Ensuring equitable access to healthcare in the age of algorithms and AI

Yesterday, Dr. Peter Vaughan, chair of the board of directors of Canada Health Infoway, spoke at Longwoods’ Breakfast with the Chiefs.

After outlining the current state and future perspectives of digitization in healthcare, his main message was two-fold: 1. We are at risk of a “failure of imagination”, i.e. we cannot fathom all the possible futures that digital disruption might confront us with and hence fail to plan for their pitfalls adequately. 2. There is great potential for algorithms to be built in such a way as to solidify and deepen inequalities that currently exist in our system, and we need government oversight of such algorithms to prevent this from happening.

The first point is easy to understand, the second point may need little more explanation. Algorithms are used widely to determine what information is presented to us online, what choices are offered to us. We are all familiar with websites, offering us items we ‘might also like’, based on our past choices and based on what other purchasers have bought.

At a time when data from various sources can be linked to create sophisticated profiles of people, it would be easy for a healthcare organization to identify individuals that are potentially ‘high cost’ and to deny them service or to restrict access to services. Bias can creep into algorithms quickly. If people of a certain age, ethnic background or location are deemed to be ‘higher risk’ for some health issues or for unhealthy behaviours, and this is built into an algorithm that prioritizes ‘lower risk’ customers, then you are discriminated against if you share the same profile, no matter how you actually behave.

Discrimination is often systemic, unless a conscious effort is made to break the cycle of disadvantaged circumstances leading to failure to thrive leading to lower opportunity in the future. As Dr. Peter Vaughan pointed out, we in Canada value equitable access to healthcare, education and other public goods. We expect our government to put safeguards in place against discrimination based on background and circumstances. But how can this be done?

Private, for-profit enterprises have a right to segment their customers and offer different services to different tiers, based on their profitability or ‘life-time customer value’. Companies do this all the time, it is good business practice. But what about a private digital health service that accepts people with low risk profiles into their patient roster, but is unavailable to others, whose profile suggests they may need a lot of services down the line? Is this acceptable?

And if the government were to monitor and regulate algorithms related to the provision of public goods (such as healthcare) who has the right credentials to tackle this issue? People would be needed who understand data science – how algorithms are constructed and how AI feeds into them – and social sciences – to identify the assumptions underpinning the algorithms – and ethics. Since technology is moving very fast, we should have started training such people yesterday.

And how could algorithms be tested? Should this be part of some sort of an approval process? Can testing be done by individuals, relying on their expertise and judgement? Or could there be a more controlled way of assessing algorithms for their potential to disadvantage certain members of society? Or a potential for automation of this process?

I am thinking there may be an opportunity here to develop a standardized set of testing tools that algorithms could be subjected to. For example, one could create profiles that represent different groups in society and test-run them as fake applicants for this or that service.

Also, algorithms change all the time, so one would perhaps need to have a process of re-certification in place to ensure continued compliance with the rules.

And then, there would be the temptation for companies to game the system. So, if a standardized set of test cases were developed to test algorithms for social acceptability, companies may develop code to identify and ‘appease’ these test cases but continue discriminating against real applicants.

In any case, this could be an interesting and important new field for social scientists to go into. However, one must be willing to combines the ‘soft’ social sciences with ‘hard’ stats and IT skills and find the right learning venues to develop these skills.

Much food for thought. Thank you, Dr. Peter Vaughan!

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Medical marijuana in Canada

I attended a very interesting Life Sciences Ontario (LSO) breakfast meeting on medical marijuana in Canada. Here are some key takeaways:

Production

  • Currently there are only 38 licensed producers (LPs) in Canada that grow the plant.
  • Regulators control access to this market tightly and barriers for new companies to become licensed producers are high.
  • One of the challenges for production is to grow a standardized crop, i.e. plants that have roughly the same level of chemical compounds in them crop after crop.
  • Canada is perceived as one of the top players worldwide for growing of marijuana under controlled conditions that will stand up to health regulators’ scrutiny (along with Israel).

