Search

Coronavirus Has Changed Healthcare Delivery-Likely Forever “Our Take”: On December 2nd the Cleveland Clinic announced it was postponing all “nonessential inpatient surgeries; from December 7th through January 4th, 2020, marking the second time the system has had to postpone elective surgeries due to the pandemic (the first following a statewide order in March of 2020). Postponements of highly profitable elective surgeries are but one of the ways that the Coronavirus has changed healthcare delivery, likely forever, leaving a digitally transformed, facility-lite but potentially less profitable system in its wake. However, providers and practitioners that embrace existing and emerging digital technologies can potentially replace lost revenues with virtual and remote care to those reluctant to use institutional settings, and even play a greater role for those looking to take charge of their own care. Description: The forced deferral of elective procedures and routine clinical care has dramatically undermined the profitability of physicians and providers. A recent article in Health Affairs noted that between February and April 2020, hospital volumes declined almost 20% and while they had recovered somewhat by June/early July 2020 they remained well below pre-pandemic levels. Nevertheless, while patients have largely scaled back in-person care below pre-pandemic levels they have embraced accessing the system via telehealth, telebehavioral health, and even at-home or self-administered testing. These changes combined with the fact that the strain on the healthcare system has made patients more amendable to obtaining care from other levels of clinicians in the system (PA’s, LPN’s, Pharmacists, etc), have permanently altered by where and from whom patients will be willing to get care in the future. In addition, with nursing homes and long-term care facilities accounting for 38% of all deaths and 5% of all U.S. COVID cases according to the New York Times, seniors are now much more reluctant to seek care in those facilities. This human tragedy caused regulators and caregivers to seek additional evidence that facilities will embrace new ways of caring for the elderly in order to restore confidence in the safety and well being of patients at these facilities. Along those lines, seniors are now much more likely to attempt to age in place longer, which is more practical with the aid of certain technologies. Finally, while a vaccine will aid in the long-term recovery from COVID’s healthcare impact, the economic impacts will be long-lasting and unfortunately cause even more people to remain unemployed for longer periods of time. For example, according to the Bureau of Labor Statistics, by November 2020 the percentage of unemployed individuals who had been unemployed for 27 weeks or more rose to a seasonally adjusted 36.9%, up from 19.2% before the pandemic began, With research showing a direct correlation between the period one remains unemployed and their ability to eventually return to the workforce, many people will likely remain permanently unemployed and as a result, permanently lose employer-sponsored coverage. Given that by some estimates as many as 4M could remain permanently unemployed post-pandemic, and that employer-sponsored coverage is by far the most profitable form of coverage, effectively subsidizing Medicare and Medicaid, this shift in payor mix will further hurt providers. Implications: The pandemic has brought about a of sea change for healthcare condensed into just a few short months. While the changes have put tremendous pressure on the finances of providers in the near-term if they don’t respond by embracing a dramatic change in business models they may not survive. While typically slow to embrace change, consumer acceptance of new delivery models and unprecedented regulatory responsiveness to COVID have created one last opportunity for the healthcare system to bring itself into the digital age on its own terms or risk being overhauled by outside forces. First and foremost, although there are highly effective vaccines on the horizon, and we are on the cusp of bringing this pandemic under control, there is no guarantee the world will not see another virus in the not-too-distant future. We must be prepared financially as well as clinically. Moreover, despite the current reimbursement and regulatory uncertainty surrounding many telehealth changes during COVID, providers have to embrace the new normal as this is what consumers have now come to expect. As Joseph Kvedar of the ATA put it “the doctor’s office is now in your living room”. Although some will cite potential reimbursement differences, given the low incremental cost to treat patients virtually, physicians should be able to see patients more efficiently provided they are given tools to help with administrative tasks. For example, virtual transcription tools could aid with paperwork to allow larger panel sizes at a fraction of the cost of physical scribes. In addition, early research indicates that missed appointments have decreased markedly with the implementation of telehealth with one study showing that overall missed app[intments telehealth are down over 35% and almost 24% for Medicaid patients. In addition, many forward-thinking elder care facilities are now embracing the use of telemedicine and other remote care tools to connect patients to clinicians (and families) and keep patients out of harm’s way or from going to centralized “nursing stations”. Bluetooth-enabled fall-detection systems, motion and video sensors, and other wearables now allow for real-time monitoring at a much more sophisticated and connected level than ever before, facilitating aging in place. Although dealing with the shift in payer mix will be difficult, in a transformed healthcare delivery system providers and physicians will need to reduce their reliance on high margin episodic and elective procedures. Over time we see the plethora of real-time sensors, monitors, therapeutics, recovery tools, and data science changing the very nature of healthcare from periodic check-in and repair to one of constant monitoring and fine-tuning. More Than 100,000 U.S. Coronavirus Deaths Are Linked to Nursing Homes; COVID-10 and the U.S. Economy; New Data Shows Patients Save Fuel, Time And Missed Appointments With Telehealth The Employer’s Role in Creating a COVID-19 Testing and Vaccination Infrastructure Event: On November 30, 2020, Benefits Pro released an article explaining why employers will be well-positioned to support large-scale vaccination efforts. As employers are typically responsible for vaccinating about 25% of the U.S. population for flu, they can bring the same strength and efficiency to a COVID-19 response through testing and vaccination. Description: Many employers have already initiated testing programs in an effort to responsibly bring employees back to the worksite. For example, CVS Health has included retail and onsite point-of-care testing where physical distancing can be difficult. In addition, Delta Air Lines is providing employee COVID-19 testing with a rapid-response option for flight crews to help employees and customers build confidence about traveling with Delta. As employers already educate and engage their employees, they can help employees overcome any apprehensions or barriers to access, achieving a more widespread immunity. As a result, employers will be well-positioned to support a large-scale vaccination effort. Implications: Just as employers have supported influenza preparedness, they can build on the infrastructure they’ve already created for immunizations to support the national COVID-19 testing and vaccination infrastructure. Employer-provided vaccinations could be the first step for companies to finally open their offices. This could bring more productivity and well-being among the employees. Companies could require or financially incentivize employees to be vaccinated in order to physically come in to work to promote the vaccine. Rolling out employer-provided vaccinations could also reduce health disparities as companies can cover workers from underserved communities and backgrounds. While some may not have access to a vaccine in a vulnerable neighborhood, his / her employer may provide another means of accessing the vaccine at a more convenient time or place. Employers could also educate the employees and customers to encourage them to trust the vaccine in order for a safe return to the workplace. While there may be some logistical obstacles in vaccinating employees at work such as refrigeration, freezing or even ultra-cold storage, which could complicate the transportation, storage, and location decisions, many employers may be large enough or work with trade associations to figure out ways to overcome these. The Employer’s Role in Creating a COVID-19 Testing and Vaccination Infrastructure Antiracism Training in Medicine Event: On December 3rd, JAMA Health Forum published an article addressing the ongoing racism and biases not only occurring today, but specifically within the healthcare realm. Given a rise in the deaths of unarmed African Americans, disparities in infection and death rates due to the Coronavirus, and lack of both healthcare and everyday resources during this unprecedented time, healthcare organizations are being urged to address racism and discriminatory practices within their organizations to promote better patient outcomes and health equity. Description: As a result of the visibility that racial injustice and discrimination have been given outside of healthcare, addressing this issue within healthcare has become a key issue. Currently, many medical programs lack cultural competency as well as diversity and inclusion training within their curriculum, leaving medical professionals ill prepared when treating patients of other ethnicities. As a result, many organizations have incorporated mandatory antiracism practice and training to address racism and bias and to advance health equity. Although this serves as a significant steppingstone, the article states that more can be done to make real advances as opposed to surface level training activities that ultimately show no improvement in antiracism competencies or in institutional measures of inclusion, equity, or health outcomes. Implications: As a result of the pressing need to assure that healthcare workers are adequately trained, several recommendations have been proposed including: 1) aligning antiracism training with the mission, vision, values, and priorities of the institution to provide that it is factored into the institution’s strategic goals, success metrics and incentives to ensure that it is effective, 2) establishment of steering committees made up of diverse institutional leaders, faculty, staff, and students to oversee and direct training, 3) ensuring institutions are building antiracism vocabulary to promote consistent communication and developing a longitudinal anti racist training curriculum that ultimately meets stakeholder needs, and, 4) developing external partnerships to build trust with vulnerable communities and community organizations and to create good relationships between students and trainees to avoid, consciously or unconsciously, harming participants. By incorporating these recommendations into healthcare organizations and curriculum, healthcare professionals can successfully fulfill their oaths and ethical responsibilities to treat patients, students, trainees, and colleagues with the utmost respect and equity. Antiracism Training in Medicine Primary Care Leaders Call for Clarity About Booking and Recall IT Systems for COVID Jabs and Distributing a COVID-19 Vaccine Across the U.S. - A Look at Key Issues Event: A recent article in Mobihealthnews highlighted the raised concerns in the U.K. about the IT system that will be used to book and recall patients for administration of both doses of the COVID-19 vaccine. Analogous to the U.K., the U.S. faces similar challenges in the rollout of the vaccine distribution process, as presented in an article by the Kaiser Family Foundation. Description: Questions surrounding the logistics of the distribution of the COVID-19 vaccine remain as concerns have been raised that the current booking system is not prepared for the vaccine rollout. The biggest challenge lies in how national mass vaccination centers would link to primary care IT systems to view records of those who received the vaccine to ensure that the entire population is vaccinated. Under Britain's National Health Service (NHS), DrDoctor has launched a solution aiming to streamline the vaccine booking process by linking two required appointments. The Medicines and Healthcare products Regulatory Agency (MHRA) has an AI tool that will process adverse reactions to COVID vaccines in the U.K. Vaccine distribution in the U.S. faces similar but more complex challenges. First, funding for vaccine distribution is critical to health outcomes because there is a strain on state and local public health infrastructures. Secondly, logistics and monitoring are also expectd to be an issue because government-led distribution has never before been done in the U.S for the entire population over a short period and this will be done individually by each state. Actual vaccination sites and accessibility to these sites remain an issue and follow up with each individual who has received the vaccine to ensure they receive the same vaccine on time. Similar to MHRA, the U.S. is implementing an enhanced safety monitoring system to track vaccine adverse events. Lastly, getting the public to trust the vaccine is crucial to positive health outcomes because of concerns around the speed with which the vaccine came to market, general concerns around safety, efficacy and side effects and the concerns raised within the context of the political differences during the election. Implications: There is no doubt that distributing the COVID-19 vaccine will be a massive, complicated effort in both the U.K. and U.S. While planning for distribution has been underway for months, there are still numerous questions and concerns about how challenges will be overcome. Operation Warp Speed has provided pharmaceutical companies with over $10 billion to support research, development, manufacturing, and distribution of COVID-19 vaccines, yet challenges remain. COVID-19 has disproportionately affected specific populations who are vulnerable and may face severe outcomes if not vaccinated. The accessibility of sites for equitable access to the vaccine remains unclear due to the transportation and location-based barriers to health care. The CDC and local jurisdictions are currently implementing a new vaccine tracking system to monitor vaccine administration; however, it remains unclear if the new system will integrate with existing immunizing information systems. Successfully addressing the barriers and challenges identified is essential to ensure the most excellent health benefits accrues from administering COVID-19 vaccinations across the globe. Primary Care Leaders Call for Clarity About Booking and Recall IT Systems for COVID Jabs & Distributing a COVID-19 Vaccine Across the U.S. - A Look at Key Issues DeepMind AI's Protein Folding Prediction Achieves Unprecedented Accuracy, Opening Doors to New Disease Treatments Event: On November 30th the DeepMind subsidiary of Google announced it has cracked a decades-old protein-folding challenge with an artificial intelligence system called AlphaFold. DeepMind noted that “figuring out what shapes proteins fold into is known as the ‘protein folding problem’, and has stood as a grand challenge in biology for the past 50 years”. This discovery could eventually help identify new treatments for diseases, among other nonmedical uses. Description: DeepMinds’ winner for the Critical Assessment of protein Structure Prediction (CASP) competition, AlphaFold’s average error in predicting protein structure is a distance of 1.6 angstroms, which roughly translates to 0.1 nanometers, or the width of an atom. Among a collection of the most difficult protein targets, the system’s median score dipped down to 87 Global Distance Test (GDT). By understanding the protein-structure, it will play a key role in developing cures for diseases such as Alzheimer’s, Parkinson’s, cystic fibrosis and Huntington’s. DeepMind also announced working on predicting protein structures within the COVID-19 virus of which the technology will play a key role in environmental sustainability. Implications: Such machine learning techniques bring new breakthroughs in both human health and fundamental biology and will bring better understanding of the body via accurate protein-structure prediction. Since a protein’s shape is closely linked with its function, and the ability to predict this structure unlocks a greater understanding of what it does and how it works, developing treatments for diseases or finding enzymes that break down industrial waste, are fundamentally tied to the shapes of proteins and the role they play. This discovery will dramatically reduce the time and cost involved in determining a proteins structure versus current methods. Not only will this help researchers develop new cures for diseases associated with misfolded proteins but it will also brings major breakthroughs in understanding the disease and in drug discovery. AlphaFold: a Solution to a 50-Year-Old Grand Challenge in Biology

