October 1-4, 2017; Santa Clara, CA; Full Report – Draft

Executive Highlights

Greeting from Santa Clara and Health 2.0! Although this annual digital health meeting had little focus on diabetes this year, we gleaned a lot from novel products in other therapeutic areas and broader thoughts on the landscape. Enthusiasm remains quite high for digital health, though it’s clear the field is still under-delivering relative to the hype for it – changing healthcare delivery is going to be a long marathon, and value takes time to prove. The one exception is telehealth, where there has been tremendous success, as we understand from health system delivery experts as well as patients. The words of Qualcomm Life’s Dr. James Mault and Philips’ Jeroen Tas (at CES 2017) still ring true: “We’re at the bottom of the hockey stick and the peak of the hype cycle.” We watch Dr. Mault closely – see his top five success factors for digital success here (from the 2017 JP Morgan meeting), see his “Powering Intelligent Care Everywhere” talk here from the 2017 Qualcomm Life “Connect Life 2016” here, and his remarks from Musings Under the Moon on digital health that happened during the ADA in 2016 where he warned that healthcare providers were not ready for this new world of digital health. See our top 15 highlights from Healthcare 2.0 below!

Top 15 Highlights

1. HHS CTO Mr. Bruce Greenstein and former IBM Chief Healthcare Officer Ms. Janet Marchibroda applauded FDA Commissioner Dr. Scott Gottlieb and digital health leader Mr. Bakul Patel for their role in advancing regulatory innovation.

2. In a big data and analytics session, we were very impressed by the seven featured companies: two big ones, Microsoft and Verily, as well as GNS Healthcare, Cardinal Analytix, Base Health, Haystack Informatics, and Velir. The assortment demonstrated the potential for analytics to revolutionize how care is administered and delivered, how populations are managed, how healthcare can be made more efficient/costs can be managed, and how data can be effectively communicated.

3. We learned that Roche mySugr’s bolus calculator is under FDA review during a star-studded panel on the evolution of care delivery featuring Virta CEO Mr. Sami Inkinen, mySugr CEO Mr. Frank Westermann, Livongo CMO Dr. Jennifer Schneider, Omada CMO Dr. Paul Chew, and Canary CEO Dr. Adam Kaufman, as well as renowned Stanford clinician Dr. Alan Glaseroff.

4. 11 startups caught our eye, many with significant implications for diabetes. The two companies that impressed us the most – Drug Stars and Health Pals -  are described in detail below, with a complete list of notable startups and their diabetes learning in the subsequent table.

5. In California Medicaid pilots, Omada Health participants achieved on average 4%-5% weight loss, 86% completed the first four lessons out of 16, and 68% completed nine lessons – statistics comparable to those seen in the non-Medicaid population.

6. A dozen digital health startups battled it out on the Health 2.0 stage, pitching their fascinating products in rapid succession. At the end, the audience voted Suggestic as the winner, an AI-based nutrition app with clear implications for diabetes (a nutrition app that is exciting people is very positive from our view). We summarize other companies’ below, several with exercise, food, and diabetes data implications.

7. AMA’s Dr. Marie Brown delivered a passionate talk, citing harrowing stats about how providers are spending their days: for every one hour face-to-face with a patient, they spend two hours in the EHR. They spend one to two hours in the EHR at night (“meaningless work at home away from family”), and this “unsustainable crisis” has led to a rise in physician burnout.

8. Interoperability with EMRs has the potential to make serious waves in the industry. As Mr. Paul Black, CEO of Allscripts Healthcare Solutions noted, “the access to data could be very disruptive (to the business models of EMR vendors and providers) and we want to be on the disrupting end, rather than the disrupted.”

9. Byteflies CEO Mr. Hans Danneels introduced the Sensor Dot, a small, Bluetooth-enabled wearable device capable of measuring PPG (a measure of blood flow), ECG, respiration, motion, electrodermal activity, and EMG. The idea is an off-the-shelf sensor platform allowing companies to get to a proof-of-concept quickly. We see potential for CGM here.

10. Dr. Daniel Kraft’s keynote address was clear: By thinking “convergently and exponentially,” we can move from episodic, reactive “sick care” to continuous, proactive healthcare.

11. CEOs from Noom, Amino, and Vida Health sat down to discuss their digital health products in intimate, fireside chats. We were thrilled to see two of the three companies were working on diabetes directly.

12. Mr. Davide Vigano of Sensoria and Ms. Sarah Thomas of Genesis Rehab Services announced a partnership between the two companies to develop a new company, Sensoria Health, aimed at creating a wearable platform for the aging population.

13. Bayer announced an upcoming self-care innovation program for startups: g4agenerator.com. This focus is on novel products in three areas we care a lot about, digital health, nutrition, and external pain management as well as other areas like skin/sun protection (hugely important but not an area that affects people with diabetes disproportionately). Applications will open soon, to be paired with a PR/social media campaign. Bayer hopes to disrupt itself and discover new ideas/models. We’re staying very tuned!

14. Mr. Michael Millenson offered his fascinating take on physician-patient power dynamics in a future where health care will emanate from multiple sources.

15. Mr. Joe Flower rang in the 2017 Health 2.0 Fall Conference with an energizing keynote on how to think about the future of healthcare, aptly applying seven words from award-winning poet Jane Hirshfield: “Everything changes. Everything is connected. Pay attention.” A sidenote: how incredible to see poetry celebrated at Health 2.0! Ms. Hirschfield published her first poem shortly after she graduated from college in 1973 – she was in the first class at Princeton to include women, in 1973.

Highlights

1. HHS CTO: FDA Digital Innovation Portfolio…One of Smartest, Freshest Pieces of Public Policy I’ve Seen”

HHS CTO Mr. Bruce Greenstein and former IBM Chief Healthcare Officer Ms. Janet Marchibroda (Director, Health Innovation Initiative, Bipartisan Policy Center) applauded FDA’s Dr. Scott Gottlieb and Mr. Bakul Patel for their role in advancing regulatory innovation. Said Mr. Greenstein, “the digital innovation portfolio is really cutting edge. It’s one of the smartest, freshest pieces of public policy I’ve seen. It’s one that you read through and say, ‘wow, they got this right.’ So watch that.” Mirroring Mr. Greenstein’s sentiments, Ms. Marchibroda called Dr. Gottlieb “just fantastic around advancing innovation … In the old days, entrepreneurs needed a whole band of lawyers and compliance people to reach market – I’m really excited and encouraged about today.” High praise for FDA’s digital health efforts from some heavy hitters! As a reminder, FDA just announced the nine participants in the PreCert pilot program, seven of which have diabetes ties: Apple, Fitbit, J&J, Pear Therapeutics, Phosphorous, Roche, Samsung, Tidepool, and Verily. PreCert will allow the agency to first look at the company, rather than primarily at the product being submitted. This “firm-based approach,” sort of like a ‘TSA Pre-Check’ for digital health submissions, is intended to expedite product reviews from vetted companies – either minimizing the burden of submissions or eliminating them in some cases (see our detailed report here). 

