Inspiration

I left practicing medicine 10 years ago because of significant disappointment in the ability of the healthcare system to support patients between visits and to embrace their contribution as part of the team. I was inspired to push the limits of patient participation and to build technology to facilitate dramatically better care.

What it does

Health Activation is the process of empowering patients to break free from the typical reactive healthcare experience and to become proactive in taking control of their health.

The Twine Health Activation Platform is a cloud-based SaaS offering that runs as an app (iOS and Android) and in the browser (Chrome, Firefox, and Safari) for patients and their care team members. It synchronizes with Apple HealthKit and Google FIt, and therefore leverages a wide variety of connected devices (glucometers, blood pressure cuffs, pedometers, etc.) and apps (MyFitnessPal, LoseIt, etc.)

Twine empowers patients to co-create action plans and goals with members of their care team through shared decision making. These action plans are automatically synchronized to the patient's devices (phones, tablets, computers, etc.) and provide timely reminders and learning opportunities through the course of the day to help support the patient in successfully achieving goals. Streamlined communication tools including secure text (with attachments, photos, videos, etc.) and video calls allow patients to get support from the care team right at the moments that they need it. Powerful analytics including artificial intelligence on the care team dashboard allow the quick identification of patients in need so that the right care can be delivered to the right person at the right time. A powerful new class of cohort-based intervention analytics leveraging daily patient self-report data give the care team real-time insight into effectiveness of each care team member and into interventions at large.

How we built it

Our core team spend 6 years at the MIT Media Lab researching health activation and building a predecessor platform called CollaboRhythm. We built what was likely the first healthcare app on a smartphone in 2006 and have continued to push the limits of patient participation since then. We used this experience to begin building Twine in 2014. We have worked with thousands of patients and over 70 healthcare organizations/practices in refining its functionality and impact on the experience, outcomes, and cost of care.

The Twine platform consists of two major components. A client application (the TwineClient) that is implemented as an HTML5 single-page application using the AngularJS framework. The TwineClient is available as both a web application and well as a native mobile application (packaged with the Cordova framework) for iOS and Android. A server application exposing a RESTFul API (the TwineServer) is implemented with NodeJS leveraging MongoDB as the database. The TwineClient and TwineServer are both hosted on Amazon Web Services.

Accomplishments that we are proud of

Our team has published the largest impact hypertension (26mmHg drop in blood pressure in 3 months) and diabetes (3.2 drop in HbA1c in 3 months) in the world by a significant margin. This work was done with the Massachusetts General Hospital (https://www.twinehealth.com/hypertension-rct) and the Joslin Diabetes Center (https://www.twinehealth.com/diabetes-study), respectively, and also demonstrated significant cost reductions and improvements in patient satisfaction.

We have reproduced these results consistently with other organizations, and we expect to report on similar outcomes in hypercholesterolemia, COPD, asthma, CHF, etc. as we have partners leveraging Twine across dozens of different condition / wellness interventions.

We have demonstrated that Twine can produce a 3x increase in health coach (a particular type of care team member) panel size and a 66% reduction in all cause office visits in parallel with the outcome improvements listed above. This degree of scalability has the opportunity to profoundly affect healthcare costs.

Challenges we ran into

The biggest challenge for Twine has been that the majority of healthcare is paid for under fee-for-service mechanisms and thrives when outcomes are poor and costs are high. Most Accountable Care Organizations do not have nearly enough risk in their portfolio of payment contracts to justify improvements in primary care - only in 90 day hospital readmissions, certain bundled payments, and other glancing blows at healthcare outcome deficiencies and cost problems. We know this because we succeeded in dramatically improving hypertension and diabetes outcomes with several ACOs only to be told that they did not want to the interventions because the outcomes decreased revenue (fewer office visits, fewer referrals, fewer ER visits, fewer hospitalizations, etc.).

What we learned

We have learned a great deal over the past 10 years about the learning science and health psychology of patient behavior change and how to build technology that maximizes collaboration between patients and care teams.

We have also learned that the market of workplace health is an incredibly exciting space for innovation in primary care. Self-insured employers have a tremendous desire to improve the experience of healthcare and to decrease costs because they are directly responsible for the healthcare bill for their employers. Many are contracting with providers directly to build primary care practices on premise and are experiencing 20-40% decreases in total cost of care with the dramatically improved care that can be delivered outside of fee-for-service medicine. Others are contracting with near-site practices or adopting biometric screening and health coaching programs.

Even health systems are deploying new models of care for their own employees as an opportunity to learn to deliver value-based primary care. They want to lower their own healthcare cost and improve employee health, but they also want to build competencies for when their mainstream value-based care contracts cross the risk threshold that they will need to leverage the same models for all of the lives covered.

Twine now works with a variety of workplace health vendors and employee health programs at health systems and our business is focused on expanding in this market.

What's next for Twine Health Activation Platform

Our team is currently working on a number of exciting enhancements to the platform that we believe are going to dramatically enhance the experience for patients and the scalability of care teams. In the coming weeks, we will release a patient self-directed experience in Twine that allows people to get started setting and achieving goals even before a health coach or care team is available. Then we will augment this experience with the ability for patients to add family members, friends, and peers and to work with multiple care teams simultaneously. The vision is for Twine to become the center of all healthcare experiences for a patient.

Alignment with the GE Health Cloud

Twine will be pursuing HITRUST certification this year and is looking for partnership opportunities to expand our reach in the healthcare market. The advantages that the GE Health Cloud is designed to to support HITRUST certification and has a mission to help its partner companies to connect with the GE network are both exciting propositions.

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