Power to the Patient

By Catherine
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By Catherine Bolgar

Senior Patient Having Consultation With Doctor In Office

The explosion of chronic diseases threatens to be a major health issue in coming years, especially with the baby boomers entering old age. Getting patients to participate in, and assume responsibility for their own care, is key to keeping health care costs in line. In 2050, the number of people older than 60 is expected to reach 2 billion.

Indeed, health budgets are under pressure in all countries, causing a rethink of how to structure the way it’s delivered and paid for. For example, both the U.S. and U.K. are moving toward value-based or outcome-based care, with incentives for providers to coordinate care and improve quality of care, rather than payment based on the number of procedures done.

“The key word is going to be patient engagement,” says Felipe Lobelo, associate professor of global health at Emory University in Atlanta. “That means not just taking care of someone who’s sick, but also preventing someone from getting sick in the first place. The health-care system is going to be more proactive in working with people to make healthy choices.”

Doctor and patientOne study found that having a voice in decision-making led patients to better adhere to treatment, with better outcomes. Another found that patients who used online systems to see test results, manage their medication list and exchange secure messages with their providers felt more in control of their own care and were more satisfied.

“The bigger challenge is what to do to keep patients well,” says Phil Koczan, chief clinical information officer at UCL Partners, a health-science partnership linking higher education and National Health Service (NHS) members in the U.K.

The difficulty is how to identify those patients, many of whom don’t see a doctor on a regular basis, and how to change their behavior.”

Five key behaviors are related to avoiding chronic disease—never smoking, regular physical activity, no or moderate alcohol consumption, normal weight and enough sleep. In a recent study, only 6% of Americans do all five.

While physicians try to offer advice and support to people with risky behaviors, “it’s quite difficult and time-consuming, and resources are limited to offer that sort of support,” Dr. Koczan says. “But there’s a lot of benefit if we can get it right.”

Wearable devices and mobile applications can help—if patients stick with them. A device “doesn’t say how to change eating habits or how to change exercise habits. It’s not personalized enough,” says Vibhanshu Abhishek, assistant professor of information systems at Carnegie Mellon University in Pittsburgh. “Devices need to get more personalized and give specific recommendations based on current behavior. Just walking 10,000 steps isn’t enough. It has to give goals and specific instructions to individuals—if I ate a big lunch, then here’s how much more I need to work out today.”

Devices are most useful “when the intervention is tailored to the patient,” agrees Dr. Lobelo. For each patient, “it needs to be tweaked. It’s a never-ending series of projects and applications, not one universal solution.”

Another aspect of prevention involves keeping patients with diseases or chronic conditions from becoming sicker. Most patients with chronic conditions are at home, not hospitalized, so no doctor or health professional regularly observes whether they follow the recommendations they’ve been given, Dr. Abhishek says. “Mobile apps provide an opportunity to collect this information in a cost-effective manner on a continuous basis. Using algorithms or health-identification tools, a doctor can figure out whether a treatment is working. It hasn’t been possible to do this in a generalized way because data collection has been so expensive. In the future we can say treatment A works for this type of patient, and treatment B works for this other type of patient, based on the data from mobile devices.”

Measuring the pulseA number of online platforms offer information and support for self-care by patients with different diseases. The University of Pittsburgh developed iMHere, a mobile health platform to empower chronic-disease patients for self-care under a clinician’s guidance. For example, iMHere aims to help spina bifida patients avoid secondary complications, such as skin problems and urinary tract infections, through remote monitoring, with clinicians sending patients customized treatment plans. Other programs aim to help cancer patients manage their care, such as managing the accumulation of lymph fluid after breast cancer treatment.

Health systems are going to be more proactive in working with people to make healthy choices,” Dr. Lobelo says. “Including patients—that’s the center of the whole thing. We want to encourage people to self-measure and use the data to improve their health. An active dialog needs to happen.”


