things that are considered boon by some and curse by others. New technology usually does this to people. The steam engine, the telephone and the computer all have been greeted both as the savior and the nemesis of the mankind. 


Using Artificial Intelligence in Healthcare is one such subject. If you have to believe what the media says, AI is going to transform healthcare in the near future. In fact, the services of the doctor may not be needed very often, if at all. AI will do everything in medicine including diagnosis, treatment and even finding out new drugs.

But not everyone is so optimistic or even welcoming. The idea of machines taking care of our health is creepy to some. Others claim that AI can never replace a doctor, at least not in a foreseeable future. Medicine is too complex for machines to figure out.

(You must have noted that I am using Healthcare and Medicine interchangeably. The reason being that this is what most people do. Healthcare is the practice of medicine and as such is wider than it. I refer to healthcare as including medicine.)

The reality, like in the case of GST and most other things, will be somewhere in the middle. The purpose of this article is to find that balanced view. In effect, what I will be saying is:

“while the replacement of the doctor is a faraway dream, there are a number of things that AI can do in medicine even today. This can turn out to be valuable help for doctors, patients and other stakeholders”.


Let me first present a short introduction to AI.

AI, like Philosophy, is a very hard term to define. AI is not really one technology. It is a collection of techniques. Strictly speaking, AI is actually an ambition. The ambition of machines to imitate human capabilities.  
   
But this definition does not take us very far. Since human capabilities are many, ranging from walking to writing poems, imitating any of these capabilities can be called AI. So for our purposes, we will define AI as the pursuit of those capabilities that are strong points of human beings.

As an example, consider language. Reading an article and understanding its gist is a simple matter for us humans. For machines to achieve this capability will be quite something. If that happens, machines can go through a number of articles for us and feed us with the just the little bits that we need.

A whole lot of mathematical and computational techniques have been developed by researchers in the last sixty years to achieve this goal. Deep Learning, Machine Learning and NLP are some names given to a bunch of such techniques. In the last few years, AI has risen to prominence mainly due to three reasons – availability of data, increase in computing power and discovery of new methods. 

Armed with that introduction, let’s try and put down the areas where AI can make a difference in healthcare. While we do that, we can also try to answer the ‘replace the doctor’ question.

Diagnosis: Diagnosis is the hardest part of medicine. There is no definite pathway to diagnosing a patient. A lot depends on the experience and intuition of the doctor, in that way, it is more of an art than science. As of now, it is difficult to see AI taking over this role. However, there are many areas where AI is already making a difference:

  • Conditions in which diagnosis is dependent on analysis of a signal over time, such as an ecg or an eeg. Machine Learning combined with signal processing can achieve good results here. Arrhythmia or irregular heartbeat is an example of such a condition that AI can detect well.
  • Diagnosing some disorders involves referring to a lot of data such as past and present reports, images and history. Gatro-intestinal disorders are notoriously difficult to diagnose and require a lot of information to refer. AI can make a big difference here by sifting through the pile of data and presenting important facts to the doctor.
  • In radiology, the volume of cases is huge and the radiologist needs to look at every image to come to a conclusion. Some investigations like MRI produce a large number of images for each patient. This makes the doctor’s time a bottleneck in handling the ever growing number of patients. Deep Learning has shown great promise in being able to classify medical images. For example, it can separate images that indicate normal functioning from those that have some abnormality. This will enable the radiologist to focus on the abnormal cases first. This method will also be a boon for the remote places where a radiologist is not available.
  • AI has provided a new method for laboratory investigations. This may mean that in the future most lab tests including pathology will be done with basic instruments at a very low cost. In a disease like HIV/AIDS, being able to determine the viral load in a quick and inexpensive way can be a very big benefit to the patients. 


Treatment: The biggest contribution AI can make to treatment of patient is in the area of drug discovery. Currently, discovering a new drug costs more than 2.5 billion dollars and takes more than a decade. The pharmaceutical industry is desperately searching for new ways to reduce the cost and time. AI may be one of the solutions to this problem. Machine Learning and Deep Learning are being used in various stages of drug discovery, such as identifying candidate molecules and studying the expected response of the new drug.

In our fight with cancer, AI may be an important weapon. Personalized Oncology is rapidly getting attention from the medical community as the way forward in battling with the cancer scourge. To describe in brief, cancer is not one disease – the cancer of every patient is different. If the individuality of cancer is decoded, a personal treatment path can be planned for every patient. AI will become a key part of this process.

AI is already playing a role in treatment by making robots that perform surgeries. This contribution will grow in the time to come with the robot costs falling and capabilities growing. This will reduce the strain on surgeons and they will be able to perform far more surgeries in the same time. 

Care: Care during the illness and recovery is as important as the right diagnosis and treatment. Along with IoT, AI will transform patient care. Everything from medicine intake to prescribed activity will be monitored by these systems. Monitoring includes two components – sensing and analysis. While the sensing part is done by the IoT devices, analysis is provided by AI. 

Prevention: Prevention is definitely preferred to hospitalization and AI is going to play a major role in this. It will involve both personal and public health. Personal health is monitored by the wearables and other simple devices. The AI systems will process this data to look for possible indications of disorders so that they can be fixed inexpensively. 

Public health will be monitored in the same way but from data that is coming from various healthcare institutes. This enormous data will forewarn us about various health risks such as outbreaks of diseases. It will enable the state to take measures to avoid the calamities.

In short:
To summarize, AI will really be a transformational technology for healthcare. It will make healthcare cheaper and faster and enable it to reach more number of people. AI will reduce the strain on doctors and nurses. However, for the future that we can see, AI will serve more as an assistant to the doctors, rather than being their replacement. 

Author
Devesh Rajadhyax

Founder and CEO, Cere Labs, AI, Machine Learning, Deep Learning

Four ways in which #AI can help humankind @deveshrajadhyax


Artificial Intelligence is receiving more than its fair share of public attention. On one side there are promises of miracles, while on the other side there are warnings of doomsday. What is probably missing is a simple listing of clear benefits. This is article is an attempt to create such a list.


Artificial Intelligence is more of an ambition than a technology. The ambition is to imitate human capabilities. Since human capabilities range from walking to solving mathematical problems, AI also encompasses systems of various types – ranging from the humble calculator to Google’s DeepMind.

In this article, I am majorly referring to the AI systems that try to achieve the cognitive abilities of human beings. Cognitive abilities refer to the processes of our mind such as understanding, reasoning, planning and selecting the right action. Understanding a question and supplying the right answer from our memory is an example of cognitive ability, the one that AI systems called ‘chatbots’ try to imitate.

Cognitive systems are currently in their initial phase of development. Once they come close to human beings in their competence, they can prove useful to humankind in a number of ways. Here are some:

1. Better utilization of resources: In our current world, it requires a human being to use resources. For example, a car needs a driver. Platforms like Uber have made it possible to share your car when you don’t need it, but it still requires a skilled human being. Talk to your Ola or Uber driver and you will realize that they are already working at the limit of their capacity. A cognitive system driving vehicle will use them much more efficiently. You will actually need much fewer vehicles than you need today (and probably a lot lesser parking!). This is true of most other resources.

2. A fairer society: Human beings have many faults in their thinking. In another article I have highlighted this faults, called biases. These biases have their roots in the evolution, so the AI systems will (hopefully) not have them. ( Pl see http://blog.cerelabs.com/2017/06/will-ai-evolve-to-be-as-bad-as-humans.html). This will make decision making at all level fairer for the people. To take an example, typecasting is a very strong bias that we suffer from. This affects decisions taken by, say an interviewer. We can hope to see much fairer selection processes in the future. For an interesting example of how statistics can help to break biased notions, see the movie or read the book ‘Moneyball’.

3. Repositioning of human efforts: World over, a large number of people are engaged in time consuming tasks that require moderate cognitive ability. Take for instance cooking. A big part of a woman’s day in India is spent in preparing food. Cognitive systems such as robot chefs can easily take over these jobs, freeing up a lot of time that can be invested in more valuable responsibilities like education of the children. In the industries, as the simpler tasks are done by cognitive systems, humans can move up the value chain, pushing the efficiency of the enterprise higher.

4. Improved care: Currently, care of patients, elderly and disabled is primarily a human responsibility. Many times, this compromises the quality of care as people cannot take out so much time from their daily activities. Cognitive systems can make the life of those in need of care much better. They can talk to the elderly and carry the disabled to places otherwise difficult to reach. The systems can keep an eye on chronic patients, not just reminding but making sure their regimen is adhered to.

This is of course just a small contribution to an ever growing list of benefits. While we keep our eyes open to the warnings given by the likes of Stephen Hawking and Elon Musk, we should continue in our efforts to harness the power of AI for these benefits.

Author
Devesh Rajadhyax

Founder and CEO, Cere Labs, AI, Machine Learning, Deep Learning

Philips Digital Healthcare Conclave 2017 #ConnectedCare In Focus by Sagay Mary, @hisagay


What if expensive, specialized patient monitoring systems in ICUs could be replaced with discreet sensors that transmitted all the vital health data directly to the doctors’ smartphones? What if the data could be analysed to deliver intelligible insights as well? Not only would it ensure better quality of care, it would also help bring down equipment and overhead costs for the hospital by eliminating expensive equipment and by even allowing patients to be cared for at home. The good news is that, this is not a hypothetical scenario but a real possibility as technology makes connected healthcare a reality.


The 2017 edition of the Philips Healthcare Conclave held on 28th July 2017 addressed the confluence of technology and healthcare and its significant impact on patient care, accessibility, and affordability. The conference shed light on why Connected Healthcare is the need of the hour for our country and how it can solve the existing healthcare problems. The conference was graced by the presence of industry stalwarts like Dr. Shalini Rajneesh, Principal Secretary Family and Health Welfare, Government of Karnataka and Dr. Pramod K. Varma, Chief Architect, Aadhaar. The speakers discussed how Connected Care and AI supported by UIDAI (Aadhaar) could help in addressing the challenges faced by the Indian Healthcare System. 

The discussion also highlighted The National Healthcare Policy 2017, which talks about how Connected Healthcare is the solution to the existing healthcare problems in India. The policy suggests the setting up of a National Digital Health Authority (NDHA) to regulate, develop and deploy digital health across the continuum of care using digital technologies. It highlights the role of Aadhaar to make connected healthcare a reality by establishing a seamless and efficient National Health Information Network. The panel also discussed how Philips has been at the forefront of using digital technology in healthcare. Its various connected care solutions have increased accessibility to care in remotest corners of the world, empowered patients to manage their health while also giving health providers tools to improve patient outcomes. With a mission to touch more than 3 billion lives by 2025, Philips is working towards creating meaningful innovations that will make Healthcare accessible to all.

Affordability, accessibility and the over-all ecosystem were in sharp focus through all the discussions during the day. All the speakers emphasized that a comprehensive overhaul of existing healthcare frameworks cannot happen in isolation; it requires a supportive ecosystem to be sustainable and scalable. The ecosystem ranges from primary health care centers and doctors to healthcare technology companies and start-ups. Most importantly, in a Connected Healthcare scenario, Internet networks and seamless connectivity are just as important as any directly medical element. The speakers almost unanimously agreed that a connected healthcare system in India needs both the private and public sectors to work in tandem.

The conference saw industry thought leaders emphasizing the current state of readiness for implementing connected care systems in India, as well the areas that need attention. Technology stacks like Aadhar are already in place, ready for both public and private enterprises to build comprehensive healthcare solutions on. At this juncture, it is important to focus on developing and empowering the macro ecosystem to work with digital systems. From education and awareness programs to data security protocols and legal frameworks, both government as well as the private sector needs to work together to ensure a robust and workable system.

 As with any major technology disruption, people are at the crux of the move to Connected Healthcare systems. The speakers stressed the fact that doctors will remain relevant even in the future tech enabled state of healthcare, and be empowered to better diagnose and treat their patients with the use of technology. The conference also highlighted the fact that ultimately, digital healthcare systems will go a long way in reducing costs. Currently, Karnataka alone spends more than Rs. 6000 crores to extend healthcare services to just 5 percent of its total population. Connected Healthcare systems have the potential to guarantee universal access to quality healthcare with seamless links between hospitals and people.  

Affordability, accessibility and adoption were hot topics within the healthcare sector even about 30 years ago. While they still remain in focus three decades later, now for the first time, there is a strong glimmer of hope, as technology makes it easier to find answers to these challenges. As the experts at the conclave pointed out, the world has just scratched the surface of Connected Healthcare, the possibilities are endless and future looks bright. 

Author
Sagay Mary

Manager, Corporate Communications at Philips, Bangalore responsible for branding and communications

#VR #AR can increase efficiency and reduce cost in medical education #meded by Dr. Vikram @drvikram

Virtual Reality and Augmented Reality has the potential to transform key areas in healthcare. Medical Education, Rehabilitation, supply chain the list is endless and what is limiting us is our own imagination.

Last week I was speaking at the IT Healthcare Summit on the potential for VR/AR to transform healthcare. I also shared my views on this post before the conference. In my discussions with the delegates, I realized that the foundation of medical education in India can be improved drastically. One just needs to look around medical colleges in India to understand the state of the dissection halls there. 


Often, they suffer from the lack of cadavers so essential for understanding key aspects of human anatomy. This leads to a weakness in fully grasping aspects of human anatomy that would help them become better doctors and improve care outcomes. A light-hearted representation of this was seen in the movie “Munna Bhai MBBS”. Often the students must share a single cadaver and this does not help the students at all. But VR/AR can change that.

A pilot at Miami Children’s Hospital saw that the retention in students who were taught through AR/VR was 80% as compared to 20% for those who were taught through traditional methods. In India SRM University in Chennai and Global Hospitals in Hyderabad have been piloting AR/VR 

Another area where AR/VR played a critical role was in training surgeons and physicians on complex procedures like “Tracheal Intubation”. Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill, or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction. (Source: Wikipedia)

A major hospital chain increased the efficiency of their surgeons by 35% by using simulation of tracheal Intubation using VR/AR vs a specialized training that would have required them to travel to a special center. The cost savings were more to the tune of 500% using this method.

But the major effect of AR/VR would be in rehabilitation. Already pilots have been conducted in areas like PTSD by the US Army. The Indian Spinal Research Institute is already using VR/AR technology to use it in the physio therapy process for rehabilitation post-surgery.

The potential is immense and the use cases are still building up. But what’s stopping us ? Well I look forward to your comments and suggestions to get us moving in this direction. Looking forward to your views and suggestions on the same. 

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Dr. Vikram Venkateswaran

Dr Vikram Venkateswaran is a healthcare thought leader who writes and speaks about the emerging healthcare models in India and the role technology plays in them.
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Internet of Things #IoT : Healthcare & Medical by @vsolank1

Application of “IoT”, the latest buzz word as many would like to call it, are numerous and have been covered under the topics below

















Healthcare industry is one the largest in any country both in terms of the required reach to the masses and in terms of per capita budget. Human beings save money to live comfortably, to get their child married, to buy a house and last but not the least to pay for medical bills. As per the latest reports on USA health stats only 21 out of 100 people (< 65 age) have medical coverage. But the spend on prescription drugs is rapidly increasing from 2004 ($192 B) to 2014 ($297) however maximum of this spend is funded by private savings. Scenario is not much different in other developed countries.















On the other end if we look at developing countries like India, then as per WHO the top 10 reason of deaths in India includes heart diseases, obstructive pulmonary, stroke and so on.
















Other emerging and under developed nations will have similar stats or even worse. So why do I think IoT based solutions can improve these stats in a positive way? Let’s see some of the health and medical related IoT apps, devices, solutions and monitoring systems that can have a cost effective impact on these issues. Additionally I think if Government increase its spend on R&D it can immensely help to make the solutions more scalable and deployable.

Proactive Health Solutions

Yolo Health ATM is an integrated health screening kiosk with integrated medical devices such as Glucometer, BP monitor, BMI calculator, etc, and also staffed by a medical attendant. This can be next generation kiosk that will help people, short on time, to be more proactive about their health. This also holds potential to be deployed in rural areas where primary healthcare penetration is limited. Wearables such as FitBit, Apple Watch and various health bands are not new to us and they help a great deal in tracking your activities in real time.

Remote Patient Monitoring

Healthcare providers and family members always wish to monitor the health of the patient in real time. Pre and Post operative measures are taken to monitor patients health and IoT can enable solution that can allow to achieve this more efficiently and economically. Real time information, published through cloud, will help caregivers to make informed decisions and diagnosis, which are more evidence based. In the current world it is a mixture of symptoms, patients reactions and doctors gut feel which sometimes leads to trial and error diagnosis. IoT can provide real time data and more accurate information at the right time, which can revolutionize the healthcare market. This will also help in preventive disease management, reduced health care cost, enhanced patient experience, reduced errors and shorter recovery cycle.

Drugs Management

From the point of improving process on the manufacturing and R&D facilities using sensor based proactive maintenance systems and real time information feeding pipes to improving the tracking of drugs from the point of distribution to the point of purchase – IoT has a big role to play. While I won’t go deep as they are not directly healthcare related but I would like to mention – supply chain management, fleet management, asset tracking, temperature and humidity monitoring and inventory management are all the categories of solutions that can help in this area.


Forbes article talks about partnership between Qualcomm and Philips to focus on creating healthcare IoT solutions such as connected dispensers for medicines, biological sensors, self care glucose meters for diabetics to an integrated cloud system for health record monitoring. Connected Medical Equipment which can transmit the data captured through sensors and of course from the patient directly onto the cloud for transparency and monitoring purpose as described here is a very handy use case for IoT.

Personal Health Data Security

However the concern many of us is security and safety of that sensitive private data about my health to be lost, hacked, misused by anyone. What if the data is captured and used for targeting ads at me? I think this is fine because it will only SPAM my life but not endanger it. Healthcare IoT Security Risk is a worth short article to read. LinkLabs also talks some of these use cases and concerns nicely.

#IoT, #M2M, #Healthcare, #Medicine, #Wearable, #Remote Patient Monitoring

Author
Vinay Solanki

Vinay has 10+ years of experience in Internet of Things(IoT), WiFi as a Service, Mobile money, Global projects and team management, client engagement, and consulting.

Currently he leads IoT and WiFi business for Bharti Airtel, aggressively driving business opportunities in this space. Prior to this he was the Global Head for revenue assurance and fraud management for Airtel Money (a mobile wallet) managing 17 countries in Africa and pan-India, focusing on building comprehensive financial risk picture for Airtel Money.

