Unexpected findings

It's fascinating to meet people in healthcare and hear them dismiss the potential value of a tool like Twitter. Despite an increasing amount of noise, I do find it a great place to listen and learn. For me personally, it's been a very powerful tool, and has taken me to places I've never imagined. One of those places is Cedars-Sinai Medical Center in Los Angeles, California. By chance, I'd come across Dr Brennan Spiegel on Twitter earlier this year, and through our online interactions, discovered that we had common interests in Digital Health, especially in the context of understanding whether these new digital tools and services being developed are actually having an impact in healthcare.

Dr Spiegel is Director of Health Services Research at Cedars-Sinai Health System, Director of the Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), and Professor of Medicine and Public Health in Residence at UCLA. I was particularly intrigued by the work he does at CS-CORE, where he oversees a team that investigates how Digital Health technologies, including wearable biosensors, smartphone applications, and social media, can be used to strengthen the patient-doctor bond, improve outcomes, and save money. So whilst I was out in California, I popped into Cedars-Sinai Medical Center to spend some time with him and his team to understand their journey so far in Digital Health.

With Dr Spiegel and the CS-CORE team - the picture was taken remotely using Dr Spiegel's Apple watch! 

With Dr Spiegel and the CS-CORE team - the picture was taken remotely using Dr Spiegel's Apple watch! 

To give you some context, Cedars-Sinai Medical Center is a non-profit, has 958 beds, over 2,000 doctors and 10,000 employees. It's also ranked among the top 15 hospitals in the United States, and is ranked first in Los Angeles by US News and World report. In addition to Dr Spiegel, I met with Dr Christopher Almario, Garth Fuller, and Bibiana Martinez

What follows is a summary of the Q&A that took place during my visit. 

1. What is the big vision for your team?
"The big vision is value of care. Value is our true north. It puts patients first while also reminding us to be judicious about the healthcare resources we use. Take Cedars-Sinai, a traditional volume based center of excellence. How do we transform our hospital, that has excelled in the fee-for-service healthcare environment for so long, and transform it into a value-based innovation center while maintain our top-notch quality of care? It seems like a magic trick to transform from volume to value in healthcare. How do we do it at scale, and how do we keep people out of hospitals when healthcare systems have  been designed to take people in? Our mission is to figure out how to do that. This could be a blueprint for how other health systems could do this and which doctors could do this. How do we align incentives? How do we create a Digital Health strategy that works within the existing clinical workflow? How might we use an E-coordination hub? These are all open questions ready for rigorous research. 

What does innovation mean at Cedars-Sinai? We see ourselves as a hub of innovation and are now developing a new 'Value Collaboratory' under the guidance of our visionary leader, Scott Weingarten, who directs Clinical Transformation at Cedars-Sinai. We offer a set of tools to help value-based innovators make a difference. We're going to be doing a lot over the next 5 years. Digital Health is just one small part of that. The Value Collaboratory will be the centre for ideas within Cedars. For example, if innovators seek internal funding for a project, then they can work with the collaboratory to refine their idea, evaluate its health economic potential, and create a formal case for its support."

2. Tell me more about the team, what types of people work in CS-CORE
"There are 12 of us in CS-CORE, and we have a combination of health system and statistical expertise. We have social scientists, behavioural scientists, mobile health experts and more. It's a multi-disciplinary team. For example, Dr Almario is a gastroenterologist, who has always been interested in health services research, and was awarded a career development award from the American College of Gastroenterology, which is very rare, in Digital Health to pursue research. Garth Fuller with a background in health policy and management has been working with us for the last 5 years and has a strong interest in medication adherence, and conducts research to understand how we can show that 'Beyond the Pill' strategies in the pharma industry are working. Bibiana Martinez with her background in Public Health is hands on, and works with our patients. Bibiana helps filter the real world barriers faced in Digital Health research and bring them back to our team. We have an all-hands-on-deck research crew."

