Category Archives: Personalization

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Microbiome Apps Personalize EAT recommendations

Richard Sprague provides a useful update about the microbiome landscape below. Microbiome is exploding. Your gut can be measured, and your gut can influence your health and well-being. But now …. these gut measurements can offer people a first: personalized nutrition information.

Among the more relevant points:

– Israel’s Weitzman Institute is the global leader academically. Eran Elinav, a physician and immunologist at the Weizmann Institute and one of their lead investigators (see prior post).
– The older technology for measuring the gut is called “16S” sequencing. It tell you at a high level which kinds of microbes are present. It’s cheap and easy, but 16S can see only broad categories,
– The companies competing to measure your microbiome are uBiome, American Gut, Thryve, DayTwo and Viome. DayTwo and Viome offer more advanced technology (see below).
– The latest technology seems to be “metagenomic sequencing”. It is better because it is more specific and detailed.
– By combining “metagenomic sequencing” information with extensive research about how certain species interact with particular foods, machine-learning algorithms can recommend what you should eat.
– DayTwo offers a metagenomic sequencing for $299, and then combines that with all available research to offer personalized nutrition information.
– DayTwo recently completed a $12 million financing round from, among others, Mayo Clinic, which announced it would be validating the research in the U.S.
– DayTwo draws its academic understandings from Israel’s Weitzman Institute. The app is based on more than five years of highly cited research showing, for example, that while people on average respond similarly to white bread versus whole grain sourdough bread, the differences between individuals can be huge: what’s good for one specific person may be bad for another.

CREDIT: Article on Microbiome Advances

When a Double-Chocolate Brownie is Better for You Than Quinoa

A $299 microbiome test from DayTwo turns up some counterintuitive dietary advice.

Why do certain diets work well for some people but not others? Although several genetic tests try to answer that question and might help you craft ideal nutrition plans, your DNA reveals only part of the picture. A new generation of tests from DayTwo and Viome offer diet advice based on a more complete view: they look at your microbiome, the invisible world of bacteria that help you metabolize food, and, unlike your DNA, change constantly throughout your life.
These bugs are involved in the synthesis of vitamins and other compounds in food, and they even play a role in the digestion of gluten. Artificial sweeteners may not contain calories, but they do modify the bacteria in your gut, which may explain why some people continue to gain weight on diet soda. Everyone’s microbiome is different.

So how well do these new tests work?
Basic microbiome tests, long available from uBiome, American Gut, Thryve, and others, based on older “16S” sequencing, can tell you at a high level which kinds of microbes are present. It’s cheap and easy, but 16S can see only broad categories, the bacterial equivalent of, say, canines versus felines. But just as your life might depend on knowing the difference between a wolf and a Chihuahua, your body’s reaction to food often depends on distinctions that can be known only at the species level. The difference between a “good” microbe and a pathogen can be a single DNA base pair.

New tests use more precise “metagenomic” sequencing that can make those distinctions. And by combining that information with extensive research about how those species interact with particular foods, machine-learning algorithms can recommend what you should eat. (Disclosure: I am a former “citizen scientist in residence” at uBiome. But I have no current relationship with any of these companies; I’m just an enthusiast about the microbiome.)

I recently tested myself with DayTwo ($299) to see what it would recommend for me, and I was pleased that the advice was not always the standard “eat more vegetables” that you’ll get from other products claiming to help you eat healthily. DayTwo’s advice is much more specific and often refreshingly counterintuitive. It’s based on more than five years of highly cited research at Israel’s Weizmann Institute, showing, for example, that while people on average respond similarly to white bread versus whole grain sourdough bread, the differences between individuals can be huge: what’s good for one specific person may be bad for another.

In my case, whole grain breads all rate C-. French toast with challah bread: A.

The DayTwo test was pretty straightforward: you collect what comes out of your, ahem, gut, which involves mailing a sample from your time on the toilet. Unlike the other tests, which can analyze the DNA found in just a tiny swab from a stain on a piece of toilet paper, DayTwo requires more like a tablespoon. The extra amount is needed for DayTwo’s more comprehensive metagenomics sequencing.

Since you can get a microbiome test from other companies for under $100, does the additional metagenomic information from DayTwo justify its much higher price? Generally, I found the answer is yes.

About two months after I sent my sample, my iPhone lit up with my results in a handy app that gave me a personalized rating for most common foods, graded from A+ to C-. In my case, whole grain breads all rate C-. Slightly better are pasta and oatmeal, each ranked C+. Even “healthy” quinoa — a favorite of gluten-free diets — was a mere B-. Why? DayTwo’s algorithm can’t say precisely, but among the hundreds of thousands of gut microbe and meal combinations it was trained on, it finds that my microbiome doesn’t work well with these grains. They make my blood sugar rise too high.

So what kinds of bread are good for me? How about a butter croissant (B+) or cheese ravioli (A-)? The ultimate bread winner for me: French toast with challah bread (A). These recommendations are very different from the one-size-fits-all advice from the U.S. Department of Agriculture or the American Diabetes Association.

I was also pleased to learn that a Starbucks double chocolate brownie is an A- for me, while a 100-calorie pack of Snyder’s of Hanover pretzels gets a C-. That might go against general diet advice, but an algorithm determined that the thousands of bacterial species inside me tend to metabolize fatty foods in a way that results in healthier blood sugar levels than what I get from high-carb foods. Of course, that’s advice just for me; your mileage may vary.

