Kry expands its telehealth service to France — under new brand, Livi

Swedish telehealth startup Kry, which bagged a $66M Series B in June for market expansion, is executing on that plan — announcing today it will launch into the French market on September 15.

This will be the fourth market for the 2014 founded European startup, after its home market of Sweden, along with Norway and Spain. When we spoke to Kry in June it also said it was eyeing a UK launch, and it says now the country is “coming up next” on its launch map.

Kry’s boast for its service is it lets patients ‘see’ a healthcare professional within 15 minutes — i.e. via a remote video consultation on their smartphone or tablet. It recruits doctors locally, in each market where it operates.

The French launch introduces a new brand name for the service, which will be called Livi in the market.

Livi will also be Kry’s brand for all markets outside the Nordics (derived from the Swedish word for ‘life’ — which is ‘liv’).

European state-funded healthcare services vary by country but in France Kry says the government is implementing a national system for public reimbursement of digital healthcare consultations via video — “in light of unequal access, increasing costs and over-usage of emergency services”.

So it’s evidently aiming for Livi to tap into that public money pot.

“I am very excited about bringing our service to French patients,” said Kry CEO and co-founder Johannes Schildt in a statement. “Our vision is great healthcare for everyone, regardless of who you are or where you live. Using digitalization we will fast forward the future of healthcare, making it patient focused, proactive and economically sustainable. The fact that France is opening up for digital healthcare on a national level should be an inspiration to the rest of Europe.”

Over in the UK, the new minister responsible for health, Matt Hancock — who was previously in charge of digital matters — has made increasing the National Health Service’s use of technology one of his key priorities, announcing yesterday a further £200M to plough into upgrading NHS IT systems.

Which will also, presumably, be music to health app makers’ ears.

Kry says its telehealth service has now generated more than half a million patient meetings, across its existing markets, saying it grew 740% in 2017 — which it claims makes it the largest digital healthcare provider in Europe.

In its home market of Sweden it also says it accounts for more than 3% of all primary care doctor visits.

While in March this year it added an online psychology service to its offering, and says it’s now the largest provider of cognitive behavioral therapy treatments in Sweden.

Investors in the digital health business include Index Ventures, Accel, Creandum, and Project A.

Femtech hardware startup Elvie inks strategic partnership with UK’s NHS

Elvie, a femtech hardware startup whose first product is a sleek smart pelvic floor exerciser, has inked a strategic partnership with the UK’s National Health Service that will make the device available nationwide through the country’s free-at-the-point-of-use healthcare service so at no direct cost to the patient.

It’s a major win for the startup that was co-founded in 2013 by CEO Tania Boler and Jawbone founder, Alexander Asseily, with the aim of building smart technology that focuses on women’s issues — an overlooked and underserved category in the gadget space.

Boler’s background before starting Elvie (née Chiaro) including working for the U.N. on global sex education curriculums. But her interest in pelvic floor health, and the inspiration for starting Elvie, began after she had a baby herself and found there was more support for women in France than the U.K. when it came to taking care of their bodies after giving birth.

With the NHS partnership, which is the startup’s first national reimbursement partnership (and therefore, as a spokeswoman puts it, has “the potential to be transformative” for the still young company), Elvie is emphasizing the opportunity for its connected tech to help reduce symptoms of urinary incontinence, including those suffered by new mums or in cases of stress-related urinary incontinence.

The Elvie kegel trainer is designed to make pelvic floor exercising fun and easy for women, with real-time feedback delivered via an app that also gamifies the activity, guiding users through exercises intended to strengthen their pelvic floor and thus help reduce urinary incontinence symptoms. The device can also alert users when they are contracting incorrectly.

Elvie cites research suggesting the NHS spends £233M annually on incontinence, claiming also that around a third of women and up to 70% of expectant and new mums currently suffer from urinary incontinence. In 70 per cent of stress urinary incontinence cases it suggests symptoms can be reduced or eliminated via pelvic floor muscle training.

And while there’s no absolute need for any device to perform the necessary muscle contractions to strengthen the pelvic floor, the challenge the Elvie Trainer is intended to help with is it can be difficult for women to know they are performing the exercises correctly or effectively.

