Approaching Healthcare Technology In 2015:

The Impact of Hardware on Telemedicine Advancement

September 15, 2014Rough Draft: Version 1.0

Situational Overview: Using HealthKit For TeleMedicine Development

September 10, 2014• Payment- Insurance auto-payment via TeleHealth appointments. (Cigna/Apple

Appointments) —> could possibly be integrated into iCal

• Video- Advanced video from iPhone6 will allow for more advanced remote patient appointments.

• Image Stabilization & Medical Purposes- The image stabilization features of the advanced camera can be used

• Doctors w/o Borders & Specialists in US- Integrating doctors without borders with Epic Health Systems specialists to provide high-quality medical care to patients being treated abroad.

• iWatch & Wearables- Impact of iWatch on patient/predictive analytics and remote patient monitoring.

• AT&T & Verizon- AT&T has suggested that they will be responsible for covering the wireless services of major health providers. (I.E. hooking up all the iPads with WiFi & the server rooms with remote monitoring/chronic disease management constant sharing capabilities)

The Providers: Verizon / AT&T

• Provider Key Roles-

• Remote Patient Monitoring/Chronic Disease Management- Providing wireless service to care providers for purposes of remote patient monitoring data transfer.

• AT&T- Will work with large hospital systems and existing care providers. Likely that Verizon will have their own group of large-scale contracts with care providers, but AT&T has stated that this is a strong monetization strategy in their future (when it comes to healthcare data technology.)

New Devices & Why They Matter

• iPhone6 (Music, Camera) = TeleHealth

• iWatch (Health, Payment) = Nike Fuel For Every1

Breaking Down Individual Hardware Significance

• iPhone6- The iPhone6 will allow for advancement in the technical medical technologies available for mobile consumption.

• New Camera- Will allow for the advancement of telemedicine facilitation through mobile devices. The powerful camera (which will be used by medical providers across the world), will be equipped with the software/hardware to conduct “significant” medical review through remote appointment.

• Fitness Calibrator- The fitness calibrator makes the iPhone into a wearable-like device, which hasn’t been massively available previously. The phone could possibly serve as an activity tracker, meaning that people would only need to have their phone on them (or near them with the iWatch), and have this activity data automatically uploaded to their activity data charts.

• iWatch- The significance of the iWatch is the mass-market for wearables and advanced medical activity monitoring.

EHR Add-Ons & Certification

Requirements• Certification Requirements- EMR Add-on companies currently have to get approved by a third-party for “medical clearance” to be adapted to an existing EMR system.

• Drummonds & EMR Certification Companies- Will these companies that exist entirely for this purpose be forced out of the market? Do these certifications, which cost tens of thousands of dollars, still have any credibility or requirement?

Retail Health & Centralized Patient Data

• “You’re Sick, We’re Quick”- Partnerships with CVS Health will allow for patients to go to minute clinic and allow them to easily access patient records and accrued medical data from wearables.

• WalMart- WalMart has encouraged health data innovation, and could play a strong role in releasing the healthcare technology movement to non-urban regions throughout the US.

• CVS / Walgreens- Could be fighting a battle to be the primary instant care provider of patients across the US. Would assume that the would partner with insurance companies to make sure that their services are covered under common patient insurance plans— meaning that patients would no longer be required to have a primary care physican, and could instead easily just pull-up to a CVS whenever they’re sick. This concept could have a major impact on healthcare revenues from major provider groups. (Need to do a thorough analysis of healthcare provider revenues).

Using Medicare & Medicaid Correctly: Advancement of Free

Healthcare

• Retail Healthcare- The increased patient data, and likely centralized patient record system, will allow for the onset of “retail healthcare,” in which medical care will be offered at retailers like Wal-Mart and CVS.

• CVS Health-

Developing “EHR Modulars” w/ HealthKit:

Building IAAS/PAAS Add-Ons• EPIC Systems Connection- This initial partnership could be a signal to major health information technology providers to make partnerships with HealthKit and ApplePay for purposes of appointment processing and medical data storage/transfer.

• Hospital Systems & Patients- One hospital system integration is the equivalent to thousands of providers for start-ups with a per provider revenue structure. (The Fee Model) —> $79.99/review for disease diagnosis facilitation could easily run up revenues in the billions under the right product.

Eli Lilly Pharmaceuticals

• Eli Lilly’s Medication Adherence Department- The Big Pharma giant has recently taken an interest in medication adherence innovation

Celgene

NYC Start-Ups To Watch

• AdhereTech- Medication adherence technology “hardware” provider with an interactive pill bottle.

