Symposium Value Based Health Care

Universitätsspital Basel
September 20th 2018

Basel Symposium

Picture taken during the symposium showing Prof. Matthias Rose explaining the timeline of patient’s questionnaires and follow-up.

Under the lead of Prof. Christoph A. Meier, the first national symposium on value-based healthcare took place at the Basel University Hospital. Gathering several speakers, it allowed us to have a deep dive into Value-based healthcare and its implementation in the hospital setting.
We know today that the healthcare system doesn’t work properly in terms of quality and prices. It needs to switch from volume to value not only from a mindset perspective but also from a payment standpoint.
Beside initiatives like Smartermedicine and Lean, Value-based healthcare is necessary today to make our healthcare system more sustainable.

Keynote – Value-based health care

Dr Jens Deerberg-Wittram

Taking the Dunning-Kruger effect showing the link between incompetence and self-confidence, he showed how we could potentially explain significant mortality rate differences between hospitals in Switzerland (and everywhere else in the world). When you are inexperienced, you tend to be self-confident. The more experience you are getting, the more you are losing confidence to get it back after some time.

Dunning-Kruger is linked to 3 elements:
– People underestimate risk and complexity
– People overestimate their ability
– People never reach out for help
It is linked to quality problems and outcome issues in the hospital setting.

The other problem is how much money we spend to achieve those poor outcomes. Healthcare costs currently grow faster than the GDP. That deviation puts the question of the sustainability of the system at the center. None of the solutions we tried seem to work: more competition (US) or public centralization (Sweden) lead both to increased costs. In a nutshell, the financial challenges in healthcare cannot be solved by a political solution.

Michael Porter, in his book Redefining healthcare shows that value has 2 components: 1/ health outcomes that matter to patients and 2/ cost to deliver the outcomes.
Outcome measurement the first step towards value-based healthcare. In order to do so, healthcare organizations should start to measure quality and reduce variation in patient outcomes. Then the standardization of the outcome metrics will enable comparisons across and within health systems. Public reporting and transparency will support the continuous improvement of the system, especially if reimbursement is closely linked to the patient outcomes.

Outcomes measurements should also be uniformly and internationally defined. ICHOM provides standard sets for outcomes measurements by therapeutics area / disease. With already 23 standard sets developed covering 50% of the global disease burden, ICHOM is also working on having adult and pediatric sets for multi-morbid patients (preventing them from receiving questionnaires for each pathology they have).
Financial incentives to improve value could be implemented through several models: bundle payment, complication guarantee, result-dependent payment.
Bundle payments are the most appropriate model to finance care. In Sweden, the money the hospital gets will depend on the pain the patient is feeling 6 months after the surgery. 40% of the revenue could be tied to patient reported outcomes. Risk-sharing agreement are also part of the landscape.

What to do to implement Value-based healthcare?
– Organize integrated practice units. Organized by disease
– Measure outcomes and costs for every patient
– Move to value-based reimbursement model
– Integrate care delivery between separate facilities
– Expand excellent services geographically
– Build enabling IT platform

The Economy of VBHC for the Payers

Prof Thomas Szucs, Helsana

It is important to be more fact-based and not anymore policy-based. Value-based healthcare is an evolutionary process.
It could start by using data that we already have. Helsana did a study to evaluate performance indicators for chronic disease in alternative insurance models. They saw differences and were willing to understand the underlying reasons of those variations? In diabetes and cardiovascular disease, they could see statistically significant difference in the reduction of hospitalization by 13 and 8%, respectively. But it was not the case for asthma.

Pharmaceuticals are an innovation that could prevent expensive hospitalization in asthma, for example. However, where does value come in? In an efficient, market price is regulated through supply and demand but healthcare is not a normal market (beneficiaries do not pay or decide; there is information asymmetry and a need to build capacity to protect from potential economic downside).

What makes a product “valuable”?
– Unmet clinical need of high priority
– Meaningful clinical difference
– Clinical and other evidence that cannot easily be ignored or discredited
– Manageable budget impact
– Acceptable cost-benefit ratio

You need clinically meaningful differences to determine the extent of innovation. But very often price does not reflect value as there are price regulations, price referencing schemes and health technology assessments.

Values are benefits over price. Values are not static over time.

Pricing situation today lacks transparence. Current margin structure creates false incentives (low generic quota, high generic prices, slow adoption of biosimilars).
In Value-based pricing, the vision is to minimize the risk of inappropriate pricing. We need real world data. For example, Entresto real world evidence data showed beneficial impact on quality of life. Appropriate does not mean neither affordable nor accurate unfortunately.

For more:
Responsible pricing in value-based assessment of cancer drugs: real-world data are an inevitable addition to select meaningful new cancer treatments, W. van Harten, eCancerMedicalScience, 2017.
The enigma of value: in search of affordable and accessible health care, T. Szucs & al., European Journal of Health Economics, 2017,

Implementation of ICHOM at the USB

Prof Marcel Jakob, Prof Walter Weber

The real case of the implementation of ICHOM at the Basel University Hospital in two areas:

Breast surgery
The goal was really to improve the quality of life and aesthetic outcomes for breast surgery.
ICHOM was chosen because of the standards defined by the team. Using the best tools and the most appropriate questionnaires as well as KPI (oncoplastic breast conservative surgery) allows doctors to have the most useful and actionable feedback from patients. Patient reported outcomes should be measured in everyday standard clinical practice.
ICHOM allows patient reported outcomes measures (PROM) to be benchmarked among institutions. PROM are also discussed with the patient to refine further treatment and refer her to the appropriate specialist.
Implementation phase was supported by intensive collaboration between chief medical office and clinicians. It follows the clear path of Plan-Do-Check-Act in 6 steps:
– Initial discussion
– Kick off with the team
– Realization
– Reviews, attend consultation hours
– Adaptations on the process
– Evaluation, key learnings and handover to the clinic
1 year later: 97% of patients are included in ICHOM. It is widely accepted by patients (close to 95%).

Orthopedics
Orthopedic implementation of ICHOM at USB for hip replacement. The main expectation were quality-based: indication, perioperative management, surgical performance and postoperative care.
In a nutshell, the quality of life is expected to be better after the treatment. However, there were some challenges, especially the additional workload because of different types of patients.
Quality control is an effort that has to be supported by all staff members. Filling a questionnaire on the iPad could be difficult for some people sometimes because of the technology or because of the type of questions. Personnel should be available to help the patient; otherwise, there is an increased risk of drop-out. To improve the acceptance of the questionnaire, it needs to be adapted and shortened.
It is important to explain why those studies are important in order to recruit and motivate patients to follow up and be committed.
Opinion of patient could change based on to whom they speak. It is fundamental to interact with the patient to find out her/his true opinion.
Good visualization of PROM allows doctors to focus on the patient’s problems and to factually show improvement or deterioration of the health and well-being.

For more:
OECD Working group on Healthcare Quality Indicators and Outcome (HCQO).

VBHC for Depression & Anxiety

Prof Matthias Rose

Depression and anxiety are the most frequent disorders (#2 for depression and #7 for anxiety in global burden of disease)
Many scales and initiatives are country specific. Howeve, international standardization is fundamental to allow benchmarking as well as best practices implementation. ICHOM promotes an international standardization (see below).

ICHOM approach.jpg

Source: ICHOM website.

Michael E. Porter, the pioneer and founder of Value-based healthcare, sets the definition of value in one of his article  as well as the methodology for outcomes measures.

Porter

Source: M. E. Porter.

In order to define the most appropriate measures, it is crucial to have the thorough understanding of the disease trajectory. Do we have a comprehensive measure of the disease focused on psychometric soundness, comprehensiveness, the number of available translations but also available royalty free.

Factors for Success and Sustainability of PROMs

Prof Jan A. Hazelzet

How to maintain the success of patient reported outcomes measures (PROM) in the future?
A lot of quality measures currently exist, but the majority is dedicated to processes even if some of them cover quality and outcomes but mainly medical outcomes and few linked to patients.
What are the benefits and the harms that the patient will get from the intervention? This is one of the first question to ask. Growing evidence, supported by the movement Smarter Medicine, goes in the direction of decreasing medical intervention when unnecessary.

Two books set the scene in the context of patient-centric care:
Eric Topol: The patient will see you now
Michael Porter: Redefining Health Care

Actually, we can only make healthcare better if we redefine it.
Health care quality should be focused on being:
– Effective
– Patient centered
– Safe
– Efficient
– Timely
– Equitable

There is more than the cost, the flow is equally important as well as the patient experience; and that is value. Focusing on the individual with the disease and not on medical specialties to change the mindset and becoming patient-centric. A team-based approach, in which a team is accountable for the whole process could help set up real care path toward a fully integrated care. It means change for organization and culture.
Patient reported outcomes measures means questionnaires because biomarkers and clinical analysis do not consider how the patient really feel. Results of the questionnaires should be discussed with the patient, it will support the commitment and the follow-up of the patient. Visualization is also extremely important for both the patient and the doctor
Overall health sets make sense for multi morbid patients instead of sending the patient 3 different sets.
The patient should definitely be considered as a real partner. Patient engagement/involvement is really strong and meaningful. Value based care is patient centered care instead of clinician based. It should be integrated and continuous. A disease team (united, responsible, and accountable) could define a care proposition with data support as well as performance data set. Patients can help with focus groups
Data should be FAIR – findable, accessible, interoperable, reusable

For more:
Evidence-based medicine and values-based medicine: partners in clinical education as well as in clinical practice.