2. Verily, MICROSOFT, and OTHERS on Analytics in Healthcare

In a big data and analytics session, we were very impressed by the featured companies: Verily, Microsoft, GNS Healthcare, Cardinal Analytix, Base Health, Haystack Informatics, and Velir. The range demonstrated the potential for analytics to revolutionize how care is administered, how populations are managed, how healthcare can be made more efficient/costs can be managed, and how data can be effectively communicated.

• Verily CTO Dr. Brian Otis spoke about Verily’s efforts to engage and track people before they are sick by integrating sensing capabilities into devices that people use every day anyway. His first example was the glucose-sensing contact lens project that Verily is (still) working on with Novartis – this has not had a tangible timing update in ages. The miniscule chip that Dr. Otis and co. developed for the lens has enabled Verily to develop a toolkit of “mini technologies,” first and foremost the second-gen glucose sensor with Dexcom. “In type 1 diabetes,” he said, “you acutely, hour-by-hour, depend on CGM, so you may be much more willing to use a device. But if you have non-intensive diabetes or prediabetes, the device has to be much cheaper and smaller to be tolerable.” He also discussed Liftware, the stabilizing line of silverware that Verily makes for people with neuro- or musculo-degenerative conditions. Not only does it make people’s lives easier by allowing them to eat unassisted, but it also collects data on the type and severity of tremor, which will likely be used later to titrate deep-brain stimulation or medication. Cool!
  
  • It will be a few years before readouts are made public, but the Baseline Study has apparently already detected some early signals. Dr. Otis went on about the genius behind the Study Watch, which crams a host of sensors into an aesthetically-pleasing time-keeper that doesn’t inundate the wearer with superfluous data, though it is always collecting data in the background and sending it to Google’s cloud (the more data, the better from Verily’s point of view). Despite its impressive functionality, Dr. Otis articulated that battery life is job number one – the device has to last over a week, because otherwise people won’t wear it, meaning none of the cool sensors would be doing anyone any good. What can CGM devices learn from this product?
  • Dr. Otis emphasized the need to capture more data outside of the clinic, which we’re “… just not capturing at all. Especially if we’re trying to catch people that may be sick. Look at the automobile industry – safety, efficiency, and performance are all getting better, while the mass of cars on the road is also going up. This is possible because they instrumented cars with a huge number of sensors, constantly generating data, making decisions. There are two types of feedback loops: second-by-second tuning of the engine, and long-term monitoring of different maintenance conditions over time. Both of those can be applied to human body, but we’re doing a terrible job of that. The modern car has hundreds of sensors, and makes one million bits of information per second of data that we can compute and analyze. On the other hand, most healthy people step on a scale once a day, maybe generating 12 bits of data per day. Which is crazy, because bodies are more important than cars. It’s very frustrating that we’ve done such a bad job. We’re working hard to better instrument the human body in an unobtrusive way.”
• Microsoft CMO Dr. Simon Kos demonstrated Case Western Reserve University’s use case for the HoloLens VR system in studying human anatomy. He sauntered around a static VR male standing before him (only visible on the screen showing his goggle view, of course), causing the specific view to change from just silhouette, to muscles, to vasculature, simply by saying “next.” There were a few technical glitches, but there were audible chuckles of wonder coming from the audience – we interpreted these as moments where individuals realized that they were living in the future. The application of AR and VR to medical education is obvious, as is the application to diabetes education – could seeing exactly how glucose damages microvasculature in a real-looking body help deter the consumption of sweets? Or perhaps seeing oneself 30 years into the future, looking happy and fit because he had exercised for the past 30 years, would help encourage healthy habits.

• GNS Healthcare uses causal machine learning – algorithms figure out how genomic differences drive changes in phenotype and ultimately disease. The result is basically a simulation that takes into account many layers of data to figure out causal relationships in disease, genetic, and drug interactions that can be predictive and basically a patient avatar on which to test therapies in a hypothesis free manner, which rapidly accelerates discovery. In the future, Co-Founder and Chief Commercial Officer Dr. Iya Khalil envisions physicians putting patient information into an algorithm and seeing a baseline prognosis. From there, they would be able to query – what happens if we treat this specific patient with drug A? How about drug B? How about both? The company is already working with the Multiple Myeloma Research Foundation, collecting tumor samples and looking at all other available sources of data to teach the algorithm to derive causality, predict likelihoods of responses to different treatments, and understand what drives the response. The work has shown that 10%-15% of newly-diagnosed patients are not likely to respond to any available therapies, elucidating a tremendous unmet need, and provider researchers with a new patient population that they can study and develop new pharmaceuticals for.
• Cardinal Analytics (fresh off a $6 million raise) and Base Health are very similar in their goal to identify patients that will be costly to the system soon – not this year, but maybe two, three, or four years down the line. In a simplified model, most people with no claims in one year don’t have claims in the next year either. But there’s a small percentage who do get sick in the next year, and they can be very, very high cost (shown in green in the image below; Base Health calls these “invisible patients”). In a demo, Base Health CEO Dr. Jason Pyle suggested that the ROI of intervening immediately in the 724/17,000 patients in a health system that match this description could be as high as 4,000%. This does make sense, the cost of not intervening proactively could be a series of heart attacks, leading to renal failure, chronic health failure – the health of an individual could be ruined, and the costs can be staggering. In diabetes, we hear a lot about prediction of future acute events (such as severe hypoglycemia), but thinking about predictive analytics in this broader sense too seems very high potential.
  
  • Dr. Pyle pointed out that there are currently 56 million Medicare members, but we’re about to face a torrent of 70 million new members thanks to the advent of Baby Boomers. This will be the single largest migration of people into a managed care system in all of human history. Base Health hopes to help the country survive the Medicare Boom by stratifying on risk, identifying the invisible patients.