How Virtual Reality #VR and Augmented Reality #AR is transforming Healthcare by Dr. Vikram @drvikram

Digital is transforming healthcare. It is creating new channels for improving patient experience, creating better clinical processes and engaging doctors and other para-clinical staff like never before.


It is also creating new models for areas like medical education, rehabilitation and managing supply chain. In these there key areas Augmented Reality (AR) and Virtual Reality (VR) are playing a key role. But first let’s start with the definition and differences between AR and VR.


Augmented Reality or AR is a live direct or indirect view of a physical, real-world environment whose elements are “augmented” by computer-generated sensory input such as sound, video, graphics or GPS data. So the game Pokemon Go is a good example of AR. (Source: Wikipedia)

While VR on the other hand VR- Virtual reality (VR) is a technology that uses Virtual reality headsets, sometimes in combination with physical spaces or multi-projected environments, to generate realistic images, sounds and other sensations that simulate a user’s physical presence in a virtual or imaginary environment. (Source: Wikipedia) So VR requires a headset specialized for the same. 

The Industry seems to be taking notice of this emerging area. These are some numbers from the industry

1. More than 150 of Global Fortune 500 investing in AR/VR
2. VC and corporate investment upto $2.3 Billion in AR/VR Startups 
3. IDC projects revenues from AR/VR to grow from $5.2 billion today to $162 billion by 2020

But why are the key reasons why AR/VR has reached this level

1. We have more computing power than ever before. Today we have GPU’s and TPU’s that put immense computing power at our disposal
2. There is a explosion in digital data. By 2020 it is believed that we would have created 40,000 Exabyte of data
3. Finally programmers today are writing better algorithms. That is why machine learning is mainstream today

So what are the implications of the same in healthcare?

There are clearly implications in Medical Education. Pilots conducted in Miami Children’s hospital have shown an 80% increase in retention while using AR/VR. There are other pilots involving treating war veterans using VR for Post Traumatic Stress Disorder.

I will be speaking on this topic on, 23 Aug 2017, at the IT Healthcare Summit 2017 in Bangalore. It will be interesting to discuss and other topics on digital health and how it is transforming healthcare in India. Looking forward to hearing your views on the same. 

Author

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Dr Vikram Venkateswaran is a healthcare thought leader who writes and speaks about the emerging healthcare models in India and the role technology plays in them.
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Order Sets: A POKA-YOKE for Clinical Decisions by Dr. Ujjwal Rao, @DrUjjwalRao – Part 2/2

The full potential of a CDSS can be realised when it is seamlessly integrated into the clinical workflow and is evidence-adaptive


In continuation to the the part one of the article, in the part 2 of the “Order Sets: A POKA-YOKE for clinical decisions” Dr. Rao is

ADDRESSING THE KNOWLEDGE GAP THROUGH CDSS:

THE POWER OF ORDER SETS

A “Physician Order” is a communication directing a particular service or action to be taken in the care of a specific patient. Medications, diet, physical activities, laboratory tests, radiologic studies, therapies, treatments…all are among the literally dozens of orders written to guide the care of each and every patient by the physician throughout an ordinary day. 


Thus the physician ordering process is complex and time-consuming. In addition, the continuous explosion of new evidence-based information results in the reality that providers often make mistakes, at best failing to provide the highest value care, and at worst causing preventable injuries and deaths. And while computers can address avoidable mistakes from the most mundane sources (such as illegible hand-writing), the greatest threat to patient safety and cost waste is the knowledge gap.

Fortunately, when a physician realises that he or she needs information, CDSS reference solutions provide access to current, credible, evidence-based knowledge (either integrated into an EHR, available over the internet, or in print). Thus by their very nature, reference solutions require that the physician knows he or she doesn’t know something.

But medical knowledge is doubling every two months. Clearly many times the physician doesn’t know what he or she doesn’t know… Thus patients are placed at risk because physicians are unaware that new information and knowledge is available.

Order sets are the best solution to this dangerous problem. Order sets automatically push current, credible, evidence-based information specific to the patient’s clinical history and current clinical status directly to the physician at the point of care. Take for example:

A 52 year old man is admitted for surgical treatment of a right-sided colon cancer. His surgeon regularly operates on such patients, removing that segment of large intestine harboring the malignant tumor. But like many, this surgeon is unaware that this patient’s young age and tumor location suggest an inherited syndrome requiring a much more extensive operation to prevent a second cancer over the next decade. 

If the surgeon “doesn’t know what he doesn’t know,” how can he look up “inherited colon cancer” in his CDSS reference solution? He can’t. But when the patient is admitted to the hospital, order sets specific for colon cancer patients are automatically pushed to the physician. These order sets can be commercially available or can be created by the hospital, healthcare system, regional, or international experts (physicians, nurses, pharmacists, etc.) and represent the evidence-based guidelines and information on colon cancer. Thus the order sets educate the surgeon and recommend that he order a simple blood test to check for the inherited cancer syndrome. If integrated within an EHR, the physician can actually click on embedded hyperlinks to view the EBM sources of the recommended orders. 

The surgeon will likely accept the recommended order and confirm that the patient suffers from the syndrome. Then the surgeon can search the CDSS reference solution and rapidly learn the appropriate surgical procedure for the patient, as well as how to test and screen family members for the inherited syndrome.

Thus order sets address the knowledge gap, including providing the physician with what he “doesn’t know he doesn’t know.”

But there is a risk with evidence-based order sets because clinical knowledge is advancing exponentially. When order sets are implemented but inadequately maintained, they drive providers to practice outdated medicine on a widespread basis [14]. Thus it is critical for evidence-based order sets to include a knowledge-base that continually reflects current evidence. In the near future, evidence-adaptive order sets will be empowered through advancements in machine learning and artificial intelligence. 

Today, much evidence adaption is performed manually, with professionals (using computer systems) to rapidly review new EBM for updating order sets. CDSS which incorporate order sets can reduce medication errors up to 81% [15], and today, order sets represent the most impactful CDSS solution to empower physicians in delivering the highest quality, most cost-efficient evidence-based patient care.

THE ECONOMIC ARGUMENT FOR ORDER SETS

One of the greatest challenges of healthcare reform worldwide is the reluctance of those paying for technology to invest in EBM and CDSS. The question, of course, is return on investment (ROI). However, the potential ROI of order sets through reduction in adverse drug events (ADE) and unnecessary diagnostic tests alone is projected to be enormous (in one academic hospital estimated at up to $10 million [16]). Although there remains a dearth of high-quality evidence on the cost impact of order sets, many operational benefits which intuitively link to cost reduction have been demonstrated. Including: reductions in overall length of stay; postoperative length of stay; and the total cost for multiple surgical procedures, including total knee arthroplasty, appendectomy, total laryngectomy, cholecystectomy, carotid endarterectomy, gastrectomy, inguinal hernia repair, and colon surgery [17].

University of Kentucky Healthcare (UKHC) adopted a well-known commercial order sets solution in 2013 [18], demonstrating improvements in compliance to standard practices and elimination of unnecessary tests. At the University Hospital Frankfurt in Germany, implementation of order sets focused on gastroenterologic care reduced average length of stay and overall physician ordering time while elevating physician satisfaction scores for computerised ordering [19].

ORDERING BETTER CARE: CONCLUSION

The multi-factorial healthcare dilemma including preventable medical errors, the information explosion, slow knowledge diffusion, a growing regulatory environment, and increasing litigation has rendered Clinical Decision Support Systems indispensable. 

Order sets are designed not only to answer questions that the physician is asking, but also to answer critical questions that the physician doesn’t know he or she should be asking. Founded in current, credible, evidence-based information, order sets are the most impactful of physician CDSS solutions. 

Combined with reference and other CDSS solutions, order sets have the potential to empower physicians in providing the safest, highest quality, most cost-efficient healthcare; that is, a truly reliable Poka-Yoke.

Suggested Reading

Dr. Ujjwal was also asked in a recent interview with BioSpectrum India, to share more about the challenges, and most urgent needs in today’s healthcare systems. 

Some might argue that technology is the way forward but Dr. Ujjwal is of the view that technology is only the vehicle through which information and knowledge is delivered. High-quality and consistent care needs to be driven by both tech and evidence-based medicine. The full article can be read online here: 

http://www.biospectrumindia.com/interviews/71/9023/evidence-based-healthcare-is-the-need-of-the-hour.html


References
[13]: Sackett, David L., et al. “Evidence based medicine: what it is and what it isn’t.” Bmj 312.7023 (1996): 71-72.

[14]: Bobb, Anne M., Thomas H. Payne, and Peter A. Gross. “View point:
controversies surrounding use of order sets for clinical decision support in
computerised provider order entry.” Journal of the American Medical
Informatics Association 14.1 (2007): 41-47.

[15]: Bates, David W., et al. “The impact of computerised physician order entry on medication error prevention.” Journal of the American Medical Informatics
Association 6.4 (1999): 313-321.

[16]: Glaser, J., J. M. Teich, and G. Kuperman. “Impact of information events on
medical care. “Proceedings and abstracts of the 1996 Healthcare Information
and Management Systems Society Annual Conference. 1996.

[17]: Ballard, David J., et al. “The Impact of Standardised Order Sets on Quality and Financial Outcomes.” Advances in Patient Safety: New Directions and
Alternative Approaches (Vol. 2: Culture and Redesign). Rockville (MD): Agency
for Healthcare Research and Quality (US); 2008

[18]: Elsevier Clinical Solutions. How Elsevier Helped University of Kentucky Health-Care® Bring Order to Their Order Sets. N.p.: Elsevier Clinical Solutions, 2016. Print.

[19]: Zwack, Laura. Electronic Order Entry with Order Sets at University Hospital Frankfurt.Munich:Elsevier, 2016. Print.

Author
Dr. Ujjwal Rao

Dr. Ujjwal Rao is Senior Clinical Specialist in Integrated Decision Support Solutions, and is based in New Delhi, India. He provides strategic counsel to health providers on designing world-class clinical decision support systems with Elsevier’s comprehensive suite of current and evidence-based information solutions that can improve the quality and efficient delivery of healthcare.

An experienced emergency physician, executive, clinical informaticist and technology evangelist, Dr. Rao has a decade of experience serving in trust and corporate hospitals in various roles ranging from clinical administration, hospital operations to quality & accreditation. In his former positions, Dr. Rao led EHR implementations for large hospital groups and designed bespoke healthcare analytic solutions to raise profitability.

His passion to see transformation through technology led him to volunteer as a quality consultant with the United Nations. He also currently serves as an Assessor on the Panel of the Quality Council of India for the National Healthcare Accreditation Standards body, NABH.

Dr. Rao obtained his degree in Medicine and then specialized in Hospital and Health Systems Management, Medical Law and Ethics before completing his PhD in Quality and Medical Informatics.

Order Sets: A POKA-YOKE for Clinical Decisions by Dr. Ujjwal Rao, @DrUjjwalRao – Part 1/2

Poka (unintended mistake) Yoke (avoid) is the Japanese equivalent for “error proofing”.  
This Lean Manufacturing strategy is more relevant than ever in healthcare today. Why?

FIRST, DO NO HARM
The Supreme Court of India recently ordered one of the largest compensations so far in the country to a girl who lost her vision at birth in a case of medical negligence. The girl, who is now 18 years old, was born prematurely at a government hospital but was discharged from the hospital without a retinopathy test, a must for prematurely born babies. By the time the family discovered the lapse, the girl had lost her vision [1].


Fentanyl is a potent opioid medication used as part of anesthesia. A hospital pharmacist received an order for a ‘fentanyl drip 5,200 mcg per hour,’ which a nurse had just transcribed after accepting a telephone order. The pharmacist called the nurse to clarify the dose. The nurse confirmed that, although the dose was large, she had “read back” the order to the anesthesiologist several times to make sure she had heard the dose correctly. The pharmacist called the anesthesiologist himself, only to find that the intended order was for a fentanyl drip 50 to 100 mcg per hour [2].

The frequency of preventable medical errors resulting in patient injury and death is staggering. It is estimated that for every 100 hospitalisations, approximately 14 adverse events occur, translating to roughly 43 million avoidable patient injuries worldwide each year. In terms of quality of life for those inadvertently hurt: the loss of nearly 23 million years of healthy life [3]. And avoidable medical errors don’t just injure patients. Between 200,000 and 400,000 patients die every year in the United States as a result of preventable medical errors, [4] making avoidable hospital deaths the number three killer of American adults. 

These stunning figures clearly directly oppose the fundamental principle of medicine: First, Do No Harm.

THE MEDICAL INFORMATION EXPLOSION

Based on an extrapolation of a 2011 study [5] the stacking of CD-ROMs holding all of medical information available by 2020 would reach from earth to the moon and a half of the same distance beyond. And the rate of our medical knowledge growth is hard to fathom: by 2020, all that humanity understands about the body, health, and healthcare is projected to double every 73 days [6].

Just to keep up with the Primary Care literature would require a General Practitioner to read for 21 hours every single day [7]!

DIFFUSION OF KNOWLEDGE TAKES (A LONG) TIME

“Diffusion of medical knowledge” is the acceptance of new scientific discoveries into clinical practice. And such diffusion takes an extraordinarily long time… 

Back in the early 19th century, the idea of hand washing prior to examining pregnant women was considered revolutionary, and it was only after decades that hand washing to prevent puerperal fever was universally accepted in clinical practice. But you don’t have to look so far back. Take the case of β-blockers, a class of drugs whose beneficial effect in heart attack patients was established almost 30 years ago. Yet today, β-blockers are still widely under-prescribed [8]. 

The tragic reality is that even today, it takes an average of 17 years for only 14% of new scientific discoveries to find their way into daily clinical practice [9]. Thus our patients routinely wait to be prescribed drugs or undergo procedures or interventions proven effective decades earlier.

In the end, we have a disastrous collision of realities: all medical knowledge will soon be doubling every 73 days, while it will likely take decades for any new knowledge to routinely be incorporated into patient care.

GOOD CARE PAYS – POOR CARE COSTS

Healthcare is being reformed globally. In particular, the payment models are increasingly moving away from Fee-for-Service (FFS) to Pay-for-Performance (P4P). Full-fledged or partial P4P models are now increasingly being adopted by most of the developed nations, including the USA, UK, and Australia, among others. P4P models aim to encourage care providers (individuals and institutions) to provide better quality care by linking reimbursement (provider payments) to clinical and performance outcomes. The models also penalise medical errors, adverse outcomes, and excessive diagnostic and treatment costs. Thus in the P4P model, providers and healthcare systems risk significant financial penalties if they are unable to avoid adverse clinical outcomes and unnecessary tests and procedures.

To summarise, healthcare is now faced with a new dilemma: a significant burden of preventable medical errors, an explosion in the rate of medical information growth, and the historically slow adoption of new discoveries. Add to this an expanding regulatory environment demanding high-quality care plus the rapid rise of medical malpractice litigation and providers must ask themselves, “Is the practice of medicine no longer humanly possible?”

A SOLUTION TO THE MULTI-FACTORIAL

HEALTHCARE DILEMMA


So how do we reduce (and eventually eliminate) preventable medical errors? Providing current, credible, evidence-based information and guidance at all points of care is a cornerstone in the answer to this question. In the area of medication errors (a common form of preventable patient injury and death), a system analysis of a large sample of serious mistakes [10] identified 16 major types of causative system failures. All of the top eight were deemed preventable through the provision of better medical information.

Today, Clinical Decision Support Systems (CDSS) are being hailed as a major
weapon in the battle against preventable medical errors [11]. And at the heart of the most impactful CDSS lies evidence-based medicine (EBM). Advocated as a method to improve clinical outcomes [12], the incorporation of EBM into powerful CDSS has the potential to transform healthcare safety and quality, a true healthcare Poka-Yoke! As such, EBM is the foundation of evidence-based care, broadly defined as patient management through the conscientious and judicious use of current best evidence from clinical care research integrated with individual clinical expertise [13]. And to complete the picture, evidence-based care should also include patient preferences, input, and active participation. 

Clearly based on the foundations of the healthcare dilemma, in order to be safe, effective, and efficient, today’s physicians, nurses, pharmacists, therapists, patients, and other healthcare stakeholders must have real-time, mobile access to current, credible, evidence-based information. While many have been disappointed that Electronic Health Records (EHRs) have not on their own solved the dilemma, it is critical to appreciate that technology is the vehicle through which EBM and other information is delivered, not the primary source of information itself. In the absence of technology (in fact, long prior to the development of computers and the internet), current, credible, evidence-based information allowed the world’s leading healthcare providers to deliver high quality, evidence-based care.

Today’s technology represents a great leap forward in accessing high value care information at points across the globe, with the knowledge provided by EBM integrated into EHRs and available via “the cloud,” all as part of CDSS.

Evidence-based care is most impactful when current, credible, evidence-based knowledge is incorporated into the provider workflow; thus, the most advanced CDSS are “workflow-integrated.” More importantly, these systems are evidence-adaptive [12]; that is, the clinical knowledge within the CDSS continually reflects current EBM from the research literature plus sources of practice expertise. 

The full potential of a CDSS can be realised when it is seamlessly integrated into the clinical workflow and is evidence-adaptive [12].

Stay tuned for the Part TWO of the Blog from Dr. Ujjwal Rao.

Suggested Reading
Dr. Ujjwal was also asked in a recent interview with BioSpectrum India, to share more about the challenges, and most urgent needs in today’s healthcare systems. 

Some might argue that technology is the way forward but Dr. Ujjwal is of the view that technology is only the vehicle through which information and knowledge is delivered. High-quality and consistent care needs to be driven by both tech and evidence-based medicine. The full article can be read online here: 
http://www.biospectrumindia.com/interviews/71/9023/evidence-based-healthcare-is-the-need-of-the-hour.html

References
[1]: Vaidyanathan, A. “Supreme Court Orders Compensation of Rs. 1.8 Crore to
Chennai Girl in Medical Negligence Case.” NDTV, July-Aug. 2015. Web.
http://www.ndtv.com/india-news/supreme-court-orders-compensation-of-rs-1-8-crore-to-chennai-girl-in-medical-negligence-case-777238

[2]: Institute for Safe Medication Practices. “Safety Briefs: Single Digits.”
Medication Safety Alert! 9 (July 2004): 1.

