healthcare technology

CureLauncher connects patients who cannot find a cure for what ails them -- or in some cases what is killing them -- with clinical trials offering cutting-edge treatments.

 

"Clinical trials offer drugs and treatments that can still be years away from market, but some patients can't wait," said David Fuehrer, president and co-founder of the new company.

 

"Many miss out on potentially beneficial treatments because they don't know how to connect," he said.

 

Only 4 percent of Americans know how to find a clinical trial, according to the Center of Information and Study on Clinical Research Participation.

 

Meanwhile, trial sites across the country face delays because they need more participants.

 

Faster treatments

 

The free CureLauncher service uses a patent-pending matching system to connect those with chronic disease to one or more of the nation's 20,000 trials that are accepting participants.

 

By helping these two groups connect, the founders hope to not only help the more than 200 million Americans living with chronic diseases, but also help bring better treatments to the market faster.

For most of time medicine was a guessing game. Doctors, or witch doctors, or shaman would inspect a patient, stir a potion and hope it would work. With some notable exceptions, modern medicine isn't so different. The data collection—blood pressure, heart rate, weight, reflexes—is largely rudimentary. We're getting by, but technology can take us so much further.

 

Even technology that fits in your pocket.

 

In the past year or two (or three) iPhones and iPads have been a fixture in doctors' offices around the world. Why carry a clipboard when you could pull up records via Wi-Fi and type the information directly into the patient's medical record? Perhaps even more powerful is the idea that these devices can be collecting data all the time.

 

Smartphones are incredibly powerful tools for anything as simple as data mining to something so sophisticated as measuring a patient's sleeping pattern. There are apps that can help regulate your mental health, apps that can help you keep track of what and how much you eat. There are apps that can take your blood pressure and you blood sugar. There are even apps that help you cope with aging.

 

While an app can't cure a disease, some of the newer, more experimental medical apps can do truly extraordinary things. This technology can not only help you feel better; it can prevent illness by spotting symptoms early on.

 

Social media can predict the success of a new drug launch much faster than traditional methods. Many pharmaceutical companies try to measure the success of their launch based on weekly script trends.

 

The difference between social media data and data derived from prescriptions is significant: social media data can predict the future, while script data record the past.

 

Social media can also, to some degree, explain events and not just record them, since patient posts are much more nuanced than purchase data, often sharing the why and not just the what.

 

Using older methods, it can take years to understand the result and impact of a new drug launch. Today social media can provide early vital signals in real time.

 

To illustrate this, let’s look at Tecfidera (formerly called BG-12 during clinical trials), a new multiple sclerosis drug that Biogen launched on April 13.

As a quick reminder: Treato distills the patient voice from billions of patient-written social media posts on over 2,000 health blogs and forums. We filter out the patient experiences from the spam and other noise and analyze them using proprietary Natural Language Processing algorithms in our Big Data processing servers. The result is unique insights into drugs, conditions, and all that’s in between.

 

Twitter is a popular source for receiving and sharing new information about vaccines, and also a basically reliable one, according to a study published in the June issue of theAmerican Journal of Infection Control, the official publication of the Association for Professionals in Infection Control and Epidemiology (APIC). 

Researchers from the University of Texas at Austin analyzed 9,510 vaccination-related tweets from one week in January, 2012 to determine the most popular and influential messages. A final sample of 2,580 tweets that had received engagement through re-posting and sharing was then coded for frequency of sharing, tone toward vaccinations, links to sources (e.g., news outlets, advocacy groups, or healthcare providers), and whether the claims being made in each tweet were scientifically substantiated. 

Overall, 33 percent of the 2,580 tweets carried a positive tone about vaccines, 54 percent were neutral, and 13 percent were negative. Of the 14 percent of tweets that contained medical information, more than two-thirds offered content substantiated by scientific research. 

The most popular messages concerned a potential children's malaria vaccine, development of the NeuVax E-75 vaccine for breast cancer, the effectiveness of a herpes vaccine in women, the Centers for Disease Control and Prevention's recommendation of a human papilloma virus vaccination for boys, potential approval for a lung cancer vaccine, and a blog post discrediting vaccine-autism connections. 

Miscommunication in a healthcare setting can have dire consequences, and is more likely to occur when clinicians and patients don’t speak the same language. While some healthcare settings have access to interpreters, others often do not.