Distribution

  • Dispensaries are illegal – there is no legal grey zone. It is not Health Canada’s job to monitor dispensaries. This is the responsibility of municipalities. There seem to be crack downs on dispensaries occasionally, but then they spring up again.
  • The only legal way to obtain medical marijuana in Canada is through licensed producers, and they will ship the product to the patient directly.
  • There is currently a push to make other forms of distribution legal. At the forefront of this is Shoppers Drug Mart’s effort to convince regulators to let them dispense the product at their pharmacies. So far, no luck.

Acceptance in physician practice and among patients

  • Clinical studies on the benefits of medical marijuana are challenging since it is difficult to grow a stable product that will have the same properties throughout the course of the trial. Getting clinical studies published in peer-reviewed journals is also challenging. However, audience members felt that Canada is in an advantageous position in terms of conducting more research in this area.
  • The Canadian Medical Association does not condone widespread prescribing of medical marijuana, but it also does not actively deter physicians.
  • One of the challenges for physicians in prescribing medical marijuana is the fact that the product comes in a variety of forms and may not be stable/standardized. Many are uncomfortable prescribing the dry form, since it is unclear how exactly to dose it for a given patient. Prescribing the oil may be easier for physicians.
  • Patients may also have different preferences for an oil vs an inhaled product or even an edible.

Taxation

  • Experience in the U.S. has shown that the market will be impacted by decisions on taxation. If, for example, medical marijuana is taxed heavily and the recreational use of the product is taxed more lightly, patients will tend not to bother getting a prescription.

Regulatory

  • The regulatory process is moving slowly, slowly. While a regulatory framework has recently been proposed, making it into law could take 18 months or longer. According to meeting participants, the proposed framework will likely undergo many changes, and a final decision is not expected before 2019.

The LSO breakfast meeting took place on January 19, 2017 at the offices of Fasken Martineau in Toronto. The meeting was chaired by LSO Board member Dr. Alison Symington. The panelists were:

Ken Clement, CEO of ABcann Medicinals Inc, a licensed producer of medical marijuana. ABcann’s business is focused on growing organic standardized medical cannabis, recognizing that an expertise in growing standardized crops positions the company well in the medical marijuana market.

Christelle Gedeon, Associate at Fasken Martineau DuMoulin, is one of the firm’s regulatory affairs specialists with expertise in pharmaceuticals, medical devices, natural health products and medical marijuana, among other things.

Nick Antoniadis, Principal at Nick Antoniadis Consulting, is owner of his Toronto-based management consulting company. He is a marketing leader with over 20-years-experience in global healthcare. In the medical marijuana market, he has focused on connecting with and gaining insights from patient aggregators such as prescribing physicians.

Summary prepared by Barbara McGrath, PhD, Owner of Creative Research Designs, a company that provides customer insight and market research to companies in healthcare. This summary was not reviewed by LSO or any of the meeting participants. It reflects my own understanding of what was being said. You can contact me at: barbara@creativeresearchdesigns.com

cannabis

Why Startups don’t do market research (but should)

Startups are great at coming up with innovative ideas, but why don’t they ever do market research?

“A startup is a human institution designed to create a new product or service under conditions of extreme uncertainty”, said Eric Ries in The Lean Startup. Extreme uncertainty is a defining feature of the startup experience. Uncertainty about the product, the supply chain, the customer, the business model. Two key success factors are experimentation and customer orientation. They enable the startup to achieve product-market fit and to creative a product that can eventually be commercialized.

Getting input from target customers is essential in developing a great offering. Yet, when I talk to startups about conducting market research, many dismiss the idea.

Often, startup founders believe market research is only for large multi-nationals, or that it comes later in the evolution of a company, when a company is established and has multiple successful product lines. Some think it is too expensive or they don’t fully understand the ROI. In addition, many founders tell me that they already have all the customer information that they want.

Let’s look at how startups typically gain information about their market, and what they are missing out on by not conducting market research:

1. At the early stage, founders’ market research typically consists of talking to ‘friendly individuals’ who are willing to give some feedback on the startup idea. The problem here is that the selection of individuals is very likely biased towards people who have a positive affinity to the founder and/or to the product to begin with. It is simply easiest to reach out to your existing network. How objective is the feedback of these individuals going to be?

In addition, we tend to connect with people who are similar to us – similar in age, in gender, in ethnic background, in social status – as it lets us stay in our social comfort zone. How representative are these people for potential users of your product? Particularly if a startup is developing a health-related product or service, potential users are likely very different from the twenty-something healthy males who tend to populate the startup community.

