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Jonathan Javitt on the Future of Direct-to-Patient Connectivity

Former White House healthcare adviser and TelCare founder Jonathan Javitt casts a vision for telemedicine’s future, and explains why connected devices are just the beginning.
Interview by Mark Plaster, MD

Telemedicine: Tell us a bit about the health IT work you did for the Bush administration.

Jonathan Javitt: First of all, I didn’t join the Bush Administration in order to computerize medical records. I joined the Bush Administration because I was so shocked and outraged on 9/11 2001 that I felt like it was time to join the fight. And I actually spent the first 18-24 months of my time in the Administration in the National Security Health Policy Center, working on stuff that had nothing to do with Health IT but was all about preventing the next bioterrorism attack. At the end of that stint, the President’s chief domestic policy advisor came to me and said: We’d really like you to consider doing something in the civilian health care sector. And we talked about a number of different opportunities. I said: Well, you know, the thing I’ve always wanted to do is get the paper out of the health care system and move the United States in the 21st century when it comes to medical records and Health IT. And they said: Well, that’s not on our agenda. Why are you talking about that? I said: Well, here’s the problem. We’re going to spend $2 trillion on health care next year. And right now the only options on the plate are either deny care to patients or pay less money to doctors in the hospitals. Or both. If you deny care to patients, you run the risk of killing people. And if you reduce payments to doctors in hospitals, we’re at the point where they just go out of business. So the only third alternative is to make health care more effective and more affordable. And the only way I know to do that is with Health IT.

Even before we’d done anything, [Bush] put a line in the State of the Union saying: Electronic medical records save lives and save money. And people were scratching their heads and saying: Where did that come from?

So we convened a task force. The President appointed me as the Chair of the Health Committee of the President’s Information Technology Advisory Committee. And we started listening. We started doing town halls all over the country. I went to HIMSS and did a couple of town halls and talked to people in industry and really started listening and understanding: Well, what can electronic medical records do and how do you deploy them? And over and over again we started hearing: Well, until you really connect the patient to the electronic medical record, at best you’ve taken something that could be done on paper and put it into a computer. But the minute you connect the patient, now you can create magic. So that was the surprising outcome of the process in which we engaged. And it’s really what led directly to TelCare.

Telemedicine: How do you feel about the current state of Health IT?

JJ: I’m not satisfied with the direction and pace of electronic health records. Then again, I’ll spend my life being dissatisfied. It’s never fast enough for me. It’s never comprehensive enough for me. That’s why I’m always pushing.

Telemedicine: Why did you launch TelCare?

JJ: So our focus is on using connected medical devices to join doctors and patients around improving care for chronic illness. And right now our first product is a connected blood glucose meter. Every time you test your blood sugar, the data goes up to the cloud. You get immediate feedback. And we’ve got a published study showing that that seemingly simple innovations – we didn’t invent the blood glucose meter; we didn’t invent the cell phone. All we really did was take a couple of chips out of the cell phone and put them inside the blood glucose meter. That little intervention seems to double or triple adherence to blood sugar testing. And at least from one study it’s reduced the cost of care by 50 percent. The real reduction is you’re spotting the people who are running sugars of three, four, 500 on a daily basis before they wind up in the hospital. These are people who wind up in the hospital in hyperosmotic coma. These are people who stroke. They wind up with gangrenous toes. All of that’s avoidable. The product is commercial. It’s been FDA cleared for more than two years now. We’ve put out 50,000 units in people’s hands.
    
Telemedicine: Where do you see the greatest opportunities for remote monitoring?

JJ:  I think the low-hanging fruit for avoidable hospital admission is people with diabetes. It’s people with pulmonary disease. Cardiology is a little tougher. Cardiac event monitoring is technically more difficult. And building the device that lets you really spot the events is more difficult. Although I’ve seen one interesting technology for people who have sort of chronic unstable chest pain and getting cardiac enzymes drawn on a regular basis; I’ve seen a pretty nifty electronic device that’s almost as good as enzymes. But if you just attacked diabetes and pulmonary disease, that’s a lot. You don’t have to go the whole enchilada to make a huge difference. You could start out by putting the history gathering and review of systems gathering tool in the front room of the ER.

