David Haddad's Blog

After much back and forth and pulling my hair out trying to get this app on Firebase. Camino is live.

Check it out: caminohealthapp.com

COVID-19 has sparked an interest in learning to code. Got deep into reading and learning HTML/CSS with books, online tutorials and using codementor.io to fill in gaps. Over the last two months I’ve been getting into Javascript and learning how to put the pieces together to make something that I think would be interesting/useful. After being dissatisfied with the projects within some of the Javascript courses (I have no interest in learning how to make snake games and meme generators), I decided to  work on something from my world of digital health. 

Enter Camino.

The idea is really simple: doctors recommend that you do stuff, apps and devices collect information about your health, Camino tells you how far off the road to better health you are from medical guidelines. 

How does Camino work? 

A user signs-up to the Camino service with Google Authentication 

User connects to an app or device that they use the most

User selects a “data prescription” of interest

Camino calculates and generates a result of how far the user is off the path

Camino suggests to the user to sign-up for services that will help them continue on their path

That’s it.

I’d like to connect a SMS service in the future to add a results page but that’s biting off more than I can chew. 

At the moment, I’m working on the meat and potatoes of the app for myself and seeing if I can get authentication to work for one device, spit out one analysis and then grow it from there.

Right now I’m working on Fitbit and Apple Health with the backend in Firebase. 

With Fitbit, I plan on using the WebAPI to authenticate and get user data. 

With Apple Health, I plan on doing an upload feature where we upload the .XML file from Apple Health and run the analysis based on the upload results. No mobile app (cause who wants to get locked into Apple).

For the data prescriptions, I plan on starting with minutes of moderate activity. Doctors (and medical guidelines) recommend that you get 150 minutes of moderate activity per week. What the heck is “moderate” mean? Well there actually is a way to determine this with step data through something called cadence.

Once I figure out how to get FItbit data in a JSON file then I can run the analysis on the steps data per minute per day/week.

I’m learning how to write all this with Vanilla Javascript, HTML and CSS. No frameworks (yet).

Been thinking how someone could ride the telemedicine wave right now and do right by patients and providers. 

Here’s what I’d do if I cared to make another health tech startup: Marco Polo app but for patient care. 

Problem this would solve

Video visits and telemedicine are ephemeral and kinda silly in this new world we’re living in. 

After a video visit the information just discussed is gone. Poof. Gone. 

There’s no continuity of care and the patient is scratching their head as to why they just paid $25-70 for a doc to tell them to “go to the emergency room”.  Plus, no one actually communicates on the regular synchronously. 

How this Marco Polo for healthcare app would work?

Patients invite their doc and/or care team to join their conversation. 

Patient records their question/medical concern with video in the app (just like Marco Polo)

Care team responds with video asynchronously! 

Video clips get combined together so rest of care team can watch in their free time

Presto change-o you now have asynchronous video communication service that solves the continuity of care problem AND could be a lot easier for docs and patients.

How cool would it be if I linked all my disparate docs into one video chat room where they can watch each other’s diagnosis and review and argue in “semi-real time” about what’s actually going on with me?  No more faxes, shitty EHR dashboards and email. 

I’d be down to try this out. 

How would you make money from this?

For patients, I’d make it free to use to start. On the free version, patients could only get a certain amount of minutes of video. Once they hit a certain number of video minutes, they’d need to start paying $X/month  to save messages and have unlimited threads with their care teams. Kinda like Slack.  

For healthcare providers, if more than three patients invite them to join the platform, on the fourth patient, the doc then needs to pay a per provider, organizational fee ($Y/month)

No ads, no EHR, no crappy patient portals. Revenue would make this service sustainable and incredibly profitable (the lifeblood of any business).

What a great conference. One of the better one’s I’ve been to. 

I noticed a few things that might be of use:

New primary care companies (like Aledade, Iora, Village, Crossover, Caremore and more) are chipping away at the incumbents. When these companies started, I remember hearing from the big guns that those services will never work (excuses around scale, capitalization, etc.). Today they are covering hundreds of thousands of patients and having meaningful results. The more they progress, the more these primary care companies of the future will be taking the incumbents’ lunch. It won’t happen over night. 

