Jamie Titak

HealthIT & mHealth Enthusiast

The Importance of Doctors and Patients Staying Connected between Visits

I recently interviewed Todd Johnson, Chief Executive Officer at HealthLoop to learn more about how HealthLoop is keeping patients engaged with their providers in between visits to improve quality of care.

HealthIT & mHealth: Could you provide me with some background information about yourself and HealthLoop to start off with?

Todd Johnson: I have been in healthcare IT since 1999 prior to joining HealthLoop as the CEO two and a half years ago.  I was the CEO of a healthcare company called Salar, which sold software solutions to large academic medical centers and health systems.  HealthLoop is a Silicon vValley based digital health company with thirty-five employees.  It was started by a primary-care physician, Dr Jordan Shlain.  The general premise of the company is: as patients we spend 99.9% of our time not with our doctors, yet our doctors are the ones guiding our diagnoses and our treatment plans.  Once doctors have given you your treatment plan and discharged you, there is no feedback whatsoever about what is going on with you.  The healthcare system has been completely designed around optimizing transactions.  Doctors and hospitals source of revenue is based on how many patients they see, how many procedures they do and how many patients are staying inpatient at the hospital.  The healthcare system has gotten really good at optimizing around throughput, shortening our visits with our providers and shortening our stays in the hospital.  Therefore as patients we are getting increasingly less time with our doctors.

Nationally we are spending forty-four billion dollars on medical care that is unnecessary.  If the physician knew that the patient was doing well, or more importantly knew that the patient was not adjusting well to the treatment or having adverse events, they could intervene and modify the treatment plan to be more cost efficient and provide and a better outcome for the patient.  Through an acute episode of care, HealthLoop checks in with patients on an often daily basis with to remind them on what they need to do, guide them and educate them on what is expected and how they should be feeling.  This assesses how they are recovering so that if there is a complication the doctor can be notified before it is too late.  The provider can then take the necessary steps to mitigate the issue and make sure that the patient gets the best treatment possible.  We do this through technology, we have a team of clinicians out in Mountain View that we call empathologists that offer care plans to patients.   The care-plans detail what to expect through a very specific episode of care.  When the patient is diagnosed or scheduled for a surgery, they get enrolled in one of these care-plans and receive daily check-ins from the provider.  The patient can then log into a secure site where they get an interactive dialog of what they need to know for that particular day, what they need to do that day and what symptoms they need to look out for.

HealthIT & mHealth: Do the providers have pre-set messages that they can easily send out during their normal workflow?

Johnson: I think you are hitting on one of the fundamental challenges of the business, which is doctors and their teams are short on time.  The implementation of HealthLoop is designed to be absolutely frictionless.  There a couple of different ways a patient can get enrolled in HealthLoop.  A physician can order their enrollment through the patient’s medical record, just like they would order a drug.  However, the most popular method of implementation is integrating with the scheduling system where HealthLoop enrollment will be automatically triggered by certain events.  The care plan is all pre-filled so there is really nothing that a provider has to do on a daily basis.

HealthIT & mHealth: Does HealthLoop then pick up on the ADT and SIU HL7 messages?

Johnson: Yes, that is a popular methodology for collecting diagnosis and patient health information, but it is not the only methodology that we utilize.  We also use order events, and hospital discharge messages.

HealthIT & mHealth: Are you looking to continue using HL7 or are you looking into FHIR or web services?

We love FHIR, I think it will take a few years to get to any reasonable set of critical mass in the real world.  Traditionally, healthcare IT systems have been really difficult to implement and it adds to a good chunk of the expense, time and organizational resources to get systems up and running. Being a Silicon Valley company, with Silicon Valley designers, we are always trying to figure out how to make integration into existing health systems as friction-less as possible.  We have our implementation time down to just a couple of weeks for large health systems, which health systems are not used to.

HealthIT & mHealth: What different conditions have you found can be aided the most by using HealthLoop?

Johnson: We search for the conditions with the biggest impact.  You could create a protocol for patients with the common cold, which would include a lot of patients, but the failure rates for the common cold are extremely low.  Therefore, we look for episodes of care where there is enough variability in cost and outcome and where having this type of patient management system can have a true impact on patient outcomes and total cost of care.  If you look at the road map towards value-based care, CMS has identified those conditions, which include procedures such as spine surgeries, cardiac catheterizations, and coronary artery bypass.  In order to have a positive impact on the workflow of entire practices, we have developed specialty modules like Orthopedics, OBGYN, Neurology, Cardiovascular, ENT and general surgery.

HealthIT & mHealth: What are the patient engagement numbers like for HealthLoop?

Johnson: We have an opt-out protocol so all patients get enrolled unless they alert their provider that they would like to opt-out of the program.  Eighty-one percent of those patients activate their accounts and are actively engaged.  Providers usually predict that their younger patients will be more engaged than their older patients.  The truth is that the sixty to seventy year age group is the most likely age group to be one-hundred percent engaged.  Even the elderly cohorts are engaged up to forty-seven percent of the time.  The least engaged cohort is the eighteen to twenty-five year old male.  Women are more engaged than men and mothers of children who are going through a health episode are likely to be one hundred percent engaged.  So the numbers are outstanding and what is very cool about HealthLoop is that the patients are doing all the work, we are not burdening providers with extra work.  The patients are happy to do the work because they are sick or injured and they want to be engaged to get the best outcome possible.