Although the research behind DayTwo has been well-reviewed for more than five years, the app is new to the U.S., so the built-in food suggestions often seem skewed toward Middle Eastern eaters, perhaps the Israeli subjects who formed the original research cohort. That might explain why the app’s suggestions for me include lamb souvlaki with yogurt garlic dip for dinner (A+) and lamb kabob and a side of lentils (A) for lunch. They sound delicious, but to many American ears they might not have the ring of “pork ribs” or “ribeye steak,” which have the same A+ rating. Incidentally, DayTwo recently completed a $12 million financing round from, among others, Mayo Clinic, which announced it would be validating the research in the U.S., so I expect the menu to expand with more familiar fare.

Fortunately you’re not limited to the built-in menu choices. The app includes a “build a meal” function that lets you enter combinations of foods from a large database that includes packaged items from Trader Joe’s and Whole Foods.

There is much more to the product, such as a graphical rendering of where my microbiome fits on the spectrum of the rest of the population that eats a particular food. Since the microbiome changes constantly, this will help me see what is different when I do a retest and when I try Viome and other tests.

I’ve had my DayTwo results for only a few weeks, so it’s too soon to know what happens if I take the app’s advice over the long term. Thankfully I’m in good health and reasonably fit, but for now I’ll be eating more strawberries (A+) and blackberries (A-), and fewer apples (B-) and bananas (C+). And overall I’m looking forward to a future where each of us will insist on personalized nutritional information. We all have unique microbiomes, and an app like DayTwo lets us finally eat that way too.

Richard Sprague is a technology executive and quantified-self enthusiast who has worked at Apple, Microsoft, and other tech companies. He is now the U.S. CEO of an AI healthcare startup, Airdoc.

====================APPENDIX: Older Posts about the microbiome =========

Microbiome Update
CREDIT: https://www.wsj.com/articles/how-disrupting-your-guts-rhythm-affects-your-health-1488164400?mod=e2tw A healthy community of microbes in the gut maintains regular daily cycles of activities. A healthy community of microbes in the gut maintains regular daily cycles of activities.PHOTO: WEIZMANN INSTITUTE By LARRY M. GREENBERG Updated Feb. 27, 2017 3:33 p.m. ET 4 COMMENTS New research is helping to unravel the mystery of how […]

Vibrant Health measures microbiome

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Microbiome Update
My last research on this subject was in August, 2014. I looked at both microbiomes and proteomics. Today, the New York Times published a very comprehensive update on microbiome research: Link to New York Time Microbiome Article Here is the article itself: = = = = = = = ARTICLE BEGINS HERE = = = […]

Microbiomes
Science is advancing on microbiomes in the gut. The key to food is fiber, and the key to best fiber is long fibers, like cellulose, uncooked or slightly sauteed (cooking shortens fiber length). The best vegetable, in the view of Jeff Leach, is a leek. Eating Well Article on Microbiome = = = = = […]

Arivale Launches LABS company
“Arivale” Launched and Moving Fast. They launched last month. They have 19 people in the Company and a 107 person pilot – but their plans are way more ambitious than that. Moreover: “The founders said they couldn’t envision Arivale launching even two or three years ago.” Read on …. This is an important development: the […]

Precision Wellness at Mt Sinai
My Sinai announcement Mount Sinai to Establish Precision Wellness Center to Advance Personalized Healthcare Mount Sinai Health System Launches Telehealth Initiatives Joshua Harris, co-Founder of Apollo Global Management, and his wife, Marjorie has made a $5 million gift to the Icahn School of Medicine at Mount Sinai to establish the Harris Center for Precision Wellness. […]

Proteomics
“Systems biology…is about putting together rather than taking apart, integration rather than reduction. It requires that we develop ways of thinking about integration that are as rigorous as our reductionist programmes, but different….It means changing our philosophy, in the full sense of the term” (Denis Noble).[5] Proteomics From Wikipedia, the free encyclopedia For the journal […]

Marketing Automation Software

Pardot believes they are perfecting lead generation through supplemental technologies.

See Pardot Website

Salesforce.com believes in the idea enough to buy them.

At a high level, this is about accepting that most leads are not “hot”, Pardot offers a way to nurture all warm leads and monitor whether they are moving toward cold or hot. If hot, the Pardot nurtures tha relationship in a way most relevant to the lead. They call this Smarter lead generation and effortless email marketing.

My friend Andrew M is a Salesforce expert and swears by them.

Alzheimer’s Genetic Risk Assessment

CREDIT: NPR article

CREDIT: Bill Gates 11.13.17 Blog Post on Alzheimer’s

FDA Approves Marketing Of Consumer Genetic Tests For Some Conditions

April 7, 20171:40 PM ET
JESSICA BODDY

23andMe is now allowed to market tests that assess genetic risks for 10 health conditions, including Parkinson’s and late-onset Alzheimer’s diseases.
Meredith Rizzo/NPR
The U.S. Food and Drug Administration approved 23andMe’s personal genetic test for some diseases on Thursday, including Alzheimer’s, Parkinson’s and celiac diseases.
The tests assess genetic risk for the conditions but don’t diagnose them, the FDA says. The agency urges consumers to use their results to “help to make decisions about lifestyle choices or to inform discussions with a health care professional,” according to a press release about the decision.
Jeffrey Shuren, the director of the FDA’s Center for Devices and Radiological Health, wrote, “it is important that people understand that genetic risk is just one piece of the bigger puzzle, it does not mean they will or won’t ultimately develop a disease.” Other known factors that can play into the development of disease include diet, environment and tobacco use.