Round Table with Questions & Discussion

– How do you see the integration of GP? The most natural starting point is the identification of conditions where GPs play a crucial role. Integration between GP and hospitals is very crucial. The exchange of information between GPs and hospital is equally important to insure the close follow-up of the patient and the continuity of care. For many patients, the visit to the doctor’s office is very important. Putting iPads on the waiting room to collect some data on the patient that could help the follow up is also crucial.

– Value based care has to be linked to payment and we need to reward institutions that can provide good quality of care. In Switzerland, an experimental article will be approved soon and a pilot project should be launched right after.

– How to manage the fact that people will select always the best surgeon on the list and never go to the last on the list? The transparency will probably be more on the institution level and not specifically on the single doctor. Institutions will be specialized and will do volume in specific procedures. The main incentive should be that healthcare providers offering the same medical specialty talk to each other and share best practices.

– Value-based care should be supported by the doctors or it could not be implemented. Start with clinician champions that can talk and teach to the others.

– Value-based care adds value to the patient file and knowledge on how to better care and follow up with him.

 

Symposium francophone de soins primaires – A quoi ressemblera le cabinet de médecine de famille du futur ?

A_doctor_talking_with_a_patient

Image source

Lausanne – 18 juin 2018

 

Points-clés des sessions plénières du symposium

Plusieurs points ont émergé des présentations et des discussions de cette journée. A l’avenir, plusieurs initiatives permettraient une amélioration de la prise en charge des patients tout en optimisant les ressources :

  • Développer la prévention et se concentrer sur le maintien de la santé de la population afin de limiter les besoins à long terme.
  • Mieux connaître les populations régionales, leurs besoins et leurs différences. Focus au niveau méso (en rapport aux autres niveaux : le niveau macro est le pays, le niveau micro est une patientèle, le niveau nano est l’individu).
  • Détection précoce des patients qui nécessitent une prise en charge particulière afin de limiter le recours aux urgences
  • Développer les compétences d’autogestion et d’éducation du patient (« patient empowerment »).
  • Innover dans le formation de nouveaux profils professionnels afin de favoriser l’inter- et la multi-disciplinarité (Advanced Nurse Practitioners, IDSP,…) visant la prise en charge globale et coordonnée du patient.
  • Intégration des évolutions technologiques pour faire levier sur les connaissances et améliorer l’efficience.

Introduction

Le caractère crucial et très important des soins de santé primaire a été révélé dans un rapport de l’OMS (Organisation Mondiale de la Santé) il y a plus de 10 ans. Depuis, beaucoup de progrès ont été réalisés dans le monde grâce à de multiples réformes, mais il reste encore du chemin à parcourir. Les réformes ne concernent pas que les prestations mais sont aussi politiques car elles sont liées à l’organisation des systèmes de santé.
La médecine de premier recours ou médecine de famille doit répondre à de nombreux défis comme l’accroissement des maladies chroniques, la fragmentation des soins, l’augmentation des coûts et l’épuisement des soignants, entre autres.

De nouveaux modèles d’organisation ainsi qu’une vraie collaboration avec le patient, soutenue par l’interprofessionalité des soignants, permettra de couvrir une grande partie des besoins de soins de la population. Dans ce cadre, la création de connaissances est fondamentale, basée sur le contexte macroéconomique et organisationnel, la recherche ainsi que l’expérience de terrain. Plusieurs exemples suisses illustrent que la réflexion est actuellement en cours : mise en place d’un Chronic Care Model à Neuchâtel, étude QUALICOPC…

La médecine de premier recours est importante dans la mise en place de certaines initiatives de santé publique car les deux domaines se chevauchent pour un certain nombre d’enjeux.

Intégration Soins primaires et Santé publique

Source: Intervention du Prof. Nicolas Senn.

Pour que cette interaction entre santé publique et médecine de premier recours puisse être optimale, il y a une condition très importante qui est l’inscription des patients. Celle-ci permet leur catégorisation ainsi qu’une optimisation de leur prise en charge.
L’inscription de patients dans un registre permet une attribution à un médecin de référence. Il s’agit d’un levier puissant pour favoriser l’intégration entre santé publique et cabinets médicaux. L’analyse de population est ainsi plus précise et permet d’ajuster les ressources aux besoins.

Retours d’expérience de plusieurs pays dans le domaine de la coordination des soins et de l’interdisciplinarité

Suisse (Canton de Vaud) – Vue politique – Prof. Dr. Stéfanie Monod

Plusieurs enjeux critiques pour le système de santé de demain :

  • Le vieillissement de la population et des professionnels de santé
  • L’augmentation des maladies chroniques
  • La numérisation et l’arrivée en force des technologies de l’information dans le domaine de la santé
  • Les opportunités et les dangers de l’explosion technologique
  • Les patients et leur nouvelle posture (leur nouveau rôle)

L’environnement sociétal est en changement et il est difficile de voir l’impact. Pour répondre aux besoins, il est impératif de renforcer le système de prise en charge.
La vision politique comporte des difficultés d’horizon car il n’est pas possible de planifier à long terme alors que la santé publique se doit de voir 5, 10 ans à l’avance afin d’anticiper les besoins et de planifier les ressources nécessaires pour les satisfaire. Comment concilier les deux ? Maintenir la santé de la population, son autonomie et retarder les situations de fragilité et de dépendance (seuls 20-30% de la population totale sont des individus à risque et 5-10% des personnes fragiles et dépendantes).

Les soins primaires sont donc au cœur de l’action. Il faut renforcer les capacités du système communautaire (renforcer la promotion de la santé, améliorer la gestion des maladies chroniques et la coordination des soins, prévenir le déclin fonctionnel, maintenir l’indépendance et l’autonomie). Il faut donc se concentrer sur les soins primaires tout en limitant les capacités stationnaires. Le virage ambulatoire doit ainsi être encouragé.

Plusieurs mesures ont été mises en place dans le Canton de Vaud :

  • Nouveaux modèles en médecine de famille
  • Pratique infirmière avancée (ANP – Advanced Nurse Practitioner)
  • Articulations entre dispositifs institutionnels et soins de première ligne
  • Formation
  • Nouveaux modèles de financement
  • Dossier du patient informatisé, langage commun

Le tout doit être soutenu par le développement des compétences patients ainsi que le développement de partenariats avec des prestataires ainsi que le soutien des infirmières de pratique avancée.

 

Suisse – Expérience pilote – Améliorer la coordination en médecine de famille – Prof. Nicolas Senn, Dr. Monika Diebold, Dr. Regula Cardinaux

En Suisse, la part de cabinets médicaux où un seul médecin est actif reste encore élevée (45%) en comparaison aux autres pays (UK : 4% ; Australie : 8% ; Suède : 19% ; Canada : 23% ; USA : 30%) en 2015.

La collaboration avec les autres professionnels comme les infirmières ou les gestionnaires de cas est différentes en fonction de la région géographique : plus fréquente en Suisse Romande (85.3% des cabinets collaborent) et au Tessin (76.5%), elle est plus faible en Suisse Allemande (49.8%).

Plusieurs initiatives ont été lancées en Suisse pour faciliter la coordination des soins : Projet « soins coordonnés » dans le cadre de Santé 2020, Programme de promotion de l’interprofessionnalité dans le domaine de la santé de 2017 à 2020, eHealth Suisse.

Dans le canton de Vaud, un projet pilote pour développer un nouveau modèle de coordination en médecine de famille a vu le jour récemment. Le constat de départ fait état de cabinets de groupes de 2-3 médecins, souvent très occupés par les activités de coordination et d’éducation thérapeutique avec une population de patients moyennement complexes.

Après une recherche de littérature, un nouveau modèle de coordination des soins a été ébauché visant à :

  • Optimiser la prise en charge des patients
  • Soutenir la continuité de la gestion, de l’information et de la relation
  • Diminuer les hospitalisations et le recours aux urgences
  • Développer un fonctionnement interprofessionnel au sein du cabinet
  • Développer un partenariat médecin de famille-santé publique

Plusieurs interventions ont été listées et choisies comme par exemple la mise en place d’un système de soutien à la coordination des soins et le développement d’une structure pour favoriser les relations entre les soignants ainsi qu’entre les soignants et les patients.
Des études d’impact ont également été réalisées afin de vérifier l’adéquation de ces interventions dans le contexte particulier de la médecine de famille. Un modèle a été défini afin d’être mis en application.

Coordination des soins

Source

Ce modèle vise à s’adapter à chaque cabinet, il est flexible et non limitatif. Il est en train d’être mis en place dans le cadre d’un projet pilote avec environ 10 cabinets. Ce retour d’expérience sur 2-3 ans permettra éventuellement d’appliquer certains ajustements avant un déploiement de plus grande ampleur.