Healthcare 2.0 and Underserved Communities

Interview with Garth Graham, MD, MPH, President of Aetna Foundation

HealthIT & mHealth: What types of philanthropy does Aetna Foundation do?

Garth Graham: In general, we do grants targeted in the space of innovations that help underserved and hard-to-reach communities. We fund technological and other kinds of population health innovations targeted for health care providers.

HealthIT & mHealth: What type of innovations has Aetna Foundation supported for underserved communities?

Graham: We have funded a number of different projects that deal with clinical care or public health within these populations.   An example project is a two-way text messaging system provided to churches within African American communities. The project aims to connect health ministers in those churches with people in the congregation that are interested improving their health. Another project works to integrate the social determinants of health with the patient encounters in the EHR. This allows providers who are viewing a patient’s clinical results to integrate social factors into clinical decision making.

HealthIT & mHealth: What are the typical health issues that underserved populations face?

Graham: In underserved and minority communities you see a higher rate of heart disease, diabetes and many cancers. There is a higher increase in a lot of chronic illnesses.

HealthIT & mHealth: What types of educational materials does Aetna Foundation provide for this community and their children?

Graham: We work with a number of grantees who are directly working with children around using technology to improve health. For example, we work with well-known organizations like the YMCA, which have a long track record of working with kids. We work with a number of these groups using technology that children are familiar with to help educate them around the kinds of things that will make them healthier.

HealthIT & mHealth: How did the passing of ACA affect the foundation and your projects?

Graham: The ACA in general, theoretically brought more coverage to minority groups and other underserved communities. However, that did not directly affect our projects. We are partnered with the HHS, the HHS IDEA Lab and folks in the community to come up with ideas around how to use technology to improve health in underserved communities. We announced some of the grants we are doing with the HHS at Health 2.0. The ACA created entities like the HHS IDEA Lab, which has helped to create more nodes of innovation to help develop some of these ideas.

HealthIT & mHealth: What are the top disparities and barriers that the underserved population faces?

Graham: There are two major barriers. One is access, which includes access to primary care and access to specialty care. The other is strategies to improve preventative care in these communities.

HealthIT & mHealth: Does Aetna Foundation do any projects focusing on mental health issues?

Graham: Access to mental health services is a major problem for the underserved communities. A lot of underserved individuals within these communities may not present directly to a mental health provider, they may present to a primary care provider. We work with organizations such as NAMI, which tries to bring more integration of mental health care into the primary care setting.

HealthIT & mHealth: I even have problems trying to read my own healthcare bills. Are there resources to help underserved individuals navigate the convoluted healthcare industry?

Graham: There are two challenges there, one is health literacy in general, which is a challenge even for physicians and other healthcare workers.   It is so complicated. The other challenge is a language barrier. What we are really looking to do is create technology that will educate people at a specific time when they are experiencing healthcare questions. A big part of it for us is using mobile health and digital health technology to give people the health information they need, right when they need it.

HealthIT & mHealth: What do you think the next policy or technology should be that would help this population the most?

Graham: I think the two major things are empowering people, and making the healthcare system simpler for these communities. We are looking at ways that we can do that with technology

HIPAA-Compliant Messaging

Interview with President of TigerConnect, Itamar Kandel

HealthIT & mHealth: Can you give me some background information about tigertext?

Itamar Kandel: We started tigertext almost six years ago; we identified a problem with the market where doctors and clinicians were adopting smartphones at a much higher rate than almost any other segment of the population. They would bring their cellphones to the hospitals and use them as one of their main channels of communication. Instant messaging was such an easier form of communication than emailing, faxing, paging, or communicating through the EHR systems. SMS fit into exactly with what providers wanted to do. There is a much higher likelihood to get ahold of a doctor if you have their SMS phone number. We identified two key elements that providers have cellphones and they are bringing them to workplace, using them as a communication channel. To add to that, the SMS method of communication was completely not HIPAA compliant. Meaning, it is not authenticated, it is not encrypted and it lived forever on the cellphone network. That was a huge liability for the hospital. The origin of the company was really let’s try and solve that problem. The way we solved it was that we created our own HIPAA compliant and encrypted messenger that was very similar to WhatsApp, iMessage and other chat clients. Tigertext messages do not live forever on the server, messages self-destruct within a certain period of time.

That is version one of the company, creating the messenger with all the current healthcare regulations supported. So far it has been a successful product; today we are the biggest vendor in the market. We are in about five-thousand facilities around the country. Four to five of the largest healthcare systems in the country are our customers including: CHS, UHS, Barnabus, Geisinger, Multicare and Tenet. For those facilities, we basically come in and install the closed-network communication system that allows clinicians, technicians and nurses to communicate in a very easy, but HIPAA compliant secure way.

HealthIT & mHealth: Do the hospitals typically need custom setups for messaging?