[3]: Jha, Ashish K., et al. “The global burden of unsafe medical care: analytic
modelling of observational studies.” BMJ quality & safety 22.10 (2013):
3809-815

[4]: James, John T. “A new, evidence-based estimate of patient harms associated with hospital care.” Journal of patient safety 9.3 (2013): 122-128.

[5]: Hilbert, Martin, and Priscila López. “The world’s technological capacity to
store, communicate, and compute information.” Science 332.6025 (2011):
60-65.

[6]: Densen, Peter. “Challenges and opportunities facing medical education.”
Transactions of the American Clinical and Climatological Association 122
(2011): 48.

[7]: Alper, Brian S., et al. “How much effort is needed to keep up with the
literature relevant for primary care?.” Journal of the Medical Library Association 92.4 (2004): 429.

[8]: Bradley, Elizabeth H., et al. “Quality improvement efforts and hospital
performance: rates of beta-blocker prescription after acute myocardial
infarction.” Medical care 43.3 (2005): 282-292.

[9]: Balas, E. Andrew, and Suzanne A. Boren. “Managing clinical knowledge for
health care improvement.” Yearbook of medical informatics 2000.2000 (2000):
65-70.

[10]: Leape, LucianL., et al. “Systems analysis of adverse drug events.” Jama 274.1(1995): 35-43.

[11]: Bates, David W., et al. “Reducing the frequency of errors in medicine using information technology.” Journal of the American Medical Informatics
Association 8.4 (2001): 299-308.

[12]: Sim, Ida, et al. “Clinical decision support systems for the practice of
evidence-based medicine.” Journal of the American Medical Informatics
Association 8.6 (2001): 527-534.

Author
Dr. Ujjwal Rao

Dr. Ujjwal Rao is Senior Clinical Specialist in Integrated Decision Support Solutions, and is based in New Delhi, India. He provides strategic counsel to health providers on designing world-class clinical decision support systems with Elsevier’s comprehensive suite of current and evidence-based information solutions that can improve the quality and efficient delivery of healthcare.

An experienced emergency physician, executive, clinical informaticist and technology evangelist, Dr. Rao has a decade of experience serving in trust and corporate hospitals in various roles ranging from clinical administration, hospital operations to quality & accreditation. In his former positions, Dr. Rao led EHR implementations for large hospital groups and designed bespoke healthcare analytic solutions to raise profitability.

His passion to see transformation through technology led him to volunteer as a quality consultant with the United Nations. He also currently serves as an Assessor on the Panel of the Quality Council of India for the National Healthcare Accreditation Standards body, NABH.

Dr. Rao obtained his degree in Medicine and then specialized in Hospital and Health Systems Management, Medical Law and Ethics before completing his PhD in Quality and Medical Informatics.

#IoHT is already delivering tangible cost savings, but continuous investment is essential – Accenture

Image Source: https://www.accenture.com/us-en/insight-accenture-2017-internet-health-things-survey

The Internet of Health Things (IoHT) is already delivering tangible cost savings, but continuous investment is essential


In a recently published report by Accenture [2], based on a survey of 77 Healthcare payers and 77 Healthcare providers in the US, the reports findings indicate that healthcare leaders are at risk of missing out on substantial cost savings, if they don’t take the full advantage of Internet of Health Things (IoHT).


The report indicated that by introducing more connectivity, remote monitoring, and information gathering IoHT can encourage more informed decisions, better use of resources and empowering healthcare users.

According to estimates, the value of IoHT will top US$163 billion by 2020, with a Compound Annual Growth Rate (CAGR) of 38.1 percent between 2015 and 2020.[1] Within the next five years the healthcare sector is projected to be #1 in the top 10 industries for Internet of Things app development.[2]

What is Internet of Health Things?

Internet of Health Things (IoHT) is the integration of the physical and digital worlds through objects with network connectivity in the healthcare industry. IoHT transforms raw data in simple, actionable information and communicates with other objects, machines or people. IoHT can be leveraged to improve access to health, quality of care, consumer experience and operational efficiency 

Source: Accenture Report
Source: Accenture Report








The report lists four major takeaways for the payors and providers

The Time is Now

Despite challenges with security and privacy, inaction is not an option. There are players outside of traditional healthcare organizations looking at these same industry challenges and considering ways to capture the opportunity. If providers and payers do not invest in demonstrating IoHT value now, they risk losing out to non-traditional players. Going forward, providers and payers must identify parts of the business where IoHT solutions may be applied to do things differently—and do different things to grow in the long-term.

Measure and Build on Successes

Providers and payers have already demonstrated value through IoHT—but they need to continue investments to better understand where programs are successful to prepare for future scaling. They need to measure effectiveness beyond the technology and then build on those areas of effectiveness quickly to offer value across the business. By demonstrating the benefits and best practices, providers and payers can strengthen business cases, encourage adoption and drive interoperability.

Put consumers First

Providers and payers must continue to incorporate IoHT solutions that drive better experiences and healthier patient outcomes, along with key medical and administrative cost savings initiatives. IoHT solutions offer the seamless collection of patient-generated health data, enabling providers and payers to provide more convenient, personalized and effective care. They must train their workforces to make IoHT a part of the “new normal.”

Form Nimble Partnerships

Technology and innovation partners can help payers and providers quickly test and learn how IoHT can drive business value to inform future scaling requirements. Strategy and change management partners can help to integrate these new technologies into their workflow, culture and training. 

Key Findings of the Survey

  • 73% consider IoHT to be a major change, and consider IoHT to be a major disruptor in three years. 
  • however, 49% say the leadership at these organisations are yet to understand the potential of IoHT. 
  • As IT investments are going up so are the IoHT investments seeing to become a major budget line item.
  • Healthcare providers and payors are investing in IoHT in three areas of their businesses – RPM, wellness and operations. And these organisations are reporting real benefits from the initial programs.
  • While 57 percent of healthcare organizations surveyed say that their IT departments lead the IoHT charge, 26 percent say their research and development (R&D) divisions are leading their IoHT efforts and one in ten organizations even have dedicated IoHT subsidiaries or business units.
  • RPM Based IoHT: 33% of PROVIDERS report extensive operational cost savings from their RPM IoHT programs. 42% of PAYERS report extensive medical cost savings from their RPM IoHT programs. 
  • The majority of both providers’ (76%) and payers’(75%) RPM IoHT investments are focused on cardiac conditions. Interestingly, in the past, behavioral health has not received investment at similar levels to traditional high-cost areas such as cardiac, but the spotlight appears to now be shining on this area. Mental health, including behavioral health, is a relatively high priority for both providers (48 percent) and payers (55 percent)
Source: Accenture Report, [2]


References

[1] “The Internet Of Medical Things–What Healthcare Marketers Need to Know Now,” January 2016, Victoria Petrock: Contributors: Annalise Clayton, Maria Minsker, Jennifer Pearson, eMarketer.

[2] Accenture 2017 Internet of Health Things Survey 
https://www.accenture.com/us-en/insight-accenture-2017-internet-health-things-survey


And there you go, its fairly simple and we look forward to you sharing your experiences with our community of readers. We appreciate you considering sharing your knowledge via The HCITExpert Blog

Team @HCITExperts
Author
Team HCITExperts

Your partner in Digital Health Transformation using innovative and insightful ideas

What is #ConnectedCare? Is the Healthcare Industry ready to embrace it in India?

During the recently held #PhilipsChat the from Philips Healthcare set the agenda to discuss various aspects of what is Connected Care? 
(http://blog.hcitexpert.com/p/connected-medical-devices.html

Whenever a TweetChat is held, the moderator puts out an agenda for the discussion. Once its time, the participants share their point of view by Tweeting out their responses to the questions, tweeted by the moderator. 


The Connected Care #PhilipsChat questions follow and I Look forward to You sharing your thoughts and point of view on the role of Connected Care in Healthcare: 

1. How would you explain connected care in one line? 
2. Is the healthcare industry ready to embrace connected care?
3. How are your organization using connected care? Since when?
4. Based on your experience, what are the elements to enable connected care further?
5. How are you involving policy makers to embrace connected care?

If we take these questions with an india context, how connected care can enable the affordability and accessibility to healthcare in India. These are the most often mentioned aspects of Healthcare, that needs to be addressed by not only the government, but also the Startup community willing to disrupt the Health Tech / Digital Health industry. 

I have attempted to share my thoughts on Connected Care questions put forward during the tweetchat and I hope you will consider sharing your insights by filling in the form below

1. How would you explain connected care in one tweet?

An always connected channel of communication of care between the patient and provider, from “touch time” to “face time”  

2. Is the healthcare industry ready to embrace connected care?

In India, with the major push for digital services by the govt and private healthcare facilities, and with 350+MN internet users connected care is the only way to solve the accessibility to healthcare problem (1:3200 doctor to patient ratio)

4. Based on your experience, what are the elements to enable connected care further?

The connected care needs to bring about change in thought of how to use a connected care framework for the patient as well as the doctor. 

For the patient, connected care is about 
– experience that enables an ease of access to care
– Ability to build their own healthcare record’s completeness 
– Have a better set of processes and #workflows to manage their health and care 
– Have the ability to find “patients like me” and be part of the community 

For the Doctor, I believe it will be about 
– how to glean new insights from the data stream
– How to collaborate with a patient via an always connected model? What signifies the end of a consultation? 
– To build constantly evolving care plans for their patients, based on realtime, near-realtime, time-delay, or frequency per day/week month updates
– To evolve more treatment plans based on the insights that can be drawn from the raw patient data feed (an e.g.)
– How to build a community and be part of a community of specialists to keep themselves up-to-date on the current research and practices.


I am including the Questions as a Google Form, do consider sharing your insights into what is Connected Care? And how do you see it being enabled for the benefit of the patients and clinicians.

Author

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8 things Indian Doctors must do in order to invent-develop a successful medical device in India by @DrJagdishChatur

In India, we have 1 doctor for every 1,700 patients (WHO recommends 1:1000). We produce about 30,000 doctors and 18, 000 specialists every year. It is estimated that we will need four lakh doctors by 2020 to meet the minimum WHO requirement of 1:1000 doctor-patient ratio. 


Doctors, therefore, need to do more than what they are already doing in order to address the burden of clinical problems in India. One effective way could be by contributing to the development of affordable medical devices that reduce skill and are specifically designed for wider usage within our healthcare system so as to help reach a larger subset of a patient population. This can be through providing novel technologies to healthcare workers or through the most effective involvement of general practitioners in order to reach a larger patient population especially in underserved regions.


Inventing medical devices: A perspective of India is the first published book that focuses purely on medical device innovations in India and describes ways for clinicians and engineers to work together as a team. I hope that entrepreneurs who wish to develop new medical devices that will help patients in our country can refer to this book to access some information about inventing medical devices in India in our otherwise infantile yet rapidly emerging med tech ecosystem.

Based on my experiences as a clinician and as a serial MedTech innovator, I recommend that every clinician should keep in mind the following before they venture out to invent something new.

1. Form a team

Find an engineer and a product designer who are willing to take the idea from conceptualization to commercialization on a full-time basis as a start-up company and include them in your team. Most doctors, who understand the clinical problem well, seldom understand the technical challenges. Also being burdened with work it is practically impossible to drive the 24-36 month effort of development all by themselves. By forming a team that starts a company, a formal entity is created to take the idea to its logical conclusion.

2. Work with professionals

Many doctors have tried to co-develop new technologies with engineering students by partnering with engineering colleges. However due to the academic setting and limited clarity on how the technology licenses can be transferred to a private entity for funding and commercialization, these efforts end up as student projects that never leave college boundaries. Therefore, it is recommended Doctors find working professionals with 2-5 years experience at healthcare hackathon’s (jugaadathon’s), engineering conferences and social medical groups.

3. Have realistic expectations from your contributions

Ideas that come in a few minutes or hours of brainstorming alone don’t always solve a need. It is ideas that are developed meticulously over 2 to 3 years by following all the recommended processes and guidelines to create something which can be used safely, effectively and reliably on patients are the ones that eventually can solve the need. It can take INR 2-4 crores and a multidisciplinary team of 6-8 individuals and 2-3 years to make even a moderately complex device like a hearing aid. Therefore, it’s probably realistic and fair for the doctor who is only providing intellectual input and time to expect a low single digit royalty or company share for their efforts.

4. Have necessary know-how on the entire process

Not just idea generation but there are many other things that are involved to take the product to the Market successfully. It helps to know that a prototype that works once is not the final product. In fact to get to the stage of a product, the prototypes must be repeatedly tested, improvised and validated before it becomes a clinically tested and reliable product that can improve patients’ lives. The sustainability through an effective business model is probably the most important factor that will keep the product accessible to the patients in a consistent manner. This can surely help in the reduction of the overall clinical burden of the problem.

5. Do not discontinue your clinical engagements entirely

While it is great to invent devices it is equally important to continue clinical work as it keeps clinicians grounded to the need. This is important to have the depth of understanding in both clinical usage and technical development. As a clinical innovator, I have found a way to balance my time doing both. And if one has a good team, a few hours in a week which is probably the time spent writing research article’s (Which doctors do anyway) is all that one needs to spend in order to develop a new technology.

6. Raise smart money and don’t dilute equity early

Start with Government funding opportunities till you develop a proof of concept and have hired a team. Today, with the Make in India efforts, there are numerous grants available to take an Idea to proof of concept. These grants even allow funding of company incorporation and salary expenditures. These can, therefore, allow a clinician to form a team, incorporate a company and file intellectual property in addition to developing a proof of concept. Further private/public investment can be raised thereafter which will be welcomed investors as they prefer to invest when the team and concepts are developed to some extent rather than investing in a very early stage ideation phase. This also helps startups save their company shareholding/equities until a later dilution.

7. Be more than just a feedback provider

Clinicians understand the clinical space and the problems very well. It is, therefore, vital to share that information with the engineering, design and business team members so that the technology is suited to be used in a realistic clinical setting. Educating the team, leading the clinical testing/validation and improving product adoption should be provided in addition to critical feedback on the developing technology.

8. Don’t be afraid to fail

As a clinician trained in India, I can confidently state that we are trained to have a very narrow window of error. As important as this is in the clinical setting because we deal with living patients, this resistance to failure is probably counter-productive in the field of inventions. For a product to be failure proof, it should have failed in all possible ways during the development and bench top testing and all these causes for failures systematically rectified.

Author
Dr. Jagdish Chaturvedi

Dr. Jagdish Chaturvedi is currently Director, Clinical Innovations and Partnerships at Innaccel Acceleration Services Private Limited and ENT practitioner. He has authored the book’Inventing medical devices – A perspective from India’. His core expertise lies in the process of identifying and analyzing unmet clinical needs for quick development of low-cost and high quality medical devices. Since 2010, he has co-invented, developed and commercialized multiple affordable medical devices.

#DigitalHealth at an Inflection point by Mary Meeker, @kpcb reviewed by Manish Sharma @msharmas


Please note the above slides have been extracted from the Mary Meeker, Internet report 2017 purely for the purposes of this article. The statistics mentioned in this Blog have been taken from the Mary Meeker Internet Report 2017, relevant for DigitalHealth. For more details please view the complete report here  

While reviewing the Mary Meeker, Internet Report 2017 I found came across the statement “DigitalHealth at an Inflection point”. So in this article (as also the slide deck above) I have tried to review the Digital Health specific updates and provide a correlation to them by linking it up with the India Internet section that has also been highlighted in the report.


We are seeing a great many startups bringing the healthcare services by deploying Digital platforms, I think it will be an interesting exercise by the incumbents as well as new innovators, to view these two sections of the Mary Meeker report while preparing to expand their digital footprint or while trying to bring in new services to the market. Do we see a new category of Digital Health startups that can leverage the customer segmentation and growth in the customers with access to mobiles and internet penetration.

We start with the India Internet growth story, and proceed to the Digital Health story. 

The India Internet Story

There are some interesting insights related to the India Internet Story. These are:
  1. With 355 MM users, India is second to china in the number of Internet Users. A 40% Y/Y growth and 29% penetration. This presents a large customer base for the Digital Health Startups providing services online
  2. India is number 1 in terms of the number of Android apps downloaded, greater than the US. So an obvious first choice of platform on mobiles
  3. India has been recording a steady growth in the smartphone shipments, at 15% Y/Y
  4. There has been a reduction in the cost of 1GB of data from $3.15/ 1GB to about $2/ 1GB. Including Jio, the cost comes down to $0.33/ 1GB
  5. There has been a push from the Government towards “Digital” services as can be seen from the following initiatives: Jan Dhan, Digital India, Skill India, Startup India. Government’s Policies rolled out with speed and scope
  6. India identity via Aadhar + eKYC, Digital authentication of 1B+ people, 82% of the population have aadhar, has the potential to enable services with speed, scale and scope (e.g., SIM card activation from 1-3 days to 15 minutes)
  7. 46% of Internet users primarily consume local language content. 6 Languages spoken by > 50MM users (excluding english)
  8. Young India: 64 % of the population, 72% of the Internet users less than 35 years of age
  9. 27% increase in the Consumption Class (income levels at which consumers start to have the ability to spend beyond basic necessities). 
  10. India consumption is focused on basics, i.e. 54% of personal consumption expenditure

The India Healthcare Story

  1. India Healthcare has a high and rising out of pocket spend, <20% insurance penetration (a potential area for disruption?)
  2. India Healthcare reimagined: Increasingly accessible via mobile and affordable via online aggregation and price transparency. Savings on Services like Online pharmacy (20-30%), lab tests ordering (40-50%).