Les enjeux de ce projet sont importants :

  • Répondre aux besoins sanitaires actuels en soins de premier recours
  • Développer l’interprofessionnalité en médecine de famille
  • Encourager un partenariat entre les cabinets privés et le Service de Santé Publique
  • Effectuer un « scale-up » du projet pilote aux autres cabinets du canton
  • Assurer un juste équilibre entre flexibilité et pratiques uniformes
  • Permettre l’intégration des évolutions technologiques

 

France – Rôle des infirmières ASALEE – Dr. Hector Flacoff, Gaëlle Savigneau

En 2004, un dispositif expérimental, précurseur d’Asalée, a été lancé dans le département des Deux-Sèvres. L’objectif est d’offrir un suivi individualisé aux patients en équipe pluriprofessionnelle (médecin – IDSP ou Infirmière Déléguée à la Santé Publique). Le financement est assuré aujourd’hui par l’assurance maladie et le ministère public. La collaboration est innovante et évolutive ; elle s’est développée dans toute la France avec plus de 550 IDSP. Le soutien et l’encouragement de cette initiative se poursuivent avec son inclusion dans la stratégie nationale de santé 2018-2022 dont l’objectif est de renforcer l’accès territorial aux soins.
Ce type de prise en charge fonctionne bien pour des pathologies chroniques nécessitant un suivi rapproché et une éducation thérapeutique. Un projet thérapeutique et un objectif de vie seront définis avec le patient. L’infirmière s’occupe du suivi et ne sollicitera le médecin que pour des problématiques particulières ou pour les visites de contrôle. Cette approche permet souplesse et temporalité pour le patient. L’infirmière peut en effet prendre plus de temps pour écouter et échanger avec le patient sans pression temporelle. L’infirmière est payée par l’institution Asalée, le médecin ne va que signer un contrat de coopération et mettre un local à disposition pour l’infirmière. Les échanges entre le médecin et l’infirmière seront ensuite réguliers en fonction des cas.

 

Belgique – Innovation dans les maisons médicales – Dr. Jean Macqt, Dr. Hubert Jamart, Monique Ferguson

La Belgique est un pays en réformes permanentes étant donné sa situation politique où la concertation prend beaucoup de temps. Des incohérences dans la répartition des compétences s’ajoutent à cela induisant des négociations sur l’organisation des soins entre le fédéral et le régional.
A la base, la majorité des prestataires sont privés et l’offre hospitalière est importante. L’assurance maladie fédérale reste le garant d’un accès financier aux soins d’une manière libre.
Le système évolue en permanence au rythme des résultats de ces discussions et est le fruit d’un équilibre entre les différents piliers existants en Belgique (catholique vs. non catholique, francophone vs. non-francophone,…).
Ces tendances empêchent l’intégration des soins d’une manière structurée et optimale. De plus, chaque acteur y va de son initiative d’intégration répondant à des logiques territoriales, de fonctions « intégratrices », de dossiers partagés, de nouveaux modes de paiements,…

Plusieurs projets ont été lancés dont Integreo qui va viser à favoriser les échanges entre les « case managers » et les réseaux de soins tout en soutenant le patient dans ses connaissances en autogestion.
Il existe en Belgique plus d’une centaine de maisons médicales (intégrant environ 2500 professionnels) soignant plus de 250’000 patients. Il s’agit d’un secteur en croissance dont l’essor a été favorisé par le GERM (Groupe d’Etudes pour une Réforme de la Médecine).

Plusieurs idées comme le paiement forfaitaire et un changement dans l’enseignement de la médecine afin d’encourager les échanges entre professionnels ont permis de soutenir ce développement de coordination des soins (parcours de soins, communication, équipes multidisciplinaires,…).

Le DEQuaP est un projet d’autoévaluation participatif qui permet aux maisons de santé de s’améliorer en continu en fonction du retour des professionnels mais aussi des patients.

 

Québec – Gestion des cas et interprofessionnalité – Prof. Catherine Hudon, Prof. Mylaine Breton

Le Québec vise principalement l’intégration des volets santé et sociaux par le biais d’un modèle basé sur la centralisation. Celle-ci a eu des effets importants sur le nombre d’établissements qui est passé de 683 à 34 en quatre décennies. Le territoire a été divisé en régions afin d’y implanter des centres ayant des responsabilités populationnelles.
Plusieurs structures permettent un bon fonctionnement du système comme les équipes multidisciplinaires, les pratiques de groupes, les attributions d’infirmières ainsi que la contractualisation des échanges.

Pour les patients complexes, sollicitant beaucoup le système, le « case management » peut vraiment apporter énormément de valeur tant au patient (meilleure prise en charge) qu’au système (moins de frais d’urgences).

On parle de cas complexes quand plusieurs conditions sont réunies : maladies chroniques, précarité socio-économique, troubles de santé mentale. 80% des coûts sont générés par ce type de patients.
Complexity

Source : A Conceptual Model of the Role of Complexity in the Care of Patients With Multiple Chronic Conditions, Grembowski, David PhD & al., Medical Care: March 2014 – Volume 52 – Issue – p S7–S14.

L’objectif est d’évaluer, planifier, faciliter et coordonner les soins pour répondre aux besoins de la personne et de ses proches. Assurer une meilleure communication entre toutes les ressources permet également une optimisation des soins et des résultats.

L’infirmière qui gère le cas devient la répondante principale et va se concentrer sur le projet de vie du patient. Le patient devient un partenaire à part entière, éduqué et responsabilité, qui va faire des choix en collaboration avec les professionnels. Pour ce faire, un repérage efficace et précoce est nécessaire pour optimiser les ressources et les structures.

 

Sources & références

The Chronic Disease Self-Management Program: the experience of frequent users of health care services and peer leaders, Family Practice, 2016.

Médecins de premier recours – Situation en Suisse, tendances récentes et comparaison internationale, Obsan, Dossier 50, 2015. https://www.obsan.admin.ch/sites/default/files/publications/2015/obsan_dossier_50_1.pdf

Case Management for Frequent Users with Chronic Disease in Primary Care. Conference Presentation, 2013.

Nouveaux modèles de soins pour la médecine de premier recours. Rapport du Groupe de travail „Nouveaux modèles de soins pour la médecine de premier recours“ de la CDS et de l’OFSP, 2012.

Les soins de santé primaires – Maintenant plus que jamais. WHO, 2008.

Médecine personnalisée – Quelles libertés dans la santé de demain ?

Histoire et cite

Table ronde du 23 mars 2018 à l’Université de Genève dans le cadre du festival Histoire et Cité

Interventions de Micheline Louis-Courvoisier, Bertrand Kiefer et Christian Lovis

La diversité des intervenants permet la combinaison d’une perspective historique avec une approche de société pour analyser les problématiques d’aujourd’hui et de demain concernant la médecine personnalisée.

Quelles libertés pour le malade d’hier ? – Micheline Louis-Courvoisier

Micheline Louis-Courvoisier nous propose une approche historique de la médecine personnalisée. En tant qu’historienne et spécialiste de l’histoire de la médecine, elle nous explique comment se passaient les consultations au 18ème siècle et comment on peut relier ces expériences au contexte d’aujourd’hui.

Au cours du 18ème siècle, les consultations se faisaient sur une base épistolaire (correspondance écrite entre le soignant/médecin et son patient). Il y a plusieurs raisons à cela : la médecine basée sur les humeurs n’avait pas besoin de l’examen du corps physique ; les soignants étaient plus rares qu’aujourd’hui et souvent, même en cas de consultation occasionnelle en personne, les patients donnaient des nouvelles à leur médecin dans l’intervalle. On écrivait donc à son médecin, cependant ceci était réservé à la partie lettrée de la population.

Cette pratique permettait au médecin d’analyser l’expression de la maladie chez chaque patient en fonction de son ressenti. Le patient organisait son récit à sa manière, il n’y avait pas de lettre-type et chacun d’entre eux s’exprimait différemment. L’écriture en elle-même avait probablement également une valeur thérapeutique puisqu’il a été prouvé par plusieurs études récentes que si un patient relate ses symptômes par écrit, cela permet de le soulager partiellement.

La transmission des sens s’effectuait d’abord du somatique au sémiotique (de la maladie et des symptômes à son expression par le patient) et du sémiotique au somatique (par le médecin qui essayait d’interpréter les mots du patients). Afin de faciliter la compréhension par le médecin, le patient utilisait très souvent des comparaisons ou des images pour représenter et détailler ce qu’il ressentait.

La connexion entre les émotions et le corps a toujours été analysée et a encore été étudiée dernièrement dans une étude publiée en 2014. Les personnes participant à l’étude devaient reporter les sensations corporelles en lien avec des émotions stimulées.

topographie corporelle

Topographie corporelle des émotions de base (supérieures) et des émotions non basiques (inférieures) associées aux mots. Les cartes du corps montrent les régions dont l’activation a augmenté (couleurs chaudes) ou diminué (couleurs froides) lorsqu’on ressent chaque émotion. (P < 0,05 FDR corrigé ; t > 1,94). La barre de couleur indique la plage de statistiques t.

Source : Bodily maps of emotions; Lauri Nummenmaa, Enrico Glerean, Riitta Hari and Jari K. Hietanen; PNAS January 14, 2014. 111 (2) 646-651.

Ce type de consultation permet de constater que la relation médecin-patient reposait sur plusieurs dimensions : précision de la sensation, précision de l’expression et précision de la transmission. Au 18ème siècle, la médecine était donc très personnalisée et individualisée puisque le lien entre le médecin et le patient, basé sur une correspondance d’écrits, permettait des traitements adaptés en fonction de chaque situation.

