Health Business Blog

In this podcast interview, geriatrician Mary Jane Koren, MD, MPH explains how the Advancing Excellence in America’s Nursing Homes campaign, which she chairs, is working to improve the quality of life for nursing home residents. The campaign provides resources to nursing homes and consumers, including this helpful tip sheet for residents and family members on ensuring quality of care.

In this podcast interview, Dr. Koren and I discuss the overarching goals and specific objectives of the campaign, the role residents and caregivers can play, interaction with the culture change movement, and the impact of health care reform.

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David Williams interviews Dr. Mary Jane Koren Play Now | Play in Popup | Download

Another robotic first (from MedGadget):

The world’s first remote robotic heart rhythm treatment procedure was conducted at the University Hospitals of Leicester. It was performed using the Catheter Robotics Remote Catheter Manipulation System. A 70 year old man with atrial fibrillation had a catheter ablation controlled by a robotic arm, while the cardiologist – sitting in a separate room – used remote control to steer the catheter endovascularly into the heart to correct faulty tissue fibers. Although it was controlled from an adjacent room in this case, the fully remote-controlled robot could be controlled from anywhere in the world. The procedure was successfully completed in one hour and the patient is supposedly doing well.

I fully believe that medicine will go global within the next 20 years. Information-intensive specialties, especially radiology, have been the first to demonstrate the potential. That’s pretty straightforward in retrospect: using the Internet to transmit digital images for interpretation.

Even as teleradiology began to catch on, most observers assumed it was a special case. And yet high-definition teleconferencing has already enabled remote ICU monitoring. With the advent of robots we should see the emergence of remote surgery, too.

A couple things will hold back the wave for a while: regulation and the comfort level of people who are used to doing things the old way. But the wave won’t be held back forever.
Coming workforce shortages (caused by demographics but also barriers erected to immigration) will make people more flexible. A new generation of Internet-savvy patients won’t be so scared of remote treatment. And as quality measures and public reporting proliferate, patients will realize their clinical outcome may be better with an excellent remote doctor than a pretty good one who happens to live close by.

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This is the transcript of my recent podcast interview with Cyndy Nayer of the Center for Health Value Innovation.

David Williams: This is David E. Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Cyndy Nayer, President and CEO of the Center for Health Value Innovation.

Cyndy, thanks for being with me today.

Cyndy Nayer: It’s my pleasure David.  Thank you for inviting me.

Williams: Tell me about the Center for Health Value Innovation.  What is it?

Nayer: Our tag line is “the information resource for value-based benefit design.”  We identify value and share the innovation that is getting the value so that employers, purchasers, health plans and patients get the most for every dollar they spend on health care.

Today we can all agree that we have not produced a healthier America. Yet we spend more than any other country in the world.  For that reason, we came together as a multi-stakeholder organization to begin to say, “How can we do this better?  What’s the thinking?  What’s the measure?  How can we begin to identify innovations and then bring the stories of innovation and value to the general marketplace?”

So that’s who we are.

Williams: You talk a lot about value-based design. It’s kind of a buzzword in the industry.  But what does it really mean?

Nayer: I’ll start by telling you what it doesn’t mean.  It doesn’t mean free drugs for diabetes. As late as this morning someone said, “Oh yeah, that’s the story about free drugs for diabetes.”

It was never about that.  Value-based benefit design identifies what parts of my population are at risk and guides the implementation of either an insurance plan design or a suite of incentives or both to engage the member population, the providers and the purchasers.

But let’s focus on the population for a moment. Engaging the population in managing their health better can mean being compliant with their program of care. But more importantly, as our latest research shows, it’s much more important to be compliant and persistent with prevention and wellness.

In other words, it’s always easier to stay healthy than to get healthy. That’s what we’re working on now: how do we design a broader care continuum to keep people as healthy as we possibly can?

Williams: One of the elements that you need in designing or implementing a system like that is good access to information. There’s certainly a lot of emphasis on health information technology these days, but how is health IT playing into value-based design?

Nayer: It’s critical. And it’s much more than the electronic medical record, which seems to be the focus of all the HIT at least in the press.  It’s really important that we get electronic medical records in place so that are transportable with patients, and quite frankly the patient needs to own his or her data.

But beyond that, health information technology can integrate different data sources, such as health insurance claims, pharmaceutical claims, lab data, appraisal data, electronic medical records at the population level –not the personal level. That information can be leveraged to understand the different risks and begin to group different risks.