Telemedicine: How has your recent move to Israel impacted your med tech ventures?

JJ:  For me Israel is just the world’s greatest medical start-up environment. Part of what makes it so exciting is if you show up with $100,000, the Chief Scientist for the State of Israel will match it with $500,000. That’s why Israel is ten percent of the NASDAQ. That’s amazing. As I drive from my house to the university where my wife teaches, I pass Qualcomm and Google and Yahoo and Microsoft and Intel. Pretty amazing start-up environment. Oh, and GE and Phillips.
I’m part of a venture fund over there as well. We just did an IPO. I’m passionate about what TelCare is doing, but I’m passionate about the whole field. So, for instance, in the last three months we’ve had two IPOs out of Israel. One’s a company called ReWalk. It’s an exoskeleton that lets people with quadriplegia walk for the first time since their injury. The second one’s a company called Check-Cap. It’s a capsule you swallow with a camera in it and it’ll show you the small bowel. The problem is once it gets down towards the cecum, it can’t see through the fecal stream. So that’s the end of its usefulness. So Check-Cap has a capsule with a very small X-ray emitter in it. It’s doing the same kind of reflectance X-ray as the body scanners in the airports and images the entire large bowel for you. It passes through and you poop it out. It’s a prep-less colonoscopy.
 
Telemedicine: What are telemedicine’s greatest hurdles moving forward?

JJ: I don’t think the hurdles are political. First of all, the payers are terrified of opening one more spigot for reimbursement. That to their way of thinking is always going to be additive to everything else.

A big hurdle is that, until recently, the technology wasn’t there. I mean, if you walked around the ATA ten years ago, you would have seen pretty clunky old modems; I mean, real Rube Goldberg stuff. You know, TelCare is the first product where somebody ever took a state-of-the-art cellphone chip and put it inside a medical device and said: This is seamless. All you got to do is stick your finger, put a drop of blood on the strip, pull the strip back and it transmits. Nobody ever saw that before. Even now most scales, you know, you got to pair it with an iPhone. Well, that’s a frustrating process. It stays paired until your phone pairs to your car. And then all of a sudden it knocks off the Fitbit. The whole Bluetooth thing to is very unstable. I think you’re going to see cloud-connected devices.

Telemedicine: What about the challenge of health data security?

JJ: Some patients will say: Well, is this HIPAA compliant? Or is this secure? And you’ll say: Well, here’s the data that says it is. And that’s the end of the conversation. People are worrying more about their bank accounts being hacked than their health records being hacked. I’ve known a number of people who were killed or injured because their health information was not available to somebody when it needed to be. I’ve never met anybody who was killed, injured or even inconvenienced because their health information was improperly made available to somebody it shouldn’t have been. HIPAA is a great law. Being able to put somebody in jail for invading somebody else’s private information is a really good thing. So, I’m not suggesting for a minute that that’s not a good legal remedy. But normal levels of encryption are more than adequate to deter all but a committed thief.

And if you’re going to be a committed thief, you’re better off spending your time invading somebody’s bank account.

Telemedicine: How do you see payment reform and capitated care driving med tech?

JJ:  Once you’re doing capitated care, then the government policymakers say: It’s not our problem anymore because we pushed the risk down to the care system. If med starts capitated and they can do half as many visits, they will. I just spent time with a young man today who’s built a little company around normal low risk OB. And they put a box together that costs a couple hundred dollars with a scale and a blood pressure cup and some nifty apps. And they’ve got OB groups who are taking a $3,000 global fee for labor and delivery. And they’re saying: Gee, by deploying this and we’ve got a daily weight and a daily blood pressure we can cut our number of prenatal visits in half. So the Med Star OB Group is paying a couple hundred dollars per woman for this product and service because they’re saving $800 per woman. So capitation does drive the stuff in the right direction. Now the problem you run into of course is some bright guy will say: Well, why don’t we do a study because maybe we’re seeing people twice as often as we need to? So rather than paying this nice little start-up company a couple hundred dollars for their box, let’s just cut the number of prenatal visits in half and see if anybody suffers. That’s what’s going to happen.