Symcat Blog

Early in medical school, I was involved in the care of Ted, who could have been my grandfather. At 76 he was as spry as any of the patients on the ward and always welcomed me with a “morning, Doc!” He was admitted because he was having concerning chest pain several times a week. Opening and closing 2.8 billion times throughout his life, his heart valves had gradually become hard and inflexible preventing blood from leaving at its usual rate. Now, it was risking his life. He had several treatment options available to him: valve replacement through open-heart surgery, a new minimally-invasive procedure where they snaked a new valve through the body’s blood vessels and into the heart, or just taking medications to help with his symptoms. It was my job to help Ted figure out which option was best for him.

Medicine is a highly cognitive discipline, demanding deliberate analysis and careful attention. Moreover, the body of evidence-based practices and medical knowledge continues to grow. Indeed, it has far outstripped physicians ability to stay up-to-date on the latest research. As a result, researchers and businesses have since the 1960s been working to codify medical practice and knowledge so as to offer cognitive support to health care providers trying to advise patients like Ted. These software-based tools usually place textbook knowledge at a doctor’s fingertips. Many of them such as INTERNIST and DXPlain became highly complex diagnostic tools.

However, despite the tens of thousands of person hours that went into developing them they failed to see widespread adoption. This seems strange, maybe even a tragedy, when one considers that as many as 15% of diagnoses made in the US are wrong. That number approaches 50% when considering physician’s management decisions. So why haven’t these tools been more widely adopted?

In general, getting physicians to use decision support tools has significant barriers. For one, there is a perception of a highly-optimized workflow being very sensitive to disruption of change. However, this is not the main obstacle. Physicians are amenable to tools that genuinely save time. However, many decision support tools require a substantial investment of time.

Take, for example, the STS calculator assessing Ted’s risk during cardiac surgery. Insofar as it can predict morbidity and mortality, it is a very useful tool. As you can see, though, there are a number of variables to contend with. Over 40 once you start answering questions and getting into the decision tree logic. Unfortunately, in this example it is hard for a physician to really weigh the different probabilities of death and injury that it presents. Would you prefer a 5% risk of dying from a procedure with a 90% chance of improving symptoms or a 2% risk of dying with a 70% chance of improving symptoms? “How much risk of death am I willing to tolerate for a shot at a cure?”

To answer that question you would need to know about your life expectancy, your quality of life with and without your symptoms, and critically, your own preferences about the type of life you want to lead. Everyone wants to live a healthy and happy life for as long as possible, but when you have to make trade-offs, the decision becomes a deeply personal one.

Of course, there are cases when the trade-offs seem very small. Prescribing a well-studied medication with few risks can dramatically increase a person’s years of healthy life. In these cases, though, no calculator is needed. A physician’s intuition and expertise alone are usually enough to guide a patient in their care.

But when it comes to the decisions at the margins, when even a physician is ambivalent about the right course of action, there can be no other way than to have a frank conversation about a patient’s values. In other words, borderline numbers quoting risk will not appreciably change the final decision. And a decision support tool that cannot change someone’s decision is useless. So, it’s really up to the patient. In these cases, it’s easier and more valid to ask a patient about their values and avoid exposing them to risk calculators derived from special study populations with extensive caveats.

Of course, this may not be true of all physician decision support, just a lot of it. Yet, the story goes a little differently for patient decision support. While there is generally good agreement between a physician’s intuition and actuarial risk, there is a huge gap between patient’s intuition and said risk. That means patients stand to gain much more from the tools that physicians have for the most part rejected. Patients can derive benefit from risks and recommendations quoted by these tools not just when the difference among choices is marginal, but potentially every time.

It’s encouraging to witness a burgeoning of apps designed to effectively communicate to patients the risk of medications and procedures. There are a great deal of new usability and vocabulary challenges to address in these efforts, however.

At Symcat, we’re trying to combine our medical expertise with sophisticated user-interface design to improve patient decision support, but there are others trying to do this as well. What attempts to communicate medical information to patients have impressed you the most?

