It starts off with the historical context: Dating back to the 19th and 20th centuries, when infections and surgeries ruled the medical wards, our healthcare system was originally designed for acute care, delivered in discrete episodes. Now, with chronic illnesses that are treatable and nonlethal, our system lacks the proper means to get after the day to day interventions around lifestyle, medication management, behavior change, and so on. Enter the smartphone, smart pillboxes, Internet of Things, apps…you’ve heard this stuff before.
The rest of the paper is the good stuff. Kvedar and colleagues systematically go through a handful of leading disease states and provide specific examples of digital therapeutics that have shown promise. They’ve done a nice job of selecting a balanced roster of companies; these “digital therapeutics” showcase the diversity of today’s digital health market across product offerings, market strategy, clinical and technological rigor, hardware vs. software, and more. Below is a summary table of the companies or programs featured:
|Initiative (Company)||Summary Description||Notes on Market Approach|
|Diabetes||Text2Move (Partners)||Automated, personalized SMS to encourage activity||Pilot program at Partners Healthcare|
|BlueStar (WellDoc)||Personalized blood glucose testing system||FDA cleared, available by physician prescription only|
|Prevent (Omada)||Online coaching course for prediabetics||Employer/employee-targeted solution|
|Glooko||Glucometer data platform to engage Pts and MDs||DTC, provider, payer, employer|
|RTM (Podimetrics)||Early detection of diabetic foot ulcers||Still in pilot stage (provider and payers)|
|Respiratory||Propeller Health||Inhaler-based sensors and environmental data feed pt app and MD website||4 FDA clearances; partner with device manufacturers; employer, payer, system users|
|SmartQuit (2Morrow)||6 month+ smoking cessation app with||DTC (freemium) and employer/payer sponsored|
|COPD Navigator/ Asthma Health (LifeMapSolutions)||App for COPD/Asthma management (PRO, external data, med reminders, etc)||DTC (free), employer, payer, or system sponsored|
|Craving2Quit (Claritas MindSciences)||3 week program: App, online community, video support groups||DTC or employer sponsored|
|Physiological and Psychiatric||Jintronix||MSFT Kinect-based rehab program for stroke patients||FDA Cleared; MD-prescribed (early stage company)|
|Project EVO (Akili)||New neurological testing and intervention||Still in research phase|
|MoodGYM (Australian National University)||Digital Cognitive Behavioral Therapy program||Free/DTC online|
|Cardiovascular||AliveCor||Mobile ECG and companion app for patients and MDs||Provider-focused, some payer sponsorships|
|Wireless BP Cuff (Withings, iHealthLab||Wearable with cloud-based app for patients and doctors||Both companies’ products are FDA-cleared; DTC and sponsored packages available|
|Sonde Health||Voice-based monitoring for neurological/physiological changes||Still in research/pilot phase|
|Medication Adherence||Discover (Proteus Digital Health)||Ingestible pill, App, and portal for MD/Researchers||FDA Cleared; early stage/pre-market, with early delivery system and pharma partners|
|MediSafe||Adherence App and companion resources||DTC Free; employer/ payer/system sponsored|
|Mango Health||Gamified adherence App||DTC Free; employer/payer sponsored|
|MemoText||Multimodal reminder app (phone, email, SMS, etc)||Pilot stage; have employers, payers, and pharma partners|
Again: suffice to say if you like this chart you will love the actual paper. The descriptions are concise and detailed at the same time, with some outcomes data peppered in for good measure. Outcomes, good measure….get it?
The only glaring omission throughout the paper: Zero mention of the caregiver or family’s role in successful digital interventions. As far as oversights go, this is a ‘two-fer’:
- First of all, chronic diseases are deeply rooted in lifestyle, diet, activity, habits, behaviors, which are in turn entangled in the social and communitarian webs that we all live in.
- Secondly, this is a ripe opportunity to harness the unique power of digital tools, which enable sharing, education, goal-setting, gamification, and other approaches that can bring people together.
Analysis and Commentary:
- Is digital health ready for the provider market (or vice versa)? Not really.
- Are payers convinced of a long term ROI? Not really.
- Are consumers willing to pay for this stuff? Not really.
