Today’s post takes a look back on 2011 by reviewing our predictions earlier in the year and assessing where we hit the mark, where we missed and if there is such a thing, where we came close. So without further adieu…

1. MU Initiatives Move to Tactical 
Hit This did come true as meaningful use, while still top of mind for the CIO, is not top of mind for others in the executive suite who are now looking at how to compete in the future as reimbursement models shift from fee-for-service to value-based contracts.

2. C-Suite Strategy Focuses on New Payment Models 
Hit An admittedly “softball” prediction, this was a natural fall-out of prediction numero uno. And yes, the consultants are making out like bandits as we predicted they would helping senior execs figure out their future competitive strategy.

3. RCM & Charge Capture Systems Require Overhaul 
Miss By and large, most vendors in this sector have not done a whole lot yet as they await to see how the market develops. With most healthcare organizations struggling to get the basics done (e.g., meet MU requirements, ICD-9 -> ICD-10, apply analytics, etc.) we are not seeing big demand from customers and subsequently, not a big push by vendors.

4. Mergers & Acquisitions Continue Unabated
Hit Another “gimme” of sorts for we had this prediction in 2010 and it was a “hit” and need only look at this market with its some odd 300+ EHRs to choose from, everyone wanting to call themselves at HIE vendor (last we checked, HIMSS listed some 189 HIE vendors alone), countless other HIT solutions to see that this market is far from mature. But arguably the biggest news in 2011 was Microsoft’s capitulation that despite the billion dollar plus investment, it wasn’t cut out or the clinical market and dumping its HIT assets into a new joint venture with GE. What we are also seeing is some rationality return as valuations have moderated. This may have led to Thomson Reuters’ recent decision to not sell-off its healthcare division – no one was willing to pay the high price tag they had on this property.

5. Federally Funded State Initiatives Struggle
Toss-up There has been some progress and there are those that would vehemently argue that Beacon Communities, RECs and state HIEs are moving ahead briskly. But then again, we do get some disturbing reports that all is not progressing as once envisioned, one might even go so far as to say some of these programs are beyond just struggling, but clearly going off the tracks. We’ll reserve judgment until we see clear evidence of such pending disasters, which will likely be prevalent, but highly distributed.

6. Changing of the Guard at ONC
Hit Not long after we posted our 2011 predictions, Blumenthal announced his resignation from ONC. We could not have been more prophetic if we tried.

7. Physicians will continue to go Ga-Ga over the iPad and the fast-following touchscreen tablets much to the chagrin of CIOs.
Hit Enabling physicians access to health information systems via their hand-held mobile devices, including touch-screen tablets is still a struggle for most organizations. At first, IT departments turned to Citrix as stop-gap measure, but the UX was far from ideal. In our recent research we found many an IT department still struggling to address this issue. mobile enablement of physicians is a top priority.

8. Apps Proliferate: Consumer-facing First, Private Practice Second, Enterprises Dead Last
Hit In hindsight, another admittedly easy prediction to make. What may be a more interesting prediction is when will mHealth Apps really become a truly viable market? Does the profitable exit of iTriage/Healthagen, which was picked up by Aetna portend such? By our standards, no. Go back to our recent post from the mHealth Summit for more in-depth analysis.

9. The Poor Man’s (doctor’s) HIE Takes Hold
Miss We thought that the Direct Project would quickly take hold and see rapid adoption among smaller physician practices and those organizations looking to “connect the last mile” to small affiliated practices in their network. Not happening yet though the current administration is doing its best to push this technology by requiring all state designated entities that are standing up statewide HIEs to include Direct in the strategic operating plan.

10. Analytics & Business Intelligence Perceived as Nirvana 
Hit, kind of… In retrospect, not even sure this was really a prediction but simply more of a statement as to where healthcare organizations are headed with their HIT investments. We have a long ways to go, though there is certainly no lack of vendors that now are touting some form of analytics capabilities. Our advice, tread carefully as most solutions today are half-baked.

