I’m probably going to go a bit over my head here in exploring whether hospitals or health systems can really securely deploy iPads (or any mobile Apple devices) as enterprise devices. This is obviously relevant. I’ve heard from multiple vendors that providers are asking about iPad versions of web applications.

I’ve also read about mobile device management (MDM) several times in the last several weeks, first with the new Voalte-MDM partnership and second with the recent VA RFI. And just this week, I’ve had several discussions about the challenges of actually deploying tablets — specifically iPads — as enterprise devices.

I like my iPad. It’s a great tool for clinicians for both data access and order entry. I’m not as concerned as most in healthcare about security. I’ve seen such blatant HIPAA security violations that I can’t imagine that having access to PHI or other sensitive information over mobile — as long as the mobile device isn’t storing the data locally — would make it any worse.

Maybe the reasons I’ve seen so many violations are that I know a lot of medical students and residents. I’m not really sure though as I’ve seen other violations from academic and community docs, especially in the spirit of research. Some examples include leaving paper medical records in public or semi-public places (including on printers at libraries), e-mailing charts or reports over Gmail (university e-mail is just not user friendly) to provider friends and family to fax or scan, and text messaging patient information (this seems like a daily thing.)

These things happen all the time, at least in my experience, so I come to the HIPAA discussion with low expectations. Maybe some providers are more cognizant than others, but I think most just do what needs to be done to get their work done. If a provider needs to reach a colleague and ask a question involving PHI, SMS might be the easiest process and that’s likely what will be used, despite the insecurity of SMS.

With that in mind, I went out to see what options existed for securing an iPad. Little did I know (and maybe I should have) that the Apple Push Notification Service supports third-party MDM services. The way it works (shown below), is that MDM vendors can use Apple Push to poll and modify managed devices at any time.

The Apple Push Service supports several key restrictions on devices (the full list is more extensive than this) with its messaging:

• Installing/Removing apps
• In-app purchases
• Safari/iTunes/YouTube access
• Passcode requirements
• Account setup (Wifi, email. VPN, etc)
• Device info (network, MAC, UDID, build version, etc)
• Remote Lock
• Remote Wipe
• Clear Passcode

To do any of this with an iPad or an iPhone, you’ll need more than Apple Push, because that’s only the connectivity component. You’ll need an MDM server, which is exactly what the VA is looking for with its RFI. The VA is looking for an MDM solution that can support up to 100,000 devices running across all of its facilities. This will be a national solution. The RFI does not specify a mobile platform, instead stating it will test Windows, Android, and the iPad.

The only MDM vendors that I’ve heard of are Good Technology and AirWatch, the vendor that recently partnered with Voalte. These device management solutions support all of the configuration options that Apple supports and make it easy to manage lots of mobile devices across an enterprise regardless of mobile operating system.

The next big question is whether a health system would support a bring-your-own-device (BYOD) strategy. I know providers would love it and both AirWatch and Good Technology support it by providing specific security around certain apps. I’m not sure the app restrictions on a provider-owned device are adequate for a health device. Well, I think they are enough, but I’m not liable if something happens, so I’m not sure I’d have the same opinion if I was potentially personally liable.

Are iPads really secure using an MDM server with Apple’s Push Notification Service? Compared to the way I see security now, I’d say yes, but I’m sure some CTOs and technology folks would disagree. The issues with security are and will always be human issues. Providing access to sensitive data over mobile won’t change that.

What is the VA and other systems likely to do, at least if you assume mobile is coming? I’d be very curious to hear what CIOs have to say to that. I know John Halamka, MD, is a big fan of mobile and has written on how to deploy mobile in a health system. He was also featured at a recent Apple event, if I recall correctly.

My bet is that systems like the VA will end up purchasing a certain number of tablets for employed physicians, which is a growing percentage of physicians, and provide limited support for affiliated physician groups.

But this is only related to health systems. Independent community docs will be using their own iPads and iPhones with Practice Fusion and drchrono and others, likely without any major security platform installed.

Travis Good is an MD/MBA involved with health IT startups.