The Digital Health at an Inflection Point

There are some interesting insights related to the Digital Health being at an Inflection point. These are:
  1. 100 years ago: human touch; 25 years ago: machine assisted/ analog; Today: technology enabled/ digital
  2. 4 trends highlight the current Digitisation of Healthcare and the Virtuous Cycle of Innovation: Data Inputs, Data Accumulation, Data Insights, Translation. Together these trends are helping measure Outcomes and rapidly iterate to enable compression of Innovation Cycle times.
  3. The earlier analog medical technology is increasingly being replaced with Digital Technology, and is (continuously being) connected
  4. Diagnostics Technology: increase in the number of measured / monitored data attributes
  5. Increasing adoption in the use of wearables, for health and wellness. For health, heart rate and temperature
  6. Leading technology brands are well positioned to participate in the Digital Health wave, with the customers stating in a Rock Health survey they will be most willing to share healthcare data with the likes of Google, Microsoft, Samsung, Apple, Amazon, Facebook and IBM (in that order)
  7. Data Accumulation enabling the proliferation of Digitally native healthcare related datasets
  8. Proliferation of health apps, with a 5% Y/Y growth in the US and 15% Y/Y growth in rest of the world
  9. EHR adoption is leading to a broad and centralised accumulation of data with various types of patient data elements in a native digital dataset , e.g., clinical results, scanned images, vital signs, problems, medications, allergies, etc
  10. In the US there has been an increase in the number of hospitals allowing for the patients digital access to the healthcare information
  11. There has been an increasing digitisation of inputs fueling a 48% Y/Y growth in healthcare data
  12. Data Accumulation: a typical 500-bed hospital generates 50 petabytes of data (1 petabyte = 1 mm gigabytes).
  13. Rise in inputs + increase in digital healthcare data = medical research and knowledge is doubling every 3.5 years
Now that you have these data points available to you, what are the Digital Health business categories can you think of? Digitisation = Democratisation. 

How can we make use of the various natively digital datasets available to deliver better and improved healthcare services to the customers. How can the hospitals adopt Digitisation to improve service delivery. More so what is the shape of a Digitally enabled hospital? Your thoughts? 

Stay tuned to our list of Startup Categories that you can consider for your next startup.

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Blog Series: #IoT in Healthcare by Swetha Jegannathan @csweths


The opportunity in #healthcare IoT is estimated to be $2.5 trillion by 2025. How are we embracing this change? The Types of Opportunities (http://blog.hcitexpert.com/2016/05/infographic-iot-in-healthcare-opportunities.html) that present themselves to the Startups, Healthcare IT organisations are tremendous.
Presenting the insights shared by Swetha Jegannathan (@csweths) on #IoT in Healthcare #PhilipsChat.
Q1: In the near term (1-3 years), What are the top 3 innovations in IoT that can benefit healthcare?:
Swetha Jegannathan:
1. Geriatric Care – IoT is and will continue to be of great value in elderly care, allowing the doctors and care givers to monitor, track and alert when away from their loved ones – especially in cases of neurological disorders like Dementia and Alzheimer.
2. Maternal and Infant Monitoring – IoT, through monitoring devices worn by the individual, can provide timely intervention in the area of maternal and infant health – one of the primary goals of the UN sustainable development agenda.
3. Remote consulting – The low doctor patient ratio in India can be effectively overcome through remote consulting – making patients responsible for their well-being – leading to the doctors and hospitals prioritise focus on emergency and chronic patients.

Note: Since radio frequency is central to most of the IoT innovations, innovator must adhere to protection standards on effects of radio frequency (RF) fields as tabulated by the International Commission on Non-Ionizing Radiation Protection (ICNIRP, 1998) and the Institute of Electrical and Electronic Engineers (IEEE, 2005)

Further the paper “IEEE Standard for Safety Levels with Respect to Human Exposure to Radio Frequency Electromagnetic Fields, 3 kHz to 300 GHz” also gives few pointers on safe use of the IOT technology. http://emfguide.itu.int/pdfs/C95.1-2005.pdf
Q2: Is an IoT based system going to be a utility or a service?:
Swetha Jegannathan: The system will be successful if offered as a service. Hospitals would be the drivers providing this service to their patients with companies engaged in the manufacture and distribution of medical devices being the enablers of the technology.
Q3. Do you see any device, connected via any protocol and with any cloud; as the future, if yes how will that be achieved? Standards?:
Swetha Jegannathan: RFID based devices connected through the anti-collision protocols and the Apple watch will be the future.

The RFID chips are inserted into the human beings for unique identification and capture of information relating to their general health and well being like blood pressure, weight, blood sugar levels.  The RFID tags can also be used for improving the efficiency of the medicine distribution networks as tracking of the medicines becomes easier.

Prevention of inappropriate usage of the collected information in terms of charging higher insurance premiums or classification of the individuals tracked by the device is one of the biggest challenges to its widespread implementation. However, if used judiciously, healthcare can certainly move from curative to preventive care.

RFID standards need to focus on the following:
– How the RFID systems work
– What frequencies do they operate on and how to use a common frequency across the globe
– Method of data transfer
– Communication between reader and the tags
– Complementary products development compatible to the RFID
 
Q4: In India (or your country), what are the Digital Infrastructure requirements for enabling IoT based Innovations in Healthcare?:
Swetha Jegannathan: In India, most of the patient data is available in physical form and this needs to be converted to electronic form.  Only if 100% of the required data is in electronic form, further analysis can be simplified.
For all the required data to be available electronically and their analysis, high end scanners, significant investment in hardware – to cater to large databases – and software (machine learning – image recognition; AI) to effectively manage data and make decisions. Further, a standard medical data code for data transmission and retrieval is a prerequisite.
Once the data is collected, stored and retrieved efficiently, analysis is accurate and easier leading to appropriate decision making.
Q5. How can hospitals leverage #IoT based solutions for service delivery and patient care? :
Swetha Jegannathan: Some usage of IOT in the indian and international hospitals are given below:
GE used sensors in a New York hospital to track the usage of hospital beds resulting in  optimised occupancy levels and reduced the emergency room wait times by four hours.
e-Alert, a HW/SW solution by Philips Healthcare, virtually monitors the health of its machines to prevent outages. Timely alerts on the wear and tear of the machines leads to savings on replacements and repair.
In India, Manipal Hospitals has been using a wearable device for the expecting mothers to enable doctors to remotely monitor real time information of the growing foetus.
Apollo hospitals has been an early adaptor of IoT in the country in healthcare for accessing patient records at one go with its Unique Hospital Identification initiative across the country.
In addition to the above, the hospitals can leverage IOT in the following areas:
– Clinical decision enablers
– Effective control on hospital borne infections
– Targeted and painless surgery using AI/ VR.
– Connected care pre and post discharge
Q6: What are the aspects of Connected Care for the Patient Care Continuum (https://twitter.com/HCITExpert/status/692309239570628608):
Swetha Jegannathan: Connected care for patient care continuum would include:
1. Preventive health – with regular check-ups, timely alerts and early interventions
2. In-Patient Care – Personalised treatment enabled by technology
3. Post operative care – Remote tracking, consulting and treatment follow-ups using telemedicine and diagnostic tools.
Q7. Please share usecases for Connected Care for: Healthy Living, Prevention, Diagnosis, Treatment, Homecare:
Swetha Jegannathan: The use case suggested is based on the premise that it is executed at state level involving the hospitals and care givers.
– The state monitors the citizen’s health using IoT technology – Wearable/ regular check-ups to name a few
– State collects data and, post analysis, alerts the hospitals if there is a deviation from normal
– Concerned citizen and the hospital are in touch and the identified individual is put on preventive treatment with periodic observation of the readings
– If the preventive treatment is successful, then sustenance is monitored through home care including life style changes
– If the preventive treatment is not working for the individual, further investigation is encouraged.  Post investigation, if the individual is diagnosed with the suspected condition, the relevant treatment procedure is given to the individual.
– Monitoring of the progress of the individual’s condition during the treatment is an important step
– On conclusion that the treatment is successful, the hospital, through IOT, will monitor the relevant data periodically.
– The hospital and the individual may decide to have remote follow up consultations till the individual is deemed to be healthy again and there are no signs of relapse.
Q8: What are the Healthcare based Smart City components? How can Local, State and National Government’s make #IoT solutions in healthcare economically viable?:
Swetha Jegannathan:
The following are the healthcare based Smart City components:
– Digital e-health and m-health systems
– Remote patient monitoring leading to customised treatments and medication
– Devices and wearables linking patients with remotely present doctors and nurses
– Data anonymisation
– New innovations on sharing medical learnings that are digitally collected
– Common medical data standards for collection, distribution, analysis and retrieval

The implementation of the Smart City concept in healthcare can be achieved by having a model district containing the above components.  This model needs to be continuously monitored and course corrected (wherever relevant) for it to be successfully expanded to the state, other states and finally the country.

Healthcare based Smart City components, if implemented efficiently, will lead to optimisation of the healthcare costs incurred by the governments.
Q9: How can private hospitals justify the RoI’s of Smart Hospital Components? :
Swetha Jegannathan: Thought, the initial investment and efforts required may be enormous, the patient convenience and hospital resource optimisation through the process streamlining will be worth the efforts and the investment. With the entire patient record being seamlessly available to all the relevant stakeholders, significant savings will be achieved in collecting, sharing and transcribing data – in terms of cost and time. This would also minimise medical errors and, in turn, enhance the reputation of the hospitals in the long run.
Q10: Give us a Buzzword we are going to be hearing regarding IoT based innovations in Healthcare.:
Swetha Jegannathan: Human barcoding
Q11. Tell us a 5 Year view of IoT in Healthcare and what would a Patient Experience in a Smart Hospital?:
Swetha Jegannathan: In 5 years the patients should be able to experience hospitals as wellness clinics with patient centric design in both service and delivery being the priority. This would be achieved if the following plan in implemented in a systematic manner:
– The patient will be assigned to the nearest healthcare facility by the smart city based healthcare network algorithm
– When the patient walks into the hospital (without any physical file), the face recognition technology will retrieve his records and direct him to appropriate department for treatment and physician without any wait time
– Incase of further investigation, the medical record will be sent to the nearest laboratory that then collects the samples from the patient and send the results to the hospitals online for further deciding treatment protocol, including surgeries and therapies. Alternatively for some tests FDA approved diagnostic mobile applications can replace the laborious laboratory tests and share the results instantly with the hospital over the data cloud
– Painless surgeries with targeted robotic precision will be the norm
– During the treatment course (either as in-patient/ out-patient), medical prescription is shared electronically with the pharmacy that delivers the medicine to the patient
– Home care will be an extension of the hospital care with the wearables monitoring the patient’s health and alerting medicine/ therapy schedule
– Physicians will do remote consulting for acute cases, thus freeing them and hospital facilities to attend to only chronic patient in person
– After the recovery stage, the IoT based diagnostic kits will be used to monitor the health of the patient remotely and alert any relapse or detect a new condition

Thus, seamless integration of health system and data without human intervention (or edits) will greatly reduce medical errors and enhance the patient experience.
Q12. Finally: What areas of IoT based innovations are you looking to partner with Startups for? Can you give us two areas?:
Swetha Jegannathan: – Technologies looking at reducing or eliminating the radiation effects of radio frequency that is so central to IoT use cases.
– Smart human centric designs to make healthcare more patient centric without compromising on the human touch.


Stay tuned to the #IoT in Healthcare Blog series Bookmark this link to follow on the insights being shared by the experts on the HCITExpert Blog:

Author
Swetha Jegannathan

Swetha is a lifescience/ healthcare IT consultant with focus on business flow, pre and postsale lifecycle of a software. She has been fortunate to be part of different sub-sectors within the health and life science vertical, be it e-health and m-health at Eli-Lilly Co-Innovation lab for HCL, Singapore or Clinical Data Management & Computation and Laboratory Information Management Software (LIMS) suite at Phase Forward – Waban Software group (now acquired by Oracle) and Ocimum Bioslutions. She has catered to clients across major pharmaceutical majors in US, Europe and South East Asia.

She was instrumental is setting up the DNA sequencing wet lab for MWG Biotech (Now Eurofins), a German company, when they were establishing their base in India in 2004.

Swetha is also passionate about promoting green businesses and innovations that are socially relevant, economically viable and environmentally sustainable. An advocate and practitioner of natural living, she has also done social work assignments with focus on sustainable agriculture, food security and environment. (nominated for the UN Online Volunteering Award in 2010 and her volunteering work was published in UN Online Volunteering newsletter March 2011) and covered in The Strait Times, Singapore national daily.

Specialties: Digital health, Green business, Start-up facilitator, Business Analysis, Consulting, Entrepreneur, Marketing, Social Media, Project Management, Presentation Skills, Networking.

#DigitalHealth Startup? How to evaluate your #Startup like a VC or Angel by Manish Sharma @msharmas


#Startup, is a favourite word we hear these days from AiM to PM. At times it has connotations of a journey to fulfil, a dream to Startup is to Just go for it, and at times it brings about the memories of your struggles and wins, from that journey. But to startup is to also understand the basics of the entire process of establishing a business and running it.


You can proceed on two paths, just get started and learn by doing or you could get started and follow a process that allows you to ask yourself some questions each step of the way. I worked in a company that had a “Board” room named as Kaizen. I remember spending a great many hours in that room discussing what would be the new path our product would take and also showcasing the future releases of the product to existing and prospective customers. That was a room that also helped the team to see first hand the reactions of these very customers to our solution and not a meeting went by when the team came out of that room thinking what other “WOW” moment we can create for our customers. 

From the Kaizen room, the teams always came out wanting to do better and wanting to be the best. And I feel and see the same enthusiasm from the Digital Health Startups I have been following for quite sometime now. Guess we had built in a continuous feedback loop that allowed us to get updates from our various customers and what they were saying about us and also having the ability to constantly innovate and continuously improve. 

Well I digress, I was here to tell you about how you need to think like a VC or Angel and the reason I mention the story is to state the point, that in the rush and din of starting up, funding, customer acqusitions, round two, series a, b, c… etc, we tend to stop thinking about the basics. The Business Plan Evaluation Aids, that I list in this blog post, will help you define a schedule that will help you continuously improve, track, change and pivot your business plan to meet the needs of the customers you are serving or want to serve. 

And the best part is that the BPEAs are driven by fundamental questions that are generally asked during a due-diligence process of funding, IPO, exits or business evaluations by third party auditors. The BPEAs help you build a “Continuous Feedback Loop” to continuously evaluate yourself with metrics that will help you determine where you are, where you want to go and what you must do to reach your goal. 

Why is there a need for this process, in a startup? Arent’ startups supposed to Hack-It, Jugaad-a-thon it, Frugally Innovate, be Agile? And at the same time we also hear the statement, “9 out of 10 Startups will fail”.  Or of late, have been hearing about stats such as why do most Indian Startups close within 5 years. Lets try to turn that tide and improve the odds. Lets build to last !! (taken from a famous strategy book, i always like referring to and like the title because its not about exits, its about building something tangible and long term. Thats my personal take on starting up)

Lets try, by adding some semblance of method to the Startup madness and agility, by considering the Bell Mason Diagnostic as a Business Plan Evaluation Aid (BPEA) for your startup. The Bell Mason has been used by the Authors of the Model, to evaluate Technology Startups since the late 90’s (and has been used around the world to evaluate about a 2000+ ventures).

I came across an interesting statistic from a study, Venture capitalists reported devoting 8 to 12 minutes on average to evaluate a business plan (Sandberg 1986). Much of the evaluation is purely intuitive, despite the existence of several decision aids, which might be expected to aid both efficiency and consistency in the decision-making process.” 

So if you are able to prepare yourself to provide the VC or Angel with the best information about your startup and a story line that is compelling, you might just get funded. And perhaps that is what differentiates that one startup that makes it?

Another interesting story from the recently concluded Google IO, 2017. I remember one of the top executives from Google making the presentation and talked about how they had been “preparing” for this presentation from a long time. Well its Google, they dont need to do it, they can Just Do It too? Right? 

Same is the case, with Apple, when we have heard, read and seen the great presentations made by Steve Jobs for every single presentation for a new product launch, like the iPhone Launch

Let there be planning and evaluation at each stage of your journey, after all you might either have the time in the Elevator to Pitch or have 8 to 12 minutes, make them count.

The Bell – Mason Diagnostic (BMD) – A Startup Evaluation Model

The Bell – Mason Diagnostic [1] involves answering questions about your Startup. The authors where involved in evaluating Technology Investments. The model can be used by startups to evaluate their current stage, or can be used by corporates, planning on investing in new technologies and ventures (Intraventures).

What is the Bell – Mason Diagnostic Evaluation Model?

The BMD, consists of the following aspects that every venture, startup or intraventure can evaluate themselves on.

1 The Founding Premise

The the BMD Model’s founding premise is

“You dont need to understand the Technology to ask the basic business questions” 

2 The Four Diagnostics

The BMD model is built on the following 4 Diagnostics that each company/ project needs to do, depending on the current Stage of their startup/ venture or intraventure

  1. Space: 12 standard dimensions of any venture
  2. Time: 4 Stages of company development
  3. Quantification: Questions under each dimension to evaluate the company
  4. Visualisation: The graph showing the current status of the company based on the stage of company development

1. Space

There are 12 Standard Dimensions of Analysis of a venture. These highlight the various aspects of a startup. 

The 12 Dimensions of the Bell Mason Diagnostic are: 

12 Dimensions of the Bell – Mason Diagnostic (BMD)

  1. Technology Engineering
  2. Product
  3. Service Delivery/ Manufacturing
  4. Business Plan
  5. Marketing
  6. Sales
  7. CEO
  8. Team
  9. Board of Directors
  10. Cash
  11. Financeable
  12. Control

The twelve dimensions are organized in four groups, each containing three dimensions:

  • ProductTechnology/engineering, manufacturing and product
  • MarketBusiness plan and marketing and sales
  • PeopleCEO, top-level team, and board of directors
  • Finance/ ControlCash, financeability, and operations/control

2. Time: The 4 Stages of Growth
The 4 Stages of Growth for every Startup or Venture or Intraventure according to the Bell Mason Diagnostic are: 

  1. Concept (0 to 12 months) – Discovery
  2. Seed (3 to 12 months) – Definition
  3. Product Development (12 to 48 months) – Development
  4. Market Development (24 to 48 months) – Deployment


There is a more updated definition of the Startup Stages that can be found here >> http://www.bellmasongroup.com/approach/

BELL MASON DIAGNOSTIC – STAGES


You can also review the 5D Delivery Process that I have written about here:  http://blog.hcitexpert.com/p/5d-service-delivery-framework.html

3. Quantification:
The quantification process involves asking a series of questions to oneself for your own company or to the startup being evaluated. Each of these questions are based on the 4 Stages, the 12 Dimensions. Each of the questions has a simple rating 1, 2, or 3. Each of these ratings can be attributed with a weighted score to arrive at the efficacy of a company or an idea. This is the way the startups can codify their work using a best practices approach to starting up.

4. Visualisation:
Once the Founding Team has answered and presented their idea within the purview of these stages and dimensions, the results are plotted onto the radar chart. 