Biden’s Public Option Brings Americans One Step Closer to Fixing the System Event: Among President-elect Biden’s stated legislative goals is to improve healthcare access by lowering the Medicare eligibility age from 65 to 60 years old and allowing those below age 65 to buy-in to Medicare via a “public option”. Under Biden’s plan, eligible participants between the ages of 60-65 could maintain their existing source of coverage or purchase Medicare via the public option. While it is impossible to analyze this portion of the plan in isolation (and we will include additional analysis in later posts), we believe the Medicare public option is a net positive for healthcare access and would generally improve the quality and lower the cost of care in the U.S. Description: Under the proposal, Biden plans to create a public health insurance option which would let individuals purchase Medicare coverage. As noted by the Committee for a Responsible Federal Budget (CFRB), since “Medicare rates are generally lower than private insurance, the public option could be cheaper than alternatives in many cases…[and] competition from the public option could reduce the cost of private insurance as well”. Biden’s proposal would make coverage available to those who lack coverage, those with Employer sponsored insurance, those who get coverage through the current ACA exchanges and in states where Medicaid was not expanded. It is estimated that under the plan approximately 15-20 million uninsured Americans would gain coverage. Biden’s proposal would pay for coverage by increasing the amount of ACA premium subsidies and financing them by increasing the top marginal tax rate (to 39.6% from its current 37%), increasing tax rates for those making over $1M per year on capital gains (to 39.6% from the current 20%) and estate taxes (via the addition of a stepped up cost basis). While many insurers oppose the plan fearing that pressure from the public option could significantly shift coverage, according to Avalere only about “13.4M individuals currently enrolled in employer sponsored insurance [ESI]”, or approximately 9% of the total ESI market (and likely less-as discussed in implications) would buy in to the public option. Biden’s plan should not be confused with a nationalized or single-payer healthcare system, as: 1) It doesn’t require that everyone be enrolled in a single government insurance plan, 2) it does not contain limits on provider payment rates, 3) it does not eliminate the Medicaid eligibility gap, and, 4) it does not allow those in households eligible for ESI to take advantage of Federal insurance subsidies. Despite the fact that many would argue that his plan would be the beginning of a move in that direction, given the lack of traction gained by Senator’s Sanders and Warren during this election cycle, we see this as highly unlikely for the foreseeable future. Implications: The current U.S. healthcare system is unsustainable for well known reasons of cost, quality, inefficiency and equity. While Biden’s public option will create some near term shifts in sources of coverage for payers and providers, it would provide coverage for many Americans without healthcare insurance or struggling to pay premiums, and we expect over time will actually benefit providers and payers. For example, as cited earlier, Avalere estimates that 13.4M would shift from ESI to Biden’s public option, realistically any public option will have to be bid out to the commercial insurance companies in the same way Medicare Advantage is currently run. Although some have surmised that employers may chose to drop employees to let them buy into a public option plan or that large segments will drop employer coverage to buy into Medicare, we note similar arguments were made with ACA exchange plans and never materialized (and could run afoul of discrimination laws). Moreover, given that Medicare Advantage is one of the most successful government programs ever and now accounts for almost 40% of Medicare enrollees up from 25% in 2011 we expect payers to benefit from additional application of analytics and further economies of scale in treating this cohort. In addition, despite the fact there is some dispute about MA margins, given that over 50% of MA market share is concentrated among three of the public managed care programs that would argue in favor of its profitability and attractiveness. Although Biden's plan will increase the national deficit by $800 billion in ten years according to the CRFB, additional improvements in coverage could bring additional benefits of lower costs and improved outcomes much like were seen in the early years of the ACA. Primary Care: Estimating Democratic Candidates’ Health Plans; Comparing Health Insurance Reform Options; Measuring the Scope of Presidential Candidates’ Coverage Proposals Pre-Symptomatic Detection of COVID-19 From Smartwatch Data Event: A study shows consumer smartwatches data can be used for the pre-symptomatic detection of COVID-19. The study analyzed physiological activity data from 32 individuals infected with COVID-19, identified from a cohort of nearly 5,300 participants, and found 81% had alterations in heart rate, number of daily steps, or time asleep. Using retrospective smartwatch data, it was shown 63% of the COVID-19 cases could have been detected before symptom onset in real-time via a two-tiered warning system based on the occurrence of extreme elevations in resting heart rate relative to the individual baseline. Description: This cohort study investigated whether smartwatches could be used to detect COVID-19 at an early, pre-symptomatic stage. Smartwatches included Fitbits, Apple watch, Garmin devices, and others. The parameters evaluated were abnormal resting heart rate (RHR), heart rate-to-steps ratio, sleep and activity alterations, heart rate signals and other symptoms. These were evaluated for association with COVID-19 and to establish an approach for the early detection of early COVID-19 onset in real-time. The study found that all the above parameters were altered by COIVD-19. Elevated heart rates occur before disease and provide utility as a general signal of respiratory illness. CuSum an online detection method with the ability to detect altered physiology in advance of symptoms, was developed to detect early stages of COVID-19 illness in advance of symptoms using a smartwatch. Implications: As the findings suggested, activity tracking and health monitoring via consumer wearable devices can be used for large-scale, real-time detection of respiratory infections, including COVID, often pre-symptomatically. With the second surge of COVID-19 currently hitting the US, the use of smartwatches could help substantially improve widespread testing detection. In addition, the application of wearable devices to virus detection has ample potential to mitigate the spread of the pandemic as well as addressing respiratory illness overall. It allows self-monitoring, the early detection of symptoms and the ability to place suspected virus carriers in protective protocols without having to expose themselves or others to additional sources of infection. Pre-Symptomatic Detection of COVID-19 From Smartwatch Data Flow Depression Headset to Tackle UK’s ‘Lockdown Loneliness’ Event: A recent article in Mobihealthnews examined the positive health outcomes resulting from the new rollout of the Flow headset and therapy app treatment. Individuals in the UK and EU have been using it to tackle depression and ‘lockdown loneliness.’ Recent user analysis shows that 81% of patients using the Flow headset and therapy app reported feeling better after just three weeks. Description: The Flow depression headset aims to alleviate the burden of loneliness caused by lockdown by improving accessibility to treatment delivered to patients within 48 hours. Patients who use Flow and the behavioral therapy app wear a brain stimulation headset that improves areas known to impact depression, emotion regulation and sleep quality while increasing social support with the app. The therapy program provides an interactive chatbot therapist and a constant companion that offers personalized behavioral therapy in areas proven to reduce symptoms of depression. A study in Plos One indicated that loneliness is a significant public health issue with 70% of people with depression feeling isolated and with worse quality sleep due to the pandemic. Implications: The COVID-19 pandemic has resulted in lockdown measures limiting social contact, which adversely affected mental health outcomes. Providing patients with access to therapeutic applications such as Flow will help tackle common conditions like depression and improve emotion regulation, sleep quality, and increase social support. Rates of loneliness during the initial phase of the lockdown were high, and findings have shown that supportive interventions can reduce loneliness that leads to depression and other mental health symptoms. Flow appears to be a promising solution for patients and clinicians because it's tailored to individual needs; it is controlled in real-time and can monitor a patient's condition and progression of treatment thus far. Flow Depression Headset to Tackle UK’s ‘Lockdown Loneliness’ AliveCor Gets FDA Nod for Suite of Cardiac Focused AI Algorithms Event: On November 23rd, Mobihealthnews reported that AliveCor received FDA clearance for a new suite of algorithms called Kardia AI V2 that interpret ECG data to detect cardiovascular illness. The company also recently announced a $65 million Series E funding round to support its research. Description: The algorithms are designed to capture sinus rhythms with premature ventricular contractions, supraventricular ectopy, and with wide QRS. They work using AliveCor’s KardiaMobile and KardiaMobile 6L devices, which are at-home consumer health management devices that can take 30-second electrocardiograms (ECGs) and are linked to a smartphone app. AliveCor stated the new algorithms will reduce the number of unclassified readings and have improved sensitivity and specificity relative to the company’s atrial fibrillation and other algorithms. There will also be new visualization features on the app, once these algorithms are implemented that will allow users to see their heartbeat average, PVC identification (extra heartbeats that disrupt your regular heart rhythm causing your heart to feel like its fluttering) and tachogram (for detecting heart rate variability analysts). Implications: FDA clearance allows AliveCor to move forward with product development using their new AI technology and implement it in their current devices. Heart disease is the leading cause of death in the United States, according to the CDC. Tech companies have taken the opportunity to participate in the fight against heart disease using innovative new approaches the medical community would otherwise not implement on its own. The marketing for AliveCor’s new algorithm suggests it can improve cardiac care and telehealth services by bringing advanced preventive measures into the home thus lowering costs and improving quality. AliveCor Gets FDA Nod for Suite of Cardiac Focused AI Algorithms Smartwatches Could Monitor Coronavirus Vaccine Safety Event: On November 19th, Lifewire reported that the U.S. Centers for Disease Control (CDC) plans to use smart watches to monitor the safety of coronavirus vaccines if they are distributed in the U.S. Using V-SAFE, a smartphone based health checker researchers will be able to check in on vaccine recipients for health problems. Although this is an efficient way of monitoring patients, adherence to privacy and HIPAA regulations may be an issue as well as long-term patient compliance. Description: With the roll out of the COVID-19 vaccine, health officials are concerned about the safety and how they will monitor the vaccine recipients. Although the results of two vaccine trials are expected to be more than 90% effective, health officials want to continue to monitor the safety of these patients along with millions of others who will receive the vaccine in the upcoming months. The CDC plans to have those who are vaccinated use V-SAFE, a smartphone based health checker that will use phone numbers from the registration process to send text messages and web surveys from the CDC to check in with recipients for any health problems resulting from the disease. Daily texts and emails will be sent within the first week followed by weekly messages thereafter for the following six weeks. Some privacy advocates have also raised concerns regarding the security of the data generated by the smartwatches in this program due to the lack of some safeguards found in contact tracing solutions. According to data privacy and protection advisor, while medical data is usually regulated under HIPAA, since participants will be using commercially available devices for this project, HIPAA may not be applicable. In addition, healthcare officials have raised questions about getting people to participate long term without feeling coerced into wearing the device in order to receive the vaccine. Implications: While imperfect, the continued monitoring of patients via smartwatch after receiving the vaccine can aid in tracking adverse effects that may not become apparent during clinical trials. With the device, experts have the ability to see side effects or adverse events and can quickly in real-time or near-real time decide if it is a true safety concern. When needed they can make vaccine recommendations for improvements. Although data privacy could be an issue, many experts feel this can be addressed as long as patients are fully consented and informed about the distribution of the data and how it is being shared. Perhaps of greater concern is the tendency for individuals to stop wearing their smartwatches after a period of time. As such, healthcare professionals need to reiterate the importance of consistently wearing the watch so patients can see how it will benefit their well-being and the wellbeing of others in such studies. Smartwatches Could Monitor Coronavirus Vaccine Safety

Our Take: Another Arrow in the Quill of Disruption-Amazon Pharmacy to Make its Mark Our Take: On November 17th, Amazon announced the launch of Amazon Pharmacy in the U.S (technically Amazon Pharmacy and Amazon Prime prescription savings benefit-PrimeRx). This new service allows customers to purchase prescriptions through the Amazon app using most forms of insurance as well as 24/7 access to consultations with pharmacists. With PrimeRx. Prime members can purchase branded and generic prescriptions at discounted rates on the app or at 50K pharmacies across the U.S with free two-day delivery or in-store pickup and automatic enrollment included in the program. While the addition of a broader pharmacy offering takes Amazon more deeply into the prescription drug business, over time we expect this expansion will succeed and position the company well to disrupt already existing pharmacy giants. Given its strong existing customer base, deep reserve of existing financial and distribution resources, and low prices combined with customers increasing reliance on online shopping platforms during COVID, we expect Amazon to broadly disrupt the market for retail pharmaceutical sales. Description: Amazon began entering the pharmaceutical market with its acquisition of PillPack in 2018, and appears poised to apply lessons learned from that acquisition to deepen penetration into the pharmaceutical market. Amazon pharmacy will offer 80% off generic medications and 40% off brand scripts for prime members, providing better deals than purchases made at brick mortar competitors. The company also provides transparency, showing the cost difference between paying for medications out of pocket or using health insurance. The service will feature a two-day delivery option for Prime members as well as easy to navigate platforms and pharmacists to answer questions related to medications. Customers can also use other Amazon devices such as Alexa as another means of purchasing medications and for medication related reminders. As a result of these features fulfilled through Amazon’s partnership with Inside RX (a subsidiary of CI’s Evernorth), other retail giants already in the pharmaceutical market are looking to add features such as delivery tracking, price transparency, and lower prices to remain competitive in the market. Large retailers, such as Walmart, who are already engaged in the pharmacy business are also expected to increase physical presence and add pharmacy delivery in an attempt to compete with Amazon’s latest additions. This expansion puts Amazon in more direct competition with pharmacy giants CVS Health Corp. and Walgreens Boots Alliance Inc.as well as with newer online pharmacies such as GoodRx. Implications: Given Amazon’s deep bench of distribution expertise along with Amazon’s user friendly and familiar online interface, we see high likelihood of successfully disrupting the market. As the COVID pandemic continues to cast a shadow on in-person retail, online first will continue to take share as the default choice whenever possible, further allowing Amazon to deepen ties with U.S. Prime members, now numbering over 100 million. We also see this as a threat to other online pharmacy offerings like GoodRx given the relative size difference in subscriber bases of well over 10x, but do not believe it to be the primary target (more in a later post). The extension of online pharmacy, where medications can be purchased from the comfort of your own home at competitive or more steeply discounted prices and arrive within two days. This will be particularly important during this next wave of COVID and position Amazon as the default option for prescriptions over the next 9-12, months allowing it to solidify the change in consumer behavior.In addition, the prospect of steadily increasing case counts and additional COVID restrictions will likely further limit office/facilities-based work and trips outside the home, undercutting one of the brick and mortar store’s main competitive advantages; proximity and ability to serve urgent needs. For example, Amazon could integrate Whole Foods to help supply those who require prescriptions for emergent needs by supplanting it's free one hour grocery pickup, (launched in October), which has been very popular with new customers who account for over ⅓ of curbside orders. Of course, as Amazon always does, we expect them to continually iterate, gather data and develop new options which will further enhance their chance of success. The Other Shoe Drops: Amazon Pharmacy is Here Race and Health A lack of Data on Race Hampers Efforts to Tackle Inequalities Event: The most recent issue of The Economist published an article on “Race and Health” noting that the lack of solid data and data collection hampers efforts to address inequalities. The article notes that “COVID-19 has laid bare countries broad racial inequities in health and exacerbated them… [and] also highlighted the scarcity of decent data on ethnicity and race.” In addition, it noted that much like the debate on gender equality there is “too much intuitive argument and too little data”, however, unlike gender, many remain uneasy about asking for and collecting information on ethnicity and race. Description: During the initial months of the pandemic in New York, black and Hispanic children were 2 times more likely to lose a parent/caregiver to COVID than those who were white or Asian. In England a black man is nearly 4 times more likely to die from the disease than a man of similar age. During the peak of the pandemic, due to scarcity of data, only 7% of reports about COVID deaths recorded data on ethnicity. While it is understandable that many groups such as Jews and Roma or Romani of Europe are opposed to registering race or ethnicity since they have seen how it can be used detrimentally against them, this would argue for using data privacy and security to de identify data rather than not collecting it. For example, after Brazil began collecting data in the late 1990s broken down by five different skin colors the gulf in infant mortality between indigenous and white babies became apparent, simultaneously demonstrating the need for a move away from catch all terms (such as BAME in Britain-Black, Asian, Minority or Ethnic).. Implications: The COVID pandemic has highlighted the need for better collection and analysis of more granular data on race and ethnicity to address inequities as well as the potential role for digital tools to help fill this gap. As the Brazilian example demonstrates, the only way to tackle the inequalities and injustices is by bringing up statistical visibility and ensuring that data has the right degrees of granularity. In addition, researchers need to highlight that race itself is not the cause of disparities but rather a reflection of policy failures such as access to education, healthcare and employment. A Lack of Data on Race Hampers Efforts to Tackle Inequalities Telehealth Impact During COVID-19 Event: On November 17th, the COVID-19 Healthcare Coalition published the Telehealth Impact Physician Survey, which captured the opinions of 1,594 physicians and other qualified healthcare professionals. More than 75% of respondents said telehealth enabled them to provide quality care; however, barriers and challenges still exist and are anticipated beyond the COVID pandemic. Description: The survey has allowed telehealth to prove its value as a safe, effective, and necessary care delivery option that can provide quality care to patients when and where they need it. The survey findings also show strong support for telehealth from physicians and qualified healthcare professionals. Of those surveyed, 60% reported telehealth has improved the health of their patients, 68% report they’re motivated to increase telehealth use in their practices, 55% indicated that telehealth has improved the satisfaction of their work, and 80% indicated that telehealth improved the timeliness of care for their patients who are also in favor of using telehealth for care. The survey also found that about 73% of respondents indicated that no or low reimbursement would be a major challenge post-COVID, and more than 64% said technology challenges exist for patients, serving as a barrier to the sustainable use of telehealth. Barriers and challenges have to be addressed because telehealth services are anticipated to be highly used even after the pandemic. Implications: Telehealth and remote care services have proven critical to the management of COVID and the future of healthcare, especially since it’s here to stay. Future telehealth policies should be data-driven and seek to address the challenges for patients and