• HelloHealth- Application system that facilitates telemedicine appointments/ “transactions”. (looks like they switched to a revenue cycle management platform—which would exclude them from the race, as ApplePay will likely integrate with a major RCM provider.) ——could be also integrated with a major supplier of employer healthcare finance management providers. (recently public one could be a major partner)

Individual Product Healthcare Impact

Analysis: iPhone6+

Impact of New Health Indicators

• Activity- Pulling Nike+ metrics

• Blood Pressure/Blood Sugar- New data indicators integrated from third-party medical hardware add-on devices.

• Heartrate-

• Hydration-

• Nutrition-

• Oxygen Saturation-

• Respiratory Rate-

• Sleep-

• Weight-

iPhone 6 Individual Features &

Healthcare ImpactMaximizing Hardware Offerings When Developing

For HealthKit

Using The Fitness Calibrator For Fitness

Applications • Start-Up Casualty: Amiigo- The whole concept of this start-up was to have a wearable that adapted like the calibrator does. (Lifting Weights, Running Upstairs, etc.)

• Advancement of Shoe Clip- The shoe clip could be a powerful wearable for fitness, etc. Applying advanced footwear wearables to specified sporting activities could be a smart market pivot. (Assuming that the advanced technology specific to this individual wearable will be outpaced by the advancements in the iWatch & Apple’s wearable strategy. (iPod —> iPod Mini, etc.)

• Price For Amiigo- Depending on the intellectual property, Amiigo is likely to be valued low (depending on their current orders)—the product is currently in a pre-launch stage, and has been active on KickStarter. Acquisition of the company could be an important part of the cycling sneaker wearable integration strategy. The real value in this acquisition would be the technology for integrating the calibrator specifically into a sneaker (or footwear). This intellectual property value would significantly decline if the iPhone6 basic technology can map foot steps and foot calibration as accurately, or more accurately, than the existing technology that powers the Amiigo footwear device.

Medical ID: Stored Patient Registration via

ApplePay/Passbook

Medical ID Concept- Patients will be able to store their medical history on ApplePay, and transfer this data to providers through NFC/ApplePay secure payment.

Apple HealthKit

Shared Care Plan Management: HealthKit

Functionalities• Shared Care Plan Management- Apple’s family sharing invitation technology indicates that patients will easily be able to share their medical data stored on iOS8 with family members through a pre-formatted data sharing platform. This ability to share medical data with family members can easily be applied to care providers of an individual patient.

Learning From The Amiigo Casualty: Developing Fitness Applications For The Calibrator

• Accelerometer- Not much without the accelerometer?. The major concept of the wearable was the ability to track workouts and the intensity of individual sets.

• Customized Fitness Applications- Athletes will be able to review their workouts with precision—knowing the intensity of the workout, weak spots, and immediately receive a comparison analysis to previous workouts.

Personal Health Data Management

• More Data, New Data- The increase in wearables, in addition to the iPhone6, is bringing both larger amounts of patient data along with new forms of patient data into the healthcare data “ecosystem.” In addition to the new advanced forms of wearable data that will be integrated into Epic Systems, it should be noted that there has not be any data transmitted automatically from wearables into a major health information system to date. This is a significant note, as the concept could span hundreds of millions (if not billions) of people as the iPhone/iWatch technology becomes more prominent globally.

• Apps For The New Data- Much of the health data that will be collected through the iPhone6 & iWatch has yet to be introduced into the healthcare data ecosystem. This new data can be used for advanced predictive algorithms for medical analysis by care providers, as well as for chronic disease and personal care management.

• Device Add-Ons- Market for new hardware that can connect to the iPhone6 & integrate with HealthKit likely to be a major growth sector in the healthcare technology market. Apple has discussed the requirements for medical device certification with the FDA— meaning that it is likely that these hardware add-ons will not require FDA approval, making the development process much more open and easy.

• Individualized Athletic Profile- Developing a software that will allow for athletes to capture an accurate measure of their current athletic state.

• Actual Medical Metrics- Using add-ons to the iPhone6, patients will be able to measure and record vitals that were previously not commonly taken, yet alone recorded through technology for long-term analysis. These metrics include glucose levels, blood pressure, hydration, sleep cycles, and advanced activity data. These metrics can be used to develop an individualized overall health concept for patients to measure their health/fitness performance against a metric customized to their body and “ideal fitness state.”

Determining Overall Athletic Health Using Fitness Metrics: Capturing An Accurate Depiction of an Athlete’s

Current Fitness State• Collecting An Accurate Image of An Athlete’s

Current State- Combining all of the metrics that are produced through wearables into individual metrics that focus on athletic strength and core fitness as the metric for “healthiness.” Meaning that the concept would be to determine the ideal fitness level of an individual person, and develop their fitness metrics to measure their current fitness state in relation to this idealized “fit” state.

