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The Driver: Cured, a healthcare digital marketing and customer relationship management (CRM) platform, has raised $10 million in its Series A funding round. The round was led by DNA Capital and joined by CU Healthcare Innovation Fund, UCHealth, High Alpha, Waterline Ventures, Matchstick Ventures, and Headwater Ventures. Upon closure of the round DNA Capital partner Partha Mishra, will join Cured’s Board of Directors. Proceeds of the funding will be deployed in accelerating the advancement of the Digital Marketing and Insights platform, and the continued growth of Cured’s team of healthcare and customer experience experts. Key Takeaways: Cured’s clients have sent over 35 million interactions through the company’s solutions. According to Pew Research, 80% of Internet users have searched on health-related topics online yet less than one-third typically use patient portals. Cured is a pioneer of deploying machine learning models to contextualize outputs, which are then applied to a health system setting. According to the company, Cured has a 45% appointment scheduling rate, significantly above the industry average. The Story: Cured was founded in May of 2018 by CEO Andrew Sawyer, Ashmer Aslam, and Ro Narayan; former employees of Epic Systems and SalesForce. During their time in other roles, the founders noticed that healthcare organizations were consistently under-utilizing CRM, other marketing automation tools, and similar cloud-based platforms relative to how productively they were being used in other industries (ex: retail, financial services). Unlike other industries, the healthcare industry sends digital communication to patients as an exception instead of a norm. To address this gap, the founders defined an initial roadmap of numerous solutions they envisaged on a platform, which eventually became the minimum viable product of Cured Health. Since its launch Cured has partnered with leading health systems, healthcare services, and digital health organizations to transform their growth and experience strategies through technology. Cured provides a range of services to consumers that include driving consumers to preventative services, creating awareness of healthcare options suitable to their situation, and providing guidance to foster adherence and engagement. Cured enables leading healthcare organizations to engage patients as customers by enhancing user experience. With an established customer base of several top 50 health system and healthcare services organizations, Cured solutions enhance interaction with patients, partner relationships management, patient outreach relevance, and patient access experience and efficacy. These created interactions using data from EMRs and other sources, improve healthcare behaviors and patients' connections on more accessible and convenient platforms. The Differentiators: Health systems have a lot of structured clinical and industry-specific data, yet data exchanges are complex and resource-intensive. Cured has developed prescriptive data schemas for more efficient management, storage, and mobilization of data. It is one of the first companies to introduce personalized templates, communication channels, and CRM technology to connect with healthcare organizations. Cured is a pioneer of deploying machine learning models that are tailored to an individual’s healthcare based on where they are in their unique healthcare journey which the company believes can markedly improve engagement and loyalty. The data which provides context around when and where a patient is in their care drives communications and marketing strategy that allows health systems to gain insights on consumers’ behaviors and make predictions on their responses to future communications. According to Bill Altorfer, a principal at Cured, “we deploy machine learning models to better understand your first-party data…[which] allows you to not only gain significant insights into your consumers’ behaviors but also predicts how they will respond to your future communications and allow you to message those who are the most likely to take the action you desire”. Along these lines, detailed analytics helps healthcare organizations in understanding the ROI and performance of their marketing engagements. This unique approach of making data personalized and relevant for consumers helps differentiate Cured from its CRM competitors whose output is often limited to compiling customer data with limited analytics. Applying insights from modeling to identify gaps in health service utilization and more timely delivery of healthcare services to patients helps improve utilization and outcomes. Cured’s latest innovation in healthcare marketing allows healthcare organizations to use over 70 “curations” or pre-built templates of patient journeys with tailored content to create campaigns for customer experiences and custom content to deliver engagement points across different channels. Curations are Cured’s portfolio of 70+ interactions and corresponding care pathways, personalized with content relevant to healthcare consumers at specific points as patients. From care communications and front door inquiry responses to lifecycle and retention communications and growth and awareness campaigns, Curations tie all digital interactions together under one platform. Compared to other regular marketing templates, Curations is tailored specifically for healthcare organizations. As noted by Altorfer, “Curations are powered by standard first-party data [models] used by the vast majority of healthcare organizations and can be personalized to every consumer at every stage of the consumer lifecycle.” The Big Picture: As healthcare becomes increasingly digitalized, patients are becoming more proactive and informed consumers of their role in their own health care and Cured's technology can help them gain proactive insights into their consumer’s behavior. As providers and consumers become more data-driven, CRM systems like Cured make more data available for both parties to be partners in care, something that has historically been lacking. As Ashmer Aslam CTO of Cured put it, “you should view your provider as a trusted advisor and I don’t think any of us feel that way. If the health system is not being proactive, then there is no reason for me to choose your health system over any other.” Despite major advancements in marketing technology, data gathering, and the analytics that accompany it (ex: customer engagement, click-through rates, etc.) many of these advancements have not been deployed in healthcare. According to Ashmer, “all these things that exist in other industries just need to be translated into healthcare speak.” In addition, healthcare has long had lower rates of digital engagement than other industries, in part due to privacy issues but also due to poor user experience and design. For example, EMR portals are typically underused with the ONC reporting in 2018 that less than 60% of patients were offered online access to their records, and only one-third of patients routinely using portals to access them. Tools like Cured’s can not only help track portal utilization and awareness but strategically help encourage utilization. In addition, improving marketing analytics has impacts beyond just provider economics. Health systems investment in improving patient engagement with healthcare services and information can improve patients and health system outcomes in terms of tangible metrics such as medication adherence, disease prevention, and chronic care thereby lowering costs and improving care. Cured Raises $10M Series A; Launches Next Generation Healthcare Digital Marketing & CRM Solutions; CEO Spotlight Andrew Sawyer of Cured; Sneak Peek: Curations -70+ Pre-built Patient Journeys to Attract, Engage, and Retain Healthcare Consumers

Our Take: While FHIR may help improve many of healthcare’s data interoperability problems, it will not solve all of them. Getting the full value of new data sources created by the digitization of healthcare and making it interoperable requires not only looking at what is currently available and supported by the HL7 standard but what may not be as well. Healthcare payers and providers will have to be compliant with the interoperability rules but need to think holistically about their own organization and how to create a flexible technology architecture, in addition to what is provided by HL7 to ensure an organization’s specific data requirements are met. As data interactions will vary dramatically as new digital tools are incorporated into current workflows, stakeholders need to consider the best ways to use and incorporate these into the future of care, when implementing a data standard and planning for interoperability. ​​Key Takeaways: According to the Pew Charitable Trusts, “approximately 40% of survey respondents said COVID made them more likely to support efforts that enable data-sharing among a patient’s providers and let people download their personal data from EHRs to apps.” Between 2009 (when HITECH Act passed) and 2015 basic EHR adoption went from 12% to 72% for hospitals and from 22% to 54% for ambulatory EHRs. Research done by ONC on individual’s perceptions of data privacy and security shows approximately two-thirds of respondents remain concerned about unauthorized viewing when data is shared by providers. According to the IQVIA Digital Health Trends report, there are now over 350K health-related mobile apps, and almost 90K were created in 2020 alone, driving the need for data access and interoperability. The Problem: For years healthcare has been plagued by underinvestment in technology and systems that were dominated by records kept on paper and exchanged by fax. In 2009 the U.S. Congress passed the HITECH Act hoping to spur investment in technology to digitize paper-based hospital records. The HITECH Act incented hospitals and physicians to adopt electronic medical record systems (EMRs) by giving them reimbursement payments and other benefits for using EHRs which met certain standards. One of the goals of the HITECH Act was to improve the efficiency and accuracy of healthcare records while improving the exchange and portability of records. However, while the HITECH Act did successfully move the vast majority of hospitals and physician practices onto EMRs and other electronic record-keeping systems, by and large data remained largely interoperable, trapped in silos behind the walls of individual institutions, and often not shareable between EMR vendors or interoperable between systems. To help overcome these issues in 2016, the U.S. Congress passed the 21st Century Cures Act which addressed the issues of interoperability, information blocking, and patient access to records. As required to implement the 21st Century Cures Act, in March of 2020, the ONC published the information blocking rule that took effect in April of 2021. While the ONC Final Rule created a number of legal requirements for interoperability, we feel healthcare is at a critical point where it is more important to explore the true functional requirements for interoperability. One of the core issues regarding interoperability is that interoperability is more than just implementing a standard or being able to have two systems exchange data with each other. It is beyond the technical challenges of integrating multiple vendors with different compliance needs. In addition, healthcare is also plagued by the fact that there is no single system of record for interactions with the system and even no single way to identify patients (ex: a national patient identifier). For example, interactions with hospitals and physicians are governed by clinical data generally stored in an EHR detailing clinician interactions, medications, prescriptions, lab tests, imaging, and other diagnostics. By contrast, claims data is used by payers (healthcare insurance companies) to track and pay for providers used, charges billed and discounts to those charges and prescriptions filled.In addition, there is often a third system that is used to track and reconcile financial transactions with patients, payers, and providers. Often data can be lost between systems or very difficult to exchange between systems. For example, while claims data