Kandel: Yes and no. The system itself is so simple, it is a messenger, everyone knows how to use a messenger. We are a cloud-based company so there is almost no hardware at the clinic or hospital. The configurations are also very straight-forward. That said, that leads me to the next iteration of our company. We have opened our APIs and started working with other systems like EHRs and EMRs such as: Epic, Cerner, Allscripts and Meditech. We have also done integration with scheduling and lab systems. Here’s an example of how the integration with the Cerner EMR works. A physician orders a blood test for a diabetic patient to test their glucose levels. The lab technician conducts the test, then enters the results into the Cerner EMR and the EMR immediately triggers a notification because the results are abnormal. This notification is then securely sent to the physician’s cell phone via TigerText containing the actual lab results along with any other pertinent patient information. Without this integration, the long lag time between the blood test and the physician seeing the results could be potentially life threatening, but with the tigertext integration, it’s almost instantaneous – about 13 seconds on average.

HealthIT & mHealth: How do you integrate with the EHRs? Is it by HL7, XML, CCD ect?

Kandel: Every vendor has a slightly different integration structure. For example, with Cerner we integrated right on the SMTP pipe. Cerner had sent emails that way previously and now they can send text messages utilizing the SMTP pipeline. With Orion’s HIE product, we integrated directly with their Rhapsody Integration Engine. An ACO, Scottsdale Health, a client of Orion, created specific workflows with tigertext to lower readmission rates. The new workflow enhanced discharge procedures, which translated into an incredibly low readmission rate.

HealthIT & mHealth: Do the devices that run tigertext need to be encrypted?

Kandel: We work well with BYOD devices because the app is self-contained, so no information is ever saved on the phone and lives on the HIPAA compliant server. Therefore, the issue of phone encryption is not as important. The messages are encrypted in transit from the server to the app, a full end-to-end encryption. The hospitals have the ability to remotely wipe all the information in the app on the phone and perform forced log outs. In addition, there is a PIN lock on the app to for security.

Never forget your pills again

Interview with Jon Michaeli EVP of Business Development at Medisafe

HealthIT & mHealth: What separates Medisafe from other medication adherence applications?

Jon Michaeli: The first thing we usually talk about is that we are not an app, we are a platform.  There are some programs in the app store that are just apps, you download it and get reminded to take your medications, that’s it.  Forgetfulness is a major reason why people do not take their medications, but there are many other reasons such as: support systems, motivation, cost of medication and side effects.

As a platform, we try to address all the underlying causes, not just forgetfulness.  In order to tackle all of these issues, you cannot just be an app that you download.  You have to be connected to the broader health system because it is not just enough for the patient to remember to take their meds.  Patients also need intervention from the outside from the doctor, the care team, and payers to stay out of the hospital.   We have a cloud-based infrastructure and the app is a consumer channel. The app is what patients use, but it is not the only thing.  Data flows and interaction capabilities are all stored in the cloud; we are bringing in data from the outside for the patient so that they can connect to the patient portals and import their medications.  This helps alleviate user input issues and personalize the experience for patients.

Medisafe’s caregiver component, the Medfriend, allows any user to add a family member or a professional caregiver. That Medfriend is notified if the patient misses a dose. The caregiver can also view the medication schedule and see how the patient is doing.  We also have a partnership with GoodRX to provide coupons to users for their medications.  We are currently doing pilots with hospital systems and PBMs.  The University of Arkansas Medical Sciences group did a study on four-hundred-sixty-one adherence apps and Medisafe came out first.  We have 2.2 million users and nearly 100,000 reviews in Google Play and the Apple app store with an average rating of 4.5 out of 5.  We have already begun to look at data from patients with high blood pressure and found that users of the Medisafe platform lower their systolic levels by an average of 19.3 mmHG within 30 days.

HealthIT & mHealth: Do the push notifications ever annoy patients or do they just hit the “snooze button”?

Michaeli: Our users are engaged and what we hear from most users is that they rely on the platform to be reminded to take their medications.  The notifications are keeping them adherent to their medications and when they hear that sound they are very thankful that it is there.  What we have done to make it more human and personal is to allow users to choose different voices to remind them to take their medications.  You can even have Obama, Austin Powers or Elsa from Frozen remind you to take you pills. The users really like it and they look forward to getting the notification.  Alert fatigue may affect some users, but we have not seen a decrease in engagement from the majority of our users.


HealthIT & mHealth: How do you integrate with EHRs to collect medication data?

Michaeli: We work with a middleware company called Human API and there are others out there that are starting to do similar things connecting data.  It is patient-enabled; the user goes to the Medisafe app and clicks on a button to import their meds. The user is then taken to the middleware company that allows them to find their hospital or clinic in a list.  Once the user has selected their clinic, they will input their login information for that particular clinic and it will automatically import the medications to the user’s profile in the platform.

HealthIT & mHealth: Do patients ever worry about privacy or security issues?

Michaeli: We are HIPAA compliant.  A lot of users hear about us from their pharmacists, doctors or friends, which helps to engender a trusting relationship with the user and reinforces our credibility.  Our CTO came from Checkpoint Software, a cyber security company, so we take privacy and security very seriously.

HealthIT & mHealth: Will the app alert you of possible side effects or drug interactions?

Michaeli: We have access to the Drug Interaction Database, but we are not using it to its full capability today because it was not one of the first issues of non-adherence that we were seeking to solve.  There is a lot that goes into the decision tree of who you would notify when there is an interaction and what responsibilities that person has once they have received the interaction information.