SHOTS – HEALTH NEWS
23andMe Bows To FDA’s Demands, Drops Health Claims
The FDA has previously scolded the company for marketing the personal genetic testing kits without the agency’s consent. In 2013, the agency told 23andMe to stop selling its personal genome kits in the United States until they gained FDA approval by proving they were accurate.
The company agreed to work with the FDA, as we reported, and a recent FDA review of peer-reviewed studies found more consistent links between certain gene variants and 10 diseases, the FDA says.
As a result, the FDA is now allowing 23andMe to market tests that assess genetic risks for the following 10 diseases or conditions:
▪ Parkinson’s disease, a nervous system disorder impacting movement 

▪ Late-onset Alzheimer’s disease, a progressive brain disorder that destroys memory and thinking skills 

▪ Celiac disease, a disorder resulting in the inability to digest gluten 

▪ Alpha-1 antitrypsin deficiency, a disorder that raises the risk of lung and liver disease 

▪ Early-onset primary dystonia, a movement disorder involving involuntary muscle contractions and other uncontrolled movements 

▪ Factor XI deficiency, a blood clotting disorder 

▪ Gaucher disease type 1, an organ and tissue disorder 

▪ Glucose-6-phosphate dehydrogenase deficiency, also known as G6PD, a red blood cell condition 

▪ Hereditary hemochromatosis, an iron overload disorder 

▪ Hereditary thrombophilia, a blood clot disorder 


The company’s $199 Health and Ancestry test is available directly to consumers, without seeing a physician or genetic counselor. Consumers’ DNA is extracted from a saliva sample. After mailing in their sample, people can see their results online.
“This is an important moment for people who want to know their genetic health risks and be more proactive about their health,” said Anne Wojcicki, the CEO and co-founder of 23andMe, in a company press release.
Sharon Terry, the CEO of the Genetic Alliance, a nonprofit organization that advocates for health care for people with genetic disorders, likens it to another consumer test. “Women learn they are pregnant using a test directly marketed to them and buy it off the shelf in a drugstore,” she told NPR. “In 10 years we will marvel that this is an ‘advance’ at all. Imagine pregnancy tests being only available through a doctor!”
Robert Green, a professor of medicine at Harvard Medical School, says people should be able to access genetic information in whatever way is best for them. “Some people really want this [genetic] information on their own, and others want it through their physician,” he said. “Both those channels are legitimate. People should just be aware that this information is complicated.”
But some are still concerned about whether the genes in question actually correspond to a higher risk of disease reliably enough to warrant direct-to-consumer marketing and testing, as opposed to genetic testing with the guidance of a professional.

SHOTS – HEALTH NEWS
Don’t Get Your Kids’ Genes Sequenced Just To Keep Up

SHOTS – HEALTH NEWS
Personalizing Cancer Treatment With Genetic Tests Can Be Tricky
Some health professionals worry that consumers will “take the results and run,” as Mary Freivogel put it. Freivogel, a certified genetic counselor and the president of the National Society of Genetic Counselors, added that genetics are just “one piece to the story when it comes to developing a disease.”
Freivogel said speaking with a genetic counselor before getting tested for disease is important. “Direct-to-consumer testing takes away a pre-test conversation,” she said, where counselors can help patients think about questions like: “What do you want to know? What are you going to do with this information? Is it something you’re prepared to know, or is it going to just make you anxious?”
And it isn’t clear what consumers should do with their newly calculated disease risk, especially for conditions like Alzheimer’s for which there isn’t a cure or even a course of action to prevent the disease.
What’s more, having the genes is not the same as having the diseases the genes are associated with. A person may have genes that are associated with Alzheimer’s, for example, but that doesn’t mean he or she will ever get the disease. Conversely, some people develop Alzheimer’s without the identified risk genes.
The Alzheimer’s Association does not recommend routine genetic testing for the disease in the general population because it can’t “productively guide medical treatment.”
A genetic test result for Alzheimer’s is “not going to provide useful information even if you’re at an increased risk,” said Keith Fargo, director of scientific programs at the Alzheimer’s Association. “It’s not like there’s a drug you can take right now [to prevent the disease] or a lifestyle change you can make that you shouldn’t make anyway,” such as exercising and eating right to keep your brain healthy.
John Lehr, the CEO of the Parkinson’s Foundation, says personal genetic tests can help identify risk for Parkinson’s disease. But, he wrote in a statement following the FDA’s announcement, the foundation recommends “that people who are interested in testing first seek guidance from their doctors and from genetic counselors to understand what the process may mean for them and their families.”

NEST Smart Home Update

I have been tracking Google’s NEST for awhile now. It’s the best example I know of a learning system for the home. The latest is …. it is still the best!

================
CREDIT: http://thewirecutter.com/reviews/the-best-thermostat/

We spent more than a month trying five popular smart thermostats—testing the hardware, their accompanying mobile apps, and their integrations with various smart-home systems—and the third-generation Nest remains our pick. Five years after the Nest’s debut, a handful of bona fide competitors approach it in style and functionality, but the Nest Learning Thermostat remains the leader. It’s still the easiest, most intuitive thermostat we tested, offering the best combination of style and substance.

Last Updated: November 10, 2016
We’ve added our review of Ecobee’s new Ecobee3 Lite, and we’ve updated our thoughts on HomeKit integration following the launch of Apple’s Home app. We’ve also included details on Nest’s new Eco setting and color options, a brief look at the upcoming Lyric T5, and a clarification regarding the use of a C wire for the Emerson Sensi.

The Nest works well on its own or integrated with other smart-home products. Its software and apps are solid and elegant, too, and it does a really good job of keeping your home at a comfortable temperature with little to no input from you. Plus, if you want to change the temperature yourself, you can easily do so from your smartphone or computer, or with your voice via Google or an Amazon Echo. All of that means never having to get up from a cozy spot on the couch to mess with the thermostat. While the competition is catching up, none of the other devices we tested could match the Nest’s smarts. The expansion of the Works with Nest smart-home ecosystem and the introduction of Home/Away Assist have kept the Nest in the lead by fine-tuning those smart capabilities. The recent hardware update merely added a larger screen and a choice of clock interfaces, but the ongoing software improvements (which apply to all three generations of the product) have helped keep the Nest in its position as the frontrunner in this category without leaving its early adopters out in the cold.

