High-performance clinical teams speak softly

The advantages of speaking softly

I started thinking about the constraints on eClinical technology for decentralized clinical trials and patient-centric product development.

The best planned patient-centric trial will not succeed if the data quality is poor at the sites.

When a CRA on the team is disgruntled, it is infectious. Speed and efficiency in your clinical operations team does not matter even if you suck it up and move on.  The bad feelings and lack of collaboration are a net loss.

Learning teamwork from large jazz ensembles

I am a serious amateur musician. I play saxophones, clarinet and I’m the contractor in the JP Big Band.

It’s been almost a year since we performed – with COVID.

Experienced wind instrument musicians know that when you play pianissimo, you can play faster. When you play softly, your intonation is better.   If you play softly with good intonation, then you can hear the other musicians in the ensemble.   When you hear the other musicians in the ensemble, then you can play better as a group.   An ensemble that plays softly with good intonation sounds better.   It sounds ‘tight’.     Playing softly with good intonation together as an ensemble, enables a wider dynamic range.   Wider dynamic range means that the entire group can be really pianissimo or totally forte-fortissimo.

The downside of playing loud

On the other hand, if you play loud, you do not hear the other musicians.   Playing loud creates stress on your body and brain.  The stress wears you out and causes more stress because you are never sure you will hit that note or make that phrase.   The physical and mental stress caused by playing loud influences everyone around you, not just your own mind and body.

Let’s apply the idea of playing softly to collaborating with other people.

When you speak softly, people listen better.   You can deliver your message more effectively when people listen to you without feeling threatened.    If you speak softly with clear messages, you can hear the other people in your group.     A group that speaks softly sounds better.  It sounds ‘tight’.   A group that speaks softly can achieve a wider dynamic range of response because the group is not challenged by listening issues.

A wider dynamic range enables a group to respond faster and more effectively to problems and changes, because people are all talking at the same time in a cacophony of sound.

The downside of being loud in a clinical trial operations team

On the other hand, if you talk loud, you do not hear other people.  You only hear yourself.  Talking loud creates stress on your body and brain.  The stress wears you out and causes more stress because you are never sure you explained yourself properly   The physical and mental stress caused by speaking loud influences everyone around you, not just your own mind and body.

The benefit of speaking softly with other people in the clinops team

Speaking softly goes beyond stress reduction and improved communications.       It enables you to build a much stronger core for the entire business / operation. Speaking softly has additional benefits:

– Makes it easier to confirm facts instead of based on authority and loudness.
– Makes it much easier to debate evidence
– When everyone speaks softly no one is an absolute authority on anything. The boss and the newest sales person on the team have equal input.
– Speaking softly enables the team to generate multiple hypotheses
– You don’t get too attached to an idea and start yelling about how good it is because it is, after all, your idea.

10 free ways to reduce risk in your medical device clinical trial

You cannot outsource quality in your medical device clinical trial

Collecting low-quality data means that your trial is likely to fail. You will not be able to prove or disprove the scientific hypothesis of your medical device clinical trial. You will have wasted your time.

You cannot outsource quality, you have to build it into the trial design


How to ensure patient adherence in decentralized clinical trials

With COVID-19, it is challenging to physically visit patients in clinical trials.

Life science companies are increasingly  turning to decentralized clinical trial models.

With 10X more data from patients and their connected devices, how can we assure patient adherence to the clinical protocol

Are we discovering new opportunities or forgetting old lessons learned?

In this post, we will show how to ensure patient adherence by understanding the difference between boundaries and rules


How to get digital health apps to work together – the power of simplicity

Sunrise off the coast of the Dead Sea in Israel

We are using too many buzzwords to defeat SARS-COV-2

Original published on Medium.com

The LA Freeway model of clinical monitoring

A freeway paradigm helps explain why onsite visits by study monitors don’t work and helps us plan and implement an effective system for protocol compliance monitoring of all sites, all data, all the time that saves time and money.

But first – let’s consider some  special aspects of clinical trial data:

Clinical trial data is highly dimensional data.

Clinical trial data is not “big data” but it is highly-dimensional in terms of variables or features of a particular subject.