providers alike. Telehealth has helped address several issues such as provider shortages and the growing gap of access to care in the most vulnerable populations. There should be further exploration to ensure high-quality delivery of telehealth and sustainability over time. Government officials, physicians, and other stakeholders need to work together to address challenges that remain for patients, including lack of access to technology, internet, low broadband connection, and low digital literacy. Telehealth Impact During COVID-19 Financial Problems aren't the Only Reason that Patients don't Pay their Medical Bills on Time Event: Health Leaders Media reported that a recent survey by Waystar found a number of varied reasons why patients don't pay their medical bills on time, with financial problems being only one among many. The study found that while 48% of those surveyed had been late on a medical bill, only 43% said they fully understood their bill and 56% had received a surprise medical bill. Overall the study noted that patients are confused, unaware, or misinformed of their medical bill information, all of which contribute to keeping them from paying on time. Description: Waystar surveyed 1,000 consumers who have received a medical bill from a hospital or specialty provider for medical treatment within the last six months. They found that financial difficulties were cited by only 51% of those surveyed. However, over a third (37%) assumed their insurance would pay it, while 20% were unclear about how much they owed while another 20% assumed their bill was incorrect. The article went on to note that sometimes “the bills themselves stood in the way of people paying” with only 57% of those surveyed not fully understanding their most recent medical bill. In addition, although 46% of consumers state that their provider proactively gave them an upfront cost estimate for healthcare services, they also stated that those estimates were often inaccurate. Implications: Medical bills are easily misconstrued by patients due to misconceptions, lack of clarity, lack of communication, and erroneous out-of-pocket estimates. In looking to improve billing and collections payers and providers should look to simplicity and clearer language as much as financial assistance. In addition, there needs to be a clearer end-to-end process for patients to understand and pay their medical bills. This could include clarifying the payment procedure with the patient, setting up an automatic payment system, advising patients of the out-of-pocket costs sooner, or setting up push notifications to the patients to pay on time. More work is needed to make this a user-friendly and seamless process for patients. Financial Problems aren't the Only Reason that Patients don't Pay their Medical Bills on Time Digital Mental Health on the Rise, but Engagement, Access, and Trust Continue to be Barriers Event: On November 17th, an article in Mobihealthnews noted that although digital mental health has raised significant amounts of capital and gained much broader adoption, it is still hampered by a lack of clear efficacy standards, poor engagement and user trust issues. The article which reviews a new report from WISH entitled, the Digital Mental Health Revolution: Transforming Care Through Innovation and Scale-noted that despite the fact that about one in five people are affected by mental health issues and an estimated one in twenty disabled by mental health issues, getting people into care remains a barrier. Description: Since the beginning of the pandemic, 75% of some populations are experiencing psychological distress, and many are developing mental illness for the first time. In order to combat this and other existing mental health issues, providers and payers have turned to digital therapies to help expand care. Nevertheless a gap remains between what people need and what existing systems can deliver. The WISH report identifies 4 key attributes that should be central to decisions by health systems, developers, investors, and users on what to buy and build in the future: 1) moving apps to an integrated operating system of care, 2) developing tools that are highly effective and engaging, 3) addressing inequalities, and 4) building trust in digital tools. Revolutionizing in those areas will accelerate progress, close the gap, and overcome barriers that include access, relevance, privacy, and security. In addition, the report points out that despite the explosion of mental health tools, with over 10,000 mental health apps currently available, many of these tools have underperformed, leaving a gap in “effective coverage” for mental health disorders. Implications: While the COVID pandemic has helped advance the technology and digital tools available to address the ongoing mental health crisis, with digital tools at the forefront, as few as 10% benefit from traditional mental health services, even in well resourced countries. Policy makers need to distinguish between heavily researched tools which face low rates of consumer adoption and commercially driven innovations, which have less research to support effectiveness, but see higher engagement rates. Among other things the report suggests focusing on tools that have proven effectiveness, low cost and engagement with large volumes of patients worldwide such as : instant crisis text messaging, digitized or gamified versions of cognitive behavioral therapy (CBT) and online training for patient facing staff. In addition the report highlighted the need to include “all nationalities, ethnicities, ages, and [those with] specific disabilities in addressing mental health issues. Digital Mental Health on the Rise, but Engagement, Access, and Trust Continue to be Barriers K Health raises $42 Million to Expand its AI-powered Telemedicine Platform Event: Venture Beat released an article that K Health, a startup with a software platform that digitally connects patients to doctors has raised $42 million to expand its AI-powered telemedicine platform, bringing its total amount raised to $139.3 million. According to the article, K Health’s platform takes into account medical histories, the clinical outcomes of millions of people, and the experience of thousands of doctors to deliver treatment information on hundreds of diseases. K Health's smartphone app, “K”, boasts more than 4M members and, according to the company is growing 10K-15K members per month. Description: K facilitates in-app visits from doctors that K users can speak to for a $19 one-time fee or for $9 per month. No insurance is required. The doctors review an AI-assisted breakdown of the patient’s symptoms and then diagnose, prescribe, or refer the patient as appropriate. K Health users can also text message doctors at any time. Mental health services are offered, and prescribed medication can be delivered to users for $34 per month. Additionally, K Health rolls out test maps that shows where people are reporting COVID symptoms and a nationwide map that shows all COVID testing centers. The company announced it will collaborate with the Mayo Clinic to integrate the health system’s Clinic Data Analytics Platform to support Mayo patients and doctors. Since the onset of the COVID pandemic, more than one million new people have turned to K Health for their primary care and mental health needs. K Health has grown 1,000% just this year alone. Implications: According to a study published by the U.S. Centers for Disease Control and Prevention (CDC) millions of patients wait at least two hours to see a health care provider. As the pandemic is continuing, the market for chat-based healthcare solutions is growing. Tech giants like IBM, Facebook, and Microsoft have partnered with governments and private industry to roll out chatbot-based solutions in response, as have a number of startups. In addition, the pandemic has accelerated the move to remote and virtual care. Even before the pandemic, 9 out of 10 seniors said they’d prefer to stay in their homes over the next 10 years, highlighting the need for these types of solutions. In addition, K Health can help bridge the gap for those without health insurance or in underserved communities, with prices starting at $9 per month to chat with a doctor or $19 for a one-time session and mental health services for $34 per month. K Health Raises $42 Million to Expand its AI-Powered Telemedicine Platform

5 Ways to Make Sure Your Employees are Okay Event: On November 12th, Benefits Pro released an article advising five ways employers can make sure their employees can successfully navigate the stressor caused by the COVID pandemic. With millions of people affected by the Virus, Benefits Pro reminds employers not to overlook the toll it can take on the mental health of their employees. Description: With all of the virus' stressors, U.S. workers are experiencing higher than average levels of mental health issues during the pandemic. While HR and employee relations teams would normally want to step in and help, working remotely makes it difficult to identify exactly who needs assistance. As such, advisers suggest five strategies on how to read between the lines and offer support to employees who may be struggling.1) Set up frequent touchpoints-connect frequently with employees both in team meetings and one-on-one which will allow employers a chance to assess how people are doing. 2) Use analytics to read between the lines-look for anomalies like significant reductions or massive increases in productivity. Either could signal employees are struggling. 3) Understand that women may face more hurdles than men so they may necessitate special focus. Research from CARE indicates COVID-19 is having a disproportionate impact on women, with Mothers, senior-level women and black women particularly at risk. 4) Make sure employees are aware of resources offered. Be proactive and remind employees of your benefits and ensure that furloughed employees are aware of any extensions of mental health benefits (if offered). 5) Share personal experiences to destigmatize mental health issues. For example, invite a C-level executive to share their experiences with employees so people who are struggling know they’re not alone. Implications: Remaining productive and focused at work is challenging for many employees given pandemic induced stress of being isolated while working from home, balancing work and home-schooling, taking care of vulnerable loved ones, and more. As a result Employers need to be taking additional steps to proactively uncover mental health issues that may be brewing below the surface before problems become more serious. Given experts like Dr. Fauci don’t expect life to return to “some degree of normality” until late 2021 [even with a vaccine] employers will likely need to evaluate and strengthen the breadth and depth of their mental health offerings and the visibility of those offerings, at least for the foreseeable future. 5 Ways to Make Sure Your Employees are Okay Patient Experience Better When Patients Visit Docs of Same Race Event: On November 11th, PatientEngagementHIT released a study conducted by the Perelman School of Medicine at the University of Pennsylvania, addressing the correlation between patient experience scores and the race of both patient and doctor. In addition, the study looked at the need for health systems to address racial implicit bias in medical settings. The study concluded that patient experience scores tend to be at their highest when a patient sees a physician of the same race and that health systems must do a better job at addressing implicit racial bias in medical settings. Description: The researchers looked at approximately 120,000 patient experience scores for an urban academic medical center, focusing on the “likelihood to recommend” domain. The study found that patients who saw physicians of their own race or ethnicity were more likely to rate their physicians higher on patient experience surveys than those who saw physicians of a different race or ethnicity. Although the differences in rating seems small, with black patient’s rating white physicians 0.03 points lower on “likelihood to recommend” than their rating for black physicians, that 0.03 points difference could lower a physicians mean score on Press Gainey ratings from the 100th percentile to the 70th percentile. Implications: The results of the study reiterate the association between race/ethnicity and patient-physician interaction/ outcomes and the implicit racial bias black patients have experienced in healthcare. This ultimately impacts healthcare delivery, health disparities, and morbidity and mortality rates amongst African Americans. The results serve as a warning for healthcare organizations, especially those that may rely heavily on patient experience scores for compensating physicians, and that addressing the needs of their patients from a culturally diverse perspective is crucial. The study reinforces the belief that cultural competency and efforts to address implicit bias in healthcare is essential as is the need to understand/pay attention to non-verbal social cues. Patient Experience Better When Patients Visit Docs of Same Race FDA Releases Final Guidance on Clinical Trial Diversity Event: On November 9th, the FDA finalized guidance for promoting diversity in clinical drug studies and released its report “Enhancing the Diversity of Clinical Trial Populations--Eligibility Criteria, Enrollment Practices, and Trial Designs Guidance for Industry ''. The guidance considers both demographic considerations (ex: sex, race, ethnicity, age, location of residence) and non-demographic characteristics (ex: comorbid conditions, disabilities, those at extremes of weight range, etc) of populations. Description: The FDA’s 21 page guidance includes recommendations on how clinical trial teams can widen eligibility and enrollment groups for those historically underrepresented in trials such as the Black and Latinx community, pregnant women and those with certain physical conditions. Recommendations include, broadening eligibility criteria to increase diversity by among other things, requiring fewer exclusions related to concomitant medications (prescriptions or OTC drugs/supplements that may cause side effects) or comorbidities as more data on drug metabolism and drug-drug side-effects becomes known. In addition, the guidance suggest sponsors should make more effort to enroll participants who reflect the characteristics of clinically relevant populations with regard to age, sex, race and ethnicity stating that sponsors should include an “inclusion plan” no later than the “end of the Phase 2 meeting”. The guidance also states that sponsors should look at trial design and methodological approaches such as adaptive trial design and enrichment to broaden participation. Implications: The guidance clearly raises the bar for sponsors to be more proactive in trial design and recruitment so that they can “endeavor to include diverse populations to understand …risks and benefits [of medical products] across all groups. In the guidance the FDA made clear that sponsors will be responsible for taking additional steps including offering and making patients aware of financial reimbursements for expenses associated with costs incurred to participate in trials. In addition, study designers are going to have to ensure that they incorporate ways to reduce the frequency of clinic visits for elderly and disabled by using digital tools like electronic informed consent, telehealth and remote blood pressure monitors to replace or supplement in-person visits as well as mobile medical professionals (ex: nurses and phlebotomists) when that isn’t possible. Finally, the guidance notes that to broaden participation sponsors will have to engage underserved populations earlier in the drug development process and work more closely with communities through outreach and public education efforts to assess trial participant needs and drive higher support. FDA Releases Final Guidance on Clinical Trial Diversity & FDA Guidance Trial Diversity Designing Better Tech for Seniors Means Simplifying Tech for Everyone Event: A recent article in Mobihealthnews noted that many caregivers have turned towards technology and digital health solutions to keep older adults healthy and independent. A recent report from Rock Health highlighted that 77% of people over the age of 55 say they want to age in place, and only 50% believe they will because of barriers such as home maintenance, lack of transportation and mobility, inadequate preparation, and age-related accessibility. Description: Since 2010, the 65-and-older population has grown by over a third and by 2030, one in every five Americans will be of retirement age. As the demographics of the U.S. age, many caregivers have turned towards technology and digital health solutions as ways to keep older adults healthy and independent. In addition, according to a recent study, more than 60% of Medicare-eligible seniors say they’ve embraced technology more during the pandemic. Consequently. tech developers need to create products targeted at older adults that are designed to help them age and stay independent without stigmatizing them. Digital technology for seniors should be created with the P’s in mind – purpose, people, and possibilities. Technology built with a purpose makes seniors feel useful in society and their communities. It is associated with fewer heart attacks, better sleep, lower stress hormones, better immune system, and lower healthcare costs. Using digital health technology to connect with people can reduce isolation, affecting about 25% of adults over the age of 65. Isolation and loneliness lead to higher blood pressure risks, heart disease, obesity, a weakened immune system, anxiety, depression, and even death. Implications: As time progresses, technology is evolving and will outpace the ability to keep up with it. Barriers that keep seniors from using technology include a lack of instructional guidance on using it, a gap in knowledge, poor eyesight and hearing, and cost. Designing technology for everyone means creating customization features for smaller populations critical in making better solutions for seniors while remaining usable for everyone. Digital health technology should be customized to ease and assist seniors in their daily living activities while being in full control of their health. With a disproportionate share of COVID deaths occurring in senior care facilities, more older Americans are likely to want to live independently longer and the design of technology will need to keep pace. If it does, with the increased application of technology, seniors can decrease loneliness and experience better mental and physical health for longer periods without needing to be cared for in an institutional setting thus saving costs and improving quality of care and quality of life. Designing Better Tech for Seniors Means Simplifying Tech for Everyone From Today to Telemedicine: 3 Gaps and Risks Event: A recent article from Healthcare Dive pointed out the growing trends in telemedicine since the pandemic, and its usefulness for patients who live in remote areas and especially for those who are elderly and/or otherwise at high risk for contracting COVID. However, while the healthcare industry makes the case for greater use of telemedicine, 3 key risks and gaps were identified that must be addressed for it to be a vital and enduring component of virtual care. Description: As COVID hit, face-to-face office visits dropped, and telemedicine took a sharp rise (tenfold increase). If telemedicine is here to stay for the long run, there are 3 identified risks/gaps to be addressed: 1) Health Care Providers (HCPs) need to be comfortable with telehealth technology-among 1700 physicians surveyed in June only half were comfortable with the current technology, 2) HCPs need tools for going beyond “superficial” observations. Using current technology providers may be able to spot the usual but miss the unusual leading to potential misdiagnosis or medical errors, 3) Policies need to support telemedicine-COVID prompted temporary relief with reimbursement in telemedicine visits, however, until there are comprehensive reimbursement policies, it is likely to still have gaps in telemedicine availability. Implications: The pandemic has had a tremendous positive impact on telemedicine; it has allowed patients to accept this new platform of care. This method of delivery of care is highly dependent on physicians. Thus physicians must wholeheartedly embrace the new technology and must be responsive. As digital health tools become more widely deployed, additional tools and product development are going to be required to ensure proper remote diagnosis (ex: IoT sensors, bluetooth enabled diagnostic devices, etc.). While a number of regulatory hurdles were quickly set aside during the pandemic, regulators, payers and providers will have to reassess the ecosystem to bring policies and regulations up to date with the years of progress gained in only the last 8-9 months. From Today to Telemedicine: 3 Gaps and Risks Clashing Studies Highlight a Digital Health Void Event: On November 11th, STAT HealthTech released an article reviewing sharply contradictory studies on a new product from Pear Therapeutics. The new product is reSET-O, a prescription digital therapeutic that uses software to deliver cognitive behavioral therapy to patients with opioid use disorder. Description: While a study from Expert Review of Pharmacoeconomics & Outcomes Research showed that Pear Therapeutics reduced hospital stays, emergency department visits, and other care in a group of 351 patients, another study from the Institute for Clinical Economic Review presented that reSET-O would actually increase costs by $1,400 over a five-year period compared to the current standard of care. Surprisingly, neither study is necessarily wrong. Each study evaluated the product based on different sets of information over varying time periods.As noted by the Digital Therapeutics Alliance, digital therapeutics rely on high quality software to deliver evidence-based interventions to patients to prevent, manage, or treat disease…[and] can be used independently or in concert with medications, devices, or other therapies to optimize patient care and health outcomes.” As such evaluating their effectiveness involves an entirely different regulatory approach than current therapies. Implications: The different results from the two studies show that further research and clear evidentiary standards are needed to evaluate digital therapies and services. If conclusions remain conflicted, these products will remain mired in confusion. In addition, without clear standards the category could remain susceptible to fraudulent products or claims. As such, it is incumbent on the industry and trade groups such as the Digital Therapeutics Alliance to develop widely accepted, transparent and reproducible standards of effectiveness. Clashing Studies Highlight a Digital Health Void (STAT HealthTech-Subscription Required)

