Entrepeneurship on the front line - innovate stage, 2 september 2015

Clinician Entrepreneur
Innovate Stage

Vivienne Parry
Broadcaster and Scientific Journalist

Sir Bruce Keogh
National Medical Director
NHS England

Talking Heads
Professor Tony Young - National Clinical Director for
Innovation, NHS England
Jane Cummings - Chief Nursing Officer for England
Professor Jacky Hayden – Dean of Post Graduate
Medical Studies, HEE North West

Entrepreneurship on the Frontline
Randeep Grewal – Portfolio Manager, Trium Capital
Jean Nehme & Andre Chow – Co-Founders, Touch Surgery
Dr Hinnah Rafique – Director, Help Me I’m a Medic
Nick Hartsthorne-Evans – Chief Executive and Founder,
Pumping Marvellous
Seb Tucknott – Founder, IDB Relief

Nexus of Government and Industry in
Innovation
James B Peake MD
Lieutenant General USA (Ret)
Senior Vice-President, CGI Federal

Nexus of Government & Industry
in Innovation
James B. Peake, MD
Lieutenant General, USA (Ret)
Senior Vice President CGI

Innovation
Not Only The New Bright And Shiny Object
Old Idea Enabled
New Way Of Doing Business
-
Innovative Idea Vs Innovation
Make Something Better Happen!

4
Army Medical Footprint
DS/DS
OEF
OIF
DNBI = .261
DNBI = .107
DNBI = .143
% = Personnel Assets in Theater
DNBI Episodes / 1000 Soldiers
Combat Service Support, (-) Medical
Medical
Combat
Combat Support
Other
35%
24%
23%
14%
5% 32%
41%
35%
22%
5%
6%
24%
26%
5%4%

Office of the Surgeon General
THEATER
CONUS BASE
Medical Centers,
Scientific Expertise
Forward
Surgical Tm
VA
In Theater Health
Services
68W/ 18D
Evacuation
Active
Reserve
TO&E TDA
Network-Centric
System of Systems
AO
Centers of
Excellence
Care In The Air
ESSENTIAL
CARE
Skip Policy
Continuous Healing
Reach Back
Digital Links
INTEGRATEDFROM CONUSTO THE FOXHOLE . . . JOINT
PARADIGM SHIFT

1,917
9,426
TOTAL
EVAC’D
72TOTAL INPATIENTS
00NEW INPATIENTS
OEF
3645TOTAL INPATIENTS
16NEW INPATIENTS
OIF
CONUSEUROPE
STRATEGIC EVACUATION
OPERATION IRAQI FREEDOM / OPERATION
ENDURING FREEDOM
12 HOURS
TO
48 HOURS
DOOR TO DOOR – ICU TO ICU

DT 60 Lab
Analyzer
I-STAT
Laboratory Equipment
ORDERS OF MAGNITUDE CHANGE!
WEIGHT – CUBE - RELIABILITY

68 W:
COMBAT MEDIC
Focusedtraining:
• Emergency Care
• Evacuation
• Force Health Protection
• Limited Ambulatory Care
2nd Largest MOS in the Active Army:
• Greater Scope and Depth
• More Proficiency from Schoolhouse
• ST 105/GT 110
FUTURE
FORCE
CURRENT
FORCE
ArmyAfter
Next
5 Years
E-4/ E-5
27 Years
CSM
2005
2025
Time
16 wks of Training
Includes clinicals & FTX
EMT-B Certification
Required sustainment

New Hemostatic Products on the
Battlefield

Medical Simulation
• Mannequin-based simulatorscan
train medicsand PAson chest tube
insertionand hemorrhage
• Virtual reality medical
trainers presentimmersion
environmentsuperimposedovermedical
tasks for realisticembeddedtraining
capabilityinFCS
• Computer-basedtrainingcan
incorporate haptics, tissue-tool interactions,
and real-time graphicsto augment reality
(allowsforembeddedtraining)

cimit
$$
Massachusetts GeneralHospital
Brigham and Women's Hospital
Massachusetts Institute of
Technology
Charles Stark Draper Laboratory
Medical Simulation
Traumatic Brain Injury
Operating Room of the Future