Catherine Bolgar is a former managing editor of The Wall Street Journal Europe, now working as a freelance writer and editor with WSJ. Custom Studios in EMEA. For more from Catherine Bolgar, along with other industry experts, join the Future Realities discussion on LinkedIn.

Photos courtesy of iStock

Digital Doctoring

By Catherine
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By Catherine Bolgar

The rapid increase in personal devices and smartphones with sensors and applications that can track various measures of users’ health offers new avenues for preventive care.

Particularly useful are bluetooth-enabled off-the-shelf devices such as weight scales, non-invasive blood pressure monitors or pulse oximeters, as well as regulated medical devices such as on-body devices like insulin pumps, on-body sensors that monitor such things as electrocardiography, temperature or glucose, and even pill bottles that track medications.

Researchers in Japan designed a smartphone app to identify early signs of dementia in the elderly. Argentina, Guatemala and Peru have mobile health (mHealth) initiatives targeting noncommunicable diseases such as cardiovascular disease. In Malawi, an mHealth project for new mothers has helped reduce unnecessary trips to the doctor.

Some mHealth projects give medical professionals less-expensive tools that enable them to reach remote patients in developing countries. The Portable Eye Examination Kit (PEEK) is being tested in Kenya to provide comprehensive ophthalmic testing via a smartphone.

“This is a very exciting, fast-moving field,” says Felipe Lobelo, associate professor of global health at Emory University in Atlanta. “There are many opportunities to integrate mHealth into preventive care for patients. When we say preventive care, it’s not just primary health, like warding off diabetes years from now, but also managing disease for people who have risk factors,” such as getting a person to make lifestyle changes after a heart attack to prevent a subsequent episode.

AliveCor  is one of the first FDA-cleared devices to be cleared by the U.S. Food and Drug Administration (FDA) for smartphones which provides for the monitoring and display of the patient electrocardiography, heart rate and wireless transmission of data to a healthcare provider helping patients to more effectively manage their condition and to be more proactive in their care.

Most wearable devices and smartphone apps are targeted at consumers for general wellness, but aren’t regulated by the FDA or by similar agencies in other countries because they aren’t intended to be used to diagnose diseases.

We see huge health potential and revenue potential if these devices become part of health care,” Dr. Lobelo says. “But for that to happen, serious steps need to be taken for standards for clinical use,” such as ensuring accuracy, security and privacy of the data.

The other hiccup is on the patient/consumer side. “The problem is, people download apps on their phones and stop using them after a week,” says Vibhanshu Abhishek, assistant professor of information systems at Carnegie Mellon University in Pittsburgh. “Engagement is a big issue.”

Dr. Abhishek and some colleagues studied a healthy eating project to see whether mHealth actually improved outcomes. They found that people did a better job of recording what they ate, but that feedback from a dietician significantly improved results, whereas peer support didn’t keep people involved nor did it affect eating habits.

Dr. Abhishek sees five levels of engagement with mHealth devices and apps:

  1. providing general information about the right thing to do.
  2. tracking information about consumers over time and giving a summary, such as steps taken, which are measured against a benchmark.
  3. getting personalized recommendations for improvements based on the tracked data.
  4. predicting life-threatening conditions based on data from the devices, such as high blood pressure or low blood sugar.
  5. giving tracked data to the health-care provider, who can see whether a treatment is working or can give patients advice via an app.

“We’re just now getting to level three,” Dr. Abhishek says.

Digital technology isn’t limited to mHealth. The U.K.’s National Health Service (NHS), a leader in digitization, aims to be largely paperless by 2020, with records connected across services from primary to secondary to social care. Despite a mandate since 2009, not all U.S. health-care providers have switched to electronic health records. Canada remains dependent on paper for many patient records.

Computers excel at data-driven tasks like calls for immunizations and refilling patients’ prescriptions for medications, says Simon de Lusignan, professor of primary care and clinical informatics at the University of Surrey in Guildford, U.K. Data also provides a surveillance system for predicting the winter flu season.