Slipping Away: Does the Employer-Sponsored Health Care System Have an Expiration Date? Event: On November 3rd, Benefits Pro released an article stating that the employer-sponsored health care system may come to an end if employers don’t move more quickly to improve the system. According to former Florida Governor Jeb Bush’ “for those who believe in markets, choice and patient responsibility haven’t been offering creative 21st-century suggestions...there has been very little discussion about alternatives” to expanding Medicare. Description: The article noted that unless the Employer-sponsored insurance (ESI) industry can deliver on much needed reforms, its day’s might be numbered. It added, that “while there is still time to step in with solutions that ease the pain”, by some estimates, “if the health care system can’t be righted within the next five years, we’ll be looking at a full government takeover”. It is also clear that existing healthcare industry participants are resisting change and that the current system is “riddled with throwing technology on top of broken processes” instead of fixing “the process and then [applying] the technology”. As a result many are looking to big names like Amazon (and its Haven health care venture), Google, Apple, and Microsoft to bring health care costs under control and improve outcomes. Implications: ”Our country is creeping--in some cases jogging and even sprinting--toward a government dominated healthcare system” as pointed out by former Florida Governor Jeb Bush, but employer resistance to innovation and true improvement risks crippling the system. While COVID has laid bare the shortcomings of the system it has also dramatically accelerated the pace of change. Taking advantage of this opportunity now is especially important as Millennials, the largest generation in history who are expected to make up 75% of the workforce by 2025, are starting to get to the point where they interact with the healthcare system and demand more. Smart employers can take advantage of the opportunity to design a curated, more modern ESI healthcare plan or risk a permanent move toward a government-run healthcare system. Slipping Away: Does the Employer-Sponsored Health Care System Have an Expiration Date? Amazon Teams up with 2 Ohio Health Organizations on Telemedicine Offering Event: On November 2nd, The Daily Record reported that two Ohio healthcare companies have partnered with Amazon to offer telemedicine services with free prescription drugs to Amazon’s customers. This partnership serves as another significant strategic investment in Amazon’s quest to infiltrate the healthcare space to create better health options and outcomes for consumers. Description: Since the early 2000’s, Amazon has worked diligently to enter the pharmaceutical market, investing in companies such as Drug.com with plans of expansion. In June 2018, the company successfully did so with its $1B acquisition of PillPack, a pharmaceutical company with licenses in 49 states that would help to accelerate expansion in the market. The companies partnership with Healthcare Advisory Network, a healthcare consulting firm in Centerville, Ohio and BasiCare Plus, a national prescription and telemedicine program in Wooster, Ohio came together over the past two years to offer employer groups, colleges, and associations telehealth services. The partnership with Amazon was inspired by many patients opting to use telehealth services due to COVID-19 concerns instead of going to a doctor’s office for non-urgent medical issues. The organization also offers coverage with no copays or deductibles through telemedicine service MDLive for up to nine family members starting at $65 for a three-month subscription. Additionally, the program provides discounts on medications at more than 65,000 pharmacies. For patients to obtain these services, it is as easy as going on Amazon’s website and searching BasiCare Plus. Implications: This partnership has extended Amazon’s penetration of the pharmaceutical market, increasing its leverage over other retail giants as they seek to gain a footing in the healthcare industry. The partnership also gives the businesses the opportunity to provide inexpensive health care to people who lack coverage and allows patients to avoid copays and deductibles when visiting a doctor, urgent care or emergency room for non emergency issues. Given the company’s extensive distribution network, Amazon can use this leverage to disrupt everything from the pharmaceutical supply chain to Medicare drug benefit management. Its continued move deeper into the healthcare realm will either drive changes in healthcare delivery or force the existing retail giants to become more competitive. Amazon Teams up with 2 Ohio Health Organizations on Telemedicine Offering MIT Researchers’ AI Model Detects COVID-19 by Listening to Coughs Event: On November 4th, an article in Mobihealthnews reported that MIT researchers developed an AI tool that can listen to a person’s cough and determine if they have COVID-19, whether or not they are symptomatic. The research, first published in IEEE Open Journal of Engineering, reported that for asymptomatic positive cases, the tool performed at 100% accuracy. Description: To build the artificial intelligence tool, researchers solicited more than 70,000 audio recordings of individuals coughing, with an average of three coughs per subject in addition to accompanying information about a subject’s condition through an online website. Researchers trained and validated a convolutional neural network-based model using the cough recordings and an equal number of randomly selected COVID-19 negative samples. This was done by listening for specific acoustic biomarkers related to muscular degradation, vocal chord changes, sentiment or mood changes, and changes in the lungs or respiratory tract. The new artificial intelligence tool yielded 97.1% overall accuracy, 98.5% sensitivity, and 94.2% specificity. Implications: MIT envisions its new AI tool as a low-cost COVID-19 pre-screener that can be deployed in settings where comprehensive diagnostic testing is unavailable or cannot scale for entire populations. According to the research, “this noninvasive, free, real-time prescreening tool may prove to have a great potential to complement current efforts to contain the disease in low-infected areas, as well as mitigate the impact in highly infected areas, where unconscious asymptomatics may [unknowingly] spread the virus.” The same MIT team has been developing vocal biomarkers for use in diagnosing respiratory conditions and Alzheimer’s disease, suggesting that there may be some other higher level biomarkers that can be used to diagnose diseases thought to be unrelated. MIT Researchers' AI model Detects COVID-19 by Listening to Coughs Curve Health Raises $6M Seed Round Event: On October 29th, Citybizlist reported that Curve Health which delivers connected senior care via a platform that combines telemedicine, smart billing, health information exchange, and predictive analytics had raised a $6M seed round. Description: Curve Health advances connected senior care by enabling physicians to remotely care for patients in skilled nursing facilities (SNFs), in the home, in ambulances or wherever they may be. Curve Health combines telemedicine, a health information exchange, predictive analytics, and smart billing into a single platform, resulting in higher quality care and significant return on investment. In addition this ensures a virtually seamless patient experience. Curve Health, which is built on, and expands, the Call9 platform, not only facilitates telemedicine but creates a true virtual hospital-level care experience for patients and providers. By bringing the hospital to the patient, Curve is able to improve outcomes, reduce unnecessary hospitalizations and improve bottom lines. Implications: Patient transfers from SNFs to EDs can be stressful and traumatic for patients and expensive for providers, Curve is built on a platform that has been demonstrated to markedly reduce transfers to ED’s thereby improving patient experience while simultaneously cutting the risk of infection. In addition, by using telemedicine, Curve allows seniors to age-in-place longer enjoying the comfort of their own home. By reducing transfers and hospitalizations, services such as Curve can redirect high cost institutional care to a more appropriate setting and significantly reduce patient cost while improving care. Curve Health Raises $6M Seed Round Patients Shirked Diagnostic Testing, In-person Preventive Care Amid Telehealth Boom this Spring Event: In a recent article Healthcare Dive reported that during the Covid-19 pandemic while numerous patients opted for telehealth visits there were also substantial drops in diagnostic procedures and preventive elective care. Description: While telehealth boomed during the pandemic, there are certain services that providers are not able to deliver virtually including routine diagnostic procedures used to detect major health conditions before they progress. Overall, healthcare utilization dropped 23% in March and 52% in April. Mammograms and colonoscopies dropped more than 65% in March/April compared to last year; musculoskeletal surgery, cataract surgery, and MRIs all dropped by 45% or more; chronic conditions including blood sugar tests fell 50%, chemotherapy dropped 4%, and, vaccination for children under 2 years dropped by 22%. Comparatively, telemedicine visits jumped 4,000% compared to the year prior, but only replaced about 40% of the drop in in-person visits. Implications: Delaying diagnostic procedures poses a danger to high-risk patients since early signs of serious diseases may get missed leading to potential adverse outcomes. The pandemic has caused fear and anxiety among patients surrounding in-person visits unless they are absolutely necessary. However, providers and payers can use improved communication and a more collaborative environment to engage patients and ensure they get the necessary tests and treatments. Telemedicine can factor in by scheduling screening appointments to connect with patients and build confidence that will get them back to the facility for necessary testing and procedures. Not only would this benefit patients, but increases in diagnostic and elective services would help replace revenues lost during the pandemic and have positive financial implications on providers as well. Patients Shirked Diagnostic Testing, In-person Preventive Care Amid Telehealth Boom this Spring

Patients Report Scrolling on Social Media, Exercising and Drinking During Virtual Doctor Appointments Event: On October 28th, an article in Mobihealthnews reported that patients admit to often being distracted during virtual doctor appointments, with as many as 24% reporting multitasking during the visit. The article noted that new research from DrFirst showed the most common distractions were surfing the web, checking emails, or texting. Description: Virtual doctors’ appointments have given patients the ability to consult with healthcare providers at their convenience. DrFirst surveyed 1,000 consumers nationally ages 18 and up in June of 2020. Of those surveyed, 73% of men and 39% of women said they had been distracted during a telehealth visit, and more than 24% of respondents admitted they had been distracted by things such as watching TV (24%), checking social media (21%), eating (21%), playing video games (10%), working out (18%) and even drinking (9%), The survey asked patients how telehealth can be improved, and responses indicated there could be higher-quality video, texting doctors before the appointment with any questions, the option to see their personal physician for telehealth visits and more user-friendly technology. Implications: While research from Massachusetts General Hospital suggests that “virtual visits are just as effective as in-person visits.” Empirical survey research like the above challenge that assumption, especially when it indicates that patients are distracted and not fully engaged with their healthcare providers. In addition, although telehealth usage has increased dramatically with 22% of consumers indicating they have had a virtual visit in 2020 (up from 8% in 2019) and 80% of physicians reporting they have had a virtual visit in 2020 (up from 22% in 2019) quantity and quality are not the same. Although telehealth has made dramatice strides in 2020, when patients are multitasking and inattentive, they are less proactive about their health, potentially leading to lower quality care and poorer health outcomes. Patients Report Scrolling on Social Media, Exercising and Drinking During Virtual Doctor Appointments FBI, HHS Warn of "Increased and Imminent' Cyber Threat to Hospitals Event: On October 29th, Healthcare IT News reported that the FBI and HHS had issued a joint alert warning of ‘increased and imminent’ cyber threat aimed at healthcare providers and public health agencies via ransomware. The warning suggested hospitals, practices and public health organizations take "timely and reasonable precautions to protect their networks from these threats" – which they said include targeting with Trickbot malware, "often leading to ransomware attacks, data theft, and the disruption of healthcare services. Description: The alert sent by the Cybersecurity and Infrastructure Security Agency (CISA), the Federal Bureau of Investigation (FBI), and the U.S.Department of Health and Human Services (HHS) state that malicious cyber actors indicated their desire to infect systems with Ryuk ransomware (responsible for 75% of attacks) at more than 400 healthcare facilities for financial gain thus, suggesting timely and reasonable precautions to be taken against these threats. The illegal cyber activities include credential harvesting, mail exfiltration, crypto mining, point-of-sale data exfiltration, and the deployment of Ryuk ransomware. The agencies advise patching operating software, changing passwords regularly, multifactorial authentication, disabling remote desktop assistance, and configuration check to prevent issues. These attacks have recently affected hospitals in upstate New York causing system failures. UNC1878 has disrupted hospitals throughout the U.S. with ransomware, forcing them to divert patients to other healthcare providers as the hospital networks go offline. Implications: With Ransomware attacks on the healthcare system not only threaten the security of the institution in terms of medical data, but it will prolong patients' wait time to receive critical care as a result of hospital networks being taken offline. This could be especially troublesome with COVID cases on the rise. While these threats are still ongoing, hospitals and healthcare organizations need to take up precautionary recommendations suggested by CISA, FBI, and HHS in a timely manner and secure their systems. The warning also noted that the perpetrators were often demanding ransom payments both to preserve the data that had been compromised and a second ransom to decrypt it. Attacks such as these demonstrate the continued increase in risk of health data as a cyber target as well as the need for vigilance against multiple types of threats going forward. FBI, HHS warn of 'Increased and Imminent' Cyber Threat to Hospitals Fitbit CEO Hints at Company's Telemedicine Plans Event: A recent article in TechSpot reviewed an interview Fitbit CEO James Park gave to the Wall Street Journal where he discussed Fitbit’s strategy in wearables and telemedicine as it pursues its merger with Google, noting that Fitbit’s premium health and fitness service already has over 500K users worldwide. The article noted that although the company has experienced some hardship it has managed to remain among the top five wearable makers worldwide and hopes to have a more significant impact on healthcare with the addition of new software and services. Description: One of the first developers of wearable technology, Fitbit has generally been focused around health and fitness, agreeing in 2019 to be bought by Google (the purchase still needs regulatory approvals). While Fitbit had expected demand for its devices to decline during COVID lockdowns, the company has noticed that business is doing better than expected and users remain connected to their devices and software services. In addition, earlier in 2020 Fitbit released results of a study with the Stanford Medicine Healthcare Innovations Lab and Scripps Research Translational Institute that validated an algorithm Fitibit had developed for the successful detection of COVID prior to the onset of symptoms. The company is doing additional research and is expected to seek regulatory approval for the device. Implications: Upon completion of its merger with Google, Fitbit will have a solid and loyal user base combined with a generous balance sheet to continue to pursue innovations within health and fitness. In addition, aligned under the Google umbrella along with its other consumer brands such as Nest, and YouTube, Fitbit has the potential to leverage its consumer reputation along