• Recommended By A Soldier In The Field
• Commercially Produced
• Rapidly Fielded To The Force

Deployable CT Scanner
Philips MX 8000

AMPUTEE CENTER OF EXCELLENCE
Best of Academia, Industry, Veterans Affairs

Evolution of Bar Code Medication Administration (BCMA) within the
Department of Veterans Affairs.
Coyle GA, Heinen M.
Abstract
TheDepartment ofVeteransAffairs Medical CenterimplementedBar
Code MedicationAdministration (BCMA)between1999and 2000 in
161 Medical CentersorHealth Systems….Nurseshavemovedfrom
manual to electronicmedicationdocumentation … A marked
decreasein medicationadministrationerrors is a result of
implementingBCMA.
Nurse Admin Q. 2005 Jan-Mar;29(1):32-8
One Nurse’s
Observation
And Good Idea!

Increasing Access to Care via Telehealth
28
In 2012, VA’s Telehealth programs:
• Provided care to half a million
Veterans
• Provided 1,429,424 episodes of
care
•Supported 42,699 patients to
live independentlyin their own
homes, instead of long-term
institutional care

Armed Forces Institute of Regenerative Medicine
Rutgers / Cleveland Clinic ConsortiumWake Forest/ PittsburghConsortium
• Extremity Injury Treatment
• Cranio-maxillofacial Reconstruction
• Skin Injury Treatment
• Vascular Composite Tissue
• Genitourinary and Lower Abdominal Injury Treatment
Imagining the Future

A CGI “Spark Center” –
Collaborative Tools – Partnership Spaces
I
N
N
O
V
A
T
I
O
N

What Industry Can Bring
Innovation Partners

Industry & Government
Partners In Innovation

Activities at a single CSH
• From Jan 2004 – Dec 2004
• Outpatientvisits ~ 17,000
• 3,444 Trauma admissions
• 703 (21%) required transfusion
– 220 (31%) require massive transfusions
(> 6 units PRBCs)
50 (23%) received fresh whole blood
• >1700 units used since war started
•Repine et al, J Trauma, in press

Fresh Whole Blood
Drive in Tikrit,
Very Routine
Hemostatic Resuscitation

What Fuels Innovation?
An Exponential Perspective from
Silicon Valley
John Mattison
Assistant Medical Director
Chief Medical Information Officer

Copyright John Mattison 2014
What Fuels Innovation?
An Exponential Perspective from Silicon Valley, and A
Strategy for Global Collaboration
In the Era of the Plecosystem
Innovation Expo
NHS England
Manchester
September 2, 2015
John Mattison, MD, CMIO, CHIO
Assistant Medical Director
Kaiser Permanente, SCAL
@johnemattison

Key Questions:
1. What are the “BIG HAIRYPROBLEMS” thatareroot
causesof our global health, and
2. Howdo we perform rootcause analysistofocus our
innovationefforts on the truecauses of those problems?
3. Why is innovation the buzzwordof the 21st Century?
4. What is ‘new’ about ‘innovation’?
5. What is the role of SiliconValley?
6. Howdoes the UK and the NHS exploit the virtuesof “the
valley” and leave the vices behind?
.

Audience Survey
1. Have heard of KaiserPermanente?
2. Know whyAndyGroves (intel), Vinod Khosla (Sun) agree 80% of doctors
will be unnecessarysoon?Afterconsumeractivation and self-service
3. Know why$500B was spent last year on pharma M&A?
4. Believe we can begin eliminating both Malaria and Sickle Cell Disease
within 2 years? CRISPR/cas9 + Gene Drive + DNA Clews = killer triad
5. Believe we’re within 2 years of a once-in-a-lifetime flu vaccine on HA stem?
6. Know whyglobal collaboration is socritical forunderstanding genomics?

