This is the unedited transcript for webinar: Product Development Ecosystems: Defining Your Value in the Digital Age. To watch this presentation in full, click here.
Hello everyone and thank you for attending today’s webinar, Product Development Ecosystems: Defining Your Value in the Digital Age. I’m Heather Thompson. I’m senior editor for Medical Design and Outsourcing. Before I begin, we’re just going to cover a few housekeeping items.
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Today we’re going to be talking about how product development efforts can fit in the ecosystem of healthcare. Our experts today are Bill Evans and Yechiel Engelhard. Bill is the SVP of innovation at Bridge Design, a Ximedica company based in San Francisco. He is a respected author and speaker on design and innovation. Welcome, Bill.
Our second speaker is Yechiel. He is the founder and CEO of Gecko Health Innovations, which was recently acquired by Teva. He has spent over 15 years as an entrepreneur in healthcare technology space, and he is an award winning physician with clinical experience both in small and large healthcare systems. I’m really pleased to have both of you here today to provide some insight in how to improve healthcare outcomes, reduce costs, and increase a product’s chance of success in the market. Over to you, Bill.
Good morning, everyone. I’m Bill Evans, VP of Innovation at Ximedica. Our specialty as an FDA registered company, is developing regulated medical devices for our clients. Our work is leading edge. It’s about physical devices and digital technologies coming out of labs like MIT and Stanford for start ups, all the way up to working for fortune 20 companies around the globe from Denmark to Cincinnati. Some of you may also know me as the founder of Bridge Design in San Francisco and, as Heather said, we are now a proud member of the Ximedica family.
Today I’ll be talking about ecosystems. Why you might want to consider them and how to go about defining and creating them with the most value to your customers and users. This slide shows just a few of these ecosystem devices we’ve worked on. Upper left is the care tracks, which we did for Gecko and this is an ecosystem product for respiratory diseases and it will be spoken about in greater detail today by Yechiel, of course.
To the right is a product we did for Helius. We designed wearable physio-therapy device that stimulates brain neuroplasticity to the tongue, and it’s to help treat the symptoms of brain disease and trauma. We’ve done many products to healthcare and patients, patients with chronic disease, for instance, that include ecosystem aspects to their design. Our job used to be about designing individual products. Today, it’s often about designing ecosystems. Why is this the case? There are, of course several drivers, but cost is the main one.
The CDC stated in 2015 that as a nation, we spend over 80% of our healthcare dollars in the treatment of chronic disease. It’s, of course, pressure in the developing world, too. They’ve got much less money available to pay for healthcare, yet their population is aging and demanding improved healthcare, too, so, this cost issue is global.
Another driver, is of course, improving outcomes. Hopefully doing this while improving the quality of life of patients and, of course, the quality of life for busy healthcare professionals, too. We need to consider ecosystems not just because of this oft quoted virtuous duet of reduced costs and improved outcomes. A third important pressure industry is that if patients, providers and payers have a choice, and this is going to be an increasingly better informed choice, they’re going to take the solutions from companies that offer the best overall outcome and cost, not necessary those who have the best individual drug therapy or diagnostic.
A high value ecosystem surrounding your physical products can considerably improve your company’s competitiveness. What really matters is the outcome and cost over the patient’s entire treatment, and, of course ultimately their life. Now, whether it’s a joint replacement or preventing a costly hospital readmission, now it’s also about building loyalty to your products in much the same way that the big smart phone companies, like Apple and all the Android players, build an ecosystem of other devices and must have services to wed their users to their brand. Also, sometimes it’s not that we lack solutions, it’s that patients or healthcare professionals either don’t embrace them or don’t know the best thing to do at that very moment when actually would really help.
For instance, if a patient has an asymptomatic condition, such as in the early stages of a chronic disease like diabetes or sleep apnea, when the symptoms aren’t necessarily very noticeable yet, these patients adherence to their treatment, such as taking ad rug or using a c-pathogen, is typically as low as 50 percent, yet, as many of you are aware, if these patients stuck to the treatment today, it would have significant impact on the quality and duration of their lives and, of course, to the overall cost of their healthcare.
What do ecosystems look like and how do you go about uncovering one that will be valuable to users of your product? Yechiel will be speaking later in this webinar in more detail about care tracks, so let me use a hypothetical example that’s been chosen to illustrate the breadth of who will be effected and how it might work. It’s set only just slightly in the future.
