“It’s awesome” says my daughter about her recently acquired communication device: the Apple iPhone, and at age 14, she is impressively tech savy. She has been showing me amazing applications such Shazam in which the iPhone “listens” to music you are playing and tells you the name of the song and the artist…amazing applications that seem simple enough once put in motion but…..simple or not, somebody has to conceptualize the application and then put it in motion. And yes we have been doing these things for eons but to have them all at your disposal easy and in the palm of your hand….Its seems that Mr. Jobs was born with this innovation genetic sequence in his DNA.

I remember a particularly critical blog opinion written about the iPhone upon initial launch by one “innovation” consulting firm professing to be experts in implementing innovation within your firm! It is questionable what their portfolio of innovation products or services consisted of. This was your basic market research firm latching on to the flavor of the day. I believe the innovation effort originates from traits inherent in an individual’s personality and thrives in certain environments and innovative people naturally gravitate to innovative industries/firms (and by extension….don’t stay long at firms that stifle free thought and progress). If you want to develop an innovative firm, recruit innovative people. It is all there in the history of their choices and accomplishments. I’m not sure if Mr. Jobs bought the services of these types of here today gone tomorrow consulting firms, but the gadgets his firm launches have encouraged other innovators to come out with revolutionary applications that threaten all sorts of engrained habits in industry especially healthcare delivery which can at times appear to be innovation inertia defined. And these new ways of executing on simple life tasks will definitely help save us all time and $$$.

Take a disease very prevalent in developed countries and growing in prevalence in Asia: diabetes. This can be a very difficult and complicated disease to treat and a very expensive disease to treat. Type 1 diabetes, due to a total lack of insulin production from the pancreas, suspected to be autoimmune in susceptible individuals, requires life long insulin administration. Type II diabetes is what your overweight grandparents have but unfortunately you don’t have to be so old to develop it. It is a consequence of poor diets (fried potatoes) and sedentary lifestyles (couch potatoes) which result in people well above their ideal weights and the resultant insulin resistance. Your pancreas makes the stuff but your cells don’t respond to the degree they should to manage your blood sugar and fats metabolism. Both versions require absolute meticulous monitoring of management (medication dosing, blood sugar, hemoglobin A1C) and attention to potentially severe complications if management is poor. Both also, in presence of other risk factors such as smoking, hypertension, family history of cardiac disease, and others are a recipe for chronic and costly investigations and interventions. The main long term complications involve nerves (diabetic neuropathy) or blood vessels (diabetic retinopathy, diabetic nephropathy, coronary artery disease disease CAD, cerebrovascular disease (TIAs and stroke), and peripheral vascular disease (diabetic foot ulcers/amputations)) and most require chronic interventions including long term pharmaceuticals, repeated specialist visits, aggressive diagnostic investigations, and surgical interventions.

The closer patients maintain normalized blood sugars over a long periods of time the less the incidence and severity of complications, the better the quality of life for the patient, the less interventions required and the less economic burden for patient, family, payor and society. Sounds like a win-win for all involved. However, this is much easier said than done. Patients easily become fatigued by the treatment protocols and compliance drift is inevitable. First, it is difficult enough to engage in lifestyle modification such as regular exercise and diet scrutiny on a sustained long term basis even if you are healthy. Once to twice a day tablets is simple enough though tedious, however, more complex patients require insulin injections which can be of several types (short, medium, and long acting) several times a day. Then, even if you do commit to lifestyle modification and you take your medications as directed, stress, infections, variations in exercise and other factors can still toss off your blood sugar control. And we haven’t begun to discuss the actual monitoring. The most common way to check glucose levels involves pricking a fingertip with a lancing device to obtain a blood sample and then using a glucose meter to measure the blood sample’s glucose level. This must be done at least twice a day and for more complex patients, before each meal and before bed. Sometimes it is even required to do the test mid way through the night. Patients are required to keep records of these levels and visit their physician every 3 months (or sooner) who will calibrate the treatment (adjust insulin types or doses or change medications). Most times monitoring records are incomplete and it is difficult for physicians to make the appropriate adjustments. Physicians then become reliant on long term indicators of sugar control such as hemoglobin A1C. It is even unclear as to how physicians can determine whether patients are taking their medications appropriately and on time.

Well, a company called UTS has attempted to make the process easier and they are utilizing Apple’s iPhone as one of the possible interface technologies.

Features from the product page:

Glucose records are colored according to their value levels. High levels of glucose are highlighted in red and marked with a red alert sign. This allows you to quickly find peak levels.

Adding a new record is simple, as no typing is required for entering a glucose level value.

In addition to blood glucose, you can also track carbohydrates, insulin and medications.