Gary and Mary West, founders of the West Wireless Health Institute, form an investment fund seeded with $100 million. It seeks early stage companies with the potential to lower healthcare costs. The initial portfolio includes six companies that offer a wide range of healthcare services. All profits (returns) from investments will go into medical research. Very cool.

The VA just put out an RFI seeking a national mobile device management (MDM) system to support its mobile device strategy. Some stories are reporting that the VA is buying 100,000 tablets, but the RFI is only looking for an MDM to support “up to” 100,000 tablets. Considering the statements made by the VA in the past, my bet would be that it is planning on supporting staff-owned devices in addition to VA-owned devices. The RFI also states that the MDM vendor has to deliver only 60 tablets during each year of performance: 20 that are Windows-based, 20 Android-based, and 20 iPads.

Clinical communications vendor EXTENSION announces integration with Polycom handsets. The new service connects Polycom handsets to EXTENSION messaging, allowing the legacy handsets to communicate with EXTENSION-enabled smart phones.

Mobile provider GreatCall announces the 5Star Responder Device. The device provides push-button access to "Certified Response Agents" or 911. In the case of an emergency, the service can also be used to communicate with first responders to provide them with information about the users location, profile, meds, or medical history. The cost is $50 for the device, a $35 activation fee, and $15 per month. As long as people remember to carry it, I could see this bringing peace of mind to adult children of elderly parents.

Just in case GreatCall users forget their responders, they can always be tracked by GPS-enabled shoes from GTX Corp. The shoes are being marketed specifically for Alzheimer’s patients. As odd as it sounds, I think this would be great for families. I know my family would have loved it for my grandfather, who had Alzheimer’s and would wander off. I feel as though somebody should apologize for the video above, so I’ll say I’m sorry. I think GTX needs to raise some marketing money.

A new report by Manhattan Research finds that 26% of consumers used mobile phones to access health information in the last 12 months. This number includes consuming health-related news, so I wouldn’t put much stock in it. The press release also mentions that 8% of the population used phones for med refills or reminders, which seems sky high to me. They must be including people using mobile phones to call pharmacies, which is more indicative of a mobile phone trend than a mobile health health trend.

Washington Hospital Center (DC) and AT&T jointly develop a platform called CodeBlue to connect teams of providers around critical care patients. It works over Web and mobile, enabling providers to see patient data and video even if in transit to the hospital. It could be helpful in preparing facilities for fast-track patients who need to go straight to the cardiac cath lab, for example.

Numera launches an iOS version of its Numera Net Gateway. The new app allows users to automatically upload biometric data from Numera device partners via iOS-connected device. It’s being tested with hypertensive patients.

A CSC report provides guidance for how healthcare organizations should develop social media policies. Most of the report is dry and not of much use, at least from my perspective, but the table of current healthcare social media examples is good.

PharmaSecure closes a round of fund raising worth $3.9 million. Its product prints unique codes on medications packages that can then be verified over SMS by consumers. The service is designed for developing countries, where counterfeit medications are such a significant problem. PharmaSecure has been able to secure relationships with major drug makers across India that will allow it to protect over 1.5 billion med packages over the next year. Additional services to drug makers, like real-time market intelligence and direct connections to consumers (a bit scary) are also part of the package.

For those with an interest in global mobile health, Popular Mechanics has a good profile on it and of Josh Nesbit of Medic Mobile, who has become a leading voice on the subject. The best quote is in relation to mHealth hype vs. reality, in which Nesbit says, "All the media coverage and promises made about mobile health in recent years make it seem as if millions of health workers in developing nations have already integrated their phones into their daily practice. In reality, only about 20,000 have done so." I have been shocked to hear from people on the ground in Africa about the lack of current use of mobile technology in healthcare, despite what we hear in the news.

More on global health, this time from speakers at the recent Connected Health Symposium. Speakers called developing countries a "blank slate" because telehealth systems don’t need to integrate or interoperate with existing systems (because they don’t exist.) Despite that advantage, the lack of financial resources and health infrastructure to address acute issues identified using telehealth present unique challenges for those working in developing countries.