HealthIT & mHealth:  What were some of the questions you received from the panel that you were on at Health 2.0?

Michaeli: The panel was basically companies that were addressing medication non-adherence in different ways.  There were four of us and we presented a demo of our solutions and fielded questions.  Some of the questions participants had were: what differentiates you from the competition, what is unique about you product, and why are you relying on user input and is user input an accurate way to reflect medication adherence.


How McKesson is Preparing for the HL7® FHIR® Standard

The next generation of standards created by Health Level Seven (HL7) is FHIR®, which combines features from HL7®v2, HL7®v3 and CDA®. I was fortunate enough to have a conversation with Sally Love Connally, VP of Strategy and Business Development at McKesson, to learn more about McKesson’s perspective on FHIR and how they are currently using the new technology.

HealthIT & mHealth: How is McKesson currently utilizing FHIR?

Sally Love: We are extremely excited about the potential power and capabilities that FHIR offers. FHIR is still relatively new. McKesson is trying to accelerate the maturity of the standard so that it is commercially ready to meet the needs of our market. McKesson was one of the first stakeholders in Project Argonaut along with several other key stakeholders initiating the effort to really push FHIR forward. We recognized that FHIR combined with REST are essential components to achieve the level of person-centered interoperability required for the transition to value-based payments. Currently, we are actively working with Argonaut to progress the standard as well as with our internal teams to determine where the use of FHIR makes the best sense for us as a company. We are excited about its capabilities and see FHIR as a powerful tool for a variety of uses cases, including real-time clinical decision support (CDS), where sharing discrete data makes sense.

FHIR also enables SMART-based applications to personalize workflow and address some of the key provider challenges as they use EHRs. Overall, it is important for care coordination, and it is amazing how excited people can get about a standard, which is pretty rare in our industry. As with any standard, there will be growth challenges, and it’s best to begin using it—that’s the only way to learn its limits and where improvement is needed. McKesson is conducting a series of internal connectathons in which we are building on the strength of our FHIR experiences and expanding our knowledge of the power and the strength of the standard. Our people are seeing that FHIR is easy to learn and has a lot of practical applications for our solutions.

HealthIT & mHealth: Do you currently have any clients that use FHIR?

Love: We have not rolled FHIR out in a production state at this point. Our RelayHealth business is the service provider for CommonWell Health Alliance and its RESTful services were inspired by early drafts of FHIR. At this point, other McKesson businesses are looking at it for the next stage of our applications and solutions. We are in the process of talking to customers who are interested in working with us on various use cases and proofs of concept.

HealthIT & mHealth: Will clients who are currently using the CDA architecture switch over to FHIR completely or use both FHIR and CDA architecture for different processes?

Love: We see FHIR as a complement to the CDA. I believe there will continue to be a place for the CDA in our market; full document exchange is going to remain important. However, FHIR will be used more frequently in the granular exchange of information for use cases where there is no need to move the entire document.

HealthIT & mHealth: What types of projects are you doing with the Argonaut Group?

Love: We are currently working on profile mapping. In fact, most or all of the vendors are focused on profile mapping and looking at the common clinical data set. Argonaut is focused on the original Meaningful Use Stage 2 (MU2) data set. With the Stage 3 NPRM coming out, the common clinical data set has been expanded, so we are reconciling that. Argonaut has just kicked off phase 2 with significant focus on implementation to continue to improve on the quality of the specifications and ultimately the implementation guide.

At HIMSS, we did a demonstration with our Paragon® electronic health record at the CommonWell Health Alliance booth. We demonstrated FHIR with Cerner and Athenahealth, sharing medication information in a variety of care delivery scenarios that involved all three vendors. It was a compelling example of what FHIR can do. We used the CommonWell Health Alliance® broker to fan out across the systems looking for a common patient and then pull the medication information from each site that the sample patient had visited and present it to the provider. This exchange could be used by a care coordinator to update a shared plan of care, or it could be used by a provider at a point of service to understand the patient’s current medications. The real-time exchange of information is use case-specific so you don’t have to go through the entire summary of care information. Instead you can immediately access the medication information, which is what the provider would need at that point in time.

HealthIT & mHealth: How many clients do you think will be using FHIR in the next two to three years?

Love: We will begin to introduce FHIR-based services gradually. As we move toward the 2015 edition of certification for HIT and see Stage 3 rules finalized, the APIs we offer are likely to be FHIR-based. Customer adoption will be driven in large part based on their meaningful use stage and participation in alternative payment model programs. Customers will look for solutions that enable them to share information inside their health systems and more broadly across the community. As that need grows, so will the demand for the types of services supported by FHIR.

HealthIT & mHealth: How does FHIR improve interoperability?

Love: The standards in use today are often cumbersome and dated. They don’t take advantage of web-based technologies, and that is the beauty of FHIR. When you combine FHIR with REST, there are many things you can do that are not possible with the traditional HL7 or SOAP-based standards. FHIR not only supports increased granularity, but also modularity. There are smart apps that are FHIR-enabled, which can personalize the user experience. This goes well beyond the things that we can do today.

When you combine the broad industry efforts of CommonWell-type alliances that are solving for patient matching, consent and authorization with FHIR and REST, you can see that person-centered interoperability is possible. Add the market shift to value-based care delivery models that demand levels of care coordination and patient engagement never before required, and we are at a unique place where interoperability is doable.

