#35 - My Watch Says I'm Dying

Apple's putting an EKG on every wrist. And other things that happened in the world of healthcare.

Things That Happened

An Apple Watch EKG a day… You may have already seen it if you happened to open your eyes this week, but Apple announced at their 2018 Keynote that the new Apple Watch Series 4 will be able to perform an electrocardiogram. It will also monitor users for low and high heart rate, and can also detect if the user has fallen. As Tim Cook put it, they’re trying to make the Apple Watch into an “intelligent guardian for your health.” 

If you missed it, you can always watch the keynote. Just interested in the bit about the Apple Watch health features? Here you go

Here’s a roundup of the many threads associated with the somewhat dramatic conversation occurring around Apple’s EKG: Christina Farr wrote an FAQ explainer, which is a good place to start if you’re not terribly familiar with EKG tech and what it can do. The CEO of consumer EKG company AliveCor accused Apple of using ‘alternative facts’ to market the device as the first direct-to-consumer EKG. Jonah Comstock unpacks the incredible regulatory timing around the announcement - the FDA clearance was issued just one day before the announcement. And Quartz doesn’t think Apple Watch’s EKG is really all that impressive at all. Also, doctors in general are worried this will result in emergency rooms and phone lines flooded with false positive atrial fibrillation alerts. 

Fernando Zampieri@f_g_zampieri

2018: AppleWatch can diagnose atrial fibrillation

2020: AppleWatch can prescribe amiodarone

2030: Over 100,000 Apple Watches attend to American Heart Association Congress

September 13, 2018
My take: Apple Watch EKG is a good thing and an inevitable step in the right direction. I’ll explain below.  

More-a Iora. Iora Health is adding 10 new practices to their network, specifically located to cater to Humana’s Medicare Advantage policyholders. This expansion is likely fueled by Iora’s $100M Series E, raised in May. I’m intrigued by Iora’s model for a number of reasons, chiefly their value-based care model where they aren’t driven by fee-for-service payments, and their in-sourced EHR and technology that allows them to rapidly iterate on the software that enables their growth and innovative change. For more on their care model, check out this interview with founder and CEO Rushika Fernandopulle, and for more on their technology here’s a blog post from Andrew Schuztbank, VP of Product and Technology. 

Unhealthy Conversation. Researchers have found that nearly 10,000 tweets on the topic of healthcare reform originated from accounts linked to Russian trolls. While 80% of the tweets were conservative leaning & and anti-ACA, some praised the law in a bid to sow political discord within the Democratic party. Most importantly, these weren’t just in a quiet corner of social media; it’s estimated that the tweets reached millions of Americans. 

Lost in the wash. AliveCor, the company that until Wednesday made the best-known Apple Watch based EKG device, was just granted breakthrough device designation by the FDA. Their diagnostic for hyperkalemia, which uses a neural network to read EKG output for elevated blood potassium levels, will now be expedited through the FDA approval process. The real question: how long does AliveCor continue producing their own hardware before pivoting to simply making AI-based diagnostics that run on the Apple Watch? 

Things Worth Understanding

You can broadly group the reactions to Apple’s new watch-based EKG into two cohorts: the dreamers and the optimists, and the worriers and the realists. At least from my observation point, the first group comprises the more tech-inclined among us: venture capitalists, journalists, and startup folks. The latter group mostly have the letters ‘MD’ following their name. 

Neither group is wrong in their approximation. They’re just reacting in their natural way to a new technology, and a new workflow. VCs and tech-people spend most of their time thinking five years in the future, wondering which niche things today will be changing the world tomorrow. Doctors, on the other hand, spend their time performing an exacting service where there is no room for error, and thus are predisposed to rely on past experience and evidence when evaluating something new. 

Aaron Carroll, a pediatrician, wrote in The New York Times this week about how hard it is for doctors to ‘unlearn’ bad practices. He traces the lineage of a best practice around controlling patients blood glucose levels in the ICU. In 2001, physicians were told that tight glycemic control would save lives. By 2009 countervailing evidence was enough to convince the medical establishment to reverse this guidance and say that tight glycemic control was, in fact, harmful to patients. From his piece: 

It’s hard to change behavior, but over time, physicians did. By 2009, the use of tight glycemic control had increased to about 23 percent [from 17 percent in 2001]. Many might have hoped for more, but at least there was progress.

Starting in 2009, however, the reverse was recommended. Doctors were asked to stop… That didn’t happen. From 2009 through 2012, there was no decrease in tight glycemic control.

It’s understandable, then, that when Tim Cook and his friends at Apple beamingly demonstrated the single-lead EKG that they would put on the wrists of millions of consumers, doctors grew worried. I saw concerns from MDs about the rigor of the study submitted to the FDA to prove the accuracy of the device, and worries that hypochondriacal patients would call 911 as soon as their Apple Watch told them they might be experiencing atrial fibrillation. These are well-founded concerns that speak to the physician’s desire for rock-solid evidence, and a slowed pace of change. 

As the world of tech turns its focus to healthcare and gets closer to the clinic, doctors will increasingly find themselves outside of their comfort zone. The worriers are being forced into the world of the tech optimists. The world of the tech optimists is governed by consumer demand, and thus places the needs and wants of the consumer above all else. When there is an opportunity, using technology, to give consumers more information about themselves, and to do so with regulatory blessing, it’s going to happen. 