with its future parents to tap into the growth of telemedicine. However, given several data privacy miscues by Google, Fitbit will have to provide solid reassurances about data privacy in order to convince consumers to invest in tools like a connected thermometer and an otoscope with confidence. Fitbit CEO Hints at Company's Telemedicine Plans & Fitbit CEO Reveals the Company's Plan to Conquer Fitness Wearables and Telemedicine Nutrium App, which links Dietitians and Patients, Raises $4.9M Led by Indico Capital Event: In a recent article, Tech Crunch noted that Nutrium, a digital health startup which links dieticians and patients via an app had raised $4.9m. According to the article Nutrium now offers professional nutrition software to 80,000 nutrition professionals and 800,000 patients in more than 40 countries. Description: Nutrium gives patients integrated nutrition counseling which combines professional advice, continuous monitoring, nutritional analysis, meal planning and access to commercial products all in one place. This app brings together nutritionists, patients, products and wellness data to enable healthier and happier lives. With this investment round, Nutrium plans to double the team size in the next 24 months in order to focus on platform development and expand global sales in markets like Spain, France, Italy, the U.S. and the U.K., where the company already has a strong customer base. Implications: A healthy diet throughout life supports normal growth, development and aging, helps to maintain a healthy body weight, promotes healthy pregnancy outcomes and reduces the risk of chronic disease leading to overall health and well-being. This app, and others like it, which give the user critical tools for a healthy diet could be an essential part of maintaining a healthy lifestyle. In addition, poor diet and nutrition levels, particularly earlier in life have been linked to slower educational and emotional development in children which can often plague them later in life. Apps such as Nutrium, which expand access to easy and convenient nutritional counseling can help increase healthy lifestyles, particularly in underserved communities. Nutrium App, which links Dietitians and Patients, Raises $4.9M Led by Indico Capital Fitness Wearable Whoop Joins the Unicorn Club with $1.2B Valuation Event: MobiHealth News reports that the fitness wearable Whoop announced a $1.2 billion valuation following its $100 million in Series E Funding. Unlike many other fitness wearables, Whoop is available via a subscription service and measures sleep performance and heart rate variability, which is part of the information used to calculate a proprietary active recovery score called the Whoop recovery score. Description: The WHOOP Strap 3.0 collects 24/7 physiological data including sleep, fitness and recovery to provide the most accurate and granular understanding of your body. That data is then sent to a corresponding app, which can give users insights about their training and recovery. WHOOP Strap 3.0 also comes along with personalized coaching. The app will provide users with sleep recommendations and can measure the stress someone has over a 24-hour period. It's lightweight, waterproof, and features the new and improved 5-day battery life and bluetooth low energy connect. Implications: Wearable device tech companies are growing, from Apple Watch, to Fitbit, to Amazon to now Whoop. Whoop uses its data to provide personalized coaching on sleep and stress as well as the amount of sleep and recovery a body needs from certain activities. Exercise technology which incorporates body feedback can be used not only to improve athletic performance but also to monitor and react to certain disease states. As a result, this will likely accelerate the pace of change in the traditional patient-doctor relationship due to the influence medical wearables have given their ability to automate processes, expedite diagnosis and treatment and allow people to monitor their own health. Fitness Wearable Whoop Joins the Unicorn Club with $1.2B Valuation Cross-border Collaborations Lead to Data Sharing Efforts During COVID-19 Event: A recent article in Mobihealthnews highlighted lessons learned from panelists who attended the World Health Summit, centered around the importance of global collaboration and data sharing during a pandemic. Among the conclusions noted was that in taking on a pandemic, “global collaboration and data sharing are key”. The panel also highlighted the importance of digital technology as the world tries to understand, manage, and overcome the impacts of the disease. Description: The World Health Summit was held virtually October 25th-27th, with this year’s topic naturally being current knowledge about Coronavirus,new strategies in the worldwide fight against pandemics and the role of Europe and the WHO in global health. During the presentations, panelists noted, “in a pandemic there is no sense in having solutions which apply only within our national borders. You have to have solutions that work around the world because people are moving all the time." The panel also pointed out how digital solutions have become seamlessly crucial as the world continues to overcome COVID-19. Including the new European Union (EU) interoperability gateway system, which connects contact tracing and warning apps amongst participating EU countries. The system would notify a person of the possible risk of infection if they were around someone who was infected, regardless of their location [if participating]. While COVID is the Summit’s current focus, the article noted that participants were also joining forces to look ahead at pandemics of the future, including the UK’s Trinity Challenge. Implications: The Summit clearly highlighted that “digital collaboration underpins the coordinated systematic approach we need to strengthen health systems and our healthcare.” However, panelists remained mindful of the need for data security, with the article pointing out that while the applications for digital are increasing, protecting patient privacy should still be front and center. Participants also concluded that although collaborating globally and accelerating interoperability, has the potential to improve response to future disasters, “the use of data and analytics in global public health, particularly the use of non-health data is not as good as it needs to be and varies across countries”. This clearly indicates the potential for strides to be made in all countries on the issue of social determinants of health data and solutions. Cross-border Collaborations Lead to Data Sharing Efforts During COVID-19

FDA Patient Engagement Advisory Committee (PEAC) Meeting on Adaptive AI and ML Event: (10/22) On October 22nd, the FDA Patient Engagement Advisory Committee (PEAC) held a meeting to discuss complex issues surrounding Artificial Intelligence (AI) and Machine Learning in Medical Devices. Attendees included several patients, companies, clinicians, and other high-level leaders. The meeting was centered on issues around the medical devices, its regulation, and usage by patients, in addition to their concerns on data privacy and transparency. The committee made recommendations on improving AI and machine learning in medical devices by giving careful consideration to datasets and how it can be used to train and improve algorithms. Adaptive AI presents new challenges for patients, companies, and regulators regarding informed consent, considering where the device would learn algorithms, use algorithms to improve decision-making, and make advanced improvements moving forward. Description: AI technology will be used to improve diagnosis and make recommendations for a course of treatment. Using adaptive AI will allow machines to learn more freely and improve what it learns from each sequence it is running. For future AI models to be successful, there must be a diverse representation in the intended patient population's data. Diverse and unbiased patient cohorts will allow for less biased data and remove clinical variables that lead to AI devices' mistakes. When data is not present for certain groups in a population, AI researchers cannot study them and find ways to combat societal issues. Incorporating and collaborating with patients in the creation of AI technologies will provide transparency and confidence in the products; however, many barriers exist even after a product makes it to market because criteria can change over the device's life. Adaptive AI makes decisions dependent on the life it sees out there – an apparent reason why it must be regulated because devices should differentiate between good and bad decisions to ensure safe outcomes. The committee struggled with a decision on how to explain the challenges of how explainability and transparency in AI models can be presented to patients. Implications: Large clinical datasets can be used to train and improve AI algorithms, leading to immense improvements in AI-based systems that diagnose as well as those that determine treatment protocols and actually treat patients. AI technologies will change clinician workflow and ensure continuous safety and efficacy in delivering ongoing quality care to patients.However, because ML algorithms can “learn” and “change” over time, medical diagnoses and treatment can change as adaptive AI models change as well, raising ethical concerns around transparency and informed consent. In addition, adaptive AI models also suffer from the shortcoming of biased training sets and under representation of underserved communities. As a result, patients and regulators need the ability to understand and examine models too so that the risks and consequences of any changes to treatment protocols due to improvements in the models can be assessed. In addition, the committee appeared to strongly imply that new informed consent releases would be required when changes to AI algorithms make meaningful changes in treatment or diagnosis protocols. FDA Patient Engagement Advisory Committee (PEAC) Meeting [YouTube Video] After COVID-19 Spurred a Boom in Telehealth, Systems Mull How to Sustain Momentum Event: (10/20) Healthcare Dive recently published an article highlighting the Center for Connected Medicine/Klas Research’s 4th Annual “Top of Mind for Top Health Systems Report”. Among other things the report looked at trends in telehealth reimbursement post-COVID and health system’s potential responses. Description: When the pandemic began both commercial and government insurers waived numerous rules and regulations to increase access to telehealth including waiving co-pays for telehealth visits and equalizing reimbursement for in-office and telehealth visits. While the Federal and State regulators continue to explore which rules to make permanent (for Medicare and Medicaid beneficiaries), some private insurers have recently changed some rules (including the waiver of patient co-pays) for telehealth visits. This survey of 117 executives at 112 provider organizations gave some insight into how provider organizations were planning to respond depending on how these changes settle out. Implications: As noted by Healthcare Dive “a lot of how much [providers] are going to invest in technology is going to have to have to do with what regulations end up looking like.” Since the regulations will to a large extent dictate reimbursement (which were approximately 30% lower for telehealth prior to COVID), despite the recent uptick in volumes, profitability will drive continued usage. For example, over 30% of respondents to the study noted that they were unsure of what they would do if reimbursement returned to prior levels, while 20% said they would continue providing telehealth services and 16% said they would analyze the continued viability of continued use. Moreover, it looks like payment and regulation will be top of mind for the foreseeable future with 25% or respondents noting that payment models and regulation were the top areas for future telehealth improvement. How [Vendor Neutral Archives] VNAs can Address the Challenge of Data Accessibility and Analysis How [Vendor Neutral Archives] VNAs Can Address the Challenge of Data Accessibility and Analysis Event: (10/19) A recent article in Mobihealthnews noted that if healthcare providers had more accessibility to aggregated data, it would be easier to combat difficulties such as reducing clinician burnout, improving efficiency, and increasing patient satisfaction. Vendor Neutral Archives (VNAs) can drive better outcomes by enabling data to be provided as a source of AI, business intelligence, or to deliver clinical information and insights. Description: A recent survey conducted by McKinsey & Company found that data integration and analytics is one of the major trends reshaping imaging services and influencing the future of healthcare. VNAs which allow access to data from any vendor system in multiple formats, improving workflow and reducing the time taken to complete different stages of an imaging exam will enable data to use artificial intelligence to provide decision-making support. This is an essential component in connecting existing systems to open platforms and specialists with patients. VNAs will eliminate the need to switch between systems or wait for data to arrive from other sites because prompt access will be given to correct data from any location in the network. Implications: The world and healthcare in particular is in the middle of a data explosion. The amount of healthcare data collected is currently projected to double every 73 days compared to 2010 when it was said to be doubling every three and a half years. As a result, healthcare costs have been growing faster than expected, and payers are looking to more sophisticated technology to improve the management of costs. Data integration and analytics to realize the value of data have become more crucial for healthcare delivery. Using VNAs will improve clinician workflow, financial, and operational performance of departments and organizations, reduce clinician demand, lower costs, and provide better patient outcomes. How [Vendor Neutral Archives] VNAs can Address the Challenge of Data Accessibility and Analysis CDC's 'Virtual Human' Relays Prostate Cancer Info Through Candid Conversations Event: (10/19) Mobihealth News recently published an article that the CDC launched a prostate cancer information program with a uniquely digital face: a "virtual human" named Nathan who speaks with men about screening and treatment. The CDC noted that the tool can help increase screening since “the decision to be screened and treated for prostate cancer can be overwhelming and complicated” … “some of this is driven by discomfort and long-identified stigma” with a prior examination protocol. Description: "Talk to Someone About Prostate Cancer" takes the form of an in-browser interactive video developed by health simulation company Kognito. In the video, Nathan introduces himself and prompts the viewer by asking how confident they are talking to their provider about prostate cancer screening. Users indicate their response by clicking one of several text responses, prompting a relevant reply, and kicking off a series of question and answer conversation trees. Implications: Prostate cancer is among the most common cancers in American men. Thirteen in 100 men will develop prostate cancer during their lifetime, and two or three will die due to it, according to the CDC. As symptoms vary, there is a high need for men to speak to doctors about whether or not they should undergo screening. Virtual health engagement tools that employ digital avatars can help some patients open up about difficult-to-discuss topics, providing a new way for individuals to become more engaged in their care. The CDC's virtual conversation effort comes after this summer's "Access Initiative for Quitting Tobacco," which combines free nicotine replacement therapies and conversations with a similar digital human named Florence that used a microphone and artificial intelligence to interpret spoken questions. CDC's 'Virtual Human' Relays Prostate Cancer Info Through Candid Conversations COVID-19 Impacts on Cancer Care Event: (10/21) On October 21st, the Journal of Clinical Oncology Clinical Cancer Informatics published an article highlighting the significant drop in cancer screening, diagnosis, and treatment for Medicare beneficiaries. The changes in the utilization of cancer care services is attributed to the decrease in routine healthcare visits brought on by the COVID pandemic.The research was conducted by Avalere, a leading healthcare consulting firm, in collaboration with the Community Oncology Alliance, a non-profit advocating for community oncology practices. Description: The study found that for the period March-July 2010 compared to 2019, there was a significant decrease in cancer screening, biopsies, surgery, office visits, and therapy with variation by cancer type and site service. At the peak of the pandemic in April, screening for breast (-85%), colon (-75%), prostate (-74%) and lung cancer (-56%) were all all significantly lower as indicated. The decrease in diagnosis and delay in care is attributed to the stay at home order to reduce COVID-19 transmission, especially amongst the elderly and immunocompromised. As a result, many healthcare providers accommodated short term adjustments to cancer care delivery, such as temporarily discontinuing non-emergent care screenings, shifting delivery of care to telehealth, and delaying surgeries and other in-office cancer services to reduce transmission risk. Although the stay at home orders were lifted in May and June, utilization of certain oncology services continue to lag, fewer patients are undergoing screening, with many providers and patients choosing to reschedule or completely forego screening, leading to fewer cancer diagnoses. Implications: With the decrease in screenings, diagnosis, and cancer care delivery, researchers found that cancer is likely to present itself at a later stage and require more complex care thus lowering the likelihood that patients will respond and ultimately be cured. To combat this, stakeholders are encouraged to increase awareness of the dangers of medical distancing and regain seniors’ confidence in their ability to safely receive care. Policies and technology to promote access to cancer care have the potential to reduce the projected morbidity and mortality amongst the population. However, further studies need to be conducted to understand the overall impact on different patient populations and potentially take corrective action. COVID-19 Impacts on Cancer Care Researchers Combine AI with EHRs to Improve [COVID] Hospitalization Prediction Event: (10/21) A recent study by researchers at the NYU Grossman School of Medicine has applied AI to EHR (electronic health records) data to predict more accurately good outcomes from COVID-19 treatment. In particular researchers wanted to provide clinicians with actionable information that could be easily integrated into their exister workflows Description: Researchers undertook the study to apply AI to EHR data to help hospitals and doctors more accurately manage patients who had tested positive for COVID. The model analyzed 3000 retrospective cases and developed a model that could identify hospitalized patients likely to have good outcomes with 90% accuracy. In addition, researchers deliberately sought to reduce the number of features and variables used in the model, opting to go with the minimum data requirement needed to make a prediction. Implications: The study predicts outcomes in hospitalized COVID patients with a high degree of accuracy while integrating to current data infrastructure. However, researchers noted the need to remain vigilant when designing AI related tools as there are instances where the physician’s knowledge exceeds that of the machine and must be integrated with the AI output. The researchers also found that to be effective AI learning solutions require two distinct components; 1) addressing a clearly defined use case that clinical leaders will champion and 2) [developing a model that] motivates changes in clinical management, based on model predictions. Researchers Combine AI with EMRs to Improve [COVID] Hosptialization Prediction