© 2015 McKesson Corporation and/or one of its subsidiaries. All rights reserved. Paragon® is a registered trademark of McKesson Corporation and/or one of its subsidiaries. CommonWell Health Alliance® is a registered trademark of CommonWell Health Alliance Inc. HL7®, CDA® and FHIR® are registered trademarks of Health Level Seven International. Other product or company names mentioned may be trademarks, service marks or registered trademarks of their respective companies.


Startup Spotlight: hidn tempo, a Wearable that Measures Stress Responses

I was given the opportunity to speak with Jonas Angleflod and Johan Lidenmark of hidn technology to learn more about hidn tempo.

HealthIT & mHealth: What does the hidn tempo wearable measure?

Jonas Angleflod: We measure three metrics. We measure stress, sleep quality and activity, all three combined give us a more complete picture of what’s happening. When it comes to stress markups from a physical point of view, those could be related to physical activity as well. This is why we are measuring physical activity and movement as well to ensure that the stress happening in the body is not connected to any physical activity.

HealthIT & mHealth: How do you determine that the stress in the body is not caused by physical activity?

Angleflod: We are using GSR, galvanic skin response, which basically looks at the changes in the conductivity of the skin. It has been used within psychology for decades now as a tool to help patients during sessions to see if they were moving from one plateau to another, calming down or getting more stressed. But since we can do that in real time, we can actually measure the movement of the conductivity, which is based on how much you sweat and how much your sweat glands are moving. We are looking for a specific pattern which suggests stress and we are looking for changes in where you are on a scale. Since we have an accelerometer, which looks at movement in all three dimensions, we can rule out stress caused by movement. For example, a period without movement for five seconds in which the wearable suggests a stress response, we can conclude that it is an emotional response. The emotional response could be stress, happiness, or any other emotional response. For this reason we also added the ability to ask the user what is happening. What we have seen is that stress becomes a downward spiral, you do not just get one markup and then nothing happens, the stress markups increase in amount in a short period of time. What we see is actually a series of stress markups and when we see that we alert the user that this is happening and they are at stage one. After the user is alerted we ask them what they are currently doing, where they are, and what they are feeling, which could be both positive and negative feelings. It stores the negative feelings related to stress together with the stress markups. The physical and psychological data puts the complete picture together.

HealthIT & mHealth: Do plan to sell the wearable through physicians or directly to consumers?

Angleflod: The plan right now is to sell directly to consumers. We are working on the business model, we have two variables on the model. One is buying the product up front with everything included for eighteen months, the other is buying the wearable as a service during those eighteen months, basically one-eighteenth of the cost every month. We are currently in beta testing and we going to open an even larger user test at the end of the summer. Once we finish that test we are planning to start production. We are aiming to start delivering products at the fourth quarter of this year.

HealthIT & mHealth: What kind of accuracy does hidn tempo have?

Angleflod: The most accurate way to measure stress is to measure the amount of cortisol that you have in your body. However, that would mean that we would have to put something in the mouth of the user in real time, which is not very practical. We are above the ninety percent range when it comes to measuring emotional markups utilizing GSR. We also take away the physical activity in regards to measurements as well as query the user, both of which increase accuracy.

hidn tempo


Startup Spotlight: Self Echo, Improving Mental Health with Technology

Ever since Sigmund Freud invited his first patient to visit his office and lay down on his couch, clinicians have been forced to rely on what their clients tell them during their therapy sessions. But human memory is notoriously unreliable, and evidence suggests that people aren’t very good at remembering what they were doing, feeling, or thinking in the days or weeks since their last visit. Furthermore, life is lived in the trees, not the forest, which means that we just aren’t very good at seeing the larger patterns of our own behavior. Mobile Therapy allows people to easily and effortlessly share real-time information about our thoughts, feelings, and actions to our therapists, who can use this information to inform their treatment plans. “How have you been this week?” is a question that therapists need no longer ask because before their client sits down, they will already know the answer.

Consider an analogy in the world of medicine. Once upon a time, if your physician wanted information about your heart rhythm, he or she had to measure it in the hospital. But those measurements were of limited use because they didn’t tell the physician what your heart was doing under normal circumstances – as you ate, slept, walked up the stairs, argued with your spouse, and so on. That all changed in 1949 with the invention of telemetric cardiac monitoring by a scientist named Norman Holter. Today, if your physician is worried about your heart rhythms, he or she will send you home with a Holter Monitor attached to your belt, and this device will collect data about your cardiac functioning as you go about your daily activities. These data are invaluable and irreplaceable, and most physicians would not consider treating you without first collecting them. I think psychotherapy is about to enter the “Holter phase.” In the not too distant future, it will be unthinkable for therapists to treat clients without first collecting solid, real-time data about how and how well their client is functioning in his or her everyday life.

Dr. Daniel Gilbert, professor of psychology at Harvard University and Senior Scientific Director of Mobile Therapy

I was able to get the chance to speak with Jacques Habra, Thought Leader and Executive Board Member at SelfEcho, Inc to learn more about the SelfEcho app and the Mobile Therapy platform:

HealthIT & mHealth: How did the team come up with the idea for Mobile Therapy?