 

In Botswana, the official language is English, but many Batswana speak only the native language of Setswana. To help prevent healthcare miscommunication in the southern African country, a smartphone medical translation app has been developed for healthcare workers for use on either iPhones or the Android operating system.

 

The app was designed by faculty and staff at the Botswana-UPenn Partnership (BUP), the Biomedical Library and Department of Linguistics at the University of Botswana (UB), the University of Botswana Medical School, the Global Health Programs Office at the Perelman School of Medicine, and DuoChart, an Indianapolis-based company that specializes in translation materials.

Startup companies are coming up with new technologies aimed at getting people to take medicine only as directed.

 

Taking medication haphazardly—skipping doses, lapsing between refills or taking pills beyond their expiration date—has been linked to health complications and hundreds of millions of wasted dollars for insurers and hospitals.

 "After six months' time, only half of people taking prescription medicines are taking them as directed," said Troyen Brennan, chief medical officer of drug retailer CVS Caremark Corp. 

Health insurers and pharmacy-benefits managers like CVS have long relied on robo-calls, mailers and face-to-face meetings with pharmacists to keep patients on their dosing schedule.

 

Now they are evaluating a range of more cost-effective technologies, from pills and bottles with digital sensors, to data analytics software and social games that offer patients rewards.

 

Insurers and pharmacies are motivated in part by Medicare, which offers financial rewards for proving their members have improved their overall adherence to medication schedules.

 

They also stand to benefit if their members are healthier. The New England Healthcare Institute estimates that some $290 billion in costs is wasted each year on unnecessary hospital and doctor visits by people who failed to comply with their medication schedule.

 

CVS is pilot-testing technology from Virginia-based RxAnte Inc., which sells an analytics platform that looks at millions of patients' claims data and clinical data to identify people at highest risk of failing to comply with doctors' orders.

 

These patients include people with a spotty track record of adherence, those who take several different medicines or those facing unwanted side effects, Chief Executive Josh Benner said.

 

"It's all a targeting game," Mr. Benner said. "We predict individual behaviors, and suggest interventions."

 

Digital health may be garnering all the glory for its promise to transform health care, but take a closer look and you’ll find a promising next wave of health care investments.

 

With a proliferation of mobile apps and data being generated at a dizzying pace, few investments have yet to fulfill their financial promise. The real money will be made when companies build services around these applications, make the data actionable, and connect all this inbound patient data to the physical health care system.

 

Expect companies that find new, creative ways of connecting data to patients, determine what to do with the data when it’s generated, and figure out ways to creatively (and profitably) engage the health care system, to attract the attention of VCs and entrepreneurs alike. Here are three areas worth watching

Smart Sensors

 

Software Systems for Data Analysis

 

New Service Models for Patients

 

Everything that can be done digitally and virtually will be done digitally and virtually. This will dramatically improve access to and efficiency of the traditional health care system. Call centers will be staffed not just by the traditional nurse, but also by physicians, pharmacists and other professionals who can provide a higher level of care.

 

Tool makes it easy to search for health providers who are active in the Medicare prescription drug program.

 

 What’s the purpose of Prescriber Checkup?

A. We’ve made it easy to search for doctors and other health providers who are active in Medicare’s prescription drug program, called Part D. You can find out how many prescriptions each wrote and which drugs were prescribed. You can compare your doctor with others in his or her specialty and state. And you can check out the drugs you are taking or any that your doctor recommends.

 

Is this new information?

Until now, the identities of doctors and which drugs they prescribed in Medicare Part D have not been public. ProPublica obtained the data under the Freedom of Information Act and investigated prescribing patterns. We are making the data available to help consumers stay informed.

How can today's mobile technology make a difference? Put simply, by giving staff the right information and tools to do their job, in any place, at any time.

 

Of course, many staff are already ‘mobile workers’, moving between wards and outpatient clinics on different sites or treating patients at home or in GP surgeries. Yet current approaches to mobile working are often highly inefficient. What health boards need to do is to ‘mobilise’ each healthcare professional's entire job, using the latest generation of mobile solutions. These overcome issues of limited and clumsy web-based access to existing back-office systems by providing native smartphone and tablet apps that draw together the information and tools staff need to support them as they work.

