Category: Gastroenterology

20 Jul 2020

How real is Virtual/Augmented Reality in healthcare? (Exponential Tech Part 4)

We have so many immersive experiences today that transport us to a reality that existed in dreams and fantasies earlier. Welcome to the world of Virtual Reality (VR). As the name suggests, it’s virtual and yet the experience is meant to feel real. A computer-simulated alternate world that you experience with sensory devices such as handsets and gloves.
Then there is Augmented Reality (AR), here the focus is the real world and there are digital elements superimposed. One of the best examples of this is in the Ikea Place app. If you wanted to see how an IKEA sofa looked in your living room, you just tap the product and use your phone camera to place the digital sofa in your living room to see how it looked.

 

So how does all of this fit into healthcare? Let’s check out some of the interesting applications in use.
In gastroenterology, the use of AR in the endoscopic unit helps improve the polyp detection rate, polyp classification, polyp size estimation, etc. Key to the AR technology is image processing and computer vision. Image processing allows the deconstruction of the image captured as a part of the input (camera) into a series of parameters and properties. The computer vision refers to the high-level image processing which allows the computer to interpret the image or series of images.
AED4EU is an app that uses AR to show all known Automated External Defibrillators in the location near you. AED4EU will also give you the phone number and address.
AccuVein uses augmented reality by using a handheld scanner over the skin and shows nurses and doctors where veins are in the patients’ bodies. It’s been used on more than 10 million patients, making finding a vein on the first stick 3.5x more likely.
These are just a few applications putting AR to good use in healthcare. Let us round up the overall benefits of AR and VR in medicine as it potentially promises to revolutionize treatment, therapy, training, and education.
1. Surgical Simulation, Training, and Education
Virtual Reality transports you directly inside the human body to access in 3D view even the tiniest of veins that otherwise would be impossible to see. Currently, medical students learn on cadavers, which are difficult to source and do not react as live patients would. In VR however, you can view minute details of the body in a 360° CGI (Computer-generated imagery) reconstruction & create training scenarios that could substitute common surgical procedures.
Case Western Reserve University and the Cleveland Clinic have partnered with Microsoft to develop a HoloLens app called HoloAnatomy to visualize the human body in an easy and spectacular way.
With Microsoft’s HoloLens Headset, app users are able to see everything from muscles to veins before their eyes through a holographic model. This has the potential to revolutionize medical education.

 

Specialized training simulators can be created to improve surgeons’ skills in various scenarios. Simulated models help many surgeons, plan, and rehearse before the actual surgery, as a part of preoperative planning. These virtual models of the patients’ bodies can be made using the MRI, CT, and Ultrasound scans.
Such simulators can also be used by trainee residents and students in developing intuition and decision-making abilities.
AR enables experienced surgeons to remotely assist residents by using an Internet connection and therefore opens the way of excellent distant teaching. Compared to virtual reality (VR) simulators, where the whole simulation takes part in a CG (Computer-generated) environment, the main advantage of AR simulators is the ability to combine real-life objects with CG images, resulting in satisfactory tactile feedback.
By monitoring and transmitting the image of a surgical site between two distant stations, remote virtual collaboration is possible between two surgeons. This concept is sometimes referred to as “telepresence”. A VIPAR ( Virtual Interactive Presence Augmented Reality) system was used in an effort to allow communication between Vietnam and the USA.
Another interesting example of immersive training experience is the HumanSim system which enables doctors, nurses, and other medical personnel to interact with patients in an interactive virtual training environment. This measures the participant’s emotions via a series of sensors. Helps the medical professionals to develop more empathy for patients among other things.
2. Virtual reality diagnostics
Virtual reality is often used as a diagnostic tool in that it enables doctors to arrive at a diagnosis in conjunction with other methods such as MRI scans. This removes the need for invasive procedures or surgery.
3. Virtual robotic surgery
A popular use of VR is in robotic surgery. This is where surgery is performed by means of a robotic device that is controlled by a human surgeon, which reduces the time and risk of complications. The robotic device is accurate, meaning smaller incisions, reduced blood loss, and faster recovery.
Robotic-assisted surgery with Da Vinci surgical systems are cleared by applicable regulatory agencies for use in a number of different procedures such as colorectal, cardiac, urology, general surgery, gynecological, head and neck, and thoracic.
4. Treatment of phobias, anxiety disorders, and addiction
Combined with biosensors that monitor physiological reactions like heart rate and perspiration, therapists can assess how patients react to stressful situations in a safe, virtual environment. This is applied to the treatment of post-traumatic stress disorders and patients with various phobias.
VR can also be a useful tool to treat addicts and prevent a relapse from occurring by exposing them to the right stimuli.
VR can help people with autism develop social and communication skills. It can also diagnose patients with visual or cognitive disabilities, by tracking eye movement.
5. Patient Education
The ability to view the inside of the human body in Virtual Reality is not only useful for doctors, but also for patients. VR allows patients to be taken through their surgical plan by virtually stepping into a patient-specific 360° VR reconstruction of their bodily anatomy. This helps them in the understanding of the treatment.
6. Pain Management & Physical Therapy
VR’s healing capabilities are used in physical therapy and pain management too. UW Harborview Burn Centre uses the VR game, Snow World, to alleviate the pain for burn victims during wound care. VR distracts the mind from the source of pain and immerses the patients in an alternate world of snowmen, snowballs, and penguins.
VR for physical therapy has also been shown to be effective in speeding recovery. Allowing the patient to do their prescribed daily exercises in a virtual environment makes the activity more fun, keeps them in high spirits during a long recovery period. Today, we also have the option of having a digital physiotherapist at home by means of a VR avatar.
Future Trends and Challenges
The adoption of AR and VR in healthcare is forecast to grow even more quickly, with the value of the market increasing by 38% annually until 2025.
However, there are challenges in the mainstream adoption of these technologies.
► Cost is definitely one of the factors. These technologies are expensive. A lot of big investors like Google and Facebook have pumped billions into the VR market, allowing for some very powerful hardware like the Oculus Quest to hit the market. The total cost of ownership of the technology solutions will need to be contained if it is to be adopted widely.
► Mobility is another challenge. One of the biggest limiting factors with current technology is the need for restricting headsets, display units, and all the cords used to connect them. However, hardware devices have started to trend towards being “untethered”. Facebook’s Oculus headset that initially needed to be connected to a powerful PC, became available as the self-contained Oculus Quest version.
► VR requires higher bandwidths and superfast networks. 5G will open up new possibilities for these technologies. Data transfer speed of 3 gigabytes per second (as opposed to 100mbps for home broadband) would be required to stream data from the cloud. Rather than needing to be connected to PCs, viewing devices will upload tracking data to data centers on the cloud where the heavy processing will be done. The rendered images can be delivered back to the user in real-time thanks to the speed of 5G and other advanced networks.
► Lack of knowledge and research around AR/VR in health care. A quick search of research studies shows over 3,536 publications with “virtual reality” or “augmented reality” or “mixed reality” in the title since 1991. Unless there is more knowledge and useful research available, mainstream adoption will be slow.
► Regulatory/Policy/Insurance issues. As with anything new in healthcare, unless there is wide adoption of this technology, regulatory and insurance challenges will be a given.
As Facebook, Google, Oculus, Samsung, and Sony continue to aggressively market VR/AR experiences for consumers, more people will be exposed to it and interest will grow. That said, patient demand and pull will have a powerful influence on administrative and clinical decision-makers.
Healthcare facilities from across the globe are now utilizing immersive applications such as vein visualization, surgical visualization, etc. Development-driven healthcare professionals are researching areas that could potentially benefit both customers and businesses. While some of the hospitals are not equipped to handle these technological advances, many of them (including third party companies) are choosing to invest in the same.
A lot of the VR and AR applications mentioned above are still in their infancy. However, the potential for VR in the healthcare sector is huge, limited only by the imagination and insight of those creating and applying the technology.