Jacques Habra: I’m a serial entrepreneur and I often lecture at colleges and universities about what it takes to be an entrepreneur. One of the main things to be successful, productive and happy is to “know yourself.” You need to know your strengths, weaknesses, capacity, and patterns. The original idea was to build an app to allow for the average person to know themselves better.  The smartphone can collect a tremendous amount of data and various environment variables on what someone is doing, where they spend their time, and how different locations and activities make them feel. Then, the goal was to provide real objectionable data to help them understand what they like and what they don’t like, when they are most likely to be successful, and when they should take a break. When we started to develop that product we realized that we had a really powerful psychology tool; we realized that giving the average person that information about themselves isn’t necessarily going to transfer to change. In order to change you really need an expert, in this case a clinical psychologist or medical professional to really embrace the treatment and help you as an individual to make actionable adjustments in your life to manage through the problems and opportunities that the system helps you discover.

HealthIT & mHealth: How does the patient typically interact with the SelfEcho app?

Habra: Throughout the day and based on geographical movements, the user is prompted to answer questions, with a frequency from one to ten times a day. The questions are always customized around the client. The client will get a notification that says “Time for a SelfEcho check-in”. The client can either dismiss the notification or complete the check-in.   It takes about a minute to do a full check-in, which consists of a few questions followed by a Facebook-like status update of what you are doing, where you are and who you are with. The system knows your most common locations, most popular activities, most common people you interact with in order to allow for rapid input. This allows the clinician from various establishments, one of which is WhiteSands Tampa, to experience all of details of the check-ins in very meaningful psychological terms.

HealthIT & mHealth: What type of data does the Self Echo app collect on the patient?

Habra: Sixty percent of the data we are tracking is active data provided by the individual through momentary experience sampling surveys and about forty percent is passive data, that does not require end-user input. Linguistic analysis provides data to the Mobile Therapy system passively. SelfEcho is the only company in America that has a license to the LIWC System system out of the University of Texas in the field of psychotherapy.   The LIWC system allows the app to extract emotional sentiment based on the words that patients use in emails or social media broadcasts. Our software analyzes the text and provides a score around things like positivity, negativity, social connectedness, and authenticity. It’s important to note that the Mobile Therapy platform in no way reads emails and no emails are downloaded. The LIWC system only numerically scores the content.

HealthIT & mHealth: Does the app collect accelerometer data from smart phones?

Habra: Yes, we tie into third party APIs like the Apple Health Kit to provide physical metrics alongside the psychological metrics. However, most psychologists simply want access to the psychological metrics, which is plenty of additional data for them at this point.

HealthIT & mHealth: What types of questions do you ask patients to collect active data?

Habra: The questions are all customized around the specific diagnosis of the patient. The clinician can chose which questions to ask the patient and create custom questions and metrics. A patient will typically be asked five to six questions at a time that focus on psychological metrics like stress, anxiety, depression, guilt, social connectedness, fear, anger, or concentration just to name a few.

Self EchoMobile Therapy

HealthIT & mHealth: What type of algorithms and formulas do you use to analyze data?

Habra: Everything we use is based on scientific research and most of our algorithms and formulas are based on American Psychological Research papers. Everything is vetted through our science team and they are the ones that are designing the questions, the weighting of questions and the potential clinical benefits of the individual client data.

HealthIT & mHealth: Does the app give feedback to the patient?

Habra: The patients have the right to all of their data under HIPAA, but most clinicians do not want their clients to see any data at all because they could misinterpret the data. This is one of the reasons our product is targeting the end-user through the clinician; the only way the end-user can access the data and reports is through the clinician.   The clinician has a sense of what the data means and how to make the data actionable. For example, if the data is suggesting that the client is having a really good day and they are feeling despondent that would be very confusing for the patient. In addition, if data suggests that the patient is depressed and they are feeling great about themselves, they might get depressed because they are supposed to be feeling depressed.

HealthIT & mHealth: Have you found that psychologists have enough time in their workday to analyze all the data?

Habra: That is the entire business model right there and the answer is that we encourage the clinician to offer one of three different types of programs. Mobile Therapy increases the clinician’s practice revenue, so with Mobile Therapy, the clinician can actually make more money.   The light version, which clinicians usually offer for free or a nominal charge of ten to twenty dollars per month would involve the clinician looking at the data for five minutes before and five minutes after the session. The next level up entails having the clinician reviewing the data thirty to sixty minutes between sessions with a recommended extra charge of fifty dollars per month. The third level is known as concierge psychology, which enables the clinician to provide care right at the moment the patient needs it. For example, if the app detects that the patient is suffering from a bout of depression or having a panic attack, the clinician can be notified instantly and send the patient a reminder to practice breathing techniques or contact the patient for a therapy call or visit. Mobile Therapy recommends that clinicians charge at least one-hundred and fifty dollars for concierge psychology, however some clinicians charge as much as two-thousand dollars a month. Despite recommended charges, clinicians can charge whatever fee works best for their practice.

HealthIT & mHealth: Do patient’s insurance pay for the Mobile Therapy Service?

Habra: We are meeting with lawmakers and heads of insurance companies at the end of the month in DC to continue the process of obtaining an insurance code for Mobile Therapy and are hoping for an insurance code in three to six months.