Some big players are actually listening to patients. Patients want convenience, good quality care and a low and transparent prices. I was quite impressed by the work of Cambria. Let’s see if others will follow. 

Speakers took off the gloves. They publicly attacked the monopolies that are forming in healthcare. From the payers, health systems, EHR vendors and big pharma. The biggest threat to the American healthcare system are these monopolies. They fix prices, supply and lobby government to pass laws in their favor. I’m glad people talked shed light on this. Typically at these conferences everyone is either high-fiving each other or puffing their chest about how great their companies are. Some of that was going on, but WAY less than other events. 

More people with influence, money and good ideas are entering healthcare to disrupt it from within AND from the outside. Good luck to the incumbents. Get your acts together.

A lot of discussion around benefits and self-insured employers. Noticed a lot of companies in the Exhibit Hall serving this market. While I’m not thrilled by employer-sponsored healthcare, employers might be in a better position to offer better care and coverage than insurance companies and health systems. 

All in all, I’m happy to see where healthcare is going. I hope the monopoly players were listening. There is a world of activity happening and only through innovation will be able to make care better and more affordable for the average American. 

In order to get to a better idea, we have to start with bad ideas. Here is the start of a bad idea: patient unions. It looks similar to examples like direct patient care models, employer self-insurance models and insurance itself. But this patient union is different in a few fundamental ways:

Citizens, not consumers, not employees, not even patients, have a right to healthcare for small dues. 

Fees would be as much as you’d pay for Netflix. Think about it. If Netflix can change culture for $14.99 per month and spend billions on new content AND get the producers of that content paid, then we can charge a small amount per citizen for healthcare. Not to mention they are bringing an audience of 150 million people to these content producers. Healthcare could do better. 

There’d be local chapters which contract directly with local providers

The patient union would advocate on Washington for patient rights, would also contract directly with the health providers for services 

Unlike with an insurance company, the healthcare provider would get paid as quickly as possible so they can improve cashflow and offer better service 

This union would be a cooperative with some leaders, but with active participation from every citizen on how to spend money and receive service--something insurance companies or your employer do not allow. 

Why not a labor union? 

I don’t think that a labor union has the best interest of people’s healthcare. From my limited understanding, labor unions tend to spend more time fighting for employee rights and the right to work and be paid fairly. 

Also your individual health should not be dictated by who you work for. We need to decouple your right to quality and affordable healthcare from your employer. 

Your employer is motivated by increasing profits, not their employee’s individual health. 

Doesn’t AARP do this? 

Yes they do. But what about the rest of the country? While I’m for senior health rights, this a big country and everyone should have the right to quality healthcare. 

Created more time for the people delivering healthcare. Not so they can do more, but less. 

Think about it. 

In our unique American flavor of capitalism, if a technology cuts the time in half to deliver a service or make a widget, the corporation will only need half as many people to do the work. They then get the remaining few to do more with the technology so the corporation can make more profits.   

What if instead the technology served it’s purpose to cut the time in half so the people working could have more time to spend with their families, exercise, eat right, enjoy life. People get paid to do a good job for less time. 

The WHO now classifies burnout as a medical diagnosis under ICD-11: https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/129180281

Burnout amongst physicians is huge and costing the US health systems billions: https://annals.org/aim/article-abstract/2734784/estimating-attributable-cost-physician-burnout-united-states

In today’s Persicope I cover:

Movie review of The Inventor documentary

Should Silicon Valley be leading the charge in health? Does that model work for humans? 

How do we raise trust markers in big tech companies

I call out Google’s Verily for not publishing their data re: the Baseline Study. Are they being like Theranos? 

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To watch more of my Periscopes check it out here.

On today’s Periscope I talk about the Apple Health Study:

1/3 of those that had false alarms did actually have AFib. 2/3 did not but even though there are false alarms we have never been able to track this before. 

Should Apple, Google, and other big tech give us information about our health? Are they crossing too many lanes?

Where’s the Google Baseline study results? Let’s see it

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To watch more of my Periscopes check it out here.