 


Originally published on LinkedIn, by Suzette Sugathan, Director, NextServices
Image Credit: Pexels.com

 

_

COVID-19: The Way Forward for Gastroenterology Practices
COVID-19 is a double whammy of both clinical and business disruption. This ebook will help you explore possible scenarios and be a guide in your plans for the future.
button_download
01 Jul 2020

Looking for a post-COVID health-tech idea? Find it in 3D printing (Exponential Tech – Part 3)

From printing food to organs, 3D printing is a fascinating exponential tech industry in the making. This week we shall delve into its application in healthcare.
In this article, you’ll understand where the opportunities are in this upcoming field.
• What is 3D printing?
• Bioprinting and its uses in regenerative medicine 
• Other applications of 3D printing in healthcare
Current challenges and future of this promising technology
To put it simply, 3D printing is a process of making 3D solid objects from a digital file. It’s an additive process, wherein an object is created by adding layer after layer of material. Until finally the desired object takes shape.
3D printing in healthcare: Four core areas
As per the report published by Allied Market Research, the global 3D printing healthcare market accounted for $972.6 million in 2018. It is expected to reach $3.69 billion by 2026, growing at a CAGR of 18.2% from 2019 to 2026. Here are the four major areas.
1. Bioprinting tissues and organoids (grow from stem cells)
2. Manufacturing customized medical and dental devices
3. Manufacturing surgical tools
4. Producing patient-specific anatomical models
► 1. Bioprinting tissues and organs
Bioprinters are 3D printers with one key difference. Instead of using materials such as plastic or metal, these printers deposit layers of biomaterial. That means these printers use cells to build living tissues. That eventually become blood vessels, bones, heart, or skin.
In the early 2000s, researchers discovered that living cells could be sprayed through the nozzles of inkjet printers. That didn’t damage the cells. But the problem was cells need a nurturing environment to stay alive: food, water, and oxygen. Such an environment is made possible by a micro gel that has vitamins, proteins, and other nourishing compounds. Researchers plant the cells around 3-D printed scaffolds made of biodegradable polymers or collagen so they can grow into a fully functional tissue.
For example, this method could be used to “print” a bladder, a simple organ consisting of only two types of cells. Here are the steps:
a) Scan a patient’s organ to determine size and shape
b) Create a 3D model from the scans
c) Using degradable polymer, print scaffolds to help cells grow in 3D
d) Place the organ in the patient’s body
e) Watch the scaffold slowly disappear after surgery
Isn’t it fascinating? There’s more.
In a landmark achievement, Tel Aviv University has 3D printed a small heart using human tissue. While the organ itself is smaller than one would need in a transplant, it is a massive step forward for bioprinting. Here the bio-inks used were “personalized hydrogel”, extracted from the fatty tissues of the human test patients.

 

Bioprinted bones are made with a durable and regenerative biomaterial capable of fusing with a patient’s natural bones over time. Eventually being replaced by them.
Researchers in South Korea developed 3D printed artificial corneas. Meanwhile, an Australian bio fabrication center called BioFAB3D built a handheld cartilage printing device called the BioPen. The BioPen is filled with stem cells derived from a patient’s fat. That helps in creating and implanting custom scaffolds of living material into failing joints.
Wake Forest School of Medicine has designed a printer that can print skin cells directly on to a burn wound.
Bioprinting also has its uses in clinical trials. It can use 3D printed tissues and organs without conducting trials on animals. Loreal, the French cosmetics major, partnered with 3D bioprinting company Organovo to 3D print human skin. This helps test their products before they get to market.
As this amazing area evolves, organ donations will be a thing of the past. The space of regenerative medicine will bring hope to many people around the globe.
You could even be printing your own personalized medicines soon. The possibilities are truly exciting.
► 2. Manufacturing customized medical and dental devices
3D printing has made manufacturing of medical devices less complex, much faster, more cost-effective, more customized, and easier to sterilize.
Prosthetics – 3D printing has completely transformed the prosthetics industry. Now you have perfectly fitted devices that are more cost-effective as well as functional.

 

Surgical guides – Both dental and medical surgeries require precision. A 3D printed surgical guide can help a surgeon line up holes, incisions, and implants as per the patient’s anatomy. Now with 3D printing, these guides can be produced rapidly to specifications.

 