Each of the sections of the radar chart, corresponds to a dimension of the BMD and depending upon the outcome of the questions under each of the dimensions, helps the person evaluating the proposal to identify the steps ahead.

So how does the Bell – Mason Diagnostic Evaluation Model, work?

Identify the Stage of your startup: Based on the Stage your startup is at, The Bell Mason Diagnostic presents the various dimensions that you need to focus on. 

These dimensions are relevant for that stage of your company (venture or intraventure). Each of these dimensions comes with a series of questions that need to be reviewed and answered by the startup team (project, venture, intraventure). The focus areas for each startup stage are defined by the following radar chart.

[2]: Source: How Bell Mason Diagnostic measures the companies – https://www.finsia.com/docs/default-source/jassa-new/jassa-1996/warning-bells-or-sound-of-success-.pdf?sfvrsn=2

You can event do a quick run through each of the dimensions relevant for the current state of your startup and rate each of the dimensions with a score of 1 to 5. That will help you identify if you are able to move your startup from one stage to the next. It also helps the startup to evaluate what are the tasks they need to perform to move from one stage to the next.

For instance, at the concept stage the BMD shows that the Startup needs to evaluate the following dimensions: technology, business plan, CEO, cash and financeability. [2]

Another important aspect of the Bell Mason Diagnostic, is to help the startup identify the equity they can give out at that stage of the startup. Using this method the founders can understand the finance they would need, the type of finance they can go for and the amount of equity they should be able to give away at each of the stages 

How to, Build to Last

As startups we need to beat the odds i shared earlier, 9 out of 10 startups fail? Why startup if you accept the fact that you are going to be keeping the batting average at the above number. The average is not acceptable as a rapidly evolving startup nation. 

We need to focus on how we can build organisations that are Built to Last and while we can still remain agile in our delivery process, but at each stage of your startup, we need to evaluate the current state by answering these in-depth questions which can pile up quite fast and under the radar. 

The BMD helps the startups run an iterative and a continuously improving and evolving analysis of their company that in turn generates a list of activities, to-do lists, product backlogs, etc that will help the company to move to the next stage of their startup journey.

While I am not proposing that you keep doing the same thing again and again, you can surely use the BMD to also identify if you need to pivot, exit, re-strategize and work at other aspects of your business plan to improve what you are building/ developing.

There are many other models of Startup (or venture, intraventure) Evaluation. In this blog post I have tried to present the Bell Mason Diagnostic to help you get started on a task of evaluating the current state of your startup. Be it due-diligence, or preparing for presentation to new board members or members of the executive team, use this model to help you identify the next steps to be taken. 

Just remember building a product requires getting your fundamentals right, the BMD framework can help you do that.

While you are working on evaluating your startup using the Bell-Mason Diagnostic (BMD), you might also consider reviewing the following Business Plan Evaluation Aids (BPEAs). “A BPEA is a highly specialised subset of human decision aids used for the specific purpose of screening entrepreneurial business plans. Any decision aid is used to provide assistance and structure to improve the accuracy and consistency of human judgment.” [6]

1) the FVRI System (Fiet, Gupta, et al. [2003]) and 
2) the New Venture Template (Mitchell [1995])
3) The Venture Opportunity Screening Guide (Timmons [1994])
4) ProGrid Venture (Bowman [1997])

I have put together an excel sheet that will help you arrive at the “Go – No-Go” for each of the Startup Stages. Let me know and I can share the same with you. Drop me an email at manish.sharma [at] hcitexpert [dot] com. In the followup Blogs I will present some of the other BPEA tools listed above and share the various categories of healthcare startups.

If you are a Digital Health Startup, I would like to hear and share your story, what is the solution you are developing, more importantly why?

Here is an interesting write up by Shailesh Gogate (@sgogate), on 5 lessons learned while assisting Healthcare #startups 


Source: http://www.bellmasongroup.com/approach/

Here is an Update, got an interesting update from Mr. Raj Grover, shared by him on the Fundraising for Indian Startups on what aspects should be covered in a startup pitch 

[5]: The Bell Mason Diagnostic: http://www.bellmasongroup.com/approach/
[6]: Assessing the Efficacy and Standardization Potential of Five Competing Venture Capital Investment Evaluation Approaches  http://www.kevinhindle.com/publications/C16.2005%20JPE%20Efficacy%20of%20five%20approaches.pdf
[7]: An exhaustive list of 200+ Incubators in India: https://inc42.com/startup-101/startup-incubators-in-india/?utm_source=facebook&utm_medium=social&utm_campaign=authors

Author

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Manish Sharma

Founder HCITExpert.com, Digital Health Entrepreneur

Connect with me via any of my Social Media Channels

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5 lessons learned while assisting Healthcare #startups by Shailesh Gogate @sgogate


18 months ago Faichi Solutions, http://www.faichi.com/ an offshore product engineering partner, decided to focus on two verticals: Healthcare and Media/ Publishing.

To scale a company, one should pick one or two verticals to focus on (especially when you have limited budget 🙂 ). These two verticals were identified based on the number of clients we had in those 2 verticals and customer references :).


In the first 4 years of operations, we had worked with a Population health product which was pivoted from a Wellness product, a Patient Management product, and a Health Management platform. In the last 18 months, we have worked/ working on two TeleHealth products, another Population health, a Behavioral Health, and two Health Management products.

While assisting different Healthcare ISVs (product companies a.k.a Independent Software Vendors), Faichi Solutions was initially a product engineering partner. Having that said, we learned a lot (and continue to learn) of business and operational issues (and are now an integral part of the development and release lifecycle). Listing 5 learnings (amongst many) below:

1. Add a product owner even if the Client has one: Core members of a startup end up wearing different hats. It’s hard to manage/ explain (and document – the biggest challenge) user stories, workflows, questions of the developers/ testers (should be accessible). Solution: Have another product owner who mimics client’s product owner. It removes a lot of roadblocks. This is very helpful to finish the number of user stories planned during a sprint.

2. Be ready to educate your Client and be educated: When your key point of contact is a domain expert and not a tech expert (although she thinks she understands technology), you end up educating the Client on technology and its processes. One has to communicate in a way which is politically correct (without hurting the ego of the entrepreneur, requires a different kind of skill). In the same breath, would like to point out, engineering partner needs to understand the nuances of client’s business. Sometimes a simple step in a use-case could be nerve-wracking, keep an open mind to learn.

3. Incorporate business dependencies while estimating a task: While estimating development effort for a user story, e.g. integration with EHR, one may estimate 4 to 5 weeks. However, there are a lot of business dependencies which have to be considered. For e.g. To get a buy-in from the CIO of a hospital / large clinic (particularly if it’s an on-premise EHR) to integrate with a product can take up to six months or more (or none). There are tons of such examples.

4. Have a domain expert on the project: Even if you are engaging with client’s VP/ Dir of Engineering, there are a lot of user stories which need clarification before and during the designing or coding process. For e.g. while moving from ICD 9 to ICD 10 codes, there is an architecture and UI change. The domain expert should point this out early in the process. There are changes being incorporated in US Healthcare, which is going to affect the revenue of a product. One should be able to filter out key implementations from the list of buzz words floating around (e.g. MACRA).

5. Build accelerators to reduce time to market: Anticipate what features are likely to be added to multiple products. For e.g. for telehealth clients, “Patient Intake forms” will be needed in a few months time. For a different set of clients and prospects, Chronic care management workflow will be required. In the initial years, we could not anticipate these needs. However, in the last 18 months, we added a few accelerators which add significant value for our clients. Not only these accelerators are helpful in reducing time to market of our clients, they were also helping in reducing clients’ cost.

There are a lot of best practices which have to be followed while working with offshore teams e.g. Good / Open communication, Tools and Processes, Daily standups, SCRUM masters on both sides, and much more. All of these are implemented and optimized as the relationship with Clients mature. However, the ones which come to mind at the top the head for Healthcare startups are listed above. Am sure engineering/ operation managers will have a lot to share. Feel free to add your learnings in the comments section below. 

Author
Shailesh Gogate

Shailesh Gogate is an entrepreneurial business development leader with deep expertise across Product Engineering services. Shailesh holds more than 20 years of IT industry experience working with companies across the world. He has a strong interest in product management and adds value to healthcare product companies to make them successful.

What is #BlockChain? Implications for Healthcare by @msharmas

In my previous article I discussed about the benefits and barriers to the use of an Integrated Health Information Platform. In healthcare the need for presenting the Information to the Right Person at the Right Time has been proven to improve outcomes in patient treatment.

Will HIE 2.0 benefit from the use of Blockchain in presenting the information to the Right Person at the Right Time? 


What is Blockchain?
Various definitions of Blockchain have been put across based on the context of the use. Some of these definitions are: 

A digital ledger in which transactions made in bitcoin or another cryptocurrency are recorded chronologically and publicly.

“The blockchain is an incorruptible digital ledger of economic transactions that can be programmed to record not just financial transactions but virtually everything of value.” Don & Alex Tapscott, authors Blockchain Revolution (2016)

The Blockchain is a decentralized ledger of all transactions across a peer-to-peer network. Using this technology, participants can confirm transactions without the need for a central certifying authority. Potential applications include, fund transfers, settling trades, voting etc.

Blockchain is a distributed system for recording and storing transaction records. More specifically, blockchain is a shared, immutable record of peer-to-peer transactions built from linked transaction blocks and stored in a digital ledger. [1]

A Blockchain is a data structure that can be timed-stamped and signed using a private key to prevent tampering. There are generally three types of Blockchain: public, private and consortium. [6] 

How is Blockchain different?

Traditional databases are proprietary to the entity that maintains them and owns them. And the information stored within these databases are accessed only by providing access via an application or shared by the entity in some form of a distributed architecture. 

On the other hand, “blockchain is enabling a database to be directly shared across boundaries of trust, without requiring a central administrator. This is possible because blockchain transactions contain their own proof of validity and their own proof of authorization, instead of requiring some centralized application logic to enforce those constraints. Transactions can therefore be verified and processed independently by multiple “nodes”, with the blockchain acting as a consensus mechanism to ensure those nodes stay in sync.” [2]

A quite often stated example for explaining Blockchain is the Google Doc example. Earlier, collaborating on a document involved a serial approach to making changes to a document. Only once the author has completed the document, can it be forwarded to the next person to edit and provide feedback. 

But consider the Google Doc (or any of the other collaboration tools), once you have created a google doc, you can start creating the document and also share the same document with other collaborators who can also make changes to the document at the same time allowing for reconciliation of changes to be incorporated within the document to finalise it. The author takes the comments from the collaborators and generates the finalised document.  


Blockchain: How it Works?

A transaction is requested. The transaction is broadcasted to the peer-to-peer network consisting of computer nodes. The network validates the transaction and the initiating entity’s status using relevant algorithms.  The transaction record is then considered to be verified.

On verification, the transaction record is added with other transactions to create a new block of data for the decentralized ledger of all transactions across a peer-to-peer network.

The new Block is added to the existing ledger of all transactions, i.e., the Blockchain. The transaction is now complete. 

Types of Blockchains

Permissionless or Unpermissioned Blockchain allows anyone to join the network and participate in the block verification. For instance, a permissionless blockchain example is the Bitcoin.

Permissioned Blockchains restricts the nodes in the network who can contribute to the consensus of the system. Only permissioned nodes have the rights to validate the block transactions.

For instance, most enterprise Blockchains are permissioned blockchain and allow for privacy, scalability and fine-grained access control. [5]

There are more types of Blockchains.
Interoperability in Healthcare

The context of discussing Blockchains in healthcare is Interoperability. There are various use cases that come to mind, when we talk about interoperability in Healthcare. (most are N:N interactions) 

  1. HIMS to Lab Equipment
  2. HIMS to PACS
  3. HIMS to HIMS
  4. HIMS to Apps
  5. HIMS to Portals (Patient, Physician, etc)
  6. Portal to Portal
  7. Stakeholders to HIE
  8. Hospitals to Insurance

You can consider the number of stakeholders in the Interoperability ecosystem and continue to add them to the above list of use cases. And that allows one to understand the current fragmented nature of the Patient’s Healthcare Information. 

Each of the above stakeholders, generate the patient care record and have the need at one time or another to share this information with others in the ecosystem. We have already seen the benefits and barriers to information exchange. 

For the purpose of this blog, lets consider the Healthcare Information exchange use case. HIEs’ share the patient information in a network that is accessed by participating entities. The Patient information available on the HIE can be accessed as and when required by the patients’ treating doctor. 

The availability of a patient information, at the right place and at the right time was (one of) the intended purpose of a Health Information Exchange. HIE frameworks relied on a centralised or federated or hybrid architectures [3] to make the information available to the participants in the exchange. The exchange is maintained by an entity.

In the nationwide Interoperability roadmap defined by the ONC (US) [1]. They define the critical policy and technical components required as  

  1. Ubiquitous, secure network infrastructure
  2. Verifiable identity and authentication of all participants
  3. Consistent representation of authorization to access electronic health information, and several other requirements


Additionally, the ONC challenge stated Potential uses to include:[6]

  1. Digitally sign information
  2. Computable enforcement of policies and contracts (smart contracts)
  3. Management of Internet of Things (IoT) devices
  4. Distributed encrypted storage
  5. Distributed trust

In India, an  Integrated Health Information Platform (IHIP) is being setup by the Ministry of Health and Family Welfare (MoHFW). The primary objective of IHIP is to enable the creation of standards compliant Electronic Health Records (EHRs) of the citizens on a pan-India basis along with the integration and interoperability of the EHRs through a comprehensive Health Information Exchange (HIE) as part of this centralized accessible platform. 

IHIP is envisaged to enable
  1. Better continuity of care, 
  2. secure and confidential health data/records management, 
  3. better diagnosis of diseases, 
  4. reduction in patient re-visits and even prevention of medical errors, 
  5. optimal information exchange to support better health outcomes

With the understanding of What is Blockchain, What is Interoperability in Healthcare and What are the use cases for Interoperability in healthcare, do you think Blockchain Technology can be used in Healthcare? Do share your thoughts and use cases.

And while you share your usecases, do read up on the very interesting two part series from Dr. Senthil N, on the  Unintended Consequences of new Technologies in Healthcare, Thoughts on Blockchain 

In the next part of the blog, I will explore some of these use cases in healthcare and for the purpose of defining how Blockchain can help interoperability of Patient Transactions across healthcare facilities.


References



3. Health Information Exchange – Architecture Types https://corepointhealth.com/health-information-exchange-architecture-types

4. Bitcoin is the Sewer Rat of Currencies, interview of Andreas Antonopoulos by Mark Frauenfelder http://ow.ly/XDMe30bumBy

5. Blockchain – What is Permissioned vs Permissionless? by Deva Annamalai on Core Dump https://bornonjuly4.me/2017/01/10/blockchain-what-is-permissioned-vs-permissionless/

6. ONC Blockchain Challenge: https://www.healthit.gov/newsroom/blockchain-challenge
Author

[tab]
[content title=”About Manish Sharma” icon=”fa-heart”]

Manish Sharma

Founder HCITExpert.com, Digital Health Entrepreneur

Connect with me via any of my Social Media Channels

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[content title=”Latest Articles”]

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Blog Series: #IoT in Healthcare By Rajesh Batra, @rbatra868


The opportunity in #healthcare IoT is estimated to be $2.5 trillion by 2025. How are we embracing this change? The Types of Opportunities that present themselves to the Startups, Healthcare IT organisations are tremendous.
During the #PhilipsChat, on the 10th April 2017, we asked the experts what they thought about the current trends and focus areas that the IT Industry, Medical Device Manufacturers, Hospitals and Startups will need to keep in view in the near and short-term while making their organisation ready for the Digital Transformation that can be and will be enabled by #IoT in Healthcare.  
Presenting the insights shared by Rajesh Batra (@rbatra868), VP-IT, Kokilaben Dhirubhai Ambani Hospital, Mumbai on #IoT in Healthcare #PhilipsChat.

Q1: In the near term (1-3 years), What are the top 3 innovations in IoT that can benefit healthcare?:
Rajesh Batra: Home care and home physiotherapy

Q2: Is an IoT based system going to be a utility or a service?:
Rajesh Batra: Service

Q3. Do you see any device, connected via any protocol and with any cloud; as the future, if yes how will that be achieved? Standards?:
Rajesh Batra: Yes. Even today, there are trials going on for pregnancy related data coming to hospitals. Elderly care is also happening

Q4: In India (or your country), what are the Digital Infrastructure requirements for enabling IoT based Innovations in Healthcare?:
Rajesh Batra: The cost for thin broad band, which is used in IoT needs to come down

Q5. How can hospitals leverage #IoT based solutions for service delivery and patient care? :
Rajesh Batra: It is an eco system under evolution. We need to wait for a couple of years, when hospitals will be focused on delivery through IoT

Q6: What are the aspects of Connected Care for the Patient Care Continuum (https://twitter.com/HCITExpert/status/692309239570628608):
Rajesh Batra: Elderly care and Preventive care

Q7: What are the Healthcare based Smart City components? How can Local, State and National Government’s make #IoT solutions in healthcare economically viable?:
Rajesh Batra: Not sure of Government role in IoT. It is best done in Public Private partnership to keep it viable. Government can’t be responsible for service delivery. However, government can look into duties for devices and cost of thereof and cost of thin broadband.

Q8: How can private hospitals justify the RoI’s of Smart Hospital Components? :
Rajesh Batra: As said, it is an evolving service. So it needs to be watched closely

Q9: Give us a Buzzword we are going to be hearing regarding IoT based innovations in Healthcare.:
Rajesh Batra: Home care and Elderly care

Q10. Tell us a 5 Year view of IoT in Healthcare and what would a Patient Experience in a Smart Hospital?:
Rajesh Batra: Refer to my presentation at Philips Innovation day https://youtu.be/oxllMGzp6gI

Q11. Finally: What areas of IoT based innovations are you looking to partner with Startups for? Can you give us two areas?:
Rajesh Batra: At the moment, we are in the process of implementing Beacons for a better patient experience at the hospital.