Plus, the ecosystem within which founders operate tends to be highly tech savvy. Getting feedback only within their own ecosystem gives founders a rather poor idea of how regular people would see their product. Granted, tech savviness is going to increase in the future. But do you really have enough time (and cash reserves) to wait for fifteen or twenty years until the majority of the population has caught up with you?

Opportunity missed: Conducting market research early on may help a startup discard an idea more quickly that won’t be popular outside their immediate circle of friends and like-minded acquaintances (‘fail early, fail fast’). Real market research means soliciting feedback from individuals that are not personally connected to you, and who belong to the intended market segment for your product.

Many startups use Kickstarter/Indiegogo as a means to assess if there is really a market out there for their product. While it is comforting to know that two thousand people are backing your campaign and are willing to pay good money now for something great to materialize in the future, this is not enough to build a successful company on. Also, let me tell you a little secret as a market researcher and anthropologist who is in touch with the ‘common man/woman’: Many people have never heard of Kickstarter or Indiegogo.

2. As startups mature, products typically go through many iterations and user experience is incorporated in a continuous feedback loop in the product development process. The UX lead will bring in users, expose them to the latest version of the product and propose adjustments accordingly. In addition, the product itself, assuming that it has a digital component, sends back usage data, which allows the startup to assess how well certain features are performing and conduct A/B tests.

Having a mountain of data that streams back through the device or app makes founders confident in their ability to optimize the product. While this is certainly the case, at times it is hard to ‘see the forest for the trees’. As startup guru Steve Blank said, you need to ‘get out of the building’ to understand your potential market and to learn about your potential customers.

Usability research and user experience research are essential for product development from a technical standpoint and from a design standpoint. In contrast, market research helps you understand the broader picture, beyond your immediate product to prospective customers and their evolving needs and pain points for which your product (along with many others) may provide a solution.

Some methods employed for market research are similar to user research, and some are different. Market research consists of the full gamut of large-scale, quantitative surveys, mobile quick check-ins, trade-off exercises, ad tests, focus groups, location-based research, ethnography, online discussion boards, co-creation labs, in-depth one-on-one interviews and many more.

Opportunity missed: User research looks at, well, users. Market research looks beyond. Only input from a wider target audience will help your startup understand where your product is missing the mark in a fundamental way.

You should also engage in market research as a ‘disaster check’ before going to market. While your product may be delightful and great in terms of functionality, perhaps you are not communicating something that you think is trivial, but that consumers want to know. Safety in wearable devices is a good example. It may be obvious to you that devices have to undergo rigorous safety testing before you are allowed to sell them to people, but the regular person may not be aware of this. If you launch a new wearable without a footnote on safety in your communications, you may be impacting your sales in a significant way. While safety may not be the reason people want to buy your device (unless it is a safety device) they want to be reassured that it is not going to harm them.

Then, after a successful product launch, your startup will only be able to continue expanding its market if you find out what non-users need and want, and if you understand their perceptions of the competition. A successful product fulfills a need better than other products. To find out what target customers need and how your product stacks up against others in addressing that need, you have to engage in market research.

Market research enables startups to step out of their comfort zone, go beyond speaking to the ‘enthusiasts’ and ‘evangelists’ and build an offering that resonates with a larger audience. Do not miss out on this opportunity to critically examine the appeal of your idea and to lay the foundation for exponential growth.

Market research for startups has clear ROI in the following areas:

  • Establish the size of your potential market (ROI: A key talking point when you approach investors at your next funding round)
  • Determine size of different segments within your market and prioritize them in terms of their potential for your product (ROI: Don’t waste money and effort on marketing to a segment that you have personal affinity to but that is tiny or less likely to buy your product)
  • Uncover needs and pain points of potential customers (ROI: Allows you to pivot early, and conserve precious early funding, if your product misses the mark)
  • Validate and refine user personas (ROI: Supports better product-market fit and sets you on a growth trajectory beyond current users to potential future users)
  • Optimize marketing and communications to focus on the product benefits that potential customers most care about (ROI: More bang for your advertising buck)
  • Get an understanding of competitive offerings, how your product stacks up and how to position your product for success (ROI: Stay ahead of the competition and get a bigger share of the pie)
  • …and last but not least: Obtain unbiased feedback on what people really think about your product (priceless 🙂 )

Some questions that startups may have about market research: Is it expensive? Can I do it myself? How do I go about it? There are many reasonably priced ways to conduct market research. Some components can easily be done by the startup itself. However, it is important to get expert advice on methodology and on the design of the research questions, to ensure your research is representative and unbiased.