3. What has surprised you during your research in Digital Health?
"We've had some unexpected findings. For example, we had a patient who reported less pain, and our original expectation was that the data from her wearable would report that she had been walking more, as the pain was subsiding. However, that wasn't the case, as her pain decreased, she was walking less. It turns out the patient was an author, and being free of pain meant she could sit for hours on end and finish writing her book. Completing the book was the outcome that mattered to the patient. What should we do when a patient's steps fall from 1,500 a day to almost 0? Do we give them a call, simply because we perceive it as unhealthy? How often does your doctor ask you what your goal is for your visit? I show these charts of pain vs steps when I teach my health analytics class at UCLA, to challenge how my students think."

4. How else have your assumptions about how patients use Digital Health tools been challenged?
"In healthcare, we often make a lot of assumptions about the needs and wants of patients. We have been fitting Virtual Reality goggles with hospital patients, so that we can transport them from their hospital bed to far away places such as Iceland. One patient asked if we could transport him somewhere more tropical, as the hospital is cold, and having a VR experience in Iceland made him feel even colder. 

We had an instance where a patient wasn't able to charge her Fitbit. We tried to explain over the phone, but it actually required a house visit in order for this patient to understand how to charge the device. We thought we could put sensors around the ankle joint of patients to measure steps, and some patients felt like they were under house arrest when wearing our sensor on their ankle."

5. What are some of the most exciting projects you're working on today?
"Well, we create our own technologies and sensors. We find out soon if our first sensor is approved by the FDA. Also, with the vision of our hospital Enteprise Information Services (EIS) team, our hospital's EHR is now connected to Apple's HealthKit, it's a great achievement, we now have 750 people pouring in real-time sensor data into our EPIC Electronic Health Record. We've also developed My GI Health, a patient provider portal which by gathering information on symptoms in advance of a visit to the doctor, helps us learn more about a patient's GI symptoms. The computer doesn't forget to ask questions, but sometimes the doctor forgets to ask questions. Although much of our research is in GI, we are working across healthcare. We are now building a version of My GI Health for rheumatology, for example. We are also interested in testing whether the first visit to a specialist doctor should be virtual or in person? What would patients & doctors actually want? We are putting a study design together now that will compare both types of visits."

6. What are some of the challenges you face in your research?
"The research we do is often challenging for the IRB because it’s so different.  We work closely with our IRB to explain the nature of our work. As more academic groups conduct Digital Health research, it will be important that medical centers develop regulatory expertise around this type of work.

There is also an urgency to test quickly, fail quickly and succeed quickly. What we need is a high level discussion to understand what risk means in the context of Digital Health research. Can we generate evidence faster?"

7. What are you doing to help ensure that no patient gets left behind in Digital Health?
"We are soon going to start a community-based study in partnership with African American churches in Los Angeles. We will work with these 'mega churches,' which have up to 10,000 congregants, and will distribute healthy living experiences delivered by Virtual Reality goggles using Google Cardboard.  We will also use an app for obesity and diabetes management. We observe that many families from minority backgrounds are mobile first, and we see that the next digital divide is opening up over mobile. Healthcare isn't built for mobile. We are also researching the mobile usability of hospital websites across America."

8. What message would you like to share with others also on the same journey as you?
"Listen to the patients, get used to Digital Health being dirty and difficult, it may be harder than you think. We can say that with some authority now, that it can sound easy, but in reality it's been very hard. Our team has developed devices and applied them directly to patients; what happens next is often unexpected and challenges our assumptions. Digital Health is really hard to do. We have to focus on the how of Digital Health. We understand why it's valuable, but not as much about how we will be doing it. Value is another big theme - we need to improve outcomes and reduce costs of care. It takes time to do it right. We also try to never forget the end user, both the physician and the patient. 

This work is 90% perspiration, and 10% inspiration. You need to have a sense of humor to do this because, you’re going to get a lot of unexpected bumps and failures. It’s a team sport to figure it out. Defining the problem in terms of the health outcomes and costs is the key, and generating a solution that has value to patient and providers is paramount.. 

Finally, the 'cool test' is so seductive. Don’t been fooled by the 'cool test' in Digital Health. What may be cool to us may not be cool to the patient. Don’t be seduced by the 'cool test' in healthcare."