Runner-up

Ecobee3
Not as sleek or intuitive as the Nest, but it supports Apple’s HomeKit and uses stand-alone remote sensors to register temperature in different parts of a house, making it an option for large homes with weak HVAC systems.
The Ecobee3’s support for remote sensors makes it appealing if your thermostat isn’t in the best part of your house to measure the temperature. If you have a large, multistory house with a single-zone HVAC system, you can have big temperature differences between rooms. With Ecobee3’s add-on sensors (you get one with the unit and can add up to 32 more), the thermostat uses the sensors’ occupancy detectors to match the target temperature in occupied rooms, rather than just wherever the thermostat is installed. However, it doesn’t have the level of intelligence of the Nest, or that model’s retro cool look (which even the Honeywell Lyric takes a good stab at). Its black, rounded-rectangle design and touchscreen interface have a more modern feel, it looks a bit like someone mounted a smartphone app on your wall.

Ecobee3 Lite
Ecobee’s new Lite model is a great budget option. It doesn’t have any occupancy sensors or remote temperature sensors, but it would work well for a smaller home invested in the Apple ecosystem.
For a cheaper smart thermostat with most of the important features of the more expensive models, we suggest the Ecobee3 Lite. This budget version of the Ecobee3 lacks the remote sensors and occupancy sensors of its predecessor but retains the programming and scheduling features, and like the main Ecobee3, it works with a variety of smart-home systems, including HomeKit, Alexa, SmartThings, Wink, and IFTTT. However, the lack of an occupancy sensor means you’ll have to manually revert it to its prescheduled state anytime you use Alexa, Siri, or any other integration to change its temperature.

real people should not fill this in and expect good things – do not remove this or risk form bot signups

Table of contents
Why a smart thermostat?
Smart-home integration
Who this is for
The C-wire conundrum
Multizone systems
How we picked and tested
Our pick
Who else likes our pick
Flaws but not deal breakers
Potential privacy issues
The next best thing (for larger homes)
Budget pick
The competition
What to look forward to
Wrapping it up

Why a smart thermostat?
A smart thermostat isn’t just convenient: Used wisely, it can save energy (and money), and it offers the potential for some cool integrations. If you upgrade to any smart thermostat after years with a basic one, the first and most life-changing difference will be the ability to control it remotely, from your phone, on your tablet, or with your voice. No more getting up in the middle of the night to turn up the AC. No dashing back into the house to lower the heat before you go on errands (or vacation). No coming home to a sweltering apartment—you just fire up the AC when you’re 10 minutes away, or even better, have your thermostat turn itself on in anticipation of your arrival.
Technically, thermostats have been “smart” since the first time a manufacturer realized that such devices could be more than a mercury thermometer and a metal dial. For years, the Home Depots of the world were full of plastic rectangles that owed a lot to the digital clock: They’d let you dial in ideal heating and cooling temperatures, and maybe even set different temperatures for certain times of the day and particular days of the week.
The thermostat landscape changed with the introduction of the Nest in 2011 by Nest Labs, a company led by Tony Fadell, generally credited to be one of the major forces behind Apple’s iPod. (Google acquired Nest Labs in 2014; Fadell has since moved on to an advisory position at Alphabet, Google’s parent company.) The original Nest was a stylish metal-and-glass Wi-Fi–enabled device, with a bright color screen and integrated smartphone apps—in other words, a device that combined style and functionality in a way never before seen in the category.
The Nest got a lot of publicity, especially when you consider that it’s a thermostat. Within a few months, Nest Labs was slapped with a patent suit by Honeywell, maker of numerous competing thermostats.
But once the Nest was out there, it was hard to deny that the thermostat world had needed a kick in the pants. And five years later, not only have the traditional plastic beige rectangles gained Wi-Fi features and smartphone apps, but other companies have also entered the high-feature, high-design thermostat market, including the upstart Ecobee and the old standards Honeywell, Emerson, and Carrier.
The fact is, a cheap plastic thermostat with basic time programming—the kind people have had for two decades—will do a pretty good job of keeping your house at the right temperature without wasting a lot of money, so long as you put in the effort to program it and remember to shut it off. But that’s the thing: Most people don’t.
These new thermostats are smart because they spend time doing the thinking that most people just don’t do.
“The majority of people who have a programmable thermostat don’t program it, or maybe they program it once and never update it when things change,” said Bronson Shavitz, a Chicago-area contractor who has installed and serviced hundreds of heating and cooling systems over the years.

Smart thermostats spend time doing the thinking that most people just don’t do, turning themselves off when nobody’s home, targeting temperatures only in occupied rooms, and learning your household schedule through observation. Plus, with their sleek chassis and integrated smartphone apps, these thermostats are fun to use.

Nest Labs claims that a learning thermostat (well, its learning thermostat) saves enough energy to pay for itself in as little as two years.
Since the introduction of the Nest, energy companies have begun offering rebates and incentives for their customers to switch to a smart thermostat, and some have even developed their own devices and apps and now offer them for free or at a greatly reduced price to encourage customers to switch. Clearly, these devices provide a larger benefit than simple convenience. Because they can do a better job of scheduling the heating and cooling of your house than you can, they save money and energy.