We can identify the kinds of interventions that we might do to get better engagement and better outcomes.  It can be done on a personal level but it’s much more powerful when it’s done on a population level. And as you can understand it would be less invasive of privacy if it’s done on the population level.

That’s the importance of health information technology. We need to be able to bring it in from many different sources and integrate it.  Part of the work of the Center is identifying the disparate information sources and allowing others to benchmark against what we’re doing.  We have worked very hard over the last 18 months to be able to put together a platform that we could benchmark against and we have more of that kind of information coming out over the next 18 months.

Williams: You mentioned that the Center is a multi-stakeholder organization.  What kinds of stakeholders do you have at the table?

Nayer: At the beginning we recruited renegades who were in large companies that I had worked with, companies such as Caterpillar, Whirlpool and Quad Graphics/QuadMed. Very quickly the health plans began to come on board and then we began to attract physician organizations, hospital systems, and benefits consultants.

Our latest research was through an alliance with Buck Consultants, a national consulting firm that shows the impact of value-based benefit design.

The reason it’s so important to have multiple stakeholders at the table is because you want to do your best when you’re identifying populations at risk and the kinds of interventions that you might do.  You want to do your best to not cause unintended consequences.  This gives us an opportunity to say, ‘Well if we try to put this kind of incentive into place and do this kind of engagement, what might happen over there and how do we get ahead of that so that everybody is aligned in outcomes?’

The outcome is a healthier consumer. It is not a lower cost.  Sometimes it actually costs more but in the long run we get a healthier workforce, a healthier consumer and particularly a healthier community. Right now we’re recovering from the economic tsunami that hit us.  It’s incredibly important that we focus on healthy communities.

I should also add that we represent well over 40 million covered lives now.  So our depth and breadth of accumulating information and data is pretty big.  We can answer some pretty provocative questions and actually play it out because of the folks that are at our table. They’re an elite group of innovators and integrators and that’s what we look for.  This is not a general membership organization.  We want the best of the best and we do have them at our table.

Williams: How well placed are the traditional health plans to incorporate value-based concepts into their products or offerings?

Nayer: The first iteration is typically around pharmaceutical coverage.  If you give people free drugs and get them compliant with their drug therapies, particularly in chronic care, that’s a huge win because we do see total costs and total work performance improving. But all of us around the table know that it’s much more than just the benefit design for drugs.  It requires service providers, health information technology, and an enormous amount of communication delivered in multimedia.

As an example, if you want to communicate with me, I want to be communicated with through e-mail.  If you want to communicate with my daughter you’re going to communicate through text.  If you want to communicate with my husband, he wants print.

We have to be able to reach people with the message that they want at the time that they need it and with the method that they want. Otherwise we miss the opportunity to do behavior change and achieve better outcomes.

The health plans understand this.  There is an incredible dichotomy however.  The difference is the amount of resources that the payer or purchaser is willing to commit in order to get those outcomes. It requires a complete educational program so that a small employer understands that if you want to get people engaged and compliant, it’s going to cost a little bit more money for a couple of years until you begin to see the return on your investment.

We are walking that finite path: We can do better.  We know how to do better.  Are you willing to pay for it? That’s a hard question to ask because peoples lives are at stake.  We all understand that and the health plans understand that.  Some of the folks on our panel look like very conservative folks.  There are clear renegades doing clear “renegadish” kinds of work with us and we enjoy that.

Williams: You have new members coming to the table.  Last month TriZetto joined. I think of them mainly as a core claims processing system although I understand they’re probably branching out into other areas.

Can you tell me a little bit about the story behind that one?

Nayer: We’re really excited to have TriZetto on board. Last year we began –under a confidentiality agreement so that they could understand where we were going– to detail each other on what their vision was for integrated health management and how that would fuel where we were trying to go.

Let’s be sure to explain who TriZetto is for those who don’t know.  TriZetto adjudicates the claims for about 48% of the Blues plans around the United States, which gives them a pretty big footprint.  They have been following value-based design and found that we had the most experts.  I was clearly one of the most vocal people and they came to me.

We met for a long time. At the first meeting they said, ‘Cyndy, where are you going?  What are you leading?  Who is on board?  What are they thinking?’