• Haystack Informatics mines the EHR to generate a picture of a clinic’s workflow efficiency. Specifically, it identifies how long it takes employees to perform individual tasks, patient wait time, how long providers spend with patients, and bottlenecks in the system. Mr. Kevin Klick, Haystack VP of Business Development, demoed the product, showing how anomalous employee behavior was highlighted in red or green based on performance. One nurse in particular, “Randy,” sees the fewest patients in this cohort, and spends the most time in the EHR. The clinic can then drill down and figure out how to best support her. Mixing in compensation data, Haystack can perform automated time-based cost analyses to figure out how a clinic can deliver care at the lowest cost. The software is being piloted by several health systems. This could be perceived as Big Brother, but it may be the future to optimize time-based efficiency. Could patient outcomes, satisfaction, and quality analyses be thrown into the mix to capture the full picture?
• Velir specializes in data visualization to communicate insights in a clear and engaging manner, with the goal of informing policy, changing behavior, educating, and “building public discourse one fact at a tie.” VP of Data Strategy Mr. Andy Krackov showed a few examples of the group’s work. We fully support this work – many people falsely believe that information itself will lead to a change in attitude and then action – not so! We’ve often wondered how diabetes data could be better presented with color, analogies, and new displays to make it more intuitive and motivating.

3. Roche mySugr Bolus Calculator Under FDA Review; “Transformational” One-Year Virta Data “In the Process of Rolling Up”

We learned that Roche mySugr’s bolus calculator is under FDA review during a star-studded panel on the evolution of care delivery featuring Virta CEO Mr. Sami Inkinen, mySugr CEO Mr. Frank Westermann, Livongo CMO Dr. Jennifer Schneider, Omada CMO Dr. Paul Chew, and Canary CEO Dr. Adam Kaufman, as well as renowned Stanford clinician Dr. Alan Glaseroff. During a demo, Mr. Paul Sytsma, Virta Marketing Lead, also announced that one-year Virta data is “in the process of rolling up” and “it looks like they’ll be transformational.” We cannot wait to see that data – see our piece from earlier this year about Virta’s launch.

• In the Roche mySugr demo, Mr. Westermann demonstrated the bolus calculator feature, which he confirmed is under FDA review. In Europe, the calculator is CE Marked and patient-facing (i.e., no provider setup needed), though we’re not sure how it will go in the US. Accu-Chek Connect, WellDoc, and Lilly’s Go Dose, the three FDA-cleared app-based bolus calculators in the US (that we are aware of), are all set up by the provider. Mr. Westermann also briefly explained Roche mySugr’s coaching feature, though didn’t mention the direct-to-consumer Pro bundle, which soft-launched in the US last month and that we’d like to understand better (it offers unlimited test strips, an Accu-Chek Guide BGM, the Roche mySugr app, and 24/7 CDE access for $39.99 per month.) Dr. Glaseroff characterized the bolus calculator as “very exciting” because it scales and automates a crucial skill for diabetes, despite his observation that very few people are remotely accurate at carb counting. Although we agree with that sentiment, this should hopefully pave the way for more ambitious decision support tools – also, getting people better at counting carbs is addressable – it’s making sure they want to count carbs or remotely care about it that is more challenging from our view.
• Dr. Schneider said, Livongo can identify people who had six lows in the past week and reach out to them, such that 66% doesn’t have a single low blood glucose two weeks later. She noted that while eA1c might be useful, she sees the power of machine learning in day to day prediction. Another value of Livongo’s service, she said, is ensuring that all patient-generated data is used and useful – if a patient always measures blood glucose of 100 mg/dl at noon, then a Livongo CDE may suggest that he/she doesn’t check at that time anymore, but shifts to new/more informative time. We agree and also think we need to figure out how to get funding for professional CGM for anyone who is not on CGM already – so that the field can help the community see the “quality” of A1c.
• Notably, Virta Marketing Lead, Mr. Paul Sytsma, demoed the product’s patient portal, informing the audience that the ongoing clinical trial has surpassed two years duration. Initial 10-week data was very positive, and the company is “in the process of rolling up one-year peer reviewed results – it looks like they’ll be transformational, showing the durability of the results.” We saw one-year data in poster form at ADA, though with just a portion of the population and we were extremely impressed. Dr. Glaseroff responded that it makes sense that the intervention would work to reverse diabetes, but was concerned that not many patients would choose to enter the program. Mr. Inkinen responded that Virta is typically able to activate ~30% of the population within three months, which he added is three-times more than typical interventions in employer populations. In order to reach the oft-stated goal of reversing diabetes in 100 million people by 2025, that means Virta will need a funnel of ~300 million people – let’s see if that kind of scale is attainable! On the other hand, Mr. Inkinen pointed out, 300 million may be an overestimation for two reasons: (i) 30% enrollment came in just three months, so it may be higher after a few more months; and (ii) Better name recognition in the future could boost Virta's "conversion rate." We love the ambition and Mr. Inkinen reminds me of the most impressive tech leaders like the founders of Google – he’s already been highly successful himself in health and we love that he’s taken on such a difficult challenge. (It goes without saying Close Concerns would love to see far more companies get rich getting people healthier and we’ll feature multiple leaders doing this in an upcoming piece.)
• Dr. Glaseroff is a big fan of the Canary Health method, because it “assumes that it isn’t the specifics of disease the you need to focus on, but rather how you live your life. Skills-based, with peer-to-peer support … It’s an enabling thing, and generally people have changes that are lasting.” He seemed very familiar with the program, suggesting that Stanford’s Dr. Katie Lorig, whose research underlies it, deserves a Nobel Prize. She’s been a Professor at UCSF in the School of Nursing since 1985; we are excited to do more study on her work. A sidenote – we’d love to see more focus on behavior and support on the Nobel front; the prizes for 2017 were all announced this week.
• Omada didn’t have a demo, but Dr. Chew spoke very engagingly to several major points, emphasizing that payers need to see ROI, which is difficult in prediabetes because it is not clear who will progress to diabetes – across a whole population however, there will surely be savings. He also spoke to the importance of meeting people where they are – employing services that are multilingual, culturally sensitive (e.g. dietary recommendations), and family/caregiver-engaging.
• Ms. Sophie Thacher, a patient representative on the panel, noted that she’s seen “incredible success” with her OpenAPS system – this is automated insulin delivery. After initiating her DIY (do it yourself) closed loop system, she was able to reduce her A1c by 1.5% in 90 days – and this is even more notable because undoubtedly she had less hypoglycemia. Ms. Thacher said that the alumni network is the most important aspect of the Canary Health platform – finding others with type 1 diabetes on Twitter helped her to take charge of her diabetes. 
• Dr. Glaseroff is known for developing a team-based model of primary care that leverages behavior change, rather than prescriptive tactics. At an independent practice association in Humboldt County (Northern CA), he and his team were able to reduce diabetes-related death by 29%, while the statewide rate was flat. In 2011, he and his physician wife were tapped by Stanford to lead the new Coordinated Care clinic – one for the 5% of patients in the 30,000-person Stanford employee network who account for 50% of health care costs. Thus far, through deft payment and staffing architecture based on design-thinking approaches, Dr. Glaseroff and team have reduced ER visits by 59%, admissions by 29%, and cost by 13%, all the while keeping quality and satisfaction metrics well into the 90^th percentiles.