Topics covered on today’s Periscope:

Medicare for All 

US healthcare costs won’t be covered by taxes alone which makes me suspect that Medicare for All as sufficient to increase access to quality healthcare services

Need to invest in innovation, new medicines, new therapies, reducing costs of drugs and medical devices

What are the drivers of the cost of healthcare? 

No one is able to answer clearly. Will be an ongoing topic of discovery. 

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To watch more of my Periscopes check it out here.

Topics covered in today’s Periscope:

People using digital health companies to get of going to work.

Original forum discussion

Companies that will quickly give you a doctor’s note: 

98point6.com

https://get.mdproactive.com/online-doctor/

doctorondemand.com

Yes I need to clean my keyboard. 

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Check out my Periscope channel where I’ll be doing little bites while we build up to my podcast: No Recipe. 

I've been saying it for years: Make more health workers.

Open up more spots at medical and nursing schools across the US and we can solve many of the health workers shortages we face.

Take a look at the most recent HRSA report on Health Professional Shortage Areas. California (my state of residence) is barely at 50% coverage. Yikes!

The US gets almost 40,000* applicants to medical school and only accepts around 17,000. And they graduate about the same. Now if you look at the residency programs there are almost 30,000+ slots for various specialities. I understand that many of those empty slots are available for international medical graduates (IMGs), but if health worker shortages are such a problem why are we not increasing the number of medical and nursing graduates?

Is it because of imagined prestige that if you let more people in, then it won't seem as competitive? Is it because if you have too many graduates you won't get that donor funding to pay for that new heart transplant ward? Is it because physicians and nurses want to keep their high salaries and want to artificially constrain supply?

What is it? We hear these reports about medical schools opening up 50 more spots or 25 more spots and they are congratulated as heroes. I'm not impressed.

Health worker shortages are a serious and pressing issue and should be classified as a "national emergency".

Not sure if this is a sequential step, but once we figure out how to produce more health workers, we can then figure out how to distribute them to practice in places with the greatest shortages and make them more productive with good technology and better workflows.

It's funny with all of these value-based care initiatives which are mostly focused on how to best to pay for healthcare services, we don't hear a lot about how we're going to solve the health worker shortage gaps.

What are your ideas for how to solve the health worker shortage problems in the US?

Thriving with Kaiser Permanente 

Lately I’ve been thinking about small changes I can make today that will positively effect my future.

I’m reminded of the Japanese business practice of kaizen which is to continuously improve.

In a world filled with change and uncertainty the most we can do is evaluate what’s working and not and try to improve it little by little.

If you just improve 1% per week, you’ll have ~70% improvement over an entire year.

Imagine you’re trying to lose weight or trying to make your business better. Instead of thinking you have to run a marathon the moment you step outside, try to just improve a little each week. Evaluate it every week, think about what could have worked and contributed to it not working.

Make an assertion (“I will do X and Y will happen”). Test it and then evaluate the next week.

If you keep your expectations low and do this week by week, you might be pleasantly surprised to find how much you’ve improved.

I'm often asked how in the heck I got into mobile health.

Well, here goes.

It was 2008 (yes, 10 years ago) and I was working as a health economist for the World Bank. I was stationed in Tamale, Ghana (about 11 hours north of Accra), partnering with the Ministry of Health  to help with their scale-up plans for their changing health workforce. We were interested redistributing more health workers to the rural areas, reducing attrition, training a new cadre of workers and financing given an uncertain economic situation. Before we could get into policy making, I had to collect data to power my economic model.

With my trusty thumb drive, I traveled up and down the country, meeting district health managers to get them to share information on their health labor force (with the government's consent, of course).

It was the actions of one district health manager in Tamale that had me scratching my head. This manager, who was also a medical doctor,  answered a phone call during our meeting and took the call.

For some reason at that time, as I learned later, in many parts of West Africa, not answering your cell phone is seen as disrespectful to the person making the call.

The manager pointed his index finger at me, asking me to wait, and he started discussing a patient’s lab results with a nurse in the rural area. I motioned if I should step outside while he finished the conversation. He waved his hand for me to stay put.