Let me use the example of Sue, a fictional but archetypical consumer of healthcare. She’s been living with Type 1 diabetes for 20 years. She’s a busy mom and she’s now under pressure by her health plan to get her diabetes under control. The plan has referred her to a local health practice that just added the service of more closely managing people with diabetes. They want Sue to move from the very unconnected world of finger stick blood tests and multiple daily injections of insulin, to an integrated ecosystem product of an artificial pancreas that includes an app on her smartphone connecting an insulin pump and a continuous monitor. This is a first generation device, so it still needs Sue to input some information. For instance, her food intake. Now, Sue, is prepared to give the new system a try, but she’s wondering, “Can I trust this new way of doing it? I’ll have to give up some of the tings I’m used to controlling.”
For the first time she has an app on her smart phone that she must run 24 hours a day and her phone is now life support. She’s got to wear stuff on her body, and she’s worried that this might advertise her diabetes to the world, especially when she’s wearing light clothing. Her diabetes is being managed by a busy doctor who’s just taken on prescribing this new therapy. It’s the first product that he’s worked on that gathers real time data from his patients. He’s worried that the decision to port software in the cloud that filters what he’ll see is not missing anything that he might need to take action on. The doctor is now compensated partially by how much money he saves the health plan, and of course, this requires a new way of thinking about his business.
The health plan itself is going up learning curve of working with patents in many different stages of the disease and, of course, with enumerable comorbidities, and it’s having to learn how to use, how to combine historic big data with real time patient data to optimize the treatment for Sue today. Of course, researchers at the company that designed the artificial pancreas and academic researchers are interested in looking at the data to refine algorithms as well.
As we explore this ecosystem that could help Sue, it clearly gets pretty complicated pretty quickly. Sue, of course, as well as her healthcare providers, don’t want to make a project out of her disease. They all just want it to work as seamlessly and with as little effort and distractions as possible. How do we create an ecosystem around our medical devices to help us with this? There are 4 areas my colleagues and I at Ximedica consider critical in designing for these new complex ecosystems.
The first one is to understand the broad context of the disease and the stakeholders and probe to see where you can offer the most value. Your company cannot realistically be integrated across all aspects of the disease managed in ecosystem and that goes, of course, to whether your an entrepreneur in a health startup, or if you’re in a fortune 100 company. You need to research the people part of the system by digging deeply into the needs of the various stakeholders, like the patients, providers, and payers. You also need to understand the medical condition in the broadest context looking for opportunities to smooth the journey from illness to wellness, lowering overall cost and improving outcomes. For example, not just the replacement joints if you’re an orthopedics company. Not just the diagnostic result if you’re a monitoring company. Not just the cardio metabolic drug if you’re a pharma.
In the orthopedic joint manufacture example, they might look at building out an ecosystem that now includes specialized physical therapy apps for both patients and therapists, and perhaps a custom wearable around the cutoff to monitor much more specific aspects of physical therapy and adherence, and, of course, all in the service of lowering the overall costs to the health system and shortening the patient’s recovery time.
You need to determine the most valuable place for your stakeholders to get information or use the device. Don’t assume it’s an app or a wearable. It might be presenting data through an existing electronic health records. It might be a text to a nurse or a patient. Or, you might be using GPS tracking to take into account the context of where the patient is as well. Your supporting devices might be wall or bed mounted, not really a wearable. It’s got nothing to do with how cool the technology is, or how much information you can throw at people. It’s all about relevance. To be laser focused on what that person will find most useful at that moment of need.
Make sure you sweep away any clutter, highlighting the minimum information that is the highest value at that point in time. All too often medical informatics data is presented perfectly factually correctly, but in a way that makes it hard for users to cut to the chase. To make data more actionable, think hard about the hierarchy of importance. Look for ways to interrelate disparate types of data in an easy to understand graphical manner that assists people to recognize useful patterns and make it graphically elegant to draw people into looking at it in as uncluttered a manner as possible. As you optimize the value of the information device, use leverage the best practices in user centered design. This typically starts with the design research that I’ve been just talking about and gradually hones in on solutions through multiple prototype iterations with user feedback, of course, every step of the way. Nowadays, fortunately, it’s getting less expensive and time consuming to create more sophisticated simulations of both physical and virtual ecosystem products.