Eventually, we will have long-term data that will provide insight about whether a patient is stable or changing. Computers can assemble data that may be scattered around a clinical record to produce a risk score, which “may help us in how to intervene and manage people,” he adds.

A holistic view of the patient would be progress, says Phil Koczan, chief clinical information officer at UCL Partners, a health science partnership linking higher education and NHS members in the U.K. A diabetes patient might see a specialist for diabetes, a general practitioner for other treatments, and an eye specialist.

The big potential is for joining records up and giving patients sight and control of their records,” Dr. Koczan says. “Technology will link with mobile phones that will record personal health data that’s then made available to clinicians.”

That’s No. 5 on Dr. Abhishek’s levels of engagement, “giving patients the right information so they can act upon it and take the right decisions, and give information in some form to the health-care providers so they can improve the care.”

Dr. Abhishek concludes, “We’re in the very early days of mHealth. Eventually I think it’s going to be a very big component of how we can live healthier lives.”


Catherine Bolgar is a former managing editor of The Wall Street Journal Europe, now working as a freelance writer and editor with WSJ. Custom Studios in EMEA. For more from Catherine Bolgar, along with other industry experts, join the Future Realities discussion on LinkedIn.

Photos courtesy of iStock

Soon, artificial human organs may be used to personalize drug prescriptions

By Alyssa
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By: Quartz creative services


A team in Luxembourg has developed a machine that can mimic the physical and biological conditions inside your digestive system. Just add a pinch of your personal microbiome and watch how your body would react to certain foods or drugs. Is this the future of personalized medicine?

At a microscopic level, about 100 trillion bacteria live in and around your body, with a large proportion residing in your gut. The kind you find in yogurt and fermented tea, Lactobacillus acidophilus, is one of the most common, but there are hundreds of varieties. Each individual has a slightly different mixture of bacteria, and it’s known as your “microbiome.”

Medical research has begun to pay more attention to these gut flora since 2012, when the NIH, FDA, and DARPA began funding studies into machines which might explore the link between your microbiome and your risk for diseases like diabetes, obesity, IBD, and Crohn’s. Even some neurodegenerative diseases have been shown to have some link to your bacterial cocktail, and research suggests these critters have an effect on your everyday cognitive functions, too.

Until recently it has been impossible to actually use these gut flora outside the body—to simulate a real human reaction to a drug compound, for example. If put in just the right environment, such a simulation could help doctors predict an individual’s response to pharmaceuticals, foods, allergens, supplements, and environmental factors, opening up the promising possibility of creating personalized treatments that could drastically reduce the likelihood of disease, drug interactions, and costly post-hoc treatments.

The implications for drug personalization are particularly profound. According to the FDA, adverse drug reactions are the fourth largest cause of death in the United States, causing over 106,000 deaths annually. Stimulated human organs, such as a machine-based human gut, offer the opportunity to run predictive pharmaceutical tests on the efficacy and safety of various drug compounds. The findings from such tests could inform which drugs doctors choose to administer to patients and reduce the likelihood of drug interactions in individuals being treated for more than one condition.


What’s so hard about simulating a human organ?

“In the gut, you have really strict requirements in terms of the oxygen concentrations,” says Pranjul Shah, PhD and cofounder of Orgamime, the Luxembourg-based biotech startup whose gut-on-a-chip machine received wide acclaim in June 2016 following the publication of its white paper in the journal Nature.

The challenge, Shah says, is reproducing the exact bacterial habitat as it exists inside the intestines, a complex task. “Human cells need oxygen to survive and thrive, [but] the bacteria need to be in a steep, zero-oxygen environment,” says Shah. In the gut, two environments—aerobic and anaerobic—exist within a few microns of each other. It’s hard to build a machine from plastic and simulated mucous that can do the same thing. “This gradient is so steep that many other systems which have tried to do that have failed to achieve it,” he says.