If you’d like to get more information on what market research can do for your startup, please contact me. I am happy to give you an initial consultation free of charge. You can reach me at: barbara@creativeresearchdesigns.com

Also published on Medium

Microsoft spitting into Google’s soup

Has your computer been sending you ceaseless reminders to update to Windows 10? I have just updated mine, and now I understand why Microsoft is so adamant that everyone gets the new operating system. Because it is not just an operating system.  

Pumpkin soup

If you choose the ‘Express Setup’ features, you will give Microsoft access to all sorts of data that would not normally be shared with your operating system provider. It will allow Microsoft to make the sorts of rich data connections that so far only Google with its web of interconnected and super-user friendly services has been able to gather (and profit from handsomely).

My new operating system is also very persuasive in getting me to use its search engine Edge and so far I have found it difficult to stay with Google as the default search engine. What a huge coup for Microsoft and major threat for Google! I read an article or two about Edge, saying what a great new thing it is, but who knows who pays these blog writers… Also, when you search on Edge, ominously the old Bing logo appears – not very reassuring, since nobody really liked Bing, right?

But…so far I have not figured out how to keep Google as my default search tool and perhaps I’m starting to like Edge. So what’s Google going to do about that?

Have you upgraded your Windows yet?

Disclaimer: I am not in IT, perhaps I am not fully understanding all the technical details, but the business strategy seems pretty clear…

How pharma may or may not win in a digital world

Healthcare is going digital at a rapid pace. A recent article by McKinsey & Company titled ‘How pharma can win in a digital world’ outlines emerging trends in digital health and how pharma needs to evolve to keep up with the times.

A number of predictions in this article are, I believe, misguided and reflect a common, but incorrect understanding of the potential of digital in health.

Digital health collage 2

Prediction # 1: “Patients are becoming more than just passive recipients of therapies”

Patients have certainly become more knowledgeable about their own health and about available therapies. And hopefully, health-related apps are helping people lead a healthier lifestyle and stay on top of their medical conditions and medications. However, patients have never been passive recipients of therapies. Patients have always had the choice of taking or not taking their pill, cutting it in half, skipping a dose, forgetting to take it, taking it with food when they are not supposed to etc.

Having served pharmaceutical clients for more than a decade, I have frequently observed that it is difficult for someone within the industry to understand that the medicine they are producing is not the be-all and end-all of a patient’s existence. Life is a busy thing. You work, you look after your family, you eat, you entertain yourself, and you may have a health problem that benefits from taking a medication. The act of taking a pill consumes a fraction of your time and attention. Medicines for health issues that are non-symptomatic may be forgotten because the patient does not feel sick. Medicines for chronic, life-threatening conditions may have suboptimal compliance because the patient would rather not be constantly reminded about his or her precarious situation. For acute conditions, compliance wanes as soon as the patient feels better. Side effects deter patients from taking their pill, etc. Compliance would not be such a huge unsolved problem for pharma if patients were ‘passive recipients of therapies’.

Prediction # 2: “Patients will be actively designing the therapeutic and treatment approaches for themselves with their physicians”

I have read this type of statement numerous times in articles about the future of pharma. Perhaps I am lacking understanding of what’s technologically possible nowadays, but for now let’s assume I have a pretty good handle on it. Designing a pharmaceutical product is an extremely specialized and complex process that involves scientists and labs. A chemical or biological compound with certain properties is created to address a specific health issue, and this compound cannot be easily customized. Rather, it is created and then subjected to rigorous testing, costing hundreds of thousands of dollars (or more), and if it does not hold up to scrutiny, then it’s back to the lab for more experiments and tweaking before another round of expensive testing resumes.

Physicians who spend most of their time in clinical practice do not design therapeutic and treatment approaches. They are merely the retailers of those approaches, acting as consultants to their patients and advising them which approach may be best suited for them. And patients will not be actively designing their own therapies unless they are experimenting with mixing pills and brewing up concoctions of their own invention (caution: don’t try this at home, kids!).