is predominantly financial, clinical systems have to deal with structured data (ex: coding for diagnosis and testing), unstructured data (ex: physician notes in free text fields), and fields involving different storage mediums and signal processing (ex: blood tests, EKGs, etc.). While much improved from earlier in the decade, these issues remain at the heart of poor communication between providers, payers, and patients and, often in inefficient coordination of care. The Backdrop: As noted on its website, “founded in 1987, Health Level Seven International (HL7) is a not-for-profit, standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services.HL7”s mission is to provide standards that empower global health data interoperability.” In addition, the Office of the National Coordinator for Health Information Technology (ONC) also provides national guidance in the US regarding data standards and expectations for improving data interoperability. The ONC and HL7, among other organizations, have worked to establish the Fast Healthcare Interoperability Resources (FHIR) standard for how to structure and format health data to provide guidance to improve the implementation of health IT solutions. According to “A Brief History of FHIA and Its Impact on Connectivity”, “FHIR seeks to be the next-generation foundation by which electronic health records (EHRs), digital health applications, and consumers use and exchange structured healthcare data.”The FHIR standard helps developers and clinicians develop software to access and exchange data by using a shared structured format for making an Application Programming Interface (API). APIs themselves are a standard for how to exchange and access data that requires multiple parties to understand how the API works, such as what variables are available for programs that interact with the API to be able to perform operations for creating, reading, updating, and deleting data. An API can be thought of as a series of doors that can provide access for different software applications, and the standard is like a map that provides the route for how to find a specific door, and an API key is a key that allows you access to the door that you were granted access to. By using APIs HL7 is seeking to bring healthcare applications and systems closer to more typical consumer-driven applications which are plug and play between systems. According to HHS the goal of the interoperability rule is to “support a patient’s access and control of their electronic health information [and by using APIs] patients will be empowered to more securely and easily obtain their electronic health information from their provider’s medical record for free’” As Donald Rucker, National Coordinator for Health Information Technology at ONC stated when the Final Rule was announced, “delivering interoperability actually gives patients the ability to manage their healthcare the same way they manage their finances, travel and every other component of their lives. Implications: Digital health has the potential to radically change the process and efficiency by which healthcare is delivered, however, one of the biggest challenges faced by these products is an inability to interact with, extract and exchange patient data within or among existing systems. Having standards, such as FHIR, create an opportunity to simplify the development and implementation of products that leverage health data as it moves into the digital age. This is particularly important as digital health products, which can improve the ability to monitor and thus intervene with patients such as wearables and other remote patient monitoring and virtual tools, generate significant amounts of data that needs to be exchanged, analyzed, and acted upon in real-time to have maximum impact. In addition, FHIR was developed with current clinical processes and workflows in mind; this means while it may help solve the issues and data requirements of workflows and care protocols of today, it will not future-proof the organization in the creation of the healthcare delivery system of tomorrow. Healthcare delivery systems must develop a roadmap for integration with systems that generate health data, and real-world evidence for treatment research that will be used in the future. Moreover, having an interoperability standard does not solve healthcare’s data issues outside of interoperability, such as data completeness, data integrity, managing structured and unstructured data, and data security. As healthcare slowly begins to shift data to the cloud, development and implementation times will be dramatically reduced but this will shift the burden to chief information officers (CIOs) and Chief Medical Information Officers (CMIOs) to ensure they are deploying the right architecture designed for new data models as well as the different types of data to be stored, processed, and analyzed in care going forward. While FHIR is a major step forward in easing the exchange of healthcare data, it is important to consider how FHIR does and does not fit the data requirements of your organization. Other solutions that have compatibility with FHIR API standards and have additional features and support for other forms of health data may or may not be more appropriate. As pointed out in “A Brief History of FHIR and Its Impact on Connectivity” “nothing has fundamentally changed about how EHRs implement and use standards with FHIR. Real disruptors may use FHIR, but the real change in value and hence disruption is going to come [as it addresses] ‘what problems does FHIR not solve." Related Reading: Shared Nationwide Interoperability Roadmap: The Journey to Better Health and Care | HealthIT.gov There's an API for That | Journal Of AHIMA FHIR: What's Great, What Isn't So Good, and What It's Not Built to Do A Survey Of Health Information Exchange Organizations In Advance Of A Nationwide Connectivity Framework

Our Take: With the increased momentum towards reopening the economy, vaccine passports will become important in the United States (U.S) even if they are not mandatory. Vaccine passports, which serve as official proof of vaccination are now required by several countries for traveling and accessing social and recreational spaces. In the U.S, mandating vaccine passports has been rife with debates with several states either banning its usage outright or partially allowing private businesses to choose to mandate vaccination. Notwithstanding the general push back against vaccine passports, ease and convenience considerations could incentivize an increased COVID vaccine uptake. Key Takeaways: The U.S. lacks a national framework for vaccine passports so digital vaccination credentials are largely led by state and private initiatives but have been hamperd by personal rights, privacy and equity concerns. While no state has mandated the use of vaccine passports, 7 cities require that customers must undergo vaccine checks through a digital vaccine verification system before entering businesses. Your chances of dying from a confirmed case [of COVID] roughly double with every five to eight years of age Twenty states have banned vaccine passports either through executive orders or legislation. The Problem: American culture is deeply rooted in individual liberties and states rights. Any attempts perceived to depart or infringe on the right to choose or personal freedom are resisted as illustrated by protests against mask mandates in a number of cities and states. Vaccine passports pose a big challenge as it requires the extraction of possibly private data and more importantly vaccination. Requiring vaccine passports to gain entrance into restaurants or sports venues could be interpreted as compelling Americans to get vaccinated and a subtle enabler of discriminatory practices. Furthermore, the legal basis for such requirements is currently working its way through the courts, and the extent to which the vaccine protects the vaccinated against current and new variants is a matter of constant scientific testing. In addition to the debates around civil liberties, the debate around vaccine passports centers around three issues: 1) the ability to use vaccine passports as de facto tracking devices, 2) the basic legality of vaccine passports, and, 3) potential inequities raised or made more severe requiring vaccine passports. An argument can be made that requiring vaccine passports would expose those who don’t have them to being tracked and potentially prosecuted for participating in events that require passports. In addition, there are concerns about possible exploitation or fraudulent use of data in the absence of regulations and guidelines. For example, immigrant rights activists worry that tracking features could be used to monitor the movements of undocumented immigrants and potentially expose them to arrest or even deportation. In addition, the very legality of government organizations, businesses, and employers to require vaccine passports is being questioned by civil libertarians and those politically opposed to such mandates. While numerous legal opinions have taken the position that businesses can lawfully mandate employees to get the COVID vaccine, provided exemptions are made for legitimate medical or religious grounds, this is actively being challenged in the courts. Similarly, school mandates that do not offer exemptions or testing as an alternative are being challenged (six states do not offer exemptions on personal or religious grounds). Legal clarity on this issue is expected to take some time as this issue winds its way through the courts. As we go to publication, the U.S. Court of Appeals for the Second Circuit blocked the imposition of the New York City school vaccine mandate for teachers and other professionals. According to Reuters, the court “granted a temporary injunction to a small group of public school teachers and paraprofessionals who are challenging the mandate, which does not allow for weekly testing as an alternative.” Conversely, the Federal court and the Court of Appeal for the Seventh Circuit ruled that Indiana University’s COVID mandate requiring students to get vaccinated was lawful. In terms of potential inequities created by a vaccine passport requirement, several studies show that blacks and Latin Americans were almost 50% less likely to receive the COVID vaccine compared to their white counterparts. While some may choose not to get vaccinated for a variety of reasons, substantial research exists that underresourced minority communities lack access to the vaccine compared to other non-minority communities. Hence, vaccine passports may potentially exacerbate existing inequities of the COVID pandemic by punishing people who are willing to get vaccinated but unable to access the vaccines. Moreover, some have argued that the so-called “digital divide” could further alienate Americans that lack access to either broadband internet or smartphones. While this argument holds less weight with respect to smartphone access than broadband (approximately 90% of people have smartphones, compared to lower percentages for broadband), this could still be an issue for those who may have limited data plans or are not as technologically sophisticated in the use of their phones (potentially making paper vaccine passports an option might address this issue). The Backdrop: Although vaccine passports seem novel they actually date back as early as the 1800s where proof of immunization was required for smallpox. For the COVID pandemic, several nations have adopted a similar measure in the form of pass systems or vaccine mandates before people can get into indoor events. While France recorded a drop in Coronavirus infection a month after implementing vaccine passports, England recently reneged on immediate plans of adopting vaccine passports while keeping it as a likely option. Italy and Israel are implementing a green pass system with Israel achieving an impressively fast vaccine roll-out. In the United States, President Biden has put forth a 6-point agenda with the goal of creating an unprecedented path to vaccine mandates especially for businesses with 100 or more employees by announcing a vaccine or test mandate. President Biden’s mandate coupled with the FDA’s full approval of the Pfizer COVID vaccine likely puts vaccine