 

No unnecessary visits ‘back to base’

 

If we look at the typical working day of a community nurse, we can see how it will change when mobile technology is used to mobilise their entire job.

Using traditional IT solutions, a community nurse will typically begin their day by travelling to their ‘base’ at a hospital health centre for a team meeting and to plan their day's schedule. Then they need to make sure they have gathered all the patient records and other documents they will need during the day, before finally heading out for their first visit.

 

With the latest generation of mobile solutions to support them, the nurse does not need to travel to the office. They can simply log on to an app on their smartphone from home and get access to all the information they need for the day's visits, from lists of appointments and tasks to comprehensive electronic patient records, including results, photographs and x-rays. They have saved both time and the cost of an unnecessary journey in to the office thanks to a smartphone app.

 

Patient records at your fingertips

 

Maybe it's the nurse’s first visit to this patient. Traditionally, they will dig out a map, wrestle with a personal Satellite Navigation, or have to stop and ask for directions. The smartphone app shows the location of the next visit and works out the best route for all visits for the day reducing carbon footprint and maximising travel time.

 

Then, while they are with the patient, they will need to keep a record of any care given, chart any readings and note any other changes in the patient's condition. With the traditional approach, they would have two options: they might take notes on paper, which would need to be entered into the records later, taking more of their time away from patient care – and probably requiring another trip to their ‘base’. Or they might boot up their laptop and key in the data there and then, a process that healthcare professionals report often puts a barrier between them and patients.

 

With an app-based solution, however, our nurses can capture all the information they need with a few taps on their smartphone's touchscreen, whilst still talking naturally with patients and their carers. They can even snap a photograph of the current state of a wound for example that can be immediately added to the patient record.

 

With the right mobile technology, they also do not have to worry about whether or not they have a signal, or about driving around until they find one: they can enter the data while they are still with the patient, even if they do not have a signal, confident the information will be synched automatically when their smartphone next connects. There is certainly no need to return to the office at midday or the end of the day to update records and complete paperwork. Even their mileage, expenses or requests for supplies can be entered through the app.

 

Double-amputee Jason Koger used to fly hundreds of miles to visit a clinician when he wanted to adjust the grips on his bionic hands.

 

Now, he’s got an app.

 

Koger came to Philadelphia this week to demonstrate the i-limb ultra revolution, a prosthetic developed by the British firm Touch Bionics. Using a stylus and an iPhone, Koger can choose any of 24 grip patterns that best suit his needs.

 

The previous version of Koger’s myoelectric device required programming by a prosthetist, meaning Koger had to fly to Advanced Arm Dynamics in Dallas. The prosthetist would work with Koger to pick a few grip patterns — such as pinching, pointing or shaking hands — to program into the i-limb.

 

Yet sometimes Koger would get home and realize they weren't the ones he needed. Now, the latest i-limb comes with iPhone or iPad app that allows Koger to reprogram his hand with the touch of a stylus. On Thursday, he demonstrated by gripping an orange, a baseball and a can of soda.

 The i-limb allows fingers and thumbs move independently to conform around certain objects, said Ryan Spill, a prosthetist for Advanced Arm Dynamics' new office in Philadelphia, who is working with Koger. The thumb is also motorized, not passive, as in previous prostheses.

For a new generation of patients, could the laptop — or even cellphone — replace the stereotypical shrink’s couch? A crop of new startups wants to take psychotherapy into the 21st century.

 

About one in five Americans will experience a mental health challenge during their lifetime, according to the Substance Abuse and Mental Health Association. But experts say that 60 percent of them will never seek help. The lack of available care, inconvenience and cost are all barriers to access, but so is the fear of prejudice and discrimination from friends, family and even employers.

 

“Stigma and shame is a huge factor – maybe the most important one,” said Oren Frank, founder of mental health startup Talktala. “People who have been to regular therapy are less ashamed of it, but people who are newcomers are paralyzed by fear.”

 

Online options enable people to receive therapy on their own turf and terms, without needing to update others on their whereabouts – and they offer the benefit of anonymity.

For weeks, I have been thinking of ways to apply Glass to my daily routine of taking care of patients.I’m a surgeon and depending on the day, I can be in one of many areas, from the clinic, to the OR, from the ICU to the ED or the Trauma Bay;taking care of patients during rounds or teaching third or fourth year medical students.