Aujourd’hui, la situation a changé et le patient n’écrit plus à son médecin. Ce n’est pas pour autant qu’il ne bénéficie pas d’un traitement personnalisé.

Quelles libertés dans la santé de demain ? – Bertrand Kiefer

Bertrand Kiefer nous parle de la technologie et de son impact sur le système de santé mais aussi sur notre perception de la santé en elle-même.

Le pouvoir de la technologie s’accélère et dissout progressivement les liens que l’humain entretient avec la nature. Cette domination graduelle permet de dépasser la nature. Aujourd’hui est une époque centrée sur l’hybridation entre l’humain et les machines, entre l’humain et les informations grâce à l’émergence de nouvelles technologie dans le domaine des prothèses (orthopédie, cardiologie), des organes (transplantation), des cellules (immuno-oncologie) et des gènes (technologie CRISP-Cas9).

L’individu peut être vu comme un système de données. La réalité augmentée qui en est dérivée permet de voir plus que la réalité engendrant ainsi une individualisation plus poussée ainsi qu’une nouvelle dimension de la communauté.

Régis Debray, mentionné par Bertrand Kiefer, a étudié la progression des sociétés dans le contexte de l’évolution des technologies (voir tableau ci-dessous). Selon ses propos, la période actuelle est caractérisée par les réseaux, les algorithmes et l’individualisme. La technologie a donc considérablement changé l’humain et, aujourd’hui, des tendances quelque peu extrêmes émergent, comme par exemple le solutionnisme (vision philosophique qui présuppose une solution technologique à tout problème humain) ou encore le transhumanisme (mouvement prônant l’usage des sciences et des techniques afin d’améliorer la condition humaine en supprimant la souffrance, la maladie, le vieillissement ou la mort).

mediologie

Source

Ces tendances soulignent toutes que la santé personnalisée est possible aujourd’hui grâce à toutes les données qui permettent des diagnostics et des traitements plus précis.

Par contre, on a perdu le concept de normalité puisqu’il n’y a plus de « bonne santé ». En effet, un être humain se positionne toujours sur un continuum car il est toujours porteur de facteurs de risque et de prédispositions. De ce fait, on n’arrive plus à distinguer ce qui est normal de ce qui est pathologique.

L’humain garde toutefois sa liberté, qui, pour l’instant, perdure encore dans les fondements de notre société. Cette liberté permet aussi de construire la relation médecin-patient à travers les décisions partagées et les discussions liées à chaque pathologie malgré des incertitudes croissantes. Les asymétries dans la transparence contribuent à ces incertitudes car les personnes et leurs données deviennent de plus en plus accessibles, à l’inverse les entreprises et les gouvernements s’enfoncent dans l’opacité tout en surveillant étroitement les individus à travers leurs données.

Même si une partie des actes médicaux pourrait être accomplie par des robots ou des auxiliaires technologiques, la relation soignant-patient comporte tellement de niveaux (langage verbal et non-verbal, plusieurs niveaux d’interaction, transfert et contre-transfert) qu’il n’est pas possible de la remplacer. Elle est également ancrée dans une communauté de destins, sous-entendant que le soignant fait preuve d’empathie puisqu’il est lui-même faillible et mortel, tout comme son patient.

Médecine personnalisée et prédictive – Christian Lovis

Christian Lovis nous parle du déterminisme sous-jacent à la médecine personnalisée et prédictive. Le déterminisme part du principe selon lequel la succession de chaque événement est déterminée en vertu du principe de causalité. Se pose alors la question de savoir dans quelle mesure nous sommes déterminés ou libres de ce qui nous arrive ?

La biologie moléculaire s’appuie principalement sur ce déterminisme qui est encore en évolution puisque l’on n’a pas encore découvert tous les marqueurs de toutes les pathologies existantes. Le lien de causalité est parfois aussi difficile à établir. Cependant, une grande partie des thérapies ciblées contre le cancer cherchent à enrayer les processus qui se cachent derrière ces marqueurs. Ceci a contribué à améliorer l’efficacité des traitements de manière significative.

Il faut toutefois être conscient que la génétique n’explique pas tout. Selon un chercheur, seuls 10% de notre santé seraient déterminés par les gènes et la biologie. A nuancer toutefois puisque lorsque la génétique est contributive, elle l’est massivement.

determinant of health

Source: Public policy frameworks for improving population health, A.R. Tarlov, Ann N Y Acad Sci. 1999;896:281-93.

Ce qui est unique en nous est beaucoup plus important que ce que l’on a en commun avec les autres êtres humains. De plus, il a été prouvé que ce n’est pas forcément la séquence codante de notre ADN qui détermine la caractéristique génétique mais les séquences régulatrices qui entourent celle qui est codante.

Les données qui caractérisent le comportement ainsi que l’écosystème dans lequel nous vivons jouent un rôle majeur dans notre santé et sont disponibles pour être analysés. Progressivement, comme discuté précédemment, la donnée va remplacer l’humain. Nous sommes tous uniques mais le danger est de devoir ressembler à une catégorie particulière avec laquelle nous avons des points communs mais qui ne nous correspond pas complètement. Cette catégorisation induira une perte de la liberté individuelle qui pourrait potentiellement entraîner une dangereuse émergence des eugénisme et hygiénisme du passé.

Les données risquent fortement de remettre en question le système solidaire qui existe aujourd’hui. Ceci est principalement lié au fait que les données qui sont collectées sont structurées et elles perdent du contenu au cours du processus de structuration. Il y a un énorme décalage entre la perception de la société civile sur la santé et la réalité. La société civile doit lutter pour comprendre cette nouvelle médecine qui est basée sur un grand nombre de données et une technologie de plus en plus imposante.

Le développement des algorithmes et de la technologie va fort probablement déplacer le rôle du soignant vers des tâches beaucoup plus humaines et empathiques tout en laissant les algorithmes décider du meilleur traitement.

E-health Day – Internet of Me: Vision and Challenges

IMG_7174

I had the opportunity to attend the e-health day in Sierre (TechnoArk) on June 3rd 2016. The event was well organized around big players (Boston Scientific, Roche), showing their vision of the technology and its implementation in their own business model, and startups (L.I.F.E. Corporation, Karmagenes) unveiling their innovations in the field. Moreover, other stakeholders like the health insurance Groupe Mutuel and government-financed agency CIPRET presented their real-world experiences. The event was closed by a panel discussion on the relationships between eDoctors and ePatients.

Globally, the vision of health is: health care providers will be able to improve health outcomes by working with digital patients (the data collected by sensors will be integrated and analyze to provide personalized treatments and consequently better outcomes). Several projects are developed: prosthesis control, diabetes management, vital signs monitoring for elderly people…

Below I summarize the key takeaways from the most interesting talks (not all of them).

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BOSTON SCIENTIFIC – MEDTECH : WHICH BUSINESS MODEL FOR THE E-PATIENT ?
By Frédéric Briguet, EU Digital Health Engagement

  • The goal of the presentation was to provide clues on which business model is the most appropriate for digital health companies.
  • Medical technology companies create and develop products for patients but they really have to be aware of their ecosystem and the influences that will drive patients’ behavior.
    Body sensors brought revolutionary tools to life. They are wireless, responsive, use mobile devices and allow data analysis to be performed. However, what is the real impact on health and disease management? Many companies have sensors supported by solid hardware, cloud data collection and a dashboard for mobile phone.
  • Despite the evolution of technology, we are still lacking clinical studies and proofs. In addition, the user dropout rate is pretty high (after 6 to 8 months, users abandon the sensor(s) and the app). Needless to say that, on top of all the previous disadvantages, the amount of data generated is extremely heavy and it is difficult to extract the most relevant indicators to analyze them.
    However, the first digital health products helped open new perspectives and the potential of connections between all the stakeholders. Empowering and engaging healthcare providers is also one of the key benefits of the first digital health initiatives. Beyond those elements, what’s crucial to ensure adoption and reimbursement is to demonstrate the cost savings the technology could bring to the current health care settings. Doctors also have to support it and be convinced of the use and utility for their own patients.
  • All in all, the future of healthcare is expected to improve outcomes, reduce hospital readmission rate and control costs while maintaining care access.
  • The experience of the speaker allowed him to say which business models where the most appropriate to survive and thrive in that new field. He established 4 directions (that can be combined):
    1. The patient is not a consumer. Generally speaking, he is not really willing to know that he’s ill. His main focus is to live. Family and friends are the most concerned about the patient’s health and wellbeing. Creating and developing tools that could ease the burden for the supportive people around the patient is generally well received and adopted.
    2. Understand the business ecosystem. Knowing where to position the company is fundamental to avoid being stuck in a no man’s land. Focusing on lifestyle, coaching or care pathways is different and requirements increase massively for the care pathway segment.
    3. The population is ageing and increasing. The health care system will have to support an additional financial burden with the passing of the years because we know that the majority of the costs is generated toward the end of life. Hospitals are paid today according to their own efficiency (shorter hospital stays as well as improved outcomes will generate higher payments from heath insurances). It is the OPM principle (Other People Money) meaning that the patient (who consumes) is not the payer. It is then crucial to find new solutions to reduce the costs.
    4. Understanding the disease is more than fundamental. Compliance and adherence management and control in order to avoid hospital readmissions is one of the main issues of the whole healthcare system. Beyond that point, enhancing and improving the patient’s experience as well as the quality of care could well trigger new motivations for the patient to be compliant to his treatment.
  • Go beyond sensors-mobile-cloud-dashbord to include blockchain technology, augmented reality, internet of things… + any relevant technology or innovation that can bring value to the system. This value has to be demonstrated and proved as viable for the whole system.
  • The technology has to be integrated in the patient’s experience, nearly invisible, but not less complex.

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PATIENTS LIKE ME – THE POWER OF WE
By Chris Fidyk, Business Development Director Europe

  • Accelerating research and development of new treatment but also allowing patients to support each other and exchange life experience with a disease is the main goal of PatientsLikeMe. That network is maybe the smallest social network but the larger medical registry with more than 500’000 patients. Patientslikeme provides tools for patients to put their disease into context.
  • Today, there is a lot of momentum about patient centricity. It becomes more mainstream. Patients owe other patients their own experience (drugs, symptoms,…). Empowering people to express themselves about their journey in the disease. Then, when all the stories are aggregated, meanings and trends can be extracted.
  • It is also possible to see all people taking the same drug, its perceived effectiveness as well as some conversation analytics allowing to understand which symptoms are the most talked about, the treatment awareness, the barriers to access in addition to the reasons behind their treatment failure or cessation or continuation.
  • Data (experience and discussions) stay online and available even when the patient dies to enrich other patients’ lives. Regular video postings on Patientslikeme Youtube channel show patients sharing their own experience with the website and how it helps them cope with their disease.

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ROCHE DIABETES CARE – EHEALTH: THE FUTURE WE CREATE TODAY
By Horst Merkle, Diabetes Management Solutions Director

  • You can only do something with data when you can access to it.
  • Infrastructure is the foundation for innovation and creativity” – as quoted by a speaker at the Connected Health Conference.
  • How to meet the future? The lack of healthcare staff, the increase in chronic diseases and the rising healthcare costs are the challenges. How to manage them: accountability and empowerment for the patient and the consumer. Mastering your own health with less health and care services.
  • Today, technology-driven health is messy. The solutions have to be easy to use and secure for the patient.
  • The Personal Connected Health Alliance (PCHA) is at the forefront of health and wellness in today’s society, driving advancements in mobile and communications technologies, and the growing use of new devices, health trackers and apps by consumers and healthcare providers.
  • PCHA brings together the critical elements needed to ensure that these technologies are user-friendly, secure and can easily collect, display and relay personal health data. In PCHA’s vision for healthcare, consumers can use readily available technologies to access their personal health data, receive targeted health and wellness education, consult with healthcare providers and gain support from friends and family to improve their health.
  • PCHA focused on engaging consumers with their health via personalized health solutions designed for user-friendly connectivity (interoperability) that meet their lifestyle needs.
  • Business models are the main obstacles for interoperability to work.
  • Accu-Check Connect System from Roche provides an integrated meter, an app, and online tools for better diabetes management. The glucometer can share data in the cloud with the healthcare provider.

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WITHINGS – FROM QUANTIFIED SELF TO PREVENTIVE MEDICINE
By Alexis Normand, Health Development Director

  • The main goal of Withings is to sell connected products to the general public. Those products can be bought in supermarkets and will help the consumer monitor vital signs such as weight, blood pressure,… Without being a doctor, the consumer can create a dashboard for his health. Changes in health are driven by him and, due to the fact that he generates data, he will be at the center of the data collection and analysis.
  • Those tools could also be used to enhance corporate wellness and engage employees through gamification. Employers will offer a connected bracelet and will organize a competition. Employers are however inherently screening employees for health issues and can analyze aggregated data to discover trends. Data around workout and physical activity are enriched by environmental and lifestyle inputs but also by stress management and absenteeism information.
  • In the e-health field, we are in the prevention area and also on new territories like personal health dashboard and employer focus on employees’ health.
  • E-health could be widely applied together with EHRs (Electronic Health Records). Linking EHRs to outcomes allow hospitals to monitor their performance to get more money from payers as they will limit the expenses for the system as a whole.
  • Withings also builds an open health data platform with the implementation of national observatories aggregating data from all the users. Those platforms will support research on connected devices with scientific publication and could stimulate partnerships and collaborations with other data sources.

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GROUPE MUTUEL – IGNILIFE – DAILY HEALTH COACH
By Stéphane Andematten, Marketing Leader

  • Real world business case from concept to realization in partnership with the startup Ignilife.
  • Today more than 165’000 health apps are available with 40% dedicated to medical uses and 60% to wellness.
    Regarding Switzerland, few initiatives have been developed to date. Groupe Mutuel would like to be the forerunner and not a follower in the field.
  • Ignilife is a French startup with a subsidiary in Switzerland. It is the perfect combination of entrepreneurship, medical skills and user experience. Ignilife has a previous experience with Malakoff Médéric, the leader for private health insurance in France.
  • Ignilife is a e-coaching platform based on people. It covers physical and emotional wellbeing. A first auto-evaluation is performed by the user in order to have a broad overview. An assessment is then released by the system with risk factors and advices to manage and lower their impact. Support and follow-up is provided as a selection of programs the user can choose from. He can also connect his devices.
    Close to 300 video and audio plays are available. Each time a contest or challenge is won, it is input in the platform to show the progress and evolution.
  • It is essential to develop a rich, engaging and fun platform to keep the user motivated. The goals set are reasonable and not out of reach. There is a social media component where users can exchange experience and tips. More functionalities will be developed in the next future (health at work, back health, burnout prevention,…)
    Data protection is well managed, as all the data are stored in Switzerland on independent servers.
  • Groupe Mutuel pretends it does not use data collected by user but only on an aggregated basis. The rationale behind the implementation of such a project is the focus on prevention. It will help to keep health expenses at an acceptable level in the longer term.
  • Some stats:
    25’000 Ignilife users (out of more than 1’100’000 insured people)
    Mobile users connect much more than desktop users (2x)
    91% did their auto-evaluation
    61% engaged in a coaching program
    47% changed their habits

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MANAGE MY DATA OR BE MANAGED BY MY DATA
By Stéphane Koch, Expert in Digital Experience

  • People like to measure their own weight, the calories they burnt, their heart rate,…
    There is a real value added in using quantified self.
    However, coherence is not always part of the measures and can distort statistics extracted out of the data. Sensors sometimes lose connection with the app leaving gaps or errors in measures. Improving apps with coherence system would be a big step further or even allowing the user to correct the data himself.
  • Quantified self generally has a positive impact on the user’s wellbeing but it can also generate stress if the progress takes time to emerge or if it stops. Knowing the scope of the technology as well as his body are fundamental.
  • The website DMD (in French) allows the evaluation of digital tools and the sharing of everyone’s user experience.

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CIPRET – 7000 SWISS PEOPLE STOPPED SMOKING THANK TO A FACEBOOK PROGRAM
By Alexandre Dubuis, PhD, CIPRET Valais leader

  • CIPRET is a center for the prevention of tobacco use, recognized of public interest by authorities.
    It launched early 2016 a program to help people stop smoking via Facebook.
  • A real human adventure started and succeeded. The initiative was in 2 phases: recruitment and program on the same platform. It was completely free for the users. They just had to like the page, say they are interested and accept that all the posts written by CIPRET were the first they saw when they opened their Facebook app.
  • 3 pillars of the program:
    – Daily advices (personalized and not always linked to tobacco consumption)
    – Group support (tips and experience sharing)
    – Physical desire to smoke (will only last between 3 and 5 minutes => tips given to avoid relapse).
  • Professional support has been organized at 3 levels : the first one, community managers answer simple questions ; the second one, prevention experts take specific questions ; the third level, medical practioners take care of medical questions.
  • Some stats:
    1’500 posts created
    Support was on call during the whole week from 6am to 11pm
    13’000 messages have been answered in the first weeks
  • Key strengths: no moral scolding, always up-to-date, focus on workouts, nutrition, Sunday evening chats, real meeting groups.

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L.I.F.E – EXPRESS YOUR TRUTH THROUGH YOUR ACCURATE DATA
By Dario Ossola, PhD, Algorithm R&D Coordinator

  • L.I.F.E stands for Live – Inspire – Free – Entertain
  • The project started at the core of The Ark and focused on predictive models for tiredness, exhaustion and strain with the development of a garment.
    That garment is equipped with sensors to monitor vital signs (it is medically accurate and there is no need of a smartphone). It allows total freedom.
    It can be the third platform of communication (with the first 2 being computers and smartphones).
  • The medical accuracy is fundamental and it can be used in medical practice but also in sports. That garment has the same results as the invasive methods to analyze vital signs. It allows real life measurements and expansive communication (data omnipresence, diverse data analysis levels).
  • Two web sites: http://x10x.com/ (for women) and http://x10y.com/ (for men)

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ISYPEM2 – PERSONALIZATION OF TREATMENT DOAGE THANK TO MEDICAL DATABASES
By Séverine Petitprez, Scientific associate, Clinical pharmacology CHUV and Alevtina Dubovitskaya, Research assistant, HES-SO Valais

  • Software for personalized treatment dosage.
    Unique treatment dosage works very well for simple drugs like paracetamol. Unfortunately, for oncology or chronic diseases drugs, which are much more complex molecules, it doesn’t work as well. It can lead to toxicity, side effects or no effect at all.
  • Therapeutic follow-up normally starts with a blood sample, pharmacology experts interact and guide the doctor in order to personalize the treatment.
  • A new software (EzeCHieL) do exactly the same but in a much faster and more practical way. The software can create the patient’s drug metabolism curve based on the EHR (Electronic Health Record) and medical databases. Some genetic characteristics or co-morbidities can lead to changes in drug blood concentration.
  • Interoperability (web interface) as well as confidentiality and data security are guaranteed (pseudonymisation, anonymisation).