What Did We Learn Implementing...Conversational AI in Healthcare? Event: (10/7) On October 7th, an article was published in Medium regarding Inception Health’s efforts and insight into implementing conversational AI in healthcare. Although the healthcare field may seem ideal for the implementation of AI tools and resources, they encountered several barriers that would present some difficulty in the process. Description: Inception Health (created by the Froedtert & the Medical College of Wisconsin) partners with innovative companies to solve key health care problems, develop new ideas, and scale solutions across their network and beyond. As a result, the organization sought out conversational AI because it seemed to have everything needed to have a positive impact on healthcare practice. Conversational AI is designed to teach computers to answer questions and help guide a person based on prompts. In healthcare, it can enable an enhanced and personalized patient experience and scale data access, transparency, and health literacy. While there are several tools available, the article mentions the challenges that would come with the implementation of this AI tool. This includes the biases associated with using data generated by current healthcare systems and legal restrictions that impact the ability to create these tools. As a result, the authors opted to use open source solutions to help build conversational AI agents (including Parl AI and BERT). Implications: The use of conversational AI has many components and designs that can be used by researchers to improve healthcare disparities, but the legal restrictions and biases have limited the development of medical AI to a few research projects and a few AI startups. While there continues to be a large amount of data generated by healthcare providers, most of it cannot be used for training algorithms and are severely restricted by data privacy and security regulations. While several solutions have been proposed such as developing an open-source healthcare chatbot dataset or using desensitized data to create “fake” patients with realistic health conditions for training algorithms, the data is still difficult to retrieve and additional processes are in place that create barriers. As a result of these issues, deployment of conversational AI in healthcare is not as effective as it could be and it remains behind other industries with similar amounts of data at its disposal. What Did We Learn Implementing GPT-2 and BERT for Conversational AI in Healthcare? Therapy Startup Coa Raises $3M to Launch World's First Gym for Mental Health Event: (10/14) On October 14th, Coa, a platform that offers therapy-led classes and one-on-one therapy, announced it had closed a $3 million seed round of funding. Since March 2020, demand for its workplace curriculum has grown 900% according to the company’s press release. To date, more than 3,500 people have joined Coa's waitlist for the studio launch. Coa aims to build a home for therapy, emotional fitness classes, and a sense of community. Background: Coa offers several services, giving communities a "gym" for mental health. These include emotional fitness classes to teach patients how to treat their mind like a muscle and increase resilience to deal with stress and anxiety. Users can also fill out a short questionnaire to be matched with therapists for one-on-one sessions. Coa also has the ability to partner with employers to provide employees with deep-dive sessions to develop mental health and emotional fitness skills, Q&A sessions about managing anxiety in the workplace, and workshops that follow a "learn, exercise, breakout, discuss" framework built on Coa founder Dr. Emilty Anhalt's research into the 7 Traits of Emotional Fitness. Implications: Coa's educational and emotional fitness services can help users in group or one-on-one environments in the comfort of their own home (and can even influence users to pursue careers in therapy). By partnering with employers, Coa is building an emotional safety net for employees with their companies and giving them additional resources during this difficult time. Once the pandemic is over, Coa can continue to maximize company’s and individuals' emotional well-being through regular classes, workshops, and one-on-one sessions. Therapy Startup Coa Raises $3M to Launch World's First Gym for Mental Health Oliver Wyman Executive says “Men and Women View Leadership Differently, Propelling the Gender Gap in Healthcare” Event: (10/15) A recent article in Mobihealthnews examined the continuous underrepresentation of women in leadership positions within the healthcare sector, despite years of initiatives. The article was a summary of the women in the workplace event at the HLTH VRTL conference. Description: Healthcare has a gender parity issue in terms of leadership positions with women making up only about 24% of executives of Fortune 500 healthcare companies, approximately 37% of hospital executives, and only 14% of digital health deals (defined as closed by female-led startups). Experts have noted that when companies attempt to address gender inequality without meaningful improvement there is usually something unexamined going on beneath the surface. According to many of these experts, the challenge for some women is the inconsistency at a leadership level of what a leader looks and acts like. Research indicates that the definition of leadership skills were often a function of which gender someone was speaking about. For example when leaders were asked about the top 3 leadership traits for both men and women they agreed that the most important leadership trait was confidence. Answers differed sharply on the 2nd and 3rd traits with “direct” and “decisive” cited for males, while “empowering teams” and “being collaborative” were cited for females. This inconsistency in leadership expectations sends a mixed message and makes it difficult for women to understand and demonstrate the appropriate skill sets to advance. Implications: As a result of this dichotomy, while there have been a wave of programs and initiatives at boosting women in leadership roles the results have been mixed at best. This signals that commonly implemented initiatives are not aligned with what experts think are most effective ways to close the gap. Among steps organizations can take are to directly and clearly address and eliminate the differing expectations for men and women in leadership roles. In addition, aspiring women leaders should be paired with sponsors (as opposed to mentors), who use their own political capital and credibility to advocate on these aspiring leader’s behalf. Oliver Wyman Executive says “Men and Women View Leadership Differently, Propelling the Gender Gap in Healthcare” Twentyeight Health Raises $5.1M to Scale Affordable Telemedicine Solution for Women’s Sexual and Reproductive Care Event: (10/15) TechCrunch recently profiled Twentyeight Health, a health tech company expanding access to women's sexual and reproductive healthcare for those on Medicaid or uninsured, which closed $5.1 million in seed funding last week. Background: Twentyeight Health was formed to bring contraceptive care to a population that historically hasn’t had as good access to “quality, dignified and convenient care”. To ensure it is catering to underserved communities the company works with Bottomless Closet, a workforce entry program for women as well as 8 colleges in the City University of New York (CUNY) system where 70% of the students come from families making less than $30K in annual income. The Company’s services are available in FL, MD, NY, NJ, NC and PA and it is the only telemedicine company focused on contraception services to accept Medicaid. Implications: Women who are on Medicaid, who are underinsured or without health insurance often struggle to find access to reproductive health services, and these struggles have only increased with COVID-19 pandemic limiting access to in-person appointments. Where seeking the right sexual health treatment may be overwhelming for women, Twentyeight Health makes this easier. As the company notes, low income women are 3x more likely than average to have an unintended pregnancy and nearly ⅓ of physicians nationwide aren’t accepting Medicaid. Services like Twentyeight health and others are demonstrating the efficacy of using digital tools to bring broader, more convenient and more inclusive access to care to under-resourced populations. Twentyeight Health Raises $5.1M to Scale Affordable Telemedicine Solution for Women’s Sexual and Reproductive Care Spain’s Savana Medica Raises $15 Million to Bring to the US its AI Toolkit Turning Clinical Notes Into Care Insights Event: (10/15) On October 15th, Spain’s Savana Medica announced that it had raised $15 million to bring its AI based technology from Europe to the U.S. Telehealth market. Savana has a machine learning-based service that turns clinical notes into structured patient information for pharmacists and physicians. Description: According to the company, Savana is already working with the world’s largest pharmaceutical companies and more than 100 healthcare facilities. The company states it has already processed some 400 million electronic medical records (EMRs) in English, Spanish, German and French. According to Savana Chief Executive Jorge Tello, one of the company’s main value propositions is its focus on security, where “information remains controlled by the hospital, with privacy guaranteed by the de-identification of patient data before [they] process it”. Implications: As the COVID pandemic has demonstrated, having up-to-date actionable information is crucial to treating patients as effectively as possible. Given The company’s mission is to “predict...disease at the patient level” and “discovering new ways of providing medical knowledge in almost real time could provide crucial minutes in the treatment of certain diseases and could be especially valuable during public health crises like the current pandemic. The integration of technology like Savana’s into US hospitals could ease the burden on healthcare providers, and speed response times. Spain’s Savana Medica raises $15 million to bring to the US its AI toolkit turning clinical notes into care insights Lifelight and Karantis360 Partner to Deliver Social Care Remote Patient Monitoring Event: (10/16) A recent article in MobiHealth News noted that UK companies Lifelight and Karantis360 had formed a partnership to enable safer independent living for older and vulnerable individuals by delivering a remote picture of their wellbeing. The Karantis360 solution will run on the IBM Cloud and use IBM AI and analytics coupled with a network of smart sensors to identify and learn an individual’s typical behavior. Description: According to the companies, their solution allows regular behavior and vital sign readings to be taken in homes and other outpatient care settings safely, and has optimized clinician’s workflow.The combined solution allows for timely interventions and clinical actions based on real-time physiological data. Lifelight allows the contactless measurement of vital signs by using a standard smartphone or tablet and will detect tiny changes in facial skin color which may indicate a deviation in heart rate, blood pressure, respiration, or oxygen levels. If changes appear in relation to an individual’s daily routine or vital sign readings, automated alerts will be sent to the care provider and family members. Implications: The continuing need to physically distance has increased the demand for virtual care tools like the one described by the partnership. While telehealth visits are increasingly replacing many in-person visits some conditions still require physical observations. A digital tool with sensors and remote monitoring capabilities reduces the need for certain in-person visits, while improving patient care and supporting clinical decision-making. As such the combined solution can help support earlier patient discharges and prevent readmissions in real-time without the need or cost of additional hardware. These types of apps reinforce the role of IoT devices in healthcare in the move to value-based care via lower cost, higher quality, and patient friendly solutions. Lifelight and Karantis360 Partner to Deliver Social Care Remote Patient Monitoring

Telehealth Patient Satisfaction Surges During Pandemic but Barriers to Access Persist, J.D. Power Finds Event: (10/1) On October 1st, J.D. Power released its 2020 U.S. Telehealth Satisfaction Study noting that while “public awareness with Telehealth is higher due to ...COVID-19, the barriers for the consumer to engage with the technology has been a consistent theme” in their research. Description: The survey of approximately 4,200 healthcare consumers who have used telehealth services within the last 12 months, was conducted from June-July 2020. The survey measures consumer satisfaction based on 4 factors (in order of importance): customer service, consultation, enrollment and billing/payment. Among the key finding of the study were: 1) overall customer satisfaction scores for telehealth were among the highest of all healthcare, 2) barriers to access still exist with 52% of telehealth users stating they had encountered at least one barrier that made it difficult to use telehealth: with the most common complaints being services were too limited (24%), technology requirements were confusing (17%), or there was lack of awareness around cost (15%). Researchers found that many of those who were less satisfied with telehealth had lower self-reported health, lower wellness levels, and an overall lower health status Implications: While overall telehealth patient satisfaction scores have risen, both technical and access barriers remain (with technical audio issues being the most frequently reported problem). Driven to telehealth largely by the COVID pandemic with 46% of respondents indicating safety as the main driver for utilization, providers and payers now need to address how to make the technology even easier and more accessible. It is especially important for those in under resourced communities which may have technological limitations as well as for seniors who may struggle with the technology due to physiological issues (hearing or vision loss, etc). Telehealth Patient Satisfaction Surges During Pandemic but Barriers to Access Persist, J.D. Power Finds Avalere Analysis Shows Home Care Services Reduce Medicare Spending Event: (10/2) Healthcare consulting firm Avalere recently released an analysis that showed Medicare Fee-for-Service (FFS) patients getting home-based care services experienced a reduction in Medicare spending compared to patients who did not receive home based care and actually saw an increase in spending. Specifically Avalere determined the average Medicare FFS change in per-beneficiary-per-month (PBPM) was a decrease of about 5% for those with home care versus an increase of approximately 16% for those without home care.The study also found the spending difference was higher among Medicare beneficiaries with functional limitations and multiple chronic conditions. Description: Avalere conducted a retrospective study to analyze the comprehensive effect of home care interventions on Medicare spending. The Avalere retrospective study conducted from 2009 through 2018, compared 31,000 Medicare beneficiaries with home care services between 2012 and 2017 and those without home care services. This suggests a lower spend over time with home care services. Similarly, condition-specific subpopulation PBPM spending was low for home care services. The conditions compared were Diabetes with Chronic complications (-$227 vs +$324), chronic heart failure (-$175 vs +$432), and chronic obstructive pulmonary disease (-$155 vs +$410). Implications: The analysis recommends home care services as an efficient means to manage frail beneficiaries with chronic conditions against a difficult experience of a significant decline in their health and high-cost healthcare services. Homecare can save Medicare money by preventing unnecessary emergency department visits, hospitalizations, and readmissions. While additional research is mandated to concretely determine which home care services are causally linked to lower spending, the analysis shows a correlation between the delivery of home care services and reduced spending over time. Avalere Analysis Shows Home Care Services Reduce Medicare Spending Startup Aimed at Helping Patients Understand Doctor’s Orders Abridge Launches Event: (10/6) On October 6th, a new startup called Abridge was launched fueled by $15 million in funding. Abridge is an app that uses machine learning to record a patient's doctor's visit and then turns that recording into a patient focused transcript that simplifies details of their symptoms, conditions, procedures and medications.The app is designed to increase patient understanding of their diagnosis and adherence to their treatment plan. Description: Patient adherence has long been a problem in healthcare with the CDC noting that 20% of new prescriptions are never filled and over 50% of prescriptions are taken incorrectly. According to the CDC this lack of adherence is a combination of intentional factors such as inability to pay and unintentional factors such as a patients lack of understanding of how to use the medication. Abridge was built on the basis that everyone needs an easy way to remember and understand the details of their care. The new platform aims to help patients follow their provider’s advice and educate patients about their health, by recording the doctor’s visits and translating the conversation into an understandable transcript. Implications: With access to digital tools like Abridge, patients will be more comfortable and confident at their medical appointments and it will allow them to understand and question unfamiliar terms that may interfere with diagnosis and treatment. As a result patients will be better able to understand provider instructions and gain more insight into their plan of care. With Abridge’s automated speech-recognition technology at their disposal, patients will be able to take a more active role as an engaged consumer in their own care. This approach should lead to increased medication adherence and improved health behaviors both of which should contribute to higher quality outcomes at lower costs. Startup Aimed at Helping Patients Understand Doctor’s Orders Abridge Launches COVID-19 and Psychological Distress-Changes in Internet Searches for Mental Health Issues in New York During the Pandemic Event: (10/5) The Journal of the American Medical Association (JAMA) recently published a research letter looking at trends in internet searches for mental health issues in NY during the COVID pandemic. In order to better understand the pandemic’s impact on mental health the authors used Google Trends data to examine internet search histories for people living in NY state for the terms “suicide”, “anxiety”, “panic attack”, “insomnia” and, “depression” during the period from 3/22/20 (when NY state entered a COVID lockdown) through 5/14/20 (when portions of the state began a phased reopening). Description: To better understand the mental health concerns and the impact the pandemic had on mental health the authors used trends in search data as a proxy for increase or decrease in disease. According to the authors searches for anxiety significantly increased following the lockdown and remained on average 18% higher than expected prior to lockdown for a period of three weeks. Searches for the term panic attacks rose dramatically (56%) in the first week following closures and remained at elevated levels for five weeks. Similarly searches for the term insomnia rose 21% than historical data would predict during the lockdown and remained at those higher levels throughout