mandates on a stronger legal footing and eliminates a roadblock to vaccination for some Americans, likely leading to an increase in the number of vaccinated Americans. This is because, prior to the FDA’s full approval of the Pfizer vaccine, many individuals had used this as a rationale for not getting the vaccine and several states had used the fact that vaccines had only been approved under the FDA’s Emergency Use Authorization authority as the basis for banning businesses and employers from imposing vaccine mandates. While no state currently compels mandatory vaccine checks, cities like New York and San Francisco have vaccine verification systems for vaccine checks. The California experience could make a case for vaccine passports in the U.S given the significant increase in COVID vaccine uptake and decrease in COVID deaths following implementation. When people refer to “vaccine passports” they are referring to turning proof of vaccination into some kind of electronic credential, typically via an app that is stored on a smartphone or other electronic devices. While no standard currently exists several tech companies like Clear and IBM have provided a convenient way for individual citizens to digitize their vaccination credentials through their apps. Implications: While requiring or even mandating digital health certificates or vaccine passports raises valid privacy and equity concerns by default broad-based usage could increase vaccine uptake. They could also be useful for building a public health infrastructure that allows for proactive tracking of the diseases and other potential public health emergencies. While the court battle over the legality of vaccines will likely not play out for some time, if businesses, employers, and government bodies require them for various forms of access while allowing a non-vaccine alternative like testing, the ease of use and convenience is likely to increase the popularity of these digital authorization methods at least at the margin. In addition, if the government and private businesses look to proactively and transparently address privacy and equity concerns by establishing standard guidelines for the collection, processing, and sharing of collected data, additional resistance can be overcome. For this to succeed, it is equally important that mechanisms are developed to ensure that the certifications are shown to be unbiased, reliable, and accurate. Along these lines, with proper support from concerned parties, one could envision something like a public-private partnership that seeks to broaden access to the vaccine and even devices to show evidence of a passport to underserved groups. Given the Coronavirus and its variants are likely to be with us for the foreseeable future, businesses, employers and other large organizations will look to protect their members and give them the greatest sense of protection and security. This is particularly true for those catering to customers in an older demographic for as noted in a recent New York Magazine article, “your chances of dying from a confirmed case [of COVID] roughly double with every five to eight years of age”. Moreover, some organizations will likely look to protect as many of their stakeholders and customers by requiring the unvaccinated to observe disease precautions such as social distancing and/or smaller gathering sizes (such as when restaurants limit dining party sizes). Here too, ease of access and the desire of individuals to return to pre-COVID norms are likely to increase vaccination rates. In such situations, businesses such as restaurants, bars, sports, and entertainment venues have a legitimate economic interest in maximizing capacity and are likely to allocate greater space to vaccinated patrons (a position we view as likely to be held up so long as it acts with some balance and doesn’t discriminate). The new wave of COVID cases has impacted mostly the unvaccinated so the market focus will likely demonstrate that a vaccine passport could provide the needed nudge to keep more people safe in the interest of public health. Related Reading: Digital Health Passes in the Age of COVID-19 Are “Vaccine Passports” Lawful and Ethical? “Vaccine Passport” Certification — Policy and Ethical Considerations Covid Passports: How Do They Work Around the World Vaccine Passports: Are They Legal—or Even a Good Idea? Vaccine Mandates Are Lawful, Effective, and Based on Rock-Solid Science State Efforts to Ban or Enforce COVID-19 Vaccine Mandates and Passports

The Driver: This week, Caresyntax raised an additional $30M in Series C funding for its digital surgery platform that brings AI into operating rooms to assess and improve care by providing surgeons with their performance assessments rates and helping them reduce fatal surgical complications. This funding, which Bloomberg reports “was an extension of the company’s Series C round in April” brings Caresyntax’s total raised to over $130M. Investors include BlackRock Inc., specialty insurer ProAssurance Corp, Harmonix, Relyens Group, and IPF Partners. Investors from Caresyntax’s fundraising in April include Optum Ventures, Intel Capital, and Lauxera Capital Partners. Key Takeaways: Caresyntax has a database of over 10M cases and 50,000 surgeons that it uses to support its proprietary software and AI-based insights Operating rooms generate approximately 50% of typical hospital revenues but also account for the largest percentage of deaths (70%) according to HIT Consultant. Caresyntax is used in over 4,000 operating rooms worldwide and claims to have provided optimal care for over 2M patients and be supporting over 30,000 surgeons. According to data from the National Institutes of Health, more than 1M people die annually from complications of surgery worldwide. The Story: Founded in 2013, Caresyntax allows surgeons to operate with the help of machine learning capabilities which reduces the rates of human error. According to the company’s website, Caresyntax uses data from over 10M cases and 50,000 surgeons and then applies its proprietary software and AI to “deliver insights that can be used immediately by the care team as well as longer-term by a variety of stakeholders” to improve patient safety and optimize utilization of the surgical suite. According to Bloomberg “Caresyntax’s platform is used in more than 4,000 operating rooms around the world and collects data before, during, and after surgery. It uses artificial intelligence and software to provide surgeons with insights, such as alerting them to blind spots or helping them determine why a procedure went wrong. The data can also be used to measure surgeons’ performance and assess why some teams have higher readmission rates-valuable information for insurers’ pricing risk or for investors seeking to draw conclusions about surgical volumes.” The company states their platform is HIPAA compliant and a US-certified Patient Safety Organization that has achieved ISO9001certification demonstrating its ability to ensure patient safety and confidentiality. The zero-footprint AI intervention in operating rooms takes form in various AI solutions including pre-op case planning, real-time case annotations, post-op case analytics, and more. All of these tools, when set in place, help surgeons reduce their error rates, assess their performance, and provide better care for their patients The Differentiators: As healthcare looks to continue the shift to practicing value-based care, Caresyntax is helping to position providers in value-based arrangements and where reimbursement is tied to quality and outcomes. For example, as noted by Bloomberg, “the company’s tools could help big insurers...and the government pay for performance” with reimbursements tied to meeting certain pre-defined standards of care. In addition, as demonstrated during the pandemic, elective procedures are very profitable for providers. By applying Caresyntax’s technology hospitals can better optimize the use of the surgical suite and can help them “achieve increased workflow efficiency, patient safety, and surgical performance.” Moreover, Caresyntax also allows surgeons to draw upon external resources to benchmark their performance and consult external experts. As noted by Bloomberg they “offer real-time access to outside experts, such as medical school instructors or medical device representatives through its digital platform.” As such Caresyntax was selected by the American Board of Surgery to provide a platform for its pilot program incorporating video-based assessments into their board certification process. Caresyntax has also partnered with the University of Iowa Health Care and the University of Massachusetts Medical School to improve patient safety and quality of care through various initiatives. Implications: As highlighted by a recent article in HITConsulant, while surgery can be an incredibly profitable financial center for hospitals, often “accounting for as much as 50% of total revenue” it can also be a significant source of risk leading to “70% of cause-specific deaths”. Consequently, services like Caresyntax’s which help providers improve quality and outcomes while optimizing the use of the surgical suite can be quite valuable. With more than 1M people dying annually from complications of surgery worldwide according to the National Institutes of Health and an inpatient complication rate of 11% seen in surgeries, interventions like this are necessary and beneficial. For example, the introduction of a simple surgical safety checklist reduced the death rate by almost 50% (from 1.5% to 0.8%). Given the dramatic results with a simple checklist, tools like an AI-based model hold the potential for even more significant improvements in mortality reduction and benefits in quality. As pointed out by co-founder and CEO Dennis Kogan in the HIT Consultant, “a lot of development going forward is going to focus on proactive risk management: being side by side with physicians at the right moment in time giving them actionable insights.” In addition, for both clinicians and providers to be able to participate in value-based care and take part in contracts with two-sided risk they need to be able to benchmark themselves and reduce variability in order to be able to rationally enter into contracts and reduce variability in costs. As highlighted by Kogan, “for the system [value-based care] to work in settings like an operating room, though, outcomes and surgeon performance need to be measured at a more granular level.” Caresyntax Gets BlackRock Investment in Upsized Funding Round, Caresyntax Raises $100M to Expand Digital Surgery Platform in Key Markets