Smart-home integration
Among the useful features of smart thermostats is the ability to work as part of a larger smart-home system and to keep developing even after you’ve purchased one. For example, many of the thermostats we tested now integrate with the Amazon Echo, a Wi-Fi–connected speaker that can control many smart-home devices. You can speak commands to Alexa, Echo’s personal assistant, to adjust your climate control. This function came to the thermostats via a software update, so a smart thermostat purchased last year has the same functionality as one bought yesterday.
These over-the-air software updates, while sometimes known to cause issues, are a key feature of smart devices. Shelling out $250 for a thermostat that has the potential to become better as it sits on your wall helps cushion some of the sticker shock. The Nest earns particularly high marks in this area, because whether you bought one in 2011 or 2016, you get the same advanced learning algorithms and smart integrations.
Additionally, all of the thermostats we tested work with one or more smart-home hubs such as SmartThings and Wink, or within a Web-enabled ecosystem like Amazon’s Alexa or IFTTT (If This Then That). The Nest also has its own developer program, Works with Nest, which integrates the company’s thermostat and other products directly with a long and growing list of devices including smart lights, appliances, locks, cars, shades, and garage door openers. This means you can add your thermostat to different smart scenarios and have it react to other actions in your home: It could set itself to Away mode and lock your Kevo smart door lock when you leave your house, for instance, or it could turn up the heat when your Chamberlain MyQ garage door opener activates. These ecosystems are continually growing, meaning the interactions your thermostat is capable of are growing as well (sometimes with the purchase of additional hardware).
With the release of the Home app for HomeKit, Apple’s smart-home unification plans have taken a bigger step toward fruition. While the devices are still limited (a hardware update is required for compatibility), you can now create scenes (linking devices together) and control them from outside the home on an iPad; previously you had to use a third-generation Apple TV. This change increases the number of people who will see HomeKit as a viable smart-home option. Even without an iPad permanently residing in your home, you can still talk to and operate HomeKit products using Siri on your iPhone or iPad while you are at home. The system works in the same way Alexa does, and it’s actually a little more pleasant to use than shouting across the room.
The Ecobee3, Ecobee 3 Lite and Honeywell Lyric (released January 2016) are all HomeKit compatible, and can communicate with other HomeKit devices to create scenes such as “I’m Home,” to trigger your thermostat to set to your desired temp and your HomeKit-compatible lights to come on.
Google now offers its own voice-activated speaker similar to Amazon’s Echo, the Google Home. The Home, which integrates with Nest as well as IFTTT, SmartThings, and Philips Hue, allows you to control your Nest thermostat via voice.

Who this is for
Get a smart thermostat if you’re interested in saving more energy and exerting more control over your home environment. If you like the prospect of turning on your heater on your way home from work, or having your home’s temperature adjust intelligently, a smart thermostat will suit you. And, well, these devices just look cooler than those plastic rectangles of old.
Get a smart thermostat if you’re interested in saving more energy and exerting more control over your home environment.
If you already have a smart thermostat, such as a first- or second-generation Nest, you don’t need to upgrade. And if you have a big, complex home-automation system that includes a thermostat, you may prefer the interoperability of your current setup to the intelligence and elegance of a Nest or similar thermostat.
If you don’t care much about slick design and attractive user interfaces, you can find cheaper thermostats (available from companies such as Honeywell) that offer Wi-Fi connectivity and some degree of scheduling flexibility. The hardware is dull and interfaces pedestrian, but they’ll do the job and save you a few bucks.
The devices we looked at are designed to be attached to existing heating and cooling systems. Most manufacturers now offer Wi-Fi thermostats of their own, and while they’re generally not as stylish as the models we looked at, they have the advantage of being designed specifically for that manufacturer’s equipment. That offers some serious benefits, including access to special features and a deep understanding of how specific equipment behaves that a more general thermostat can’t have.

The C-wire conundrum
One major caveat with all smart thermostats is the need for a C wire, or “common wire,” which supplies AC power from your furnace to connected devices such as thermostats. Smart thermostats are essentially small computers that require power to operate—even more so if you want to keep their screens illuminated all the time. If your heating and cooling system is equipped with a C wire, you won’t have any concerns about power. The problem is, common wires are not very common in houses.
In the absence of a C wire, both the Nest and the Honeywell Lyric can charge themselves by stealing power from other wires, but that can cause serious side effects, according to contractor Bronson Shavitz. He told us that old-school furnaces are generally resilient enough to provide power for devices such as the Nest and the Lyric, but that the high-tech circuit boards on newer models can be more prone to failure when they’re under stress from the tricks the Nest and Lyric use to charge themselves without a common wire.
Installing a C wire requires hiring an electrician and will add about $150 to your costs. The Ecobee3 includes an entire wiring kit to add a C wire if you don’t have one (for the previous version of this guide, reviewer Jason Snell spent about two hours rewiring his heater to accommodate the wiring kit). The Emerson Sensi is the only thermostat we tested that claims not to need a C wire, but it too draws power from whichever system is not in currently in use (for example, the heating system if you’re using the AC). This means that if you have a heat- or air-only system, you will need a C wire.
Note: If the power handling is not correct, the damage to your system can be significant. The expense of replacing a furnace or AC board, plus the cost of professional installation, will probably outweigh the convenience or energy savings of a smart thermostat. Nest addresses the power requirements of its thermostat, including whether a common wire is necessary, in detail on its website, so if you’re unsure whether your system is suited for it, check out this page for C wire information, as well as this page for system compatibility questions and this page for solutions to wiring problems.