 

The idea of having a device that allows me to instantly and effortlessly look up a concept or an image, take a picture or record a video
(and share it, if I choose to do so) or connect with someone by live video (thru a “Hang Out”) is a bit mind-blowing.

 

I imagine performing an operation and connecting live with group of students or surgeons, anywhere, doing a live “Hang Out”, letting them virtually “BE” in the OR with me, SEEING what I’m seeing, pointing to anatomic structures and different steps of the procedure, THRU my eyes…I envision the possibilities in distance MedEd, taking surgeons thru a complicated procedure, or one that they might not be so familiar with (surgical missions without leaving the country!).

 

The potential for remote presence medicine, TELEMEDICINE, is also amazingly exciting. I could be “video-connected” with a physician who needs my advice, and then even see and listen to the patient him/herself. I could advice a child’s parent and give them reassurance, while looking at their eyes…All these without having to go to a tele-station, hold a device in front of me or be limited by “where and when” I am. What I see and what I hear thru Glass, ONLY I can see and hear (the image is right in front of the users right eye, and audio happens via bone conductivity, so it is not audible to anyone else but the Glass user)

 

A survey of 1400 doctors reveals the top five ways they are using tablets and smartphones in their clinical practices.

 

In a clinical work setting, doctors who have electronic health records said they use their smartphones in clinical settings every day to:

 

Send and receive emails (65 percent);

 

Use apps (51 percent);

 

Instant messaging (50 percent);

 

Researching information about medications (35 percent);

 

Communicating with other physicians (32 percent).

 

 

But switch “smartphones” to “tablets” and you get this response:

 

 

Send and receive e-mails (52.4 percent);

 

Accessing electronic health records (50.6 percent);

 

Accessing diagnostic information (41.7 percent);

 

Research information about medication (33.3 percent);

 

Staying up to date with medical journals and papers (29.8 percent).

 

 

Among the other findings were

 

A little more than 60 percent access electronic medical records through their device’s browser rather than thru the vendor’s app.

 

One-third of EHR users and one-quarter of non-EHR users use a tablet device in their medical practice.

 

More than 70 percent of tablet users who access EHR through them have a password.

 

About 32 percent have a device tracker app installed on their tablet and the ability to remotely wipe all data on their tablet if lost or stolen (31 percent).

 

EHR users spend 25 hours on their tablet each week, with a greater amount of time spent on business (59%) than for personal reasons (41 percent).

 

Researchers at the University at Buffalo aredeveloping a “body area network” using ultrasonic waves and sensors to wirelessly share information between medical devices implanted in (or worn by) people to treat diseases such as diabetes and heart failure.

“This is a biomedical advancement that could revolutionize the way we care for people suffering from the major diseases of our time,” said Tommaso Melodia, PhD, UB associate professor of electrical engineering.

 

The idea of creating a network of wireless body sensors, also called a “body area network,” currently links sensors together via electromagnetic radio-frequency waves — similar to those used in cellular phones.

 

Radio waves have drawbacks such as the heat they generate, and because they propagate poorly through skin, muscle and other body tissue, they require relatively large amounts of energy, he said.

 

Ultrasound may be a more efficient way to share information, Melodia said, because roughly 65 percent of the body is composed of water. This suggests that medical devices, such as a pacemaker and an instrument that measures blood oxygen levels, could communicate more effectively via ultrasound compared to radio waves.

 

“Think of how the Navy uses sonar to communicate between submarines and detect enemy ships,” Melodia said. “It’s the same principle, only applied to ultrasonic sensors that are small enough to work together inside the human body and more effectively help treat diseases.”

 

Another example involves connecting blood glucose sensors with implantable insulin pumps. The sensors would monitor the blood and regulate, through the pumps, the dosage of insulin as needed in real time.

 

“Mobile technology, with its diffusion and characteristics, holds a great potential for health care applications. However the use of mobile phones in health care delivery has not been fully explored, and the diverse outcomes of mHealth have barely been documented,” says a studyappearing in the Journal of Medical Internet Research.

 

“Although some literature reviews cover one part or the other of the field, an overall picture is still missing, possibly due to the field’s constant evolution,” according to a team of Swiss researchers.

