Monday, August 27, 2012

Hepatitis C a Risk for Baby Boomers

The CDC is issuing a fresh warning this month about hepatitis C in Baby Boomers (those born between 1945 and 1965) as infection rates rise in this population. According to Medline Plus, the hepatitis C virus has infected 1 out of every 30 Baby Boomers ("Test All Baby Boomers for Hepatitis C: CDC"). 

Hepatitis C is spread through contact with infected blood or, more rarely, through sexual contact. Left untreated, it can cause cirrhosis of the liver and liver cancer, and death rates from the infection are rising. Roughly 3.2 million Americans are infected with hepatitis C, according to the CDC's public fact sheet on the disease. Often, however, people are unaware that they are infected until the disease has already damaged the liver. The virus can be detected with blood tests.

Vaccines are available to prevent hepatitis A, an acute liver infection which usually resolves on its own, and hepatitis B, an acute or chronic liver infection which can lead to liver problems. There is no vaccine for hepatitis C, but there are several treatments currently available with a high cure rate.

Because the disease affects such a large population, and the CDC is now recommending widespread testing for it, the incentives are high for pharmaceutical companies to develop more effective treatments for hepatitis C with fewer side effects than the current options. Sales of drugs used to suppress viruses rose nine percent in 2011, according to an article by Noah Pines on the website Medical Marketing and Media. One analyst predicts that treatments currently being used for hepatitis C and those under development could ultimately net $10 billion in sales five years from now, Pines wrote ("MM&M Therapeutic Focus: Infectious Diseases").

Monday, July 30, 2012

Dancing NHS Doctors

I've never been too interested in the Opening Ceremonies of the Olympics, because I want to get to the athletics, which always impress me. But I watched the ceremony from London this year out of curiosity, and I was pleasantly surprised. 

One part of Danny Boyle's loud and quirky vision of England in the opening ceremony especially struck me: his depiction of the U.K.'s National Health Service as an institution worth celebrating. Those were actual NHS doctors and nurses, swing dancing around a sea of children in beds in the middle of the stadium. It's hard to imagine American doctors and nurses acting so gleeful, as the pressure to reduce costs collides with the complex needs of an increasingly unhealthy population and the uncertainties about how health care reform will play out here. Meanwhile, states such as Oklahoma, for example, are fighting against government-mandated health insurance and turning down grants to help implement it.

The single-payer NHS in the U.K., designed to address inequities in health care, especially among the poor, was first instituted in 1948. Today, the service, paid for through taxes and individual fees, covers all British citizens with health care, dental care, and limited vision care. Infant mortality statistics, often used to rate the health of a country, demonstrate the success of the NHS. In 2011, infant mortality in the U.K. was 4.6 per 1,000 live births, according to the CIA's World Factbook estimate, while the U.S. rate is 6 per 1,000 live births (for comparison, Afghanistan had the highest rate in 2011, at 121.6 per 1,000 live births; Monaco had the lowest, 1.8 per 1,000 live births). Life expectancy at birth, another key health indicator, is estimated at 80.2 years in the United Kingdom and 78.5 years in the U.S.

Will our own health care system ever be celebrated on an international stage? It's hard to imagine that happening right now, but I hope we will reach that point some day.

Saturday, June 30, 2012

Avoiding Magnet Injuries

I've been thinking about magnet injuries ever since I read a story about summer injuries in kids by a Washington Post columnist. Buckyballs, the magnetic toy marketed to office workers, have caused numerous injuries to children who got their hands on them and swallowed the small, pea-sized magnets. The magnets can clamp together across internal tissues, causing intestinal blockages.

These injuries are not just limited to young children. Fox31 news in Denver reported that a thirteen-year-old girl put several Buckyballs on her tongue to pretend that she had pierced it, swallowed them, and had to have emergency surgery to remove them from her intestines. 

Buckyballs' manufacturer, Maxfield and Oberton, clearly states on its website that Buckyballs are not children's toys and are dangerous to children. But childhood injuries from Buckyballs persist.

The CDC has also reported injuries and deaths in children who swallowed magnets dislodged from children's toys or embedded in small toys. In one of the cases in the CDC report, the magnet-embedded toy in question sounds suspiciously like Valtech Magna-Tiles, a current favorite toy in my own household.

In most magnet-injury stories, a child swallows magnets from a toy intended for, and owned by, an older child or adult family member. Who, then, is responsible for preventing these injuries?

When I buy a present for a friend's child, I try to find something that will be safe for any younger siblings in the household to use as well. I know how easily these toys can fall into younger hands (and how sneaky the younger siblings can be when they want to play with a toy not intended for them).

No matter how safe the environment, though, a child or a teen can get into trouble pretty quickly. And we can't supervise our children every moment of every day. It's better to to talk with children early and often about what behavior is safe and what is not, and when to tell an adult about unsafe behavior that they do or see. This, ideally, will help them avoid injuries and make better choices throughout their childhood.

Friday, May 25, 2012

Hidden costs are bad for business

Since we live in an old house, I've hired a lot of contractors in my time. The first step, of course, is getting an estimate for the work; the second step (after I recover from sticker shock) is discussing what to add or drop from the estimate to meet my needs and my budget. I would never hire a contractor and say "just bill me when it's done." I need to know how much it will cost me, and the estimate needs to be correct.

Alas, this is not the model that some doctors follow. I was reminded of this recently when my daughter had a minor medical problem. I asked my pediatrician to take a look, but her office referred me to a specialist instead. At the first visit with the specialist, he wrote a prescription for a medication that cost $200 (I found out later at the pharmacy), then went on to bill us $191 (after insurance kicked in) for the visit. When I called his office requesting a cheaper medication option, he recommended using a $20 over-the-counter treatment off-label.

At the follow-up visit, the receptionist asked me whether I'd like to pay the bill for the first visit. No I would not, I said, because we had just received the bill a few days earlier and had not yet sat down to pay our bills for the month. If my ire was apparent, at least my daughter learned a valuable lesson: how to say no.

During the five-minute follow-up visit, I told the specialist that I was not comfortable using a treatment off-label, ignoring the bold warnings on the box. I stopped the treatment. He insisted that the off-label treatment he recommended was safe, then billed us another $191 for his time.

The saga ended at last when we saw my daughter's pediatrician for a yearly checkup a few weeks later. She recommended an alternative, $15 on-label over-the-counter treatment, which worked like a charm. 

Ultimately, we were out $400 - more than we budget for out-of-pocket health care costs each month -  to treat a problem that could be cured for $15. Had I known what it would cost at the outset, I would have held out for a (much cheaper) appointment with my pediatrician, or gone online to the fabulous Mayo Clinic Health Information site to diagnose and treat it myself.

Health care is a business, and we are the customers. Yet it doesn't always feel that way. The specialist never told me what the medication or the visits might cost me, or asked whether I was willing to use a treatment off-label, or asked my daughter how she felt about the treatment.

He made good money off of my family. But, like any business that doesn't put customers first, he lost any potential long-term revenue from us. We won't be back.

Friday, April 20, 2012

How safe is that health app? A Q&A with Happtique (Part II)

Today, I discuss who is responsible for keeping health apps from harming you, in Part II of my Q&A with Paul Nerger, Senior Technology Advisor for the mobile health application management company Happtique. (Part I explained who uses and develops health apps).

How are health apps regulated to ensure that they are safe and accurate (both stand-alone apps and those that connect to a medical device)?

There are guidelines that have been proposed by the Food and Drug Administration (FDA) for the approval of some apps; we estimate that this will be no more than 20% of the apps that are out there. These will be classified as Type I (non-invasive), Type II (semi-invasive), and Type III (invasive), and each has its own approval criteria. Type I is a self registration while the other categories require clinical trials to prove that they do no harm and are effective. [Information about how the FDA defines mobile medical applications is available online.]

But what about the other 80%? That is what our customers have been asking us. If there is a bogus app within this category, the Federal Trade Commission (FTC) has shown that they are willing to exercise their power to have it pulled off the market using "false advertising" as the rationale. [Mashable includes a health app in a list of app developers that the FTC prosecuted in 2011]. But this is also a very small percentage.

In response to this, we've come up with a Blue Ribbon Panel that is made up of a leading physician, a leading nurse, a leading medical technologist, and a leading patient advocate to develop a protocol for the certification of apps as being medically sound within their category. They are currently drafting the process and protocols that will be followed to do this certification. Once they are done, we will put in place a mechanism to allow developers to upload their apps for certification and to receive feedback on what they can do to improve their apps to meet the criteria. Once an app is certified, they will be granted a license to use a "trust mark" for the promotion of their apps. This mark will signal to both clinicians as well as patients that this app is safe and sound.

This is a big job but it is one that needs to be done and we are in hopes of having something out in about 4 months. 

How secure is the digital medical information collected via health apps? What security measures protect this digital medical information?

Private health information that is shared with your physician or any other healthcare provider is covered under the privacy aspects of the Healthcare Insurance Portability and Accountability Act (HIPAA). There are a number of technical requirements that an app developer must ensure if they fall within the HIPAA domain. As part of our certification process, we will examine how the app functions, and if it falls within the HIPAA privacy requirements we will assess if the app complies with those technical needs. If an app developer falls under HIPPA privacy but fails to meet the requirement, we will notify them and explain it to them.

Can you explain the process that Happtique will use to rate different health apps?

We are not going to rate apps but rather certify them. In our app stores that we make available to hospitals, clinicians, and patients, we will allow them to rate and comment on apps, but the certification process is independent of that. Thus, when we discover an app (either because it is sent to us or we find it in one of the public app stores) we will first classify it by placing it in the right categories to allow our end users to find it. They will then rate the apps based upon their experience and we will segment those rating based upon what type of audience that they make up. Finally, for those developers who want to be certified, we will make that available for a fee and they will need to provide us with access to their app.

We are doing curation right now and it is available to clinicians who sign up at our website at The ratings engine is also turned on and anyone with our catalog app running on their devices can start rating apps.

Friday, April 13, 2012

When your doctor prescribes an app: A Q&A with Happtique (Part I)

If you have a smartphone or a tablet computer, your AngryBirds app might have some new company soon: apps prescribed by your doctor to help you manage your health. Last month, I heard Paul Nerger, the Senior Technology Advisor for the mobile application management company Happtique, talk about the brave new world of health apps at a mobile health panel (hosted in part by the German American Business Association). Intrigued, I asked him to answer some questions about health apps for this blog. 

This is the first post of a two-part Q&A about health apps and how they will impact health care. This post explains who uses and develops health apps. Part II, to be posted next week, explores how health apps are regulated, certified, and rated. 


Who uses health apps for smartphones the most: health care providers or consumers/patients? Which group do you think will be driving demand for health apps in the future?


Clinicians use professional apps that make their jobs easier. That could be anything from keeping up-to-date on the latest medical journals, using a medical calculator, connecting with a colleague on advice, using the EHR system in the hospital, to looking up the bus schedule to figure out how to get from one facility to another.  

Patients use apps to make their lives better and more healthy. It could be a diet app, or asking questions about their health, or for those on the leading edge, tracking their own medical records.

The really interesting aspect is what happens in the future. In the near future, these two communities will start to interact with each other in ways that we've not seen before. Clinicians will start to "prescribe" apps to their patients and patients will like this because patients (i.e., all of us) trust their physicians and other healthcare professionals who look after us. With over 30,000+ apps available to help us manage some aspect of our health and well being, we will want help in figuring out what is good and what is bad, and our physicians and other clinicians (e.g., pharmacists, nurses, dietitians) will be in the perfect spot to help us.

But the clinicians need help also: they need to be able to discover an app that helps with our particular clinical condition, they need to be confident that the community within their particular professional association is confident that an app is clinically sound, and they need an easy mechanism to prescribe this to any given patient.

These are the problems and challenges that we've given a lot of thought to and are building at Happtique. 


What are the most popular health apps currently available?

There are two major categories of apps out there: medical and healthcare. The medical category is really for professionals. Apps such as Epocrates, Skyscape, 5MinuteConsult, Calculate by QXMD, MedPage Today and others are very popular with this community since they are needed by all clinicians. That does not mean that there are not some fantastic apps that are designed to solve a particular problem. For example, you might be a pediatric oncologist and you want an app to run on your iPad to help with informed consent--there is probably an app for that. Thus, the most popular medical apps might be the ones that fit a particular clinician's needs best.

And the same is true for the health apps. The most popular app for an MS patient will be very different than the most popular app for a type 2 diabetes patient.  

In other words, the quest for the "killer app" is the wrong way to look at it. Each of us, be we clinician or patient, will have our own basket of apps that makes our mobile phone or tablet right for us. Thus it is a world of choice and choosing the collection of apps that fit our need.

Again, this is why we at Happtique curate all of the medical and healthcare apps under the sun. It is important that we enable you and your physician to choose the right basket of apps to fit your needs.


Who develops health apps, and what is their motivation to develop an app?

I've seen apps built by physicians who want to make it easier for the patients that they treat to receive treatment. I've seen apps built by students who encounter a fellow student or teacher that they want to help make their life easier with a particular app. I've seen medical professionals working with engineers who see particular problems in the hospital that they want to solve and thus they build an app. I've seen leading clinicians who simply want to improve the outcomes of their class of patients. I've seen professional developers who see a market to serve and want to build a business.

In medical and healthcare, there are lots of developers coming from different backgrounds who are developing apps, but the common thread is a heartfelt desire to improve the quality of care, the quality of life, while lowering the cost of healthcare for patients. And this is why mHealth [mobile health] is different than other segments. mHealth deals with the stuff which our lives are made of and thus it is a noble cause regardless of the place that you come from.