Travis Good is an MD/MBA involved with health IT startups.

Consumers, inclusive of patients, are a big target of health reform. Patients are supposed to play a bigger role in their own care, have ready access to more of their clinical data, and even be called on to participate in the leadership of ACOs.

I  think we’ve collectively come to realize that healthcare isn’t the answer to all of our health problems, at least in the traditional sense. Individuals make multiple decisions every day that play into their overall health and wellness, decisions that have nothing to do with what medication a doc prescribed and whether a patient received an x (FILL IN WITH AN EVIDENCE-BASED PROCEDURE).

With that in mind, many new startups and some established companies are creating mobile and online tools targeting consumers. Although all of the tools I outline below are meant for use by consumers, the business model of each is very different. As I’ve written before, one of the challenges in healthcare is finding the right combination of user and customer.

Payer is Provider – ZocDoc

ZocDoc is getting a lot of press lately. It helps consumers find open appointment slots for doctors. Doctors list their available slots and ZocDoc fills them (presumably increasing utilization) for a provider participation fee of $250 per month. I’m still uncertain if this is the best business model, but investors seem to think so because ZocDoc has raised a ton of cash recently to take the service national.

Though providers use the service to list appointments, it is all about consumers if you go to its website or download its mobile app. Users search, find open slots, and book the appointment, all free of charge. I’ve read concerns that this type of booking could result in a large number of no-shows, but according to an interview I read awhile back, ZocDoc says the number of no-shows is lower than the average for health visits.

It’s little unclear from ZocDoc’s site about how many appointments it books a month. It says only that 700,000 searchers occurred. If anybody knows this number, I’d love it if you would share.

Payer is the Consumer – RunKeeper / Fitbit / Zeo

Getting consumers to pay directly for medical services, especially apps or remote services that aren’t "essential," is hard. I put essential in quotes because I think some services, like medication adherence, are essential if you only take your medications 50% of the time. I’m not sure that most patients agree with me.

From my experience, with the exception of some very low cost apps (mostly $0.99,) the only consumers who are willing to pay are those that already relatively healthy. That’s why RunKeeper does well. It caters to the right crowd.

Most vendors and investors have learned this lesson. The cost of services for chronic disease are not being pushed directly to patients.

Payer is Health System – iTriage

I think of iTriage as the health-specific yellow pages. It goes further by providing a symptom checker and medication reference. As opposed to ZocDoc, it is more system- or hospital department-based and not as focused on specific providers. I know it lists specific providers, but I haven’t heard anything about iTriage sales to individual docs. I do keep hearing about iTriage sales to health systems, hospitals, and urgent care.

iTriage is most similar to ZocDoc in terms of its revenue model. It is free to the consumer to find a provider or facility. Providers and facilities are charged for Premium Listings. These paid listings enable facilities and providers to have a nice logo, a standout color for their entry, and more information for the patient, including ED wait times and even patient pre-registration. Like ZocDoc, it’s a smart model for fast user uptake and probably the reason both ZocDoc and iTriage are doing pretty well.

As a side note, I’ve heard rumors from pretty credible sources that iTriage has some very big news it is going to be releasing soon. If anybody has any details about the news, as I’m still a little in the dark on the details, please let me know.

Payer is Employer – Castlight Health

Castlight works directly with large employers, mining claims data through a proprietary algorithm to come up with tools to help the organization and employees save money on health services. By working with large employers, Castlight is able to get access to all claims data and use it to boil down benefits into understandable and actionable tools that employees can use to make more informed decisions about healthcare. At least this is how I understand what it does.

In addition to cost, it offers quality metrics to help employees decide among providers, though I’m not sure what these metrics would be and can’t imagine how they would be generated from claims data.

I assume the employer pays some fee per employee for the service and then offers it to employees free of charge, hoping employees will use the tools to save everybody money.