11) The Buzz at HIMSS’11? Everything ACO! 
Miss While some vendors were discussing ACO enablement at the 2011 HIMSS, the vast majority were not with the key focus continuing to be meeting Meaningful Use requirements. As mentioned in previous prediction, we see MU as a tactical issue with the strategic issue being: How do we leverage IT infrastructure to support communities of care? Maybe at HIMSS’12 we’ll see more discussion of this issue, but we’re not holding our breath.

This may have been our best year yet with our predictions having only 3 clear misses out of 11 predictions made. Granted, some of those predictions were not exactly the most profound or shall we say big stretches, but we do take some satisfaction in really nailing a few.

And while we intend to provide our own 2012 predictions, no time like the present to begin the process. So we ask you dear reader, what is your 2-3 top predictions for 2012? Will Todd Park stay on at HHS? Will forced budget cuts decimate HITECH? Will the Supreme Court’s ruling on ACA have any impact on HIT spend by either payers or providers? Will mHealth Apps such as WellDoc’s for diabetic care finally receive a CBT code thereby accelerating adoption of such tools?  We look forward to your input.

And of course we wish everyone a Joyous holiday season and wish you and yours continued good health in the new year to come.

Home for Christmas by Thomas Kinkade

After being away for nearly two weeks, it is a challenge to pick up where one left off. Cruising through the reams of email (please excuse any delays in getting back to you I’ll get to your email yet, I promise), trying to catch up on my reading of the various industry rags and tapping twitter I feel pretty comfortable in stating the more things change, the more they stay the same (not exactly the best quote for an analyst to say as we thrive on turmoil…).  That being said, following are a few items that did catch my attention and may look into further:

FDA Releases Proposed mHealth App Regulations
On Tuesday, the FDA finally released guidance on how it intends to regulate mHealth Apps. Having taken a cursory review of these proposed regs, have to say I’m quite impressed as the FDA has struck a careful balance of  applying regulatory review where warranted while allowing plenty of room for innovation in this very young and still immature industry sector.  MobihealthNews has a fine write-up on this story.

WebMD Provides Abysmal Guidance and Tanks
WebMD, which has been seemingly immune to the recession, provided Q2’11 guidance that sent its stock into a tailspin and leading to a very rapid (next day) letter to investors from the Chairman to quell fears. Why is this significant? First, pharma is feeling the effects of the recession and is pulling advertising dollars off the table. Over the last few years, WebMD has been putting virtually all of its “eggs in one basket” – pharma. It appears that the golden goose of pharma is no longer laying golden eggs which will likely have a ripple effect on the multitude of other smaller Health 2.0 like companies whose business models are advertising based. Secondly, once again WebMD is projecting contraction in its “private portal” business. This is, or at least was, the 800lb gorilla in the PHR market for employers and payers. WebMD has milked this cow for about all its worth and do not be surprised if others start aggressively moving in. Cerner is one and we’ll talk about another tomorrow.

Stage 2 Meaningful Use Likely Delayed till 2014
Can’t say we didn’t see this coming as ONC’s advisory board basically recommended such but it does complicate the schedule for incentive payments which, as part of ARRA were meant to create jobs and create those jobs quickly. As the recession continues to drag on, there appears to be an acceptance that getting back to near full employment in this country will not occur quickly. Such acceptance has appeared to bring some rationality as to the rollo-out of EHRs. Choosing, installing, mapping workflow, testing, training and going live with an EHR, let alone meet the various requirements of meaningful use (MU) is no small task and this delay will bring a sigh of relief among many a CIO and eligible professional. But now one has to wonder: What does this mean for Stage Three?  Don’t be surprised if Stage Three gets the ax.

I’m sure there are other bits of news that I missed and welcome your input to help educate this off-the-grid analyst on all the wonderful things he missed as he was trudging through the temperate rain forests of Alaska or battling grizzlies for a share of their salmon (note, grizzlies don’t share).  BTW, this last picture is of one of the “deep forest creatures” you’ll find in that rain forest.

Slide 8 above shows just how dramatic the pace of adoption is for mobile+internet. What this slide points to and what our own recent research has uncovered (more to come – mHealth in the Enterprise report to be released tomorrow) is that mobile+internet is going to have a tremendous impact on all industry sectors, including healthcare.