We didn’t reveal any proprietary information at that moment but we have been working very hard so that one, to your point, they are expanding beyond just claims adjudication, but two, they’ve developed a competency to what I call ‘adjudicate on the fly.’

Typically when you look at claims, there is a 60 to 90 day lag, so you’re always looking at lagging indicators of population health management.  They’ve managed to get up into real-time speed and they’ve shared with us what the output would be. Now we’re working towards how to measure and get the right incentive to the right person and how we bring that to market.

They have some very interesting protocols in place.  They have some very innovative tests that are going on. We are in constant contact with each other to be sure that we are dovetailing.  They want to be where we are leading and we want to be where they are innovating so that we can bring this to the market.

I want to be really clear, I’m not just promoting TriZetto. Obviously they are very large, but we have several innovative technology companies on our panel.

It’s exactly that kind of thinking we want to engage in: how do we get ahead of where the crowd is going? Or as one of my colleagues said: we want to skate to where the puck is going to be, not to where it is.  I think Wayne Gretzky said that.

Williams: Wayne Gretzky said that and Professor Clayton Christiansen picked up on it in one of his articles.

Nayer: Peter Hayes, formerly of Hannaford and now secretary of our Board of Directors says it all the time. I want to give credit where credit is due.  He is the one that taught me that.  We want to skate to where the puck is going to be and if we can, we want to be the one who pushes it out there. We’re working very hard to keep pushing the envelope so that more people can get accessible, affordable and meaningful care.

That’s the other piece of the puzzle.  We want good care that’s meaningful to me and my family.

Williams: We’ve just had this big fight over health care reform.  It’s now passed and presumably will be implemented.  How does that fit into what you are doing?

Nayer: It’s been an interesting 15 months.  Over the last 40 days as this has come to an end and then during the vote, I’ve been doing quite a lot of public speaking.  The day after the vote I was speaking at a large conference of about 200 people and I said: ‘How are you all doing?’

They said ‘okay’ and I said, ‘Do you all feel like you’ve been running a marathon?’

And they said, ‘Yes.’ Then I said, ‘Well here’s the good news, you’re halfway done.’ They really wanted me to say they were all the way done.

The reality is now that the legislation is in place at least we know what we have to work with, even though it will change over time.  Now the question is how do we optimize? None of us ever thought this was only about insurance reform but okay, that’s where we are.  So we’ll start there.

Now let’s work as a team and begin to build the vision of America as the healthiest community on earth.  We certainly have enough money in the system.  The people around our table are working very hard and sharing the kinds of information and integration and innovation that they can without divulging proprietary secrets. We’re doing a lot of thinking, what we call ‘beyond out of the box.’ We’re thinking outside of the building.

We are saying, ‘Okay, in three years what will this look like?  Where do we think the pressure points will be?’ This is what we’re now doing behind closed doors and we’re bringing the information forward as quickly as we can.  The biggest change that we’re going to see is a focus on health related work performance and the concomitant or the correlated outcomes-based contracting.  You’re going to see this marketplace move very quickly to outcomes and away from widgets.  We intend to be the strongest proponents and the strongest teacher of how that gets done.

Watch what we’re doing because we are moving fast.  This is the time now to change the dynamic and that’s how it will change.

Williams: I’ve been speaking today with Cyndy Nayer.  She is President and CEO of the Center for Health Value Innovation.  Cyndy, thanks so much.

Nayer: It’s been my pleasure David.  Thanks for inviting me.

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This is a transcript of my recent podcast interview with SeeChange Health CEO, Martin Watson.

David E. Williams: This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Martin Watson. He is CEO of SeeChange Health, a health insurance company that’s just launching today.  Martin, thanks for speaking with me.

Martin Watson: Thanks David.  Pleasure to be here.

Williams: Martin you describe SeeChange as a value-based health insurance company.  What do you mean by that?

Watson: Value based is really the next iteration in benefit design within the health insurance world. Our definition of value-based is the delivery of benefits that enables somebody to change their behavior, help better manage any conditions or just take better care of himself.  The value-based label is around having people change their values such that they take better care of themselves.

Williams: Do those behaviors extend to the physicians and other providers or is it primarily a consumer focus?

Watson: Our model extends to having the physician involved.  It’s having a benefit plan that enables a stronger relationship between the consumer and their physician.

I can give you an example of how our plan works.

Williams: That would be great.