 

“Studies are becoming more theoretically sound,” corresponding author Maddalena Fiordelli, a postdoctoral research fellow at the Institute of Communication and Health at the University of Lugano, Switzerland, tells MobiHealthNews. “On the other hand,” she adds, “it seems that research is not keeping up.”

 

The volume of scientific research about mobile healthcare technology has grown as the field itself has exploded, but the quality and focus of academic studies has not kept pace with the speed of innovation, a review of 10 years’ worth of published literature suggests.

 

A health IT startup has embedded a remote monitor in an insulin pen cap to track adherence and spot potential dosage problems early as part of Sanofi's Data Design Diabetes challenge.

 

The Sanofi US competition to encourage companies to devise new ways to improve outcomes and lower healthcare costs associated with diabetes has its demo day today. In a contest that generally revolves around various health IT approaches, one company has developed a remote monitoring device to generate big data using the cap of an insulin pen.

 

Cambridge, Massachusetts-based Common Sensing produced the GoCap — a replacement cap for pre-filled insulin pens that records the level of insulin administered daily and the times it was taken. It transmits that information using Bluetooth to a mobile phone or connected glucometer. The idea is to provide a steady stream of relevant information transmitted in an easily digestable format to alert healthcare professionals to potential problems early enough before they require hospitalization and ramp up healthcare costs.

 

James White co-founded Common Sensing with Richard Whalley, both MIT graduates. In a phone interview with MedCity News, White — who is also the chief technology officer — said one reason for starting the company is that the data to gauge risk in diabetes patients just isn’t there.

 

The device offers a way for physicians and patients to gain insight into daily insulin use over time not only to confirm whether the patient is taking their medicine, but also to help physicians adjust the prescribed amount if needed. For example, maybe the patient is not taking big enough dose of insulin in the morning but needs a smaller dose at night.

Patients are starting to expect healthcare to come to them in real time, and they no longer trust that the doctor knows everything. 

Before AliveCor’s much-buzzed-about iPhone ECG even received FDA clearance late last year, many in healthcare had already christened it a disruptive innovation. Now that it’s actually on the market, we’re hearing stories that prove their case.

 

The first involved a patient with a cardiac implant who awoke in the middle of the night with cardiac symptoms. His doctor had prescribed him the AliveCor product, so he used it to take his ECG. He tried to get in touch with his cardiologist to interpret the data and let him know what to do next, but the physician couldn’t be reached. Unsure what to do next, the patient tweeted out his ECG reading. Several cardiologists responded with a diagnosis, including Eric Topol, director of the Scripps Translational Science Institute and chief academic officer for Scripps Health.

 

While hospital robots sound like the stuff of the future, the technology is already in wide use today.

 

If you’ve been waiting for the day when robot doctors will cut you open, monitor you recovery, and keep you company in your hospital room, you won’t have to wait much longer.

 

“We’re in the first inning of a nine-inning exercise. The average patient walks in a hospital and is not touched by robotics. That’s going to change in 10 years,” said John Simon, a partner at Boston-based investment firm Sigma Prime Ventures.

 

That adoption rate, Simon argues, is based on cost: As the price of robotics adoption decreases, hospitals may be more likely to invest in new technology. At their core, robots aren’t all that different from any other hospital gear.

 

The problem for hospitals, however, is that there’s a danger in pursuing robotics too far. “With medical robots,  if you automate something too much, people won’t accept it,” Simon said.

 

This results in a fine line that hospitals and doctors must manage. While some automation and robotics is good, the last thing a hospital wants to do is embrace robots to such an extent that they alienate patients.

 

Little of that, however, is on the minds of hospitals today. Right now, most of them are just trying to figure out how to get robots in the front door. Here are a few ways robots are changing hospitals today.

NEW RESEARCH SHOWS DECEPTION MAY NOT BE NECESSARY FOR THE PLACEBO EFFECT

 

Daniel Jacobs believes in the placebo effect, the well-documented but not well-understood phenomenon in which sick patients sometimes feel the same healing effects from swallowing a sugar pill that...

 

That’s the basis of his startup, Placebo Effect, which is raising $50,000 through the crowdfunding site Indiegogo to build his prototype into an iPhone app that he says can harness the placebo effect in order to help people make positive changes in their lives, such as feeling happier or quitting smoking.

 

The app offers a variety of "placebos," including images of a pill, a magic wand, a communion wafer, and other options. "Placebo pills are actually chosen often. About 12 percent of people in our testing choose pills," he said. "The reason for that probably is that in our society, we feel that pills work really well."