Secondly, you’ve got to cut through the hype of engagement and adherence and use the evidence based research. We’ve got to ask will my users use it, not simply can they use it. Research into human nature indicates that we’re going to be most successful when we meet people where they are, not where you might want them to be. We’ve got to move on from the finger wagging and yesterday’s healthcare, and rather than just simply making the path you’d like them to go down easy to use, it’s better to come round to the same side of the boulder as the people you’re trying to help, understand their needs and what drives them to be receptive to change and use those insights to help them push the boulder in a much better general direction. Of course, it’s not just the patients who have adherence issues. Doctors, nurses, family care givers, etc. will need to be cajoled and helped just as much as the chronically ill patients themselves.
The good news is that the evidence based science of behavioral psychology and behavioral economics can help us a lot here. 3 of the main things they suggest, 1 is understanding what the obstacles are to making the choice and then figuring out how to reduce those obstacles. Know what rewards are most likely to work and when. Our hint here is it’s got very little to do with the way people usually think about going [inaudible 00:14:17], a word that’s often bounded around in our industry. Then, it’s important to understand the value people place on familiarity. You’ll improve the chances that Sue will use her new artificial pancreas product, perhaps, by giving it some aspects of a retro look and feel that borrows from the way she’s used to managing her diabetes. It doesn’t follow that new and different is always best.
The third point is to choose the technology and design to be a slave to making your product get used and useful, again, not just be the cool and new thing that you think you’re offering or bringing that’s new. Think well beyond the craze of wearable bands. We’re just scratching the surface of what wearable means. Of course, as an industry, we’ve actually been implanting wearables inside our bodies for years in pacemakers and artificial joints. Remember that sometimes what you leave out that can matter the most. For Sue’s wearable technology, your team may be focused on what you feel is alluring that’s new and interesting for Sue, whereas Sue may be very worried about how large the product’s going to be and she might prefer you dumb it down a little and trade off to a minimal display, perhaps halve the drug volume in the pump, all so it doesn’t show as much beneath their clothes and, of course, beneath her party dress. This will all, perhaps, make her more willing to wear the product all the time, which is, of course, how it’s going to be most effective in treating her.
For other ecosystem products, it might mean cannibalizing or disrupting your own products to create the right ones. For many companies, this is a very hard thing to do. It’s a short statement, but actually a harder one to swallow. Look critically at your own, your team’s own skill set, that might well have matured in a different world. Figure out which piece of the jigsaw puzzle you’re missing, and then how can you incorporate those into your company and your structure of developing products such that such so you can meet these new ecosystem challenges. This may mean finding different kinds of partners, not just those you’re most familiar with. Of course, let’s plunder the consumer and tech world’s latest unregulated advances in hardware and software and figure out how to bring these into our regulated world as quickly and painlessly as possible. I was at hinge this year and those Oculus Rift goggles were being demonstrated by many people around with medical applications, particularly around training and so on, so, it’s quite interesting how quickly as an industry we can do this.
My 4th point is to understand how the FDA and the broader regulatory system effects your ecosystem offering. You might be trying to avoid having some of your ecosys developments be regulated, but most solutions to the really substantial healthcare problems we’re trying to tackle will probably require class 2 and above types of approval. This may not always be true for all informatics and wearables. Many FDA submissions get rejected first time, and, of course, remember the FDA is your partner and a key stakeholder, work with them closely right from the start to ensure that you’re one of those that gets quickly approved.
One of the things we are seeing is that many clients are creating road maps for their ecosystem roll outs that initially gives them a chance to put their toe in the water with less regulated offerings such as class 1 informatics. They go about carefully selecting partners and systems that can grow into the regulated world and understand that their plans also need to be fluid because, of course, once a product actually hits the market and competitors respond things, of course, change, because the real world does apply Darwinian like pressures on our technology and ideas.
In conclusion to my portion of this webinar, let me push this Darwinian metaphor. While digital healthcare is going to allow great new ecosystems to emerge, don’t forget the forces of natural selection. This new competitive landscape will speed up the rate of change with a brutal calling of products. To avoid becoming an inadvertent dinosaur, you’ll need to move quickly and wisely into this new environment to create and ecosystem right for your company.
Now, I’ll hand over to Yechiel for the Gecko story. Thank you.
Thank you very much, Bill. I’ll, next couple of minutes I’ll try to give an overview of the company, the product, how we get here and keep enough time for Q&A. I’ll try to speak most on the join that we did as a company developing the products, how we joined the Ximedica ecosystem and what benefit we got form this and a little bit about the business around it, as Bill mentioned. Looking at the patient, but we need to also to remember that we create a product that in the end will be used by the doctors, the insurance, the pharmaceutical companies that either buy the product itself or the [inaudible 00:19:31] that you can provide with this product.