Watson: We go to market in specific geographies. A good example is Fresno, where we’re launching. We have a number of different health plans.  For example we have an 80/20 co-insurance plan with a $2,200 deductible and $3,200 total max out of pocket. This product is real insurance and is priced very competitively to any of the other carriers, and frequently better.

We ask consumers to do three things.  They don’t have to do anything and they’ve got real insurance at a good price point, but if they do three things we reward them.

The three include: 1) seeing their physician for their routine annual wellness visit, 2) participating in a biometric session, which is just the same kind of thing as when you have life insurance and some blood is drawn, and 3) going online to our website and registering with our web portal.

When they complete those three things, in whatever order, we move the person from an 80/20 plan to 100/0 co-insurance.  We reduce their out of pocket exposure from $3,200 to $2,000 and we fund a health incentive account with $200 for a single consumer or $400 for a family.  When you look at that from an actuarial basis you’ve moved from one plan to a much richer plan while your premium stays the same. And then, based upon the data that we get back, we may identify that the person might be trending towards type two diabetes or they might have diabetes or some other condition.

We reach out to that person both electronically and hard copy. The physicians will also reach out to the people and say, “It looks like you now have type two diabetes.  You should probably do a few additional steps over the next bit.  See your doctor at least twice a year for your A1c, have a foot exam, have an eye exam, etc.”

We try to give you an incentive to go and do those things by then funding additional money into the health incentive account, another $200 or $400 for a family. That covers the cost associated with seeing the doctor for those visits.

So our whole goal is that we want people to see the physician more frequently to identify conditions sooner and then provide a richer benefit set so the person won’t be stressed financially to manage their condition.

Williams: You’re launching this company right when health reform is being signed into law.  I’m just curious if you think it’s a good time to be starting a health insurance company.

Watson: I actually think it’s great timing.  Our plan design and our focus reflects a lot of the things that are in health reform. For example we modeled our products to have 100% preventive services within the plan designs.  We’re focused the offering on segments that require guaranteed issuance, such as small businesses.

We’re also focused on behavior change because we know that if we can get people to manage their conditions even a little bit better or see the physician on a more regular basis that you can lower the overall cost trend with all of those conditions because you’re treating and servicing them sooner.

Williams: You mentioned Fresno, California as your launch site.  Why do you choose that market?

Watson: It’s a great pilot market to start off in.  It’s got a decent sized population.  We also liked the fact that it has had a hard go on the economic side so they will be hungry for a new offering that’s priced competitively.  We started talking with the hospitals and physicians more than three years ago about this concept. Community Medical and Santa IPA embraced the concept of looking at the total population of our membership and getting them to see their physicians and manage their conditions earlier rather than later. So they were willing to partner with us on this model and implement it and let us build out.

Williams: Consumer directed health plans like Lumenos and Definity that were started a few years ago ended up being acquired by the big traditional health insurers.

It may be a little early on day one but is that the path that you expect to follow?

Watson: You know, that’s a great question and I’d love to know what the future would say.  That’s not how we’re operating the company.  Frankly we don’t envision ourselves to really get beyond probably half a million members or maybe a million members over the next seven to eight years.

A lot of the competitors out there have broad networks.  That could be a potential approach but that’s not how we’re operating the company.

Williams: What financial backing do you have?

Watson: We raised $40 million from Psilos, which is a private equity firm out of New York.  They focus on health care services and software and device that focused on improving health care while lowering costs.

Williams: Are the folks that you have on your team people who have a health industry background or a health insurance company background?

Watson: We all come out of health insurance, pharma, or health IT.  We’ve all been very intimately involved with the health insurance marketplace.  Some of our team were the early participants in Definity.

Williams: Stepping back a little bit from your specific company and looking at the broader environment, both with the stimulus package and now with health care reform, there have been some pretty major shifts in the market. I’m wondering what you think will likely happen as we look over the next five to ten years as the health care environment evolves.  Do you expect that some of the actions that the government has taken are going to have the desired effect?

Watson: I certainly hope so.  I’m sure reform will continue to get changes over the next ten years.  Right now I do worry a little bit that it doesn’t appear that there has been a lot of emphasis on how you manage the cost trend, long term.  Frankly I have yet to see an estimate come out of government that’s ever even been close to what they forecast.  So I think it would be great if this thing could even be deficit neutral but I’d be very surprised.