Elvie cites a 2004 study that suggests around a third of women can’t exercise their pelvic floor correctly with written or verbal instruction alone. Whereas it says that biofeedback devices (generally, rather than the Elvie Trainer specifically) have been proven to increase success rates of pelvic floor training programmes by 10% — which it says other studies have suggested can lower surgery rates by 50% and reduce treatment costs by £424 per patient head within the first year.

“Until now, biofeedback pelvic floor training devices have only been available through the NHS for at-home use on loan from the patient’s hospital, with patient allocation dependent upon demand. Elvie Trainer will be the first at-home biofeedback device available on the NHS for patients to keep, which will support long-term motivation,” it adds.

Commenting in a statement, Clare Pacey, a specialist women’s health physiotherapist at Kings College Hospital, said: “I am delighted that Elvie Trainer is now available via the NHS. Apart from the fact that it is a sleek, discreet and beautiful product, the app is simple to use and immediate visual feedback directly to your phone screen can be extremely rewarding and motivating. It helps to make pelvic floor rehabilitation fun, which is essential in order to be maintained.”

Elvie is not disclosing commercial details of the NHS partnership but a spokeswoman told us the main objective for this strategic partnership is to broaden access to Elvie Trainer, adding: “The wholesale pricing reflects that.”

Discussing the structure of the supply arrangement, she said Elvie is working with Eurosurgical as its delivery partner — a distributor she said has “decades of experience supplying products to the NHS”.

“The approach will vary by Trust, regarding whether a unit is ordered for a particular patient or whether a small stock will be held so a unit may be provided to a patient within the session in which the need is established. This process will be monitored and reviewed to determine the most efficient and economic distribution method for the NHS Supply Chain,” she added.

Audit of NHS Trust’s app project with DeepMind raises more questions than it answers

A third party audit of a controversial patient data-sharing arrangement between a London NHS Trust and Google DeepMind appears to have skirted over the core issues that generated the controversy in the first place.

The audit (full report here) — conducted by law firm Linklaters — of the Royal Free NHS Foundation Trust’s acute kidney injury detection app system, Streams, which was co-developed with Google-DeepMind (using an existing NHS algorithm for early detection of the condition), does not examine the problematic 2015 information-sharing agreement inked between the pair which allowed data to start flowing.

“This Report contains an assessment of the data protection and confidentiality issues associated with the data protection arrangements between the Royal Free and DeepMind . It is limited to the current use of Streams, and any further development, functional testing or clinical testing, that is either planned or in progress. It is not a historical review,” writes Linklaters, adding that: “It includes consideration as to whether the transparency, fair processing, proportionality and information sharing concerns outlined in the Undertakings are being met.”

Yet it was the original 2015 contract that triggered the controversy, after it was obtained and published by New Scientist, with the wide-ranging document raising questions over the broad scope of the data transfer; the legal bases for patients information to be shared; and leading to questions over whether regulatory processes intended to safeguard patients and patient data had been sidelined by the two main parties involved in the project.

In November 2016 the pair scrapped and replaced the initial five-year contract with a different one — which put in place additional information governance steps.

They also went on to roll out the Streams app for use on patients in multiple NHS hospitals — despite the UK’s data protection regulator, the ICO, having instigated an investigation into the original data-sharing arrangement.

And just over a year ago the ICO concluded that the Royal Free NHS Foundation Trust had failed to comply with Data Protection Law in its dealings with Google’s DeepMind.

The audit of the Streams project was a requirement of the ICO.

Though, notably, the regulator has not endorsed Linklaters report. On the contrary, it warns that it’s seeking legal advice and could take further action.

In a statement on its website, the ICO’s deputy commissioner for policy, Steve Wood, writes: “We cannot endorse a report from a third party audit but we have provided feedback to the Royal Free. We also reserve our position in relation to their position on medical confidentiality and the equitable duty of confidence. We are seeking legal advice on this issue and may require further action.”

In a section of the report listing exclusions, Linklaters confirms the audit does not consider: “The data protection and confidentiality issues associated with the processing of personal data about the clinicians at the Royal Free using the Streams App.”