Castlight was co-founded by Todd Park (who I think has divested all of his interest in it since becoming CTO of HHS) and Giovanni Colella, founder of RelayHealth. It got a lot of attention pre-launch because of the amount of money it raised and the fact that Cleveland Clinic was an investor.

Payer is Family – Independa

Another model targeting consumers is to get the families (usually adult children) to pay for the services for an elderly patient. Independa offers online tools (med reminders, telehealth, etc,) as well as a new tablet called Angela to help people stay in their homes longer and avoid the need for nursing homes.

I consider nursing homes to be basically one foot in the grave. Anything that can be done to maintain independence, which is equivalent to better quality of life, is something that is worth trying. Add to that the much lower cost of services like Independa relative to nursing homes and it seems like an easy sell. The most current data I’ve seen is that ~25% of households in the US are surrogate caregivers, so this is a big market to target.

Challenges will remain in targeting consumers directly, either the patient or the family. Some degree of integration with the existing health system is necessary. Getting docs to promote or advocate for it or getting it integrated into overall care delivery would be a huge bump for Independa.

Payer is Pharma – Vitality

I think Vitality is the perfect example of the power of pharma to accelerate a business. Vitality GlowCaps helps consumers be more adherent to medications, a big benefit for patients and overall care. It’s automated and thus requires no patient input, so little to no training or interaction is needed. Additionally, it connects to families so they can track adherence and nudge patients along, leaning on resources outside of the health system.

Consumers and family have an obvious benefit, but don’t pay anything for the service. Instead, pharma pays because:  1) it increases the number of refills and medications taken (Vitality has some nice calculators to show how much this is worth for each medication); and 2) it offers access to dashboards that show real-time information on patient medication use, geography, and pharmacy used. I’ve heard (but again, this is not confirmed) that pharma pays about $15-$20 per med per month for the service. I’m still unclear if the retail pharmacies themselves pay any portion of the service.

Chasing the Payer, Lessons from Keas

Keas is a good example of a company targeting the consumer as a user, but having to shift customer models to make money. Keas started several years ago as a care plan exchange where consumers could join, find care plans for organizations or individual docs, and subscribe to these plans. Since that time, it has shifted to a health gaming company that designs health games as components of employer wellness programs.

The big lesson of Keas is that the consumer is not a great health customer. If you want them to use something, you probably need somebody else to pay for it. What’s interesting to me is that I’m now seeing new companies like Avado that seem to be doing something similar to the original Keas in terms of online care plans. I think Avado has more linkages to the providers and is straddling the portal/PHR space, but custom care plans are certainly a part of the service.

I have to run to catch a plan to DC for the AMIA Symposium. Hopefully I’ll see some of you tomorrow at my talk on startups in healthcare.

Travis Good is an MD/MBA involved with health IT startups.

I missed the McKesson Foundation’s Mobilizing for Health 2012 grant winners announcement from earlier this month. Six grants, totally $1.4 million, were givento "investigate how mobile phones can be used to improve the lives of underserved populations suffering from chronic diseases". All six target diabetics. The most interesting to me was Medic Mobile (formerly FrontlineSMS,) which is creating an SMS tool to confirm and reschedule appointments. Medic Mobile, as far as I know, is a non-profit that has been 100% focused on global health, specifically in Africa. Maybe it is trying to copy the model of Voxiva in importing mobile health experience from abroad to the US.

Mobile ultrasound vendor Mobisante finally gets its phone-based ultrasound on the market in the US. FDA clearance was obtained earlier this year, but it took time to meet some of the FDA’s implementation mandates. The Mobisante probe connects over USB with a Windows mobile device, and is not available for Android or iOS devices at this point. Tablets are apparently on the product roadmap, but I’d imagine those would be Windows-based tablets.

Indian Health Services CIO Howard Hays testifies to the Senate that telehealth can improve access to and quality of care for Native populations. OK, now that we know it works, we just need to fund it.

iHealth announces the US release of its Digital Scale, which connects to iOS devices over Bluetooth and tracks "an unlimited number of users." iHealth appears to be competing head-on with Withings and its iOS connected scales and blood pressure cuffs. The new iHealth scale ($69) is $90 less than the Withings scale ($159).