Fasten your seat belts folks, this ride is only going to accelerate.

Dr. Feldman discussed BIDMC’s platform-agnostic mobile strategy, whereby clinicians access all HIS data through the browser of whatever device they happen to be using.   Talking to Dr. Feldman was a far cry from talking with certain app-crazed technologists, who recoil at the thought of using the browser to deliver information into a busy doctor’s workflow.   At BIDMC there are no cool mobile apps, just web forms (Ajax is not welcome either).

This is not a story of antiquated technology.  I would consider BIDMC to be a lead user in the field of HIT and wireless health as they develop the majority of their systems in-house, have very large IT and informatics departments, and house the likes of globally recognized HIT leaders like John Halamka. (Full disclosure: I have been a fan of BIDMC since CEO Paul Levy co-taught my class ‘Economics of Health Care‘ at MIT.)

According to Dr. Feldman, BIDMC’s platform-agnostic architecture is working wonderfully well for them, and BIDMC has no need to jump on the app bandwagon.

Why Not the BrowserOne argument I have heard for shunning browser architecture is that the web-based user experience for a lot of clinical software is paltry – that the true potential of native UI is not realized.   Another argument centers around network connectivity, for example: “Wi-Fi doesn’t reach the basement of our hospital”, or “10 days of patient data has to be stored on the device – we can’t take chances with the network”.

Tackling the user experience argument: Most mobile browsers use the Webkit rendering engine, which renders UI widgets with the same look (but not always the same feel) as native widgets.  For a well designed webpage, this means consistency between the platform UI and the browser UI, something that nearly everyone prefers.

Now on to connectivity issues: BIDMC has invested heavily into its network infrastructure, creating a highly available, secure, very fast network. The result is that clinicians have high levels of confidence in accessing data through the browser anywhere at anytime within BIDMC.

It is a different story, however, when a doctor is out of range of the BIDMC network, where she doesn’t have the same talented networking team working for her.  Also, most hospitals don’t have a true medical grade wireless network like BIDMC.   What may help here is the FCC’s recent announcement on the use of white-space (vacant analog TV airwaves), leading to wi-fi on steroids in the not so distance future.

Headaches Avoided
Thinking of some of the headaches avoided by using a browser-based strategy:

• No client to install and support on the end-device.  Lowered complexity and fewer points of failure.
• No possible way to store data on the device.  This means no complex mobile device management because of privacy/security risks.
• No worries about who will win the smartphone and tablet wars.  If a device has a browser it is supported.

Of course, everything is a trade-off and while BIDMC has thrived with a platform-agnostic philosophy, this may not be the best strategy for all hospitals seeking to roll-out mobility to their clinicians.   In Chilmark’s upcoming report, “Enterprise Adoption of mHealth Apps: Trends, Issues and Challenges”, we’ll dive into the specific factors that would benefit a hospital to choose one architecture over the other, and highlight the trade-offs involved.

This week I look forward to visiting Kaiser Permanente Garfield Center for HealthCamp 2010, and Health 2.0 in San Francisco with John.  It is going to be a busy week!

As Eric Dishman of Intel points out in an excellent post, part of the problem may be one of definition, part of it  al ack of truly trying to understand th market, its needs, the technology currently available to meet those needs and how does that technology become a part of the workflow of traditional care processes, or augment if not disrupt that workflow.  Many questions that remain unanswered or poorly answered.

So is there really any justification for all this hype?

Yes and No.

Quite awhile back, when Chilmark first started looking into the mHealth market, we felt that indeed, there truly is something here and that provided the tools were simple enough, the value big enough that mHealth. It was at that time that we coined the term: Health is Mobile. Health does not happen when you are in-front of your laptop or desktop computer, it happens when you are on the move, going to an appointment, picking up a sick child from school, etc. Chilmark agrees with Deloitte that an mPHR like app has incredible potential, however, the lack of personal health information (PHI) in a common, computable digital format, (eg CCD or CCR) is a significant hurdle. There are also the issues of the need for a well-defined, simple to grasp value proposition for the consumer (see previous post) and subsequent business model(s) and a go to market/commercialization strategy that will make mHealth a sustainable success in the market. Not easy hurdles to overcome.