HealthIT & mHealth: Do you currently integrate with any electronic health records?

Habra: We have been approached by a few EHR and EMR companies and we are exploring integration right now. One of the most promising integrations is with Microsoft, Microsoft has a product that they use with a big clinical community. We definitely see partnering with EHRs and EMRs to be the next step

HealthIT & mHealth: Is the Self Echo app HIPAA compliant?

Habra: Everything is HIPAA compliant, which was no trivial task. Everything from the way the phone encrypts the data to how data is transmitted to the server and the dashboard itself to the way the database stores the data is all HIPPA compliant.

HealthIT & mHealth: Which mental illnesses are patients currently using the app for?

Habra: So far people really benefit in cases of depression, anxiety/stress, relationship conflicts, and recently PTSD.

HealthIT & mHealth: Has the app been proven useful for patients who typically do not feel comfortable speaking with therapists?

Habra: That is a big factor, but to be honest with you, the biggest issue is that people do not remember how they felt and what made them feel that way, positive or negative. Clients enjoy the app because it’s a way for them to provide more data to their therapists and thereby feel more invested in their therapy. Some clients report sharing more intimate thoughts through the app than they would in live session.

Moov: The Wearable Coach

Moov is an advanced wearable with a 9-axis motion sensing system that analyzes your motion in 3D and coaches you on how you can improve your workout. Moov currently has five different apps: Run & Walk, Swim, Cardio Boxing, 7 Minute + Workout and Cycling. Moov’s interactive coach utilizes artificial intelligence technology to monitor your movement and provides audio and visual feedback while you are exercising. Moov’s coaching philosophy is based on interval training, different levels of intensity, form and variety.

Moov-CardioMy favorite app that can be used with the Moov wearable coach is Cardio Boxing. It is basically like “Guitar Hero” for boxing and is so much fun. I had never boxed before using the app, however the app contains a “basic training” section that teaches the major boxing moves such as a jab, a cross, a 3-hit combo, a hook and an uppercut. The Cardio Boxing app contains three levels Light, Semi-Pro and Champion. A lot of times I will use the Light level as a warmup and either the Semi-Pro or Champion level as a cardio workout after. The boxing app is a great workout if you live in a city and cannot get outside to run because you do not need a lot of space for boxing. During the workout Moov will give you tips on boxing form such as: keeping your hands in front of your face and reminding you to take a step forward during a jab. After you finish your workout Moov will give you a report on how well you did, including information about how many targets you hit, velocity, power, technique, timing and duration of your punches.

Moov-Swim Moov is waterproof so you can keep the wearable on while you showerand wear it during a swim. The swimming app tracks how many laps you swim and allows for many different pool sizes. The wearable also tracks your stroke rate and average distance per stroke. These are important metrics if you are trying to improve your technique for a triathlon. The app also gives you tips on how to improve your stroke for example, putting your hands into the water gently so that you do not create a large wake in the water increasing friction. Like the boxing app, the swimming app gives you a report on your workout with a summary of laps, speed of turns, seconds per lap, and stroke count. The report also compares your speed to the speed of Olympic swimmers so you can prepare for Rio 2016.

The 7 minute + Workout app is based off of the viral 7 minute workouts Moov-Workoutpublished in the American College of Sports Medicine Journal and NYTimes.com. Research suggests that just a few minutes of high intensity exercise can have the same health benefits of a long run. The app contains many levels so that people with various levels of fitness can benefit from the app. The workout program consists of three sets of six exercises, each set increases the number of reps. A few of the exercises included in the app are jumping jacks, squats, planking, lunges, push-ups and crunches. Every exercise contains a video to teach users how to do the exercise correctly. The Moov coach will also give tips during the exercise to let you know if you are doing the exercise incorrectly and how you can improve. The workout report from the 7 Minute + Workout app provides information about how quickly you completed the level and how many reps of the exercise you finished.
Moov-RunThe Running & Walking app allows the user to choose from five exercise programs: brisk walking, running efficiency, sprint intervals, speed endurance and open training. The brisk walking program promotes walking at a high cadence and utilizes interval training, a hallmark of all Moov apps. The running efficiency program coaches users to improve their ability to run further and prevent injury by shortening your stride and range of motion. The sprint interval program includes high intensity intervals followed by short rests and coaches users on how they can improve their running speed. The speed endurance program is for seasoned runners and encourages the runner to hold a goal pace for distance based intervals. The open training program allows users to run with periodic distance and pace updates. The Moov coach provides feedback to the user during each workout program, giving tips on stride, cadence and technique. The workout report provides detailed information about your cadence, pace, impact, range of motion, elevation, and progress in each interval.

Taking a closer look at Epic and Interoperability

Judy Faulkner, CEO of Epic had a one-on-one conversation with Greg Meyer, Chief Clinical Officer of Partners Healthcare at the World Medical Innovation Forum on April 29, 2015.  At the conference Faulkner explained how Epic, one of the largest EHR vendors in the United States, got its start.  When Faulkner was at the University of Wisconsin, she was asked by a group of physicians to create a system that would allow providers to define their own data elements, create their own screens and keep clinical information. In just one year, Faulkner built an innovative clinical database system with the patient at the center.  Faulkner said, “It was important to put the patient at the center because there are too many data elements (about 120,000) and systems cannot interface well enough, which would hurt the patient.”  After completing the clinical database, Faulkner worked in many different departments in the hospital doing various clinical programming tasks.  Her clients would tell her that their peers wanted access to the solutions she had built for them and encouraged her to start her own company.  At first she was hesitant and replied that she did not know how to start or run a company. However, after numerous requests she acquiesced and decided to build her own company with the mission statement of “Do Good, Have Fun”.