We’ve been told that Digital Health is the Wizard of Oz, but we lack a clear yellow brick road to lead us there. Few of the vendors mentioned are pursuing channel strategies (e.g. partnering with Analytics or EHR vendors). Many are targeting employers, even though it’s clear that the verdict is out on the long-term effectiveness of wellness programs, under which many of these lifestyle-oriented interventions fit. And clearly, looking at the above chart, we’re still in a research phase in some areas.
What’s also evident is that comparing these companies to one another is a fool’s errand. Within just diabetes for example, there are self-management apps, prescribed therapeutics, hardware devices, data analysis platforms, education and coaching efforts, and interventions for acute symptoms of the disease. At one end of the spectrum there are free tools in the app store; on the other we’ve got FDA-cleared medical-grade therapeutics available by prescription only. One serves a population who has not yet developed diabetes; another targets those who have got it so bad their limbs are falling off.
Not mentioned explicitly in the paper: What will happen to the non-specialized digital health players? There is a glut of care management apps (HealthLoop, CareSync, PatientIO, Twine, Conversa, RoundingWell, etc.) that are intentionally abstaining from specializing by disease state. The broad vs. deep approach has its own merits – in particular, they’re attractive to health systems who want to design their own programs (e.g. here and here).
What Do We Talk About When We Talk About #DigitalHealth?
In recent conversations with a digital health executives, a common challenge arises. As a digital health startup today, it’s very tough to compare oneself to any other company – for better or for worse. When it comes to talking about your own brand, there isn’t a clear sense of how to do it effectively, or to whom you should even be talking to.
On one hand, making digital therapeutics easier to use for doctors has become a priority. This entails smoothing out workflow compatibility within and beyond the walls of an office practice, or striking the right balance between deep and broad when it comes to EHR integrations (though inextricably linked, it’s safe to say that the digital health and health IT industries have been moving together but separately.) This approach is fine when it comes to provider customers who are getting pitches from every direction.
On the other hand, looking at the trade winds, developing an easy-to-use consumer product, building a trusted brand, and developing an effective direct to consumer (DTC) market strategy is a tough challenge. For companies with FDA-cleared products, I wonder how much Theranos and similar cautionary tales (Lumosity, 23&Me) have deterred them from talking about themselves too loudly and proudly to consumers. The consumer-oriented stuff also matters when it comes to talking to investors, who have been conditioned to search for the next “uber for healthcare.”
Closing Thoughts: Market Strategy Matters, Even if it Doesn’t Matter Now
“[W]e can envision delivering these behavioral interventions to whole populations in the same way we fluorinate our drinking water and deliver vaccines on a large scale.”
– Kvedar et al., Nature Biotechnology, Volume 34 Number 3, March 2016
It seems inevitable that digital health interventions will become an embedded in our care delivery system. The question is not if, but when. For now, these vendors can swarm freely between payers, hospital systems, retail pharmacy shelves, and elsewhere. There is no standardized approach, no explicit incentive program being mandated by Washington, and no “killer app” driving demand. Any customer is always a good customer.
Looking to tomorrow, the writing on the wall is becoming somewhat legible.
- We should expect more regulation, from different agencies.
- We should expect (or wish for) a greater degree of compatibility and interoperability between devices, apps, and enterprise software.
- Health systems will increasingly look to vendors as partners rather than suppliers.
- There will be a shift towards predictive analytics and algorithm ownership.
- Despite the frothy headlines around value-based care, reimbursement for upstream conditions (mental healthcare, nutrition, lower back pain, etc.) remain unlikely to get a lot of funding outside of (perhaps) the employer market, who have some money to blow.
We’re very clearly in an experimental phase of market growth. There are a handful of companies out there who have built more sophisticated solutions than a commodity cloud-based app, with FDA clearances, RCT-backed outcomes data, technology patents, etc. Given they’re in the exception, they’re not sure what comes next as they begin to grease their sales and marketing gears in preparation to go to market.
Digital Health companies would be well-served to keep one eye fixed on the day to day happenings on this dynamic landscape. As the industry climbs the learning curve, companies should be able and willing to learn from others’ mistakes and successes across product offerings, branding campaigns, regulatory activity, and go to market strategies.