But there is significant change occurring and the rapid acceleration in adoption of smartphones is staggering. Recently, the market research firm IDC upped its 2010 smartphone growth projections from 44% growth to 55%. Then take a look at app sales on Apple’s iTunes. On September 1st Apple stated that 6.5B, yes, that’s BILLION, apps have been downloaded and 120M iOS devices (iTouch, iPhone, iPad) had been sold. This equates to 54apps/device. While many of these apps are for games and productivity tools, there are literally thousands of apps for medical, health and wellness purposes. What is particularly interesting about app download growth is that it is overtaking downloads of music. Maybe Apple needs to start calling iTunes iApps instead.

And then there is the story from Stanford Medical School where new med students this year have been issued an iPad in the hopes of replacing mounds of paper that are typically distributed to students for a course over a semester. The students seem to like it and even one of the doctors is quoted as saying towards the end of the article that the iPad is in an ideal form/function factor for a busy physician.

This may truly be key, for as the PWC report points out, most consumers would prefer to get their mHealth solution from their physician.  Thus, if physicians get on-board in using something like the iPad, this could become a virtuous circle.  First, the doctor will be able to easily create and update a patient’s record, digitally creating the content (PHI) that a consumer/patient could then use to populate their own mPHR. The physician’s familiarity and use of such technology will also drive a higher comfort level with using such in the process of care coordination and engagement with the consumer, including reviewing data in the consumer’s mPHR that may not have originated from their practice.  Likewise, the consumer trusting in their physician and possibly with physician encouragement,  will more readily adopt and use such a technology to better monitor and track their health or the health of a loved one.

Closing thoughts:
As Dishman points out in his post, too much is being put under the general rubric of mHealth. A clearer set of definitions are required to make sense of this market for today it is simply a mish-mash of terms extending from telehealth monitoring, which has been around for years, to novel apps on smartphones and the iPad to small, self-monitoring devices such as fitbit or even those devices that are embedded for say cardiovascular monitoring (defibrillator implants).  Even PWC in its report, decided against the term mHealth, instead going with Healthcare Unwired to express a more encompassing view of the technology advances/capabilities arriving in the market.

But are we really doing anything breath-takingly new?  On the technology front, not really, though the hype will have you think otherwise. Where the new really comes into play is in how will these mHealth/Health Unwired technologies affect the practice of medicine and the the delivery of care?This is where the real revolution will occur. This is where it gets interesting. So let’s not get so ga-ga over the technology, let us cool the hype-cycle and get down to the real business of understanding how these technologies will impact the delivery of care, the cost of care and the models of reimbursement, be it to the consumer, the physician, or the hospital.  Now that is something to get hyped up about.

Giving Credit: Thanks to asymco for the great figure charting music vs app sales on iTunes.

iPad:
Over 2M sold since its release 2 short months ago.
8.5K native iPad apps now available.
35M apps downloaded => ~17 apps/iPad.
5M books downloaded

Some analysts are now projecting that 8M iPads will be sold by end of 2010; would not be at all surprised if that number is exceeded.  On a recent trip to Martha’s Vineyard, while taking the ferry over, I saw two, separate elderly people (had to be at least 80+ years old) using iPads.  This product is a hit and its popularity will drive continuing developer interest to build out new apps for the iPad.  Having spoken to a number of healthcare workers though, the utility of the iPad in the healthcare setting has yet to be determined as many still question the ruggedness and ability to disinfect an iPad. Really do not see this as a big hurdle to overcome as such has been the case for many previous computing platforms and the iPad comes in such a compelling form factor, it really is hard to resist for numerous applications including bedside patient education, that the healthcare sector will be an important market for the iPad.

