DrBonnie360

Is there a “Platform gap” in Healthcare? A Stanford Medicine X Panel

How will healthcare data business models evolve around new “Platforms”?

 by Bonnie Feldman, Ellen M. Martin

image

Personal data is changing the way we work, live and play.  As consumers, we expect to receive personalized recommendations in a variety of areas, from shopping at Amazon, music from Spotify or movies from Netflix. 

I have been wondering how this type of data personalization can change healthcare, especially in the arena of chronic disease management. 

Some early initiatives include some simple data mashups:

In creating a panel for Stanford Medicine X,  I have been thinking about how long it will take these data mashups to become richer by including genomic, microbiomic, metabolomic and other -omic data. At the same time, I have been thinking about what business models are evolving with the growth of personal health data.  

Will new platforms bring different business models to healthcare?

A moment to define terms before we return to health data:

“Briefly put, a Platform is a business model concept, an O(perating) S(ystem) is a technology concept and an Ecosystem is a marketing concept.”

The concept of a multisided platform, which can be a service, technology or product that facilitates direct interaction between two or more parties as  seen in Airbnb, eBay, Etsy and others. 

Recent news about open API platforms for healthcare from Google FitApple Healthkit, and Samsung’s Sami  points to a growing number of giant platform companies seeking to enter the healthcare data ecosystem.  

In addition, Amazon’s recent meeting with the FDA may point to interest from another platform giant, while Apple’s discussions with Mount Sinai, the Cleveland Clinic, John’s Hopkins and Allscripts may indicate aspirations beyond consumer data.

Earlier platform entrants into the healthcare ecosystem are forming alliances to use consumer and clinical data in new ways such as:

In addition to new and expanding entrants, existing platforms from the healthcare side include:

On the other hand, Aetna closing Carepass represents an unexpected exit by a large healthcare payer/provider that was considered a segment leader.

Will the evolution of platforms outside of healthcare provide a template? 

Looking outside of healthcare may give us some pertinent insights on how IT platforms and associated business models, using open and closed data systems with a data monetization approach, have evolved. 

Outside of healthcare, open, closed and hybrid platforms, along with iterating business models, appears as a theme, evidenced by the robust merger and acquisition activity pictured below. 

Closed Platforms

Apple is probably the oldest successful closed IT ecosystem. It created a new paradigm—consumer IT—at a time when all IT was corporate.

By establishing the first consumer technology platform through its killer product, the iPod, users could live entirely in an iPlatform ecosystem of Apple products, all using a single operating system-the iOS- for desktop, tablet, mobile and music.  Apple was also the first platform company to use APIs to attract a large developer community to write applications for products in their ecosystem pictured below.

image

Open Platforms

Google appears to be multiple platform companies. First in search, later in advertising, then Gmail, and most recently, through Android, an open OS platform in competition with Microsoft and Apple. In mobile,  Android competes with Apple. In search, browser  and mobile, Google competes with Microsoft. In social media, Google+ competes with LinkedIn and Facebook.

image

Hybrid Platforms

Amazon started as an online bookseller and developed its own infrastructure to facilitate ecommerce—a platform suitable for any keywordable product, not just books—and so Amazon expanded into selling everything.  Subsequently it developed an ecommerce infrastructure-as-a-service called Amazon Web Services.  Originally developed by and for Amazon, it now generates $2B in revenues with an estimated $10B in 2016 as the backbone for digital-cloud conveniences such as dropbox. 

How will data business models evolve around these new platforms in healthcare?

Rapidly evolving business models are shown by the very active merger and acquisition activity pictured below as well as the current investor filings.

Google receives most of its revenue from online advertising.  Insight into their future plans can be seen on page 28 of the 10K  “We expect that our revenue growth rate will continue to be affected by evolving consumer preferences, as well as by advertising trends, the acceptance by users of our products and services as they are delivered on diverse devices, and our ability to create a seamless experience for both users and advertisers in this multi-screen environment.” 

Apple’s future plans reflect continued investment in R & D.  “Company continues to believe that focused investments in R&D are critical to its future growth and competitive position in the marketplace and are directly related to timely development of new and enhanced products that are central to the Company’s core business strategy. As such, the Company expects to make further investments in R&D to remain competitive.” 

image

What type of data monetization strategy will evolve in these new platforms?

Conceptually, data monetization is of the essence for platform business models.  Because the data monetization concept is relatively new, even the ways to describe the evolving business models are evolving.