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KARMAGENES – BE A GAME CHANGER MEET YOURSELF
By Kyriakos Kokkoris, CEO

  • Karmagenes is a game combining gene profiling and psychological analysis. Integrating genetics with psychology for improved personal development.
  • What defines who you are: what you are (DNA) and where you live (environment & perception).
  • Genetics meet psychology.
  • Human centric approach
  • Could be a network of personalities and connect locally.
  • Personal guide for career development, personal motivation, and physical as well as emotional well-being.

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PANEL DISCUSSION – E-DOCTORS AND E-PATIENTS, AN EMERGING RELATIONSHIP
Moderated by Sébastien Mabillard, Swiss Digital Health coordinator with 5 paticipants: Dr. Jean-Gabriel Jeannot; Dr. Pietro Scalfaro; Pierre-Mikael Legris; Christine Bienvenu; David-Zacharie Issom.

  • The market is not yet mature, a lot of opportunities are waiting to be seized.
    The patient is at the center of all motivations.
  • Despite new technologies, there is a lot to do to reach the patient. Few success stories (the CIPRET is however an excellent example).
  • What about doctors’ digital education? Patients are really driving the trend today; they stimulate doctors to be up to date and they push technology adoption.
    Patients are very often looking for information online. Doctors should be prepared and help patients to use the right web sites in order to find appropriate and correct information. Doctors should also contribute and provide content on website to populate them with correct information.
  • All that information help to start interesting conversations. Information exchange should also be facilitated. The patient could be educated to provide the appropriate amount of information to avoid overload.
  • Patient should take part and be part of medical research. The patient is the least used resource in health care. With patients’ associations, precious information is stored and exchanged. That data can be analyzed.
  • The social component is extremely important for patients. Several of them like to share their experience and find support online. They also feel useful to provide information for other that have been diagnosed recently.
  • By giving access to medical and health information, communication and interactions with doctors will be easier and improved.

The potential for disruption in healthcare by Apple

Port_and_lighthouse_overnight_storm_with_lightning_in_Port-la-Nouvelle

A lot has been said about the role of Apple in healthcare, the disruption it could bring and the need for it. If Steve Jobs was alive today, he would surely help the healthcare industry improve.

There is a lot of work and some progress are currently being made but they are slow to implement because evolution is not always seen as such (we all know about the learning curve…).

Apple is not the only company that could bring change and improvements, even disruption, in healthcare. All the technology companies are interested in this field and they will inevitably contribute to change the landscape.

What could Apple bring?

Analyze and integrate health data

The introduction of HealthKit in June 2014 was the start of a big wave of healthcare initiatives launched by Apple. Data collected via the HealthKit through wearables like the Apple Watch can be shared with the user’s doctor in order to improve the doctor-patient relationship. Data can then be integrated in the EHRs (Electronic Health Records) of the patient in order to enlarge the data collection.

Beyond data collection stands data analysis and it’s done with the help of the partnership with IBM Watson to support this effort.

Improve EHRs and real-time medical data to broaden prevention initiatives

Merging EHR and real-time data could enable the use of predictive analytics to anticipate health issues and diseases spread.

The implementation of EHRs could simplify and quicken the collection, use and consultation of medical data, especially in the case of emergencies. This could dramatically help to avoid medical errors due to the lack of specific retrospective information.

Partnerships

Apple has been and is still extremely smart in building strategic partnerships. 3 main partners worth keeping in mind:

  • IBM Watson: storage and analysis of raw data on IBM Watson Health Cloud for the data collected on HealthKit and ResearchKit.
  • Mayo Clinic: access to over 1 million patients in several countries around the world using dedicated proprietary EHR and communication tools for doctor-patient interactions.
  • Epic Systems: expertise in EHR covering over 100m people in USA.

HealthKit & ResearchKit

The main goal of the HealthKit is to collect data from wearables and other connected devices to better monitor individual health. HealthKit also allows the integration of 3rd party apps and devices.

ResearchKit is an add-on to the HealthKit as it helps create apps to improve clinical trials and medical studies.

Apple Watch v. 2.0 and new wearables

The new versions of the Apple Watch could potentially be developed into more sophisticated health-tracking devices with improved heart rate monitor. Moreover, thank to non-invasive technologies, new vital signs could to be captured and analyzed more accurately.

 

Related sources:

Why healthcare needs a Steve Jobs-like disruptor, STAT, February 2016.

Three More Industries Apple Could Disrupt, re/code, July 2015.

Steve Jobs didn’t disrupt, he adapted. So should healthcare, Becker’s Hospital Review, July 2014.

The Industries Apple Could Disrupt Next, Harvard Business Review, June 2014.

 

Image Source

The opioid pain drug misuse problem solved?

Children's_pain_scale

Today using opioids to treat chronic pain seems quite obvious for a lot of clinicians. This trivialization, beyond the responsibility of both the clinician and the patient, is responsible for the dramatic increase of opioid misuses and overdoses.

An excellent article written by Dr. Daniel Alford in the last issue of NEJM proposed smart solutions. Prescriber education is one of them. It would allow a more specific approach to addressing the opioid-misuse epidemic: benefit-risk assessment of patient’s needs and care individualization. It should be completed with patient close follow-up and monitoring as well as the careful evaluation at each encounter of whether to start, continue, decrease, increase or stop the treatment.

Training should start early in the medical education and students have to be aware of the best practices for that type of prescription. All the options for chronic pain management have to be taught and not only to doctors but to all healthcare providers in order to tackle the lack of awareness and education in the field.

Beyond drugs, other alternatives should be tested and proposed, especially when an opioid-based treatment is stopped. Explanations have to be provided in order to reassure the patient that his/her pain is manageable without this type of drugs.

The whole discussion, and a whole lot of other healthcare themes, are closely linked to the doctor-patient relationship. Trust, collaboration and open discussion are all key in order to have the best outcomes for the patient.

As a conclusion, I would like to invite you to watch the fantastic talk given by Elliot Krane, an expert in chronic pain about how this disease invades the body, what are the treatment options and what’s next.

 

Additional information:

Overdose Death Rates – US National Institute on Drug Abuse

Understanding the Epidemic – US Centers for Disease Control and Prevention

How drug use changes the brain — and makes relapse all too common – STAT – April 2017

The Painkillers That Could End the Opioid Crisis – MIT Technology Review – August 2016

Opioid Prescribing for Chronic Pain — Achieving the Right Balance through Education – NEJM – February 2016

Mortality Trends Among Working-Age Whites: The Untold Story – The Commonwealth Fund – January 2016

Trends in Opioid Analgesic Abuse and Mortality in the United States – NEJM – January 2015

When Pain Kills – AARP – September 2015

Opioid Addiction Facts and Figures – ASAM

Assessment & Management of Chronic Pain – Healthcare Guideline – ICSI – November 2013

 

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US drug pricing is on the verge of change

MoneyPills

Drug pricing is always a topic for discussion regardless of the country where you live.

The USA have long been considered as the most expensive country when it comes to drugs. Today, several initiatives are trying to contain their price and limit the explosion of healthcare expenditures. It is not easy and several political leaders failed in front of the powerful lobby supporting the pharmaceutical industry.

Maybe, instead of price cuts, we should think of more nuanced version of price control like value-based pricing or risk-sharing agreements.

An extremely interesting article explore the future opportunity of risk-sharing agreements in the USA. It is widely used in Europe as well as in other countries but shows a slow uptake in the USA. The conclusion of the article is positive as there is room for improvement. “Most manufacturers and payers expressed interest in RSAs and see potential value in their use. Due to numerous barriers associated with outcomes-based agreements, stakeholders were more optimistic about financial-based RSAs. In the US private sector, however, there remains considerable interest—improved data systems and shifting incentives (via health reform and accountable care organizations) may generate more action.”

However, despite hot debate launched by Hillary Clinton recently about drug pricing, the US Congress is still dominated by Republicans, who is completely supporting the pharmaceutical industry. Drug pricing and healthcare coverage will be one of the hottest debate question of the US Presidential Elections this fall.

Some articles are much less optimistic as they show that the bargaining power of private payers is far from sufficient to be able to negotiate discounts.

Drug pricing has to change in the USA because affordability and healthcare coverage will define the sales potential of the product. If the drug is so expensive that no one can afford it and no insurance will pay for it, it has no future sales opportunity. It is key to find a good balance between rewarding innovation and R&D efforts AND allowing patients to access the medicine and care they need.