References

  1. Here is the original Blog Post announcing the #PhilipsChat Tweetchat : http://blog.hcitexpert.com/2017/04/philipschat-on-iot-in-healthcare.html
  2. Curated list of Tweets from the #PhilipsChat: https://twitter.com/i/moments/852242427008233473
  3. Review the #PhilipsChat Transcript & analytics via @symplur here >> http://hcsm.io/2loNiv7
  4. [VIDEO] IT to #IoT in Healthcare by @rbatra868 via @PhilipsBlore  https://youtu.be/oxllMGzp6gI

Stay tuned to the #IoT in Healthcare Blog series Bookmark this link to follow on the insights being shared by the experts on the HCITExpert Blog:
Author
Rajesh Batra

VP-IT at Kokilaben Dhirubai Ambani Hospital. Responsible for HIS, ERP implementation along with IT infrastructure initiatives and IT Operations and new IT initiatives.

Blog Series: #IoT in Healthcare by Manishree Bhattacharya @ManishreeBhatt1


The opportunity for #IoT in Healthcare is estimated to be $2.5 trillion by 2025. How are we embracing this change? The Types of Opportunities that present themselves to the Startups, Healthcare IT organisations are tremendous.

During the #PhilipsChat, on the 10th April 2017, we asked the experts what they thought about the current trends and focus areas that the IT Industry, Medical Device Manufacturers, Hospitals and Start-ups will need to keep in view, in the near and short-term, while making their organisation ready for the Digital Transformation that can be and will be enabled by #IoT in Healthcare.  
Presenting the insights shared by Manishree Bhattacharya (@ManishreeBhatt1) on #IoT in Healthcare

Q1: In the near term (1-3 years), What are the top 3 innovations in IoT that can benefit healthcare?
Manishree Bhattacharya: 1. Remote monitoring of (cardiac disorders, COPD, Alzheimer’s, Parkinson’s, insomnia, diabetes, elderly, expecting mothers)
2. An integrated/connected surgical room, where devices are interoperable, regularly feeds in data into patient profile in EMR, to streamline post-operative care, both in the hospital and beyond, at patient homes
3. IoT for ensuring drug/treatment adherence, such as sensor-based pills
Q2. Do you see any device, connected via any protocol and with any cloud; as the future, if yes how will that be achieved? Standards?
Manishree Bhattacharya: Right now, developments are quite random and sporadic. To achieve larger goals, moving from connected devices to connected hospitals, some level of standardization and uniformity will be important to ensure an error-free, and secured transmission.
Q3: In India (or your country), what are the Digital Infrastructure requirements for enabling IoT based Innovations in Healthcare?
Manishree Bhattacharya: Seeing Digital Health take off in India in its full bloom is one of my wishes, and the preliminary requisite would be to encourage hospitals go paper-less – have EHR systems implemented, with a timeline set for nation-wide implementation. Just imagine how seamless healthcare delivery will be if primary, secondary and tertiary centres are integrated – data can seamlessly flow from one centre to another. Government has a very strong role to play here, that will help in creating the right infrastructure, timely adoption, establishing standards, lowering costs by promoting local manufacturing, and boosting HealthIT start-ups.
Q4. Please share use cases for Connected Care for: Healthy Living, Prevention, Diagnosis, Treatment, Homecare:
Manishree Bhattacharya:
Healthy Living – Most consumer IoT devices aim to do that – tracking exercise regimes, diet plans
Prevention – Say a heart patient puts on a wearable device that continuously monitors and sends signals to nurses/doctors for any aberration – this can ensure timely treatment and prevent a severe episode.
Homecare – A person who has just had a surgery, and is on homecare – his regular vitals, diet plan, outputs are remotely being tracked by the doctor/nurse – who can selectively revise the diet or post-surgery recovery plan. Same goes with elderly who are on home-care.
Treatment – A sensor-based pill that sends a signal to a care-giver on ingestion of the pill.
The bigger purpose – We know that not all medicines work on every patient. Regularly tracking patients not only help in timely interventions, and more personalized treatments, it also opens routes to more clinical research on personalized medicines.
Q5: What are the Healthcare based Smart City components? How can Local, State and National Government’s make #IoT solutions in healthcare economically viable?
Manishree Bhattacharya: Answering to how can government make IoT solutions viable, my thoughts would be:
  1. By promoting indigenous manufacturing to curb costs
  2. Incentivising IoT adoption in hospitals
  3. Prioritizing HealthIT in the overall start-up agenda
Q6: How can private hospitals justify the RoI’s of Smart Hospital Components?
Manishree Bhattacharya: By improving quality of care; reducing hospital re-admissions, yet prolonging the care process that extends to one’s home; and finally improving patient engagement/adherence. A patient is more likely to visit a doctor who can provide a more personalized treatment than the one who cannot. Important would be define these key metrics/KPIs right at the beginning of implementation.

Q7. Tell us a 5 Year view of IoT in Healthcare and what would a Patient Experience be in a Smart Hospital?
Manishree Bhattacharya: First, we have to understand the purpose of IoT in healthcare – it is not there just for the sake of it, but to truly enable a coordinated and long-term care, that would eventually reduce mortality, morbidity, and hospital re-admissions. Patient experience is bound to improve. A patient will not have to run from one department to another, narrating the whole problem and showing multiple reports. So when a cancer in-patient enters a psychologist’s office, and the doctor already knows the problem, and also has the latest vitals of the patient right in his tablet, he knows that the patient was not able to get any sleep the previous night and has a high BP right now. The doctor would hence probably choose to talk about things that can ease the patient’s current situation. Now, that is truly an enriching experience.

Looking ahead in the future, we may also have AI-enabled voice assistants that will make a patient more comfortable in hospital settings.
Q8. Finally: What areas of IoT based innovations are you looking to partner with Startups for? Can you give us two areas?
Manishree Bhattacharya: Would love to connect with any start-up that can provide meaningful solutions for the Indian healthcare landscape. What I would also like to see is how these start-ups are using the tonnes of data that IoT devices generate, in deriving meaningful analysis – big data, AI, and so on.

References

  1. Here is the original Blog Post announcing the #PhilipsChat Tweetchat : http://blog.hcitexpert.com/2017/04/philipschat-on-iot-in-healthcare.html
  2. 3 ways in which Information Technology can improve healthcare in India by Manishree Bhattacharya (@ManishreeBhatt1) on NASSCOM Community
  1. IoT in India – The Next Big Wave by NASSCOM http://www.nasscom.in/iot-india-next-big-wave
  2. Curated list of Tweets from the #PhilipsChat: https://twitter.com/i/moments/852242427008233473
  3. Review the #PhilipsChat Transcript & analytics via @symplur here >> http://hcsm.io/2loNiv7
Stay tuned to the #IoT in Healthcare Blog series. Bookmark this link to follow on the insights being shared by the experts on the HCITExpert Blog:

http://blog.hcitexpert.com/search/label/IoT%20in%20Healthcare

Author
Manishree Bhattacharya

Manager – Research & Advisory at NASSCOM
Business professional with 7+ years of experience in research and advisory, across IT, healthcare, and medical technologies. At NASSCOM, responsible for identifying digital opportunities, driving thought leadership/innovation and delivering actionable insights for the Indian Technology Industry

Blog Series: #IoT in Healthcare by Dave Brown (@QiiQHealthcare)


The opportunity #IoT in Healthcare is estimated to be $2.5 trillion by 2025. How are we embracing this change? The Types of Opportunities that present themselves to the Startups, Healthcare IT organisations are tremendous.

We asked experts what they thought about the current trends and focus areas that the IT Industry, Medical Device Manufacturers, Hospitals and Startups will need to keep in view in the near and short-term while making their organisation ready for the Digital Transformation that can be and will be enabled by #IoT in Healthcare.  

Presenting the insights shared by Dave Brown (@QiiQHealthcare) on #IoT in Healthcare.

Q1: In the near term (1-3 years), What are the top 3 innovations in IoT that can benefit healthcare?:

Dave Brown: Great user-centered design; cheaper sensors; integration-friendly cloud services (including ML and AI).

Q2: Is an IoT based system going to be a utility or a service?:
Dave Brown: The UI -where the rubber meets the road- is a service. The software behind it is also a service. I can see some of the hardware elements and networking tech’y being a utility.

Q3. Do you see any device, connected via any protocol and with any cloud; as the future, if yes how will that be achieved? Standards?:
Dave Brown: More public exposure of performance metrics will incentivize QI and therefore innovation. Free-market competition (between innovators) will drive down costs. With this accelerated change, risk will rise – this can’t be avoided. However, reliability and data security standards will stabilise risk.


Q4: In India (or your country), what are the Digital Infrastructure requirements for enabling IoT based Innovations in Healthcare?:

Dave Brown: Not sure.  But to my previous answer – system reliability and security standards will help confidence levels for healthcare providers who are frightened of change.

Q5. How can hospitals leverage #IoT based solutions for service delivery and patient care? :
Dave Brown: Start with the big picture in mind; begin with small, measured implementations, and look for IMPACT.  Advance quickly as success metrics show up.

Q6: What are the aspects of Connected Care for the Patient Care Continuum
Dave Brown: Healthy Living, Prevention, Diagnosis, Treatment & Home Care. THIS DOES NOT HAPPEN WITHOUT PROGRESSIVE APPROACHES TO INTEGRATION. The future = API’s.

Q7. Please share usecases for Connected Care for: Healthy Living, Prevention, Diagnosis, Treatment, Homecare:
Dave Brown: One simple picture: a FitBit user shares their data with their provider network; always-on data analysis (that also taps the user’s genomic data) triggers alerts when bad signs arise; then an automatic clinical response launches to address the issue before it becomes a serious problem. This process is AI-driven.

Q8: What are the Healthcare based Smart City components? How can Local, State and National Government’s make #IoT solutions in healthcare economically viable?:
Dave Brown: BIG question – hard to predict – creative and informed entrepreneurs will come up with many. I think these IoT solutions emerge from a vibrant startup community. Governments assist merely by creating incentives for the birth&growth of well-run startups, including spurring investment. They can also help round up healthcare executives and tech entrepreneurs to thoughtfully examine REAL problems and viable solutions (to save entrepreneurs from building solutions that no-one will buy and deploy).

Q9: How can private hospitals justify the RoI’s of Smart Hospital Components? :
Dave Brown: Similar answer as Q2a: start small and measure measure measure.

Q10: Give us a Buzzword we are going to be hearing regarding IoT based innovations in Healthcare.:
Dave Brown: Not sure.  How ’bout: “Smart API’s”

Q11. Tell us a 5 Year view of IoT in Healthcare and what would a Patient Experience in a Smart Hospital?:
Dave Brown: It’ll take more than 5 years for a real transformation to occur. But as I’ve already written, more good data (genomic + real-time consumer sensors) with strong AI will increase proactive community interventions, thus reducing the demand on urgent care.

Q12. Finally: What areas of IoT based innovations are you looking to partner with Startups for? Can you give us two areas?:
Dave Brown: We ARE a startup, committed to helping redesign workflow in urgent care.  We need to partner with companies contributing to acute care IT. We eventually need to integrate with community-care solutions to further improve the patient experience in moving from community care to acute care.

You can contact QiiQ Healthcare via their website: http://QiiQHealthcare.com
You can reach Dave via Twitter: @DaveBrutusBrown

References

  1. Here is the original Blog Post announcing the #PhilipsChat Tweetchat : http://blog.hcitexpert.com/2017/04/philipschat-on-iot-in-healthcare.html
  2. Curated list of Tweets from the #PhilipsChat: https://twitter.com/i/moments/852242427008233473
  3. Review the #PhilipsChat Transcript & analytics via @symplur here >> http://hcsm.io/2loNiv7

Stay tuned to the #IoT in Healthcare Blog series Bookmark this link to follow on the insights being shared by the experts on the HCITExpert Blog:

http://blog.hcitexpert.com/search/label/IoT%20in%20Healthcare

Author
Dave Brown

Co-Founder at QiiQ Healthcare, designer/engineer – perceptive, meticulous, smart and sensible
leader/entrepreneur – social, tenacious, visionary and realistic

With age, I’ve become a “big picture” guy, but I can and will roll up the sleeves….

I’ve led small and medium-sized user-facing technology projects: starting with strategy, and flowing right down to the detailed tactical level. I get the P&L picture, and am very comfortable driving execution.

Blog Series: #IoT in Healthcare by Srinivas Prasad M.R. @prsdsrnvs


The opportunity in #healthcare IoT is estimated to be $2.5 trillion by 2025. How are we embracing this change?

During the #PhilipsChat, on the 10th April 2017, we asked questions related to the current trends and focus areas that the Healthcare IT Industry, Medical Device Manufacturers, Hospitals and Startups will need to keep in view in the near and short-term while making their organisation ready for the Digital Transformation that can be and will be enabled by #IoT in Healthcare.
A great discussion ensued that has spawned this blog series. Presenting the insights shared by M. R. Srinivas Prasad (@prsdsrnvs) on #IoT in Healthcare #PhilipsChat. (http://en.wikipedia.org/wiki/M._R._Srinivasaprasad)



Q1: In the near term (1-3 years), What are the top 3 innovations in IoT that can benefit healthcare?:
M. R. Srinivas Prasad: In the emerging markets the IOT devices that would play an important role in extending care to the homes and community, would be those that can enable remote monitoring of cardiac patients, COPD patients and pregnancy monitoring in the rural community. These devices could be devices like Connect diagnostic ECG, Low cost but reliable wearables to monitor basic vital signs and breathing patterns and connected intelligent fetal dopplers to help monitor the child during birth helped by midwives

Q2: Is an IoT based system going to be a utility or a service?:
M. R. Srinivas Prasad: This will be a mix of both. It can (also) be an Outcome-based pricing model which is a variant implementation of the Service Model.

Q3. Do you see any device, connected via any protocol and with any cloud; as the future, if yes how will that be achieved? Standards?:
M. R. Srinivas Prasad: Need to adhere to Continua standard for these devices for open connectivity but in the near term I see that cost will prevail over the interoperability standard if regulatory bodies don’t ensure conformance from the start.

Q4: In India (or your country), what are the Digital Infrastructure requirements for enabling IoT based Innovations in Healthcare?:
M. R. Srinivas Prasad: A change in the mindset of going from paper to paperless is needed. Then there is a need to educate hospitals “Software is not free”. In addition, enabling IoT will need reliable telecom networks, work with the ecosystem to set up datacenters. Maturity & innovation around commercial business models will be a need Supporting infrastructure like connected ambulances, trained paramedics & and efficient transportation system will help.

Q5. How can hospitals leverage #IoT based solutions for service delivery and patient care? :
M. R. Srinivas Prasad: Postoperative care can be shifted to the patient’s home. This can help free up beds in the hospital which can help in increase revenue to the hospital from a new patient. Hospital-acquired infections can be reduced and finally, in bringing down the cost of care, the benefit that can be extended to the patient.

Q6: What are the aspects of Connected Care for the Patient Care Continuum?
M. R. Srinivas Prasad: From Philips Healthcare point of view Connected care for the Patient Care Continuum comprises of Healthy Living, Prevention, Diagnosis, Treatment and Homecare. Here’s a video that explains these aspects https://www.youtube.com/watch?v=Xe-KxiiIyNI

Q7. Please share usecases for Connected Care for: Healthy Living, Prevention, Diagnosis, Treatment, Homecare:
M. R. Srinivas Prasad: (elaborated on each of the aspects of Connected Care for the Patient Care Continuum)
#HealthyLiving There are many in the market but it is important to choose the right one like the ones which are accurate e.g. Philips watch. Eating healthy food but tasty from an Indian cuisine context means fried food. Philips air fryer helps air fry tasty healthy food.

#Prevention Breathing Fresh & clean air is important for us to avoid pulmonary complications in countries like ours where pollution levels are high. #Philips Air Purifier helps address this issue

#Diagnosis Early diagnosis is critical to increase survival rate and reduce the cost of treatment. Use of AI in helping clinicians early diagnosis and also managing a larger population base can help solve the India challenges. Either for aiding in detection of infectious diseases like TB or identifying lesions from brain and breast scans.

#Treatment Minimally invasive devices are the key here . Low dose interventional X-ray systems or mobile surgery systems . Radiation planning systems which aid accurate and the right dose planning.

#HomeCare Monitoring of post cardiac patients and COPD patients at home. Philips Home Co business in india extends care into the home. This reduces cost of care and also helps the hospital to manage more new patients. Monitoring compliance to medication is another key aspect when extending care to home.

Q8: What are the Healthcare based Smart City components? How can Local, State and National Government’s make #IoT solutions in healthcare economically viable?:
M. R. Srinivas Prasad: Government should step in with policies that support in “giving the last mile connectivity” to decentralize healthcare (and) help in the convergence of Mobile technology, Consumer engagement and Payment reforms.
Additionally, Population management to understand disease profiling, to understand the spread of infectious diseases like malaria, typhoid etc. Smart ambulances. Garbage clearing monitoring. Air quality monitoring device across the city. Adequate availability of AED ‘s and accessible and connected. These are all related to health care.

Q9. How can private hospitals justify the RoI’s of Smart Hospital Components?
M. R. Srinivas Prasad: Demanding solutions from healthcare companies. Looking at OPEx models where the capex requirement is low. Productivity improvement from workflow efficiencies. Productivity gains or clinicians from using AI and smart tools. Better clinical decisions and patient re-admissions which will be enhance patient stickiness and also enhance the brand which will drive more patients to the hospital.

Q10. Tell us a 5 Year view of IoT in Healthcare and what would a Patient Experience in a Smart Hospital?M. R. Srinivas Prasad: A seamless experience which helps the hospital in its business, helps the clinicians make better decisions, helps patients by reducing their healthcare costs and the insurance providers become more efficient and manage their premiums better. A win win for all. Example from the onset of chest pain to early diagnosis, to emergency care, seamless patient data flow into the hospital EMR’s. Flow or patient context and information right through the various departments in the hospital including radiology, cardiology, critical care and also seamless extension of this care into home or the community post discharge and post operative care on remote care settings. A seamless experience in a distributed care environment

Q11. What areas of IoT based innovations are you looking to partner with Startups for? Can you give us two areas? M. R. Srinivas Prasad: Advanced AI models to aid early diagnosis of chronic diseases – Cardiac, COPD, Oncology and Mother and Child space. Smart IOT devices to support Monitoring of patients under various clinical conditions post discharge. Pregnancy monitoring and post natal care. Solutions in the healthcare informatics space and connect care solutions to help extend care into the community and homes

To one other question from Mr. NS Ramnath (@rmnth): On a scale of 1 to 10, where do you think the sensors in wearables in the market today stand?
M. R. Srinivas Prasad: It’s in a very nascent stage but with a huge potential and key to help solve our healthcare challenges.