4. Notable Digital Health Startups: DrugStars, Health Pals, and 9 Others

Although Health 2.0 did not feature a lot on diabetes as we expected (it’s, of course, not a disease-specific meeting), we learn about scores of new startups, some pretty interesting and several with potentially significant implications for diabetes. The two startups that impressed us the most – DrugStars and HealthPals -  are described in more detail below, with a complete list of notable startups in the subsequent table. We’ve distilled what each company does and why we think it is important for diabetes. For those searching for interesting partners and opportunities, we believe there is a lot in this list to choose from!

• DrugStars is a fascinating gamified mobile app for logging medication doses, with each logged dose resulting in a donation to a health charity – hence the smart tagline: “Giving by taking.” Patients receive “stars” for manually logging a dose, which convert to real money donated to a health charity of choice (none chosen yet in diabetes). The approach resembles CharityMiles for running. Notably, the app also includes survey questions that can predict medication drop-off and log patient-reported outcomes. We love that it is free for patients to use, and thus far it has been supported by VC funding. The hope is to get bigger support from pharma, foundations, and payers – we assume this will rest on showing solid engagement and outcomes with use of the app. Sponsors must donate to the entire DrugStars community, meaning a pharma company can’t just support its own drug. DrugStars has ~40,000 users in Scandinavia with no marketing, and $47,000 has been donated to charities in eight months (charities not specified). We learned from a rep that it has seen very high engagement and conversion in smaller disease areas like Cystic Fibrosis, where the motivation is high to donate. Roughly ~20% of patients are still using the app at six months, a metric that rep was elated to share – he said this is higher than industry average, and obviously, this is not an app that’s going to motivate everyone. Drug Stars co-founder Søren Eik Skovlund formerly worked at Novo Nordisk as the Global Director of the DAWN studies and a Global Senior Specialist in Patient Engagement and Public Advocacy. The company has an ongoing n=950 study in diabetes – we’ll be fascinated to see if DrugStars can drive better adherence and outcomes. See below for more on the diabetes implications and ideas.

• HealthPals co-founder Dr. Rajesh Dash, a Stanford cardiologist, demoed his company’s highly impressive automated, cardiometabolic clinical decision support system for point-of-care precision prevention and public health population management. CLINT (CLincal INTelligence platform) is the engine behind the product, performing advanced analytics on multiple channels of patient data (claims, EMR, wearables, -omics, lab data, socioeconomic, etc.) to identify gaps in care and enable “precision prevention” as well as “precision public health.” All decisions are based on guidelines (AHA/ACC, USPTF, JNC, ADA, etc.) and best practices (e.g., South-Asian specific targets and guidelines). The system integrates with all major EHRs and is in the process of integrating with a broad range of wearables. We were very impressed by the demo, where Dr. Dash demonstrated CLINT’s ability to predict absolute risk reduction (e.g., if a patient with a 15% risk of heart disease and stroke were not a smoker, she would have a 7% lower risk of heart attack), and the population health view stratifies patients by risk-level and color-codes care gaps in easy-to-read icons representing medication, lifestyle changes, work up, and follow-up. Finally, a cost optimization panel shows how following a given treatment plan will alter cost over time.
  
  • An implementation of an earlier version of their system at Stanford cut patient CV risk by 33% over six months, resulting in a 15% increase in revenue, a 27% increase in capacity, and 22% projected profit increase. Wow – read more about the case study here. An RCT at Stanford has already finished enrollment, with results expected to be published later this year, and the company has pilots lined up with Sutter Health, AHA, and ACC because “you need that data to support the business models that we’re really pushing as a startup” (aka value-based). This is definitely a company to keep an eye on, especially as it publishes more outcomes and ponders grander moves into diabetes (more on this immediately below).
  • Glooko founder Mr. Yogen Dalal is a HealthPals investor, and the founders indicated an interested in moving further into diabetes. We see huge potential for this company’s involvement in diabetes – incorporating glucose and insulin data into CLINT, predicting hypoglycemia risk, and titrating insulin and other medications. After all, if they can help control diabetes, then they can get in front of CV risk in a more proactive manner.
  • The company acknowledged that it has so far focused on early adopters; notably, the response from doctors has reportedly been “overwhelmingly positive.” That said, they expect that they will have to “improve the product” by better facilitating integration with their customers’ clinical, quality reporting, and administrative workflows when they delve deeper into the adoption curve.
  • See a YouTube video of the five-minute demo here. Editor’s note: our apologies for the clickety-clacking in the background – we were typing notes next to Dr. Dash’s co-founder, who was videotaping in the audience.
  • Healthpals sent engineers into a clinic with physicians for 300 hours (!) so that they could learn about workflows and build a better product. Many believe this should be mandatory time spent for every company developing an HCP-facing product.

5. Omada’s DPP in CA Medicaid Pilot: 4%-5% Weight Loss, 68% retention After 9 Lessons

In California Medicaid pilots, Omada Health participants achieved on average 4%-5% weight loss, 86% completed the first four lessons out of 16, and 68% completed nine lessons – statistics comparable to those seen in the non-Medicaid population. This data headlined a panel in which Ms. Lovisa Gustafsson, Omada Health’s Ms. Lucia Savage, Center for Health Care Stratgies’ Ms. Rachel Davis, and P2Health Ventures’ Ms. Vanessa Mason cautioned against the misconception of the Medicaid population as low-tech. In fact, as Ms. Savage pointed out, 50% of babies born in the US are on Medicaid, and more of them are, of course, likely to be tech savvy merely due to generation. Furthermore, two thirds of those offered Omada’s DPP as part of the Maryland Medical Home pilots opted for the virtual program when given the choice. Likewise, Ms. Davis conducted focus groups comprised of the Medicaid population and was amazed by how many had cell phones and reported consistent computer access. According to Ms. Davis, the key to driving engagement is tailoring digital tools to the reality of Medicaid users’ experience. In one example, Ms. Savage detailed how alterations were made to Omada’s DPP to adjust for differences in health literacy and cultural views on nutrition. Ms. Mason pointed out that while Medicaid users might own smart phones, it’s likely that their data plans are not on continuously, preventing them from engaging with apps requiring constant linkage. Transportation poses an additional challenge – as Ms. Savage noted, a young mother with pre-diabetes who has to use public transportation to get to a daily class faces substantial barriers. This sort of individualization has big implications as we think about CGM getting to the Medicaid populations – how might the products need to change?