AppStore:
Over 5B apps downloaded.
A whooping 225K apps are now available.
15K apps/wk are submitted to Apple for approval (95% are accepted within a week).
Top 3 reasons for apps being rejected:

1. Does not function as advertised.
2. Uses private APIs.
3. App is buggy and crashes.

By end of June’10, over 100M devices using the iOS (iPhone, iTouch, iPad) will have been sold.

The AppStore has created a completely new model for app development and delivery that has been highly successful for Apple in driving sales for its ever expanding portfolio of devices.  Google is a distant second with the Android OS and the Android store of some 30K apps. In healthcare, with a few notable exceptions (e.g., ADAM, Epocrates, iTriage, LiveStrong, WebMD, etc.) most of the mHealth apps in the AppStore are pretty simplistic, what Chilmark refers to as mHealth 1.0 apps (for more info, mobihealthnews has a nice little report on mHealth apps).  But what Chilmark is more interested in is seeing how the concept of an AppStore-like environment (platform) will allow for the development of a wide range of mix and match clinical apps, which some have begun referring to as “Clinical Groupware.” Big question here though is how will meaningful use be achieved through use of a certified EHR if the certified EHR is actually a collection a disparate apps running on an iPhone or iPad?

The New iPhone:
For healthcare, a couple of new features are notable (beyond multi-tasking which was announced earlier this year as part of new OS4.0).

• New “retinal” display that Apple claims will provide unmatched resolution.  This will be particularly valuable in reviewing images.
• Video camera on both sides of iPhone combined with video conferencing app, FaceTime.  This could be particularly useful for telehealth applications wherein a remote clinician (say a nurse) is providing at home care, notices a new rash on a patient and confers with doctor at clinic or hospital, in real-time on what appropriate action (bring them in, apply slave, order Rx) should be taken.

Apple is clearly in the driver’s seat today setting the standards and benchmarks by which others will follow.  How these developments may impact the healthcare sector is something we will continue to monitor closely.

Key Take-Aways:

mHealth is clearly a top priority of the Obama Administration. Rare that an inaugural event would attract HHS Secretary Kathleen Sebelius as keynote speaker when so much is happening on the Hill regarding healthcare reform. In addition to the Secretary, day two had a keynote by US Ambassador Elizabeth Fawley Bagley.  Brian Dolan of mobihealthnews.com did a nice write-up on the Secretary’s keynote.

mHealth initiatives in developing countries do not have a sustainable business model, all are grant funded. Big problem here as the researchers are not structuring their research to collect the data needed to justify the investment(s) and subsequently define sustainable business models for the mHealth technology they have deployed. Crazy!  This is not basic research folks and those funding these initiatives need to be more diligent in reviewing proposals to insure that such data types (hard and soft savings metrics) are collected. (For a counter view on this issue read ICTworks post on the topic. FYI, ICTworks is part of inveceo, a small company formed out of Josh Nesbitt’s, who is a Stanford student, work in Africa. Josh gave one of th better presentations at this event, very inspiring.)

African countries want a platform that allows them to build mHealth apps that address the priorities they chose in a manner that reflects their culture. Consultants and pre-packaged, shrink-wrap solutions need not apply. (Note: OpenMRS appears to be gaining wide popularity in developing countries.)

Most mHealth efforts/research & roll-out, at least expressed at this event, are very narrowly focused on one disease state. Research has borne out time and again that the vast majority of those with a chronic condition and many with an episodic condition suffer from some other co-morbidity, particularly in the realm of mood disorders.  More work is required to build out these mHealth apps to be still simple to use, but also multi-faceted to address whole health.

There are some really outstanding results in the use of mHealth. One of many examples presented: A public health texting service in South Africa addressing AIDs and TB awareness, encouraging those at risk to call public health clinic, resulted in call volume increase of over 300% to public health clinics that has not subsided.

Iterative user interface design is critical. Those deploying mHealth solutions in the field have found that designing the user interface (UI) is not trivial by any means (is it ever?) requiring an iterative process as one is dealing with very small real-estate inherent in mobile devices.  End users often get icons wrong, mis-enter info, do not complete sections if too lengthy, etc. But even in designing that UI, take user inputs with a grain of salt as users often prefer UIs that they use incorrectly.