• The Combo- Activity, Dehydration, Blood Sugar, Blood Pressure, Long-Term Sleep Patterns w/ Analysis

FaceTime HD: Making The Appointment More

Authentic• Increased Call Clarity (Camera/WiFi combo)- The ability for TeleMedicine appointments to appear more authentic when performed through a mobile device through enhanced camera technology that makes up FaceTime HD.

• “Doctor Relationship”- Could psychologically make people feel more comfortable with performing a medical appointment over the phone, as they will be able to very clearly see their medical provider. This could be a significant deal when addressing the on boarding of elderly patients, etc.

Wi-Fi Carriers: Using Wi-Fi calls for TeleMedicine • Advantage: Using WiFi for TeleMedicine- Using WiFi-only

strategy means that patients only require access to a wireless network, instead of LTE, etc.

• Middle America- This is important when addressing the telemedicine needs of “Middle America.” Many of these Americans have dial-up internet connection, which would have previously prevented them from participating in telemedicine/only verification because of the speed requirements for this type of internet function.

• Network Speeds & TeleHealth- Using a WiFi only strategy, telemedicine companies will have the opportunity to reach all patients despite their home internet connection speeds.

• Public WiFi- Easily could partner with AT&T, Verizon, etc. and offer WiFi technologies for the public in mass ranges.

Individual Product Healthcare Impact

Analysis: ApplePay

Processing Health Insurance Payments via

Apple Pay• Concept: ApplePay will allow for insurance verification transactions through partnerships with insurance providers.

• Major Partners- Insurance Providers: Cigna, Aetna, Humana (fill these out— and add significant insurance providers and their patient numbers)

• Health Data- ApplePay could allow for patients to securely send their patient data through NFC. (See Patient Registration NFC concept graph)

Developing Technologies For Apple Pay Insurance & Patient

Information Verification

• Concept: Patients would have the ability to send their data through ApplePay, along with their insurance verification information. The patient information could be stored in the “ApplePay” information docket, and be administered to a care provider through NFC.

Chip & Pin: NFC Insurance Verification For Non-Device

Users • Chip & Pin Card Provider Opportunity- Could possibly be a good play when it comes to the insurance cards— as they can easily be the provider of the NFC insurance cards that will hold patient registration and insurance verification data.

• How It Works- To solve this, banks and retailers are replacing traditional magnetic stripe equipment with smartcard technology, where credit and debit cards contain an embedded microchip and are authenticated automatically using a personal identification number (PIN). When a customer wishes to pay for goods using this system, the card is placed into a "Point of Sale" (POS) terminal, which connects to the chip on the card. To complete the transaction, the customer enters a 4-digit PIN. When the POS terminal is connected to the network, the authenticity of the card and chip can be confirmed, along with the PIN, with the bank servers. If the POS terminal is not connected to the network, the chip can confirm to the terminal if PIN was entered correctly.

Eliminating Emdeon w/ Apple Pay:

$1T in Payment Processing Now Available• Eliminating Emdeon- Possibility that Apple has conceived away to work around

Emdeon for insurance payment processing. The company claims to process as much as $1 Trillion worth of insurance claims per year, which could easily be processed through a system devised by Apple.

• Blackstone Group- This could have a potential impact on Blackstone, as they have control of the company—it could possibly not have a reason to go public again, if Apple figures out a way to process insurance payments using ApplePay. (See Apple, Visa, Cigna strategy) —Either way, Emdeon is worth more than what they paid for it, despite the fact that it is in technological shambles, and will likely be unable to keep up with/maintain the complexity that is ApplePay and insurance verification.

• Taking Emdeon’s Core Market- If insurance payment processing is removed from the Emdeon revenue flow, that would leave it only with revenue cycle management. This would be under the assumption that their current revenue is focused on taking a percentage from the insurance payment process—leaving them without a main revenue source, only the ability to possibly license out their revenue cycle management software to healthcare finance management firms. Currently, the major claim to fame for the company is their insurance gateway with “unlimited” access to providers. Apple could possibly remove the requirement for this network, which would in hand remove the requirement of working with/accepting insurance on a telemedicine platform.

Mobile Payment: Automated Insurance

Verification 2.0

• Cigna- Current leader of health insurance technology in terms of engaging with the patient/plan holder. Using Cigna with ApplePay will allow for providers

• Aetna- Aetna had the Carepass, but stopped development as of recent.

Apple Pay: Insurance Verification Network

• Emdeon Intelligent Network- This could be a strong play for Apple to cut out Emdeon from the revenue processing algorithm. Currently, Emdeon is processing $1T worth of insurance payments per year through an outdated insurance exchange system. The development of ApplePay across payment providers has the potential to eventually eliminate Emdeon from the patient payment process.

• Really need to consider the scale of this operation, and also the scale of the operation that Apple has setup with ApplePay.