Highly dimensional data is often found in biology;  a common example of highly dimensional data in biology is gene sequencer output. There are often tens of thousands of genes (features), but only tens of hundreds of samples.

In medical device clinical trial, there may be thousands of features but only tens of subjects.

Traditional protocol compliance monitoring uses on-site visits  and SDV  (source document verification) that requires visual processing of the information at the “scene”.   Since the amount of visual information available at the scene is enormous,  a person processes only a subset of the scene.

Humans focus on the interesting facets of a scene ignoring the rest. This is explained by selective attention theory.

Selective attention.

Selective attention is a cognitive process in which a person attends to one or a few sensory inputs while ignoring the other ones.

Selective attention can be likened to the manner by which a bottleneck restricts the flow rate of a fluid.

The bottleneck doesn’t allow the fluid to enter into the body of the bottle all at once; rather, it lets the fluid to enter in certain amounts depending on the flow rate, until all of it has entered the bottle’s body.

Selective attention is necessary for us to attend consciously to sensory stimuli in such a way that we will not experience sensory overload. See the article in Wikipedia on Attenuation theory.


How to swim in the cold water of hybrid trials

(The water in the pool in Cascais in October was < 12 degrees)

There are over 135 COVID-19 vaccine candidates in the pipeline at the time of writing this post

Although there are always personal, political and emotional preferences, we should probably not select a clinical data management platform like we choose villas in exotic vacation spots.

The reality is that simplification of the protocol and the study conduct will have a much bigger impact on time to completion than choice of a particular eClinical platform.

COVID-19 has much wider ramifications for the clinical trial industry beyond the next 12-18 months.

COVID-19 signals a driving concern to use technology to acquire valid data from clinical trials in the fastest way possible.

Virtual clinical trials

One approach is to recruit and collect data from patients online in what is called a virtual trials model.

There is a gigantic amount of buzz on virtual clinical trials because of COVID-19. The idea is to go direct to patient with digital tools and engagement. This is theoretically supposed to cut out all the friction for recruitment and and overhead of research sites.

With all the buzz on virtual trials, no one seems to know how many virtual trials are actually being conducted. (There is a well-known axiom that technology adoption is inversely proportional to PR).

It may be that in the future, fewer than 5% of trials would remain all paper. Maybe 5%, will go fully virtual.

Hybrid clinical trials

The action will be in the middle in “hybrid”. Trials are moving away from paper, “virtualizing” a process here, a step there. I am looking to see how much of this is taking place, and to what extent COVID-19 accelerates it, and which processes and steps are virtualizing the fastest.

Based on observing 12 hybrid trials running right now on the flaskdata.io platform, today, I can assert that hybrid trials are complex distributed systems with a whole new set of challenges that make the old site/investigator-centric model look like a stroll in the park.

Connected medical device vendors understand the value of merging patient, clinical and device data into real-time data streams.  Once you have a real-time data stream, you can use real-time automated monitoring.

However, bringing merged real-time streams of patient, device and clinical investigator data into the domain of mainstream drug trials is hugely challenging because the data sources are highly heterogenous.

Combining patient outcome reporting with mobile apps, passive data collection from wearables and phones and site monitor data entry creates a complex distributed system of data sources.   Such a complex distributed system cannot possibly be monitored by assuming that there is a single paper source document. That assumption is no longer valid.

Observability of events

We need to correlate and group events across different systems, applications and users. We need to achieve low level observability of a patient while attributing it to top level cohorts and sites in the study.

This is especially difficult since the different EDC systems and digital appliances were not designed for monitoring.

You can see a presentation here on using pivot tracing for dynamic causal monitoring of distributed systems. This is work done by Jonathan Mace while he was a PhD student at Brown.   The work was done on HDFS but the concepts are applicable to virtual and hybrid clinical trials.

flaskdata.io  is a cloud platform that automates detection of deviations in clinical trials using these general concepts.

Flask provides an immediate picture of what’s going on. The picture can then be grouped by patient, physician, principal investigator, project managers all the way up to the  VP Clinical and CEO. In political terms, you might say that  we  democratize the process of observing clinical trials using metrics and automation.

