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Where Health Care and Digital Revolution Intersect

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Distruptive Innovation in Health Care

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Where Health Care and Digital Revolution Intersect

  1. 1. CONSUMER HEALTH INFORMATICS & COMMUNICATION LABORATORY Where Health Care and 
 Digital Revolution Intersect disruptive innovation in health care James G. Boram Kim Consumer Health Informatics & Communication (CHIC) Laboratory Seoul National University james@snu.ac.kr Mini Nursing Informatics Symposium · Tzu Chi College of Technology, Taiwan · June 26th, 2014
  2. 2. The World has been Changed: Banking
  3. 3. The World has been Changed: Banking
  4. 4. The World has been Changed: Traveling
  5. 5. The World has been Changed: Research
  6. 6. The World has been Changed: Medical Practice
  7. 7. The World has been Changed: Medical Practice
  8. 8. Digital [R]Evolution in Health Care
  9. 9. Health Care Crisis $0 $325 $650 $975 $1,300 3.5% 4.4% 5.3% 6.1% 7.0% 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Taiwan (% of GDP) Taiwan (Expenditure Per Capita) Not Directly Related Health Statistics in Taiwan 2010 & OECD Health Statistics 2013
  10. 10. Health Care Crisis $0 $550 $1,100 $1,650 $2,200 3.5% 4.6% 5.8% 6.9% 8.0% 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Taiwan (% of GDP) Korea (% of GDP) Taiwan (Expenditure Per Capita) Korea (Expenditure Per Capita) Health Statistics in Taiwan 2010 & OECD Health Statistics 2013 Not Directly Related
  11. 11. Health Care Crisis $0 $2,250 $4,500 $6,750 $9,000 3.5% 7.1% 10.8% 14.4% 18.0% 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Taiwan (% of GDP) Korea (% of GDP) U.S. (% of GDP) Taiwan (Expenditure Per Capita) Korea (Expenditure Per Capita) U.S. (Expenditure Per Capita) Health Statistics in Taiwan 2010 & OECD Health Statistics 2013 Not Directly Related OECD Average in 2011 9.3% of GDP $3,322 Per Capita
  12. 12. The Innovator’s Prescription: Disruptive Innovations C.M. Christensen, The Innovator’s Dilemma: When New Technologies Cause Great Firms to Fail, 1997 Performance Time Sustaining Innovations Disruptive Innovations Most Demanding
 Customers Least Demanding
 Customers
  13. 13. Business Models in Health Care Based on Jason Hwang’s Work Laboratory
 Services SpecialtyCare Im aging
 Services Clinical Research
 and Training Data Collection
 and W arehousing SurgicalSuites Solution Shops - Fee for Service • Consulting Firms • High-end Law Firms • R&D Organizations • Diagnostic Activities of Hospitals Value-adding Process Businesses - Fee for Outcome • Retailing • Manufacturing • Food Services • Medical Procedures Facilitated User Networks • eBay • Insurance • Education • Telecommunication • D-Life (for diabetes patients & families) - Membership and/or Advertising • Regulations • Licensure and Accreditation • Cultural Resistance • Payment and Reimbursement
 Policies
  14. 14. Do We Need Doctors or Algorithms? “ ” By 2025 more data-driven, automated health care will displace up to 80% of physicians’ diagnostic and prescription work. It will AMPLIFY physicians by arming them with more complete, synthesized, and up-to-date research data, all leading to better patient outcomes. 600,000Pieces of Medical Evidence 1,500,000 Patient Records 2,000,000 Pages of Text from 42Medical Journals and Clinical Trials VS 90%Successful
 Diagnosis Rate 50%Successful
 Diagnosis Rate 160 Hours of Reading a Week Just to Keep Up with New Medical Knowledge as It’s Published
  15. 15. When the Doctor is Not Needed Based on a New York Times Editorial Entitled “When the Doctor is Not Needed” ” Pharmacists “Pharmacists can start, stop or adjust medications, order and interpret laboratory tests, and coordinate follow-up care. ” Nurse Practitioners “Substantial evidence shows that nurse practitioners are as capable of providing primary care as doctors and are generally more sensitive to what a patient wants and needs. ” Retail Clinics “The retail clinics treat common conditions like ear infections, administer vaccines and perform simple laboratory tests.
  16. 16. Who is the Real Medical Expert? “ ” When we say patient-centered medicine, what we usually mean is the contrast between a patient- centered approach versus an approach where the doctor and health system is in the center and the patient is orbiting around. But, I think implicit in most of our words, when we say this, is still the notion that expertise is flowing from the healthcare system to the patient.
  17. 17. Who is the Real Medical Expert? “ ” In many cases, we have patients who are not just experts in what they feel and what they experience, but experts in the science of their disease. […]
 Patients often become micro-experts on their disease and treatment.
  18. 18. The Rise of e-Patients Pew Research Center’s Internet & American Life Project, 2013 engaged when they seek to access their own health information enabled when they have access to their own health information equipped when they understand their own health information then empowered to achieve self-management of their care “ ” You are already your own doctor. 72% of U.S. Internet users say they looked online for health information within the past year(62% of U.S. adults) 7 10in U.S. adults have tracked a health indicator for themselves or for someone else Of those, 34% share their health tracking records or notes with another person or group
  19. 19. Search: Gets Deeper and More Personalized Based on Matthew Holt’s Evolving View of a Moving Target
  20. 20. Communities: Providing Support, Answering Questions, Aggregating Data, and Tracking Outcomes Based on Matthew Holt’s Evolving View of a Moving Target
  21. 21. Tools: Unlocking Databases with New Interface and Analytics Based on Matthew Holt’s Evolving View of a Moving Target
  22. 22. Health 2.0: Better Integration of Data with Content Search Social
 Networks Tools Transaction
 Data Content Based on Matthew Holt’s Evolving View of a Moving Target “ ” All with the result of patients increasingly guiding their own care.
  23. 23. Gimme My“Damn”Data!
  24. 24. OpenNotes: Sharing Clinicians’Notes with Patients 1.8million Over So Far 92% Up to of Patients in OpenNotes Study OpenedTheir Notes 60% More than of Patients Reported Doing Better with Taking Medications as Prescribed Because of Open Notes
  25. 25. Data Liquidity: When Data Flows Faster and More Freely “ ” Consumers are managing bank accounts, investments, and purchases on-line, and many turn to the Web for gathering information about medical conditions; they will expect this level of control to be extended to online medical portfolios. Your Health Score Every area of your life affects your overall health. Your healthscore helps you understand how you’re doing and where there is room for improvement. 72 Completing even the simplest of tasks can improve your overall health IMPROVE YOUR HEALTH! Stop smoking for good Lower your blood pressure +10 Make a medicine plan Doing so can lower your risk for heart attack +5 Schedule your annual physical Make sure to update your plan of care +3 Ellen Ross D.O.B: 03.07.60 Age: 52 Gender: Female Phone: 816.555.1229 Language(s) spoken: English Email: e.ross@gmail.com Name of Provider: Ashby Medical Center Address: 1002 Healthcare Dr, Portland, OR 97266 Telephone: 415.555.1200 HEALTH RECORD Coronary Heart Disease ACTIVE CONDITIONS & TREATMENTS DIAGNOSIS Chopidogrel (Plavix) Prevent Blood Clots Astrovastatin (Lipitor) Lowers Cholesterol Aspirin Prevent Blood Clots Preventative Medicine Plan Cardiovascular Rehabilitation (exercise plan) OUTCOME Cholesterol and Hypertension fall within acceptable ranges. OUTCOME SEPT 26, 2011 Heart attack caused by 100% blockage to right artery. Cholesterol (Lipid Panel) Test OCT 26, 2012 Routine Cholesterol (Lipid Panel) Test ORDERED PRESCRIBED MEDICINES LIFESTYLE CHANGES Daily Cardiovascular Exercise Low Fat / High fiber diet Maintain healthy weight Physician: Dr. Tim LeePhysician: Dr. Tim Lee LAST OFFICE VISITCURRENT TREATMENT PAGE 1 OF 2LAST UPDATED NOV 30 2012 It is important to repeat these steps every day to maintain good health. My Medicine Plan NAME OF MEDICATION DAILY TOTAL Liptor Enteric-Coated Asprin Plavix Toprol Fish Oil 20 mg 81 mg 75 mg 25 mg 325 mg -- -- -- -- 325 mg 20 mg -- -- -- 325 mg 40 mg 81 mg 75 mg 25 mg 975 mg BEFORE BREAKFAST WITH LUNCH AT BEDTIME Lipid Panel (mm/Hg) MY GOAL 249 60 76 112 95 Below 200 Above 40 Above 130 Below 150 Below 70 225 55 92 124 82 180 45 103 130 68 185 58 132 136 6 Total Cholesterol HDL Cholesterol, NON-HDL Triglyceride LDL LAB RESULTS MAY 2012 JUN 2012 JULY 2012 SEP 2012 Body and Test Results VITALS MY GOAL 115 / 77 78 198 120/80 (resting) 60 - 90 (resting) 150 - 170 116 / 72 72 195 112 / 75 77 192 115 / 73 84 195 Blood Pressure Heart Rate Weight (mg/dL) (bpm) (pounds) MAY 2012 JUN 2012 JULY 2012 SEP 2012 ALLERGIES SEVERITYREACTIONNAME OF ALLERGY Bee Stings Penicillin Codeine Anaphylactic Shock Hives Shortness of Breath Severe Moderate to severe Moderate PAGE 2 OF 2LAST UPDATED NOV 30 2012 JU HA N SONIN Sonin, Juhan 22 Surry Rd Arlington, MA 02476 617 504 3390 juhan@goinvo.com HealthCard LANGUAGE MARITAL STATUS RELIGION English Married Atheist VISION ALERGIES MEDICATIONS VISION 20/15 None None 20/15 HEALTHPLAN Harvard Pilgrim POLICY NUMBER H468798902 1972.022.64.7489.JPS SEX M HGT 5-10 WGT 199 lbs DOB 1.Mar.1972, 40yo GUARDIAN CONTACT Kate Sonin Same address 617 548 1769 ktfresh@gmail.com PRIMARY CARE PHYSICIAN David Ives, MD 781 672 2250 VACCINATIONS Tetanus Hepatitis B Typhoid TB Diphtheria Meningeal MMR Influenza Smallpox Hepatitis A Polio Yellow Fever United States of America A+ 84 Blood Pressure Glucose HDL LDL Triglycerides Sleep Happiness Weight Alcohol, Drugs Environment Medications Exercise Nutrition Waist Circumference Vaccinations Diabetes Monitor Blood Sugar, Take Insulin 3x daily CONDITIONS High Blood Pressure Exercise 1hr day to reduce weight and waist circumference. Lose 10 pounds Eat 700 less calories/day. Reduce saturated fat to 16 grams/day. Torn bicep procedure Keep thumb straight continually by splint and tape until 24.May. Next Appointment 12.May.2013, Check-up Data current as of 29.Nov.2012 WEIGHT 199 lbs GLUCOSE 101 mg/dl HDL 35 mg/dl WAIST CIRCUMFERENCE 34 in BLOOD PRESSURE 117/79 mmHg LDL 128 mg/dl
  26. 26. Quantified Self: Self Knowledge through Self-tracking
  27. 27. Quantified Self: Self Knowledge through Self-tracking
  28. 28. Quantified Self: Self Knowledge through Self-tracking
  29. 29. Self-experimentation: Single-Subject (“N-of-1”) Trial Usual
 Care 100 People 50 People Symptoms Symptoms Experimental
 Treatment 50 People Population Based on Ida Sim’s Work
  30. 30. Self-experimentation: Single-Subject (“N-of-1”) Trial Usual
 Care 100 People 50 People Symptoms Symptoms Experimental
 Treatment 50 People Population Me Individual Usual
 Care Experimental
 Treatment Usual
 Care Experimental
 Treatment Symptoms Symptoms Usual
 Care Experimental
 Treatment Based on Ida Sim’s Work
  31. 31. Self-experimentation: Single-Subject (“N-of-1”) Trial Seth Robert measured his arithmetic speed daily: how fast he does simple arithmetic problems, such as 3+4 Several years ago, he discovered that butter — more precisely, substitution of butter for pork fat — made him faster.
  32. 32. Patient Self-Care: Home Hemodialysis Based on Joseph Cafazzo’s Work
  33. 33. Patient Self-Care: Home Hemodialysis Based on Joseph Cafazzo’s Work Improved Health Outcomes Cost-Effective ModalityPatient Autonomy
  34. 34. Patient Self-Care: Home Hemodialysis Based on Joseph Cafazzo’s Work Cost-Effective ModalityPatient Autonomy Normalization of Blood Pressure without the Need for 
 Anti-Hypertensive Medications Normalization of Abnormal Wall Thickness of the Heart Restoration of Impaired Heart Function Improvement in Peripheral Circulation Improvement in Sleep Quality Improvement in Nutritional Determinants Elimination of Dietary Restriction Improved Health Outcomes
  35. 35. Patient Self-Care: Do-It-Yourself Hemodialysis “ ” As long as you have a high school degree, understand the principle of dialysis, follow the operational instructions and keep a close watch during the process, nothing should go wrong. […] The most important part of the machine is the filter, and I can use each one eight times. A new filter costs $17, while a proper medical machine can run into hundreds of thousands of dollars. […] When I told the doctors what I was doing, they said I was crazy.
  36. 36. Peer-to-Peer Health Care: Patients Like Me 15in U.S. Internet users have gone online to find others like them People living with chronic and rare conditions are significantly more likely to do this. Pew Research Center’s Internet & American Life Project, 2011 “What is extremely difficult about having a kid with Kawasaki disease, before the diagnosis, is just the not knowing.
  37. 37. Peer-to-Peer Health Care: Patients Like Me Lithium delays progression of amyotrophic lateral sclerosis Francesco Fornai*†‡ , Patrizia Longone§ , Luisa Cafaro† , Olga Kastsiuchenka*, Michela Ferrucci*, Maria Laura Manca¶ , Gloria Lazzeri*, Alida Spalloni§ , Natascia Bellioʈ , Paola Lenzi*, Nicola Modugno† , Gabriele Siciliano¶ , Ciro Isidoroʈ , Luigi Murri¶, Stefano Ruggieri†, and Antonio Paparelli* *Department of Human Morphology and Applied Biology, and ¶Department of Neuroscience, Clinical Neurology, University of Pisa 56100 Pisa, Italy; †Istituto Neurologico Mediterraneo, Istituto Di Ricovero e Cura a Carattere Scientifico Neuromed, 86077 Pozzilli (IS), Italy; §Molecular Neurobiology Unit, Santa Lucia Foundation, 00179 Rome, Italy; and ʈDepartment of Medical Sciences, University of Novara, 28100 Novara, Italy Edited by Thomas C. Su¨ dhof, University of Texas Southwestern Medical Center, Dallas, TX, and approved December 21, 2007 (received for review August 24, 2007) ALS is a devastating neurodegenerative disorder with no effective treatment. In the present study, we found that daily doses of lithium, leading to plasma levels ranging from 0.4 to 0.8 mEq/liter, delay disease progression in human patients affected by ALS. None of the patients treated with lithium died during the 15 months of the follow-up, and disease progression was markedly attenuated when compared with age-, disease duration-, and sex-matched control patients treated with riluzole for the same amount of time. In a parallel study on a genetic ALS animal model, the G93A mouse, we found a marked neuroprotection by lithium, which delayed disease onset and duration and augmented the life span. These effects were concomitant with activation of autophagy and an increase in the number of the mitochondria in motor neurons and suppressed reactive astrogliosis. Again, lithium reduced the slow necrosis characterized by mitochondrial vacuolization and in- creased the number of neurons counted in lamina VII that were severely affected in saline-treated G93A mice. After lithium ad- ministration in G93A mice, the number of these neurons was higher even when compared with saline-treated WT. All these mechanisms may contribute to the effects of lithium, and these results offer a promising perspective for the treatment of human patients affected by ALS. autophagy ͉ clinical study ͉ G93A mice ͉ morphological analysis ALS is a devastating neurodegenerative disorder with no effective treatment that usually leads to death within 3–5 years from diagnosis (11 months for the bulbar form) (1). ALS occurrence is primarily (90%) sporadic, while only 10% is familial (fALS). Approximately 20% of fALS are due to muta- tions of the gene coding for the enzyme copper–zinc superoxide- dysmutase (SOD1) (2). Transgenic mice over expressing the human mutant SOD1 develop a pathology that is very similar to that seen in ALS patients [see supporting information (SI) Text for a comparison]. Studies in animal models or in vitro led to the identification of a variety of alterations in ALS motor neurons (MN) (1, 3, 4); however, other cells in the spinal cord besides MN are affected (5–8). For instance, a class of interneurons die either before or concomitantly with MN, as found in mice (9, 10) and postulated in humans for Renshaw-like cells (11). Again, glial cells participate in the deleterious interplay leading to MN degeneration (6–8). After the generation of the SOD1 ALS mouse models, attempts have been made to find effective treatments. However, so far, none of these trials has led to effective clinical outcomes. Lithium is a compound used as a mood stabilizer, which is neuroprotective in a variety of disease models (12, 13), such as brain ischemia (14) and kainate toxicity (15). The ability of lithium to promote autophagy, through the inhibition of the inositol-monophosphatase 1 (16–18), together with the protec- tive effects of autophagy in neurodegeneration (19–22), prompted us to test the neuroprotective effects of lithium in the G93A ALS mouse model. Based on the promising data, we obtained in mice we quickly moved into a clinical trial, which is now at the end of its second year. Results Effects of Lithium on Disease Duration and Survival in G93A Mice. G93A male mice were treated daily with lithium carbonate (1 mEq/kg, i.p.), starting at 75 days of age. Lithium treatment prolonged the mean survival time from 110.8 Ϯ 5.0 days (n ϭ 20) to 148 Ϯ 4.3 (n ϭ 20, Ϸ36% of the life span of these mice; Fig. 1a; P Ͻ 0.001) and, most importantly, increased disease duration (from a mean of 9 days to Ͼ38 days, Ͼ300%; Fig. 1b; P Ͻ 0.05) compared with the G93A mice treated with saline. Even when lithium treatment was started at the onset of motor symptoms, the increase in disease duration was still comparable (data not shown). More specifically, lithium delayed the onset of paralysis and limb adduction (Fig. 1c) and significantly improved addi- tional tests we report in SI Fig. 6, such as rotarod, grip strength, and stride length. Effects of Lithium Treatment on Motor Neuron Survival (Lamina IX of Lumbar and Cervical Spinal Cord and Brainstem Motor Nuclei). These effects were accompanied by a reduced loss of lumbar MN at 90 days of age (SI Fig. 7). However, at the end of disease (which occurred later following lithium), the number of alpha-MN within lumbar lamina IX of the G93A mice treated with lithium was comparable to that found in the saline-treated mice that had died previously (SI Fig. 8). However, even at this stage, we detected a disease modifying effect of lithium. This consisted of (i) preservation of the size of MN (SI Fig. 8 d and e); (ii) preservation of MN number and size in those areas [i.e., cervical spinal cord (SI Fig. 9) or the nucleus ambiguous (SI Fig. 10)], which degenerate later compared with lumbar lamina IX (23, 24); (iii) decreased astrocytosis (SI Fig. 11); and (iv) decreased alpha-synuclein, ubiquitin, and SOD1 aggregation (see SI Fig. 6 and Discussion in SI Text). Effects of Lithium Treatment on the Renshaw-Like Cell Area (Lamina VII). Lamina VII contains a larger number of interneurons, defined as Renshaw cells, which form a collateral circuit that Author contributions: F.F., P. Longone, C.I., L.M., S.R., and A.P. designed research; O.K., M.F., M.L.M., G.L., A.S., N.B., P. Lenzi, N.M., and G.S. performed research; L.C., M.F., M.L.M., G.L., P. Lenzi, G.S., C.I., L.M., S.R., and A.P. analyzed data; and F.F. and P. Longone wrote the paper. The authors declare no conflict of interest. This article is a PNAS Direct Submission. Freely available online through the PNAS open access option. ‡To whom correspondence should be addressed. E-mail: f.fornai@med.unipi.it. This article contains supporting information online at www.pnas.org/cgi/content/full/ 0708022105/DC1. © 2008 by The National Academy of Sciences of the USA 2052–2057 ͉ PNAS ͉ February 12, 2008 ͉ vol. 105 ͉ no. 6 www.pnas.org͞cgi͞doi͞10.1073͞pnas.0708022105 NATURE BIOTECHNOLOGY VOLUME 29 NUMBER 5 MAY 2011 411 A N A LY S I S Patients with serious diseases may experiment with drugs that have not received regulatory approval. Online patient communities structured around quantitative outcome data have the potential to provide an observational environment to monitor such drug usage and its consequences. Here we describe an analysis of data reported on the website PatientsLikeMe by patients with amyotrophic lateral sclerosis (ALS) who experimented with lithium carbonate treatment. To reduce potential bias owing to lack of randomization, we developed an algorithm to match 149 treated patients to multiple controls (447 total) based on the progression of their disease course. At 12 months after treatment, we found no effect of lithium on disease progression. Although observational studies using unblinded data are not a substitute for double- blind randomized control trials, this study reached the same conclusion as subsequent randomized trials, suggesting that data reported by patients over the internet may be useful for accelerating clinical discovery and evaluating the effectiveness of drugs already in use. Online communities such as PatientsLikeMe that provide robust methods for patients to record and share data may have the potential to be used to conduct observational studies to assess the effectiveness of treatments. Although observational studies inherently cannot meet the gold standard of randomized clinical trials, they provide an oppor- tunity to collect possibly useful early-phase data by capturing patients’ self-experimentation. Empowering observational studies of patients’ self-experimentation carries some risks. Nevertheless, an increasing level of self-experimentation is already happening1. In this context, it is possible that patient-reported outcome data collected over the Internet could be integrated into academic and/or industry-led cycles of product development and evaluation2. Approximately half of ALS patients take vitamins and unproven supplements3, whereas a smaller number go to extraordinary lengths to experiment with unproven treatments such as stem cell transplants in the developing world4. Recently, a consortium of 75 ALS physi- cians, scientists and experts (ALSUntangled.com) has been formed to investigate the use of self-experimentation, complementary and alternative medicine, and off-label drug usage5. There are a number of benefits to systematically studying patients’ self-experimentation. First, it is important to respect patients’ autonomy and their deci- sions; helping them participate in systematic evaluations may increase scientific literacy. Second, there is an obligation to collect data on the safety of self-experimentation. Unproven treatments might have substantial safety concerns, and risks to patients may be increased without a way to report safety issues. Finally, there is the chance that something (i.e., off-label usage, a change in dosage, delivery route or combination with other treatments) might actually be shown to be efficacious, leading to further study. ALS is a condition where both randomized trials and nonrand- omized clinical studies have yet to provide an effective therapy. It is a cruel and rapidly fatal neurodegenerative disease causing progres- sive weakness and muscle atrophy; median survival from symptom onset is 2–5 years6. In 2008, a study described the potential efficacy of lithium carbonate to slow the progression of ALS in a small, single- blind trial of 16 treated patients and 28 controls7. Despite skepticism from the medical community8–10, some ALS patients were enthusi- astic about the treatment11 and by their own initiative used an online spreadsheet to gather data. PatientsLikeMe built a lithium-specific data collection tool (see Supplementary Fig. 1) to capture informa- tion about the 348 ALS patients registered with the PatientsLikeMe website who began taking the drug off-label via their physician. To investigate whether the major effect of lithium carbonate reported in the original study was corroborated in these 348 patients, we under- took an observational analysis of self-reported outcomes. ALS disease progression is evaluated using the Revised ALS Functional Rating Scale (ALSFRS-R12, henceforth referred to as FRS), which measures patient-reported functional impairment in domains such as speech, swallowing, walking, arm function and respiratory function. This metric is one of the standard outcome measures used in ALS clinical trials. In the absence of randomization, blinding or a placebo group, a technique was needed to overcome potential biases, such as the inherent self-selection of self-experimentation in an online sample, the placebo effect and attrition. RESULTS Participants As of the date that our data set was finalized (28 February 2010), there were 4,318 ALS patients on PatientsLikeMe, all of whom were invited Accelerated clinical discovery using self-reported patient data collected online and a patient-matching algorithm Paul Wicks, Timothy E Vaughan, Michael P Massagli & James Heywood Research and Development, PatientsLikeMe Inc., Cambridge, Massachusetts, USA. Correspondence should be addressed to P.W. (pwicks@patientslikeme.com). Received 2 April 2010; accepted 10 March 2011; published online 24 April 2011; doi:10.1038/nbt.1837 ©2011NatureAmerica,Inc.Allrightsreserved.
  38. 38. Disruptive Innovation in Health Care Worksite
 Clinics Wellness Programs Telehealth
 / e-Visits Hospital
 at Home Automated
 Kiosk Services While
 Traveling Abroad Medical Homes
 and Care Teams Home Visits Retail
 Clinics Home
 Monitoring Wireless
 Health
 Devices Mobile Care
 Services Telecommunications Precision
 Diagnostics Information Management
 and Decision-making Tools Based on Jason Hwang’s Work
  39. 39. Worksite
 Clinics Wellness Programs Telehealth
 / e-Visits Hospital
 at Home Automated
 Kiosk Services While
 Traveling Abroad Medical Homes
 and Care Teams Home Visits Retail
 Clinics Home
 Monitoring Wireless
 Health
 Devices Mobile Care
 Services Telecommunications Precision
 Diagnostics Information Management
 and Decision-making Tools Where Do Nurses Fit In? Based on Jason Hwang’s Work Care Coordination Health Information Exchange
  40. 40. CONSUMER HEALTH INFORMATICS & COMMUNICATION LABORATORY 謝謝
  41. 41. CONSUMER HEALTH INFORMATICS & COMMUNICATION LABORATORY

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