 

Additional resources:

Private Sector Risk-Sharing Agreements in the United States: Trends, Barriers, and Prospects – American Journal of Managed Care – September 2015

It’s Time to Rein in Exorbitant Pharmaceutical Prices – HBR – September 2015

Why we can’t stop US drug companies from charging astronomical prices – Quartz – September 2015

Drug prices: Which companies may be the next targets? – CNBC – September 2015

Rational Drug Pricing – Huffpost Business – September 2015

Why Are Drug Costs So High in the United States? – Medscape – November 2014

High Cancer Drug Prices in the United States: Reasons and Proposed Solutions – ASCO – July 2014

Higher US Branded Drug Prices And Spending Compared To Other Countries May Stem Partly From Quick Uptake Of New Drugs – Health Affairs – April 2013

Pricing and Reimbursement in U.S. Pharmaceutical Markets – NBER – August 2010

 

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Alphabet (ex-Google) is the next big thing in Life sciences

A lot is currently written about the initiatives launched by Alphabet (Google) in the life sciences field.

I had the wonderful opportunity to have a look at the report written by the internet analyst, John Blackledge, from Cowen and I must say that he’s very smart at showing the huge potential of the life sciences at the core of Alphabet (Google).

This report is amazing as it allows you to have a better understanding of what’s happening now inside Alphabet (Google). I summarized the key points/quotes from the report below and I added other articles at the end of this blog post. Moreover, I will update it frequently as the news come in. This is a fascinating topic, I really hope Alphabet (Google) would be able to replicate the same success it has built with its search engine.

Key quotes & comments from the report:

  • Expansion into health care and related segments allows Google to leverage its core competencies in Internet communications technology, data structuring and analysis, and fundamental process reinvention.

 

  • Specific areas of focus in healthcare include:
    (1) the sequencing the human genome and the rise of precision medicine: despite the monumental significance of mapping the human genome and the implications for drug discovery, this was but one step in a long journey that continues to this day. Moreover, genes are but one factor in disease, and little is known about what role environment and lifestyle play.
    (2) the digitization of health data is exploding, with a virtually endless list of sources that can offer insight into clinical data, drug studies and more. As more data is digitized, there will be a profound impact on how patient care is administered, how therapies are researched, and how drugs are tested. EHRs (Electronic Health Records) are crucial but implementation is very challenging. Harmonization and data aggregation need to find their way. Wearables are another interesting topic in the digitization of health data. Social media and discussion boards as well as patients website are essential parts of the system that must be closely monitored as more and more patients use those communication channels in order to provide feedback and comments on treatments and daily struggles with healthcare providers.
    (3) the shift to value-based care, where payments are based on the value of care, is driving a change in how services are delivered and how much consumers engage in the process. From a provider perspective, doctors are incentivized to manage patients to the best possible health outcome at the lowest cost. From a patient perspective,
    consumers are being empowered to take a more active role in their own health care.
    These health care trends are being accommodated by technology advances in areas such as social, mobile, analytics and cloud computing, all areas of Google expertise.

 

  • Alphabet invests in health in five different ways:
    (1) Google Life Sciences originated in Google[x], a research lab within Google that was funded by the company’s board of directors in January 2010 to pursue “moonshots”—audacious new projects that have a low probability of succeeding, but could be truly revolutionary if they do. The company views moonshots as critical in driving the true innovation required to affect revolutionary change and avoid the “incrementalism” or evolutionary change that tends to lead to corporate irrelevance over time. The Life Sciences team is responsible for such innovations as glucose monitoring smart contact lenses. With an expanding list of intellectual property, Life Sciences has begun to accelerate its collaborative efforts with third parties. The company is aggressively partnering with leading players in the health care space on a growing number of programs.
    (2) Calico’s mission is to harness advanced technologies to increase understanding of the biology that controls lifespan. Calico was originally conceived by Google Ventures President and General Partner, Bill Maris, who observed that most companies seek to find treatments for disease and associated symptoms, but that none address the root cause of disease and death. He wondered if studying the impact of aging on genetic material could lead to the discovery of drugs that could address many age-related diseases and significantly extend the human life span.
    (3) Google Ventures has provided seed, venture and growth stage funding to a host of companies in diverse fields, but its stated focus is machine learning and life science investing.
    (4) Google Capital was formed to invest in later-stage technology companies with a focus on emerging technology leaders and potential disruptors. Unlike the earlier stage companies in Google’s other investment vehicles, the later stage companies in Google Capital tend to be fairly common household names. Although the stated focus of Google Capital is on technology companies, the collision of technology and health care is blurring the lines of what a traditional “technology” company looks like.
    (5) Google Core: Over time, Google has invested in numerous health-related initiatives within its main corporate division. These have tended to be very closely linked to the company’s core businesses, such as Search. Earlier this year, the company announced that it will add health information that has been fact-checked by physicians directly to search results. The company is also talking to the FDA about using search query data to identify adverse drug reactions.

 

  • Google’s Health-Related Focus Areas: regardless of where they are housed within Google’s corporate structure, most of Google’s health-related endeavors share common characteristics.
    (1) Longevity
    (2) Genetics and Chronic Care
    (3) Diagnostics
    (4) Diabetes/Digital Health
    (5) Medical Devices
    (6) Telehealth/Digital Health
    (7) Wearables/Fitness

 

  • Google’s health endeavors fit with the company’s goals of “making the world’s information useful” and helping millions of people. Indeed, Google believes that many of the same principles, techniques and problem solving capabilities employed by its software developers can be applied to the massive inefficiencies that exist in health care to create transformational solutions and medical breakthroughs that help people live longer, healthier lives. Health care ambitions can be summarized as:
    (1) Analyze: Analytics to inform decision-making and provide business insight
    (2) Attract: Attract health care constituents to platforms and solutions that drive engagement
    (3) Aggregate: Aggregate data from disparate sources onto the Internet or GCP

 

Additional resources:

Alphabet to help researchers predict disease – Financial Times – April 2017

Google Life Sciences Exodus – STAT – March 2016

Verily, Google’s Health Gambit, Is Stacked With Scientists. Now It Needs to Build a Business – ReCode – December 2015

Google hires mental health expert to lead new life sciences unit – Financial Times – September 2015 (Subscription required)

Head of Mental Health Institute Leaving for Google Life Sciences – The New York Times – September 2015

Google Bets on Insurance Startup Oscar Health – WSJ – September 2015

Is Health Care Google’s Next Big Business After Search? This Investment Bank Thinks So – Re/Code – September 2015

Why Google Is Going All In On Diabetes – NPR – September 2015

Google’s health startup, AbbVie team up on drug research – Chicago-Sun Times – September 2015

Google Life Sciences Company Has New Deal, Official Nemesis in Diabetes – Re/Code – August 2015

Alphabet Breathes New Life, Resources Into Google’s Health Care Projects – iHealthBeat – August 2015

Google Health – Easy as ABC. Alphabet, Calico and the Aging of Humanity – What on Earth are they doing? – Digital Intervention – August 2015

 

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Health illiteracy – A major concern in today’s medicine

Health literacy – the ability to obtain, understand and use health information

Making sure that patients understand the information provided to them is critical for health outcomes but also to avoid side effects and disease complications.

The lack of understanding leads to several issues, not only medical like drugs confusion, over- or under-dosage, mismanagement and worsening of treatable conditions, but also financial (it is estimated, for the USA, that health illiteracy costs between USD 100 and 250 billion each year).

Moreover, it is alarming to see that, in a developed country like the USA, only 12% of the population has “proficient health literacy”.

Beyond the communication, language and cultural barriers could be very difficult to get over.

How to empower patients?

Several tools are available today to empower the patients: simplified literature & visual guides to attract attention, patient group meetings led by nurses or dedicated healthcare providers, patient associations, health-related websites, websites for patients… Apart from those interactions, mobile health together with specific apps can provide access to resources regarding one’s health.

Open communication (in both ways), patience as well as avoiding the stigmatization of weak people can really help improve health literacy and simply serve as a form of emotional support during challenging times.

It is fundamental to teach not only young doctors but also senior staff in the healthcare industry in order to tackle that issue. Without proper education and information, even the best medicine is useless.

 

Additional Resources:

Health Literacy Definition – National Network of Libraries of Medicine

Health Literacy Training and Activities – Centers for Disease Control and Prevention

Health illiteracy could be the death of us – The Guardian – 2015

Understanding the true impact of health illiteracy – ArtcraftHealth – 2015

Want to Fix Healthcare? Fix Health Literacy First – Citylimits – 2015

Racial/ethnic disparities in knowledge about one’s breast cancer characteristics – Cancer – 2015

Making health literacy a priority in EU policy – EU – 2013

Consequences of Health Illiteracy – University of Texas – 2012

Many Americans have poor health literacy – The Washington Post – 2011

The Silent Epidemic — The Health Effects of Illiteracy – NEJM – 2006 – Not only health illiteracy but illiteracy stricto sensu (unability to read)

Visual Learning Tools Overcome Health Illiteracy – Patient Safety & Quality Healthcare – 2006

Health Literacy – A prescription to end confusion – NAP – 2004 (free, just register)

Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century – Health Promotion International – 2000

 

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How simulation could help us understand better elderly population’s needs and behavior – Scenario Magazine

Elderly

Simulation allows us to think about what the future might be. It also helps us to understand the current reality and day-to-day life of people, in this article, elderly ones.

Drafting global strategies for an improved care of that fragile population as one of the results of those simulations is crucial in today’s world. Actually, we need to plan for their evolution and needs as they will soon represent the majority of the society.