As a company, Gecko Health, we started about 4 years ago. We were 2 guys out of MIT that started to look at different projects we worked on the student before. I was a physician in my previous life, and I worked on a few asthma developments that I did on my own with different proofs. My partner, Mark, had a background of electrical engineering, but also looked, from personal reasons on the asthma landscapes. When we started, some of the information that existed in the market already gave some signs that there is something that is missing that can collect all the different dots, specifically for patients with asthma, and following for patients with COPD. The main 3 posts that we found were about disease care, so, how we are coordinating the disease between the patient, the caregiver, the health care providers.
The 2nd was around medication management. We know that with any chronic disease, adherence is one of the main problems and we can find around asthma, sometimes even lower than 30 percent adherence for the medication. The last part is patient management, which entitles not just the way that the patient manage their day to day disease, but also how the patient remembers what they should do, how to bring the right information for the doctor, and for the doctor to make the right decision based on good information. The market back then, 4 years ago, there was enough information, enough data by studies research that showed that by connecting those dots, by having information about how the patient use the inhaler, when they use the inhaler, and providing more tools for the patient to self-manage themselves, we can really improve the outcome and reduce the cost for the system.
The product that we built, what I show here is the one that we launch about a year and a half ago, I’ll speak later a little bit how we get to this point, but the full product has 3 main parts. We have a censor, looks like a little cap that you can use on top of asthma and COPD inhalers. There is an app that we use by patients can caregivers who self-manage the disease and we have a dashboard, a web dashboard that can be used for disease management things to remotely have all the information all the right time.
The first part is the app itself. The app lets the patients, or the caregivers, can download directly from the app store, provide everything that we believe the patient might need to have as someone that wants to self-manage their disease, or a caregiver that’s managed someone else disease. There are few basic features like reminders to use medications or to remind you when you forgot to use medication, but on top of those basic features, we build other capabilities that support the patients in the day to day management. Those features include notifications about over use or under use of medications, different statistics to show the patients where they are according to their own goals. They can invite and share information with other caregivers or with their care team. We support different goal management. We have [inaudible 00:23:13] goals for the patient that they can achieve and establish different reward system in the app itself. Everything can be connected to as many people as you want. If you’re a parent and you have a few children, you can have as many profile as you want so you can control everything from one place. [inaudible 00:23:31] also create the hub for connect to all the sensors, so, basically, what you need is the phone in proximity to the sensor to connect information from the sensors through the phone to the cloud where we host all the information.
The next part is the part for the care team. All this information is stored on the cloud in the secure cloud as we established and can be shared with the disease management care team. This can be a nurse or the [inaudible 00:24:03] coach that can see all the information that was approved by the patient. The patient is still in control of all the information and there is a process of patient they need to approve what information can be shared with their care team and only this information will be shared and only by the person specifically that the patient allowed to see this information.
Another part that we working on right now and we currently already using is the population management dashboard that allow organization, health organization, to have the care board, you’re feeding entire population under their management and how different inputs that they can use in the project can influence a patient, so they can collate between the patient that are using the full system, to patients that are using just part of the system, patients with different intervention, different demographic, location, and so on and see how the program is actually affecting the patient.
The last part is the sensor itself. The sensor, as you see, designed as a small cap that can fit on top of the, most common inhalers on the market, so they are different devices. The most common one is shaped this way, it’s called an MDI metered dose inhaler and you can put it on top of the canister and you actually, the sensor every time you use the inhaler, and we added a few other features to make sure that we have very high portability of the information. We added different sensors that know that the amount of pressure that you put the right ones for this specific inhaler. We have another sensor to identify the fact that the inhaler is on, the cap is on the inhaler the right way and so want to make sure the information we collect is securely saved on the sensor and is actually measuring the way that you use the inhaler.
When we talk about a patient, so it’s also important for us to create the same experience for the patients where they can feel like they’re getting treated the same way they used to, as Bill mentioned Apple and the other tech companies, that we want to create an experience around it. Once a patient is getting into a health program that provide the care tracks, they will get an invite thorough their email that provide all the information they need about how to download the app, how to go through the process of the app, they will have a tutorial in the phone to explain the different process. They will receive home a package that is designed to have the sensor itself and ability to personalize the sensors and an [inaudible 00:26:52] that comes in different languages inside.