Three Natural Metaphors
1. The Big Bang, and the inverted Big Bang of Big Data
2. Meiosis as the ultimate Innovation Engine
3. Tropical Rainforest and Meta-Topical Brainforests

The Inverted Big Bang:
Big Data: Hype or Reality?

Meiosis:
The Ultimate Innovation Engine

Big Data and Collaborative Discovery:
Meta-Topical BrainForests:

Two Examples
of These Three Metaphors

The future of innovation belongs to collaborators:
2013 Nobel Prize in Chemistry
 Three contributors from 3 countries of origin
 Three Universities
 Two different technologies: Newtonian and Quantum
 One new convergent method for understanding how
protein structure drives function
 Exemplar: Cross-disciplinary collaboration from
different perspectives, and multiple platforms

Four Models of Innovation:
1. **Disruption and disintermediation of old tools, jobs
and processes, with new ideas, tools, and paradigms
2. Incremental optimization of people, process and
technology (reducing friction)
3. ***Identify and Spread local success,
aka Positive Deviance, hotspotting
4. Cultural transformation
**Specialty of Silicon Valley, the rest for implementers

What is different
in the Silicon Valley PLECOSYSTEM,
and
How can the NHS exploit that
difference?

Silicon Valley & The PLECOSYSTEM:
Multi-PLatformECOSYSTEM
Six Platform Types:
1. Service Platforms: Internet, Cloud, Smartphone, Smartwatch, BlockChain, Analytics, IOT, personal realtime IOT (aka PRIOT), AI/Deep Learning, Robotics,
Avatars, Social Avatar networks, Augmented Reality, Virtual Reality (35K certified developers in healthcare VR), CRISPR/cas9, Stem Cell therapy, 3D Printers, Drones,
self-driving cars, persoanl etc.…..
2. Data Platforms: Panarome (gen-, transcript-,proteo-, lipid- …), Digital Phenome, Microbiome, Immunome, Exposome, Socialome, Neurobiome, Quantified Self,
Wearable Sensors, etc.
3. API Platforms: SMART on FHIR, OMH, Apple, Samsung, Google, EHR vendors, etc.
4. Experience Platforms: UX, Empathic design, Social-Connected, Avatar social network (intra-individual and inter-individual, locally autonomous to globally
networked)
5. *Financial Platforms: Angels to IPOs, fit for purpose and stage of life-cycle
6. Soci0-Cultural/Geo-political/Value/Ethical Platforms:
Failure Fault Tolerance?
Know your context and mind the gap!!!
Four Principles of the Plecosystem:
1. Exponential Growth: 10 yrs from first smart phone to first billion phones, same pattern for each of above
2. Synergy: Value rises exponentially with both the number of nodes accessible and the number of platforms within each of the four dimensions of the plecosystem linked
across the Plecosystem, aka Matticalfe’s law for both big data and small data
3. Data Liquidity is Critical, hence federation of data, respecting local privacy values/policy
4. Person-centricity: Matticalfe’s law:
Topology ofData/Analytics: (Optimizing the“Learning Health System”)
1. Move analytics to thedatawheneverpossible
2. Accordion model of learning to support moving analytics to source
Driving Value from the Plecosystem:
1. Intersection of big data (universe of knowledge) with little data (N=1 or N= pedigrees in kinship (trios/autism) genetic or environmental)
defines “actionable agenda” for behavioral/policy change and outcomes.
2. Innovation Index: (Density of platforms and platform skills in a social network) X (balanced missionary/mercenary ratio).
3. Innovation Context:
a) Know the balance of platform strengths within your portfolio/geopolitical context, and
b) Deliberately augment your platform deficits through strategic collaborations and “disruptive harvesting”

Larry Smarr, The Microbiome, and HPC To Analyze
Human Microbiome Complexity, Part of BIG/little DATA
10X cells, 100X genes
Almost 100 diseases with ‘microbiomic signatures’
Microbiome-Genome-Immunome-Neurobiome Linkage
No such thing as a “Common” Disease

Role of Wearable Sensors
Four Tiers of Pervasive Sensing:
1) Athlete/warrior: realtime tuning
2) Acute Illness, wireless inpatient monitoring
3) Chronic Illness: DM, Post-discharge from hospital: early
event detection and intervention (Mayo Study)
4) **Restoring Wellness/Resilience through mindfulness
(Accelerometers, GSR, glucose, cortisol,…..etc)
a) Initiation
b) Motivation, and
c) Calibration (extending observation interval of fitbit)

Three Conversations:
1. Patient with Professional Care team
2. Patient with Personal Care team
3. Patient with the Person that houses the patient persona:
“Person-Centricity”
Critical role of visualization tools:
Primary sort is values-based, drill down to data.
Assess values/objectives,
Validate, apply with SDM:
45 yo woman with new onset diabetes and hypertension:
1) Value-based SDM for options
2) Localize use of streaming data from wearables to enhance and
sustain mindfulness first and foremost.

Blue Zones: Healthy Perspectives:
Dan Buettner
Longevity Hotspots: Centagenarians
Okinawa, Japan
Sardinia, Italy
Nicoya, Costa Rica
Icaria, Greece
Loma Linda Seventh-dayAdventists
Commonalities:
1. Diet
2. Exercise: methylation
3. Sleep: clearance of beta-amyloid (Cedars fundoscopic research)
evidence of circadian disruption of melatonin & cancer
4. Social Health (caring and compassion): Fowler’s new work

Behavioral Symphony of
Wellness and Mindfulness

Behavioral Symphony of Wellness
1. Disease burdensof todayall result from disorders of
lifestyle: Obesity, Diabetesand many comorbidities
includingcancer,cardiovasculardisease, alzheimers
2. MobileSocial healthcareiscritical tosupporting healthier
micro-decisions throughoutourdays and our lives.
3. Avatars and digitalassistants will play key roles
4. Behavioral symphony (incombinationwith BJ Fogg’s
Persuasive Technology) is necessaryto shift individuals,
households, kinships and populations:
James Fowler and genetics of FB friends
5. Value proposition is best to
---focus on children
---bycreating lifelong resilience EARLY
---through coaching parenting and early childhood experiences
NB: long term investment!!

Evidence Based Symphony
For motivating behavioral change:
Balancing
a) Individual Preferences with
b) Cohort-based Outcomes and with
c) Personalized Outcomes:
WHAT tocommunicate
HOW tocommunicate(FTF vs. digitalvs. avatars, modality steering)
WHEN tocommunicate
 Three types of Virtual Visits (increased access/convenience)
a) Mydoctorcontinuityof care
b) On Demand Service
c) Storeand Forward educational/motivational, e.g. discharge,
 Multiple personal Avatars: Social AvatarNetworks will Mirror Genetic
Tribalism
 Addressing Social Determinants of Health: START EARLY

Community and Population
Health
1. What is theirrole in the new world of
“Personalized Medicine”
2. Evidence-basedApproachvs. “Dead Aid”
a) Communityhealth assessment tools
b) Validation with Community
c) Benchmarking
d) Local CapacityAssessment
e) Local Appetiteand values/priorities
f) Analytics tosequenceand synergize‘help’
g) Match.comforGov, NGOs, Foundations
h) Validated metrics forprogress
i) Goal of Self-sufficiencyand Resilience
3. Howdo we systematicallyapply“hotspotting” to Positive Deviance?

Health Communities: Asthma

Communities of Health: Obesity

Communities of Health: Depression

Mantras to THRIVE by:
 The Secret to patient care is caring for the patient.
-Sir William Osler
 The secret to health is caring for the whole person.
 The secret to wellness is caring for our friends & family
(with digital augmentation e.g. Social, gaming, avatars)
 The secret to resilience is caring for each other within and
across all of our Communities.
 Social and Community Determinants of Health are the
foundation: and we need to focus on early childhood.

Early Life Experience and HealthSpan:
Strategic Allocation of Resources
 NEJMcritique of “precisionmedicine initiativeinUS” when majordrivers
of morbidity areknownbutnotaddressed
 BarkerHypothesisand multi-disciplinary originsof fetal and early
childhool influence onlifespanand healthspan.
 In utero stressdriveslifelong disease(Dorota Chapko)
 Breastfeeding associated withhigherIQ (Rosie Cornish)
 Early childhood stressremodelsbrainand favorsanxietyand depression
(KingsCollege)
 Excessiveantibioticsinchildhood alters microbiomeand remodelsbrain
forlife. http://www.sciencedaily.com/releases/2015/05/150513140929.htm
 C-sectioncan be detected asaltered microbiomeatage 5. Weneed to focus
more resourcesonteaching emotional and physical resilienceinour
childrenthrough betterfunding of educating parents.
 QUESTION: HOWDO WE BETTER ALLOCATERESOURCES toward
gestational health, parenting and earlychildhood experiences???

What are the Implicationsfor The
Future of Human Evolution?

Homo Metricus:
embedded sensor loops

Homo Geekus

Homo FastFooderus

Mindful Man

“It has been said that the moral test of
government is how that government treats
-those who are in the dawn of life, the children;
-those who are in the twilight of life, the elderly;
-and those who are in the shadows of life, the
sick, the needy and the handicapped.”
--HubertHumphrey atHHS
We must consciously use technology, including genomic health and personalized
medicine to close social inequities and health inequalities, orwe have all failed as
caregivers.

'I've learned that people will forget what you said, people will forget what you
did, but people will never forget how you made them feel.'
Maya Angelou

Recommended Reading
1. Connected by Christakis and Fowler
2. Drive by Daniel Pink
3. The BlueZones: Lessonsfor Living Longer by Dan Buettner: sleep, exercise, social
(genetics, gratitude, forgiveness)
4. The Second MachineAge, Erik Brynjolfsson and Andrew McAffee
5. The GlassCage, Nicholas Carr
6. Enchanted Objects (IOT), David Roses
7. The Unwinding,George Packer (modern Steinbeck)
8. The Half Life of Facts: Why Everything We Know has an ExpirationDate, Samuel
Arbesman
9. PersuasiveTechnologies, BJ Fogg
10. Dead Aid, Dambisa Moyo
11. Abundance, Bold, Peter Diamandis
12. Everything Changes: Capitalism vs. Climate, Naomi Klein
13. The Shallows: What the Internet is Doing to Our Brains, Nicholas Carr
14. Reset, Habit, Switch,
15. The Mind’sOwn Physician by the Dalai Lama
16. The Better Angelsof our Nature, by Steven Pinker
17. The Power of Positive Deviance, by PeterBlock
18. Infinite Progress, How the Internetand Technology Will End Ignorance, Disease,
Poverty, Hunger, and War By Byron Reece

Questions

Recent References:
 Blockchain: http://www.aridhia.com/blog/blockchain-and-digital-health-first-
impressions/
 GenePeeks:
https://www.youtube.com/watch?v=cBZFx-cDWJ0
 Gene Drives and CRISPR:
http://blogs.scientificamerican.com/guest-blog/gene-drives-and-crispr-could-
revolutionize-ecosystem-management/
 Compression algorithms for accelerating big data research:
http://www.sciencedaily.com/releases/2015/08/150826132013.htm
 Liquid Biopsy for early detection:
http://www.sciencedaily.com/releases/2015/08/150826144108.htm
 Citizen Control of Personal health Data
sagetrust.org John Wilbanks et al, geneticsalliance.org Sharon Terry
 Childhood Stress permanently remodels brain:
http://archpedi.jamanetwork.com/article.aspx?articleid=2427470
 CRISPR/cas9 https://en.wikipedia.org/wiki/CRISPR
 Gene Drives Imperial College, London https://en.wikipedia.org/wiki/Gene_drive

Working On Both Sides Of The Pond
Dr Jack Kreindler
Founder & Chief Medical Officer, CHHP,
Sentrian, Frost Data Capital

The Need for Health Data
Fred Trotter
Healthcare Data Journalist and Author
The DocGraph Journal

Introduction - Fred Trotter
Have not reached “needs no introduction status”… but I still
don’t like giving them. Please visit fredtrotter.comto read my
bio if you care… because, lets be honest.. Most of you don’t.

What is Silicon Valley?
Its no longer a just a place. Like Mecca for geeks.

The “Lean Startup” phenomenon
One of several holy texts, along side “the innovators dilemma”,
in Silicon Valley dogma.
Application of Lean Manufacturing principles to software design

The “Microsoft of Medicine”
If I had a dollar…
And the failure of Silicon Valley to conquer Health IT.

Lessons
Only one of the vendors in this space is a traditional Silicon Valley
startup.
In generally there is a disconnect between Silicon Valley thinking
and Health IT practices.A dangerous disconnect between the best
way to make software, and how it is typically delivered in Health IT.

The single crippling assumption
That interferes with SV -> Health IT transfer of value…
That experiments are inexpensive.

Core problems in Health IT
Interoperability is a mess.
Systems do not respond to failures quickly enough.

Solutions
Patient Network Neutrality
Data transparencyto address bad or mediocre actors, and
accelerate evolution.

The NHS Scorecard
John Brittain
Principal Operational Researcher, NHS
England/DH Analyst

John Brittain
Commissioning innovation for value?
Acute Coronary Syndrome in Bradford City and North
Kirklees CCGs

Innovative medicines for Acute Coronary
Syndrome
Left: There is significantvariation
at area team level in the mix of
medicines used for Acute
Coronary Syndrome.
93

94
Relevant innovative medical technologies

For Acute Coronary Syndrome (ACS) Bradford City has significantly worse outcomes
than North Kirklees. Could the spread of innovation be a contributing factor?
95

North Kirklees has higher use of Clopidogrel than Bradford City
96

North Kirklees has higher use of Dipyridamole than Bradford City
97

North Kirklees has higher use of Prasugrel than Bradford City
98

North Kirklees has higher use of Ticagrelor than Bradford City
99

North Kirklees has only marginally higher use of Medical Technologies for
Coronary Artery Disease than Bradford City
100

North Kirklees has little use of Cardiac Combined Medical Technologies. Bradford City had no use
101

What can Bradford City learn from North Kirklees about spreading innovation?
How can both CCGs improve their use of innovation?
Discussion
102

Speed Networking
Ten Companies In Ten Minutes

Francis White
EU General Manager & NHS Innovation
Fellow
AliveCor Ltd

Edward Miller
Co-Founder
Medical Realities Ltd

Richard Fagbolagun – Head of Operations
Akil Benjamin - Head of Customer Success
Alex Fefegha – Principal Solutions Architect
Comuzi Software

Dr Michael Brooks
Chief Medical Officer
PatientSource

Odhran O'Donoghue
Co-Founder
Vardean College Med Tech Forum

Sorin Popa
Innovation Fellow
Postgraduate Institute
Anglia Ruskin University

Ifty Ahmed
CEO and Co-Founder of Pow Health

Dr Maryanne Mariyaselvam
Clinical Research Fellow
Cambridge Teaching Hospitals

Dr Adaeze Nwobodo
A&E Registrar

Dharmesh Kapoor
Director, Medinvent

Prof Rahul Kanegaonkar
Consult ENT Surgeon

Open Networking
Connect via:
england.innovation@nhs.net

Entrepeneurship on the front line - innovate stage, 2 september 2015

Entrepeneurship on the front line - innovate stage, 2 september 2015

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Entrepeneurship on the front line - innovate stage, 2 september 2015