Multizone systems
If you have more than one zone in your HVAC system, you will need to purchase a separate smart thermostat for each zone. Currently, while all of the smart thermostats we tested are compatible with multizone systems, none can control more than one zone. Even though the Ecobee3 supports remote sensors, those feed only a single thermostat—so if you want more zones, you’ll still need separate thermostats, with their own sensors. However, the Ecobee3 is the only thermostat we tested that allows you to put more than one thermostat into a group so that you can program them to act identically, if you choose.

How we picked and tested

We put these five smart thermostats through their paces to bring you our top pick. Photo: Michael Hession
By eliminating proprietary and basic Wi-Fi–enabled thermostats, we ended up with six finalists: the third-generation Nest, Ecobee’s Ecobee3 and Ecobee3 Lite, Honeywell’s second-generation Lyric, Emerson’s Sensi Wi-Fi thermostat, and Carrier’s Cor. We installed each model ourselves and ran them for three to 10 days in routine operation. We did our testing in a 2,200-square-foot, two-story South Carolina home, running a two-zone HVAC system with an electric heat pump and forced air.
For each thermostat, our testing considered ease of installation and setup, ease of adjusting the temperature, processes for setting a schedule and using smartphone app features, multizone control capabilities, and smart-home interoperability.

Human connection lies at the heart of human well-being.

See NYT article below: if these facts are anywhere close to right, a community-based BeWell Center has an opportunity to do a whole lot of good by simply being an organizer of volunteer outreach. Low or no cost, big impact, great from a philanthropy POV. Meals on Wheels, elderly check-ins, classes, etc. “Research confirms our deepest intuition: Human connection lies at the heart of human well-being.”

“Social isolation is a growing epidemic — one that’s increasingly recognized as having dire physical, mental and emotional consequences. Since the 1980s, the percentage of American adults who say they’re lonely has doubled from 20 percent to 40 percent.

About one-third of Americans older than 65 now live alone, and half of those over 85 do. People in poorer health — especially those with mood disorders like anxiety and depression — are more likely to feel lonely. Those without a college education are the least likely to have someone they can talk to about important personal matters.
A wave of new research suggests social separation is bad for us. Individuals with less social connection have disrupted sleep patterns, altered immune systems, more inflammation and higher levels of stress hormones. One recent study found that isolation increases the risk of heart disease by 29 percent and stroke by 32 percent.
Another analysis that pooled data from 70 studies and 3.4 million people found that socially isolated individuals had a 30 percent higher risk of dying in the next seven years, and that this effect was largest in middle age.”

Research confirms our deepest intuition: Human connection lies at the heart of human well-being.

Iora Health – Update …$75 million Series D (moving toward 65+?)

Here is an update on Iora Health ….. the Cambridge, Mass innovator in Health Care supporting primary care services in 34 US locations. I first began tracking them when I was tracking Turntable in Ls Vegas, which is one of their sites.

Few points:

1. I see no big announcements about closings….interesting (there are rumors the Harken Health and Turntable will cease their partnership with Iora)
2. They just raised $75 million in a Series D financing ….. really interesting. The lead investor was the Singapore State fund Temasek … also interesting (big dogs). Apparently all existing investors stayed in the Series D – a good sign. Series C was $48 million, and the dollars before that (in A and B) were $13 million, I think. So that means that they have now raised $146 million…..that is a ton of money for a venture backed company! This tells me that they are telling investors what I believe to be true….that Year 1 hurts because the subscriber base in building but years 2 and onward can be profitable……but I have found no docs that say this.
3. They say they have 34 “primary care practices”…..looked at their backup for this. Here is what they (seem to) have:

18 sites are Medicare only Advantage Plans for 65+ only —— 16 sites partnering with Humana and 2 partnering with Tufts. So Humana is their big partner, but only to support their Medicare advantage plan for seniors.

1 corporate site for Hartford Health Care employees only

3 “fund” sites —— one for cooks and one for carpenters and one in Queens for “Grameen members”…..must be a credit union for each trade maybe?

6 sites with Harken/United Health ….. but very interesting that they are not listed on their official website…. they just take about 6 sites in ATL.

1 community site – Turntable in Las Vegas

2 pilot sites

31 sites total

4. My guess: the Series D raise of $75 million is going to be dedicated to Medicare Advantage plan expansion, through Humana, Tufts, and a few others. My hunch is that they do not see how to make the community model work…moreover, they see the ramp up as being needlessly painful. My hunch is that the Medicare Advantage model is profitable in Year 1, which investors would love! My hunch is that they have figured out to make these site smaller, more manageable, more care flow positive from the start, and that they are ultimately most profitable sites. Humana and other big dogs probably see them as a way to keep health care costs down……..while maintaining or improving senior outcomes. Anyone else have a guess or facts on this????

See my notes below:

===========NOTES on IORA Health ==========
October 16, 2016

US-based Iora Health has closed a $75-million Series D financing in a round led by Singapore state fund Temasek Holdings. Other investors who participated in the round include Iora Health’s existing institutional investors .406 Ventures, Flare Capital Partners, F-Prime Capital, GE Ventures, Khosla Ventures, Polaris Partners, and Rice Management Company. “We are honored to have Temasek join Iora on our journey to transform healthcare,” said Rushika Fernandopulle, MD, MPP, co-founder and CEO of Iora Health. “Temasek’s investment in Iora will accelerate our vision of fixing health care delivery which is one of the largest business and social problems, not just in the US, but globally.