With substantially increased access to information patients can play a much more active role in selecting treatments, but they will not design them.

alchemist-300px

Prediction # 3: “Medicine will be personalized to address individual patients’ needs” (not in McKinsey article, but can be found in many other publications on digital health).

The move towards personalized medicine is certainly well underway. However, it does not mean that a therapy will be designed on the spot for the individual sitting in front of his or her physician. Again, the physician is the expert mechanic using existing wrenches and bolts to fix the car. The inventor who comes up with new wrenches and bolts does not deal directly with the customer whose car broke down.

Tools

Personalized medicines are medicines that target issues more precisely than was previously possible. While physicians used to set off a grenade to blast away your breast cancer, and half of your body as well, they now use a precision rifle that locks in on the malignant area and eliminates not much else. And depending on your genetic profile, there are different bullets that are most effective for your particular type of problem. So the array and precision of weaponry in the physician’s arsenal has increased vastly, and affordable genetic tests have contributed to better targeting of the weapons. But none of these things are designed on the spot, while you’re sitting in the examining room, nor will this be possible for a long, long time.

Explanation: Poor understanding of digital vs. physical contributes to common misperceptions

How do these misconceptions come about and why do smart people write these things?

The past five to ten years of our experience of living in a digital world have greatly impacted our beliefs in how easily things can get done and our feeling of agency. Want to customize your new car? Just click on the features that you want – sunroof, heated seats and the colour red – and you can get this exact model without any effort on your part. Select the perfect outfit? Choose the style, colour and size, and get it delivered to your doorstep the next day. Don’t like part of your video? Just delete and replace.

The ease of these digital experiences has gotten us into the mindset that things can be designed instantaneously, delivered rapidly and modified on the spot. We rarely think about the physical realities that enable our digital experiences. To give you the experience of ‘designing’ the perfect outfit for yourself, the maker has to come up with new styles to attract your desire, run efficient manufacturing to put the piece together with acceptable quality and at an affordable price, ensure the supply chain to enable the manufacturing, build in agility to adapt supply to demand quickly, and create a distribution system to bring the piece to you. All of these things are not done through click of a button, but through the hard work of setting up systems, negotiating agreements, fine-tuning machinery and materials and implementing physical processes.

It’s the same for pharmaceutical products. They are chemical compounds, after all.

Digital opportunities

However, the potential of digital solutions to transform the way we care for ourselves and the way healthcare is provided to us is undisputed. From life tracker apps that help you remember to take your pills on time to smart contact lenses that monitor blood glucose levels without pricking your finger to ingestible sensors that give you peace of mind that your schizophrenic brother has actually taken his medication, digital interfaces, algorithms and sensors can deliver great value to the patient.

The question is how this translates into business opportunities. Many people believe that pharmaceutical companies should transform themselves from being “a products-and-pills company to a solutions company” (see McKinsey & Company article). The idea is to not only provide medicine to the patient but also digital tools for monitoring of the patient’s condition, for communicating with the patient’s circle of care, for scheduling and reminders, for supporting rehabilitation after events and for outcomes tracking. From a patient perspective, this could certainly be a valuable offering. From a business perspective, the value proposition is less clear.

First of all, pharma companies do not typically have the expertise to develop digital solutions in house. Some form alliances with tech companies. Novartis and Google are developing smart contact lenses for people with diabetes and are scheduled to start trials this year. Otsuka and Proteus Digital Health have teamed up to embed a digital sensor into a schizophrenia medication to track compliance, and have submitted the first digitally enhanced new drug application to the FDA. J&J has set up a series of incubators and rewards startups for coming up with interesting ideas in digital health. Merck sponsors health hackathons.

What does the pharmaceutical company get out of this? Will physicians choose their medication over competitive products because it comes with a digital value add? Is the digital component just another cost factor that is necessary to stay competitive these days, or is there a revenue model somewhere? It seems that there is currently a climate of experimentation without a clear business model path ahead, not unlike many other areas of digital development.

In crowded markets with little product differentiation, it is possible that the companion app could become the deciding factor in recommending one drug over the other. However, it is hard to imagine that it would play any role if there were differences in efficacy or side effect profile between the compounds. A tricky little question is also what to do with patients who need to switch off one product and go to another. Should they be denied continued usage of the app?