Mobile tech may well be the silver bullet to address healthcare disparities. While there has been a significant amount of attention/discussion on health disparities that may arise via Internet-based consumer-facing healthcare services, mHealth apps may provide a balance as both African-American and Hispanic communities in the US are far more heavier users of mobile tech than Caucasians.

This was a good event, but like any inaugural event, there are always a few bugs to work-out.  Hopefully next year’s event (November 9-10) will more effectively address new technologies and modalities that will support mHealth initiatives (most tech on display here is re-purposed tech from 10yrs ago) and expand to include discussions on real outcomes, sustainable business models and consumer-facing mHealth apps with real consumers talking about their personal experiences.

As we’ve said many times in our writings:

Health is Mobile

Health does not occur when you are in front of your computer, it is a part of your every day life and actions. There is tremendous promise in mHealth apps but this market is still extremely young, nascent and immature.  A lot of experimentation occurring today but in a 2-4 years this experimentation will convert into vibrant business models.  Mobile apps will be the future of much of health, wellness, and care.  Any company/software vendor worth their salt in the healthcare space better damn well have a mobile strategy on their white board or they may well become irrelevant.

A core tenet of Chilmark Research’s which contributes to our perspective on consumer-facing applications and technologies is:

“Health is Mobile”

Health does not happen when one sits down in front of a computer screen, health occurs everyday in every action a consumer takes.  This is in large part what the Robert Wood Johnson Foundation (RWJF) uncovered in their first round of research under Project HealthDesign (PHD). RWJF has taken the next step in round two funding of PHD now focusing grant funding on technologies that support “Observations of Daily Living” or ODLs.  Earlier this week, RWJF received over 100 proposals for the ODL grants.

Getting back to Sad Scale, this little iPhone app provides the ability to self-assess one’s mood in three specific categories, Depression, Post Partum Depression and Geriatric. For depression, Sad Scale uses the Zung Self-rating scale.  Post Partum uses the Edinburgh Postnatal Depression scale and Sad Scale does not reference the scale for Geriatrics, simply referring to it as “Geriatrics Scale.”  Each of these scales provide a list of questions that are automatically scored upon completion of the self-test.  Upon completion of the test, scores can be charted and also shared via email.

Very basic, simple straight forward app, so what’s not to like?

The app is nothing more than a series of questions on the iPhone and no effort has been made to leverage many of the rich features that the iPhone API offers.  It is a simple questionnaire ported to the iPhone – nothing more, and seemingly a lot less.

The color choices for text make it difficult to read some of the content presented.

At the end of the questionnaire, it has a link to resources but these are nothing but links to the home pages of sites like the Mental Health America, PostPartum.net or American Geriatrics Society.  Could not these developers at least take the user to some truly relevant content.  Seriously, is that the best these developers could find?

When someone is suffering a depressive episode they may balk at going through and answering a series of questions like this, especially all 20 questions under the Zung scale – when someone is depressed, it is often difficult for them to even get out of bed and get dressed, so why have them go through standard questionnaire that provides no personalization and quick feedback that is meaningful.

Some suggestions to improve this app?

How about we begin with the RWJF concept of ODL, let’s provide the consumer an opportunity to record their self-observations as it pertains to mood.  For example, how about a quick mood question, how do you feel right now, at this moment in time with a simple color wheel to express mood and make color a back-end quantifiable metric for clinicians.

What about a simple open-ended question that they can answer on why they are feeling they way they are? If needed, one could also have a question with a multiple choice of common triggers to answer, including “Other” with a fill-in the blank.

Also, it might be useful to have within the app a timer that can be set that asks the user what their mood is at that moment in time.  This may prove beneficial in understanding at what times of day the user is vulnerable to the mood disorder.

Provide some meaningful resources including direct links to relevant content.  Don’t make the user have to look for it on some website.

Now, I am no specialist in mood disorders and I am sure that there are other attributes that could be added to the app that might be helpful for the consumer and even possibly the clinician, but I have close family members who do suffer from depression and it is a severly debilitating disease and it does, at least from this vantage point seem ripe for an ODL platform.  Downloading Sad Scale I had hoped that this may be the beginning of something interesting.  Unfortunately, this was the most disappointing (dare I say depressing) health & wellness app downloaded off of the AppStore to date.  This is one sad app, that even at the paltry price of $0.99 is not worth it.