Implants – 3D printing produces fine mesh structures at no additional cost. The organic structure of the device reduces the risk of rejection after the surgery is complete. These customizable implants are usually manufactured with 3D metal printing. This makes them strong, sterile, and matched to the patient’s needs.This is a test done on a sample of blood. It looks for cancer cells from a tumor that are circulating in the blood or for proteins in the blood due to the response of the immune system to the cancer. This will help in detecting cancer at an early stage.
► 3. 3D printing surgical tools
Sterile surgical instruments, such as forceps, hemostats, scalpel handles, and clamps, can be produced using 3D printers.
Not only does 3D printing produce sterile tools, but some printers based on origami, allow for the printing of tools that are precise and small in size. These instruments can be used to operate on tiny areas without causing unnecessary extra damage to the patient.
► 4. Preparing patient-specific surgical models
Creating 3D anatomical models from CT scans or MRIs is becoming increasingly useful for both doctors and patients. While these models help doctors prepare for their complex surgeries, they serve to educate patients about procedures. This helps not just reduce patient anxiety and recovery times but improves pre-operative planning and operating room efficiency. 
Source: https://formlabs.com/blog/3d-printing-in-medicine-healthcare
In the words of Dr. Alexis Dang, an orthopedic surgeon at the University of California San Francisco (UCSF) and the San Francisco Veteran’s Affairs Medical Center:
“Every one of our full-time orthopedic surgeons and nearly all of our part-time surgeons have utilized 3D printed models for care of patients at the San Francisco VA. We’ve all seen that 3D printing improves performance on game day.”
These 3D printed models are also widely used for training. For example, 3D printed endoscopic biopsy simulators are practical and useful tools in endoscopic training.
Three challenges before 3D printing goes mainstream in healthcare
As you can imagine, a regulatory and legal framework is still in the works. The scope for 3D printing is vast – from drugs and biologics to implants and prosthetics.
Beyond regulatory challenges, there are several technical challenges to overcome. These include costs of equipment, biocompatible materials, and interoperability between software and hardware.
Finally, there’s the economic hurdle of getting paid from insurance companies. While an FDA-approved 3D-printed joint implant may be reimbursed, 3D models of a patient’s anatomy and professional fees often are not.
Crossing these hurdles paves the way for the future.
3D printing in healthcare: At the cusp of an exponential curve
Consider these areas where 3D printing can be a gamechanger.
◘ A typical kidney transplant can cost more than $300,000. 3D printing has the potential to reduce that number to less than $100,000.
◘ Almost 114,000 people in the U.S. are on the waiting list for a life-saving organ donation. 3D printed organs can eliminate these queues forever.
◘ There are nearly 2 million people in the United States with amputations. 3D printed prosthetics can get people back in motion faster than ever before.
◘ The average price of a set of surgical instruments today is more than $3,000. This cost can reduce dramatically with 3D printing.
A multihospital organization can have more than 25,000 pieces of equipment. 3D printing has a big role to play here.
Emerging opportunities for business and impacting people’s lives are aplenty here. Add the power of customization and precision, you can see the power of this exponential technology.
If you are in healthcare and be a part of this transformation, the time to experiment is now.

 


Originally published on LinkedIn, by Suzette Sugathan, Director, NextServices
Image Credit: Unsplash.com, Rob Wingate

 

_

COVID-19: The Way Forward for Gastroenterology Practices
COVID-19 is a double whammy of both clinical and business disruption. This ebook will help you explore possible scenarios and be a guide in your plans for the future.
button_download
18 Jun 2020

Exponential Tech: DNA testing in cancer screening (Part 2)

In last week’s post, we cruised through a primer on exponential technologies and how it can disrupt business and life as we know it. Moving on, this week we’ll attempt to understand how this applies to cancer screening in healthcare. We’ll do so from the lens of gastroenterology (GI).
Here’s what you’ll take away from this article:
• Present DNA testing methods of colon cancer screening (stool DNA testing)
• Upcoming DNA testing methods such as liquid biopsy (using a blood draw to detect not one but many types of cancers)
• Implications of exponential technologies in cancer screening
Colorectal cancer screening 101
For those of us in the GI world, colonoscopy is not new. Using the procedure, a gastroenterologist examines the colon and rectum for abnormalities. It is a key colorectal cancer (CRC) screening method and helps in detecting or removing small polyps in the colon. Larger polyps or tumours need a biopsy and further tests.
Colonoscopy is the gold standard in CRC screening. It detects and removes precancerous polyps well before they become malignant. If you test negative, you may not need to test yourself for the next 10 years.
Almost all insurances in the US cover this procedure. The cost of a colonoscopy could vary from $500 to $3,000 depending on it happens. It contributes to a significant portion of a gastroenterologist’s income. As you’ll soon find out, this revenue stream is at risk.
Colonoscopies have certain downsides. It’s invasive and inconvenient. An endoscopist inserts a scope (5-6ft narrow tube with a camera at the end) through the anus to examine the colon. The procedure requires sedation and a bowel prep.
Exponential Tech makes its way into cancer screening
The gastroenterology circuit is buzzing with newer alternate CRC screening methods. Though not as reliable a screening tool as colonoscopy is, these methods may pick up momentum soon. As you know from my previous article, exponential technologies scale up quickly after a point.
Extremely well funded startups and established players are working on stool DNA testing and liquid biopsy. These are not small forces.
Stool DNA testing
There are “old-fashioned” GI stool tests, fecal immunochemical tests (labeled FIT) or the guaic-based fecal occult blood tests (gFOBT). These detect blood in stools.
With DNA testing of stool, however, you check for not just microscopic blood but also altered DNA. Cologuard (a product from Exact Sciences) leads in this testing method. It was approved by FDA in 2014. The company sends a kit home. You can leave it at the doorstep for UPS to pickup! There are no trips to doctors or scopes poking around the posterior. Completely contactless – it seems to have a new upside in COVID times.
Cologuard vs. Colonoscopy
► Colonoscopy detects 95% of CRC and advanced precancerous polyps. If tested negative, you don’t need another test for the next decade.
► Cologuard has a 92% sensitivity rate and a 87% specificity rate overall, in a clinical study of 10,000 patients aged between 50-84 years at an average risk of CRC. False positives and false negative results can occur, which is still a high risk to patients. This indicates that once you have your readings, you still need to consult with your provider. In case the result is positive, diagnostic colonoscopy will follow. If negative, you will have to screen again in three years because the test is unable to detect high risk precancerous polyps definitively.
Cologuard has its benefits as a more convenient and comfortable screening method. The Cologuard kit costs US$ 649 and it takes two weeks to get the test results. Medicare and most of the insurances in the US cover it.
Cologuard has covered ample ground since it got FDA approval in 2014. More than 3.5 million people have been screened for colorectal cancer. It has captured less than 6% of the large addressable market of people over 50 years old. It’s long term goal is to reach 40% of the market.
Cologuard has competition. Liquid biopsy is trying to detect not one, but many cancers
This is a test done on a sample of blood. It looks for cancer cells from a tumor that are circulating in the blood or for proteins in the blood due to the response of the immune system to the cancer. This will help in detecting cancer at an early stage.
FreenomeCellmaxGrailThrive and Guardant Health are some of the players using a blood draw for their CRC screening tests.
► Freenome. Set up in 2014, the company has received a total funding of $237.6 million. It uses molecular biology and machine learning to detect cancer. According to the company, they are pioneering the Multiomics platform that decodes cell free biomarker patterns to detect cancer at its earliest stages. It analyzes a blood sample not just for DNA shed by cancer cells but also for proteins. Any of the biological molecules Freenome detects could originate in tumor cells, or could come from the person’s immune system responding to the onset of cancer. Their focus is on colorectal cancer and the final study for FDA approval is underway.
► GRAIL. Founded in 2015, this startup also working in the diagnostics space has raised $2 billion for its technology that screens for multiple cancers. It received the FDA Breakthrough Device Designation status in May 2019. The Pathfinder Study initiated in early 2020 is evaluating the implementation of GRAIL’s multi-cancer early detection test in clinical practice.
Using a single blood draw, GRAIL’s still-in-development test can detect more than 50 cancer types across all stages. It has very low false-positive rate of less than 1%.
► Thrive Earlier Detection. The startup spun out of John Hopkins in May 2019. It’s backed by $110 million in venture funding. This is another company looking at multiple cancer screens through a liquid biopsy test.
► Cellmax and Guardant Health.These are other players betting on liquid biopsy with their cancer screening tests pending FDA approval. Guardant is a public company that’s frequently loved by Wall Street.
Liquid biopsy = autonomous cars?
Are these new screening methods like the autonomous cars we analysed last week? They may still be evolving in performance now, but, given the efforts going into product enhancement and cost reduction, they may emerge as reliable screening tools in future. Will the power of exponentials start playing out in CRC screening too?
Liquid biopsy for early cancer detection is still years away from being a reliable screening tool. Its noninvasive nature, quick turnaround times, low cost, real time monitoring etc. makes it an attractive option. However, the true power of this will unleash when the sensitivity and specificity of these tests improve as does our understanding of the biology of tumours and what can be found in the blood. Experts state it is still a few years away from effective implementation.
But wait…what about colonoscopy for screening?
Payers, patients, and physicians – all have a role to play in the choice of the screening tool.
In today’s consumer-driven healthcare, the best test for colorectal cancer screening is the one that the patients demands. A colonoscopy may be a gold standard but a patient may be unwilling to undergo the procedure.
Cologuard also invests heavily in TV advertising that influences patient demand.
Primary care doctors are now more willing to prescribe such noninvasive screening tools to cater to patient requests. As more DNA testing occurs, companies like Exact Sciences will get more data on DNA of cancers. With more data, sensitivity and specificity will improve.
Meanwhile, payers are continuing to cut reimbursements of screening colonoscopy.
The technology that we use for colorectal cancer screening will continue to evolve. The demand for less invasive, cheaper tests with faster turn-around times will continue to rise.
As with the rest of the healthcare industry, gastroenterology is bracing itself for massive change. The underlying reason for that change is exponential technologies in action.