Williams: Thanks for your comments.

Watson: I appreciate the time and look forward to future discussions.

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A “babelicious” “ladylike” edition of Grand Rounds is up at ChronicBabe, just a day after Boobquake.

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This is a transcript of my recent podcast interview with M*Modal’s Chief Scientist, Juergen Fritsch.

David Williams: This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Juergen Fritsch, Chief Scientist at M*Modal.  Thanks for your time today.

Juergen Fritsch: Thanks for your time.  I appreciate it.

Williams: We’ve just been through a very interesting demo that unfortunately the blog listeners and readers won’t be able to observe.  Tell me about speech understanding and how it from speech recognition.

Fritsch: Speech recognition to me is the literal translation of the spoken word to text.  Speech understanding goes beyond that, into understanding what the intent of the communication is and understanding what the meaning is behind the dictation, especially in the health care domain.

When physicians document they are very used to humans transcriptionists interpreting the dictation. They are typically pretty narrative and very goal driven. They don’t expect somebody to transcribe exactly what they speak, but rather really interpret and understand the meaning they want to convey and turn that into a document.  And that’s really what speech understanding is about, not literally transcribing but capturing the essential clinical facts and the meaning that the physician wants to convey.

The implication is that as physicians adopt speech recognition technology they are finding themselves having to change their pattern of dictation and their style of dictation just to accommodate the technology.  Speech understanding is a very different approach. We’re trying to accommodate physicians’ style by adapting the technology to the physicians’ way of speaking rather than the other way around.  It’s a paradigm shift in how to turn voice into documents.

Williams: I am familiar with speech recognition and how people are using it with EHRs. There is a good amount of satisfaction with using that relative to typing.  What feels different for a physician if they’re using speech understanding instead of speech recognition when they’re working with an electronic health record?

Fritsch: Usability improves.  With speech recognition, there is already an improved usability as opposed to typing and selecting information from drop down menu’s and other things that have been traditionally used with the EMR system.  But physicians find themselves going through a lengthy training period with speech recognition systems.  They have to train a profile for their voice and improve recognition accuracy that way.  They still have to navigate around by clicking or by issuing commands into different aspects of the applications.  So there is an improvement in usability but it’s not where it should be in our view.

Speech understanding takes it one level further where it’s about allowing physicians to narrate the clinical facts in a very conversational manner. Rather than clicking on the allergy field and saying “Tylenol” or “penicillin” and then clicking on adverse reaction and saying “severe reaction,” we allow physicians to just narrate the fact that their patient has a severe allergy to penicillin. That should be all that is needed for the system to pick out the intents and the components of that dictation and populate the fields in the EMR.  In that sense, speech understanding takes it to a much more user-friendly level where physicians can continue to narrate their findings the same way they have done with transcription services but still see that they are populated in a structured way in the EMR.

Williams: What about for a physician is who not using an EMR?  Are they still able to make use of your system?

Fritsch: Absolutely.  That’s a good point.  We’re not strictly about EMRs, but we are about document-centered reporting in general, allowing physicians to create narrative form of an encounter,  which is then structured and coded in a meaningful way.

That can happen on the telephone.  They can pick up the telephone and call into the service.  It could happen on a mobile device, an iPhone or a Blackberry device.  It could happen on a desktop outside of or away from an EMR system.  That’s really not too different in the sense of usability from the physicians’ perspective.

It’s all about allowing them to not have to change their behavior to dictate and narrate the encounter yet get the structure and encoded documents.  To that extent we have adopted HL7′s document architecture for representing both the narratives and any structured information and coded information that we can derive from the narrative.  This is the perfect vehicle for allowing physicians to narrate and see the narratives and then repeat the narratives and at the same time capture the essential clinical facts at the same time and allows the physicians to review and validate the correctness of those facts.  And since it’s a standard it enables interoperability with all kinds of clinical systems out there.

Williams: How is the technology actually delivered?  Is it a piece of software?  Is it a service?

Fritsch: Typically we deliver this as a Software as a Service offering, a cloud based computing offering. We’re not typically selling to the end user market; we work with partners in various health care verticals who eventually take our services as web services as cloud computing services and embed them in their offering. So you might see an EMR company embedding our services behind the scenes and using us to give the users a more user-friendly experience in the documentation.