In 1979 Epic began as a patient database, which now runs on Intersystems Cache, that later added scheduling software in 1983.  Epic was initially valued at a mere $70,000 and the ownership was divided among Faulkner’s customers who provided equity.  It is hard to believe in today’s venture capital-saturated environment; however, Epic never received any outside venture capital.  Epic is also one of the only healthcare informatics companies that has never acquired another company or product.  Faulkner said, “Even if you acquire products and rewrite them, they were written to be optimized as an individual product and optimization of the parts does not mean optimization of the whole.”  Epic has no plans to go public, “because the difficulty of going public means you can no longer focus on what is the right thing to do for the product and you cannot ignore the need for increasing shareholder value.”   Currently, Epic has no budgets, they just project revenues and review expenditures, and they do not have a marketing or public relations department.

Even though some critics say that Epic does not want patients to have access to their data, Epic is truly a system for patients because it has ten times as many patient users as it does provider users.  Epic’s patient health record (PHR) is called MyChart, which helps patients stay engaged in their care and stay healthier.  Faulkner explained that patients want to fill out their own questionnaires and was surprised to discover that patients would rather use a kiosk to fill out their information than go through the staff at the front desk.  Additionally, hospitals that utilize Epic have learned that patients prefer to schedule their own appointments and many of Epic’s clients allow patients to do so.

The subject of this year’s World Medical Innovation Forum was Neuroscience, so there was a lot of talk about patient privacy and security.  Epic tells their customers to inform patients that all patient information will be sent to other facilities if hospital interoperates with another entity, even though psychiatrists’ notes do not get sent over. The reason for this is that sometimes similar information can be found in primary care notes, which can get sent to other facilities, and laws around sharing behavioral health information are inconsistent.  Epic has found that only one-percent of patients do not want their records to be shared with other facilities, so Faulkner believes that the privacy policy should be opt-out rather than opt-in to err on the side of patient safety.

Interoperability is currently a hot topic in healthcare media. Faulkner says, “Becoming interoperable is like telling scientists to cure cancer” – it’s vague and there are many treatments and types of cancer.  Media writers and patients define interoperability as showing up at another provider’s office and accessing their patient record from their primary care physician (PCP).  Interoperability is much more difficult than non-technical people realize because as Faulkner said, “The various vendors did not sit down together and say, how are you each coding allergies?’”  Every vendor has a completely different database and until recently was using different codes for most clinical items. There are many types of interoperability and unfortunately media sources tend to use the word generically.  One type of interoperability is the same system EHR system, but a different practice. This is the most in depth interoperability possible because the database is the same.  About 80% of Epic’s clients achieve this type of interoperability through Epic’s Community Connect program; the clinical data is shared, but the financial data is not shared.

A second type of interoperability is a health information exchange (HIE). Epic’s HIE Care Everywhere, which uses the Consolidated-Clinical Document Architecture (C-CDA), can communicate with any vendor that follows the standards put in place by the Office of the National Coordinator for Health Information Technology (ONC).  Although, many media sources and vendors claim that Epic is not interoperable, in the month of April 2015, Epic customers exchanged 11.7 million records with Care Everywhere, a product which was started in 2005, many years before Meaningful Use promoted interoperability. Care Everywhere started off using Integrating the Healthcare Enterprise (IHE) profiles such as XDS, XCA and participated in IHE Connectathons which paved the way for the CDA.

Epic was ranked number one in HIE by KLAS the past 2 years:

Epic Systems

Epic has active connections to provider practices, state and regional HIEs and HISPS with most of the major vendors such as Cerner, Athenahealth, Surescripts and Relayhealth.  Epic is also a promoter of the eHealth exchange and many of Epic’s clients participate in the exchange with the VA, the DOD and the Social Security Administration.  There are more Epic connections at the VA than with any other EHR.  In December 2014, Epic joined the Argonaut Project launched by Health Level Seven International to promote the next-generation framework of interoperability, Fast Healthcare Interoperability Resources (FHIR).  The first set of FHIR protocols, which are documented on open.epic.com will come out in the 2015 version of Epic due out in June.

Some people in the industry do not see Epic as an innovative company. However, Eric Helsher, VP of Client Success at Epic said, “We were the first to put out an advanced patient portal in MyChart, we were the first organization to integrate with Apple HealthKit, and we were the first to have a patient using an EHR app on the Apple Watch.  Remote patient monitoring, like with HealthKit, we’ve being doing that type of stuff for nearly a decade with vendors like Honeywell, Phillips and Numera, where patients could have a scale or a glucometer at home and send data into Epic.  Epic customers can also use APIs and web services to create custom views and pull live data from Epic.  Epic has billions of API calls per year from third-party products that are integrated with Epic for specific functions.”