the lockdown. Somewhat surprisingly, searches for the terms suicide and depression didn’t exhibit a significant increase from pre-COVID patterns, with the authors theorizing that this might be due to the impact of a feeling of solidarity with others facing the same situation. Implications: The study lends credence to the idea of using digital tools/data like internet search terms/trends in social media to get real time indications of changes in the mental health of a population. This type of data could be very useful both in tracking the longitudinal health of certain geographic populations as well as tracking the emotional health of a population in response to specific traumatizing natural or man made events (storms, fires, terrorism, etc.). By giving public health officials a more rapid view into changes in mental health, data like the above may empower a more proactive response from public health officials. This could, theoretically lessen the impact of such incidents on a population's mental health and thus lower the cost of care. COVID-19 and Psychological Distress—Changes in Internet Searches for Mental Health Issues in New York During the Pandemic Healthtech Startup Your.MD Raises €25m from FTSE 100 company Event: (10/05) European startup newsletter, Sifted recently ran an article that London-based healthtech startup Your.MD has raised €25m (~$29.5M USD) in fresh funds from Reckitt Benckiser (“RB”) to roll out its "health hubs" concept. Your.MD has developed a self-care app, Healthily, that helps users learn, assess, navigate, improve, and track specific behaviors that lead to better health. Description: Your.MD is using artificial intelligence to help users make better decisions around health. Unlike some others however, it does not make a diagnosis. Rather Your.MD is using AI to help users check their symptoms and advises users on what they should do next, whether it be talking to a doctor, ordering tests and medications, or finding a specialist. The company also views the app as a way to help lessen the strain on the healthcare system. The app provides a symptom mapper that shows users how their symptoms compare to others around the world. According to the company, it has seen a 350% increase in the number of users over the last 12 months, from 6m users from January to August 2019 to 26m the same period this year with part of the increase attributable to Your.MD’s COVID-19 symptom mapper, which had more than 4M visits. Implications: Firms like Your.MD which allow users to measure and monitor their own health help patients save time from unnecessary doctor consultations and empowers them to stay engaged and responsible in the management of their own health. In addition, Your.MD’s partnership with RB shows the strength of working with strategic investors, such as RB, which owns several over the counter brands such as Strepsils (similar to Cepacol), Gaviscon and Nurofen (Ibuprofen) which have broad consumer reach. As healthcare becomes more retail oriented this will become increasingly important. Healthtech startup Your.MD raises €25m from FTSE 100 company AdventHealth Adds to Long-Term Tele-ICU Partnership with Advanced ICU Care Event: (10/6) A recent article from PR Newswire noted that AdventHealth, a healthcare system based in Florida, rolled out its tele-ICU care services. This is an extension of its existing partnership with Advanced ICU Care, as it joins other AdventHealth hospitals that have telehealth-enabled ICUs. The partnership involves remote inpatient telemetry monitoring in addition to virtual ICU services. Description: AdventHealth Lake Wales, is a 160-bed acute care facility that strongly believes in whole person health as well as quality care. In 2014, AdventHealth created a partnership with Advanced ICU care, which is one the nation’s leading provider of high-acuity telemedicine. This partnership provides tele-ICU services that support frontline critical teams in the ICU. Tele-ICU services consist of an off-site command center in which a critical care team made up of intensivists and critical care nurses are connected with patients in distant ICUs to exchange health information through real-time audio, visual, and electronic devices. Implications: The new tele-ICU installation will move AdventHealth Lake Wales towards achieving the AdventHealth three-tiered care goal for critical care which includes lowering mortality rates, supporting bedside providers and improving data capture to support best practice compliance. In addition, tele-ICUs can also help to support immediate and ongoing acute care needs. Given the influx of patients in need of critical care during the ongoing pandemic combined with the need to keep providers and caretakers out of harm's way, telehealth can play a vital role in delivering needed care safely. AdventHealth Adds to Long-Term Tele-ICU Partnership with Advanced ICU Care

Hims, A Direct-to-Consumer Health Company, is Going Public via SPAC Event: (10/1) On October 1st, 2020 Hims. Inc., a direct to consumer digital healthcare company, agreed to merge with a Special Purpose Acquisition Company (SPAC) formed by Oaktree Capital Management to go public. As a result of the transaction, Hims may raise up to $280M in cash, be valued at $1.6B and trade on the NYSE under the symbol HIMS. Description: Hims, Inc., is a direct to consumer company that sells health products targeted at Millennials. for both men’s and women’s health brands. Their focusing is on a variety of everyday issues and products such as skincare, hair-loss, sexual health and more recently primary care. Hims is fairly unique in that most of its products are sold via a monthly subscription and a high percentage (approximately 90% according to the company) is recurring. The transaction is expected to close by the end of 2020. Hims is the second digital health company to go public via a SPAC according to Fierce Healthcare, following acute care telemedicine company SOC Telemed’s July deal announced with Healthcare Merger Corp. Oaktree Acquisition Corp, is a SPAC formed by Oaktree Capital Management that went public in July with the intent of using the proceeds to make one or more acquisitions. A SPAC is a “blank-check” company that has the intention of buying or merging with one or more companies with the caveat that if the capital raised from investors is not invested within two years it must be returned to them. SPACs are also seen as an easier way for private companies to go public more rapidly and have less regulatory paperwork than the typical initial public offering (IPO) process. Implications: SPACs are an increasingly popular way for companies, typically those that may be earlier in their lifecycle, to come public with approximately 115 SPACs raising approximately $43B through October according to Bloomberg. SPACs also have the advantage of allowing companies coming public to make financial forecasts and raise greater amounts of capital. This can be especially attractive for competitive and financial purposes in an emerging industry such as digital health. As a result, SPACs could provide an avenue for some smaller and less mature digital health companies to go public and keep pace with many of the larger players in the space who came public via IPOs. (ex: Teladoc, Amwell, Oak Street Health, One Medical, etc). [As we were going to publication Clover Heatlh agreed to go public via a SPAC in $3.7B merger with Social Capital's Hedosophia Holdings III per Bloomberg]. Hims, a direct-to-consumer health company, is going public via SPAC Q3 2020: A New Annual Record for Digital Health (already) Event: (10/5) On October 5th, Rock Health released it’s Q3 2020 Digital Health Funding report which highlighted the surge in digital health funding so far this year. According to the report, the $4.0B that has been invested in digital healthcare companies in Q3 ‘20 means the U.S. digital healthcare companies are on pace to raise an estimated $12B this year, almost 46% higher that the record $8.2B raised in 2018. In addition, deal volumes rose nearly 22% compared to all of last year with the average deal size of $30.2B being 1 ½ times greater than the average of $19.7M seen in 2019. Description: The report noted that while the uncertainty and changes at the beginning of COVID caused a dip in funding, “since April the ...pandemic has accelerated digital health adoption by several years”. Through the third quarter of 2020, three categories of digital health investments have gained the most investment interest: on demand healthcare services, which deliver real-time or near-time health care services, saw 48 deals with approximately $2.0B invested; so called R&D catalyst companies, that support life sciences R&D, drug discovery and clinical trial management, saw 25 deals and just over $1.3B invested, while fitness and wellness companies that support fitness, nutrition and sleep, say 21 deals and just under $1.3B has been invested. While the trends in on-demand healthcare and fitness were similar to prior history, the rise in capital allocated to R&D catalysts or the life sciences was notable as it was only the 7th most funded category in 2019 according to Rock Health. Implications: As the pandemic drove patients and providers to seek new ways to access previously in-person services, opportunities for digital health exploded and funding followed close behind. While the levels of adoption have receded from their peaks, they are likely to remain significantly above pre-COVID levels. Latent resistance among both patients and clinicians was eventually overcome strictly as a matter of necessity and circumstance. However, as society seeks to deal with COVID longer term, digital health providers will face a more demanding business environment with providers dealing with depleted budgets, payers facing declining roles of commercially insured customers and government payrors facing increased demand for coverage amidst budget shortfalls of their own. As a result this period of easy money may be followed by a period of its own challenges including legitimization of business models, justification of economic returns and development of risk and regulatory controls that could ultimately lead to additional consolidation. Q3 2020: A new annual record for digital health (already) What Do CIOs Want to See from Telehealth Apps? More Than a Dozen Weigh In Event: (9/28) A recent article from Healthcare IT News highlighted the remarkable progress of telemedicine innovations since the start of the COVID pandemic and surveyed fourteen healthcare Chief Information Officers (CIOs) on what they'd like to see from telehealth platforms in the future. Description: People’s needs for telehealth services have skyrocketed and virtual care platforms are looking for ways to enhance their products in order to meet the needs of the consumer. Some features CIOs desire in virtual care include: remote monitoring tools tied into the telehealth app, real-time monitoring of vitals from home that can trigger immediate responses or alerts, more advanced AI bots that can be used to systemize the severity of a patient's concern, the ability to have simultaneous visits with multiple providers for one patient, voice recognition technology that transcribes what the doctor is saying into the EHR, and even using fictional characters during pediatric telehealth visits so children are more comfortable. Additional access issues that need to be addressed in virtual care settings include language barriers, difficulty navigating technology for telehealth appointments, and lack of availability of high-speed internet because of one’s physical location or economic situation. Implication: CIOs realize there is a demand for those seeking care through telehealth platforms, as a result, they want to integrate more optimal features into virtual care platforms. As we continue to embrace digital solutions with greater use of virtual and remote care, telehealth innovations will be taken to a new level in order to deliver timeliness, efficiency, and positive patient outcomes. A patient’s digital experience should afford synchronized communication efforts in one tool, however, the usage of all elements enlisted above will be dependent upon patient choice and clinical need. What do CIO’s want to see from telehealth Apps? More than a dozen weigh in Seizure Prediction Device Can Send Mobile Alerts Event: (9/29) Engadget released an article stating that researchers from Ben-Gurion University of Negev have developed a wearable electroencephalogram (EEG) device that can predict epileptic seizures up to an hour before the onset. The system is based on machine learning algorithms for analyzing EEG signals. Description: The device, Epiness, uses machine learning algorithms to analyze brain activity and detect potential seizures. It then sends a warning to the smartphone connected to the device. Sufficient warnings could give patients time to prepare for an onset seizure by taking medication. Those who don’t respond well enough to anti-epileptic drugs would have a chance to remove themselves from seizure-related injuries e.g driving. The algorithm has tested 97% accurate. Implications: Epiness would not only prompt patients to take appropriate medicine in advance to control their seizures, but it would also prevent seizure-related injuries that can occur during activities such as driving. This device is giving patients control of what is typically an unpredicted traumatic event. Warned patients can prepare for the onset event and care for themselves in a safe environment. Seizure prediction device can send mobile alerts Six Things to Know About Telehealth Medical Malpractice Concerns Event: (9/30) On September 29th, Bloomberg Law published an article entitled “Uptick in telehealth reveals Medical Malpractice Concerns”, addressing the issues that have arisen due to the increase in telemedicine platform usage. The article highlighted that telehealth platforms create a higher risk for data breaches and more challenges for clinicians when examining patients via digital health rather than in-person and thus must be sure to protect themselves when embracing digital health. Description: With the surge in telehealth use during the COVID-19 pandemic, The Department of Health and Human Services has temporarily relaxed regulations under the Health Insurance Portability and Accountability Act. This allows physicians to communicate with patients on various video-conferencing platforms. This raises concerns with the malpractice risks associated with virtual care since providers are now at a higher risk for data breaches of their patient’s health information. With the inability to examine the patient in-office, misdiagnosis is possible as well as improper prescription of the patient’s medication. Providers may be held liable for breaching the standard of care if patients experience any harm during “visits”, due to negligent act or omission, miscommunication, misdiagnosis, software malfunction or other technological risks. Implications: As a result of the rise in concern, physicians are urged to become acclimated to malpractice risks to avoid civil or criminal liability, which could ultimately lead to revocation of their license, suspension of the physician’s practice of medicine, monetary penalties, or imprisonment. The Bloomberg Law article suggests best practice for providers, which includes: 1) educating patients regarding their telehealth visit and providing informed consent that details potential risks and security measures, 2) the importance of documenting virtual visits and maintaining proper patient records to ensure confidentiality and standards of care are met, 3) becoming familiar with state laws associated with telemedicine. By following these guidelines, physicians can safely continue to use telehealth platforms and patients’ health needs can be addressed in the safest manner. Uptick in Telehealth Reveals Medical Malpractice Concerns

What Startups are Missing When They Talk About the ‘Consumer’ Experience & To Boost Inclusivity, Words Matter in the Healthcare World Event: (9/22 & 9/23) Two recent reports in Mobihealthnews focus on the importance of including a health equity agenda and acknowledging the importance of langage to improve consumer experience and inclusivity in digital health tools. Digital health need to make sure they “have delivery systems that communities can trust and want to access” especially for groups of people who have been historically marginalized such as those in LGBTQ+ community and communities of color. Description: Two recent panels shed insights on lessons that could be learned from the dual crises of COVID and racial injustice which have had a disproportionate impact on underserved communities and communities of color. Participants noted that when designing digital solutions for marginalized communities, it is important to take a broad look at health care needs and meet communities where they are. Words and language used by clinicians have impact and can either boost inclusivity or cause exclusion. When designing healthcare solutions, people need to consider – does this work for marginalized communities and what does management and board teams look like from a diversity, equity and inclusiveness standpoint. Implications: Panelists noted that one of the challenges Silicon Valley has in changing health care at scale is that too often entrepreneurs are reflecting their own experiences onto the challenges of healthcare today. One solution would be to tailor efforts towards a specific population served rather than roll out a one-size-fits-all program. In addition, start-ups need to guard against the “Silicon Valley-ization of Healthcare” that focuses on transactions as opposed to relationships and driving outcomes. What startups are missing when they talk about the 'consumer' experience & To boost inclusivity, words matter in the healthcare world Pain and Dementia: Common Challenges for Care Managers [AI in Pain Assessment] Event: (9/21) On September 21st, AI technology pain assessment company, PainChek, released a report entitled “Pain and dementia: common challenges for care managers”, which investigates the complex challenges care managers face daily and the relationship between pain and dementia. In August, PainChek launched its new facial analysis technology in the UK, enabling care workers and clinicians to identify and manage pain in dementia impaired patients who struggle to communicate. Description: PainChek is working to raise awareness of the importance of effective assessment of pain in people with dementia after realizing inappropriate antipsychotic prescriptions were given to dementia patients in the UK. A UK Department of Health study found that of 180,000 patients living with dementia in the UK, 80% of them were inappropriately given antipsychotic prescriptions and at least 50% of people living with dementia in the UK’s 18,000 care and residential homes regularly experience pain. PainChek is using facial analysis technology which enables care workers and clinicians to identify and manage pain in dementia impaired patients who struggle to communicate and assist them with pain management. PainChek has been granted a US patent for pain assessment invention. Implications: Antipsychotic prescriptions are overprescribed to patients living with dementia and the use of AI assistive technology will help promote the move to value-based care, lead to improved patient experiences as well as better health outcomes for patients. One of the biggest challenges is assessing pain levels for people living with dementia. Using applications like PainChek will yield improvements in communication for patients living with dementia, helping improve the quality and appropriateness of care. Pain and dementia: common challenges for care managers [AI in pain assessment] Backed by Google’s Investment Arm, Home-Based Care Startup Ready Lands $54 Million Event: (9/16) On September 16th, Home Healthcare News announced that Ready, an on-demand health care startup has raised $54 million in Series C funding. Ready delivers