Three different ways to parse data value include:

1.  Accenture analyzes the value of data ranging from raw, processed, insights, presentation to transactions.

2. O’Reilly’s Book-“Business Models for the Data Economyprovides a framework to segment monetization strategies as follows: 

  • Collect
  • Store/Host
  • Filter/Refine
  • Enhance/Enrich
  • Simplify/Access
  • Obscure

3. University of Cambridge has created a data-driven business model framework shown below.

Key activities include data aggregation, analytics and generation.  Key data sources could be free, customer-provided or tracked and generated.

These business models range from “multi-source mash up and analysis” to “data aggregation-as-a-service,” “data generation and analysis,” “analytics-as-a-service” or a  “free data collector and aggregator.”

image

More open questions for the panel “Open versus Closed Data- Where are the business models?”

In addition to the different types of data monetization strategies, another open question is will healthcare data platforms be narrow, broad or both?

Where will the medical device industry play?  How will hardware and software ecosystems evolve? 

The panelists, Chris Hogg of Propeller Health, Jonathan Hirsch of Syapse, and Jason Oberfest of Mango Health, will address some of these  questions with a focus on chronic disease management.  

See the next post to learn what the panel discussed.

Research Initiatives Around the Microbiome

image

What does a “healthy” microbiome look like? Who is part of a microbiome? How can we quantify and analyze our microbiome?

The Human Microbiome Project (HMP), a $173 million project by the NIH, was initiated to address these questions. It focuses on a comprehensive characterization of the human microbiome and the development of computational tools for the analysis of microbiome data. In 2012, NIH announced the first referenced data of a normal bacterial makeup in healthy individuals. Tissue samples from different body sites of 242 people were collected and sequenced to understand the structure and diversity of the healthy human microbiome. Scientists found that the microbiome contains 360 times more microbial genes than human genes that are involved in vital metabolic functions like digestion or the production of anti-inflammatories. Read the original article published in Nature to find out more.

The American Gut project follows another approach. Rather than carefully selecting test subjects, the founders wanted to involve the national and international public. So far, several thousand people have followed their call. If interested, you can still join the American Gut project!

Earlier this month, American Gut published preliminary results for more than 3,000 participants which described microbial composition and factors that affected the gut habitat, such as age and diet.

Individual Findings- Lone Fighters

Large studies are not necessary to contribute to the understanding of our microflora. Larry Smarr gathered information from blood and stool samples that showed early signs of the disease process, years before the first detectable symptoms of his late onset Crohn’s disease.

In another self experiment, Jeff Leach, founder of the Human Food Project and collaborator of American Gut, studies the effects of various dietary patterns on his gut microbiota.

And lots of unanswered questions

The research on the human microbiome is just getting started. Although important steps have been made towards defining the human microbiome and its role in diseases, many questions remain to be answered. Are associations with health and disease causal? How can this newly generated knowledge contribute to the development of interventions? In which diseases does the microbiome play a causal role?

Group Findings

A few years earlier, in 2012, an NIH press release announced the definition of a normal bacterial makeup in healthy individuals. This provides a much needed reference in order to study the role of the microbiome in diseases. This research article by Bäckhed et al.  elaborates on how understanding the properties of healthy microbiota could contribute to the development of interventions. The results of HMP have implications for other research fields such as epidemiology, as described by Foxman and Rosenthal.

Although science has provided important insights into the role of the microbiome in some diseases, it is still unclear whether these relationships are causal. 

Next time you look at a fellow human, pretend to be Neo from The Matrix, only try to see the trillion cells and around 23,000 genes that make up his or her body. Then, take a second look and try to imagine that the microbes within his or her body outnumber the human cells by a factor of 10.

Stay with us to find out in the next post, how scientists deal with this vast amount of information that would blow even Neo’s mind.

What questions would you like to learn more about next?

 

The Human Microbiome: An Invisible Spouse in Sickness and in Health

image

The second we are born, each of us enters a unique relationship that is going to last a lifetime. Who’s the lucky one, you ask? About 100 trillion microbes that dwell everywhere on and inside our body: the skin, the mouth, the gut. Click on the individual words in this Scientific American interactive map to explore who lives within us.

Your enemies are my enemies: The Economist describes the symbiotic relationship between us and our microbes; while we offer them shelter and raw materials, they provide nutritional services and synthesis of vitamins, as well as protection from interlopers. They also educate our immune system to discriminate between thousands of harmless species and pathogens.