6. Suggestic Wins Health 2.0 Launch! Competition; 2016 Winner Siren Care to Begin Shipping This Month

12 digital health startups battled it out on the Health 2.0 stage, pitching their products in rapid succession. At the end, the audience voted Suggestic as the winner, which we last saw demoed at DiabetesMine 2016. We were seriously impressed with Suggestic, a precision eating app that helps users identify food options that fit with their diet of choice. The user selects a diet from a wide range of options (we saw traditional – ugh – ADA guidelines in the demo, but also refreshingly lower-carb options like paleo and keto) and receives personalized meal plans and recipes. The app also identifies nearby restaurants with food options that fit the diet, providing the top three choices at each restaurant. Users can view the restaurant’s full menu in the app, with filters available so that only food aligning with the user’s diet is shown. Even cooler, if the user is already at a restaurant, scanning the menu with the app creates a real-time AR overlay identifying diet-friendly options on the menu.  CEO Mr. Victor Chapela noted that in the next few months this feature will also be available for grocery store items – wow! This app has the potential to have a major impact on those with obesity, prediabetes, and obesity, and we’re thrilled to see it receiving well-deserved recognition.

• For last year’s winner Siren Care, manufacturer of a smart sock that tracks diabetes foot care, shipping to early access members has begun as of this month, with 500 individuals signing up to join the waitlist every day. Siren care is also involved in a clinical study at UCSF (n=30) and CEO Ms. Ran Ma noted that the study is “halfway through” with positive results so far. The company is in discussions with health plans and hopes to launch a pilot later in the year. The smart sock, which houses temperature sensors to detect potential ulcers, now has been updated to include integrated sensors in the bottom of the sock so as to better detect injuries in real time, helping those with diabetes and nerve damage avoid amputations. It’s machine washable and dryable and does not need to be charged – a major win for usability. We’re very excited to see the impact this product will have on the diabetes population – perhaps the wearable might also be used to monitor activity similar to Sensoria’s product (see above).
• See below for our take on some of our other favorite startups from Launch! and their possible implications for diabetes management.

7. “Unsustainable Crisis” of Physician Burnout; 4,000 Mouse Clicks in 10-Hour Period for HCPs!

AMA’s Dr. Marie Brown delivered a passionate talk, citing harrowing stats about how providers are spending their days, discussing the psychological and medical consequences, and ultimately calling for much more research into provider workflow. Recent publications show that providers spend 50% of their days in the EHR or behind their desks; for every one hour face-to-face with a patient, they spend two hours in the EHR; they spend one to two hours in the EHR at night (“meaningless work at home away from family”). This “unsustainable crisis” has led to a huge amount of physician burnout – defined as emotional exhaustion, depersonalization, and low sense of delivering the best care – which climbed from 45% to 54% from 2011-2014. For comparison, work burnout in the rest of the population is 28% – we’d love to see figures on GP and endocrinologist burnout vs. other specialties, though it surely wouldn’t be heartening.  The causes of burnout are many: time pressures, EHR pressures, discordant values (e.g. reduce obesity vs. perform more knee replacements), lack of autonomy (“the only profession where as you climb the ranks you lose autonomy”), insufficient resources, loss of control, meaningless work, lack of teamwork, and poor peer support. Effects on the physician range from divorce, to suicide (400 physicians per year), to quitting, and to part-time work. Naturally, patient satisfaction, trust, medication adherence, reimbursement, and adherence fall, and referrals, testing/labs, malpractice, readmissions, diagnostic errors, and staff turnover all rise. Easing burden on clinicians would have ripple effects all across healthcare, but Dr. Brown urged attendees to simply “do some research” – while we spend >$100 billion per year on developing tests and treatments, just >$0.3 billion is spent on delivery model. 

• According to a 2010 study, physician mouse clicks approach 4,000 in a 10-hour shift! Many of these are meaningless, reflecting gross inefficiency: Ordering aspirin requires six clicks, eight to order a CXR, 15 clicks to order a single prescription, 40 clicks to record a hand and wrist exam. Greater than 40% of an ER shift is spent on data entry. Dr. Brown implored innovators to never utter the words “it’s only three more clicks.” We believe other data entry modalities, such as voice (Amazon Alexa, Google Home, Siri, etc.), have huge potential here.
• “Time is key. Unfortunately, the EHR is a brunt of a lot of this. It’s not everything, but it’s the face of what causes us to lose time.” As has become the norm at digital health conferences, the EHR took a beating throughout the day. Another speaker shared that a recent study found that for 100 physician orders, ~50 alerts are raised, of which 45 are overridden. In addition to being a blatant time suck, EHRs are causing alert fatigue.
  
  • According to Dr. Brown, one root of the burden is a hyper-interpretation of rules by compliance, IT, and quality assurance officers. “Go back to what does the provider really have to do. Stop saying we’ll be safer/in less trouble if we push this extra work to the clinician.”
• Dr. Brown displayed a poignant quote from AMA’s Dr. Christine Sinsky: “We wouldn’t think of asking lawyers to record the legal proceedings of the courtroom at the same time they are doing their job. So why do we expect doctors to multi-task and be distracted from both doing a good job interacting with their patients as well as simultaneously documenting?” These distractions are costly: A 2010 analysis published in JAMA showed how providers now spend the same time with patients, but the interruption and fragmentation of the experience “are absolutely enormous.”
• See our takes on this JAMA study and this JAMA viewpoint from earlier this year for more concerning statistics and ways to move forward.

8. Four Companies Demo Apps Making Use of Interoperability with EMR; API Exposure Disrupting Business Models of EMR Vendors