Cost: $24.99

The Atlas of the Human Brain is one slick application that gets a lot of ohhs’ and ahhs when I demo it to others.  Utilizing T1 magnetic resonance images (MRIs), taken in the axial, coronal and sagittal planes (89 images in all) one can look at specific slices in each plane.  On a given plane, the app will show a number of pins, each pin associated with a given region of the brain.  Hover over a pin and the name of the region is provided. Click on the pin and you are taken to a brief description of that region (e.g., location, function, etc.). Within the more detailed dscription there is also a link at the bottom to Google, which when clicked, will go forth and search for more information on that specific brain section.

Now there are two ways to get to information about regins of the brain in Brain Atlas.  The first is using simple text.  Brain Atlas has an extensive directory of virtually all of the identified regions of the brain.  If you know a specific functional area you are looking for, say Precentral gyrus (it helps with motor planning and function), just do a quick search for the name in the index, up it comes, click on it and you are taken to a list of images that one can then drill down on.  This capability is useful if you know what you are looking for and wish to retrieve information quickly.

The second approach is more exploratory and honestly, the one I had the most fun with – great eye candy.  In this case you are provided a 3-D headshot graphic in a box with ability to choose one o the three primary axis.  Drag a little bar up and down, forward and back or side to side and the 3D image shows you the images/slices it has on file.  Click on an image and up it comes with all its associated pins.  Certainly not the fastest way to find a given functional area, but definitely the most fun and interesting or simply exploring the brain.

As all information and images are stored locally, directly on your iPhone, the app is extremely fast, virtually instantaneously loading up information.

But as with any app, there are areas that need improvement which I hope we will see in future versions.

First, images of higher quality and resolution are sorely needed.  Maybe the developers of Brain Atlas did not want to overwhelm one’s iPhone with a bloated memory hog of an app, memory dedicated to storing high res (at least T2 MRI) images, but one quickly reaches limitations with this app as a result of poor image quality, especially when using zoom feature.

Secondly, again related to the image quality, I found some of the images not to be perfectly planar.  This can create some big problems, especially for a student using Brain Atlas for training. In several images, the left side of brain shows a pin and region, but the corresponding right-side pin is missing.  Better planar imaging would likely correct this problem.

Third, looking at regions ad feature of the brain via a 3-D model or n index of technical terms is fine, but what happens when one forgets that technical term, or maybe is not as well-versed as a neuroscientist or neurosurgeon, what then – wade through all the information?  A better approach that I would like to see in a future version is search capability, maybe using natural language processing (NLP) that allows one to search on function of a given region as well.  THis would greatly enhance the utility of the app for the more educated lay person or physician.

The developers of Brain Atlas have done a very nice job with this first version of the app, but they have further to go before I can warmly recommend it at the price they are currently charging, which is on the high-side by iPhone app standard pricing.  High res images, better search features and more accuracy are needed for this app to be truly one great app at a good value.

The co-creators of iTriage, who happen to be ER docs, developed the app to address a very real issue they saw everyday in their day jobs: The huge information gap that consumers have in choosing what level of care is appropriate for a given symptom.  In developing iTriage, they wanted to marry “symptomitology” with diagnosis and from there recommended best care procedures/treatment plans and who is most appropriate to conduct those procedures for that given diagnosis.

How it works:

iTriage always launches with the question: Is this an emergency? If one answers yes, app automatically calls 911.

Once one gets past the “emergency question,” iTriage presents a very long list of symptoms alphabetically with search bar at top. Search on say chest pain, viola, there it is.

After clicking on given symptom  (we’ll use chest pain) one is provided an extensive list of possible causes (33 popped up for chest pain) which are often highly technical terms e.g., costochondritis, hiatal hernia, etc. and some more basic terms such as lung cancer. Within “Possible Causes” iTriage does offer a filter to limit selection to common, pediatric and life threatening causes.