Mr. M.R. Srinivas Prasad, signed-off from the chat by urging the participants, “let’s define the future of healthcare for a better India and a better world. Technology is key! Cheers

References

  1. Here is the original Blog Post announcing the #PhilipsChat Tweetchat : http://blog.hcitexpert.com/2017/04/philipschat-on-iot-in-healthcare.html
  2. #IoT and #AI: Potent combo redefining healthcare by M. R Srinivas Prasad @prsdsrnvs on Livemint http://www.livemint.com/Opinion/iuOHAO5UCn1qzH2q5JwJvL/IoT-and-artificial-intelligence-Potent-combO-redefining-hea.html
  3. Curated list of Tweets from the #PhilipsChat: https://twitter.com/i/moments/852242427008233473
  4. Review the #PhilipsChat Transcript & analytics via @symplur here >> http://hcsm.io/2loNiv7
Author
M. R. Srinivas Prasad

CEO, Philips Innovation Campus, India

Blog Series: #IoT in Healthcare by Dr. Vikram @drvikram

The opportunity in #healthcare IoT is estimated to be $2.5 trillion by 2025. How are we embracing this change? The Types of Opportunities that present themselves to the Startups, Healthcare IT and Healthcare organisations are tremendous


During the #PhilipsChat, on the 10th April 2017, we asked the experts what they thought about the current trends and focus areas that the IT Industry, Medical Device Manufacturers, Hospitals and Startups will need to keep in view in the near and short-term while making their organisation ready for the Digital Transformation that can be and will be enabled by #IoT in Healthcare.

A great discussion ensued and that has spawned this blog series. Presenting the insights shared by Dr Vikram Venkateswaran (@drvikram) on #IoT in Healthcare #PhilipsChat.


Q1: In the near term (1-3 years), What are the top 3 innovations in IoT that can benefit healthcare?:
Dr Vikram Venkateswaran:
In my opinion, the immediate benefits are in areas where other industries have made progress: cheaper rates for Sensors, Increased security at device and sensor level. Additionally, an Increased integration of sensors and devices with EMR allowing for proactive interventions and remote monitoring for Chronic diseases.
Another aspect is Managing inventory and tagging assets are key for more hospitals, and i think that is an immediate benefit that will accrue.
To the question of, Do you think India will benefit from cheaper portable diagnostic devices or remote treatment a better stead ? asked by Divye Marwah; I would say, both patients and the hospitals will benefit.
Sukesh Kumar: Do you think #AI will help in taking healthcare to the next level?
Dr Vikram Venkateswaran: Its already happening in certain specialties like Oncology
Q2: Is an IoT based system going to be a utility or a service?
Dr Vikram Venkateswaran: Tricky one but I would say a service, with elements of a utility.

Ms. Manishree Bhattachar (@ManishreeBhatt1), Analyst with NASSCOM, “Do you think EHR implementation is a requisite, to go for a full bloom service+utility models for IoT devices?”

Dr Vikram Venkateswaran: I think so personally, without the full view of patient history, proactive intervention; depends on the care priorities for the Hospital.

Q3. Do you see any device, connected via any protocol and with any cloud; as the future, if yes how will that be achieved? Standards?:

Dr Vikram Venkateswaran: That is one of the biggest challenges today, EMR integration with IoT devices for example Wearables, remote pacemakers, Bionic Limbs, lenses with ability to monitor sugar levels and Blood Pressure.

Q4: In India (or your country), what are the Digital Infrastructure requirements for enabling IoT based Innovations in Healthcare?:

Dr Vikram Venkateswaran: Network connectivity and availability of LE sensors is the key, Most healthcare systems are still on paper records, Patient education is the key as well, massive change in perception is required.

Q5. How can hospitals leverage #IoT based solutions for service delivery and patient care? :
Dr Vikram Venkateswaran: Health Checks, remote health monitoring as a service, pro active intervention as a service

Q6: What are the aspects of Connected Care for the Patient Care Continuum?
Dr Vikram Venkateswaran: Interoperability and adherence of standards, increased communication, Change in perception of patients and hospitals

Q7. Please share usecases for Connected Care for: Healthy Living, Prevention, Diagnosis, Treatment, Homecare:
Dr Vikram Venkateswaran: Remote monitoring of cardiac pacemakers,  monitoring of blood glucose, Sweat analysis for athletes, Sleep monitoring for patients and athletes

Q8: What are the Healthcare based Smart City components? How can Local, State and National Government’s make #IoT solutions in healthcare economically viable?:
Dr Vikram Venkateswaran: Disease Surveillance, Leveraging weather data to predict disease patterns, Population health management

Q9: How can private hospitals justify the RoI’s of Smart Hospital Components? :
Dr Vikram Venkateswaran: Hospitals can prioritise understanding disease patterns

Q10: Give us a Buzzword we are going to be hearing regarding IoT based innovations in Healthcare.:
Dr Vikram Venkateswaran: Smart Care, Home Healthcare, Remote Health Monitoring, Home Health, Connected care, Connected Health

Q11. Tell us a 5 Year view of IoT in Healthcare and what would a Patient Experience in a Smart Hospital?:
Dr Vikram Venkateswaran: Hospitals to focus on critical care, emergencies and palliative care. Regular check ups and follow ups to be conducted leveraging IoT

Q12. Finally: What areas of IoT based innovations are you looking to partner with Startups for? Can you give us two areas?:
Dr Vikram Venkateswaran: Disease Surveillance, Home Healthcare

References

  1. Here is the original Blog Post announcing the #PhilipsChat Tweetchat : http://blog.hcitexpert.com/2017/04/philipschat-on-iot-in-healthcare.html
  2. #IoT and #AI: Potent combo redefining healthcare by M. R Srinivas Prasad @prsdsrnvs on Livemint http://www.livemint.com/Opinion/iuOHAO5UCn1qzH2q5JwJvL/IoT-and-artificial-intelligence-Potent-combO-redefining-hea.html
  3. Join the #Philipschat on Twitter #IoT in #Healthcare on Monday 10th April 2017, 3 PM – Health Care in India http://healthcare-in-india.net/healthcare-technology/join-the-philipschat-on-twitter-iot-in-healthcare-on-monday-10th-april-2017-3-pm/
  4. Curated list of Tweets from the #PhilipsChat: https://twitter.com/i/moments/852242427008233473
  5. Review the #PhilipsChat Transcript & analytics via @symplur here >> http://hcsm.io/2loNiv7
  6. #IoT & #AI – A potent combination redefining healthcare event by @PhilipsBlore moderated by @drvikram https://youtu.be/6cpeICKV9Fw

Stay tuned to the #IoT in Healthcare Blog Series Bookmark this link to follow on the insights being shared by the experts on the HCITExpert Blog:


Team @HCITExperts [Updated: 29th May 2016]
Author

[tab]
[content title=”About Dr. Vikram Venkateswaran”]

Dr. Vikram Venkateswaran

Dr Vikram Venkateswaran is a healthcare thought leader who writes and speaks about the emerging healthcare models in India and the role technology plays in them.
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#PhilipsChat on #IoT in Healthcare with @prsdsrnvs and @drvikram

87% of healthcare organizations will have adopted Internet of Things technology


Internet of Things (IoT) in Healthcare, or Internet of Medical Things (IoMT) are seeing an increasing adoption rate in Healthcare Organisations. In a recent study the following statistics were part of the report: [1]

1. 60% of healthcare organizations have already introduced IoT into their infrastructure 

2. In just two years, 87% of healthcare organizations will have adopted Internet of Things technology.

3. The most common area where IoT is being utilized is for patient monitoring and maintenance. 73% of surveyed healthcare executives said they used IoT in this area, while 42% said this was the main use for IoT

4. 64% of respondents said they use IoT for patient monitors, 56% use IoT for energy meters, and 33% use IoT for imaging devices.

5. 80% of healthcare executives said IoT has improved innovation

6. 76% said visibility across their organization has improved, while 73% said they have enjoyed cost savings following the introduction of IoT.

7. 57% of respondents believe workflow productivity will improve as a result of the adoption of IoT, resulting in considerable cost savings

8. 36% believe IoT will create new business models, while 27% said the use of IoT technology would improve collaboration with colleagues and patients.


And here is an #Infographic: IoT in Healthcare: Types of Opportunities, I think it will be apt to share the same with you at this time to review the market opportunity. 

The study however also highlighted the disadvantages to introducing IoT. Such as security risks, with healthcare organisations facing many cases of breaches in the past year. 


The report pointed out, 89% of healthcare organizations that have adopted IoT said they have suffered a security breach as a result, while 49% said malware was an issue.

Coming to the Tweetchat!! I am honored to be considered for hosting the tweetchat with Mr. Srinivas Prasad, CEO, Philips Innovation Campus, in India and Dr. Vikram, Founder and Editor of Healthcare India.



Mr. Srinivas Prasad (@prsdsrnvs), has over 3 decades of experience with various Technology companies. Prior to his current assignment, Prasad was Vice President-IT at FMR India, a leading US Multinational in Bangalore. He has also established and served as General Manager for the Software Architecture Division of Sony in India.

Earlier in his career Prasad worked for Alcatel Business Systems in France and Indian Telephone Industries in various capacities, leading teams in developing telecom products for the Indian and Global markets. Before his current role as CEO-PIC, he headed the Healthcare division at PIC as Sr. Director.

Prasad has an outstanding academic record and holds a Bachelor of Engineering degree in Electronics and Communication and a Masters in Business Administration.

Having a unique distinction of being a Hindu Hitachi Scholar, he has published papers at the Telecom IEEE conferences. Prasad has worked in Japan and France earlier in his career. He has been part of several national committees in India including the CII taskforce to drive Broadband adoption in India.

An ardent cricket enthusiast he has played for Karnataka state, South Zone and represented the Country earlier in his career. Read more about Prasad and his achievements at http://en.wikipedia.org/wiki/M._R._Srinivasaprasad.


Dr. Vikram Venkateswaran
(@drvikram)
Dr. Vikram Venkateswaran is a healthcare management thinker, speaker and author. He is also the founding editor of Healthcare India. He started his career as a dental surgeon running a chain of dental clinics in New Delhi. He has an MBA from IMT Ghaziabad and has worked with healthcare systems in India, US and Europe.

On April 10th, 2017 between 3 – 4pm IST, I would like to welcome all experts to share their thoughts and insights with Mr. Srinivas Prasad and Dr. Vikram  on how to leverage IoT in Healthcare.

Agenda for #PhilipsChat : #IoT for Healthcare

Q1: In the near term (1-3 years), What are the top 3 innovations in IoT that can benefit healthcare?

Q2: Is an IoT based system going to be a utility or a service?

Q3. Do you see any device, connected via any protocol and with any cloud as the future, if yes how will that be achieved? Standards?

Q4: In India, what are the Digital Infrastructure requirements for enabling IoT based Innovations in Healthcare? 

Q5. How can hospitals leverage IoT based solutions for service delivery and patient care? 

Q6: What are the aspects of Connected Care for the Patient Care Continuum (tell us about one solution each that can benefit consumers)

> Healthy Living
> Prevention
> Diagnosis
> Treatment
> Homecare


Q7: What are the Healthcare based Smart City components? How can Local, State and Indian Government’s make IoT solutions in healthcare economically viable?

Q8: How can private hospitals justify the RoI’s of Smart Hospital Components? 

Q9: Give us a Buzzword we are going to be hearing regarding IoT based innovations in Healthcare.

CT: (Closing Thoughts) Tell us a 5 Year view of IoT in Healthcare and what would a Patient Experience in a Smart Hospital?

Signoff: And everyone’s favourite question of the Tweetchat, What areas of IoT based innovations are you looking to partner with Startups for? Can you give us two areas?

To participate, just log onto your twitter account on mobile, web or tablet on 10th April Between 3-4pm, as mentioned earlier and tweet with the hashtag: #PhilipsChat 

Transcript of the #PhilipsChat

References

  1. 87pc Healthcare Organisations to Adopt Internet of Things Technology by 2019
  1. #Infographic: IoT in Healthcare, Types of Opportunities http://blog.hcitexpert.com/2016/05/infographic-iot-in-healthcare-opportunities.html
  2. The Current Status of 8 Future Technologies on Healthcare by @msharmas http://blog.hcitexpert.com/2016/09/the-current-status-of-8-future-technologies.html


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Understanding the Medical Diagnosis processes, to build an AI based solution by @msharmas


Human Intelligence

is The ability to adapt one’s behavior to fit new circumstances.

In Psychology, human intelligence is not regarded as a single ability or cognitive process but rather as an “array” of separate components. Research in building AI systems has focused on the following components of intelligence: [1]

  • learning,
  • reasoning,
  • problem-solving,
  • perception, and
  • Language-understanding

These components of human intelligence are also utilized during diagnosing a patient and defining the treatment plan and protocol for the patient.


The process of Medical Diagnosis


The process of how a Doctor goes about her diagnoses of a patient, is the ability of a Doctor to adapt to varying presenting illnesses of her patients.

  • Identify the Chief complaint of a patient
  • Gather information about the history of present illness
  • List the possible diagnosis & record the differential diagnosis for a patient
  • And then perform relevant diagnostic tests to determine the most likely causes for the presenting complaints

The Doctor initiates the process of identifying the most likely cause of the patient’s presenting illness and then based on the results of the diagnostic tests, proceeds to confirm a diagnosis and then proceed towards defining a treatment plan for enabling the patient to recover from the disease.
 

In the above simple process defined for a medical diagnosis, the Doctor (based on her training) makes use of all the “components of intelligence” to arrive at the most likely treatment plan for a patient. The process obviously gets more involved and complex depending on the type and nature of diagnosis.

Medical Diagnosis or Medical Algorithms?


From the above “very simple example” it’s clear that the doctor uses her learning and reasoning to proceed towards the best possible treatment pathway for the patient. And this can be treated as a series of Questions that help the doctor arrive at the “confirmed diagnosis” for the patient.
 

The process of Medical Diagnosis can then be treated as an Algorithm that helps the doctor arrive at a conclusion based on the presented facts.
 

Dictionary defines an “Algorithm” as, a process or set of rules to be followed in calculations or other problem-solving operations
 

The doctor in the above scenario has being processing via a set of rules and calculations and problem-solving operations to arrive at the confirmed diagnosis.
 

The doctor goes through a perception analysis to determine what specifically is presented based on the patient’s illness and then determines based on, not only the diagnostic test results, but also based on other parameters of a patient’s active and confirmed diagnosis.
 

Medical Diagnosis work in clinical practice generally has four models: [4]

  • Pattern Recognition, wherein the doctor recognizes the current patient’s problem based on her past experiences with other patients, e.g., Down’s syndrome.
  • Hypothetico-deductive, wherein the doctor performs a certain battery of tests to test a hypothesis, a tentative diagnosis
  • the Algorithm Strategy: the algorithm strategy has been used in Healthcare and has been represented using Medical Logic Modules [5], Arden Syntax for Medical Logic Systems [6] and Clinical Pathways [7] and finally the
  • Complete History Strategy has been defined to be the identification of Diagnosis by possibility. Evidence based medicine is then used to come to a conclusion of the final diagnosis. [8]

The training process to arrive at a Medical Diagnosis has been used in the past to the development of expert systems or Clinical Decision Support Systems (CDSS). Early medical AI systems have tried to replicate the clinical training of a doctor into meaningful implementations of AI in healthcare.

Usecase for Artificial Intelligence in Healthcare


Understanding the process and workflow in healthcare is going to be important in implementing solutions that are “aware” and intelligent. And the systems that need to be developed for Healthcare need to be able to assist the clinicians with systems that are more close to the clinicians natural daily workflow.


Consider the current scenario of a physician meeting with a patient in a clinic setting, with the current systems in place the “Patient Visit” workflow generally involves the doctor having to divide her time between talking to the patient, examining the patient and recording the findings on an EHR (electronic health records) system. Most such visits can last from 5 minutes to an hour depending on the specialty (for instance, general medicine to mental health). Additional complexity is added to the workflow based on the patient diagnosis.
 

There have been many studies that have recorded the doctor’s reasons for resistance to enter the visit data into a system [9]. A time and motion study of a patient – doctor interaction can be revealing in an EHR vs a non-EHR setting. While EHRs have shown their ability to reduce potential errors (as has been well documented in the report, to err is human) the additional steps of transcribing the visit data into an EHR is generally seen by the doctors as being a disruption in their natural visit or encounter workflow.
 

On the other hand, take into consideration a study of the workflow of a pathology department such as biochemistry or hematology, where the technology implementation is relatively easily accomplished. The pathology departments main “Entity”(from a systems perspective) to be processed is the patient sample and the level of automation required to process the various tests that need to be performed on the sample is quite well defined by its degrees of freedom, the test ordered by the doctor. Similarly the entity in a radiology department is the image that is the outcome of a radiology exam.
 

In radiology department for instance, an AI-based solution can enable operations at scale for enabling reading of radiology images from rural areas, where in the images get uploaded by the medical assistant or radiographer at the remote location. The AI systems now have the ability to read and report the images with increasing accuracy, but we still have some way to go before we achieve a greater deal of accuracy.
 

On the other hand, the “Entity” in a patient doctor interaction in a visit, the patient, has many more touch points within the patient care continuum and the level of complexity of this interaction needs to be dealt with in a completely different approach. While the processing in a pathology or radiology department is based on the sample or an exam, which is a snapshot at particular point in time, the treatment of a patient constantly needs to be monitored and presents more data points on an ongoing basis.
 

An AI-based solution to help a physician therefore needs to be applying for instance, the four models of medical diagnosis to a patient visit before we can call a patient visit as an intelligent or aware encounter.
 

If a doctor divides her time between listening to the patient regarding her present illness, and simultaneously recording the information on a computer system, there has been a disruption in the doctor’s natural workflow of focusing on the patient, of listening to her present illness, asking questions about onset, etc. and reviewing the results of the investigations and radiology reports. The doctor is trained to handle all these data points and process the information from the perspective of the four aspects of the medical diagnosis training of the physicians.




Here is an interesting story you would like to review showcasing a doctors 35-hr shift in Delhi, India. By the way the story lends itself to creating some really interesting “Intelligent Digital Assistants” for the doctors.   It also presents to experts developing AI based solutions for Healthcare, a fantastic time and motion study of a Doctors’ shift and the touch points to where the technology can be integrated into the Doctors “workflow”
  
Current systems do not allow that, they tend to focus on implementing a strategy of recording by exception, by recording only the exceptions and all the other aspects being marked as normal, for instance. While such aspects have been proposed and devised by working with the physicians, still they are workarounds to do what the technology of today allows or allowed in the past. 