The various different types of charts will help you control all factors affecting your health. The colored background shows whether or not your glucose level is in the dangerous, normal or optimal zone. The iPhone multi-touch technology allows the chart to be easily scaled and scrolled. Also you can compare your glucose level versus your insulin injections, carbohydrates or medication intakes. All data points on charts are touchable and provide detailed hints. All charts are highly customizable.

The UTS Diabetes also provides reports that show your summarized statistics for the specified period of time.

A unique feature of the UTS Diabetes application is the ability to synchronize your data with your online account on UTSHealth.com and optionally to share your data with your doctor, support group members, or any person of your choice.

One could argue that this is simply a high tech way where you still have to input the data. Better off with pen and paper. Well, the benefit is that your pen and paper can’t tell you what song your listening to, and more importantly the ability for real time monitoring and updates is critical. Periodic wireless synchronization would be the next step where the data would be automatically entered into patient e-records and physicians could get flagged or notifications when blood sugar level thresholds are violated. Physicians can identify non-compliance immediately and attempt to deal with it. And as technologies such as continuous glucose monitoring become mainstream the ability to use technology converged in a single multifunctional device will demonstrate clear and apparent value. CGM devices produced by Abbott, DexCom, and Medtronic have been approved by the U.S. Food and Drug Administration (FDA) and are available by prescription.

Continuous glucose monitoring (CGM) systems use a tiny sensor inserted under the skin to check glucose levels in tissue fluid. The sensor stays in place for several days to a week and then must be replaced. A transmitter sends information about glucose levels via radio waves from the sensor to a pagerlike wireless monitor. These devices provide real-time measurements of glucose levels, with glucose levels displayed at 5-minute or 1-minute intervals. Users can set alarms to alert them when glucose levels are too low or too high. Special software is available for tracking and analysis of patterns and trends, and the systems can display trend graphs on the monitor screen. This monitor could easily be your iPhone and this process would remove the necessity of the patient to input data at all. And again, synchronization with your physicians e-record system would allow effective oversight and calibration of treatment which will help us achieve the win-win all are seeking.

This is not meant to be a endorsement of iPhone or the related applications and I’m sure there may be equal or better devices but it is compelling not to have a device for music, a device for pictures, a device for phone and another device for medical monitoring. The all-in-one is appealing.

This link shows another example of an incredible potential innovation from Airstrip Technologies…again for iPhone. You would really appreciate these if you have ever been on-call.

Tej Deol, M.D.

This following interesting post was contributed by Damjan Denoble of Asia Health Care Blog

What 850 billion yuan means for China’s health care industry

Eastday.com interviewed Professor Li Ling, and provided a transcript titled “The key incentive for China’s health care system is to protect people’s health, not make money”. Prof. Li Ling is a a principal author of the 850 billion yuan health reform proposal announced by China last month.

The whole interview is worth reading, and seems to be taken verbatim from Professor Li Ling. I just want to comment on a few things of note in the interview, and I will try to deduce my observations as conservatively as possible – (there will be no Chris Devonshire Ellis sized gaffes from this blogger!).

1. Prof. Ling cites the incentive structure for Chinese doctor’s as the primary challenge of health care reform.

A: Talk to me a little bit about what you think would be the most important area that money should be spent on.

L: Public hospital. Public hospital is the key area in the whole health care system, because in China, public hospital played a leading role in the deliver system, and also we know, in the health care sector, finance and insurance is only paid money. You need people to provide service for you, if the provider has the wrong incentive, people cannot get the service they need.

A: How do you go about providing the right incentive for the providers?

L: For the provider, they should have the same interest as the patient to use the minimum cost to get the best satisfaction for the patients. But right now, obviously, in our system, the incentive is distorted. So people complain, it’s hard to see the doctor, the cost is very expensive to see the doctor. Because currently, our public hospital, they need make money to keep running. So back to your question, to make the right incentive, the doctor should get what they have to be paid decent salary, a nice job, a nice social status. Then they should use the minimum cost to provide service to ensure people’s health.

It is encouraging for a Chinese decision maker of Prof. Li Ling’s profile to make such a frank assessment of counter productive practices in the health care system. To help you read between the lines, Prof. Li says, in essence, ‘today’s system is incentivized for Doctor’s to charge patients private ‘red envelope’ fees on top of official fees for care, and also to provide treatment/procedures that patients do not need, all with the end goal of making more money. We recognize there is not much that can be done about this until we pay doctor’s salaries that are in line with the complexity of work they do. ”

Right now, a lot of doctors are held back by hospital hierarchies which dictate that senior doctors recieve a high portion of red envelope payments. Therefore, most of the private clinics one does see are opened by doctors in the late stages of their careers. If we start seeing changes in doctors’ salaries and, therefore, better public perception of doctors among the Chinese public at large due to improved service, expect the number of private clinics to sky rocket as more doctors start realizing the business power of good service. More importantly, if younger doctors are able to get into the private health care game earlier due to these salary changes (more money saved earlier), China should start seeing a lot of health innovation. Old doctors depend on prestige for business. Young doctors are going to need to depend a lot more on marketing and innovative business strategies.