Iora Health has built a different kind of health system that delivers high impact, relationship based care. With 34 primary care practices in 11 US markets, Iora serves diverse populations with an increasing focus on the most under-served and complex patients — including people aged 65 years and older on Medicare. Iora’s innovative model delivers an exceptional patient experience, with coordinated care that drives better clinical outcomes and significantly lower costs than the traditional healthcare system. Iora will use the new capital to drive further expansion and efficiencies in the model

Read more at: http://www.dealstreetasia.com/stories/55411-55411/

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Iora Health lands $28M from GE Ventures, Khosla Ventures and others
Jan 26, 2015, 9:58am EST Revised Date/Time Publish Updated Jan 26, 2015, 2:06pm EST
Iora Health, a Cambridge startup aiming to “reinvent primary care” with a novel model for payment and delivery of care, said Monday that it raised $28 million in Series C funding from new investors including Foundation Medical Partners, Rice Management Co., GE Ventures and Khosla Ventures.

Existing investors included Boston’s .406 Ventures, Fidelity Biosciences and Boston-based Polaris Partners. Iora Health will use the additional financing to fund rapid expansion to continue delivering transformative health care, according to the company. The company has raised $48.2 million in total and plans to double its current workforce of 140.
Iora Health has developed a different health care operating system that starts with primary care, driving patient experience, engagement and clinical outcomes, while reducing overall health care costs, according to the company.
“We’re humbled by the great interest in our Series C financing and we are honored to have such a great group of new investors join our current ones.,” said Rushika Fernandopulle, co-founder and CEO of Iora Health, in a statement. “In the last four years, Iora Health has grown from a start up with an idea of how to improve health care to serving and improving the lives of thousands of patients across the U.S. We are excited to grow with this round to continue to deliver on our mission to restore humanity to health care.”

Iora Health currently manages eleven primary care practices across the U.S. for distinct patient populations including employee groups, Medicare Advantage patients and union members and their families. Iora sponsors include the Culinary Health Fund, Dartmouth College, the Freelancers Union, Grameen PrimaCare, Humana, King Arthur Flour, Lahey Health, the New England Carpenters Benefits Fund and Turntable Health.
The company, founded in 2011, last raised a $13 million round of funding two years ago from existing investors including Zappos CEO Tony Hsieh.

================== IORA Practices from their website =====

Source: http://www.iorahealth.com/practices/list-of-offices/

SPONSOR: CULINARY HEALTH FUND (serves workers who participate)
Las Vegas, NV 89104
SPONSOR: DARTMOUTH COLLEGE (Dartmouth Health Connect is a primary care practice in Hanover)
Hanover, NH 03755

SPONSOR: GRAMEEN PRIMACARE (for Grameen Members)
Queens, NY 11372

SPONSOR: HARTFORD HEALTHCARE (employees and family members)
Hartford, CT 06106

SPONSOR: Harken Health and United Health Care
Metro Atlanta (6)

SPONSOR: NEW ENGLAND CARPENTERS BENEFITS FUNDS
Dorchester, MA 02125

SPONSOR: TUFTS HEALTH PLAN (for 65+ members of Preferred HMO plans)
2 LOCATIONS
Medford, MA 02155
Hyde Park, MA, 02136

SPONSOR: HUMANA (All seem to support only Humana Medicare Advantage Plan)
16 LOCATIONS

Aurora, CO 80012
Littleton CO 80123
Arvada, CO 80003
Glendale, CO 80246
Lakewood, CO 80214

Federal Way WA 98003
Shoreline, WA 98133
Seattle, WA 98144
Renton, WA 98057
Tucson, AZ 85712 (2)
Mesa AZ 85206 (2)
Glendale, AZ 85302
Phoenix, AZ 85032 (2)

SPONSOR: TURNTABLE HEALTH
Las Vegas, NV 89101

Pilot Program Renaissance Health
Arlington, MA

PIlot Program Intensive Outpatient Care
Program Partner: The Boeing Company

“Direct Primary Care”

Its pretty clear that a coalition of “direct primary care” providers is pushing Congress to recognize subscription services as a service reimbursable under Medicare.

I believe they are differentiating themselves from “concierge” care, for political reasons. The coalition says concierge care is $2000-$5000, instead of under $2000. One of the main advocates for direct primary care says that it does not seek third party reimbursement, while concierge services might.

“The Primary Care Enhancement Act of 2016” has been brought to the Ways and Means Committee, where is was referred in September, 2016 to the Health Sub-Committee.

Sponsor: Rep. Paulsen, Erik [R-MN-3] (Introduced 09/13/2016)
Committees: House – Ways and Means
Latest Action: 09/19/2016 Referred to the Subcommittee on Health. (All Actions)

===============
Direct primary care could get a big boost next year. Under the federal health care law, these practices will be able to operate in state-based health insurance exchanges. However, insurers on exchanges must offer a basic benefits package that includes hospital, drug and other coverage, so direct primary care practices will likely team up with other health plans.
If you’re considering a direct primary care practice, get a list of provided services and talk with a physician in the practice. Also, some practices that are similar to concierge care may accept insurance but charge a monthly fee for extra services. For options in your area, visit the Web site of the Direct Primary Care Coalition (www.dpcare.org).

======================
The Primary Care Enhancement Act of 2016  proposes to amend the tax code so consumers can use their health savings accounts (HSAs) to pay physicians in direct primary care (DPC), bypassing insurance. H.R. 6015 would also enable Medicare enrollees to pay for direct primary care using Medicare funds, rather than pay out of pocket.

======================
http://www.dpcare.org

Senators Bill Cassidy, MD (R-LA) and Maria Cantwell (D-WA) have introduced bipartisan legislation which clarifies that DPC is a medical service for the purposes of the tax code regarding Health Savings Accounts. The bill also creates a new payment pathway for DPC as an alternative payment model (APM) in Medicare. “Co-sponsors are important. They show Senate leaders that there is widespread support for the legislation,” said Sen. Cassidy when he addressed the DPCC Fly-in Sept. 24. We need your help today to ensure that S.1989 moves forward.  Please contact your Senators and urge them to co-sponsor the Primary Care Enhancement Act today.