 


Originally published on LinkedIn, by Suzette Sugathan, Director, NextServices
Image Credit: Pixabay

 

_

COVID-19: The Way Forward for Gastroenterology Practices
COVID-19 is a double whammy of both clinical and business disruption. This ebook will help you explore possible scenarios and be a guide in your plans for the future.
button_download
13 Jun 2020

Exponential Tech from a GenX perspective – Part 1

Until recently, if anyone mentioned anything too technical – be it digital transformation or the myriad exponential technologies hitting us today – I had a standard reflex response. I’d dig my feet in and quietly withdraw from the conversation. I belong to the GenX cluster used to the brick and mortar of things.
However, we don’t live in a world anymore where we can blindspot the digital invasion that is part of everyday living.
With Covid-19, life has assumed a momentum that no one imagined possible. Do I have a choice now but to dive in to stay relevant? 
My next series of posts will be focused on exponential technologies and its application in healthcare – gastroenterology (GI) in particular, a focus area at our company. This article is a primer on exponential technologies. In my upcoming post, we’ll dig deeper into its application in healthcare.
The rice and chessboard tale
For the uninitiated, this story exposes the power of exponentials. It’s an old tale of the king and the creator of the chessboard game.
The king wanted to reward the creator of chess and asked him to name his reward. The clever creator asked for rice. He wanted one grain placed on the first square of the chess-board and doubled with every square and wanted the total of all grains that would sit on the entire chess board with 64 squares. So now we have series of grains equaling the exponentiation of 2…1, 2, 4, 8, 16, 32…all the way upto 2^63 grains on the 64th square of the chess board. We add all these grains up and get a whopping 18,446,744,073,709,551,615 grains. Approximately over 300 billion tons of rice, which is about 400 times the global production of rice.
What started as one grain became an unthinkably large number. One to many, that is exponential power.
What in the world are exponential technologies?
We have all heard of Moore’s Law that states that the computer processing power doubles every two years. What does this point to in essence? Growth of technology with computing at its core will always grow exponentially, it’s never linear growth.
Postulated by Ray Kurzweil in 1999, the Law of Accelerating Returns states that the rate of progress in an evolutionary learning environment increases exponentially.
The more advanced such a system becomes, the faster its rate of progress grows.
Combining these laws, here’s what we understand about exponential technologies.
1. It’s exponential. At set intervals, it doubles in capability or performance and halves in cost.
2. It’s a technology with a price-performance ratio that’s solves business problems in a way that was unthinkable previously. It’s disruptive and can have a positive impact both in social and economic terms.
What are the examples of exponential technologies you’re already experiencing in everyday life? Artificial intelligence (AI), additive manufacturing, augmented and virtual reality (AR, VR), digital biology and biotech, data science, medical tech, nanotech, robotics, autonomous vehicles, etc.
Self driving cars are a reality because of exponential technologies
Let us take Autonomous vehicles (AV) to understand this further. If you’d have mentioned the idea of AVs replacing Human Driven (HD) cars to me even as far as five years ago, I would’ve laughed and scorned at the suggestion. But not anymore. 
When a Toyota Prius was remodeled with Google’s driverless technology in 2012 the price tag of owning a self driven car was over US$150k. Today, while you still can’t own a self driving car (why would you when there are self-driving cabs?), almost autonomous driving options cost between US$ 25k-35k.
Autonomous vehicles need sensors that serve as the eye of these vehicles. They need AI systems that help the vehicle to think and take decisions. There are a combination of sensors used – camera sensors, radar sensors, and LIDAR sensors. The sensors allow the car to see all the objects in short range and long range. They help determine speed and distances relative to the AV. This allows the car to travel without colliding into nearby cars or objects.
LIDAR sensors, the more advanced of the sensors, use laser light to provide 3D images of objects and surroundings with a 360 degree span. The LIDAR system that the Toyota Prius used in 2012 cost $75k. Today the performance of these sensors are way better and the cost of sensors has dropped drastically. It costs between a few thousand dollars to $100 depending on the performance required.
Artificial Intelligence (AI) software in the car is connected to all the sensors and collects input from Google Street View and video cameras inside the car. The AI simulates human perceptual and decision-making processes using deep learning. It controls driving actions, such as steering and brakes.
AI systems need to be trained with loads of data. The more the system drives, the more data can be fed to the neural network algorithms for more nuanced decision making, improving the safety of these vehicles.
Disrupt or be disrupted
So there you have it. These cars will only continue to see a drastic drop in cost and an exponential improvement in performance as we have more driving data available. They are slated to be far more safer than regular cars in a few years. Cornell professor, Bart Selman, has predicted driverless cars would be 10 times safer than those driven by humans within three years. Within a decade, they’ll be 100 times safer. According to a University of Texas report, if 90 per cent of the cars in the US were replaced by AVs, the savings across industries could reach as high as $450 billion.
If you were in the auto space and not invested in this exponential technology, you may risk extinction. You either disrupt or get disrupted.
So how does all this fit into healthcare and gastroenterology? Find out next week in the Part 2 of this series.