Automation can be used to speed delivery of valid data to decision makers in clinical trials. The basic idea is to monitor with alerts.  Some of the ideas from the talk:

Alerts are metrics over/under a threshold

Alerts are urgent, important, actionable and real
In the world of alerts, symptoms are better than causes
Validate: Are we calculating the right metric?
Verify: Are we calculating the metric right?

Do it Fast. fast. fast.

You can see my talk here: Automated Detection and response for clinical trials.

Originally published on medium.com

Home alone and in a clinical trial

1 in 7 American adults live alone

What is atherothrombosis?

If you are age 40 to 60 and live alone, your CV system is at high risk

Can social networking mitigate the risk of living alone?

Social networks detach people from meaningful interactions with one another

We expect more from technology and less from each other

Digital technology enables real interactions with real primary care teams.

This was first published on Medium at Can digital mitigate the risk of living alone

Hack back the user interface for clinical trials

As part of my campaign for site-coordinator and study-monitor centric clinical trials; we first need to understand how to exploit a vulnerability in human psychology.

As a security analyst, this is the way I look at things – exploits of vulnerabilities.

In 2007, B.J. Fogg, founder and director of the Stanford Behavior Design Lab taught a class on “mass interpersonal persuasion. A number of students in the class went on to apply these methods at Facebook, Uber and Instagram.

The Fogg behavior model says that 3 things need to happen simultaneously to initiate a behavior: Motivation (M), ability (A) and a trigger (T).

When we apply this model to patient-centric trials, we immediately understand why patient-centricity is so important.

Motivation – the patient wants therapy (and may also be compensated for her participation).

Ability is facility of action. Make it easy for a patient to participate and they will not need a high energy level to perform the requisite study tasks (take a pill, operate a medical device, provide feedback on a mobile app).

Without an external trigger, the desired behavior (participating in the study in a compliant way) will not happen.  Typically, text messages are used to remind the patient to do something (take treatment or log an ePRO diary).  A reminder to log a patient diary is a distraction; when motivation and ability exceed the trigger energy level, then the patient will comply. If the trigger energy level is too high (for example – poor UX in the ePRO app) then the patient will not comply.    Levels of protocol adherence will be low.

The secret is designing the study protocol and the study UX so that the reminder trigger serves the patient and not the patient serving the system.

People-centric clinical trials

Recall – that any behavior ( logging data, following up) requires 3 things: motivation, ability and a trigger.

A site coordinator can be highly motivated. She may be well trained and able to use the EDC system even the UX is vintage 90s.

But if the system doesn’t give anything back to her; reminders to close queries or to follow-up are just distractions.

The secret is designing the study protocol and the study UX so that the reminder trigger serves the CRC and CRA and not the CRC, CRA are serving the system.

When we state the requirement as a trigger serving the person – we then understand that it is not about patient-centricity.

It is about people-centricity.



A better tomorrow for clinical trials

A better tomorrow – Times of crisis usher in new mindsets

By David Laxer. Spoken from the heart.

In these trying days, as we adjust to new routines and discover new things about ourselves daily, we are also reminded that the human spirit is stronger than any pandemic and we have survived worse.

And because we know we’re going to beat this thing, whether in 2 weeks or 2 months, we also know that we will eventually return to normal, or rather, a new normal.

In the meantime, the world is showing a resolve and a resilience that gives us much room to hope for a better tomorrow for developing new therapeutics.

However, these days have got us wondering how things might have looked if clinical trials were conducted differently. It’s a well-known fact that clinical trials play an integral role in the development of new, life-saving drugs, but by the time they get approved by the FDA it takes an average of 7.5 years and anywhere between $150m-2bn per drug.

Reasons for failure

Many clinical studies still use outdated methods for data collection and verification: they still use a fax for crying out. They continue to manually count leftover pills in bottles, and still rely on patients’ diary entries to ensure adherence.

Today, the industry faces new challenges to recruit enough participants as COVID-19 forces people to stay at home and out of research hospital sites. 

Patient drop-outs, adverse events and delayed recording of adverse events  are still issues for pharma and medical device companies conducting clinical research.  The old challenge of creating interpretable data to examine safety and efficacy of new therapeutics remain.