Our Take: As technology and digital transformation take hold in healthcare, greater focus needs to be placed on meeting provider needs and managing clinical burnout. While the digital transformation of healthcare has both positive aspects for clinician burnout, such as the potential to apply artificial intelligence to help optimize workflows, the ability to focus clinician expertise, and the use of natural language processing to automate workflows, at present the additional burdens related to the implementation of electronic health records (EHRs) and the inefficiencies in workflows introduced by additional administrative and regulatory burdens on clinical workflows have negated the positive impact. ​​Key Takeaways: Replacing a physician lost to burnout costs a healthcare system anywhere from $250 000 to a million dollars. Clinical burnout is a global health crisis with more than 60% of providers reporting at least 1 symptom of burnout. For every hour of clinical face time, physicians spend nearly 2 additional hours on EHRs and desk work within the clinical day. A study reported physicians spend nearly half of their time during office hours on EHR and desk work, including documentation, translation to approximately 2 hours of EHR, and work time for each hour of direct patient care. Research carried out by HIMSS and UK med-tech firm Nuance Communications found 97% of doctors and 99% of nurses surveyed had experienced burnout at some point in their working life. According to Journal Annals of Internal Medicine, the economic impacts of burnout are also significant, costing the U.S. approximately $4.6 billion every year. The Problem: Clinical burnout is a major threat to the US healthcare system. Even prior to the COVID pandemic, clinician burnout was considered a global health crisis with more than 60% of providers reporting at least 1 symptom of burnout. Factors that contribute include digital tools used among different specialties, practice settings, and requirements for compliance and reimbursement (computerized physician order entry, amount of data needed to be entered in EHRs for each clinical encounter). While EHRs can be effective tools, they require comprehensive, timely and continuous training in order to reduce the digital burden on top of physicians' routine clinical duties. In addition, the organizational structure, continued improvement and development of health information technology, and coordination and implementation of policy and regulations will play a key role. The Backdrop: According to Annals of Internal Medicine, for every hour of clinical facetime with patients, physicians spend nearly 2 additional hours on EHRs and desk work during the day. In addition, outside office hours, physicians spend another 1-2 hours of personal time each night (affectionately referred to as “pajama time”), doing additional computer and other clerical work. These additional demands contribute to physician burnout which has significant economic costs. For example, according to a study by HIMSS and Nuance Communications, 97% of doctors and 99% of European nurses surveyed had experienced burnout at some point in their working life and that this impact was nearly universal. According to the Annals of Internal Medicine study noted above, the economic impacts of burnout are significant, costing the U.S. some $4.6 billion every year. These impacts can range from emotional impacts such as energy depletion or exhaustion, increased mental distance from one’s job, feelings of negativism or cynicism related to one’s job to higher rates of turnover, prevalence of substance use disorders, increased malpractice claims, greater physician errors and a higher incidence of unnecessary tests and consultations. While clinical burnout has multiple underlying causes, EHRs have been demonstrated to play a significant role in burnout as they are the intersection of clinical duties and technology. EHRs as they are currently designed and deployed can be overly time-consuming, frustrating, overly complex and require multiple screens to click through to get to relevant information. Moreover, as noted in “Physician Well Being and the Future of Health Information Technology”, EHRs [and other health IT] can be loaded with alerts to “serve population health, quality assurance, risk management, customer service, billing, or research goals, yet the sum result may be an overload of alerts such that some are ignored or clicked through, perhaps without any real attention to priority.” As the article goes on to point out, “to reduce overwhelm, tools are needed to filter, prioritize, and frame information for users and their clinical questions. Implications: Burned-out doctors are more likely to leave their practice or worse. In fact, according to the Medscape National Physician Burnout & Suicide Report 2020: The Generational Divide, over 20% of both male and female physicians reported having thoughts contemplating suicide. At a minimum this reduces patient access to care, impairs care continuation and at worst threatens the physical safety of patients themselves. To improve and ease the burden, comprehensive quality and timely training should help partially mitigate technology-related stress. However, as noted in “Physician Well-Being and the Future of Health Information Technology” from the Mayo Clinic Proceedings, “it would be shortsighted to imagine that simply fixing the EHR will prevent technology related burnout.” In addition, expanding the care team, utilizing scribes including the use of digital scribes, and dividing the documentation with streamlined team-based documentation will ease the load, improve efficiency, productivity and provide quality care. For example, a recent study in the Journal of the American Medical Informatics Association demonstrated physician documentation time was reduced by 50% with scribe implementation, thus allowing more time for patient-facing interactions. In addition, AI based digital scribes that deploy natural language processing can help physicians in the documentation process through use of time-saving, uninterrupted chain of thought processes for documentation. While many of these are still in the early stages of development and require heavy oversight and checking by human scribes (often overseas), they hold great potential. Perhaps most importantly developers and designers of HIT need to fundamentally rethink the way they design their tools for use by clinicians. Increasingly to improve effectiveness and adoption of their products, designers will need to consider the “importance of physician involvement in the design and implementation of HIT [which] cannot be overstated.” Earlier and more frequent physician involvement in development of user experience and user interface should help decrease data entry time by limiting keystrokes and/or mouse clicks through iteratively adjusting the tool’s performance based on user experience and feedback to the design team. Moreover, by more proactively involving physicians (and other clinicians) in the process, developers will move away from a failed alert-based system to one that more appropriately recognizes physician/patient engagement as one of increasingly limited time constraints. For “a strategy of approaching encounter expectations from a perspective of constraints is essential” as it will allow new products to help prioritize and highlight clinical information that needs action and should be acted on in the moment. Related Reading: The Burden of the Digital Environment: A Systematic Review on Organization-Directed Workplace Interventions to Mitigate Physician Burnout Physician Well-being and the Future of Health Information Technology Is Digital Transformation in Healthcare Contributing to Provider Burnout? An Executive Discussion: Leveraging Technology to Mitigate Physician Burnout HITECH to 21st Century Cures: Clinician Burden and Evolving health IT policy IT Contribution to Physician Burnout Remains a Problem Physician Stress and Burnout: the Impact of Health Information Technology

The Driver: Recently Wheel hired its first Chief Commercial Officer just three months after raising $50M in a series B fundraising bringing the total amount the company has raised to date to $66M. In late August Wheel announced that it had hired Tim Kollas who previously worked in Business Development for Amazon Care and as Chief Partnership Officer at 98point6, Inc. according to his LinkedIn profile. Wheel’s fundraising round was led by Lightspeed Ventures with participation from CRV, Silverton Partners, Tusk Venture Partners, J.P. Morgan, and a new investor in Future Shape. According to the company they will use the funds to grow headcount and to expand offerings into specialty care including behavioral health. Key Takeaways: According to Wheel internal data standing up and scaling a virtual care service on your own costs an average of $15MM and takes approximately 15 months. The McKinsey 2020 Virtual Care Study claims that approximately $250B or ~20% of all outpatient, office, and home health spend, could potentially be virtualized. According to the Austin Business Journal, Wheel delivered as many paid consultations in Q2 2021 as in all of 2020. A study by Nuance and HIMSS found that 97% of doctors and 99% of nurses surveyed had experienced burnout at some point in their working life. The Story: According to Forbes, the genesis for Wheel goes back to when CEO and co-founder Michelle Davey was a child and had to undergo over a decade of being “ferried between doctors for her to be diagnosed with an autoimmune condition.” After several stints working in healthcare and recruiting, Davey return to healthcare to work at a telehealth startup to do recruiting. Thinking her previous recruiting experience would give her a leg up in her new role, she was quickly surprised to learn that it had not. In 2018 this lead Davey and her co-founder Griffin Mulcahey to found a matching market for virtual healthcare providers called Enzyme which later became Wheel. According to the firm’s website, Davey and Mulcahey felt that “no one was looking out for those at the center of the healthcare engine: the clinicians on the front lines” and decided found Wheel as “the industry’s first model for delivering high-quality virtual care at scale by empowering clinicians and providing new efficiencies for healthcare companies.” The Differentiators: Unlike some of its competitors which offer branded virtual care services Wheel is one offers a private or “white-label platform that empowers companies to quickly and easily launch virtual care services on its own by providing them with the appropriate back-end infrastructure and software. In addition, while Wheel is helping traditional healthcare providers like hospitals and physician practices offer virtual primary care services, it is also helping non-traditional players like retailers, pharmacies, and employee benefit programs create their own virtual care programs under their own brand. Wheel claims that using their platform is much more efficient than standing up and scaling a virtual care service on your own, which their internal data shows costs an average of $15MM and takes 15 months. Moreover, as noted above, Wheel is looking to expand the breadth of its services beyond just virtual primary care, currently looking to move into behavioral health, labs, and diagnostic care. Interestingly given Wheel’s roots in physician recruitment and staffing, Wheels has a strong background in some of the technical issues involved in scaling a virtual care business. As Davey noted to Forbes about founding the business, one of “the biggest sticking point[s] to scaling digital health startups was understanding the regulations across all 50 states and recruiting licensed clinicians.” It appears that this expertise has aided its growth, as “80% of its growth has been organic, and the company has a 90% retention rate.” Wheel currently has approximately 120 employees and expects to increase that to 200 by year-end. Wheel charges its customers a base fee for its software and then an additional fee per consultation. The Big Picture: As Michelle Davey noted to the Austin Business Journal following Wheel’s series B, “I think we’re at least 10 years ahead of where we would have been” due to the pandemic. Given that both providers and patients were essentially forced to accept and use telehealth overnight both resistance and inertia were pushed to the side out of necessity and a transformative opening has been created for digital health. Wheel and other virtual primary care providers like it (please see our Scouting Report Oxygen: AI-Based, End-to-End, Virtual-First Primary Care) can fundamentally change the delivery of care. For example, according to the McKinsey 2020 Virtual Care Study approximately $250B or ~20% of all Medicare, Medicaid, and Commercial outpatient, office, and home health spend, could potentially be virtualized.” In addition, while there will always be some portion of the patient care that will have to be delivered in person, virtual first primary care allows providers, of all shapes and sizes, to broaden the delivery of care to more patients, and independent of their geographic location. This opens up tremendous opportunities to expand care to the underserved and to broaden care in rural areas where providing access is lacking. In addition, virtual first brings healthcare much closer to other industries by bringing patient care to the patient at the time and place they desire as opposed to the other way around. Virtual primary care also provides a mechanism to address the issue of physician burnout, where over 90% of doctors report experiencing at least one symptom of burnout in their lives. By giving them the ability to create their own virtual practice with a much lower infrastructure incidence of burnout can be reduced. While there are important issues like broadband access that still need to be addressed, technology and demand are clearly changing the nature of healthcare delivery. Behind The Screen: Meet The Startup Powering Telehealth, Telehealth Startup Wheel Hires Chief Commercial Officer to Help Shape Rapid Growth, Telehealth Startup Wheel Raises $50M Series B

