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Comment by tzier | Hacker News Reader

Digital health is difficult since:

1. [B2B] Providers/enterprises aren't willing (or able) to integrate into legacy systems

2. [B2C] Consumers see their futures selves as strangers [1], and most aren't willing to put in time now to prevent something that may or may not happen in the future (e.g. sickness)

Which is sad, because this is a huge area for tech to have a meaningful impact on lives.

There are definitely some interesting companies in the space. For example, Omada Health [2] sells to companies. Companies like them because their employees' health increases (meaning more time spent working) and insurance companies like them because their loss ratio decreases.

[1] http://www.vox.com/2014/12/18/7414105/procrastination-future... [2] https://omadahealth.com/

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The amount of data is also a huge challenge. The HL7 "standard" for patient data exchange is huge - thousands of potential data points with tens of thousands of options. The IDC-10 code set allows more than 14,400 different codes. And that's just the tip of it: https://en.wikipedia.org/wiki/ICD-10

The US ICD-10 Clinical Modification (ICD-10-CM), for instance, has some 68,000 codes. The US also has the ICD-10 Procedure Coding System (ICD-10-PCS), a coding system that contains 76,000 codes not used by other countries

The size of some data also makes exchanging it difficult. A typical MRI image is 5-10 MB with sometimes over 1,000 images in a set, and some patients will receive multiple MRIs over the course of treatment.

Scale that to millions of people, and you have some idea what larger healthcare networks are dealing with (and why the VA system has had so much trouble).

Note that this data also has to be _perfect_. Incorrect or missing data can cause real harm to real people (and serious legal trouble for the company that fucks up).

A lot of the HL7 stuff could be made a lot simpler if the hospitals embraced a simpler subset--instead, everybody picks and chooses features and fields, as do vendors, and then punt it off to integration work. It's dumb.

IHE has done good work defining conformance profiles on top of the basic HL7 standards that help to improve interoperability. Adoption is growing but still not universal.

http://www.ihe.net/

Mixed bag with IHE.

For example, IHE WCM (the waveform stuff for realtime signals) is not very good: it is overly textual for the data it represents, doesn't solve all the problems it can run into, has some weirdness with timing and how to map things into HL7, and so forth.

I wonder if part of the B2C difficulty is that insurance pays for most healthcare but (with a few exceptions) not for the lifestyle choices that would reduce healthcare costs.

If there was more of an emphasis on preventative measures that insurance paid for, I wonder if it would be different.

This is difficult due to ACA regulations. For example, Pact (formerly GymPact) was trying to give people discounts on Blue Shield of CA health insurance premiums for going to the gym. A provision/update in the ACA made this illegal about a year ago; not sure if it's changed since then.

That said, it seems likely that insurance premiums will eventually be tied to real time health data, like Metromile is doing for car insurance.

What lifestyle changes would an insurer pay for--at least without very intrusive lifestyle monitoring? (Which will increasingly be possible to do whether it's done or not.) There are often discounts for gym memberships and the like. And annual physicals are typically paid for.

A friend of mine can log exercise and turn it into free money in his HSA. I don't know whether they validate it against an activity tracker or not, but this is already happening.

I'm genuinely not sure. Paying for gym memberships, FitBits, and things to get people exercising could be one option. Or maybe insurers could use extra incentives to encourage people to get flu shots or regular checkups?

One thing ACA did which at least is plausibly useful (though whether it'll move any statistics remains to be seen) is to include an annual physical plus all CDC-recommended vaccines with $0 billed-to-patient cost. So even if you otherwise have a high-deductible plan, you don't pay a copay or deductible for those services. This isn't quite an active incentive, but it's an attempt to remove the price disincentive, with the hope that'll result in higher vaccination rates (the flu vaccine is included).

One of the biggest barriers to preventative healthcare is that it doesn't pay -- at least not quickly enough to make business sense for an insurer. There's a famous paper that looked for cost-saving interventions in preventing heart attacks and strokes, and it concluded:

"As they are currently delivered, almost all of the prevention activities are expensive. If applied fully, using current protocols and the reference assumptions about costs (Table 2), they would increase health care costs by $8.5 trillion over 30 years (Table 3), or $283 billion per year, or $1700 per person per year (data not shown). The only cost-saving activity is smoking cessation."

You can read the full paper here. It's from 2008, so perhaps some entrepreneur will be able to find the breakthrough that finally bends the cost curve: http://circ.ahajournals.org/content/118/5/576.short

The latest buzzword is precision medicine. Also if that's from 2008 then it is missing all the advancements in mobile (iPhone is 2007) and digital health monitoring like FitBit. So one of those three things could easily make an improvement over what that paper says. (Did not read the paper.)

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