MIT Media Lab spinoff Ginger.io closes a $1.7 million round of financing. Ginger.io tracks user activities, locations, and patterns (e-mail, SMS, etc) of mobile device usage. The application runs in the background of a mobile phone and does not require user input. The idea is that by tracking all of this, Ginger can figure out the "normal" routine of users and then flag any variations, potentially signaling impending health problems. From this, health systems or payers can proactively reach out to these users and hopefully prevent office and urgent care visits. I’m curious to see if this model actually works. The other potential value is to pharma companies that want to do population-based research. This to me seems like a more likely path to revenue. Ginger right now works on Android and I’m not sure you can do this kind of monitoring on iOS.

Walgreens adds a new mobile service to make prescription refills even easier, Refill Reminder Text Alerts. Users are sent an SMS when they are due a refill and can complete their order by replying with "refill." Also of note, 25% of online prescription refills for Walgreens are now generated using mobile apps.

CVS releases an Android version of its mobile app. CVS is now reaching the majority of smart phone users with apps for Android, iOS, and Blackberry. The app allows users to refill, check prescription status, and find other CVS-related info.

New research of public Tweets (is that supposed to be capitalized?) finds that people tend to surround themselves with users who share the same sentiment, either positive or negative, about the H1N1 vaccine. In other words, more groupthink and less debate. Extending from this point, the researches claim that high-risk groups, or those that hold negative views about vaccines, can be identified and targeted.

Physician Interactive Holdings, a division of Skyscape, and Remedy Systems jointly launch Tomorrow Networks. The new network is a platform for mobile health developers to market apps to providers. It sounds like a targeted marketing tool and I’m not sure what reason a provider would have for using it to find mobile health tools, despite the assertion in the story that providers need help wading through the myriad of apps currently available. Providers are going to use what is recommended to them by other providers or mobile versions of the names they already know and trust – Epocrates, UpToDate, and all the other major publishers they’ve used and liked in the past.

HCPlexus announces the little blue book (tlbb) Mobile 2.0, an updated mobile version of the application docs can use to find other providers, hospitals, and pharmacies. The new version adds some limited functionality, like adding notes to user profiles. tlbb sounds a bit like Doximity without the ability for docs to secure message and have LinkedIn-like medical profiles, which I guess is how Doximity is differentiating itself.

The State of California passes a new bill aimed at increasing the adoption of telehealth services in the state. This is probably one of the worst press releases I’ve seen in a while, but I think the bill expands the types of covered telehealth services and makes credentialing telehealth providers easier.

The Vodafone Wireless Innovation Project is open to applications. The deadline is December 31. Winners get $300K, $200K, or $100K to test a mobile health prototype in the field. Entries need to be global in scope. It’s a great opportunity if you’ve got a decently baked global mobile health idea, though I’m betting competition will be fierce.

Travis Good is an MD/MBA involved with health IT startups.

In response to my last post when I asked if EXTENSION was a Cisco partner or subsidiary, an informed reader e-mailed to let me know that EXTENSION is a Cisco Development Network (CDN) partner. I wasn’t sure as I’d seen it reported both ways, so I appreciate the clarification.

Epocrates has a new infographic on how providers find and use smart phone apps. The most interesting stats to me are that 45% of docs with smart phones download 50 or more apps and they only use seven per day (I wonder if this includes built-in apps like e-mail and SMS/iMessage?) Of course, the 266 polled were asked by Epocrates to name the three apps they use most and the most common answer was Epocrates.

Sprint partners with IDEAL LIFE to outfit wireless-enabled medical kiosks. The kiosks "are designed for high-volume traffic and can be installed in communal settings such as community centers, libraries, schools, employer facilities, living centers, gyms, health clinics and physician offices." According to the release, results can be sent to healthcare professionals to aid with clinical decisions, though I’m not sure who those healthcare professionals would be. Is the intent that integrated systems would install the kiosks, or are the kiosks supposed to be linked to some virtual service like TeleDoc or American Well?