Read more

Additional resources:

A Silver Tsunami Invades The Health Of Nations – Forbes – 2015

Implications of long-term care capacity response policies for an aging population: A simulation analysis – Health Policy – 2014 (subscription required)

Ageing and the Macroeconomy – NAP – 2012 (free registration to access free PDF)

Video: MIT constructs old-age-simulator suit to make young people feel elderly – Popular Science – 2012

The silver tsunami – The Economist – 2010

 

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The dream of the universal flu vaccine might come true – Wired

Researchers found and tested a prototype of a universal flu vaccine. The first results on animals are good.

Scientists worked with a piece of viral protein so it can teach immune systems to fight groups of viruses rather than just a single strain.

As we all know, the real issue with flu comes from its mutations. It explains why the vaccine may not be so protective against seasonal flu as the virus can change.

It is probably the beginning of a new era of hope because flu kills.

Read more: Wired Article

Additional Articles:

Science Mag

WebMD

Financial Times (subscription required)

The Guardian

Bloomberg

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A Better Understanding of the US Drug Pricing Landscape and Financial Risks Associated – Health Affairs Blog

An excellent article posted on the Health Affairs blog takes a step back regarding US drug pricing and the financial risks associated with drug development well beyond the clinical trials stage.

Key quotes from the article:

  • It may be helpful for the policy discussion to think of a drug’s value as the clinical performance and patient outcomes, while the price reflects both the value and the growing uncertainty around in-market risks of market consolidation and restricted access, branded therapeutic competition, mandatory discounts, and restrictive coverage policy.
  • As competition heats up, each sector and each entity strives to reduce input costs and maintain or improve prices — and consolidation can be an important tool to accomplish these goals. Specific to biopharma, consolidation strengthens payers’ and providers’ ability to press for drug discounts that are contractual, proprietary, and confidential.
  • Net lifetime revenues of new biopharma therapies declined from profitability in the late 1990s to slightly negative profitability by the end of the first decade of 21st century.
  • In addition to cross-sector market competition through payer and provider consolidation, there is growing intra-sectorial competition among generics, biosimilars, and branded therapeutic alternatives.
  • We should not underestimate the potential effect of mandatory price discounts on drug launch prices.
  • In-market risks for biopharma are very significant today. Because of rapid changes in the market environment, revenue expectations established when the decision is made to proceed with product development can be very different than actual revenue several years later when a product is launched.

 

Additional Resources

When Is a Virtual Business Model Suitable for Biopharmaceutical Companies? – BioProcess International – 2015

Understanding the pharmaceutical value chain – IMS Institute for Healthcare Informatics – 2014

Innovative Business Models in the Pharmaceutical Industry: A Case on Exploiting Value Networks to Stay Competitive – International Journal of Engineering Business Management – 2014

The Real Cost of “High-Priced” Drugs – Harvard Business Review – 2014

Rapid growth in biopharma: Challenges and opportunities – McKinsey – 2014

 

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The difficult implementation of value-based healthcare – The Commonwealth Fund

ValueBasedCare

“A new survey from The Commonwealth Fund and The Kaiser Family Foundation asked primary care providers—physicians, nurse practitioners, and physician assistants—about their experiences with and reactions to recent changes in health care delivery and payment.

Providers’ views are generally positive regarding the impact of health information technology on quality of care, but they are more divided on the increased use of medical homes and accountable care organizations.

Overall, providers are more negative about the increased reliance on quality metrics to assess their performance and about financial penalties. Many physicians expressed frustration with the speed and administrative burden of Medicaid and Medicare payments. An earlier brief focused on providers’ experiences under the ACA’s coverage expansions and their opinions about the law.”

Probably each start of a new system is painful and requires people to adapt to it. However, it will have to be carefully monitored as adoption by healthcare providers is crucial for the success of the new system. It will validate the concept of value-based healthcare.

Read more

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US healthcare coverage increased from 85 to 90% – TIME

In a little less than 4 years, US healthcare coverage increased from 85 to 90% according to a TIME article.

“Decreasing the number of uninsured is a key goal of the Affordable Care Act (ACA), which provides Medicaid coverage to many low-income individuals in states that expand and Marketplace subsidies for individuals below 400% of the poverty line.” as stated in an article of KFF.

However, it will be difficult to have a full coverage of the population as some individuals refuse to buy healthcare insurance as they do not see how they could take advantage of the money spent in it. Some of them could simply not afford to buy coverage despite the subsidies.

Moreover, some issues arise with the methodology used to count the number of insured/uninsured people (see the Health Affairs article at the end of the post for more details).

In conclusion and despite all the issues with people not willing to adhere or counting methodology, it is a real progress to expand coverage, especially because US were lagging behind some emerging countries (have a look at the OECD Publication “Health at a Glance 2013” on page 138-139).

And what’s really interesting is the impact of more coverage on global health as a blog post pointed out.

Additional information

Estimating the Affordable Care Act’s Impact on Health – The Commonwealth Fund – August 2015

Meet the Health-Law Holdouts: Americans Who Prefer to Go Uninsured – WSJ – June 2015

Survey: America’s Uninsured Rate Is Down To 10% – And Falling – Forbes – June 2015

Counting The Uninsured: Are We Getting It Right? – Health Affairs – May 2015

Key Facts about the Uninsured Population – Kaiser Family Foundation – October 2014

Is the Affordable Care Act Working? – The New York Times – October 2014

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MicroHealth Helps Patients Manage Chronic Illnesses

We know that chronic diseases account for the majority of health expenditures. Helping patients with digital tools improving the management of their condition is a great step forward!

10 thoughts from 5 great healthcare minds – Becker’s Hospital Review

5 important people gave their thoughts about our current healthcare system in this Becker’s Hospital Review article:

– Jonathan Bush, founder and CEO of athenahealth (Watertown, Mass.)

– Malcolm Gladwell, journalist and best-selling author

– Chuck Lauer, former publisher of Modern Healthcare, and author, public speaker and career coach

– Nancy Schlichting, CEO of Henry Ford Health System (Detroit)

– John Halamka, MD, CIO of Beth Israel Deaconess Medical Center (Boston)

My favorite thoughts in a nutshell:

– On healthcare’s sustainability: new infrastructure is essential. Obsolete systems are a burden and a brake when it comes to innovation and efficiency.

– On changing the practice of medicine: doctors will have to consider the patient as a whole and spend time taking care of all the aspects of his/her health.

– On high-price medicine: prices should be linked with the innovation the product brings to the patient and the other stakeholders including the health system.

– On sharing healthcare data: data sharing with the goal of improving the life of each patient by learning and analytics could be a game-changer in the next future.

All these quotes could inspire leadership styles and help us create, implement and deliver better care for the patients in need.

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Failure to publish the results of all clinical trials is skewing medical science – The Economist

Truth

A recent article published in The Economist highlights the fact that more than half of all the clinical trials are never published.

In any situation, if we only know half of the truth, distorsions ocurr and could lead to inappropriate and harmful decisions. A US law was passed in 2007 to encourage pharmaceutical companies to register them on a website and give follow-up on the results.

But this is not always precisely executed. After the legal maximum of a year was up, the percentage of clinical trials which had had their results published:

– 17% of those paid for by industry;

– 8% of those sponsored by the National Institutes of Health;

– 6% of those paid for by other government agencies/academic institutions.

The quantity of missing trials is huge and hiding poor results is not what we expect from scientists.

It has to change as hidden or missing data could lead to the use of inappropriate drugs in some patients. There is hope: the website Alltrials (launched by Ben Goldacre) and the charity behind this initiative are leading the movement toward more transparency. The charity “Sense About Science is working on an index, to be published later this year, that will rate pharma firms according to the extent of their commitment to publish all trials”.

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Pager is an “Uber/Amazon for Healthcare” – Forbes

Several new innovative and internet-linked services are emerging every day.

Several years ago, Amazon was selling books online, then it became a one-stop shop for many other things; Google expanded its traditional search engine business into a variety of other activities; Apple as well as other mobile phone producers launched smartphones only few years ago.., we can go on forever with examples.

Healthcare is one of the last area reached by digitalization. But the trend is now more than settled.

Recently a new startup named Pager raised USD 14 million for making your medical appointments instant and for a flat fee during extended hours (from 8:00am to 10:00pm).

A Forbes article drew some parallel with Uber for taxi ordering:  “The service finds and verifies doctors for its network and bills you automatically over a linked credit card”. However the CEO, Gaspard de Dreuzy, compared the company with Amazon instead: “Pager is focused on delivering a broader range of care options on demand than exist today. It could be a tele-consult via phone or messaging, or an in-person visit in the home, or a referral to the right specialist. We like to think of ourselves as the Amazon for healthcare.”

The service is only currently available in New York, but the company will soon expand its operations with the funds raised.

Other companies like ZocDoc or Doctors on Demand are also facilitating life for patients or people looking for health services quickly.

Below an pic from WSJ (see the related article in the Additional material section):

OnDemandDoctors-WSJ2015

Additional material:

Startups Vie to Build an Uber for Health Care – WSJ – August 2015

The Best Digital Business Models Put Evolution Before Revolution – Harvard Business Review – January 2015

There’s Now A Seamless For When You’re Feeling Sick – Huffington Post – December 2014

9 Healthcare Tech Startups To Watch – InformationWeek Healthcare – December 2014

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