Up until this point, the only time I’d ever see a doctor use a cell phone to speak to or about a patient was during holiday parties when my uncle was on call in the early 90s. He would lug around a big briefcase and duck off to a small room to have a private conversation. Based on my experience, discussing medical information over the phone was a big ordeal.

Sitting in that office in Tamale, I felt uncomfortable. Not because of the doctor (we had a great working relationship), but because I didn't understand how someone could use a piece of technology that every person carries in their pocket to do healthcare. Aren’t there rules and regulation preventing this? What about HIPAA ? Does Ghana have HIPAA laws? Isn’t it unsafe?

My first reaction was to doubt.

After that meeting and the subsequent ones during my time working in Ghana, I kept on seeing doctors, nurses and health workers who spoke with other practitioners and patients about health records and issues all on their phone.

They were using their phone to do health care. That was a moment of great tension and a sign that good things were about to happen.

Again, this was 2008.

Let’s rewind a bit for those that don’t remember. The iPhone had just come out in 2007 and the App Store wasn’t available until 2008. The apps built and offered at that time were either for productivity or games. Not so much about health.

Still uncomfortable from my experience in Ghana, I wanted to explore the relationship between these little devices in people’s pockets and the production of and access to health care. I went to my friends from Berkeley and they put me in touch with some friends that gave me a crash course on mHealth. I was beginning to be sold on the vision mHealth could bring to the field.

The world of mHealth was small in 2008. There was Frontline SMS::Medic (now Medic Mobile), UNICEF’s RapidSMS, Voxiva’s Text4baby, the Rockefeller Foundation, the mHealth Alliance, some small pilots by mobile operators, and a smattering of other projects around the world (I can’t recall everyone at the moment...forgive me, this was 10 years ago).

Intrigued by the work being done and the possibilities of mHealth, I joined a small band of raucous makers trying to change the way people engage with their health.

I was in a unique position at the World Bank to try and convince my colleagues to invest in mHealth pilot projects all around the world. After one presentation, one senior economist said to me, “mobile phones are not health care. These are toys.”

It was clear that I wasn’t going to convince him or other decision makers. It was time to try another path.

I like to mention my experience in Africa because people working in digital and mobile health tend to forget where this industry came from. My roots in mobile health were born in the Global South, not the Silicon Valley.

This is hard for some to believe that technological innovation could be produced in other parts of the world outside of the United States. A lot of what was brought to the United States came from the programs and pilots in the Global South. My colleague Jaspal Sandhu, calls this phenomenon “reverse innovation".

By 2010, Fitbit, RunKeeper and Nike had apps in the App Store and our little movement had our first ever mHealth Summit in Washington, DC. From my recollection, about 300-500 people attended that event and when you look at HIMSS today with 40,000 people in attendance, the world is really changing.

VCs started opening up their pocket books. Engineers started leaving their jobs at tech companies to point their smarts towards real health problems.

These were exciting times.

In November 2010, Deborah Estrin and Ida Sim wrote a paper in Science calling for an open data standard for this mHealth data so it could be useful in the clinical world.  In all of our discussion around mobile health, interoperability was and still is the glue that will help deliver on the promise of mobile health. I joined them to start Open mHealth.

Helping lead Open mHealth has been a true gift. We continue to build a community of health practitioners and developers to make patient-generated data more meaningful and accessible.

Today, all of these of these experiences—from the World Bank to the mHealth Alliance to Open mHealth— inspire the work I do today at Overlap.

It continues to be a wild and fun ride but I wouldn’t be here without the patience and support from people like Agnes Soucat, Chris Herbst, Kate Tulenko, Jaspal Sandhu, Mahad Ibrahim, Aman Bhandari, Nap Hosang, Murray Ross, Jody Ranck, Andre Blackman, David Aylward, Patty Michael, Lucky Gunasekara, Josh Nesbit, Ian Hay, Jennifer Potts, Joe Kim, Katherine Maher, Kaushal Jhalla, Deborah Estrin, Ida Sim, Steve Downs, Paul Tarini, Al Shar, John Mattison, Joe Kvedar and so many more (and there is more)!

Thank you.

I think mobile health and I are going to be friends for another ten years.