 


Originally published on LinkedIn, by Suzette Sugathan, Director, NextServices
Image Credit: Karol D. Pexels.com

 

_

COVID-19: The Way Forward for Gastroenterology Practices
COVID-19 is a double whammy of both clinical and business disruption. This ebook will help you explore possible scenarios and be a guide in your plans for the future.
button_download
12 Mar 2020

PoopTech to AI and the microbiome: 10 Startups in Digital GI

March is National Colorectal Cancer Awareness month. While the GI world is busy educating patients about colonoscopy, the startup world is busy finding new ways to work with the gut. 
With $3.3 billion in investor money, the gut indeed seems to be the next frontier in digital health. CB Insights called some of this technology as Poop Tech! Take a look at their market map of the fecal ecosystem.
Meanwhile, here are 10 startups that show you the spread of innovation in the digital gastroenterology space.
1/ Kallyope: A NY-based startup harnessing the gut-brain axis, the bi-directional information highway between the gut and our brain. They are combining technologies in sequencing, computational biology, neural imaging, cellular and molecular biology and human genetics to develop new therapeutics.
2/ DFree: A startup based in California created a wearable device for urinary incontinence. This device gives you a 10 minute heads-up (a notification) that it would be better for you to be near a toilet. It does so by tracking your daily bowel movements.
3/ BiomeSense: BiomeSense is a startup developing biosensors. These sensors can detect particular kinds of bacteria in patients’ feces. Basically, they collect, store and analyze data of daily human gut microbiome profiles. BiomeSense plans to help improve the efficacy of clinical trials.
4/ Docbot: An AI-enabled computer vision platform for gastroenterology practices to improve colonoscopy procedures. DocBot tracks withdrawal time, intubation rate, bowel prep, and adenoma detection rate. More than 2,000 procedures to date have used Docbot.
5/ Vivante Health: This company has made it to the list of Digital Health 150. The company makes GIThrive an all-in-one digital platform for digestive health. The app includes microbiome testing to uncover bacterial imbalance, a personal handheld digestion monitor to identify “trigger food” with a breath test, therapeutic nutrition and self-paced patient education.
6/ Geneoscopy: A life sciences startup that’s developing diagnostics that leverage RNA to prevent, detect and treat GI diseases. It has a stool-based, multi-target RNA biomarker panel that can identify colorectal cancer.
7/ auggi: This company is trying to create the world’s largest database of human stool photos! auggi hopes to build a poop tracker reliable enough to identify GI problems.
8/ AsiaBioBank: This Asian startup is collecting human gut microbiota. They want to provide safe access to fecal microbiota transplant.
9/ Viome: A microbiome analyzing startup. Viome’s ‘gut intelligence’ test kit gives a comprehensive analysis of your gut microbiome.
10/ Charmin (P&G’s toilet paper brand): They’ve created a roll bot that’ll bring you toilet paper when you need it and a smell sensor that tells you how smelly a bathroom is!
What does it all mean? Many advanced technologies are entering gastroenterology from different angles. They will multiply and accelerate the pace of digital GI. Simply put, it’s unlikely that the business of GI will stay the way it was a decade ago.
Do you agree or disagree? Are there other technologies you’ve come across that seem like digital GI. Leave a comment and let me know.

_

By Praveen Suthrum, President & Co-Founder, NextServices

 

27 Feb 2020

Physician practice consolidation: It’s only just begun

Disruption has redefined health care in the past decade.
For private practice physicians, the biggest disruptor has been consolidation.
The trend of local hospitals merging into massive health systems has significantly affected private practices. According to Avalere Health and the Physicians Advisory Institute, between 2016 and 2018 hospitals acquired 8,000 medical practices and 14,000 physicians left private practice to work in hospitals.
Here’s an example: In New Jersey, Hackensack University Health Network merged with Meridian Health system in 2016 to create Hackensack Meridian Health. Its acquisition of JFK Medical Center in Edison made Hackensack Meridian the largest hospital chain in the state. Three years later, it was a $5.5 billion not-for-profit system employing 6,500 doctors. And it isn’t done growing. At the end of 2019, Hackensack Meridian Health proposed a $400 million merger with Englewood Hospital.
Ever-larger health systems affect the flow of patient referrals a private practice needs to stay in business. They change the competitive dynamic for independent physicians, who aren’t left with many choices at this point. They must find a way to get bigger or discover a niche.
Hospital growth isn’t the only threat to independence. Big insurance companies are also venturing into the provider side of health care. UnitedHealth Group is doing this through its Optum division. Optum recently acquired Surgical Care Affiliates for $2.3 billion, setting the base for OptumCare’s primary and specialty care division, which focuses on acquiring or partnering with private medical practices.
Independent medical practices are now increasingly looking to private equity to grow and compete in response to these market forces. And private equity is responding, fueling health care consolidation with billions of dollars. A study recently published in the Journal of the American Medical Association found that the number of private equity deals with physician practices across specialties more than doubled between 2013 and 2016. According to EY, $32.9 billion in private equity was invested in 647 health care transactions in 2018 — that’s double the investments made in 2014.
Early on, private equity tended to fund specialties such as dentistry and dermatology. Later, private equity funds directed their investment philosophies to other specialties, such as ophthalmology, urology, orthopedics, and OB-GYN.
As the medical environment shifts to value-based care, private equity funds are increasingly interested in potentially profitable specialties that still have many independent private practices, opportunities where they may be able to consolidate regional markets.
One specialty that fills the bill is gastroenterology. As the population ages and people — and their doctors — focus on how the gastrointestinal tract affects overall health, the demand for gastrointestinal services will continue to expand. According to a report by Medscape, 53% of the nearly 14,500 gastroenterologists in the U.S. are employed at hospitals or other health care organizations. About 6,000 of them are in private practice.
In 2018, there were only two private equity deals for gastroenterology practices; in 2019 there were 16. In 2020, I expect to see merger and acquisition announcements for various mid-size or large gastroenterology practices. The groups supported by private equity will compete to acquire other smaller groups and expand. And new and innovative models will most likely arise as well, in gastroenterology and in other specialties. The team has made progress on an enhanced version of Cologuard®.
As these deals continue, it’s important to understand the role of private equity and be aware of the mistakes made by physician practice management (PPM) companies when they tried to consolidate medical practices in the 1990s.
PPMs brought in fresh capital and management talent, added new ancillary services, negotiated better contracts, and rushed to demonstrate to the market growth and higher revenues. Unfortunately, they also charged hefty management fees and used confusing accounting practices to make the platforms look more profitable than they were.
In the end, physician practice management companies struggled to execute on their business plans and ran out of money. By 1998, this space imploded and it only took a few years to almost disappear.
Today’s landscape is different. Physicians have become more knowledgeable about the business, technology, and advocacy components of health care. Professional trade associations, such as the Large Urology Group Practice Association and the Digestive Health Physicians Association, increasingly provide forums for private practice leaders to learn from each other and discuss ways to navigate issues that affect their ability to remain independent.
I believe that in 2020 we will see massive consolidation across health care, especially among private practices. It’s not a question of whether this level of consolidation is good — we can’t turn back the clock. The question that must be answered is how to consolidate in ways that support independent physicians and improve patients’ access to cost-effective, high-quality care.