You might see us with radiology vendors and their systems. However you will see not necessarily a local deployment and installation of software, but really a kind of ubiquitous software service model where it doesn’t matter whether you’re on your pc or away with your iPhone, calling in from your car.  You will be able to use the same technology with the same user profiles and the same quality of recognition.

Williams: You mentioned working through partners.  Do you have specific partners that are public?

Fritsch: Absolutely. In the radiology space we partner with radiology information systems and PACS systems.  We’re partnering with many of the big players including GE Health Care, who has embedded our services in their physician-reporting product. There is an EMR space we’re partnering with a variety of big players in the EMR space, including Allscripts.

We are also traditionally in a lot of the transcription service providers, all the companies that provide transcription services to hospitals. Actually eight out of ten such companies are using our services to improve their productivity in creating these documents from speech.  You won’t see it directly there but you’ll be able to see the end result, which is a structured document.

Williams: Earlier in the conversation you used the term “meaningful” and so I have to ask you about whether there is a direct fit with Meaningful Use under the HITECH Act.

Fritsch: That’s a loaded question. The term “meaningful use” is over used and misinterpreted in many ways. There is not a single vendor who won’t use the term these days.  We have actually been using that term for a long, long time — way before the government started using it.

We use the term “meaningful documents.” These structured and encoded documents fuse narrative with clinical fact, so in that respect they are a conduit to what the government means by meaningful use. We enable compliance with meaningful use rules and follow the government’s outlines of what a physician should document.  Once you have structured and encoded information you can set rules on top of that to verify whether it’s complete and accurate and compliant with all these rules.

So we do provide the infrastructure and the technology to drive compliance with meaningful use as the government defines it, but it also goes beyond that.  We can access the content of the narrative to drill down in a computable way into the contents of a narrative dictation.  That’s really unlocking content that has not been available in the past.  In the past, in order to get to any kind of physician support or compliance analysis for different rules, you had to create structured information.  You had to go into the EMR style systems to enter information into database tables.

Now with speech understanding and the technology that comes with it, it’s actually possible to unlock the narrative and drill down to the spoken word and find evidence of clinical encounters in clinical conditions that you would not otherwise find.

Williams: What kind of training is required for an end user to be able to use your technology?

Fritsch: Very little. Our focus is on not changing the physician’s behavior. Out of the box, most of the physicians that use our technology find it very useful in the sense that they don’t have to adjust their style.  They don’t have to learn how to dictate.

There is a little bit of training to learn the interface. But they don’t have to go through the training and dictation enrollment period as you have to go through with many speech recognition systems. You start using it out of the box and it gets better as you use it.

Williams: I’ve been speaking today with  Juergen Fritsch. He is Chief Scientist at M*Modal.  Juergen, thank you so much for your time.

Fritsch: It was a pleasure.  Thank you.

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The Center for Health Value Innovation is a multi-stakeholder organization that disseminates evidence of improved outcomes achieved through value-based benefits design. In this podcast interview, the Center’s President and CEO Cyndy Nayer discusses the meaning of “value-based design” (hint: it’s more than just free drugs for diabetics), the role of health IT, and how population health and wellness are brought into the picture.

She also describes the participants in the work of the Center, including TriZetto, and shares her thoughts on the role of value-based design within the context of health care reform.

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David Williams interviews Center for Health Value Innovation CEO Cyndy Nayer Play Now | Play in Popup | Download

SeeChange Health is a brand new health insurance company built on the concept of “value based design,” which provides incentives including lower co-pays and deductibles for patients who actively manage their health. For example, patients need to do three things (see their MD for a routine annual wellness visit, undergo a biometric session similar to a life insurance exam, and register with SeeChange’s online portal) in order to go from 80/20 coinsurance to 100/0,  see their out-of-pocket maximum drop from $3200 to $2200 and receive funding for their health incentives account of $200 for an individual or $400 for a family.

The company is launching in Fresno, CA with $40 million in private equity backing.

In this podcast interview, CEO Martin Watson describes the company’s strategy.

I’m excited to see innovators enter the space and hope that health care reform provides enough flexibility to allow them to operate successfully.

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I’ve written recently about how speech recognition can enhance physician productivity in the use of electronic health records. Meanwhile, M*Modal goes a step beyond voice recognition to what it calls “speech understanding” –the ability to transform physician dictation into a structured document. I saw a demonstration of the system and was impressed by the way the system interpreted the user’s dictation.

In this podcast interview, M*Modal’s chief scientist, Juergen Fritsch describes the philosophy behind the system, advantages over other approaches, and the company’s contribution to helping providers meet Meaningful Use requirements.

M*Modal has just been named to Gartner’s “Cool Vendors in Healthcare Providers, 2010″ list, and I can understand why.

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David Williams interviews M*Modal's Juergen Fritsch Play Now | Play in Popup | Download

As written, the New England Journal of Medicine article (Robot-Assisted Therapy for Long-Term Upper-Limb Impairment after Stroke) claims quite modest results for robot therapy. Between the lines, though, lie powerful hints of the impending robot revolution. (The article is free and I encourage you to read it.)

Researchers recruited Veterans Administration (VA) patients who’d suffered strokes an average of 5 years earlier. Volunteers were randomized to 12 weeks of robot-assisted therapy, intensive comparison therapy, or usual care (medical management and some rehabilitation services available to all patients).  The primary outcome was change in motor function at 12 weeks as measured by the Fugl-Meyer score. Patients were also evaluated after 6, 24 and 36 weeks.

Results showed that robot-assisted therapy did not significantly improve motor function at 12 weeks compared to usual care or intensive therapy, although there was significant improvement on the Stroke Impact Scale (SIS). At 36 weeks robot-assisted therapy and intensive therapy performed about the same, and both were superior to usual care.

So what’s the big deal? Actually a few things:

• Intensive therapy –whether performed by a robot or a human– demonstrated its superiority to usual care. The intensive therapy delivered by therapists in this trial was so intensive: >1000 movements in a session compared to 45 for typical stroke treatment –that it’s really only available under controlled conditions with a researcher standing over the therapist with a stopwatch. If you want this kind of intensive therapy for yourself you’d better hire someone with a whip (or bring John Henry back from the dead and take the hammer out of his hand).
• A close read of Table 2 (Changes in Primary and Secondary Outcomes at 12 Weeks) strongly suggests better results for the robots than the authors are willing to claim explicitly. The left side of the table measures robot-assisted therapy vs. usual care. The right columns measure robot-assisted therapy vs. intensive comparison therapy. The performance of the robot group is much better on the right side of the table than the left. If we compare the robot numbers on the right with the usual care numbers on the left, the comparisons look much better for the robots, including a 5 point improvement on the Fugl-Meyer score (which is extremely impressive for someone 5 years after a stroke).

  So why is the table set out this way? It appears that patients were only enrolled in usual care for the first 16 months of recruitment, whereas the recruitment period for robot-assisted and intensive therapy continued for 24 months. I don’t understand why the usual care recruitment was stopped –perhaps the study was on a tight budget? In any case it’s likely that the therapists operating the robots followed a learning curve during the study and were better able to operate the robots in the second part of the study than the first, which is the portion  of the study analyzed on the left side of the table. The authors state that the robot manufacturer (Interactive Motion Technologies) had “no role in the study,” which could mean the therapists had to figure out the robot for themselves and would not have been as good at first.

  The fact that this information is presented in the same table appears to be a tacit acknowledgment that the researchers also believe in the comparison I am suggesting.

• Labor savings were large. One-hour sessions required only 15 minutes of contact with the therapist for the robot versus 60 minutes for the intensive comparison therapy. That has important implications for those worried about workforce shortages over the next decades.
• Overall costs were equivalent in all 3 treatment groups (including usual care) at about $15K despite the ~$10K cost of using the robot. That means the robot group patients used only one-third of the medical resources of the usual care group ($5K versus $15K) while making significant improvements in health status. That’s incredibly good news and must have been a big surprise to the researchers.

An accompanying editorial (Brain Repair after Stroke) acknowledges the accomplishments of this study and emphasizes the broader implications.

In the bigger picture, the potential for robotic therapy after stroke remains enormous. Robotic devices can provide therapy in different functional modes, a point that was not examined by Lo et al. Robots work in a consistent and precise manner and over long periods without fatigue. They can modulate timing, content, and intensity of training in reproducible ways, with a reduced need for human oversight. Robotic devices can also measure the performance of patients during therapy. In addition, robot-based therapy can interface with computers in brain-stimulation treatment or to provide simultaneous cognitive training.

You can also check out a video of the robot in action.

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