I really enjoyed my time with Dr Spiegel and his team, not only because of the types of research they are doing, but also because of their vision, values and valor. Their unexpected findings after putting new devices on patients has subsequently made me think at length about health outcomes. I was reminded about the human factors in healthcare, and that both patients and doctors don't always do what we expect them to do. I'm glad CS-CORE are not just thinking from the perspective of medicine, but through the lens of public health too, and how to ensure that no patient is left behind. I'm not the only one who is admires their work. David Shaywitz, has recently written a post about the research conducted by CS-CORE, and mentions, "they are the early adopters, the folks actually in the arena, figuring out how to use the new technology to improve the lives of patients." 

Dr Spiegel did admit they've been under the radar so far, focusing on putting “one foot in front of the other” in research mode while working with a wide variety of partners from industry and academia. The team is also looking for collaborators who want to road test their digital health solutions in a “real world” laboratory of a large health system. Their team is equipped to conduct stem-to-stern evaluations with an eye to rigorous research and peer-reviewed publications. I see that Dr Spiegel is one of the speakers at the Connected Health Symposium later this week, as part of a panel discussion on Measuring Digital Health Impact & Outcomes. I won't be there but I hope to be part of the live Twitter discussion. 

Since my visit, I note that Cedars-Sinai and Techstars have partnered to launch a Digital Health focused accelerator. What does this accelerator aim to do? The website states, "We are looking for companies transforming health and healthcare.  Companies that are creating hardware, software, devices and/or services that empower the patient or healthcare professional to better track, manage, and improve health and healthcare delivery are eligible to apply." Techstars is one of the world's most highly rated startup accelerator programs, the other being Y Combinator. It's fascinating to see the marriage of two very different worlds, and who knows what unexpected findings will result from this partnership. In the 21st century, when we think of radically different models of care, startups and emerging technologies, large traditional hospital systems are not the first place we think of looking for them. Maybe the lesson here for large healthcare institutions is to "disrupt or be disrupted?"

In the world of Digital Health, the trend of moving healthcare out of the hospital into the home, virtual visits and telemedicine may be causing concern to hospital executives. If all of these converging technologies (often coming from startups) really are effective and become widely adopted, then surely we will need smaller hospitals, or perhaps in certain scenarios, we may one day not need to have that many hospitals at all? Perhaps the hospitals that survive and thrive in the 21st century will be the ones that boldly explore the unknown in Digital Health, rather than the ones that hide and hope that the world of Digital Health will just be a passing fad? 

“It is the tension between creativity and skepticism that has produced the stunning and unexpected findings of science.” - Carl Sagan

[Disclosure: I have no commercial ties to any of the individuals or organizations mentioned in this post]

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Day 3 - Health 2.0 Silicon Valley

Yesterday was Day 3, the final day of Health 2.0 Silicon Valley. Another day packed with demos, networking and cutting edge insights.  

The highlights of Day 3 for me were seeing the winner of the XPRIZE Nokia Sensing Challenge announced, the session on Clinical Trials and Research, Health 2.0 International session and the session on the Frontier of Health 2.0.  

Mark Winter, Senior Director, Nokia Sensing XCHALLENGE came on stage and told us more about the competition, including how it was judged. 

The winner, Nanobiosym Health RADAR was also announced at the conference by Mark Winter. It must have been a difficult choice. The video below includes the announcement as well as hearing Anita Goel from the winning team speak about their journey.  

Peter Diamandis, CEO of XPRIZE came on stage, and he believes that in the future, patients will be saying, "Don't let that human touch me, he makes mistakes". The rise of machines, I guess.  

Mark Winter announces the winner of the Nokia Sensing XCHALLENGE live at Health 2.0 Silicon Valley

Front page of Wall Street Journal - Oct 2nd 2013

Front page of Wall Street Journal - Oct 2nd 2013

The session on Tools and Platforms for Clinical Trials and Research was very good. Bill Silberg moderated the session, which included Harris Lygidakis, Roni Zeiger, Anna McColister-Slipp and Joseph Dustin. Demos from the panel members highlighting how their tools could impact clinical trials. Very timely, as yesterday's Wall Street Journal had a headline on how Merck is cutting 20% of it's workforce in the next 2 years. Having worked within GSK R&D until 2012, I've always believed that there are immense opportunities for startups to help pharma deliver the medicines that patients are waiting for. However, many people in pharmaceutical companies are terrified of even using the word 'Disruptive' in the same sentence as 'Innovation'.  