On the Move in the States with DPC
16 States Move to Clear Regulatory Hurdles for DPC 
Legislation  defines DPC outside of Insurance.
 
As of June, 2016, 16 states have adopted Direct Primary Care legislation which defines DPC as a medical service outside the scope of state insurance regulation. 
 
The DPCC has developed model legislation to help guide legislators and their staffs on the best way to accomplish  this important reform. Click here to see the model bill.
States With DPC Laws:

• Washington – 48-150 RCW
• Utah – UT 31A-4-106.5
• Oregon – ORS 735.500
• West Virginia – WV-16-2J-1
• Arizona – AZ 20-123
• Louisiana – LA Act 867
• Michigan – PA-0522-14
• Mississippi – SB 2687
• Idaho – SB 1062
• Oklahoma – SB 560
• Missouri – HB 769
• Kansas – HB 2225
• Texas – HB 1945
• Nebraska – Leg. Bill 817
• Tennessee – SB 2443
• Wyoming – SF0049

Current as of June, 2016

=============
Direct Primary Care is an innovative alternative payment model in primary care model embraced by patients, physicians, employers, payers and policymakers across the United States.The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider. In DPC unwanted fee-for-service incentives are replaced with a simple flat monthly fee. This empowers the doctor-patient relationship and is the key to achieving superior health outcomes, lower costs and an enhanced patient experience.
=============
http://medicaleconomics.modernmedicine.com/medical-economics/news/bill-could-allow-health-saving-account-use-dpc

Direct primary care physicians charge patients a monthly fee for care and access to a package of services rather than by fee-for-service or insurance. The subscription model can grant patients increased access to doctors, discounted drugs and laboratory services. 
According to Meigs, the proposed law will allow people with high deductible plans to use their HSA to pay for primary care, given that people with high deductible insurance plans can use their insurance for catastrophic coverage and hospitalizations, and cost-effectively tap their HSAs for primary care.  

============

Direct primary care and concierge medicine: They’re not the same

Direct primary care and concierge medicine: They’re not the same
SAMIR QAMAR, MD | PHYSICIAN | AUGUST 24, 2014
Samir Qamar
Direct primary care (DPC) and concierge medicine are rapidly growing models of primary care. Though the terms are used interchangeably, both are not the same. Such liberal use of terms, many times by even those within the industry, confuses those who are attempting to understand how these primary care models operate. As former concierge physician for the Pebble Beach Resorts, and subsequent founder of one of the nation’s largest direct primary care companies, I have attempted to differentiate the two based on extensive personal knowledge and experience.

First, concierge medicine. Born in the mid 1990s, this practice design was first created by wealthy individuals who were willing to “bypass” the woes of the current fee-for-service system by paying a subscription to access select primary care physicians. This access consists of same-day appointments, round-the-clock cell phone coverage, email and telemedicine service, and sometimes, as in my previous practice, house calls. Although some high-end practices charge as much as $30,000 a month, most charge an average monthly fee of $200.
In return, to allow such unrestricted access, physicians limit their patient panels to several hundred patients at most, a significant drop from the typical 2,500-plus panel size most doctors are used to. Many concierge doctors also bill insurance or Medicare for actual medical visits, as the monthly “access fee” is only for “non-covered” services. This results in two subscriptions paid by patients — the concierge medicine fee, and the insurance premium. Importantly, a few concierge practices do not bill insurance for medical visits, as the monthly fees cover both access and primary care visits.
Direct primary care started in the mid 2000s, and was created as an insurance-free model to serve a new patient population: the uninsured. In DPC, patients, and now their employers, are also charged a monthly fee, but the fee can be as low as $50 per month and there is typically no third-party payer involvement. Consumers pay physician entities directly (hence, direct primary care), and because the insurance “middle man” is removed from the equation, all the overhead associated with claims, coding, claim refiling, write-offs, billing staff, and claims-centric EMR systems disappears.

Patient panels can be as high as 1,500 patients per doctor, and there is typically no physician cell phone access or house call service. Similar to higher-priced concierge practices, DPC practices also allow for longer patient visits and telemedicine. The most important characteristic of DPC practices, however, is that insurance claims are not filed for medical visits.

Direct primary care’s definition, therefore, is any primary care practice model that is directly reimbursed by the consumer for both access and primary medical care, and which does not accept or bill third party payers.
Confusion arises from similarities that exist in both models, such as decreased patient panels, monthly subscriptions, and longer visits. There is added confusion when a DPC physician offers house calls or email access, typical of concierge practices. Confusion is maximized when a physician is by definition practicing direct primary care, yet calls the practice a “concierge practice.” Similarly, a concierge practice may decide to abstain from participating in third party payer systems, and thus would also be a DPC practice.
The distinction is important because direct primary care is explicitly mentioned in the Affordable Care Act, while concierge medicine is not. Several state laws have also recognized direct primary care as medical practice models, and non-insurance entities. In addition, the term “concierge medicine” causes visceral reactions in select social and medical circles, drawing criticism such as elitism and exacerbation of physician shortage.
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In summary, not all direct primary care practices are concierge practices, and not all concierge practices are direct primary care practices. The terms are not synonymous, and even the basic fundamentals of either model do not overlap. The key to differentiation is whether or not a third party payer is involved. If not, then the model is a direct pay, or direct primary care model, no matter what the fees.
Samir Qamar is CEO, MedLion and president, MedWand. He can be reached on Twitter @Samir_Qamar.