This is what the tech world does: it gives people more information and control. Google put the world’s information in a search bar, and now it seems Apple is trying to put all the information about you - your medical records, your activity history, and now your biometric readings - into an app. 

This is consumer-driven healthcare. Forget $10,000 deductibles; by arming consumers (patients) with more information about their current physical state we enable them to be the better consumers of healthcare that we sorely need. 

If patients have more data - and the data is accurate - the onus is on the healthcare system to figure out how to accommodate this new element. We can’t claim we’re trying to empower patients to be better managers of their health, give them the tools to do so, and then bemoan the fact that they’re gumming up the system. If patients are presenting at the ER with Apple Watch alerts, we should be giving them an access point that is better suited to this sort of non-emergent, but potentially serious notification. 

Yes, I’ll admit, I’m firmly in the tech optimist camp on this one. I believe that the pace of technological change determines the pace of systemic change. As tech enables new processes, the ways in which we conduct business and medicine will be changed as well. 

The day before Apple unveiled their EKG, AliveCor announced they’d received a breakthrough device designation from the FDA for a single-lead-EKG-based AI diagnostic for hyperkalemia. Assuming they gain approval (and it seems likely), this represents another diagnostic that can be performed using the tech Apple now has in their watch. This is only the beginning. Apple will likely add more sensors to their devices, and engineers will invent new and better ways of extracting diagnostics from the data gathered. 

Assuming they’re any good, people will buy these devices. Then, like the rest of industry, doctors and health systems will have to organize themselves around the needs and desires of an increasingly informed consumer. 

Things To Read

“30% to 37% of hospitals ranked best on crowdsourced sites were deemed worst on clinical quality measures,” Meg Bryant writes in her analysis of a Health Services Research study on crowdsourced hospital ratings. There’s a desperate need for objective, universal, and patient-understandable provider quality measures in healthcare. Without it there’s little hope for effective price competition. And yet, there are inherent and inescapable biases in crowdsourced reviews, especially when you move into areas as complex as healthcare. Often times an accurate diagnosis is the harshest one, and the right treatment doesn’t have an effect. I’m not convinced patients can reliable opine on anything but facility cleanliness, bedside manner, and wait times. 

“Adult Medicaid beneficiaries own smartphones and tablets at the same rates as the general US population,” according to a recent survey from Deloitte. If you had limited funds and could only purchase a smartphone or a laptop, which would you pick? It’s a no brainer. It makes intrinsic sense why this low-income population uses smartphones just like the rest of America, especially considering how well you can manage your digital life from a smartphone these days. Take note healthcare institutions: mobile is a need to have, not a nice to have. 

“Perhaps healthcare is now seeing the beginning of unbundling, catalyzed by the same use of technology which allows companies to focus solely on user experience in specific verticals.” Naomi Shah, an analyst at Union Square Ventures, is creating a series of blog posts on the vaunted venture capital firm’s approximation of the state of healthcare. Whether you agree with her analysis or not, it’s an interesting view into our industry from the venture point-of-view. 

And if you’re interested in better understanding the phenomenon of bundling and unbundling, listen to this short episode of the Harvard Business Review podcast with Jim Barksdale. Barksdale recalls the first time he spoke his now-famous phrase: “in business, there are two ways to make money. You can bundle, or you can unbundle.”

This small cohort is hoping to help health care turn a corner by gathering up the vast trove of records contained in hospital and medical offices and sharing parts of them in more useful ways,” Shaw Nielsen writes in Politico about the coterie of companies that are layering value-add services on top of EHR systems. While EHRs were supposed to be transformational in terms of facilitating better healthcare delivery, they’ve proven to be a drain on physician time, difficult for patients to access, and downright obstructionist when it comes to patient data movement between provider organizations. This has created an opportunity for companies to create software that does what the EHRs probably should have done in the first place. 

But EHR companies aren’t standing idly by: Epic, Cerner, and Allscripts have all created developer programs to allow third parties to create value-add applications for their platforms. Epic is also creating an initiative to allow users to share anonymized data, via Epic, with researchers. And while that’s all certainly positive, these companies might want to make sure their house is sturdy before they go off on a data adventure: EHR’s are fast becoming a major source of physician job dissatisfaction and burnout. Better hire some good UX engineers. 

Things To Get Your Gears Turning

Some smart people at Oliver Wyman Health put together 11 scenarios by which healthcare could be disrupted, both from within and without. It’s heavy on the what and light on the how, but it’ll get your brain working through the multi-various machinations of healthcare’s potential futures. The right answer is probably somewhere in there: which one do you think it is? 

Things I Listened To 

  • This new cover of Funeral Singers from Sylvan Esso (spotify)(youtube

  • This raw, genuine, and exhilarating Tiny Desk Contest entry from Hobo Johnson & The Love Makers (youtube) Note: contains swear words and cigarette smoking 

  • And I’ve been getting back into Alt-J. Especially their first album (spotify)

Thanks for reading The Healthcare Handout, a weekly update on tech and business in healthcare from Isaac Krasny. You can find him at isaac@healthcarehandout.com, or on twitter @isaackrasny

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