_

By Praveen Suthrum, President & Co-Founder, NextServices
Originally Published in
 STATNEWS

 

20 Feb 2020

Cologuard® expects to make over $1 billion in 2020. 16 Takeaways you must know from Exact Sciences Q4 2019 Earnings Call

Exact Sciences continues to be upbeat about Cologuard® and its overall business. The company expects revenues of $1.61-$1.645 billion in 2020 (Screening: $1.125-$1.15 billion and Precision Oncology: $485-$495 million). They are due to launch a liver cancer test in the second half of 2020.
Exact Sciences also made some strategic moves by buying two more biotech companies (in addition to Genomic Health): Paradigm and Viomics. That expands their total addressable market to $20 billion.
First, let’s review some stats from their press release:
  • Total revenue was $295.6 million (compare that to $290 million in Q3 2019 and $143 million in Q4 2018)
  • Screening revenue was $229.4 million, an increase of 60%
  • Cologuard® test volume was 477,000, an increase of 63% (volume of Cologuard® in Q3 2019: 456,000, in Q4 2018: 292,000)
  • Average Cologuard® recognized revenue per test was $481
  • Average Cologuard® cost per test was $123, an improvement of $6
  • Precision Oncology revenue was $66.2 million for the period Nov. 8, 2019 through Dec. 31, 2019, following the close of the Genomic Health combination
  • Oncotype DX® test volume for the full fourth quarter was 41,000, an increase of 14 percent (The cancer diagnostic test Oncotype DX® is now part of Exact Sciences via its acquisition of Genomic Health)
These takeaways are based on the Q4 2019 Earnings Call. Kevin Conroy, Chairman and CEO, Exact Sciences and Jeff Elliott, Chief Financial Officer, Exact Sciences made these remarks.
Takeaways:
1. Together with Genomic Health, Exact Sciences now has a $20 billion addressable market. The company has tested 41,000 patients with Oncotype DX® and made nearly $350 million in revenue.
2. The company is confident of reaching their long-term cost per test goal of $100 or less.
3. Cologuard®’s growth has been the result of:
◦ An expanded sales team
◦ Marketing campaigns, especially TV ads (they are already talking about Cologuard® 45)
◦ Growing payor and health system relationships
4. The company has doubled its lab capacity to conduct 7 million tests per year.
5. Exact Sciences has created a 1,000 person commercial organization (sales team). Of which, 60 sales people are focused on selling to gastroenterologists.
6. Cologuard® is very optimistic about the 45-49 years of age label expansion for screening. It expands their market to 19 million more Americans. They estimate that nearly all of them are unscreened. There’s a 50% rise in incidence in younger population.
7. According to the company, over 200,000 more patients are due for re-screening this year compared to last year. Over 370,000 patients coming up for three year repeat testing this year.
8. 106 million Americans are in the average risk screening population category of ages of 45 to 85. About 15 million are either not screened or out of compliance with screening.
9. Exact Sciences plans to further differentiate Cologuard® as a frontline screening test. The team has made progress on an enhanced version of Cologuard®.
◦ They presented data, showing new markers with improved specificity, while maintaining a high level of sensitivity in comparison to the current version of Cologuard®.
◦ Based on this study, a 10,000-patient prospective trial was kicked-off to validate Cologuard®’s performance.
10. Exact Sciences presented its third data set for its liver cancer test in November. The data showed superior performance of their test in comparison to the alpha-fetoprotein test.
◦ The test showed 80% sensitivity for all stages of liver cancer at 90% specificity.
◦ The company plans to make this test available in the second half of 2020. Total addressable market for this test is 3 million eligible Americans.
◦ Through the MolDx program, this test received local coverage determination. The test has faster turnaround time and requires less sample input.
11. They recently signed agreements to acquire Paradigm and Viomics. These companies have deep DNA sequencing capabilities.
◦ Paradigm – provides a therapy selection test for late stage cancer patients. Today, the Paradigm test is a tissue-based test. In the future, Exact Sciences plans to make a blood-based version. With the acquisition of Paradigm, the total addressable market of Exact Sciences’ Precision Oncology team is now $4 billion globally.
◦ Viomics – a team that provides critical sequencing and biomarker discovery capabilities.
12. For 2020, the three core priorities of Exact Sciences are:
Deliver more answers i.e., to grow their core business through Cologuard® and Oncotype DX®.
Enhance customer experience by making the testing process easy.
Power new growth that’s fueled by collaboration with Mayo Clinic, their experienced R&D team and a differentiated platform. They expect their liver cancer test to be next of many innovations in cancer diagnostics.
13. Exact Sciences also talked about its sales rep productivity. They laid out three key reasons of hiring a 60-rep GI sales force:
◦ To make sure GIs have proper background and clinical evidence on Cologuard®.
◦ To increase the direct orders from GIs for the patients who feel Cologuard® is a better alternative to colonoscopy.
◦ To sell the liver test and few tests in pipeline like the esophageal cancer test and pancreatic cancer test.
14. According to the company, health systems that have implemented an electronic interface order 95% more Cologuard® tests as compared to systems with no electronic ordering capability.
15. The company invested close to $1 billion in the brand of Cologuard®.
16. Data from Act Bold (a 7,500 patient study) is intended to be used to complete the design of Cologuard® 2.0 and blood assays.