home-and community-based services, aiming to provide a doctor’s office-type visit in the home. Description: Ready deploys “Ready Responders” — who are trained as EMTs, paramedics and nurses — to hundreds of patients’ homes per day. All responders are connected to Ready’s platform through their phones and are also equipped with iPads, testing and monitoring equipment. When Ready partnered with Ochsner Health System, there was a reduction in non- emergency ED visits by upwards of 70%. In addition, COVID-19 has accelerated Ready’s business in New York. Due to New York’s dire need for health care workers during the crisis, Ready launched a year earlier than anticipated, Ready’s original plan was to launch in New York in 2021, but New York’s dire need for health care workers and providers during the public health emergency sped up the process. Since Ready’s main payer is Medicaid, it was able to extend support to under-served communities throughout the pandemic. Implications: This funding will help Ready continue building out the infrastructure to scale the business, grow visit volume, enhance its product offerings and expand the range of conditions it can support. Even as the pandemic slows down, the company's market continues to grow as patients enjoy the convenience of in-home care. Given Ready's main payer is Medicaid, this service is expanding crucial care in areas of need. Backed by Google’s Investment Arm, Home-Based Care Startup Ready Lands $54 Million Amazon Expands Virtual Medical Clinic Across Washington State: 5 Details & Amazon Care: 5 Things to Know About Amazon's New Virtual Medical Clinic Event: (9/22) CNBC reported that in September 2019 Amazon launched the Amazon Care program, which offers employees virtual medical consultations with clinicians as well as in person nurse follow-ups for company employees and their dependents. Healthcare represents a $3.5 trillion sector for Amazon, which is looking for different avenues to bring technology into the work they already do. Description: The Amazon Care program was implemented to offer employees and their dependents virtual and in person medical consultations with physicians and nurse practitioners. Patients can also use the app to schedule in-home follow up visits, text a nurse on any health topic in minutes, and have medications prescribed delivered to their homes. CNBC noted the application serves to eliminate travel time, wait time, and connect employees and their families to the best trained medical professionals for optimal care. According to Amazon Care Director Kristen Helton, PHD, the program received a patient satisfaction score of 4.7 out of 5, which prompted the company to expand to all eligible employees in Seattle, Washington, where most of their corporate employees are based. Implications: With the rise of COVID, and the need to physically distance increased accessibility to virtual care is even more crucial for the well-being of employees and their families. This underscores the need for accessible and affordable employee healthcare plans which integrate virtual and in-person care like Amazon Care. For big tech companies like Amazon, Google, and Apple, among others, employee health programs represent a way to test new health-care products in an internal research and development lab. Amazon leads the way in making inroads into telemedicine, which represents a $130 billion market opportunity if the company expands its clinic beyond a pilot for its own employees. Although Amazon joined up with J.P. Morgan and Berkshire Hathaway in 2018 to form Haven, an exploration of new ways to manage healthcare expenses for their combined 1.2 million employees, that effort seems to have stalled. This new healthcare initiative may indicate that Amazon intends to pursue certain healthcare solutions on its own. Amazon Expands Virtual Medical Clinic Across Washington State: 5 Details & Amazon Care: 5 Things to Know About Amazon's New Virtual Medical Clinic Microsoft Teams Integrates with EHRs for Provider Telehealth Event: (09/22) A recent article in Healthcare Dive highlighted the fact that Microsoft Teams would integrate with EHRs providers for telehealth and that its industry specific cloud offering for healthcare, Microsoft Cloud for Healthcare, will be generally available at the end of October. Microsoft Cloud for Healthcare includes Microsoft 365, Dynamics, Power Platform and Azure and is aimed at managing patients and staff, deploying resources and promoting data insights. Microsoft also announced the AI-enabled speech-to-text software integration from Nuance. Description: Microsoft noted that its Teams platform, which has a workplace chat, file sharing and web conferencing and is HIPAA-compliant has seen rapid uptake amid the pandemic with telehealth meetings increasing 35% from April to July. Microsoft’s health system clients had pushed the tech giant to integrate with Epic and other EHRs while keeping privacy and security a top priority when creating the video platform for healthcare. In addition, Microsoft’s recent integration with AI-enabled speech-to-text software from Nuance allows patient data entry by automating physician notes taken during a virtual visit which transcribes notes into the correct EHR field, eventually doing so without human supervision Implications: Microsoft’s Cloud for Healthcare and Teams EHR integration allows it to link information and help hospitals with telehealth, care management and patient engagement through apps . This will make it easier for healthcare providers to access data and other services in a remote setting should another pandemic or crisis occur. The integration of Teams and Nuance potentially puts Microsoft at a competitive advantage over other existing large telehealth vendors like MDLive, Amwell and Teladoc, by eliminating the need to integrate a separate distinct telehealth solution and easing workflow via the automatic transcription of clinician notations directly into medical records. Microsoft Teams Integrates with EHRs for Provider Telehealth High-Tech Aids for Aging in Place Event: (9/23) On September 23rd, Kiplinger.com released an update on this year's technology to assist older users and their caregivers who cannot afford the high cost of assisted living/senior care.. Kiplinger’s highlighted six products across a range of devices not all of which are marketed direct-to-consumer. Two we are highlighting here are Smart Sole and Envoy at Home. Description: SmartSole provides a smart insole to fit into shoes with a built-in GPS. This is used to keep track of a loved one with dementia who may wander off and get lost. The device pinpoints the person’s whereabouts on a map, supplying addresses and outdoor locations to within 15 feet every five minutes. Envoy at Home is a remote caregiving service for older adults who live alone and can't afford a health aide. Using sensors, caregivers can monitor the person's wellness and safety, such as how long or frequent the patient's bathroom visits are, periods of inactivity, and whether they are taking prescribed exercise or rest. The caregiver can then receive reports and alerts on the patient. Implications: During COVID, many caregivers are socially distancing from their older loved ones and cannot be present to care for them as they are accustomed to or would like. SmartSole and Envoy at Home provide solutions to remotely care for older people living on their own. These solutions and devices like them, help older adults live independently at home longer and provide more flexibility for caregivers by allowing them to care for elderly parents from a safe distance. High-Tech Aids for Aging in Place

Targeted Cyberattacks on Telehealth Vendors Skyrocketed Along with Adoption, Report Finds & Fewer than Half of Healthcare Institutions Met National Cybersecurity Standards Last Year Event: (9/10 & 9/17) According to two recent reports, not only has the number of cyberattacks targeting popular telehealth applications risen 30% since the pandemic began, but healthcare institutions are slightly less prepared to deal with them in 2019 than they were in 2018 or 2017. First, based on the “Listening to Patient Data Security: Healthcare Industry & Telehealth Cybersecurity Risks” report by Security Scorecard and Dark Owl, there has been a dramatic increase in attacks on telehealth which saw the increase in security alerts noted above compared to the healthcare industry in general which saw an overall 77% decrease in security alerts. In addition, the CynergisTek 2020 Annual Report noted declines in four of five core security functions outlined in that National Institute of Standards and Technology’s cybersecurity framework with assisted living facilities scoring highest (96%) and physician groups scoring lowest (20%). Description: Security Scorecard and DarkOwl compared security alerts sent to IT staff at 148 of the most popular telehealth applications for the period March through April of 2020 compared to the pre-COVID period of September 2019-February 2020. They found a 65% increase in patching cadence findings, a primary secret security approach to protect data and a parallel 56% increase in endpoint security attacks. They also found security issues were reported due to increased FTP attacks (which rose 42%) and RDP attacks (which rose 27%) both of which target increases in remote and virtual workers. The CynergisTek report showed that healthcare institutions compliance with IT security policies were sliding, scoring 44% in 2019, vs. 47% in 2018 and 45% in 2017. This included a decline in four of five core functions. Implications: With the growth in remote work and the explosion of digital health due to the pandemic, the number of “digital endpoints” exposing healthcare institution’s to cyber risk has increased significantly. As a result healthcare institutions need to be even more vigilant and conscious of the risks to patient data and IT system integrity/security. Healthcare companies must work on greatly improving and patching their critical security tools enhancing endpoint protection, improving identity access management, and data loss prevention. Targeted cyberattacks on telehealth vendors skyrocketed along with adoption, report finds & Fewer than half of healthcare institutions met national cybersecurity standards last year COVID-19 Tracking Tech – Weighing Personal and Public Health Benefits Against Privacy Event: (9/18) A recent survey conducted by SecureAge Technology shows that 67% of consumers and 91% of IT professionals said they'd support a nationwide rollout of contact-tracing apps or other technologies despite the fact that the clear majority of these groups believe COVID contact-tracing technologies put individuals' personally identifiable information at risk. The report notes many have strayed away from using these resources, afraid that their personal information may be compromised as COVID has caused an increase in technologies used to educate, contact trace, and symptom report for those who may have been exposed to the virus. Description: Public Health departments have begun rolling out applications to aid with contact tracing and educating individuals regarding COVID, but recent surveys are showing that there has been increased skepticism. Although these tools have been introduced to control virus transmission, the hesitation isn’t unfounded due to major technology firms like Google and Apple that have been facing scrutiny from the public and lawmakers over the collection and use of personal data for corporate gain. Additionally, published analyses suggest that many COVID apps made available for download make little effort to protect the data they are collecting. Despite the valuable aspects of these applications such as quarantine updates, healthcare contacts, location tracking, and educational tools, the cons have greatly overshadowed the pros. Implication: COVID applications are valuable in helping users understand their risk, so they can adjust their behaviors and seek testing if necessary, but proper education is necessary to maximize the use and to save lives. The information stored in these applications are critical and need to be protected at all costs to create a safe space for use. Public health groups need to better inform the public about the benefits of these apps and ensure that the information is given with proper consent and handled responsibility, especially amongst higher risk populations that may have varying levels of literacy. COVID-19 tracking tech – weighing personal and public health benefits against privacy Why Digital Therapeutics are Flourishing Under COVID-19 Event: (9/17) A recent report in Mobihealthnews highlighted the growth in adoption and acceptance of digital therapeutics during the COVID pandemic. The article noted that not only has COVID removed some of the stigma around the conditions being treated (mental health, psychiatric conditions, etc.) and the ability to treat them digitally, digital therapeutics is not facing some of the issues in trial design and recruitment that traditional trials are experiencing. As a result, there has been increased access to evidence-based interventions which show reliability and personability to patients. Description: Digital therapeutics are evidence-based therapeutic interventions driven by high quality software programs to prevent, manage, or treat a medical disorder or disease. As a result of COVID digital therapeutics executives and industry stakeholders have seen an increased demand for efficient and accessible treatments which can be done remotely without potentially exposing them to the virus and can be highly personalized. In addition, digital trials are decentralized, can be done from home and typically allow more flexibility in recruitment all of which have been advantageous vs. standard trial design during the pandemic. Implications: Digital therapeutics are likely to yield improvements in self-care particularly for patients who are isolated due to COVID as well as reduce the social stigma around many of their conditions. With a number of digital therapeutics already approved and companies such as Big Health, Click Therapeutics, Akili, and others focused on using digital technologies to reduce development costs and increase accessibility to care for many conditions they are likely to redefine how care is delivered in many areas. Why digital therapeutics are flourishing under COVID-19 The Rise of Venture Capital Investing in Mental Health Event: (9/16) On September 16th JAMA published an opinion piece about the increase in venture capital (VC) investment in mental health noting that the sector was ripe for innovation with fewer than ⅓ of the people in need of care receiving treatment and only a subset of those actually getting adequate care. The article went on to note that while VC investment has grown almost 23x since 2013 it was important to look at potential concerns and benefits associated with the influx of money. Description: The private sector is using health and wellness as an investment opportunity after realizing there is a supply/demand imbalance mismatch for those in need of mental health treatment. However, VC supported companies often rely on the ability to grow quickly and serve a large population to maximize their return on investment which could be at odds with medicine’s evidence-based approach and the one-on-one nature of mental health treatment. In addition, there have been concerns around the security of data, privacy of client information, the lack of informed consent and broad-based nature of the apps (vs. the need for personalized treatments). Implications: The rise in venture capital investment in mental health care offers an opportunity to scale treatments that work to address mental illness. However, while VC supported mental health companies can provide improvements in transparency with diagnosis, treatment process, and costs, concerns around developing evidence based treatment, appropriate quality controls, improved privacy safeguards and the continued need for solutions to treat severe mental illness, all need to be addressed further. The Rise of Venture Capital Investing in Mental Health (abstract) Telemedicine Projected to Account for 20% of Medical Visits in 2020, Report Says Event: (9/16) Telemedicine projected to account for 20% of medical visits in 2020 according to a new Doximity Report. The new report, published last week by the Doximity physician network, is based on a randomized survey of 2,000 American adults. Doximity network data reflects "physician adoption insights," and data from the Medical Expenditure Panel Survey and commercial insurance claims to gauge the telemedicine market. Description: The COVID pandemic has spurred widespread adoption of telemedicine along several fronts at health systems, hospitals, and physician practices—primarily over concern about the spread of the novel coronavirus in healthcare settings. Telemedicine visits for nonemergency care also have been shown to be efficient and effective from both the healthcare provider and patient perspectives. This has resulted in an overall increase in telemedicine visits. Since the Coronavirus pandemic began, the number of Americans participating in at least one telemedicine visit has increased 57%, according to the report. Implications: Although COVID numbers have recently appeared to improve, given concerns about an impending second wave and the successful increase in application during the pandemic the market for digital health and increased ways to apply it will continue to grow. COVID has accelerated the rate of deployment, overcome physician reluctance to apply its use and rapidly increased consumer acceptance. As a result. more than a quarter of survey respondents reported feeling telemedicine visits have the same or better quality versus in-person visits with Doximity predicting telemedicine will account for $106B of medical services by 2023 (up from $29B of medical services in 2020). Telemedicine Projected to Account for 20% of Medical Visits in 2020, Report Says U.S. HealthCare System on Life Support, Say Test Results from New Study Event: (9/14) A recent report from The Commonwealth Fund, entitled a 2020 Scorecard on State Health System Performance, which looked at 49 indicators of health care system performance was not encouraging. According to the report, the state of healthcare issues in the U.S. such as access to, and the cost of basic medical care and minority health outcomes have significantly worsened, especially during the recent pandemic. Also, resources linked to mental health treatment have lost funding, causing an increase in drug/alcohol abuse and suicide all over the nation. Description: The report, which drew primarily from 2018 data, and some preliminary 2019 data noted, among other things there is a nationwide crisis when it comes to overall health outcomes. The Black and Latinx populations are suffering the most as well as those residing in states that chose not to expand Medicaid services. The four main conclusions made from the data reviewed: 1) Americans are living shorter lives than in 2014, with Blacks twice as likely to die from treatable conditions than whites, 2) healthcare coverage gains have stalled with both out-of- pocket costs and insurance costs worsening, 3) increased healthcare prices have driven healthcare spending growth and the rise in consumer healthcare costs, and, 4) public health dollars are already being stretched while having to contend with unprecedented challenges due to the pandemic. Implications: The current state of the U.S. healthcare system highlights the need to combat extreme deficiencies to promote better healthcare outcomes. The global pandemic has brought to light the extent of the healthcare gap and lack of access to resources that has negatively impacted the nation, especially amongst minorities. If new solutions do not emerge, Americans will continue to see a downturn in overall health, especially as COVID-19 continues to spread throughout the world. U.S. health care system on life support, say test results from new study