-Craig

I happen to fall into a large group of people who take ill once the weather starts to change and it gets cold outside. It has happened for as long as I can remember, and generally my symptoms are: coughing, head cold, runny nose etc. It’s very similar to what the average person experiences when they have a flu. Over the past few years as I’ve grown and understood myself better however, I’ve found that while I haven’t completely knocked this seasonal illness, I’ve managed to cut the bouts down and shorten the duration whenever I do have them. I’ve learned to do things a bit differently when that time of the year (usually between October and March) approaches and it’s been very effective for me. Here are some things I do and encourage you to try:

1. Drink a lot of water. Believe it or not, your Doctor was right when she told you to try drinking 2L of water daily. It’s good for your body. Water makes up 60% of your body weight and every system in your body depends on it. It flushes out toxins from vital organs, carries nutrients to your cells and provides a moist environment for ear, nose and throat tissues. The body loses water easily through breath, perspiration, urine and physical activities. Lack of it leads to dehydration and even a mild case of it knocks your energy levels leaving you more susceptible to taking ill.

2. Eat well. A balanced diet goes a long way in keeping your body functioning at its best level. Research has found positive links between immune function and certain foods, so eating a lot of those immune-building foods could be helpful. For example, Garlic has been shown to boost immunity and increase resistance to infection and stress, cheese and other dairy products contain conjugated linoleic acid, a natural component of dairy fat which has boosted immune response in several trials, Yogurt contains probiotics, beneficial bacterial with immune boosting benefits etc.

3. Exercise well and Keep in good physical shape. It’s general knowledge that exercise often prevents oncoming illness, one study has shown that exercise is linked with nearly 30% reduction in upper respiratory tract infections. During a routine exercise session, endorphins are released into your body, causing relief from certain illnesses and several psychological conditions like depression and anxiety. I advise to join an indoor sports league to help you stay active at least 2 times a week. I personally play soccer 3 times a week, I prefer team sports and encourage it for you as well, it lets other people hold you accountable.

4. Don’t smoke. This must have popped up on your screen several times and for good reason, it is bad for you. Smoking causes your immune systems to weaken and leave you more susceptible to viruses.

5. Wash your hands regularly. This is a no-brainer, viruses are easy to transfer and so when you lead a life that involves a lot of human interaction, your chance of contracting a cold or flu remains high. Just have a look at some of these stats from a recent survey:

• Only 85 percent of respondents said they washed their hands after going to the bathroom, down from 92 percent in 2006.
• 46 percent said they wash their hands 15 seconds or less. Fifteen to 20 seconds of hand washing with soap is recommended by the U.S. Centers for Disease Control and Prevention and the SDA.
• 39 percent of respondents said they seldom or never wash their hands after coughing or sneezing, compared to 36 percent in 2006.
• 35 percent said they don’t wash their hands before eating lunch, compared to 31 percent in 2006.
• 37 percent wash their hands fewer than seven times on an average day.
• Only 56 percent of respondents knew that hand washing is the most effective way to prevent colds.

Imagine how quickly the bacteria and viruses can be passed on from one person to the next. Buy hand soap and keep a hand sanitizer close by.

6. Sleep well. Getting a good night sleep has been shown to prevent common cold. In a recent study published in the Archives of Internal Medicine, researchers studied a number of participant’s sleep pattern. Each person kept track of their sleeping habit for 14 days noting how long and how well they slept the previous night as well as whether they felt rested. After 14 days, the participants were quarantined, given nasal drops containing a cold-causing virus (rhinovirus), and monitored for five days for signs of a common cold. The results showed that those who slept an average of less than seven hours per night were nearly three times more likely to develop a common cold than those who reported eight or more hours per night in the weeks leading up to the experiment.

Have any other tips you personally follow to keep cold and flu away? Share with us below.

- Tolu.

Over the last couple of days you may have noticed a few shiny, new features on the site, we are constantly trying to make Symcat easier to use and your number 1 health channel online. We are evolving beyond just a ‘symptom checker’, our goal is to help you keep track of your health and make better decisions.

We want to introduce you to some of the changes we’ve made:

Have a private profile, on us. 
You now have a health profile. You can manually add and keep track of all your medical conditions. You will also find personalized health tips in your profile.

View your health timeline. 
Your health timelines shows you the symptoms you’ve had most often, how often you’ve had them, and over what period of time. 

Print your profile. Your doctor will love it.
We’ve added a new ‘print’ feature. You can now print your health history for your doctor so that you can both work to better manage your health.

Can’t wait to check it out? We can’t wait to show you either! Sign in now.

We love getting feedback from you all, if there’s anything you think we could do better, don’t hesitate to let us know. We also have a few questions we want your thoughts on. Help us answer them here.

- Tolu.