Unfortunately, as in most marriages, times are not always as harmonious as we would like them to be. Disbalances in our microbiome have a striking effect on the body and have been associated with a wide variety of diseases: metabolic conditions, such as type 2 diabetes and obesity; heart disease;  asthma and eczema; and even autoimmune disorders like inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), and rheumatoid arthritis.

A New York Times article explores the complexity of the human microbiome and efforts to restore order to the microbial system.

The human microbiome is unique in every person and varies from day to day. Eric Alm from MIT tracked his gut microbiome for a whole year and noticed that no day is the same in the microbial universe (see his  2012 GET Conference talk). He did so by collecting and measuring stool samples every single day. Read another New York Times article to find out about new surveys that help scientists measure and understand the microbiome.

This slideshow by David A. Relman (Stanford University) views our invisible spouse as a complex ecosystem and addresses important characteristics: diversity, stability, and resilience.

Watch this video by NPR to get an overview of the functions of the microbiome. 

In our next few posts, we will be learning more about how we interact with our microbiome.  What specific topics would you like to learn about?

The Celiac Disease Foundation: Raising Awareness and Promoting Research

Elaine Monarch suffered from a mysterious illness for most of her adult life.  It was only in her 50s that she received an accurate diagnosis: celiac disease (CD).  CD is an autoimmune disease that causes damage to the small intestine when a person eats gluten, a protein found in common grains like wheat.  Ten years ago, the medical community thought that CD was a rare disorder that affected only 1 in every 10,000 people: primarily children who had digestive problems and failure to thrive.  Now, it is thought that celiac disease currently affects at least 1 in 100 people worldwide (a four-fold rise in prevalence from the 1950s).  Despite the rising incidence, only 1 in 6 people with the disease gets correctly diagnosed.  

Celiac Disease Foundation - Faces of Celiac.jpg

Elaine knew that she wasn’t the only one who’d faced the challenges of undiagnosed CD.  Even armed with her diagnosis, she couldn’t find a physician who took her seriously: the disease was not yet widely acknowledged as real.  These frustrations led her to start the Celiac Disease Foundation (CDF), in 1990.

Since then, CDF has made substantial progress in raising awareness among the general public, the medical community, and the food industry.  

  • CDF organized a march on the FDA, CDC, and NIH, in order to win recognition of celiac disease as a legitimate illness in need of funding and research.  After fighting for ten years, CDF succeeded in pressuring the FDA to create rules for gluten-free labels on food.

  • A gluten-free diet used to mean forgoing common staples like bread, and driving long distances to over-pay at speciality and health food stores.  The CDF worked with large food companies such as General Mills and Frito-Lay to initiate gluten-free versions of their popular items.  

CDF is also heavily invested in education for both patients and doctors on both celiac disease and non-celiac gluten sensitivity.  Their website offers an informational quiz used by 10,000 people each month.  If a person’s symptoms resemble celiac disease, the website can help find a local practitioner who can conduct a formal screening and diagnosis, which may include blood work and an endoscopy.

Since many physicians and the general public remain unaware of celiac disease and non-celiac gluten sensitivity, CDF conducts physician grand rounds, sends speakers to conferences and delivers outreach to the public with a simple message: “Consider Celiac, Request The Test.”  

To complement their educational work, CDF emphasizes advocacy and has a strong voice in influencing policy.  They hope that an upcoming 2015 policy summit will lead to a nationwide platform for screening and diagnosis of CD in America.  Marilyn Geller, CEO of the CDF, describes the crucial importance of diagnosis:

“A lot of physicians will hear patients describe celiac-like symptoms and tell them to go gluten free without giving a referral for a diagnosis.  That’s a problem, since celiac disease is such a gateway disorder for other autoimmune problems.  If you don’t have a firm  diagnosis and the medical required need for the gluten-free diet, it’s too easy to cheat  and do lasting damage to your digestive system.  And with no diagnosis, there’s no follow-up. Nobody is checking to see how you’re doing on your diet, testing for your vitamin levels, bone density - all those things that need to happen.  The gluten free diet is not the panacea for everything that affects a person.”

As Marilyn mentioned, there is growing evidence that celiac disease does increase the likelihood of developing other autoimmune disorders.  The CDF is working to promote awareness of celiac disease and non-celiac gluten sensitivity to help people get diagnosed and bring their disease under control.  I wonder whether their efforts will help to slow the rising tide of autoimmunity as a whole.

For further information consult the following sources:

More details about the gluten-free diet, written by physicians: