Bringing together experts across the fields of medicine and technology,  the Senscio Clinical Innovation Council is building algorithms to manage chronic disease

It’s no secret that quality health care is becoming harder to find for many Americans.

Senscio Systems’ Ibis Health program is already working to fill gaps in care for thousands from across New England. Combining AI-powered round-the-clock virtual care with clinical team support, Ibis Health engages patients in dynamic daily planning, tracking weight, medications, blood pressure, diet and other health indicators to flag risks for decline before it happens. By developing partnerships with primary care practices to coordinate care between doctor’s visits, the program serves as a lifeline for its members, who benefit from a personalized approach that adapts to their specific needs.  

Now the CIC is looking to take the support that Ibis Health provides and raise it to the next level, developing preventive and self-recovery algorithms to be incorporated by clinicians in individual patient care plans for a range of chronic conditions, including congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, asthma, hypertension, diabetes and depression and anxiety. Future clinical areas might include long Covid, substance abuse, Alzheimer’s disease, chronic pain and cholesterol/cardiac risk.  

"With health care resources becoming even more scarce and more costly, we must learn from all of our medical disciplines and computer scientists the most effective ways of keeping our chronic disease patients safe, developing their confidence and nurturing their independence,"

Dan McIntyre, co-chair of the CIC and former senior vice president for Hartford Healthcare and head of Charlotte Hungerford Hospital based in Torrington, Conn.

"That’s exactly what our chronic disease management algorithms will do. They will serve almost like in-home personal health guardians, constantly watching over our patients and providing them with a connection to a vast reservoir of medical knowledge and to our Senscio support team."

Gaps in the health care system demand a new approach

The United States already has fewer practicing physicians per capita than Canada, Israel and nearly all its European counterparts. And by 2034, the Association of American Medical Colleges predicts the demand for doctors in the U.S. will exceed supply by as many as 124,000 full-time equivalent physicians, including a shortfall of up to 48,000 primary care physicians. 
 
At the same time, as Baby Boomers (the “gray tsunami”) continue to reach retirement, the number of people ages 65 and older is expected to increase by roughly 45 percent over the next 20 years, from 55.7 million in 2020 to nearly 81 million in 2040, according to the U.S. Department of Health and Human Services’ Administration for Community Living. 

“The obvious answer is that we’ve got to figure out how to get us, those of us with chronic conditions, to do more for ourselves,” said Piali De, Senscio Systems’ co-founder and CEO. “But do-it-yourself in health care is not so simple, which is why no one’s ever gone there.”

Unlike watching a YouTube video on how to fix a leaky pipe, which relies on standardized parts and procedures, health care must be personalized to each patient’s individual needs. But De believes Baby Boomers especially are ready for a different solution, one that is accessible and allows them to maintain control over where and how they age. 

“We’re a roll-up-the-sleeves-and-do-it, we’re a take-charge generation,” De said. “We’re not going to give up control over the most important piece of our being, which is our health. … We’re going to want care to come to us, wherever we are in the world, whatever we’re going to do.”

Creating a solution for complex patients that is personalized to their needs 

The CIC is taking an approach to chronic disease management that centers on individuals’ whole health, paying careful attention to all of their conditions and how they interact with each other. This type of holistic focus is common in cancer treatment, where oncologists often serve as project managers for their patients, coordinating with surgeons, palliative care doctors and other specialists to guide them through their course of treatment. But it is increasingly rare in other specialties as health care has become less hospital-focused and more ambulatory-based, said Dr. Richard Goldstein, CIC co-chair, current chief medical officer for the Northeast Medical Group and senior vice president at Yale New Haven Health System. 

Gone are the days when doctors would come in in the morning, make rounds in the hospital and then stop in the lounge to eat and chat with each other about what might be best for a patient and how to coordinate care.

“That is completely 100 percent gone. The economics of it now is that if an outpatient physician is not seeing patients constantly every minute of every day, then money is lost,” said Dr. Neil Duval, a member of the CIC and board-certified pulmonologist. “So there is absolutely no time for physicians to connect. It’s done through the electronic record, which health care systems like to tell themselves is sufficient. So I might write a note, and in my note, I’ll say I really need to get the cardiologist’s input on this, and I’ll send that note to the cardiologist and hope he reads it, hope he responds … but then I’m on to the next patient.”

And if a patient’s information lives in multiple EMRs across various health care centers or specialists, communication between medical providers becomes even more inefficient and complicated, Duval and Goldstein said. “It’s become very siloed,” Goldstein said. “I think we just have a very uncoordinated delivery system out there.”

The CIC hopes to change that by bringing together clinical providers from various specialties to figure out how to best care for patients with multiple chronic conditions, so that treatment for one condition doesn’t tip the balance for another disease. The Council includes representation from cardiology, internal medicine, nephrology, pulmonology, psychiatry and geriatrics. Collectively these specialists will advance a care model that determines how to prioritize different treatment pathways with the goal of keeping seniors healthy and living independently for as long as they are able. The result of that expertise will then be implemented through Senscio’s AI-based platform in Ibis Health.

“We’ve been providing expert knowledge into the home in a siloed fashion [through Ibis Health],” De said. “We are now starting to create the tunnels between those silos.” 

First the CIC’s clinical specialists will work one-on-one with Senscio’s technical team to determine how to build research-based and thoughtful preventive and self-recovery algorithms for each of the chronic conditions they oversee. Duval, for example, is currently engaged in developing algorithms for chronic obstructive pulmonary disease, commonly known as COPD.

How preventive and self-recovery algorithms can help patients with COPD

There is nothing worse than not being able to breathe. Duval knows this firsthand.

As a pulmonologist with Central Maine Healthcare, Duval spent decades treating patients struggling with COPD, an umbrella term for conditions that cause airflow blockage, including emphysema and chronic bronchitis.The sixth leading cause of death in the U.S. in 2020, more than 16 million Americans suffer from COPD, and millions more go undiagnosed each year, according to the CDC. COPD is chronic, progressive and incurable — once diagnosed, it will never go away.

The key to living, and living well, with COPD is preventing exacerbations — episodes of rapidly worsening symptoms that can last for days or even weeks and result in permanent lung damage. In 2019 alone, more than 1.3 million ER visits nationwide were due to COPD exacerbations, according to the American Lung Association.

"If it gets worse, there’s no coming back from it. If someone has bad lung function … anything they lose is going to debilitate them,” Duval said. “[But] more recent research shows that you can identify people who are about to exacerbate preclinically before they know it’s going to happen. So if you can identify those things, intervene before the exacerbation, then you’ve prevented the exacerbation, and you have, by definition, improved this person’s quality of life."

As a member of Senscio’s CIC, Duval is working with Senscio’s programmers to develop algorithms that aim to do just that. Twice a day, COPD patients using Ibis Health’s proprietary AI-powered platform are prompted through a dedicated connected tablet to track their oxygen and airflow levels using a pulse oximeter and home spirometer. They also answer questions such as “How do you feel today?” and “Is your breathing worse today than it was yesterday?”

The resulting data is used by clinicians to determine whether users might be at risk for an exacerbation and to suggest steps for self-management and recovery, such as utilizing a nebulizer or turning up their oxygen, all according to the plan prescribed by their medical provider. If necessary, Senscio’s Ibis system will alert the program’s on-call clinical team to check in, or prompt patients to call their doctor or go to the emergency room.
 
“The patient stays healthy and the provider gets fewer calls because the AI will deal with most of these problems without the provider even needing to be alerted,” Duval said, adding that the algorithms will help cut down on hospital admissions and keep people out of the ER unnecessarily. Indeed, Ibis Health users suffering from COPD have reported a 37 percent decline in hospitalizations. 

"When you have 100 people and they are all getting ill, in the absence of any home monitoring, now you have 100 calls to 100 providers. With home monitoring, you take those 100 people getting ill, and apply these [algorithms], and maybe now 40 or 50 of them have managed the problem by themselves,” Duval said, explaining that the Ibis platform delivers his clinical orders. “[And] people always do better if they feel like they’re in charge of their own disease."

Creating an adaptive expert system that allows seniors to enjoy life on their terms

Once algorithms are built for each disease, the next challenge is to bring them all together and determine how they should interact with each other.
 
The goal, De said, is to give Senscio’s AI-based platform the ability to leverage the combined clinical expertise of the CIC’s members, so it can teach Ibis Health users how to take better care of themselves in the comfort of their own homes. If written correctly and updated as needed, these algorithms could also be an excellent predictor of when a chronic disease patient is heading into trouble, allowing medical providers to intervene before a situation becomes critical, McIntyre said.

“It’s on the order of a unicorn,” Duval said. “What [Senscio] is doing is quite unique. I think the true power of the Ibis [program] is going to be just that, when all of those algorithms are connected and when AI is really at a point where anything one practitioner does or anything that one algorithm does that impacts a different practitioner or algorithm, it will automatically take care of that. If I put someone on prednisone for their breathing, that’s going to make their blood sugars go up, then that should kick over to the diabetes algorithms,” while always keeping the clinical team on alert.
 
This is where the CIC’s real work begins, Council members said — and it will require curiosity, patience, respect for the whole body and a willingness to engage in the art of what might be possible. 
 
“You have to have a group of people that recognize that we can have a better health care system,” Goldstein said. “I have worked with a couple of these people before, and they are brilliant and they know their field, and I think everybody is united around keeping people as healthy as they can be. As long as that remains the focus and we put the patient first, I think we’ll be successful.” 
 
“I am completely of the opinion that this, if we can invest the effort into it, this could fundamentally change health care,” Duval said. “I truly believe that, and I want to be part of that. I want to have my name on that plaque 200 years from now.”