It is no secret that research relies critically on data collection. Whether you’re talking about pharmaceutical research, market research, or outcomes research, successful analysis can only be done with robust data that captures the metrics most relevant to the question at hand. Unfortunately, that degree of data collection can be an expensive proposition, especially when it comes to health care.

Large drug trials, costing on the order of $1B, require hiring multiple research centers to recruit patients that meet very specific inclusion criteria and then adhering as closely as possible to the study protocol. Identifying and recruiting centers itself contributes a great deal to the overall cost of the study, but there are challenges at just about every level.

Even when no drug is involved, no intervention being tested, collecting data from the the medical centers that produce it can be extremely laborious. Frequently, experts will analyze reams of paper charts in order to extract meaningful information: patient demographics, symptoms experienced, lab values, and outcome measures like duration of the hospital visit. With so much overhead required even just to look back at what happened during someone’s hospital stay, it is no wonder that individual “case reports” or “case series” were for a long time the lingua franca of medical research.

Thankfully, the costs associated with recording data have shrunk dramatically paving the way for big data to reach health care. Though privacy issues still loom, it is now possible to transfer all information about a patient onto a single jumpdrive or, more relevantly, transfer that data to the cloud for remote access. Instead of being stored in large warehouses like below (source: The Next Frontier in Health Care Reform), medical records are being transferred to virtual data warehouses.

While today most hospitals have their own warehouses, Health Information Exchanges are being created to encourage the consolidation of health record data across hospitals and health networks. New solutions will need to arise to promote data translation and virtualization (perhaps a topic for a future post.

One upside to all of this is that it will become easier to transfer your records from one health provider to the next. No longer will you have to “start over” each time you see a new doctor or carry around your entire paper chart (if you’re a particularly conscientious patient).

But perhaps the most exciting consequence of the virtualization and aggregation of health data is that it will allow us to very naturally track what happens to each person as they go through the health care system. The month-long process of digging through paper charts can be replaced by fast queries of health record databases that take literally less than a second. Instead of the prohibitive task of searching through every single chart for males over 65 who have been prescribed dabigatran, one need only incorporate that logic into a query. Maybe I decide I want to perform a similar analysis for women. Seconds later, I have my data.

There is still a ways to go, but there is no doubt that the big data trend reaching health care will improve our ability to do research quickly and cost-effectively. Having a faster turnaround on research can offer us great insights about the natural history of poorly understood diseases, what treatments are most effective, or how we can better deliver the health care we already know works. With the trend we are seeing in access to health care data, it may only be a matter of time before getting these answers is as simple as figuring out what question you’d like to ask.

What do you think? What questions would you like to ask if you had millions of medical records at your disposal? Do you have any reservations about your health data being used for medical research?

- Craig

Though it sometimes drives us to cyberchondria, the Internet undeniably offers a wealth of resources that can meaningfully impact the decisions we make when faced with illness. In addition to Symcat, there are a great many companies helping improve the quality of information available. Our friends at FoundHealth share with us one story of a young women’s experience using the Internet to help her better manage her depression and move on with her life.

Delilah, a thirty year old woman living in San Francisco, had been feeling sad, moody, and anxious all at once for the better part of few months. After endless deliberation, she finally decided to call the doctor. After enduring the arduous process of convincing the advice nurse to book an appointment, she trekked her way over, and plopped herself on the exam bed. The nurse measured her weight, recorded her vitals, and politely told her that the ‘doctor will be with you shortly.’

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Over the past few years, there’s been a wild soar in number of social apps on the web. It is now ridiculously easy to find out what your friend you haven’t talked to in 20 years is doing, why he’s in the sunny outskirts of Malaga, or learn of his newfound love for Liverpool Football Club. In fact, it can be done in seconds. On the other hand, it’s incredibly difficult to find out what the health trends are in your city are and why all of a sudden your local news channel is reporting 6 cases of meningitis in your nearest hospital. Health information has not always been “at the tip of your finger,” but all that is starting to change.

The trend of big data has significantly picked up lately and there’s been a lot of talk about it. No surprises there.

But what exactly is Big Data? Literally, as the name implies, it means a large amount of data. According to a recent article on O’Reilly Radar, it is “…data that exceeds the processing capacity of conventional database systems. The data is too big, moves to fast, or doesn’t fit the structures of your database architecture. To gain value from this data, you must choose an alternate way to process it.” The amount of data available on medicine and health is significant. A number of health focused startups have taken advantage of that data to build products that not only educate patients but also finds help for them. However, it’s not that easy…

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Great excerpt from the Inc story about innovation in HealthCare by Adam Bluestein

BIG IDEA
The Algorithm Is In
Why smart software means better diagnoses.