EMR vendors such as Allscripts have opened their APIs up to developers, and the response has been tremendous, promising interoperability and serious waves in the industry. As Mr. Paul Black, CEO of Allscripts Healthcare Solutions noted, “the access to data could be very disruptive [to the business models of EMR vendors and providers] and we want to be on the disrupting end, rather than the disrupted.” Getting diabetes data into the EMR has been historically challenging, clogging up clinician workflow and leaving substantial holes in patients’ records. Allscripts and other vendors are hoping to change that by opening up their APIs to developers, allowing for products that promise massive savings in time, cost, and hassle. Results from a poll taken at last year’s Health 2.0 showed that 37% of respondents indicated integration with EMR as “vital” to their product/service. Allscripts is now 10 years into their endeavor to support entrepreneurs looking for deep-level API exposure, providing a large installed base and the financial assistance necessary for growth. In last month alone, the company has received 100 million API calls to the database and are on track for three billion calls for 2017. They have 6,500 unique app developers building code today, not to mention the 2,000 engineers employed in-house, indicating substantial investment. Dr. Don Rucker, National Coordinator at Health Information Technology, believes that there’s good progress on provider readiness but that most movement will be driven by consumers, with the first products likely being consumer apps blending clinical and lifestyle data. Eventually, Mr. Arien Malec, SVP at Change Healthcare, foresees FHIR-based APIs allowing for a better grasp on flowing patient information. Still, he was careful to temper enthusiasm, noting that the healthcare system is slow to change, and that these new tools will require an attitude shift from providers with paternalistic tendencies. Although there’s a long way to go before widespread adoption, we can easily envision the positive impact these tools might have on diabetes management. For example, patients’ data from connected glucose monitoring and wearables could be more seamlessly integrated with EMRs across healthcare systems, incorporating notes, results, and prescriptions from multiple providers in multiple settings. This kind of model would allow for a more continuous and comprehensive form of care at a fraction of the time and cost employed today. We saw a truly compelling demo of Dexcom data flowing into the EMR from Dr. Rajiv Kumar at DTM 2015 – he has since been hired by Apple. This feels like a gamechanger for CGM and driving risk-based prioritization and care. When will we see this rolled out in a more meaningful way?

• Meducation is a patient-facing app that provides medication information in accessible language. Built upon Cerner Open Platform Services, the user can select any healthcare provider through a variety of healthcare systems and request that the provider send their health information to Meducation. At this point, the app generates the medication list to the user with intuitive instructions available in multiple languages and font sizes. Originally, this tool was accessed by clinicians who would provide the information to their patients as part of the discharge information packet. Now, patients can access and request this information themselves via their patient portal or directly through the mobile app. We like the potential for diabetes – patients could pull their medications from multiple providers (think: endocrinologists, cardiologists, pain specialists, etc.) incorporating all of them into an easily-to-read list with clear instructions. Keeping track of medications is a huge barrier, and this product could serve to reduce some of the difficulty faced by those juggling several prescriptions. This also reminds us of PillPack, which takes keeping track of, sorting, and knowing when to take pills out of patient hands. The Pillo home healthcare robot discussed above is also a hardware solution to this problem.
• CareEvolution connects digital islands of information from multiple providers in a simple-to-use app called myFHR. Users log in with their Facebook account (cutting down on the number of passwords to remember – a huge win) and select their provider. Next, they sign into the EMR system used by their provider and can request access to their health information. Medications are classified for the user and, importantly, patients can see if any of their providers are unaware of a certain medication. This is critical for those living with several chronic conditions and serves to empower patients, placing them at the center of their own care.
• MyLinks is a similar cloud-based platform that pulls health information from different providers. When demoing the product, Ms. Debi Willis, CEO and founder of the company, expressed particular enthusiasm for EMR systems like Allscripts, which allow for login using a Google ID, reducing the number of required passwords. We need much more of this in diabetes! These kinds of features seem small but definitely reduce friction and “Forgot password” hassle (or worse, downloading the app and never signing up because creating a new account is too much hassle). Patients can share medication data with their providers directly and can also type in additional information. The provider receives structured data they can view in a physician-facing version of the app.
• Medal is a physician-facing app, which allows providers to access their patients’ visit history from a variety of places. Machine learning classifies information, displaying allergies and medications, while FHIR provides the resources for access to biopsy results, metabolic panels, and more. Providers can click on each individual item to see the original source document. We thought the search tool was especially cool – a huge library of multiple semantic terms allows a search for “heart” to find a provider note reporting that the patient doesn’t have a murmur. As Dr. Lonnie Kurlander, founder of the company, pointed out, having access to a patient’s longitudinal health data can be enormously helpful for appropriate diagnosis and prevention. We can see this being particularly useful for tracking those with prediabetes or potentially even catching those at risk for prediabetes.
• For a pulse on EMR vendors’ efforts to expose APIs, see below for the results from a poll taken at last year’s Health 2.0. Allscripts had the largest proportion of respondents indicate that the access process was easy to understand (44%), followed closely by AthenaHealth (43%). McKesson came in last, with only 11% voting its access program was easy to understand, and Epic came in at 15%.

9. Bluetooth-Enabled Sensor Dot Measures Host Of Biometrics – B2b Model Allows Companies To Get To Proof Of Concept Quickly

Byteflies CEO Mr. Hans Danneels introduced the Sensor Dot, a small Bluetooth-enabled wearable device capable of measuring PPG (a measure of blood flow), ECG, respiration, motion, electrodermal activity, and EMG. The B2B model of selling a sensor platform seems encouraging for diabetes wearables, as it could accelerate timing to proof-of-concept. Mr. Danneels told us in a separate conversation that glucose sensing is not on the roadmap, but other non-invasive functions are. Sensor Dot can be programmed to track any or all of the above parameters at whatever frequency/duration the programmer sees fit for the application. Other companies can use the sensors in development, clinical trials, or as a hardware platform on which to build software. We think this could be a great way to test out the potential benefit of integrating miniaturized sensors within CGM patches – i.e., companies could quickly gauge the value of incorporating motion and other sensors into a CGM transmitter, before investing in the internal R&D to do so. Mr. Danneels likened his company’s offering to Amazon Web Services (AWS), which served as the foundation for cloud-based solutions like Netflix and Twitter – prior to AWS, developing a large-scale app took a whole lot longer because it took 1-2 years to establish the cloud infrastructure provided by AWS. The sensor itself is not water-proof in its current form, and requires a charge every 24 hours (though battery life can be extended in certain applications, e.g. an epilepsy company only has it transmit data when it senses a seizure, so the battery can last up to a week). The product Exploration Kit (five Sensor Dots, 20 adhesive patches of various form factors, one charging dock, + software account) launched at Health 2.0 for $2,700, though the company eventually anticipates leveraging a subscription model, whereby the supplies are included within a monthly service fee.