These are re-creations of paper based systems that have been translated to an electronic health recording system.
 

The Patient – Physician interaction needs to be revamped, in the current information technology systems by enabling the various components of human intelligence we have highlighted earlier:

  • learning,
  • reasoning,
  • problem-solving,
  • perception, and
  • Language-understanding

Ideal scenario for a Patient – Physician interaction would be the implementation of a solution that “records” all of the conversation during a visit and automatically creates the Visit note, by understanding the Chief complaint, presenting illness, history of the patient, procedures ordered, medications prescribed, follow-ups or referrals ordered, et al. Purely based on the conversations between the doctor and the patient.
 

Such a scenario requires the implementation and collaboration between various components of the Artificial Intelligent ecosystem. And that will be the true and useful implementation of AI for the Patient and Physician interaction, enabled by Artificial General Intelligence capabilities.
 

The change needs to be implemented by not only incorporating the changes to the core algorithms, but it also involves incorporating changes to the UI and UX design changes. AI based solutions will force a change in the way current systems have been designed.

Its important to explain the way the physician thinks while interacting with the patient. 

It’s been of late seen technology solutions to be hindering the doctor patient visit process. And hence it my endeavor to try to present the case that AI while hyped to be replacing doctors, is not yet ready for the prime time. There are areas of immense potential, radiology image processing for instance but then that’s from a process improvement perspective. And not doctor patient interaction perspective. 

For years now, technology in healthcare has been trying to take the paperless approach and has tried to “replace” paper while forgetting that there is a more important component of enabling workflow in the Patient Care Continuum. 

And it’s because of this reason, I argue that whilst it’s great for the technology hype cycle to see AI as the deliverer, we need to remind ourselves once again, that it’s not about going paperless, but ensuring the 15 min that a patient gets of the doctor’s time, are well spent with the conversation being patient focused and the technology receding to the background and generating the relevant care records.

In other areas of healthcare too it is about process improvement.

And add to that the fact that in most implementations in healthcare, clinical documentation is either cumbersome or non existent, the hype cycle of AI needs to consider these issues. From my understanding since the underlying data is fragmented, not standardized and not interoperable in majority of the instances; I took a shorter term view of the AI implementation in the systems in this article.

Current Status of Artificial Intelligence in Healthcare

There has been data explosion in Healthcare not only from the perspective of the patient care continuum, but also from the point of view of the resource management and scheduling, inventory and purchase management, insurance, financial management, etc.
 

While most of the current focus has been on building AI-based solutions that are in the patient care continuum, there are definitely many more areas within a healthcare organization that will benefit from the implementation of intelligent systems.
 

Just the other day, I attended a conference around AI and the panelists were mentioning the following uses of AI

  • ecommerce recommendations
  • learning for students based on concepts in school
  • autonomous cars
  • AI based treatments plans for cancer patients
  • intelligent assistants, chatbots
  • Teaching computers to see; etc.

And while they all highlighted areas of advancement in AI tech, they are yet to reach the ability to currently create a system that converts a doctor patient conversation to actionable events that can spawn workflows that needs to be instantiated based on the ever changing patient condition.

In the near-term, I see there will be specialized implementations of AI that will enable the brute power of technology to present the best case scenario for a particular patient condition, but an AI Physician is still a work in progress. This has been shown to be a success with the advent of cancer care solutions using IBM Watson. 

The AI systems are being implemented in various scenarios in healthcare and you could consider them to being “trained” and being presented with a great amount of data and studies. As more data is presented to these AI systems, their level of accuracy will only improve and provide benefits in-terms of scale and reach thereby reducing the time to diagnosis and time to treatment for patients having affordability and accessibility issues in healthcare.

Artificial Intelligence has already started making its way into healthcare, with 90+ AI startups getting funding to deliver solutions like;
  • helping the oncologist define the best treatment plan specific to each patient
  • a virtual nursing assistants, to follow-up with patients post discharge
  • drug discovery platforms, for new therapies
  • Medical Imaging and diagnostics
  • The use of AI in diagnosing diseases, patient education and reducing hospital costs
  • You can also find a great discussion on machine learning, wherein how machine learning could replace/ augment doctors via the health standards podcast with Fred Trotter.

Some of the other areas where AI is being implemented in Healthcare. Microsoft, Apple, IBM and other major players are all looking to AI help in curing people. And they are forming a group that creates the standard of ethics for the development of AI.

AI in healthcare also has a potential to be leveraged to be implemented in the following aspects of Healthcare Industry: 

  • Billing and Insurance Workflow, Insurance reconciliations and provider workflows can be enhanced by enabling total automation of the processes by enabling handling of the insurance claims by AI based Insurance agents. The exceptions and outliers can be escalated for manual interventions and closures.
  • Improving customer experience in healthcare by providing a 360 degree engagement, the SMAC based solutions will use the power of integrating the data streams from multiple sources to help deliver a better service to the patients.
  • Inventory and Supply chain processes can benefit from AI driven optimization by incorporating e-commerce driven innovations that allow for a democratization of product to vendor mix by searching and delivering the best cost options to the procurement department. Thereby bringing the costs down. Logistics improvements delivered in other industries need to come to healthcare to allow for the reduction in the cost of procurement of drugs, devices and durables. AI will help organizations in identifying variable costs and help them understand how to handle scenarios that will present themselves in an ongoing basis.
  • AI enabled resource management and scheduling will allow for identifying areas that need to be staffed with more resources and when additional resources need to be hired to meet with the increasing demands or provide elastic resource management based on ever changing operational demands. Booking appointments with doctors, will become a job taken up by Bots or AI assistants, enabling the nursing and administrative staff to focus more on delivering care and enhanced service experience for the patients.
  • AI-based people management systems will help hospitals in recruitment, retention and performance management of their employees. By presenting an analytics driven approach to people management, systems will be able to help employees to be trained to take up newer roles and responsibilities.

So by when will AI really take over Doctors?
 
It’s clear from the image above, that estimates of how much processing power is needed to emulate a human brain at various levels (from Ray Kurzweil, and Anders Sandberg and Nick Bostrom), “along with the fastest supercomputer from TOP500 mapped by year. Note the logarithmic scale and exponential trendline, which assumes the computational capacity doubles every 1.1 years” [10]. Kurzweil believes that mind uploading will be possible at neural simulation, while the Sandberg, Bostrom report is less certain about where consciousness arises

Based on the above point of view, an interesting question to ask today:
If a Doctor goes through 7+ years of training to become a specialist, how many days will it take for an AI based Physician?

The answer perhaps lies in the following statements

Chief scientist and AI guru Andrew Ng of Chinese search giant Baidu Inc. once put it, “worrying about takeover by some kind of intelligent, autonomous, evil AI is about as rational as worrying about overpopulation on Mars.” [11], [12].

And,

What is it that makes us human? It’s not something that you can program. You can’t put it into a chip. It’s’ the strength of the human heart. The difference between us and machines.
– Terminator Salvation, 2009

References
[1]: AlanTuring.net What is AI?
[3]: Improving Diagnosis in Health Care | The National Academies Press https://www.nap.edu/catalog/21794/improving-diagnosis-in-health-care
[4]: The diagnostic process in general practice: has it a two-phase structure? http://fampra.oxfordjournals.org/content/18/3/243.full
[5]: Managing Medical Logic Modules.
[6]: HL7 Standards Product Brief – Arden Syntax v2.9 (Health Level Seven Arden Syntax for Medical Logic Systems, Version 2.9) http://www.hl7.org/implement/standards/product_brief.cfm?product_id=290
[7]: Clinical Pathways via Open Clinical, knowledge management for medical care http://www.openclinical.org/clinicalpathways.html
[8]: Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology. Boston: Little, Brown and Co., 1991; 3–18.
[9]: Barriers for Adopting Electronic Health Records (EHRs) by Physicians https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3766548/
[10]: Artificial General Intelligence,
[11]: AI guru Ng: Fearing a rise of killer robots is like worrying about overpopulation on Mars
[12]: The Artificially Intelligent Doctor Will Hear You Now
[13]: Why we are still light years away from full artificial intelligence | https://techcrunch.com/2016/12/14/why-we-are-still-light-years-away-from-full-artificial-intelligence/
[14]: AI In Healthcare Heatmap: From Diagnostics To Drug Discovery Startups, The Category Heats Up

[15]: Doctor’s 35-hr shift on 8 bananas, a toilet in nearby cafe
http://indianexpress.com/article/india/india-others/doctors-35-hr-shift-on-8-bananas-a-toilet-in-nearby-cafe/ 
[16]: Gigerenzer’s simple rules by NS Ramnath on Founding Fuel 
http://www.foundingfuel.com/article/gigerenzers-simple-rules/
[17]: A.I. VERSUS M.D: What happens when diagnosis is automated? By Siddhartha Mukherjee
http://www.newyorker.com/magazine/2017/04/03/ai-versus-md

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Unintended consequences of new technologies in healthcare – thoughts on #blockchains pt 2 by Dr. Senthil N @nacsen


In part one of this blog I discussed blockchains and how they could be used in health care in an ideal world. 

In the real world however, block chain use poses many challenges. The challenges range from security to accessibility perspectives, some of which are unique to health care. In a healthcare blockchain, each unique identifier is a human being, not a piece of cryptocurrency. So, anyone with access to a blockchain can see how many transactions a patient has had and their timestamps, then extrapolate how healthy or sick a person has been. 

The timestamps as well as the names and inferred locations of hospitals and doctors who are granted access expose some amount of personal information about the age of a person, what provider he/she has seen and when, and possible diagnoses, location or travel patterns. So, it becomes critical to control access to the blockchain itself, not just the records that the blockchain entries point to.

It would be naïve to assume that all patients can manage authorizations to their blockchain if they have a mobile application, considering we have been struggling with patient education and patient compliance for years in the real world. 

Many patients struggle to understand their health conditions and to comply with treatments or preventive interventions, let alone being able to afford and use a mobile device effectively. I can see that mobile devices with simple screens can ask a patient whether they want to allow “Dr. X at hospital Y to access their medical record,” but the questions become complex if the access is for specific documents or specific purposes for specific periods of time. Furthermore, if the data access is for research, the authorization questions become even more complicated.

It is just as complex to help users revoke complex access patterns. When mobile phones figure out how to provide an easy mechanism to grant or revoke specific hardware or data access permissions to the umpteen number of apps in a usable manner, I would think it is possible to do so with blockchain access control.

Another challenge for patient privacy is to define a way to protect sensitive data categories (HIV, mental health or substance abuse records, for example). We need a way to protect the blockchain entries for these categories through effective use of authorization records in the blockchain. 

Authorization records will need to specify the authorized individual at applicable document and accessing healthcare provider levels rather than allowing access to the patient’s entire blockchain and accessing healthcare organization levels. The blockchain entries need to have sufficient metadata to describe sensitive data categories and the blockchain service needs to return appropriate responses when there are redacted sensitive data categories to which a provider is not allowed access.

Currently, some of the challenges in creating a longitudinal, interoperable medical record are the unique identification of patients across multiple systems and merging duplicate identifiers reliably in Enterprise Master Person Index (EMPI) systems. This becomes even more challenging with blockchains because we would require patients to provide their blockchain identifier rather than their name, date of birth, driver license or social security number. 

We would need to find each patient’s blockchain identifier to avoid creating multiple blockchains for a single patient, and we need the ability to merge or unmerge blockchains to reconcile cases where a patient ends up having multiple blockchains or when the blockchains of different patients are erroneously merged. Such capabilities are required before the technology can be adopted in health care.

Additionally, we need to consider the ramifications of a security breach and develop measures to reduce the risk or mitigate the consequences. Due to the replicated nature of blockchains, the blockchain services will potentially have blockchain entries of individuals from all over the country or the world. There are both pros and cons to allowing or disallowing global replication of blockchain entries. 

Ideally, the blockchain service should not have any personally identifiable information (PII) in order to reduce the risk of this information being compromised in a breach. Not having PII would mean that one cannot search the blockchain using a patient’s PII. So, a patient’s blockchain would need to be replicated to all trusted blockchain services so that the patient’s entire medical record can be reconstructed without knowing any PII. 

Now, if methods to identify patients become available in the future, we cannot limit the exposure of past entries that are already added to a patient’s blockchain and could get replicated globally. There is no way to guarantee the security of all the distributed blockchain services, and one breach would mean that the blockchain entries of all patients are out in the open. 

The authorization entries in the blockchain would be invalid. This would place undue burden of security on the off-blockchain medical record stores. They may have to resort to measures such as one-time passwords (single use keys) that the patient gives to the provider to further authenticate the access request, or we may need a separate trust relationship system that is outside the blockchain.

Modern medicine is “modern” due to the adoption of new technologies, while it remains “medicine” due to the almost fanatical devotion to the guiding principles of ‘primum non nocere’ and the scientific method. As practitioners and supporters of modern medicine, it behooves each of us to think through all the unintended consequences that are unique to health care, as well as applicable to other domains while we create new breakthroughs to make medicine even more modern.

The article was first published by the author on the 3M HIS Inside Angle – Blog, the article is being republished here with permission.
Author
Senthil K. Nachimuthu, MD, PhD,

a Medical Informaticist with 3M Health Information Systems’ Healthcare Data Dictionary (HDD) team at 3M Health Information Systems, Inc. He is a medical informaticist and a physician by training, and he leads the research and design of HDD Access and other clinical terminology products of 3M HIS. He is also an avid user and contributor to various open source projects, and has served as the Chair of the AMIA Open Source Working Group in the past. He also contributes to the development of various standards such as HL7 Common Terminology Services version 2 (CTS2) and SNOMED CT. In addition to clinical terminologies and ontologies, his research interests include in clinical decision support, epidemiology, data mining, machine learning and patient safety.

Unintended consequences of new technologies in healthcare – thoughts on #blockchains, Part 1 by Dr. Senthil @nacsen


Many of you might have read the recent findings by researchers Isao Echizen et al. from the National Institute of Informatics (NII) of Japan that it is possible to copy one’s fingerprints from pictures taken from up to 10 feet from the subject who was holding a peace sign, given proper lighting and focus. As cameras with more than 20 megapixel resolution become commonplace, many daylight photographs would meet this criteria. It is not farfetched to imagine that one could copy iris patterns from portrait photographs just as easily. For the majority of the world population with darker eye colors, their iris patterns would not be clearly visible in the visible light wavelength, which is why iris scanners use near-infrared wavelengths. 


However, it is easy to see that the improvements in ubiquitous high resolution photography make two technologies obsolete at once. Suddenly, copying fingerprints and iris patterns isn’t just the running gag of the “Mission Impossible” movies anymore, since there is not much we can do to retract publicly available images of one’s fingerprints and irises. The most that can be done is to use fingerprint and iris recognition technologies for convenience rather than security. The fingerprint and iris patterns would reduce the search space, but we will still need to authenticate the individual in a different way. We cannot have the fingerprint and fingerprick blood analyzer machines such as the ones in the “Gattaca” movie all over the place, so we have to use other non-invasive multifactor authentication technologies

This made me think about unintended consequences of new technologies in health care, and how those consequences could affect health care. One of the new technologies that has been popular in the medical informatics literature recently is the use of blockchains (like the ones used in bitcoin).

A blockchain is a log of all transactions that sequentially link what happened to a specific piece of digital currency. The blockchain is transparent and is replicated to multiple servers almost immediately. So, when you use a digital cryptocurrency such as bitcoin, one could verify if you are the rightful owner of that piece of currency by checking its blockchain, and maintain the log by adding the new transaction to the blockchain service.

There have been many articles recently in medical informatics/healthcare IT literature that describe how blockchains can be used to both compile a patient’s longitudinal medical record as well as manage authorization to a person’s medical record. Many of them seem to cite the article “Decentralizing Privacy: Using Blockchain to Protect Personal Data” (PDF link) by MIT researchers Zyskind et al., which describes how blockchains can be used to have data stored in decentralized stores (think hospital EMR systems), while using a blockchain service to link them all and control authorization (think health information networks).

Various articles describe how the blockchain will contain records for all data and authorization transactions for a patient’s medical record. Every time a new document is created for a patient, whether by a clinician, laboratory, pharmacy, billing system or  wearable medical device, a new record is added to that patient’s blockchain, which contains a pointer to an off-blockchain location where that record is stored, such as a specific document identifier in a hospital’s electronic medical record.

Each patient owns their blockchain, and grants or revokes access to those who can add new records to their blockchain or who can read the documents referred to by the blockchain. These data are stored in the blockchain itself as authorization records. It is easy to see that a patient could also say who can query their blockchain itself. Healthcare providers with the proper authorization can access a patient’s blockchain or add new transactions to it.

As with standard practice in medicine, I can see that healthcare providers without authorization can “break glass” during a medical emergency to treat a patient. In addition to providers, wearable electronic devices can also add transactions to a user’s blockchain to track data from their biosensors. Patients can use mobile applications or rely on a healthcare provider to grant and revoke access to their blockchain. 

Technologies like FHIR can come in very handy since every document referred to by the blockchain entries can be a FHIR resource, and the FHIR resource directory for a patient can be integrated with a blockchain service to get a distributed medical record that provides the benefits of both FHIR and blockchain technologies.

While this sounds like a great application in the ideal scenario, it is not without its challenges. Look for part two of my blog where I will discuss the challenges of implementing blockchains in health care.

The article was first published by the author on the 3M HIS Inside Angle – Blog, the article is being republished here with permission.
Author
Senthil K. Nachimuthu, MD, PhD,

a Medical Informaticist with 3M Health Information Systems’ Healthcare Data Dictionary (HDD) team at 3M Health Information Systems, Inc. He is a medical informaticist and a physician by training, and he leads the research and design of HDD Access and other clinical terminology products of 3M HIS. He is also an avid user and contributor to various open source projects, and has served as the Chair of the AMIA Open Source Working Group in the past. He also contributes to the development of various standards such as HL7 Common Terminology Services version 2 (CTS2) and SNOMED CT. In addition to clinical terminologies and ontologies, his research interests include in clinical decision support, epidemiology, data mining, machine learning and patient safety.