• Wi-Fi Processing Payments- Would be apple to process insurance payments using only a Wi-Fi connection using an ApplePay insurance verification platform. Emdeon is currently processing insurance numbers over the phone—meaning that a receptionist is taking a copy of the patient’s insurance card and literally calling the number in for verification and revenue cycle “management.” They still are using paper/phone as a means to process insurance payments (medicare/medicaid), and the mass-adoption of NFC across iPhone & Android users.

Processing Patient Deductibles: Streamlining The Joint Payment

Situation• ApplePay & Patient Deductibles- Patients will have the ability to pay for their “co-pay”/deductibles automatically through ApplePay.

• Insurance Processing/Credit Card Payments- Patients will be able to automatically charge their co-pay deductibles through ApplePay—all while processing the insurance automatically.

• Patient Payment & Healthcare “Debt” Management Applications- Advanced data about patient medical expenses has become available directly to the iPhone through the onset of healthcare technology integration into the patient/provider relationship. HealthKit developers have the opportunity to create applications that can help patients (or employers possibly) manage their healthcare costs automatically.

Individual Product Healthcare Impact

Analysis:iWatch

Main Theme of iWatch Health Announcement:

Everyone Will Accrue Personal Health Data• Multiple Sources of Patient Data- In

addition to standard wearables, there will be an additional mass-source of patient data collected from the iWatch. (In addition to the data that will naturally be collected from the iPhone6)

• Mass Market Consumer- Wearables are no longer focused on marketing to the athletic consumer, and instead are just massively available. (Concept: High-End —> Mainstream)

Current Wearables Technology Leader:

Nike+ • Nike+ & Apple Fitness Management Integration- Athletes will be able to easily access the information processed through their Nike activity tracking software directly on the dashboard of their iPhone6. Theoretically, this data will cause for patients to take their activity data more seriously, and in turn organically develop a “fitness craze” (get a better term)—> that will advance the “quantified self” and integrate it into the patient/doctor relationship.

TeleMedicine Appointment Processing: Situational

Overview• The Network- Processing appointments/payments through WiFi, with the eventual opportunity for all providers to

• AT&T will be providing the infrastructure for remote patient monitoring for care providers. Verizon will likely be doing the same, if not more, coverage of care providers for remote patient monitoring—the point here is that they are being addressed by major carriers.

• T-Mobile will be encouraging the use of WiFi calling, and the sale of phones that support WiFi calling.

• Addressing Their Market- T-Mobile’s on-boarding of WiFi phones allows for their market to be on boarded to the telemedicine patient population.

Epic: Using Epic Systems To Develop HealthKit Based

Technologies• Large Hospital Systems- Major benefit of using Epic as part of your HealthKit strategy is the access to large-scale health systems (such as universities, and public hospitals).

• Chronic Disease Management & Patient Records- The EPIC software will include access to currently existing patient records. This access to existing patient records can be a strong asset for chronic disease management softwares, and can use existing patient data to analyze and develop “comprehensive” chronic disease management plans.

• Nurses’ Notes Software: Approaching Healthcare Technologies For Providers- Building out specific applications that benefit individual providers, and participants in the healthcare treatment workflow.

• Nurses- Softwares haven’t focused on the providers of healthcare, instead have focused on the patient. As Apple takes the consumer-side of the healthcare market, the major healthcare circuit is going to have a hard time developing softwares that will maximize this data integration into the patient care workflow.

• Registered Nurses & LPNS, etc- Developing software that allows for the delegation and management of tasks by assignment hospital workers. This concept hasn’t quite been considered in the healthcare technology development scene, and could be a major trend in the feature functionality development though 2020.

• Specialists via TeleMedicine- The collaboration between Epic & Apple will allow for increased access to “high-quality/preferred” providers that are currently working at university health programs, or prestigious hospitals that already have Epic (mostly due to financial reasons). HealthKit developers will be able to create applications that are focused on providing patients with the highest quality healthcare providers, taking into consideration the concept that the best providers (in theory?) will have access to the software first.

Patient Engagement 2.0

The New Patient Engagement Pyramid:

Identifying Each Level

• “Patients As Consumers”- This strategy should apply when developing technologies for healthcare. Patients should be seen as consumers of healthcare services, with applications intent on enhancing this consumption experience through direct and two-way communication engagement platforms.

Addressing Meaningful Use Requirements with

$APL

• Develop complex wireframe of MU application of ApplePay & iPhone6/Wearable Data

Questions For The Health IT Industry:

• ICD-10- Will everything be coded in ICD-10, or will there be a new method for coding medical data to prevent hacking.

• Finger Print- Accessing and transmitting medical data through the finger print click?

• Meaningful Use-