So essentially the core controversy, related to the legal basis for the Royal Free to pass personally identifiable information on 1.6M patients to DeepMind when the app was being developed, and without people’s knowledge or consent, is going unaddressed here.

And Wood’s statement pointedly reiterates that the ICO’s investigation “found a number of shortcomings in the way patient records were shared for this trial”.

“[P]art of the undertaking committed Royal Free to commission a third party audit. They have now done this and shared the results with the ICO. What’s important now is that they use the findings to address the compliance issues addressed in the audit swiftly and robustly. We’ll be continuing to liaise with them in the coming months to ensure this is happening,” he adds.

“It’s important that other NHS Trusts considering using similar new technologies pay regard to the recommendations we gave to Royal Free, and ensure data protection risks are fully addressed using a Data Protection Impact Assessment before deployment.”

While the report is something of a frustration, given the glaring historical omissions, it does raise some points of interest — including suggesting that the Royal Free should probably scrap a Memorandum of Understanding it also inked with DeepMind, in which the pair set out their ambition to apply AI to NHS data.

This is recommended because the pair have apparently abandoned their AI research plans.

On this Linklaters writes: “DeepMind has informed us that they have abandoned their potential research project into the use of AI to develop better algorithms, and their processing is limited to execution of the NHS AKI algorithm… In addition, the majority of the provisions in the Memorandum of Understanding are non-binding. The limited provisions that are binding are superseded by the Services Agreement and the Information Processing Agreement discussed above, hence we think the Memorandum of Understanding has very limited relevance to Streams. We recommend that the Royal Free considers if the Memorandum of Understanding continues to be relevant to its relationship with DeepMind and, if it is not relevant, terminates that agreement.”

In another section, discussing the NHS algorithm that underpins the Streams app, the law firm also points out that DeepMind’s role in the project is little more than helping provide a glorified app wrapper (on the app design front the project also utilized UK app studio, ustwo, so DeepMind can’t claim app design credit either).

“Without intending any disrespect to DeepMind, we do not think the concepts underpinning Streams are particularly ground-breaking. It does not, by any measure, involve artificial intelligence or machine learning or other advanced technology. The benefits of the Streams App instead come from a very well-designed and user-friendly interface, backed up by solid infrastructure and data management that provides AKI alerts and contextual clinical information in a reliable, timely and secure manner,” Linklaters writes.

What DeepMind did bring to the project, and to its other NHS collaborations, is money and resources — providing its development resources free for the NHS at the point of use, and stating (when asked about its business model) that it would determine how much to charge the NHS for these app ‘innovations’ later.

Yet the commercial services the tech giant is providing to what are public sector organizations do not appear to have been put out to open tender.

Also notably excluded in the Linklaters’ audit: Any scrutiny of the project vis-a-vis competition law, public procurement law compliance with procurement rules, and any concerns relating to possible anticompetitive behavior.

The report does highlight one potentially problematic data retention issue for the current deployment of Streams, saying there is “currently no retention period for patient information on Streams” — meaning there is no process for deleting a patient’s medical history once it reaches a certain age.

“This means the information on Streams currently dates back eight years,” it notes, suggesting the Royal Free should probably set an upper age limit on the age of information contained in the system.

While Linklaters largely glosses over the chequered origins of the Streams project, the law firm does make a point of agreeing with the ICO that the original privacy impact assessment for the project “should have been completed in a more timely manner”.

It also describes it as “relatively thin given the scale of the project”.

Giving its response to the audit, health data privacy advocacy group MedConfidential — an early critic of the DeepMind data-sharing arrangement — is roundly unimpressed, writing: “The biggest question raised by the Information Commissioner and the National Data Guardian appears to be missing — instead, the report excludes a “historical review of issues arising prior to the date of our appointment”.

“The report claims the ‘vital interests’ (i.e. remaining alive) of patients is justification to protect against an “event [that] might only occur in the future or not occur at all”… The only ‘vital interest’ protected here is Google’s, and its desire to hoard medical records it was told were unlawfully collected. The vital interests of a hypothetical patient are not vital interests of an actual data subject (and the GDPR tests are demonstrably unmet).

“The ICO and NDG asked the Royal Free to justify the collection of 1.6 million patient records, and this legal opinion explicitly provides no answer to that question.”

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