The Digital Revolution:

As hard as it is to believe, the clinical trial industry just might be the last major industry to undergo digital transformation..

As every other aspect of modern life has already been digitized, from banking to accounting to education now, more than ever, is the time to accelerate the transition of this crucial process, especially as we are painfully reminded of the need for finding a vaccine.  Time is not a resource we can waste any longer.

Re-imagining the future

When we created FlaskData we were primarily driven by our desire to disrupt the clinical trial monitoring paradigm  and bring it into the 21st century — meaning real-time data collection and automated detection and response. From the beginning we found fault in the fact that clinical trials were, and still are overly reliant on manual processes  and this causes unacceptable delays in bringing new and essential drugs and devices to market. These delays, as we are reminded during these days, not only cost money and time, but ultimately they cost us lives.

To fully achieve this digitization it’s important to create a secure cloud service that can accelerate the entire  process, and provide sponsors with an immediate picture and interpretable data without having to spend 6-12 months cleaning data.  This is achieved with real-time data collection, automated detection and response and an open API that enables any healthcare application to collect clinical-trial-grade data and assure patient adherence to the clinical protocol.

Our Promise:

It didn’t take a virus to make us want to deliver new medical breakthroughs into the hands that need them most, but it has definitely made us double down on our resolve to see it through. The patient needs to be placed at the center of the clinical research process and we are tasked to reduce the practical, geographical and financial barriers to participation. The end result is a more engaged patient, higher recruitment and retention rates, better data and reduced study timelines and costs.

The Need For Speed

As the world is scrambling to find a vaccine for Corona, we fully grasp 2 key things: 1) Focus on patients and 2) Provide clinical operations teams with the ability to eliminate inefficiencies and move at lightning speed. In these difficult times, there is room for optimism as it is crystal clear, just how important it is to speed up the process.


Social Distancing

In this period of social distancing, we can only wonder about the benefits of conducting clinical trials remotely. We can only imagine how many trials have been rendered useless as patients, reluctant to leave their houses have skipped the required monitoring, have forgotten to take their pills and their diary entries have gotten lost amidst the chaos.

With a fully digitized process for electronic data collection, social distancing would have no effect on the clinical trial results.

About David Laxer

David is a strategist and story-teller. He says it best – “Ultimately, when you break it down, I am a storyteller and a problem solver. The kind that companies and organizations rely on for their brand DNA, culture and long-lasting reputation”.


Reach out to David on LinkedIn

7 tips for an agile healthtech startup

It’s a time when we are all remote-workers.   Startups looking for new ways to add value to customers.  Large pharmas looking for ways to innovate without breaking the system.

To quote Bill Gates from 25 years ago. Gates was asked how Microsoft can compete in enterprise software when they only had business-unit capabilities.  Gates was quoted as saying that large enterprises are a collection of many business units, so he was not worried.

The same is true today – whether you are a business unit in Pfizer or a 5-person healthtech startup

Here are 7 tips for innovation in healthcare

1. One person in the team will be a technical guru, let’s call him/her the CTO. Don’t give the CTO admin access to AWS.  He / she should not be fooling around with your instances. Same for sudo access to the Linux machines.
2. Make a no rule – No changes 1 hour before end of day. No changes Thursday/Friday
3. Security – think about security before writing code.  Develop a threat model first. I’ve seen too many startups get this wrong.   Also big HMOs get it wrong.
4. Standards – standardize on one dev stack – listen to the CTO but do not try new things. If a new requirement comes up, talk about it, be critical, sleep on it.    Tip – your CTO’s first inclination will be to write code – this is not always the best strategy – the best is not writing any code at all.  You may be tempted to use some third-party tools like Tableaux – be very very careful.   The licensing or the lack of multi-tenancy may be a very bad  fit for you – so always keep your eye on your budget and business model.
5. Experiment – budget for experimentation by the dev team. Better to plan an experiment and block out time/money for it and fail than get derailed in an unplanned way.  This will also keep things interesting for the team and help you know that they are not doing their own midnight projects.
6. Minimize – always be removing features.  Less is more.
7. CAPA – (corrective and preventive action) – Debrief everything.  Especially failures. Document in a Slack channel and create follow-up actions (easy in slack – just star them).