 

He’s done limited testing with good results, he said, and plans to do more. So far, 39 people self-reported an average of 31 percent increase in the effect they were trying to create in their lives, for example joy, energy, physical healing, or love, after one use. Seven users reported no change, and one person reported a negative change and did not complete the trial.

Jacobs’ idea may sound a bit bogus, especially since it is widely believed that the placebo effect only works if the patient believes he or she is taking a real treatment. This perceived need for deception is part of the reason doctors don’t prescribe placebos, despite the fact that they can occasionally work as well as FDA-approved treatments for some conditions.

 

 

 

We've seen a few interesting apps built specifically for Google's new headset but, to our knowledge MedRef for Glass is the first that recognize people's faces.

 

The basic functions aren't anything terribly ground breaking: you can create and search patient files, and even add voice or photo notes. What makes Lance Nanek'screation unique is its support for facial recognition. A user can snap a picture of a subject and upload it to the cloud, where it will search patient records for a match using the Betaface API.

 

All of this can be done, relatively hands-free leaving a doctors well-trained mitts available to perform other necessary medical duties. There's still a lot of work to do, and Nanek hopes that with more powerful hardware the facial recognition feature could be left running constantly, removing the need to snap and upload photos. In the meantime, if you're one of the lucky few to have an Explorer edition of Google Glass you can install the package at the source link. Otherwise, you'll have to make do with the demo video after the break.

  

I can envision apps helping patients and families manage a medical care plan.

 

if I were asked “Why should a clinician prescribe an app?” I would answer as follows:

 

Because it’s likely to help the patient reach his or her most important health goals, and is a good fit within an over-arching medical management plan.

 

In other words, if the goal is to provide sensible medical assistance to patients and families, the use of an app should be likely to:

 

Help a patient work towards the most important medical goals.This means clinician and patient should’ve discussed goals overall, and prioritized which issues are most important for the time being. Since I take care of complex older patients, prioritizing issues is really a must, and then we can set certain goals for the issues we’ve decided to focus on.Be likely to provide benefit or otherwise be clinically useful.This doesn’t mean we always need peer-reviewed studies demonstrating that use of this particular app provided a health benefit.

 

But there should be some reason to believe using an app will be clinically useful.This could be because the app facilitates collection of data needed to revise the treatment plan, i.e. documents pain, incontinence, sleep patterns, as-needed medication use, etc.Or it could be that the app digitally guides patients through an intervention previously found to be beneficial, such as a home exercise plan.

 

As with the prescription of a drug, recommending an app should include guidance as to what benefit the patient can expect, as well as a plan for ensuring that the app is delivering benefit as expected.Be a good, feasible fit within an overall management plan.Just as I don’t prescribe a medication in isolation, without considering the patient’s other medical conditions and other prescriptions, I wouldn’t recommend an app in isolation.I find that most patients and families have only so much bandwidth available for daily healthcare management tasks.

 

So in considering an app I’d also try to be mindful of how many other apps have been recommended, and I’d try to work out an overall plan that was going to be manageable for the patient. After all, there is only so much futzingwith devices that one can do in a given day.

What is person-centred eHealth?

 

Does the wording imply that ehealth in general is not person-centred. Well. To elaborate these questions further, I need to make some assumption and define what I mean by person-centred care and eHealth. 

 

Ehealth is according to  Eysenbach et al (2001) ” an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies. In a broader sense, the term characterizes not only a technical development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology”.

EHealth is not a technical solutions per se, it is also a state of mind and attitude about how we want to communicate and in that sense it could be a good tool in providing support for PCC. 

The core in my exposition is grounded on the definition of PCC found within GPCC. I have already discussed this in my previous blogs, and will for the matter of simplicity call it gPCC (Gothenburg person-centred care approach). The most central aspect in gPCC is the mutual acceptance that a person always is intradependent of the other person. At the core of the definition is the concept of partnership.

The juridical meaning of the word is that two persons reach an written or verbal agreement (contract) to perform certain commitments. Within the gPCC approach, this agreement would be manifested by a health and care plan that is agreed upon by all involved stakeholders.  So partnership needs at least two people that agree upon a certain approach in order to reach a certain outcomes.