10. Dr. Daniel Kraft on the Pathway to Continuous and Interactive Healthcare; Wearables, Augmented Reality, and VR

Exponential Medicine Founder Dr. Daniel Kraft’s keynote message was clear: By thinking “convergently and exponentially,” we can move from episodic, reactive “sick care” to continuous, proactive healthcare. Dr. Kraft detailed several of the emerging areas in digital health that he is most excited about, although acknowledged that there are big challenges including: (i) cost; (ii) demographics; (iii) access; (iv) fragmented data; and (v) the payer system. He was particularly interested in the variety of wearables coming to market and their capacity to track behavior, noting that behavior, even more so than genetics, is what really drives chronic conditions. Among the products he showed pictures of were Quell (Neurometrix’s phenomenal non-invasive pain management device), K’Watch (PKVitality’s non-invasive glucometer that is still in early development), Verily’s glucose-sensing contact lens, and Siren Care’s smart socks for diabetes foot ulcer detection/prevention. Thinking optimistically, Dr. Kraft hopes that all wearables will eventually be integrated into a single band. He also reviewed advancements in mental health, including mood apps, “digital hugs,” and virtual psychiatrists, and discussed tools utilizing augmented reality and VR. We see a lot of potential for augmented reality and VR to educate both patients and providers in diabetes. Dr. Kraft mentioned a tool that shows users their “future self” (like we saw at SXSW) – this could be extremely incentivizing for patients recently diagnosed with pre-diabetes. VR might also help teach compassion to medical students and healthcare providers, allowing them to more fully understand the lives of those with diabetes. Lastly, Dr. Kraft noted the potential in personal genomics, referencing how data from companies like 23andMe will allow for subtyping of type 2 diabetes, resulting in more personalized care. Given all these exciting developments in digital health, the trick, according to Dr. Kraft, will be to converge these tools in a meaningful way – no small feat! Notably, Dr. Kraft is the creator of the highly-praised digital Exponential Medicine gathering, which we’ll be attending this year for the first time.

11. CEOs from Noom, Amino, and Vida Health Talk Digital Health

CEOs from Noom, Amino, and Vida Health sat down to discuss their digital health products in intimate, fireside chats. We were glad to see that two of the three companies in this “CEO” session focus at least in part on diabetes.

• Mr. Saeju Jeong detailed Noom, a mobile application providing a four-month weight management and personal coaching program priced at $120. While currently directed to consumers (Noom has an impressive 47 million registered users – we aren’t sure the average engagement levels), the company is beginning to engage larger clients like insurers and pharmaceutical companies. Noom is also a CDC-recognized DPP provider and is used mainly in the US, but also in Japan, South Korea, and the UK. The company is currently engaged in a study to evaluate the efficacy of Noom and has released three Nature papers on hypertension and the efficacy of mobile health apps in general. It does not receive as much attention as Omada and we wonder how the two compare.
• Next up was Mr. David Vivero who discussed Amino, a Zillow-like platform for helping users find healthcare providers and book online. The data span 950,000 physicians, 15,000 hospitals, 9,500 urgent care centers, 130 insurance carriers, and 1,000 health topics allowing patients to quickly go from being recently diagnosed to confidently making a decision. The platform generates an easy-to-understand report with quality measures pertinent to the specific condition. Mr. Vivero announced a new feature launched at the conference, which assigns a dollar value to each provider. We can see Amino being useful for those recently diagnosed with diabetes who may feel overwhelmed with decisions; getting these patients matched with providers quickly may boost outcomes.
• Lastly, Ms. Stephanie Tilenius detailed Vida Health, a digital therapeutic platform helping patients manage a wide variety of chronic diseases, including diabetes. Vida Health delivers the DPP and pairs each user with a health coach and/or team. Their product also leverages machine learning to mine patient data. Vida prides itself on addressing co-morbidities and reports that patients with diabetes and depression are four times more expensive. The company partners with academic medical institutions like Duke University, employers like eBay, and providers like Aurora to engage tens of thousands of patients. As healthcare costs continue to rise, solutions like Vida Health, which have helped those with diabetes cut down on their number of medications, will be critical. Recently, Vida Health worked with patients who suffered a heart attack or underwent cardiac surgery at Duke University to help avoid re-admission, slashing healthcare costs. As Ms. Tilenius, who is incredibly connected in Silicon Valley, noted, AI will be critical to improve coaching efficacy and reduce healthcare costs.

12. Sensoria and Genesis Rehab Services Announce Partnership to Develop a New Company, Sensoria Health, Providing a Wearable Platform for Elderly; Ok Google Adds Appointment Booking Feature

Mr. Davide Vigano of Sensoria and Ms. Sarah Thomas of Genesis Rehab Services announced a partnership between the two companies to develop a new company, Sensoria Health, aimed at creating a wearable platform for the aging population. Sensoria produces smart shoes and socks equipped with pressure-sensing technology in the plantar area of the foot, while Genesis Rehab Services provides physical therapy, occupational therapy, speech therapy, respiratory therapy, and wellness services for older adults, touching 55,000 patients every day. By joining forces, Sensoria Health will offer a provider-facing dashboard displaying real-time gait data for every Genesis user. Providers can monitor for adherence to protocols and communicate directly with patients. Although the platform is currently intended for the elderly, this could have major implications for diabetes and we wonder if the user base will eventually be expanded to other populations. Coaches and CDEs could track their patients’ exercise progress and adherence in real time, accessing small changes in behavior that might allow for better intervention.

• We were also excited to hear from Ms. Aashima Gupta, who provided an update on a brand-new Google Cloud feature, allowing for appointment booking through Ok Google. Ms. Gupta demoed the feature, and we were blown away by the simplicity: A few brief questions were all it took for the device to book an appointment at the nearest clinic and send the user an email with the details. This feature demonstrates the incredible power of voice as an interface, breaking down barriers by making each step in the healthcare process as user-friendly as possible. With FHIR and the increasing exposure of APIs, advances like these will grow in number, creating compelling consumer experiences that drive engagement.  

13. Bayer’s Self-Care Innovation ChallengE for Startups: www.g4agenerator.com Program Coming Soon

Bayer announced an ambitious upcoming self-care innovation program for startups, and a landing page is now up at www.g4agenerator.com. The program is focused on novel products/business models in digital health, nutrition, external pain management, and skin/sun protection. The presentation made it clear that this is still very much in development, and Health 2.0 served as the first public announcement that it is coming. In 2017/2018, a partnership website, online applications, and a social media/PR campaign will open. Like other large companies with innovation challenges, Bayer hopes to find some novel ideas and accelerate these to market, supporting entrepreneurs and bringing its scale and mass-market know-how. The strings attached and specific details were not clear, but obviously it will need to be a win-win for startups to apply and participate. The fascinating background presentation noted that in the consumer world, smaller companies are “innovating faster and beating out their larger global competition.” The Bayer rep noted Dollar Shave Club, which was a terrific example and very relevant for diabetes tech: “The product is not the innovation; the business model is the innovation. Dollar Shave Club was disrupting Gillette, and that’s why it was acquired by Unilever” (a $1 billion acquisition, we’d note!). Other small companies mentioned included 23andme (DNA testing; just raised $250 million in growth financing, led by Sequoia), One Medical (reinventing primary care), Olly (supplements with nice marketing), Beyond Meat (plant-based protein that looks/tastes like real meat), and Peloton (connected indoor exercise bikes). According to a Nielsen 2016 study of the consumer packaged goods industry, the top 25 largest food and beverage manufacturers only provided 3% of the total market growth in 2016; the other 97% of growth is coming from small and medium-sized companies (see graphic below). “If you’re a big company like Bayer, you need to look at the startup community and partner or emulate them.” We like seeing this commitment to startup innovation and “disruption,” though nuance is always in the details with innovation challenges – will startups apply rather than raising money in other ways? What strings are attached? Will it be a win-win?

14. Physician-Patient Power Dynamics in Sick Care vs. Health Care

Mr. Michael Millenson (Health Quality Advisors, LLC, Chicago, IL) offered his fascinating take on physician-patient power dynamics in a future where health care will emanate from multiple sources. At times, providers will have the power:­ “When you’re really sick, you probably don’t have an opinion about staples vs. sutures,” i.e. “sick care” will not change drastically. Unlike in the past, however, Mr. Millenson suggested that for general wellness, healthcare consumers will (and already do) use general upkeep service providers and products that are completely separate from their healthcare system. These fluctuating power dynamics create an interesting paradox for health systems: In an effort to personalize care and be more patient-centric, systems are being urged to collect as much data as possible about patients – on the other end, consumers don’t want to commit to using the healthcare system all the time, but aren’t delighted when care isn’t personalized. Mr. Millenson likened the interaction to online banking, where a bank wants to “know all about me, but I want to use Venmo!” To enable a functional patient-provider relationship against this backdrop, Mr. Millenson asserted that trust is all the more important, requesting (i) transparency (sharing of data); (ii) shared engagement (providers may have to interact with patients through multiple channels, and also vendors of other health/wellness services); and (iii) shared accountability. Developing the flexibility to allow different levels of patient independence will be a paradigm shift, but it’s already happening; think how far we’ve come from the days when providers would be offended that a patient consulted Dr. Google.

On a separate panel, speakers racked their brains trying to figure out how to make the patient portal a more constant touch point for patients, until a provider in the audience pointed out that her patients are happiest when they’re not speaking to her. She said, “If I’m using a patient portal, it’s because I’m identifying as ‘in need of care.’ I’m happy if I don’t have to use it.” We agree that health apps should reduce burden, not add steps, but this is a gray area because the portal reduces burden when compared to “perfect” healthcare utilization – but for the majority of the population that doesn’t call to make appointments, let alone show up, the portal (with telehealth, appointment-booking, etc.) adds burden and yet another to log into. This speaks to the challenge of shifting from the sick care to health care mindset – how do you engage someone to think about their health when they’re not sick? 

15. Joe Flower Lays Out Table of Elements for Future of Healthcare

Mr. Joe Flower rang in the 2017 Health 2.0 Fall Conference with an energizing keynote on how to think about the future of healthcare, aptly applying seven words from poet Jane Hirshfield: “Everything changes. Everything is connected. Pay attention.” Most malls in America will close in the next 24 months, he said, yet retail is thriving. Big book stores are history, yet literature is spreading at an unprecedented clip. Digital cameras were a rounding error on the camera market in 1999, until film cameras became a rounding error in 2005. (And now, few buy a digital camera, since they are built into phones.) Encyclopedia Britannica was published in print from 1768 to 2010 – now it’s only on a website. Tesla already has a market cap greater than Ford. The common thread through all of these industry overhauls, according to Mr. Flower, is that people didn’t anticipate the changes (or their speed, form, or impact) until it was too late. The point: Healthcare is not exempt from disruption. We are currently where the camera film business was in 1999 – in 10 years, healthcare will be unrecognizable. He then made six assertions on knowing the future of healthcare: (i) We need to; (ii) We can’t – “if you make a prediction and it turns out you’re right, that’s the participation trophy. If you’re right and you’re not sure why, then you ain’t learned nothing;” (iii) We must anyway; (iv) “It has to be about you” – what you learn must be localized to your product or institution; (v) Healthcare is complex – “simple solutions are useless. Any simple picture of the future is a lie. Techno-optimism or innovationist neophilia gets us nowhere. Looking at AI, machine learning, haptic rebuilding, etc…it’s a Jetson’s future. It’s as real as using the Flintstones as a guide to the past.” (We took this to mean that AI and other technologies on the horizon aren’t a silver bullet in isolation, but must be combined with other technologies and integrated into a workflow.) (vi) The future of healthcare can be studied in a table of elements broken down into philosophical drivers, systemic factors, payment, and technology (see image below for this non-exhaustive graphic). He encouraged attendees to figure out which “element/s” their offering satisfied and drill down further in that vertical(s) instead of spreading. We really like this approach – outside science/technology progress, we have been thinking over the last 18 months or so about barriers (not enough focus on prevention or behavior change, problems like stigma, public attitudes, social norms, and the “broad bucket” of “systems” – we like that the latter is far more broken down and we’d love to discuss more about low-hanging fruit. Is there more under philosophical drivers or systemic drivers or payment or technology?

• Mr. Flower believes diversity in payment and service models in healthcare will greatly reduce inefficiencies in healthcare. We are accustomed to a unimodal framework: A patient thinks there’s a problem, so goes to the provider who performs tests and diagnoses. This system, as with any single-channel system, is inefficient, and therefore costlier than it needs to be. Changing the payment structures will attract more entrepreneurial variety, resulting in greater market disruption. WE still have yet to hear of successful payment approaches at scale and widely used in diabetes. Medtronic has arguably done the most on this (Aetna and UHC), and we’re seeing some subscription models in BGM with Livongo and Roche mySugr and One Drop. From our view, there has not been much public analysis on what is working and what isn’t and where we can learn more and what it takes for more investment.
• Mr. Flower implored attendees to get better at being futurists: “We need to be good at thinking productively and strategically about the future. We’re challenging hospitals of America to make this part of their process at AHA. They are living institutions. When they hear a speaker say that AI is the future of healthcare, they need to think about who it will displace, what it will do, how it will fit in – think in critical terms. Make that part of the process.”
• “Blockchain drives transaction inefficiencies to zero. Think about the size of your accounts receivable department, that could be eliminated, driving down costs in a huge way,” not to mention the unparalleled security of a blockchain transaction. As background, IBM Watson Health partnered with the FDA in January on blockchain. According to that press release: “By keeping an audit trail of all transactions on an unalterable distributed ledger, blockchain technology establishes accountability and transparency in the data exchange process ... IBM and the FDA will explore how a blockchain framework can potentially provide benefits to public health by supporting important use cases for information exchange across a wide variety of data types, including clinical trials and “real world” evidence data ... IBM Watson Health and the FDA plan to share initial research findings in 2017.”]

--by Adam Brown, Brian Levine, Maeve Serino, and Kelly Close