In the afternoon, in the international session, we heard from Poonacha Machaiah at Qyuki talking about The Weightloss Project. What a brilliant idea! People who are overweight and lose weight can help those in the world who are malnourished and don't have enough to eat. 

Poonacha Machaiah from Qyuki talking about The Weightloss Project

James Mathews, Chairman of Health 2.0 India posed the question - how do we bring Health 2.0 to Southern Sudan or to Syrian refugees? I'm glad he was challenging us to think of those around the world who are underserved. I remember a phrase he repeated multiple times, "Use simple tools to do great things". 

Southern Sudan

Southern Sudan

A Syrian refugee

A Syrian refugee

In Frontier of Health 2.0, moderated by David Ewing Duncan, I loved hearing from Pasquale Fedele who showed us BrainControl, a device that gives people the ability to control assistive technologies with their thoughts using a headset and a tablet.  

Pasquale Fedele, Founder & CEO of Liquidweb talking about BrainControl

Also heard from Louise-Philippe Morency, who shared his work with 'Ellie', a virtual interviewer specialising in facial recognition. Virtual humans in healthcare coming soon!   

Demo of 'Ellie' with Louise-Philippe Morency

Life isn't perfect, and neither are Health 2.0 conferences. Nearly all conferences I go to are packed with sessions, workshops, demos and exhibit halls. It's a challenge to try and fit everything in each day, as well as the all important networking with potential clients and collaborators. It's a personal choice, but if one wants to spend time meeting people at the conference, it can sometimes mean having to skip a session or two. Alternatively, some folks do their networking late into the night over a few beers or glasses of wine. Difficult choices, especially if one is jet lagged. Small things like having the Twitter handles of each speaker listed in the printed program would have made my life a lot easier. The wifi was hit and miss for me, I had problems connecting every day. It wasn't the fault of Health 2.0, I believe there were some attendees grabbing all the bandwidth. Whilst the venue had great facilities, the actual location was sort of like a big business park. Nothing to do or see if you wanted to stretch your legs and have a wander around. By and large, the conference was one of the better managed events I attend. A big thanks to all of the volunteers who were stationed around the convention centre all day and helping us get to the right room at the right time. 


This must have been one of the healthiest conferences I attended. According to my Misfits Shine activity tracker, I walked 2.8 miles during Day 3 of the conference. The layout of the hotel and convention centre meant a lot of walking! Coming from a walking city like London, it didn't bother me, but I could see that amount of walking bothered some American attendees.  

Why have I attended Health 2.0 conferences in the USA, Dubai, Berlin and Delhi? Why did I start the Health 2.0 Chapter in London? There is something unique in the vibe, that Matthew Holt and Indu Subaiya bring to each conference. Especially as they are far more down to earth and friendly than a lot of conference organisers I've met. That translates into an enjoyable experience for attendees! At other Health tech events, I've found sometimes, other attendees won't speak with you unless you are from a well known corporation or Venture Capital firm. 

I personally prefer the Health 2.0 Europe conference to the one in California. Why? Smaller group and I like smaller groups. As conferences become more popular they grow, it's inevitable. I prefer the 'intimacy' of conversations in a smaller group. When I run my Chapter meetings in London, I limit each event to 40 attendees, which means we aren't overwhelmed by having to meet 150 people during an evening. For me, it's about bringing diverse groups of people together and building a community that makes amazing stuff happen. 


Health 2.0 Europe was in Berlin last year, but this year, it's in my city, London. I'm grateful to have been given the chance to run a pre-conference workshop on Nov 17th on 'Health 2.0 Tools for the Elderly'. The increase in the aging population, and the burden on society as a result is one of the biggest crises in Global Health, the world faces in the next 50 years, and I sincerely believe we need to act NOW! If you are interested in demoing at my workshop and/or want to discounted entry into the entire conference, please get in touch. I'll do my best to help you. 




[Disclosure: I have no commercial ties with any of the companies mentioned above, apart from Health 2.0, which from time to time uses me as a consultant]