2.) Private health insurance and third party administration is on the government’s agenda, but creating a social safety net takes priority, and the Chinese are not willing to rush it.

L: As government spends more money in the health care sector, the patients right now pay around 50% of cost. In the long run, this will be adjusted. Maybe at the end, the patients’cost will be 20% or 30%. They would release the burden and could also release the tension between doctor and patient.

There is not much more information to go on here, but coupled with her statement that the government plans to cover 80% of the population with health insurance in the next three years , health insurers should have some indication as to when the MoH and the China Insurance Regulatory Commission are going to start thinking about how to really integrate private health insurance into China – at the fastest, in 3 years, after they figure out how to structure a system which covers 80% of 1.3 billion Chinese people.

3.) China imagines its insurance regulatory body to be like NHS systems in Australia, Canada, and the UK. China recognizes the runaway costs of a Medicare type system. For China a Medicare type system is not realistic, because if universal health coverage is to be sustainable, the costs need to be capped and contained within a definite budget. Private health providers can pretty much forget about cashing in on China government money – it looks like the MoH is ready to set the standards of care and cost. ;

A: We’ve talked a lot about problems that are in the system, is it a good idea maybe to have a third party supervising the system, the doctors, the patients, however the thing is, to put it on a daily basis?

L: Look at the worldwide health care model, the health care system that could provide universal coverage, one is social insurance, or government insurance plan like Germany, like Canada, the other one is like the national health service system, like British, they have this kind of system. I think which system China should adopt, maybe we need to look at the current situation. Currently in China the insurance coverage rate is very low, and to have the social insurance, the government insurance, I think the precondition is, we should have urbanization, industrialization, the population will have the formal job should be the majority. Otherwise, currently China, you have 20% or 30% people to cover the total population, it’s impossible. So now, no matter the CMS, the rural insurance, or the residential, city residents insurance, needs government invest a lot. For many, it’s the government buying insurance for them. But in the long run, we should say, this model is unsustainable. The cost is huge. Then the other is look at China currently, we have a huge public hospital, in terms of beds, 95% of public hospital. We have this system, so I always support we need to use our existing condition, to establish a low cost deliver system they we could provide the service to the people at the cost they can afford. That’s a kind of health security.

4.) The economic downturn is actually an incentive for health reform, because it encourages social harmony [read: social stability]. Also, if people are more secure about what happens to them when they are sick, they are liable to spend more, thus keeping the wheels of the economy moving.

A: I’ve heard some of the economics say there’s concern because of the economic slowdown the way it is, that health care could again get lost in the shuffle.

L: It could be, but maybe it’s also an opportunity, because we all know Chinese people saves a lot, one of the reasons is they don’t have security, they have to save money to ensure the future risk, like health, actually they don’t know how much they should save, they just save every penny they have. If you can provide the health security for the people, they can spend the money, and this could increase domestic demand. So, in other hand, this is the right opportunity for China’s health care reform.

Earlier in the interview Prof. Li Ling explicitly states that health reform goes a long way towards creating social harmony. And, let me just be the first to point out the irony of a social health care advocate in the country of China, praising a strong nationalized health care program for its ability to keep a capitalist economy moving. Meanwhile, in the United States there is a significant chunk of the population who cannot seem to grasp the concept of secure people spending more.

The take away message of this interview is that China is planning to take its time in implementing these 850 billion yuan health reforms. It sees health as a key aspect of national security and economic prosperity. If we are to take Prof. Li Ling’s interview as representativeve of the Chinese MoH approach to its its health reform plan, we could further conclude that Health policy officials are taking ques from health delivery models across the world and, for what its worth, don’t seem to find much of value in the American health delivery model (apart from, obviously, medical training and the standards of health delivery in America’s best practice institutions). What this means for foreign companies is hard to say, but foreign private health insurers have a lot of work to do, and foreign run health providers in China seem to be in the clear for providing pricey health care to expats for some time to come as the arrival of third party administrative organizations is still far off on the horizon.

But, the news is not all bad, as a stronger health system in china should catalyze innovation in China’s health industry and add a lot of value to the rest of the health care world.

Damjan Denoble