Click on a Possible Cause and you are provided a number of fields to further drill down and understand the disease including standard work-up and treatment which may prove very useful in a clinical encounter.  Standard work-up and treatment guidance is based on best practices (the developers of iTriage set-up a review board to oversee and approve work-up & treatment write-ups found in the app).

To some extent, much of the above can be found in other iPhone apps such as A.D.A.M., SymptomMD and WebMD, though none of those apps do it as extensively and comprehensively as iTriage.

But where iTriage really gets interesting is assisting the user in the next step, where do I go to get treatment.  Once one goes through the above self-triage steps, you can click to “Advice Line” which takes you to an embedded TelaDoc page where one can initiate a call to TelaDoc to get fee for service advice on your symptom(s)/condition.

In addition to geting advice, one can also click “Find a Facility” and based on the disease you have self-identified, iTriage suggests which facility is most appropriate (see figure) and then leveraging the GPS capabilities of the iPhone locates the facilities within a given radius and provides directions from current location to the one chosen. Currently, iTriage has over 67,000 facilities listed within its proprietary directory.  iTriage also has established a partnership with physician/hospital rating service, HealthGrades allowing the user to access information (like TelaDoc, for a fee) on specific facilities listed.

Nice features, especially for someone who travels as frequently as I do.

The Business Model:

Certainly the company will make some money selling the app, but at $0.99, they’ll need to sell a lot.  They’ll also have some revenue sharing with their partners Coalition America, TelaDoc and HealthGrades.  But what they are really banking on is listing services, much like the Yellow Pages, but in this case listing healthcare provider services, probably geo-located, within the app. Company emphatically stated that they will not rely on referral fees.

The Good, Innovative Aspects of iTriage:

1) Comprehensive list of symptoms and diseases with vetted work-ups and treatment options.

2) Unlike most iPhone apps, which are siloed.  iTriage founders have done a mash-up of sorts leveraging partners to create a richer, more complete experience and of course, service.

3) Puts a lot of power into the hands of the consumer.

4) Low cost to end user to promote adoption, this could easily get viral.

5) Full HIPAA compliance to appease the privacy and security community.

And the Not So Good, Needs Improvement Category:

1) Interface is challenging and does not appear to be designed with the average consumer in mind.  Far too many of the diseases listed for a given symptom are in obscure medical terminology that is difficult to decipher.  This may be fine once a medical professional has confirmed a diagnosis and one wishes to know standard work-up and treatment, but as an entry point into self-triage, not so sure this is the best approach.  The filter feature helps to simplify searching on diseases, but while his may shoprten the list, there remains the technical jargon.  More graphical capabilities are needed – A.D.A.M. & WebMD have done a good job here that iTriage would be wise to emulate.

2) iTraige would also benefit from a built-in Natural Language Processor (NLP) allowing a consumer to enter common terms to search for a disease rather than a very long pick list.

3) Invoking the services of partners, particularly HealthGrades and medical bill negotiation service Coalition America is less than ideal. Right now, it is basically a punch-out to the Home Pages of these partners’ websites.

The Wrap:

A lot of utility in a small, cheap app that one can have with them wherever they go and tons of promise for the future as they expand partnerships and functionality to include such things as average costs of procedures, medication checking, etc.  In its current form, it is certainly a good app to have when traveling, and if having fallen ill with no idea where to turn – iTriage can be a great resource.

But this app, in its current version, requires a sophisticated user and takes some practice (too much in our book) to navigate effectively.  The developers have many plans in store for the app and will be releasing at least two more updates prior to Apple’s launch of the new iPhone OS 3.0, which is expected this summer. Let’s hope those versions focus on usability, the GUI and better embedding of partner services, rather than adding anymore features of which they have plenty for now.

ADDENDUM:

Just as we were geting ready to publish this, came across a presss release from Healthagen sent out today, 4/16/2009 announcing that iTriage will now have a cost estimator to assist the user in identifying potential cost of care.  Another nice feature Healthagen, but please, let’s get that interface cleaned-up.