To be truly solutions providers, pharma companies would need to be structured differently, around disease states, not around products. It would make more sense to form a company that is, say, a ‘cardiology broker’, offered great digital tools to manage a variety of cardiologic conditions and give patients access to the full gamut of cardiology drugs available. The sales reps for this company would not overtly or covertly ‘push’ one or two drugs, but they would advise physicians on what is new in the field and impartially discuss the merits of the different options. There are some attempts of pharma companies to become leaders in a therapeutic space and assume the role of expert provider – for example Roche or Novartis in oncology, where both companies have a large product portfolio. However, by and large, this type of business model does not apply to how pharma companies are organized and how they make money currently. It would be more applicable to private payors, and we see some organizations in the U.S. moving in this direction.

Low-hanging but sour fruit

The obvious area where digital tools can be used very effectively to drive engagement is patient-related. Arguably, a more engaged patient will likely be more compliant and stay on therapy longer, resulting in immediate benefit to the bottom line.

However, while many companies try to be patient-centric, any direct engagement with a patient carries the risk of an adverse event report with it. While adverse event reporting systems have been set up to keep patients from harm, unfortunately, reporting requirements are ridiculously broad. Nobody is keen on generating massive amounts of adverse event reports for their drugs. So digital engagement of patients has to be done with all sorts of caveats to reduce the risk of learning about an adverse event. Some companies stay away from direct engagement with patients altogether for that reason; others have taken the plunge and struggle to come up with creative ways around the problem.

Another challenge in engaging with patients through digital tools and platforms is finding appropriate engagement formats for particular audiences. A platform that has been designed to help kids with pain through gamified challenges and ‘levels’ may not be the right approach to engage a 70-year old cancer patient. Very little testing and research has been done to date to find out what tools best support patients with certain conditions. The key here is to be open to a multi-platform approach. While a game may be great at motivating one audience, a combination of text reminders and phone support may be best suited to keep another audience adherent to their treatment. Unfortunately, many of the vendors that design patient engagement tools on behalf of pharma are either all digital or not digital at all. What would be needed is a new type of vendor who can pull together various types of tools and customize them for a particular target patient population.

Low-hanging sweet, sweet fruit

One area where pharma could employ digital innovation easily and with sustained impact is in the way companies communicate with physicians. While almost everyone has switched to iPads for detailing over the past few years, pharma companies (in Canada, my home turf) still have limited understanding of how digital can be used to improve access and deliver value to physicians. Knowledge about different forms of digital engagement is lacking in marketing departments where people think Twitter and Instagram are for self-absorbed teenagers with too much time on their hands. Also, there is a feeling that digital is not important to the physicians who are core to the business. However, as one year after another go by and younger physicians become key opinion leaders and high prescribers, companies may find that they have missed the boat in establishing a digital rapport with these individuals.

Only recently have some companies started to think about conducting media audits and finding out from their core target how they use digital tools and what might be of value to them. Putting some effort and resources into understanding the myriad of different ways digital can be used, and physician preferences in this regard is relatively simple and will almost certainly have a payoff within a five-year timeframe. There will likely be some resistance from the sales folks who tend to see alternatives to face-to-face engagements as a threat to their position. However, I believe that the 21st century sales rep needs to be an expert in offline and online relationship building. Pharmaceutical companies need to figure out how to integrate different forms of digital and non-digital engagement optimally, and create internal structures and tools to maximize value for the customer.

Cartoon

McKinsey & Company article source:

http://www.mckinsey.com/insights/pharmaceuticals_and_medical_products/how_pharma_can_win_in_a_digital_world

Image sources:

‘Digital health collage’: Made the image myself

‘The alchemist’: https://openclipart.org/detail/222415/alchemist

‘Tools’: DeWalt DEWALT DWMT72163 118PC MECHANICS TOOL SET on http://toolguyd.com/dewalt-ratchets-sockets-mechanics-tool-sets/

‘Cartoon’: I’ve seen this cartoon on the web many times, but don’t know who made it originally. I’ve copied it from https://effectivesoftwaredesign.files.wordpress.com/2015/12/wheel.png?w=640