When aches and pains keep you up at night, Google is not your friend. According to a 2008 study, about 50 percent of people who diagnose their ailments online believe that the higher the search-engine ranking, the more likely it is that they have the disease. Guess what? “That’s completely false,” says Craig Monsen, a computer engineer and Johns Hopkins medical student who co-founded Baltimore-based Symcat, a new kind of online symptom checker. “When you type a symptom into Google, the problem is you’re not getting content sorted by likelihood. For back pain, your top results might be malaria or tuberculosis; for muscle twitching, you’ll get Lou Gehrig’s disease. The fact is, these are actually quite uncommon. That causes undue concern or is at best unhelpful.”

Apart from the bad-diagnosis problem, says Monsen, online sources like WebMD are more like encyclopedias than diagnostic tools; they’re really just textbooks put on the Web. “That works well for search-engine optimization,” says Monsen. “But it doesn’t provide an answer to what you have or tell you what you can do about it.” Symcat’s focus is to answer these questions as quickly as possible, using a data-driven approach similar to that used by companies such as Netflix or Pandora to suggest movies or music.

The software’s simple interface lets users type symptoms into a search box, prompts them with follow-up questions, and then compares the responses against patient data from the Centers for Disease Control and other public sources. Using the same kind of triage algorithm as physicians, Symcat presents a list of possible causes and their percentage of likelihood, and recommends next steps that could include self-care, calling a nurse practitioner, or visiting an urgent-care center.

Why not just call the doctor? “That’s great if you have access,” says Monsen. “But that’s the problem—so many people turn to the Internet because the health care system is not optimized for access. Your average wait time to get an appointment is about three weeks, and your appointment is 12 minutes long. The ER is convenient, but that creates another problem.

“There’s a growing recognition that we need to do a better job getting people to the right level of care, or else they will take advantage of the most expensive option, which is the ER,” Monsen says. “It’s not Symcat’s intention to be a substitute for a doctor, but to empower people with actionable information and be a guide to the universe of health care options—a first step to figuring out where you belong in the system.”

Read the full article here: http://www.inc.com/magazine/201210/adam-bluestein/the-coming-revolution-in-health-care.html

As exciting as the digital health space is right now, there is still little guidance or validated path to getting off the ground. As part of an effort to help aspiring health care entrepreneurs, I’ll be writing a series of posts explaining some of the decisions we made for Symcat. It hasn’t been a year since we’ve started, but my hope is that our few months of experience can help those who are just getting started themselves.

One of the questions I’m most frequently asked is if our time at Blueprint Health, a health start-up accelerator, was worth it. To participate, the program requires 3 months of relocation to the NYC offices in SoHo and the forfeiture of a nearly 6% equity stake in the company. The program basically offers $20k, mentorship from its network, and office space. A few other health start-up accelerators (ie Rock Health, Healthbox) have some variations but basically the same theme. They are all very selective accepting 3-5% of applicants. While it’s nice to be accepted, there’s still the important matter of deciding if it is right for you.

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Heads up: we’ll to be presenting at Health 2.0 San Francisco in a few weeks. October 9th to be precise.

Originally we were slated for The Future of Personalized Medicine, but we will now be presenting as part of Payment Reform and Transparency: Tools for Financial Management and Decision-making. Honestly, it seems like Symcat can fit in most of the talks, but despite the session’s lackluster title this one should be good. The session includes Castlight Health (notable for a recent $100M round), as well as Cake Health and Simplee.

We are also going to be presenting at a second talk with title to be determined.

We should be there for the entire conference (Oct 7-10). If you’ll be at the conference and want to meet up, shoot me an email.

Also, if you’re going to MedicineX next weekend, I’d love to hear about it. We were supposed to present but wound up having a conflict that weekend. C’est la vie.

Craig

If you check Symcat on a regular basis, you know how often we’re trying out new features and tweaks to the site. We introduced a big one yesterday that we’re pretty excited about. 

The “Ask the SymCommunity” feature allows you to attach a question to your visit profile. This doesn’t affect the probabilities that appear for likely conditions…yet…but it does allow you to ask other Symcat users for help.

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