Plus, the machine needs to reproduce the physical changes caused by food material passing by, an effect called “shear.” “The bacteria are used to some kind of shear in the gut because it’s a constantly pulsating environment,” says Shah.


Will gut-on-a-chip machines change what you choose to eat?

The food industry, rife with pseudoscience, will also be transformed. While machines like Orgamime’s can facilitate personalization of drug compounds, they could also be used to verify food manufacturers’ health claims, or definitively prove whether ingredients like high-fructose corn syrup are actually bad for humans.

“There have been a couple of papers which came out very, very recently that say that artificial sugars—not natural sugars, but artificial sugars—are really a big problem,” says Shah. The true link between high-fructose corn syrup, gut flora, and diabetes might be deduced using gut machines like Orgamime’s. Shah, whose family has a history of diabetes, has already stopped consuming high-fructose corn syrup. “If you get the Mexican Coca-Cola, it’s real sugar,” he says. “Even when I’m traveling in the US, if I have an option, I ask for the Mexican Coke.”

Also on trial will be yogurts, the health claims of which will have to be substantiated with data, Shah predicts. “We’re getting a lot of requests from companies which are selling off-the-shelf probiotics which claim to boost your memory or help you lose weight,” he says.

Straight-up bacteria might even become a food group, of sorts. Bacterial transplants, already shown to be effective for treating the GI tracts of immuno-suppressed individuals, might become commonplace for all patients after a surgery or bout of illness. Family members might lend you their strains, or doctors might mix up completely artificial cocktails as substitutes and test their effects in a machine. The point is, it will be highly customized to you.

“A most suitable donor could be chosen based on your genetic makeup, the current system of bacteria that you have, and your diet, your stress level, your lifestyle, and the environment that you live in,” says Shah.


How can we prove the gut-on-a-chip actually works?

Shah began working full time on his machine in 2011 alongside Orgamime’s cofounder Sivakumar Bactavatchalou. Though it began while Shah was a PhD student in life sciences, the project now incorporates recent advances in electrical engineering, IT, and 3D printing. It is comprised of eight computer-controlled bacteria chambers, each of which mimics a different segment of the human intestinal tract.

To prove their simulation was accurate, Shah and Bactavatchalou conducted two published clinical studies (one in Europe, one in South America) to see if they could predict human subjects’ reactions to probiotics. Patients were first endoscoped to take a sample of gut material, then given six weeks of probiotic therapy with a live culture known as Lactobacillus rhamnosus, or LGG, commonly found in yogurt.

In gut science, one marker of impact for a probiotic supplement is your body’s secretion of proteins called cytokines, which send signals to other cells. Whether or not these cytokines are pro-inflammatory—a sign the body is being attacked, and invoking an immune response to deal with the threat—can be assessed by looking at the RNA excreted by the cytokines.

When Shah tested his patients’ RNA secretions alongside the Orgamime simulated gut, the results were identical. “We took the same bacteria, same type of cells, same conditions—and we see exactly the same genes to be influenced in our system at the molecular level,” Shah says.


What this means for existing drugs

About 30 percent of new pharmaceuticals fail in human clinical trials despite promising animal tests, according to the NIH. Orgamime’s technology could call into question every compound discarded by drug companies over the past 50 years. Those compounds can now be re-assessed for usefulness as a result of the more accurate simulated-human testing that has become available. Anywhere from 300,000 to 500,000 discarded compounds could be re-tested.

“I expect every pharmaceutical industry will open up their closets to startups,” says Shah.

But first, the FDA must approve the validity of machines like Orgamime’s. The department has announced it will begin clinical trials sometime in 2017. “If something like this happens,” says Shah, “it’s going to be the biggest game changer in the field of medicine, at least in the drug testing and development, in the last 50 years.


To discuss this and other topics about the future of technology, finance, life sciences and more, join the Future Realities discussion on LinkedIn.

This article was produced by Quartz creative services and not by the Quartz editorial staff.

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