Our Take: To fully complete the transition to the digitalization of healthcare we must incorporate greater humanity, compassion, and empathy in the care we deliver. While there was a rapid shift from in-person care to telemedicine and digital health during the pandemic, it is essential not to lose sight of the importance and differences in the expression of compassion, humanity, and empathy between digital and in-person care. In a period where social isolation and fear of seeing clinicians in person, even when sick, has led to a reduction in preventive care visits, telehealth has played a key role in maintaining that much-needed connection among patients, clinicians, and care-delivery networks. Digital health has and will make it easier for patients to communicate with doctors without having to travel, saving them time, energy, and cost, therefore enhancing access in a myriad of ways, however, caregivers cannot lose sight of the need to blend the use technology with the need for old-fashioned authentic human connections with their patients. Key Takeaways: Clinicians routinely interrupt patients after only 11 seconds when patients are describing symptoms, yet patients generally provide relevant diagnostic information if they are allowed 35 seconds to speak. Educational training that included self-reflection and reflective writing aimed at increasing empathy showed 100% of students experienced a positive change in empathy. Raising awareness about digital empathy is the first step in educating trainees and preparing them for this technologically driven world. More than 80% of diagnoses are made on history alone while less than 40% of patients give given the chance to talk about why they came in for their visit. The Problem: The patient-provider relationship revolves around trust, human connection, and compassion between patients and doctors. Many clinicians believe that over 80% of diagnoses can be discovered by doing the patient history alone. Therefore it is important for clinicians/ providers to determine what they need to prepare for during their visits. It is not only about the patient as a person exhibiting symptoms of a disease, but also the process of understanding those symptoms within the context of the patient’s life by taking a brief moment to communicate and connect with the patient. For example, studies have shown that on average doctors routinely cut off patients within 17 seconds of patients describing their symptoms when in fact if they had let them talk for only 3 minutes patients would have given them relevant diagnostic information. By allowing patients this time and letting them open up, they can explain their unique circumstances which can contribute meaningfully to the diagnosis. Digital healthcare has many advantages and has given patients greater access to clinicians who are now more available and approachable in some ways than they were before, but clinicians must make sure they are present, focused, and actively listening to patients to create the same bond as in-person care. The use of technology to establish a communication channel between patient and provider should not be an excuse for the loss of compassion and emotional connection between them. The Backdrop: According to a recent McKinsey report entitled, “Telehealth: A Quarter-Trillion- Dollar Post-COVID-19 Reality?” 76% of consumers were interested in using telehealth in the future, up from 11% in 2019. In addition, the report also found that 57% of healthcare providers viewed telehealth more favorably than they did prior to COVID. While telehealth and digital healthcare tools had been around for years, given the fact that both providers and patients had to transition to virtual care almost overnight, the transition was not smooth. Both patients and providers had to acclimate themselves to this new normal. For seniors, for whom medical and social care was a primary form of in-person interaction, the lack of in-person medical care contributed to feelings of social isolation, loss of a bond, and the loss of empathy that many patients felt deeply. For years clinicians have recognized the role of empathy in patients’ care. As noted in “The Emerging Issue of Digital Empathy”, published in the American Journal of Pharmaceutical Education, empathy increases both patient satisfaction and compliance and enhances a practitioner’s ability to treat patients. The article goes on to note that empathy has strong positive effects on patient’s health outcomes and helps reduce the risk of malpractice litigation. Digital communications are often devoid of many of the non-verbal cues typically associated with in-person interactions which can lead to more impersonal interactions. Consequently, clinicians must pay careful attention to how they relate to patients in digital visits. As noted by Charles Alessi, MD, Chief clinical officer at HIMSS, COVID-19 forced us to jump into digital modalities to deliver care, but empathetic care isn’t just about care related to COVID-19, it is really is about the care we give in our everyday interactions with patients and citizens. As he stated, ”virtual platforms were made available quicker than we can imagine yet it was reported that patients were scared and wanted more authentic human interaction when seeking information. Patients not only wanted to be seen and heard but also listened to.” Along those lines, a study published in the Journal of General Internal Medicine reported that only 36% of patients are given the opportunity to speak up about why they came in for their visit; while only 20% of specialists actually asked their patients what was wrong. While many clinicians struggle with communication even with in-person settings and maintaining two-way communication seems difficult, human touch can often cover up a lack of effective communication skills. However, when dealing with digital interactions, clinicians must call on an entirely new skill set. Caregivers need to recognize, understand and resonate emotionally with the patient’s complaints, distress, and pain. Compassion and empathy in the digital health platform will provide a strong foundation in building this ever-growing virtual health platform. Efforts to address the issue of digital compassion, empathy, and communication should be integrated into clinical training and must be a building block to delivering optimal patient care. Implications: While empathy, compassion, and active listening can come easier to some than others, it is not an innate skill. For example, as noted in a recent article entitled, “How Technology Can Advance Empathetic Care“, empathy can be taught to nurses and doctors, with new ways of communicating that add more to the overall care of a patient. Moreover, although technology can seem like a barrier to human touch, technology can also be deployed to help train the skills that improve empathetic care. Virtual reality and augmented reality tools have been shown to help nurses who have recently received academic training but have not received practical experience directly working with patients. Augmented reality scenarios can teach clinicians how to handle difficult conversations and deliver bad news. In addition, technology allows facial recognition technology to provide instant feedback to clinicians on their effectiveness in reading a patients’ demeanor via the computer. Clinicians must recognize that technology used in a healthcare setting is usually biased in their favor to give them insights into a patient’s physiological condition and may also provide insights into their emotional state. For example, so-called “Compassion tech” which Andy Shin the Chief Operating Officer of the American Hospital Association Center for Health Innovation proposes defining as “knowledge-based products or services that improve the ability of users to recognize, understand and resonate emotionally with another’s concerns, distress, pain or suffering” can aid in gaining insights to a patient but are not a substitute for establishing strong solid communication with that patient. While technology can be used to bridge the gap between provider-patient relationships we continue to recommend 5 steps for connecting with patients via digital health, these include 1) staring into the camera when you speak with a patient; 2) don’t interrupt and instead allow patients to tell their story; 3) where possible use visual clues from a patients surroundings to learn more about their situation; 4) learn the art of the pause, actively train yourself to stop and listen to the patient; and, 5) embrace natural interruptions on video (ex: kids, dogs, etc.) on both sides of the interaction, they humanize it. All of these actions allow you to create a stronger, more lasting connection with your patient (please see our webinar entitled “Transforming the Digital Health Experience to Build Consumer Engagement, Loyalty, and Brand” with Ingrid Lindberg, Co-Founder, aubreyAsks & CXO of Chief Customer). Related Readings: Digital Health is a Cultural Transformation of Traditional Healthcare Compassion Tech: Merging Technology, Consumerism and the Human Connection for Health Innovation How Technology can Advance Empathetic Care The Emerging Issue of Digital Empathy Telehealth: A Quarter-Trillion-Dollar Post-COVID-19 Reality?

Our Take: Health disparities are even more dominant in the 18 states that did not expand Medicaid under the Affordable Care Act (ACA), leading to greater unnecessary drains on state budgets. For example, in West Virginia which did expand Medicaid, the uninsured rate among Blacks and Hispanics dropped by over 60%, while the decline was under 20% in states that did not expand Medicaid. Similarly, as noted in a study by the Commonwealth Fund, while Medicaid expansion increases total Medicaid spending by approximately 23% and federal Medicaid spending by 38%, it has not increased state Medicaid spending, at least in the period between 2015-2019. As noted in the report, this is because “states can save from 15 cents to 40 cents on every dollar of care it can shift to expansion (assuming 2020 expansion match rates).” Given the emerging disparities in healthcare access and affordability amongst Americans, the expansion of Medicaid by the states is crucial to help reduce the differences in health outcomes, the prevalence of chronic diseases, and other health disparities. Key Takeaways: During 2014–17, Medicaid expansion was associated with a 4.4 percent to 4.7 percent reduction in state spending on traditional Medicaid. Although the ACA improved healthcare access and reduced the rate of the uninsured, it did not close the racial gap in healthcare coverage (Health Equity) According to the Commonwealth Fund, “states can save from 15-40 cents on every dollar of care it can shift to expansion (assuming 2020 Federal fund matching rates).” Over 500K Louisianans have enrolled in Medicaid since expansion in 2016, including those seeking care for hypertension (59K), colon cancer (53K), and diabetes (22K) all conditions that disproportionately impact the underserved. The Problem: Enacted in 1965, Medicaid, is a joint federal and state healthcare program that is financed jointly by funds provided by the federal government and state governments. Under the program, the federal government matches each dollar of state spending on its Medicaid program. The federal match rate varies by state and is based on what is referred to as a federal “matching formula”. The percentage match ranges from a minimum of 50% to nearly 79% in the poorest state (Alabama) and averages just over 56% nationwide for FY 2022. Under the ACA Medicaid coverage was expanded to nonelderly adults with income up to 138% FPL (~ $17,000 for an individual in 2019) with enhanced federal matching funds. Prior to enactment of the law, individuals typically had to meet very strict state eligibility standards to qualify with many low-income adults failing to qualify and thereby lacking coverage. Moreover, most states and federal laws also excluded adults without dependent children