_

References
1) Exact Sciences Corp (EXAS) Q4 2019 Earnings Call Transcript (The Motley Fool)
2)
Exact Sciences Investor Relations – Quarterly Results
3)
Exact Sciences Fourth-Quarter 2019 Earnings Call Presentation
You might also be interested in
1) Cologuard® plans to capture 40% market share. 21 takeaways from Exact Sciences Q3 2019 Earnings Call
2) Cologuard® = Google car?
10 Jan 2020

What private equity has in store for GI in 2020

Gastroenterology investment dominated the specialty in 2019, with no signs of slowing down in 2020.
Here, NextServices President and Co-founder Praveen Suthrum examined the current PE landscape in GI and offered insights into the future.
Note: Responses were edited for style and content.
Question: How will the four established (and fifth possible) PE-backed platforms coexist and continue to acquire practices?
Praveen Suthrum: Initially, platforms tended to be regional first and national afterwards. In 2019, we saw a few national deals. The PE platform in Texas [the GI Alliance] acquired a group in Illinois. The PE platform in Florida [Gastro Health] acquired a group in Washington. Newer platforms [like US Digestive Health] will tend to consolidate practices in their home region first.
However, that doesn’t stop conversations from happening across states. When a large or midsize practice puts itself in the market, it attracts bids from everyone. Investment banks will approach all the platforms on behalf of their clients to attract the best bids or determine strategic fits.
Through 2020, we will see merger and acquisition announcements of various mid-size or large GI practices. The PE platforms will compete to acquire and expand. And newer PE platforms will form in other regions.
Q: Three years down the road, what does the GI space look like?
PS: Three years down the road, we will see between eight and 11 PE and strategic platforms. We will see a significant portion of large and midsize GI practices consolidated into PE platforms or into alternative strategic platforms, like the one created by Jamison, Pa.-based Physicians Endoscopy and Silver Springs, Md.-based Capital Digestive Care.
Other players like Nashville, Tenn.-based AmSurg might come up with their own offerings. Companies like Eden Prairie, Minn.-based OptumCare might acquire a few GI practices. We will also see multi-specialty deals. Certain health systems will build GI divisions and acquire or partner with GI practices in their area. Some of these deals might fail, we just don’t know which ones.
We will begin to see [PE firms exit] around 2022-23 when some platforms will move onto the “second bite” of the apple. Newer PE players will enter the market, but overall the net result will [lead to] larger, consolidated GI practices.
Other trends will play out, such as stool DNA testing becoming more common. Screening colonoscopy will increasingly become a lab test, and endoscopies will be more about diagnostic colonoscopy. Artificial intelligence-based endoscopy will become available [which will help] GI doctors increase [polyp] detection. These technology trends will also accelerate business consolidation, because GI practices will see the advantages of getting bigger and more sophisticated.
Q: How many deals do you expect to close in 2019?
PS: There are at least 16-20 deals in the works at various stages right now. Closing deals before the end of the year could have certain financial advantages. For example, if the valuation of the PE platform increases in January, then the practices joining the fold now will benefit from that upside.
Q: Do you believe this level of consolidation is good for GI?
PS: Consolidation is inevitable and it’s not unique to GI. Large aggregators such as CVS and UnitedHealth Group create a trickle down effect across the spectrum. The entire healthcare industry is consolidating.
When hospitals in a certain region organize themselves to become larger health systems, it creates a risk for independent practices by impacting the referral network. In this environment, the consolidation of GI practices is necessary to remain independent for the future. The question is not whether consolidation is good or bad for GI. The question we must ask is how we make things better for GI.
In the 1990s, physician practice management companies tried to consolidate medicine. The reasons were similar — fragmentation, better contracts and so on. But PPMs failed badly, and it left a lot of debris. As the industry consolidates again, we must learn from the past and aim to do it right this time. Getting PE in GI wrong could have too high of a cost.

_

Written by Eric Oliver | December 23, 2019  |  Originally published on Becker’s GI & Endoscopy

Our new book Private Equity in Gastroenterology – Navigating the Next Wave is still available for download. Here was the best compliment we got to date: “I need my entire board to read this!”
downloadnow
18 Nov 2019

Cologuard® plans to capture 40% market share. 21 takeaways from Exact Sciences Q3 2019 Earnings Call

Did you listen to the latest quarterly earnings call of Exact Sciences on October 29th? It was insightful.
In Q3 2019, Exact Sciences screened 456,000 people with Cologuard® with over $290 million in revenues. In the last five years, the company screened more than 3 million people.
They are now ready to capture at least 40% of the US colorectal cancer screening market (currently they are at 5%).
These notes are based on remarks by Exact Sciences Chairman and CEO, Kevin Conroy, the Chief Financial Officer, Jeff Elliott and President of Cologuard®, Mark Stenhouse.
21 Takeaways from Exact Sciences Q3 Earnings Call
1. Three priorities for 2019:

Powering Pfizer partnership

Enhancing Cologuard®

Blood based cancer diagnostic test

2. Over 180,000 physicians have ordered the Cologuard® test thus far. Over 3 million patients (456,000 people in Q3 alone) have been screened. New facility has capacity to screen 7 million patients per year.
3. Together with Genomic Health (acquisition in 2019), the company’s addressable market is $20 billion.
4. $35 million invested in R&D for pipeline projects:

Cologuard for age 45 and above

Cologuard 2.0

Liver cancer test

5. Exact Sciences sees “a clear path to Cologuard® cost per test of $100 or better.”
6. Last month, the FDA approved their label expansion providing access to Cologuard® for 19 million average risk unscreened Americans from ages 45 to 49.
7. Several national and regional payors lowered their coverage screening age for Cologuard® to 45 years, following the American Cancer Society guidelines update last year, including Aetna, CareFirst and Blue Shield of California.
8. Exact Sciences implemented Epic’s health IT platform. They hope to enable electronic ordering for a greater share of customers.
9. At ACG 2019, the company presented data on Cologuard® to show a five-point increase in specificity with new markers (92%), while maintaining similar level of sensitivity.
10. To validate the performance of an enhanced version of Cologuard®, the company initiated BLUE-C, a prospective trial.
11. Along with Mayo Clinic, the company initiated a 7-year, 150,000 patients prospective study called Voyage to evaluate Cologuard®’s impact on screening.
12.  The company will be presenting data at the Americans Association for the study of Liver Diseases, demonstrating superior performance of their liver test compared to the alpha-fetoprotein test.
13.  The company gave in a broad comparison among colonoscopy, Cologuard® and the FIT test:

> Colonoscopy –  highly accurate but low patient-friendly test

> Cologuard® – high accuracy and high patient friendliness

> FIT test –  lower performance yet high ease of use of the patient’s part

14. The first time a blood-based cancer test would potentially be in the US Preventative Services Task Force guidelines would be in the 2026 to 2027 time-frame.
15. According to the company, 96% of Cologuard®’s patient population is able to receive Cologuard® without any cost share (i.e., a $0 co-pay).
16. The company said the re-screening business is a growing opportunity and would be a sizable business next year.
17. According to the company, 50% of people who get a Cologuard® test have never been screened before. With 19 million Americans in the 45 to 49 age group and about 35 million Americans in the older age group that have never been screened, this market is going to grow and it’s going to continue to grow at a steep pace.
18. To date, the company only captured about 5% of the addressable market (total available patients per physician). According to the company, there are about 300 patients on average per physician that could use Cologuard® today.
19. With electronic ordering, a physician orders an average at least 20% more than those on traditional fax orders.
20. A blood-based test is likely to model as an annual test and is likely to be priced at one-third of the cost of a Cologuard® test today.
21. The company is focused on bringing a lower-cost approach to market for people who refuse both Cologuard® and colonoscopy.
References: 
1) Exact Sciences Corp (EXAS) Q3 2019 Earnings Call Transcript (The Motley Fool)
2) Exact Sciences Investor Relations – Quarterly Results
3) Exact Sciences Third-Quarter 2019 Earnings Call Presentation

_

By Praveen Suthrum, President & Co-Founder, NextServices. 

Our new book Private Equity in Gastroenterology – Navigating the Next Wave is still available for download. Here was the best compliment we got to date: “I need my entire board to read this!”
downloadnow
12 Nov 2019

GI consolidation in 2019: PE and other deals thus far

Towards the end of 2018, we saw two back-to-back PE platform announcements: The GI Alliance (by Texas Digestive Disease Consultants) and United Digestive (by Atlanta Gastroenterology Associates). That seemed to have laid the ground for deals in 2019.
2019 was a busy year for GI consolidation. Sometimes we don’t realize the pace of activity unless we look at it all at once. Download the infographic to view GI consolidation from 2016 until end of 2019 all at once.

downloadinfographic

Here’s the list:
February 2019: Gastro Health acquiring Gastroenterology Specialists, continuing Florida expansion efforts — 4 insights (Becker’s ASC)
April 2019: Birmingham health group acquired by Miami-based Gastro Health (Birmingham Business Journal)
May 2019: $130M private equity deal to unite 3 GI practices, create 7th largest group in US (Becker’s ASC) – * 4th PE-funded GI platform
July 2019: Illinois Gastroenterology Group joins the GI Alliance (PR Newswire) 
July 2019: Covenant partners with Arizona specialty clinics (Nashville Post) 
August 2019: Physicians Endoscopy, Capital Digestive Care team up to create management platform (Becker’s ASC) – * Alternative to PE funded platforms
September 2019: GI Alliance partners with Southeast Texas Gastroenterology Associates — 4 insights (Becker’s ASC)
September 2019: Gastro Health acquires Puget Sound Gastroenterology, a premier provider serving the Seattle area (Yahoo Finance) 
October 2019: Arizona Digestive Health joins GI Alliance (PR Newswire) 
October 2019: GI Alliance forms 2 partnerships in 5 days — Adds Texas GI partner (Becker’s ASC) 
November 2019: Indianapolis Gastroenterology and Hepatology joins GI Alliance (PR Newswire) 
November 2019: United Digestive expands in Georgia, partners with the Center for Digestive & Liver Health (Business Wire)
November 2019: GI Alliance partners with Amarillo Endoscopy Center — 3 insights (Becker’s GI & Endoscopy)
November 2019: Gastro Health establishes platform for growth in the Mid-Atlantic through acquisition of Gastroenterology Associates of Northern Virginia (Gasto Health website)
December 2019: Peak Gastroenterology acquired by Varsity Healthcare Partners — 4 insights (Becker’s GI & Endoscopy)
December 2019: GI Alliance expands into a 6th state with GastroArkansas (GI Alliance website)
December 2019: GI Alliance acquired Lubbock Digestive Disease Associates and South Plains Endoscopy Center, further expanding its presence in Texas (Becker’s GI & Endoscopy)
January 2020: Gastro Health makes 3 acquisitions, including 2nd Virginia practice (Becker’s GI & Endoscopy)
Expect more announcements in the coming weeks and months. My sources tell me there are at least 16-20 deals in the works.

_

By Praveen Suthrum, President & Co-Founder, NextServices. 

Our new book Private Equity in Gastroenterology – Navigating the Next Wave is still available for download. Here was the best compliment we got to date: “I need my entire board to read this!”
downloadnow
[Free Ebook]
[Free Ebook]
[Free Ebook]
[Free Ebook]
[Free Ebook]
[Free Ebook]
[FREE GUIDE]
[FREE GUIDE]
[HOW TO GROW YOUR LAB THROUGH REFERRALS]
[HOW TO GROW YOUR LAB THROUGH REFERRALS]
[Adenoma Detection Rate Infographic]
[Adenoma Detection Rate Infographic]
[Referrals: Your Most Powerful Network]
[Referrals: Your Most Powerful Network]
[The Ultimate Guide To Boost Your Online Ratings And Grow Your Patient Volume]
[The Ultimate Guide To Boost Your Online Ratings And Grow Your Patient Volume]
[The Ultimate 13-Point Checklist To Increase Patient Volume]
[</span></span></span></span></span></span></span></span></span></span></span></span><span style="font-family: Lato;"><span style="font-size: 20px;">The Ultimate 13-Point Checklist To Increase Patient Volume</span></span><span style="font-family: Lato;"><span style="font-family: Lato;"><span style="font-family: Lato;"><span style="font-family: Lato;"><span style="font-size: 20px;">]
The Handy AR Bundle - 4 pre-designed templates to help you get paid faster]
[ </span></span></span></span></span></span></span></span></span><span style="font-family: Lato;"><span style="font-size: 20px;">The Handy AR Bundle - 4 pre-designed templates to help you get paid faster</span></span><span style="font-family: Lato;"><span style="font-family: Lato;"><span style="font-family: Lato;"><span style="font-family: Lato;"><span style="font-size: 20px;">]