A new study out of Johns Hopkins finds that video games, specifically those on the Wii, help with physical therapy in ICU patients. The most amazing part for me is that 50% of the Wii sessions were conducted with patients who were using a mechanical ventilator.

Got a pre-VC startup? Applications for the the second round of Rock Health’s incubator program are open. I think it opened last week and the deadline is November 14. If you and your founders can’t commit to being in San Francisco or one of you isn’t a developer, you can apply to the Member Program.

I just learned about another startup event at the mHealth Summit, this one being presented by HIMSS. I’m a little confused by all of the inclusion criteria for companies, but it is clear that companies need to be seeking $2 million or less.

A postdoctoral researcher at UC Davis built an iPhone microscope capable of visualizing to the cellular level. He did it with a $40 lens, some rubber, and tape. The top row above is from a commercial microscope and the bottom row is from the modified iPhone. I’d be curious to see how well this would work on much lower-end phones with cameras because iPhones are still too pricey to be distributed to rural parts of the developing world.

The VA reports that 430,000 veterans have used Blue Button to download healthcare claims history, far exceeding expectations. The Blue Button information, which I would think as claims would be a limited PHR, contains demographics, emergency contacts, medication lists, and wellness reminders. I’m not sure how Blue Button uses claims information to do wellness reminders.

Fitbit releases its version 2 pedometer called Fitbit Ultra. The $99 device adds a stopwatch, an altimeter, and a slightly larger display. It’s a cool product for a specific user.

The state of Deleware launches a site to help its residents find aging and disability services. You can search the site for different categories of services and get a list of providers based on geography. The listings have no info (no costs, no reviews) beyond address and if the provider takes public insurance. It’s a start, and perhaps it really is hard to find those services.

GigaOM has a new research note, The future of mobile health, 2011–2016. You have to sign up for a GigaOM Pro Subscription to access the full report. Companies mentioned in the report include Epocrates, GenoMed and Mobisante.

First Impressions of iOS 5

It’s nice and didn’t slow my devices down at all. I’ve installed it on both my iPhone and iPad (technically my son’s iPad.) I use his iPad mainly to read up on current happenings, so the notifications and messaging enhancements didn’t do much for me. iCloud is nice because it dumps all the iBooks (I use it only for kids’ books), movies, and music across my devices so I’m more willing to buy them on the iPad.

On the iPhone, I like the new Notification Center, though it’s hardly as revolutionary as some have said. Having SMS and push messages slide down from the top of the screen and not require a click is very useful. Pulling down from the top to see the Notification Center from any screen is good too, but I use it mainly for easy access to the weather (a tip: slide your finger right on the weather bar in the Notification screen to see the five-day forecast.) It would be better if I could delete e-mail directly from the Notification screen instead of still having to open e-mail.

The lock screen is improved by being able to see new notifications and previews of messages. It’s a small but useful feature to me. You can’t see the weather from the lock screen as far as I can tell.

I like the "Reader" option in Safari. I read a lot of Web pages on my phone, and in one click I can remove ads and format the content for the mobile screen, which is very cool. Also, the ability to Tweet directly from Safari is great because I can Tweet stories I come across, tag them with @myen, and they automatically get dumped into Evernote so I can find them later. It saves me the step of e-mailing the story to my Evernote e-mail address, which also doesn’t get the story on Twitter.

I haven’t used iMessage (or more correctly, I haven’t used any of the new features added to iMessage/SMS) but my big question is whether non-SMS iMessage would be considered HIPAA-compliant messaging, at least provider-to-provider. With the recent reports about Apple FaceTime encryption being HIPAA compliant, then if Apple used the same encryption scheme for iMessage, wouldn’t iMessages also be HIPAA compliant? Maybe I’m missing something, so I’ll throw it out there to the readers.

And if that is the case and non-SMS iMessage is HIPAA compliant, why sign up for Doximity to DocText since such a high percentage of docs have Apple devices?

Travis Good is an MD/MBA involved with health IT startups.