from Medicaid no matter what their income level (or lack of it). The ACA effectively eliminated many of these burdensome eligibility criteria and extended coverage to adults that did not have dependent children. However, as part of the ACA, states were required to expand Medicaid coverage or face a penalty. Arguing that States should have a choice in expansion, in 2012 the National Federation of Independent Business (NFIB) backed by a number of states sued to block the implementation of the ACA in the National Federation of Independent Business v. Sebelius (“Sebelius”). In this case, the states argued against the constitutionality of Medicaid expansion since it compelled states to follow federal regulations, among other things. In 2012, the Supreme Court ruled letting the bulk of the ACA stand but held that penalizing states for not expanding Medicaid was an unconstitutional exercise of Executive branch power, thereby leaving it to the states to decide whether to expand Medicaid. Following the Supreme Court’s ruling in Sebelius expansion of Medicaid became largely a political litmus test with states run by Democratic governors largely expanding Medicaid and states run by Republican governors largely opposing the expansion of Medicaid. This resulted in a patchwork of policies and coverage for the underserved and low-income individuals. The Backdrop: Due to the polarizing nature of the ACA and the political environment in the U.S. at the time, many states chose not to expand Medicaid for their residents. Since, as noted by the Kaiser Family Foundation, “Medicaid is the nation’s public health insurance program for people with low income and covers 1 in 5 Americans. With the vast majority of Medicaid enrollees lacking access to other affordable health insurance. including many with complex and costly needs for care”, many were left without care or substandard care. However, it was not until recently that studies look at the disparity of care among the underserved between expansion and non-expansion states. Not surprisingly these studies have found distinct differences in care for low-income and minority populations in Medicaid expansion and non-expansion states. For example, a November 2020 article in Health Affairs found that “by comparing changes in outcomes for low-income women in expansion and non-expansion states, [they] document greater pre-conception health counseling, pregnancy folic acid intake (which reduces the likelihood certain birth defects in newborns), and postpartum use of effective birth control methods among low-income women (reducing the likelihood of unplanned pregnancies) all associated with Medicaid expansion. This is particularly important as according to the March of Dimes, Medicaid covers roughly half of all births in the United States, including many high-risk pregnancies. In addition, a study entitled “Medicaid and Mortality: New Evidence from Linked Survey and Administrative Data” (“Medicaid and Mortality”) found that failure to expand Medicaid in states likely resulted in 15,600 additional deaths over this four-year period that could have been avoided had these states elected to expand coverage.” The study stated that individuals aged 55 to 64 in low-income households have four times higher mortality rate compared to 0.4 mortality rate for higher-income individuals in the same age group. Similarly, according to the Center for Budget on Budget and Policy Priorities (CBBP), “the share of opioid-related hospitalizations in which the patient was uninsured has plummeted 79 percent in expansion states, compared to just 5 percent in non-expansion states.” The CBBP also notes that more than 550,000 Louisianans have enrolled in expansion coverage since the state expanded Medicaid in 2016, including those seeking treatment for hypertension (59,000), colon cancer (53,000), and diabetes (22,000) all conditions that disproportionately impact the underserved and low-income communities. Implications: While the ACA was successful in helping to reduce racial and ethnic disparities in healthcare coverage, particularly among the uninsured, the results were uneven due to the differences in coverage for expansion and non-expansion states. As demonstrated above additional disparities in access and quality care can be mitigated by further expanding Medicaid to those states that have chosen not to do so. For example, according to the Kaiser Family Foundation, if all states that are currently eligible to expand Medicaid were to do so 2.2 million people would gain coverage as would an additional 1.8 million people with incomes of between 100% and 138% of the federal poverty level. This is particularly important as KFF points out more than 30.2% of nonelderly adults without coverage said that they went without needed care in the past year because of the cost compared to 5.3% of adults with private coverage and 9.5% of adults with public coverage. Moreover, as noted earlier, this expansion would come at savings to the states of between 15-40 cents of any dollar the state spends on care. In addition, an analysis by the CBBP finds that costs for uncompensated hospital care, which was provided by hospitals but never paid, would actually decline by approximately $18B (using 2016 dollars) if Medicaid expansion were broadened. As demonstrated by the Coronavirus Pandemic, the underserved and low-income are most at risk in healthcare. As highlighted in Medicaid and Mortality above, Medicaid is the largest insurance provider for 72 million low-income Americans who often face higher rates of “diabetes (by 787%), cardiovascular disease (552%), and respiratory disease (813%) relative to those in higher-income households” with the authors concluding that Medicaid expansion can dramatically reduce mortality rates for low-income individuals. Clearly underserved communities stand to receive greater health benefits, lower prevalence of chronic conditions, and a reduction in the rate of uninsured by expanding coverage. Related Readings: Did Obamacare Expand Access to Insurance for Minorities? In Some U.S. States, Hardly at All States' Performance in Reducing Uninsurance Among Black, Hispanic, and Low-Income Americans Following Implementation of the Affordable Care Act Medicaid and Mortality: New Evidence From Linked Survey and Administrative Data When States Don’t Expand Medicaid, Women Suffer The Impact of Medicaid Expansion on States’ Budgets Chart Book: The Far-Reaching Benefits of the Affordable Care Act’s Medicaid Expansion

The Driver: Recognizing the opportunity in “virtual first primary care” Oxygen Healthcare was launched during the Coronavirus pandemic to provide an end-to-end solution for physicians looking to rapidly deploy virtual-first primary care. Backed by $3M from Paul Heywood and with a founding team that has been involved in a number of successful startups, Oxygen offers AI-based solutions that provide clinicians with an entire virtual primary care ecosystem The Key Takeaways: Nearly 40% of physicians have a side-gig and almost 75% of them say that enjoy it at least as much, if not more than their primary job Integrated, virtual-first primary care practices like Oxygen will help clinicians streamline clinical workflows and improve the quality and cost of care Virtual primary care doctor, consulting, expert witness and investor are all popular additional sources of income for physicians Nearly 20% of primary care clinicians surveyed by the Primary Care Collaborative during COVID said someone in their practice plans to retire early or already had left the practice. The Story: Founded in 2020, Oxygen’s goal is to combine “the best of robotic automation, AI, and digital healthcare technologies to create an outstanding virtual healthcare experience.” Targeted primarily at independent practitioners, Oxygen allows them to quickly and easily establish their own virtual practice for approximately $200 per month. Oxygen also offers an affiliated group model but that is not as great a focus initially. The platform incorporates telehealth, an EHR, prescription ordering, and administration/billing all into one seamlessly integrated software package. The platform is designed to be “turn-key” so that a practice can be up-and-running within a matter of hours. Once operational, clinicians can prescribe medications, order lab tests, and have all data entered right into the integrated EHR. To get started on their platform, all providers have to do is set up their profile, declare their specialty and payment preferences, and establish their availability. Currently, Oxygen is in its initial rollout phase and the platform is open to all specialties. From the patient’s side, the Oxygen app is an intuitive, patient-friendly portal where patients are asked to complete their health profile and questionnaire before their appointments. Patients can choose their provider and request an appointment. Additionally, patients are sent push notifications for upcoming appointments. Currently, the Oxygen app has the capability to upload and integrate data from consumer wearables health apps such as the Apple Watch or Fitbit and is working on others. While Oxygen’s EHR does not currently integrate with the major provider-based EHRs , this capability is expected to be incorporated in the very near term. According to the company, their founding team has helped build investments with over $1B in value and been involved in successful startups with exits to Google, Oracle and others. The Differentiators: Oxygen’s platform gives independent physicians a rapid way to provide “virtual-first” telehealth services in a comprehensive, integrated platform, This eliminates the hassle and inconvenience of having to contract for separate EHR’s, billing/administrative functions, telehealth platforms, etc. In addition, Oxygen’s app is intuitive from both the clinician and patient side, the platform is easy to navigate, clear, and graphically appealing. In addition, Oxygen’s app allows clinicians to review lab/test results before they are sent to patients or have them sent directly to patients in a contextualized form (ex: high, low, within normal range), based on the clinician’s/patient’s preferences. This will become increasingly more important as healthcare consumerism increasingly drives the healthcare delivery model. In addition, by directly integrating data from consumer wearable devices, Oxygen’s system is allowing clinicians greater visibility into continuous monitoring of their patient’s daily lives and vital statistics. While there is some debate about the value of consumer-grade vs. medical-grade data, over time there is no doubt that this gap will close with improvements in technology and the information will become increasingly more valuable to clinicians in diagnosis and treatment. The Implications: Virtual first is increasingly gaining a lot of interest among both clinicians and digital healthcare investors as providers look to meet patients where they are. While it certainly won’t be appropriate for all cases, virtual-first can extend access to care for many who would not be able to or want to have to deal with the time or inconvenience of having to visit the doctor for a physical appointment. In addition, “virtual-first” is appealing for physicians who feel overworked and overburdened by the administrative portion of their jobs so are beginning to look at ways of supplementing or replacing income. For example, a recent article in Becker’s Healthcare noted that nearly 40% of doctors have side-gigs, prompted largely by income losses from COVID and that almost 75% of them like their side gig equally or more than their primary job. Services like Oxygen’s which are purpose-built for virtual care and help to optimize all facets of running a practice from billing right through referrals should benefit from this trend. In addition, by incorporating AI into their model, Oxygen will increasingly find ways to streamline the workflow and improve the quality and cost of care. Moreover, as providers and patients look to ways of extending care beyond facilities to incorporate remote patient monitoring “virtual-first” will already allow EHRs and other systems to incorporate the appropriate data and analytics so they can be analyzed and applied within clinical practice and workflows.

Our Take: With the rise of ransomware attacks, healthcare providers and application developers need to make sure they are practicing exceptional cybersecurity controls and security hygiene to avoid being victimized and to recover quickly if they are. As noted in a recent Forrester blog post, entitled “Ransomware: Surviving by Outrunning the Guy Next To You”, ransomware is about making yourself a less vulnerable target than others and protecting your critical infrastructure, ensuring that staff is familiar and practicing security protocols, reducing the potential places for malware intrusions and ensuring the safety of healthcare systems and patients. Key Takeaways: According to CISO magazine, 97% of organizations faced a mobile malware attack and 46% had at least one employee download a malicious mobile application in 2020. Between 2010-2017, over 176.4 medical records were breached by criminals aiming to monetize off of the medical and private information stored by the healthcare systems. According to the HHS, “4 out of 5 U.S. physicians have experienced some form of a cybersecurity attack.” Surveys indicate that recent ransomware attacks only heighten patient’s hesitancy to provide personal information and data online. The Problem: On May 1, 2021, Scripps Health in Los Angeles reported that it had begun experiencing a ransomware attack that would ultimately last several weeks. According to Scripps the attack exposed the health and personal information of approximately 150,000 patients, forced it to take its IT system offline for several weeks, and required medical personnel to revert to using paper-based records. This is only one example of the increasing rise in ransomware attacks on healthcare facilities that are occurring more frequently, putting patient’s information at risk and disrupting operations or entirely shutting down healthcare services. This not only places patients at risk but damages the healthcare organization’s brand and reputation. These ransomware incidents raise questions on the role healthcare systems themselves and users of these healthcare technologies and applications play in ensuring the security of patient data and their basic operating infrastructure as well. For example, according to HealthcareDive, “fewer than half of healthcare institutions met national cybersecurity standards last year” and IT and cybersecurity spending for healthcare systems remain low relative to other industries. The Backdrop: Cybersecurity, or lack thereof, is directly related to the protection of the delivery of healthcare to patients and patient health information. The possibility of a cyberattack increases the risk of exposing patient information, erasing or deleting health records, and even shutting down the entire system. Ransomware is a very dangerous example of what may result from attempts at email phishing or malware or targeted bugs. Ransomware is malware implanted by cybercriminals that utilizes encryption to in effect hold user information hostage for a ransom ranging in amounts from thousands to billions of dollars from the organizations that rightly own the data. Moreover, even when the demands for ransom are met, not all the data is recovered. For example, In 2020, the average “bill” paid to cybercriminals by companies to recover their information toppled upwards of 1.3 million dollars yet only about 69% of the stolen data was ever retrieved following this payment. Oftentimes, ransomware is launched into systems via emails and plug-ins such as USBs and other hardware. The data is encrypted so that owners of the data cannot access files, applications, or their databases unless they pay the ransom in order to get the “key” to decode or decrypt the data. Ransomware can also be designed to affect other parts of an organization’s systems. Due to the sensitive nature of its data and the life-and-death impact that data issues or delays can have on the quality of care the healthcare industry is vulnerable to and has been a prime target of ransomware. For example, in 2020 over a third of healthcare systems reported being hit with ransomware, and 65% of those reported that they had paid the ransom to cybercriminals to get their data unencrypted by the attackers. As noted above, this lack of IT security is in part due to institutional constraints, such as a lack of financial resources and understaffed and underfunded IT teams. These problems were heightened by the COVID crisis when healthcare systems had to deal with the stress of the shortage of physical facilities for patients and dramatically increased workloads on staff (some of whom became ill with COVID). Just as healthcare workers are expected to maintain certain practices and procedures for physical hygiene, healthcare organizations need to ensure they have and are following similar policies and procedures for data privacy and security and their online presence. These methods are most effective when they are communicated broadly throughout the organization, practiced widely, and the subject of drills so they can be put in place quickly in the event of an emergency. One suggestion for healthcare providers would be to follow the lead of organizations in the financial services industry, which generally have been at the forefront of cybersecurity controls. As such we would suggest that healthcare organizations implement the controls recommended by the New York State Department of Financial Services in a recent National Law Review article. These include: Email filtering and anti-phishing training for employees, including regular exercises and blocking malicious attachments and links; Vulnerability and patch management, including a documented program to identify, assess, track and remediate vulnerabilities on all enterprise assets; Multi-Factor Authentication, including for all logins to remote or internal privileged accounts; The disabling of Remote Desktop Protocol (“RDP”) access wherever possible, and if RDP is deemed necessary, restricting access only to whitelisted originating sources; Privileged access management, including implementing the principle of least privileged access; A way to monitor systems and respond to suspicious activity alerts, including an Endpoint Detection Response (“EDR”) solution; Comprehensive, segregated backups that will allow for recovery in the event of a ransomware attack; and An incident response plan that explicitly addresses ransomware attacks and will undergo testing, including with the involvement of senior leadership. Implications: The dramatic increase in ransomware combined with the proliferation of digital health tools requiring remote access has lead to an exponential increase in points of vulnerability points for healthcare suppliers, their partners, and their customers. As a result healthcare organizations need to make sure they look closely at any applications they may deploy in their systems to ensure they don’t expose vulnerabilities or create new ones. Similarly, application developers need to ensure they are following strong coding standards and design techniques and incorporating strong security tools from the earliest stages of development. While these may sound fairly straightforward, as noted in a recent article review in the Journal of Medical Internet Research, approximately 15% of the articles they studied noted that developers lack the expertise to secure mHealth apps, pay little or no attention to the security of mHealth apps and lack the resources for developing a secure mHealth app. As a result, we recommend that both app developers and those looking to deploy new digital health apps in their environment follow steps similar to the ones outlined in the W2S solutions blog entitled “Security Issues App Developers Need To Deal With While Developing A Mobile App.” While not meant to be exhaustive, the recommendations and others will help protect from ransomware entering an organization’s system. These include: Writing secure code, that uses strong coding practices like signing in and code hardening Encrypting data during development thereby making it more difficult to be accessed by malicious attackers Using third-party application libraries sparingly and testing code after using it to ensure the code is not compromised Using only authorized Application Programming Interfaces and using a central authorization for the complete API to ensure maximum security Deploying high-level authentication via such means as Multi-factor authentication (ex: OTP login, biometrics) Incorporating session management as a feature, in case the device is lost or stolen and using tokens instead of identifiers when managing sessions Testing continuously and properly, use emulators and penetration testing to determine any vulnerabilities Staying on top of evolving security technologies and threats to ensure that you are using the latest protection for your application Related Readings: Scripps Health EHR, Patient Portal Still Down After Ransomware Attack What Is Ransomware? Fewer Than Half of Healthcare Institutions Met National Cybersecurity Standards Last Year ​​More Than 1/3 of Health Organizations Hit by Ransomware Last Year, Report Finds. Security Issues App Developers Need To Deal With While Developing A Mobile App (Blog) A Wave of Ransomware Hits US Hospitals as Coronavirus Spikes

The Driver: Castor, a provider of clinical trial software to empower decentralized clinical trials, recently raised $45M in a Series B funding led by Eight Roads Ventures and F-Prime Capital with additional investments from existing investors Two Sigma Ventures and Inkef Capital. With offices in New York and Amsterdam, Castor is attempting to disrupt an antiquated clinical trials process that is often not digitally driven and which results in approximately 40% of trials being halted due to slow enrollment. The Takeaways: Less than 5% of patients participate in clinical trials and trial diversity is a persistent problem, particularly for certain disease populations. According to data from IQVIA, 49% of patients drop out of clinical trials before completion and 48% of trial sites miss their enrollment targets. On average new therapies take approximately 10 years to reach the market and cost approximately $3B to develop. A typical travel requirement is for patients to visit a trial site 15-20 times over a 6 month period. The Story: Founded in 2012, while CEO Derk Arts was doing his final medical internship in an intensive care unit in the Netherlands and had to assist with a clinical trial. As part of the trial, Arts had to input case report forms into each individual patient's case report file which then had to be combined in order to get results for the study. Upon using this system, Derk soon realized it would not scale easily. Building upon the programming experience he had used to help support himself while at school, it took him two weeks to build a prototype for use in the ICU, according to the company’s website. After doing a little more research Arts states that he came to find out “that almost all unfunded investigator initiated studies used Excel or SPSS for data collection” as colleagues noted open source software was too complicated to build and professional systems were too costly. According to the company, Derk soon partnered with a friend who was a PhD student and within two months they had built what was to become the Castor Electronic Data Capture system. Castor states that the EDC offers a “modern, self-service clinical research platform which enables every researcher worldwide to design studies and integrate data from any source in real-time.” Castor is attempting to use human-centered design to improve the speed, efficiency and patient experience of the clinical trial process. The Differentiators: Traditionally clinical trials are based around a physical trial site around which trial participants are recruited and to which they periodically report to have their blood drawn and other lab tests to evaluate the efficacy of the drug candidate. Often the process was very paper intensive and manually based. Castor is attempting to modernize this legacy process through the use of digital technology. Castor’s enrollment portal allows organizations to recruit, screen and obtain electronic informed consent forms in an automated fashion. This is extremely important as trials often have a difficult time recruiting diverse populations, in part because of the difficulties that many underrepresented communities have in accessing trial sites. For example, according to Pharma Voice, patients often have to travel an average of 50 miles to reach a trial site. In addition, Castor’s platform allows “participants to easily provide data, and stay up-to-date from the comfort of their own homes”. As noted above almost 40% of trials are halted due to missing enrollment targets, in part due to the burdens trials place on their participants such as manually having to keep records of medication administration, efficacy and side effects. By allowing trial participants to keep records and communicate through its app, Castor’s platform streamlines and simplifies the process for patients. In addition, with the average cost to successfully develop and bring a drug to market equaling approximately $3B, Castor’s products empower companies to drive down trial costs and speed delivery of new products helping to drive competitive advantage. This is achieved via real time visibility into trial data which facilitates monitoring patients and incorporating trial amendments (if necessary), and flexible remote data capture which provides an API that allows data collection from other systems. The Big Picture: As noted by Castor co-founder and CEO Derk Arts, prior to COVID, clinical trials were “stuck in a rut”, the process was cumbersome, required heavy manual input from both patients and trial personnel and did not allow for easy monitoring of side effects or changes in trial protocols. However, due to the need for social distancing and to limit exposure to COVID, digital clinical trials gain new popularity, By reducing travel time and expense for participants, which often spans several times per week over a six-month span, tools like Castor helped increase recruitment of more diverse trial panels and the recruitment of sub-populations which can be critical in certain diseases. In addition, as illustrated by a number of short trial stoppages during COVID vaccines development, rapid tracking and monitoring of drug candidate side effects can be crucial in helping speed products to market and in investigating potential issues or the need for changes in protocol. Moreover, the pace of pharmaceutical innovation relative to the amount spent on R&D is largely unchanged since the 1950’s, in part because of the difficulties encountered with recruiting, retaining and completing trains, Castor and products like it, which bring the process into the digital age, should help speed the pace of innovation. Castor, a Clinical Trial Process Company, Raises $45M to Create More Human-Centered Research, Castor Raises $45M Series B to Modernize the Clinical Trial Process and Maximize the Impact of Research Data on Patient Lives

Our Take: For the past two decades, Virtual Reality (VR) and Augmented Reality (AR) have emerged as treatment protocols for mental health and are regularly studied in psychological research. Using an immersive experience, individuals feel as if they are in an environment other than the physical world they are actually in and experiencing sensations consistent with the artificial environment. The AR/VR industry has had a growing interest in medical applications over the past 20 years; however, the pandemic caused a boom in the usage of virtual reality in behavioral healthcare. For example, as reported in Scientific American, “a new wave of psychological research is pioneering VR to diagnose and treat medical conditions from social anxiety to chronic pain to Alzheimer’s disease.”. Although there is success with VR/AR therapies, additional research is necessary in order to ensure users are receiving cost-effective, high-quality care to cope with mental health issues. Key Takeaways: Recent studies indicate VR compares favorably to existing treatments in anxiety disorders, eating and weight disorders, and pain management. Over 5,000 studies indicate that VR has the ability to diminish pain, steady nerves, and boost mental health. In December 2020, 2 in 5 adults (42%) reported symptoms of either anxiety or depressive disorder, an increase from 36% when measured in August. There are ways to blend VR and AR into the healthcare system, by incorporating VR treatments into psychiatric care and providing better directions for VR-based treatment and clinical research. The Problem: Following a dramatic increase in usage during the Pandemic, studies have revealed the benefits of using AR/VR technology in treating mental health and the need to increase the use of such technologies. AR/VR technologies have the unique characteristic of physically creating a sensation for patients that can be used to cause them to feel as if they are in stressful or uncomfortable situations to use in a therapeutic context. Combining that with automated therapies or virtualized coaching would guide the individual to better cope with the stressful situation. The need for social distancing during the Pandemic led to increased treatment via AR and VR in conjunction with counseling and cognitive behavioral therapy to treat addictions, panic disorders, phobias, eating disorders, and post-traumatic stress disorders (PTSD). Successful use of AR/VR in treatment protocols during COVID underscores the need for greater focus to be placed on seamlessly blending VR and AR technologies into the treatment of mental health. This includes incorporating VR treatments into psychiatric care, and providing better direction for VR-based mental health treatment and clinical research. The Backdrop: AR and VR technologies have been used in the treatment of mental health since the late 1990’s. Within a safe and controlled environment AR/VR VR technologies can, through a controlled and deliberate process, increase levels of stimuli or exposure to situations that would provoke anxiety for a particular individual. Slowly as each level of exposure continues to reveal a lack of actual threat, the individual becomes less and less anxious around that stimuli. Virtual reality exposure therapy (VRET) and augmented reality exposure therapy (ARET) are most commonly used to treat PTSD. A study published in the Journal of Psychiatric Research carried out in accordance with PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-analyses aimed to review the efficacy of VRET and ARET as PTSD treatment. The study included participants who have PTSD due to various traumas with a cut-off score on the Davidson Trauma Scale ranging from 40 to 65 points (the Davidson Trauma Scale, a common measure of PTSD ranges from 0-68, with 68 indicating extreme PTSD). The study concluded VRET might be an effective alternative to current psychiatric treatments for PTSD, especially among patients who have not responded to previous treatment. While it has not always been feasible to use exposure therapy for patients, these relatively new digitally assisted exposure therapies of ARET and VRET will broaden the ability to treat more patients. VRET creates the digital surroundings, and ARET adds digital fear stimuli to the user's physical world, aided by an interactive digital device such as a computer, smartphone, or tablet. ARET and VRET aim to increase the sensation of the presence of anxiety-provoking stimuli during exposure therapy, thus improving the efficacy of the treatment. In addition, these treatments are less dependent on the patient’s imagination and make it possible to reproduce the traumatic stimuli in a systematic, consistent and realistic way. An article from JAMA reported that in December 2020, 2 in 5 adults (42%) reported symptoms of either anxiety or depressive disorder relative to 36% in August 2020. These numbers indicate the toll the pandemic had on individuals. The pandemic exacerbated the highest rates of PTSD and anxiety among healthcare workers (22.8%). This rise in mental health care needs during the pandemic caused the healthcare industry and local communities to depend more on VR therapy. Overall, according to a study entitled, “Impact of the recreational use of virtual reality on physical and mental wellbeing during the Covid-19 lockdowns” an increase in VR usage during the lockdown helped keep people occupied and improved their mental health and physical wellbeing detailing that over 75% of increased VR use was for fitness, 55% for socializing and 37% for meditation. Although virtual reality treatment for mental heatlh needs to be used cautiously as not everyone can tolerate it, there are over 5,000 studies that reveal VR can diminish pain, steady nerves, and boost mental health. For example, an early study on VR and PTSD found that of 20 service members who enrolled in and completed the study treatment protocol, 75% had experienced at least a 50% reduction in PTSD symptoms and no longer met DSM-IV criteria for PTSD at post-treatment. Average PTSD scores decreased by 50.4%, depression scores by 46.6%, and anxiety scores by 36%. Implications: Originally applied to PTSD, virtual reality treatment has since been broadened to include areas such as anxiety and stress disorders, schizophrenia, autism, dementia and pain. Recent studies have shown that VR-based strategies have positive impacts and have successfully been used to manage mental health issues. For example, a literature review of 36 articles examined VR use during clinical trials and the effects it had on individuals when therapy was administered. It revealed that VR environments can help alleviate the symptoms of depression, improve cognition, and even positively impact social functioning. One study in particular examined the effect virtual reality headsets have on pain distraction during immunizations. It found that the use of the VR headsets improved those who had fears and pain in 94.1% of subjects. AR/VR therapy is also a cost-effective strategy to help individuals cope with phobias, anxiety and other underlying issues. Given the increase in PTSD cases following the pandemic, VR and AR are receiving more attention as potential treatment modalities because of their effectiveness and ease of use. This type of therapy can broaden access to care for those whose time for treatment may be limited or who can now access the treatment because of the continually declining cost of the technology. While the cost of virtual reality equipment in the early 2000s was about $25,000, VR headsets are now available for under $300. Additionally, though the decrease in cost allows for easier access by a larger population and can reduce disparities in those seeking care, it does not guarantee the quality of care. For example, researchers have reported a significant number of cases where individuals are both self-diagnosing and self-treating, leading to adverse effects. AR and VR therapies need to be administered in a controlled environment with patients gradually introduced to the appropriate stimuli and scenarios in order to develop a proper therapeutic approach that will help them to overcome their fears. While there is solid backing for this approach, more well-designed, evidence-based research in this field is necessary. Literature reviews in this area revealed limitations in the current research and highlighted the need for future research, notably high-quality randomized controlled trials. This would allow researchers to gain important additional information related to side effects and adverse effects of the therapies. In the research process thus far, the benefits of AR and VR have produced successful results; however, there have been times when these environments were incomplete, untested, and not properly trialed by psychologists. For example, although there are many positive aspects of VR therapy, an article entitled “Virtual experience, real consequences: the potential negative emotional consequences of virtual reality gameplay” noted that there are negative emotional consequences in some VR scenarios such that users may experience vertigo, nausea, or dizziness. This is a clear indication that more research needs to be completed in the area to ensure end users derive the best experience from the technology and get the highest quality of care that can be rendered. Moreover, the process of developing and implementing VR needs to have clearer rules in place so that patients and providers can identify and report the successes, failures, and limitations of the treatment. In this way the necessary safeguards and improvements can be put in place. The importance of this is underscored by a report by Perkins Coie, which says that 68% of healthcare professionals believe that AR/VR training simulations will be the primary focus of new solutions and applications through 2022. The report highlights that the AR/VR market will be used to simulate surgical training for doctors and nurses, palliative hospice care, pain management, and 3D visualization of diseases at the molecular level. VR technology will also allow doctors to visualize and assess patients remotely to aid early diagnosis and treatment while protecting health workers from potential exposure to contagions. For AR & VR technologies to achieve these goals all necessary steps and controls for seamless integration into the clinical setting need to be considered and codified. This therapy is technologically driven and consequently sufficient initial and ongoing training needs to be provided as well as continued support and supervision to ensure that clinicians are using the technology as safely and effectively as possible. Related Reading: Efficacy of Immersive PTSD Treatments: A Systematic Review of Virtual and Augmented Reality Exposure Therapy and a Meta-analysis of Virtual Reality Exposure Therapy Virtual Reality Therapy: Emerging Topics and Future Challenges The Pandemic Saw Surges of PTSD in Healthcare Workers- Can Virtual Reality Therapy Help? Virtual Experience, Real Consequences: the Potential Negative Emotional Consequences of Virtual Reality Gameplay A Literature Overview of Virtual Reality (VR) in Treatment of Psychiatric Disorders: Recent Advances and Limitations