This is the product that we launch a year and a half ago. The product itself is class 1 regulated with the FDA and the CE. It’s fully patented for about a year and a half now, issued a year and a half ago. We worked with Ximedica on the full spectrum of process and the design of the product and we’re working with them also to get to the next step of mass production. We build all the software here internally in Cambridge. The core team here in Cambridge is a software for all the platform that we develop, so we have engineers for IOS, Android, the web interface, we build the back end in the data infrastructure on AWS and we also designed the stream ware for the sensor.
Part of the process together with Ximedica and prior to this was to make sure that we build something, as Bill said, that the patient actually want to use and actually need. Very early on in 2013, we designed a large research that included patients, health care providers, caregivers from different demographic that help us to define what those patients need. We already did that had a few mock ups that to try to answer the question that I mention in the beginning and we use this information to develop this second and this third generation. In April ’14, we adapted the second generation, and this was together with Ximedica after we had the first walking prototypes and we came out with even more inputs that help us to change the whole experience around the product and make sure that we provide enough information, or the right information to the patient in the right time, according to what we learned.
Now let’s go back a little bit, 2 years before that. This is what we came when we wanted to start building the product. As a company, we started in 2012, we internally the thing that build the company, build a few prototypes to make sure that we have proof of concept, both with the patient and with the healthcare system. When we came to Ximedica, we came with something like this. We came with a product that already had all the basic functionality but very far from what eventually we launched, both from the feature that we can provide to the patient and the way that we use the product and this was a very long process from learning what is really important. If it’s the way that we collect, what data we collect, how we store information, how we tweaked it, we want to create the entire experience, so many change. In the end, you can see the similarities form what we had back then almost 4 years ago.
This is the full process of where we are today and where we were in 2012. We started as product that’s designed mainly for children and the design that we built originally was for children, so most of the app and the sensor has a lot of different features that can help us to communicate both with the parents and with the children around private, making the whole process fun, and as we continue with the process we designed, you can see the app in 2013 that we tested, and we designed more and more around the UX and UI for adults that ask for something that they control both their children and themselves. Around 2013, we came up with solution that can help both to self manage adult patients and for the younger population that want to already be involved with the treatment process.
Part of the process was also re-branding and adding some more apps around it, rebuilding 2013/2014 and other app that was regained for children to support their own understanding of how to take care of themselves as an adult, and we added a whole communication system to improve in the back end around the blue tooth 2, blue tooth 4 to make sure that we are more reliable in communication between the sensor and the phone.
Just a little bit for the end around the business model. The product support the patient in self manage disease and we would love to see [inaudible 00:31:54] to be better patients in the long run, but to start and sell the product, we were focusing on where we can create immediate impacts, and an impact that can support the majority of the healthcare system. The main impact that we saw that we can create is both on the clinical level, but even more so when we try to introduce a new product on the costs. Good management of the patient with asthma can easily fade a few thousand dollar every year for our health care system.
With this information we went on and started to work with different parts of this continuance. We worked with disease management companies that are already have different plans for other diseases and looked for solution that they can now remotely monitor their patients and support them remotely for those severe and high risk patients. We worked with different insurers in the country, again, to support different internal programs they had for high risk patients so they can provide the assistance for the patient for free so the patient doesn’t have any barriers in accepting a new product that is not cheap from the cost part. We worked with many ACOs and providers around the country that also [inaudible 00:33:19] more monitoring and remote medicine systems.
Lastly, as I mentioned before, as part of the acquisition that we had about 7 months ago, we started to last year to work more and more with the pharma industry and PBMs. Those industries are seeing themselves more and more as part of the full solution for the patients and want to make sure that they’re also providing a service for the patient and not just be the drug or the pill in the end. As part of those services that you can see today, many PBMs are getting into the healthcare services systems and providing everything from remote nurse to help with adherence to the medications, remote retail pharma and so on, and for this we provide the umbrella where they can connect directly to the patient and help the patients to manage those exact features that can help them to provide this service.
With this, I’ll leave the table for Q&A. Thank you very much.
Yechiel, thank you. That was so informative.
Now we’re going to start our Q&A, so please feel free to go ahead and submit any questions you have. We do already have some in the hopper ready to go, so we’ll start with this one. How do these ecosystems fit in a reimbursement scheme? What are some of the issues with monetizing information support systems that surround a device?
Bill do you want to stab on that?
Yeah, Yechiel do you want to take that first? Yeah, Yechiel do you want to have a go at that one first? I’d be interested from your perspective on that given what you’ve gone through. I’ve got a perspective, too.
Sure. I’ll start from my perspective. We went with a product and this is something, Bill mentioned, we are currently in the product of a class 1. For this, we made sure that the feature that we presented and the claims that we had on the product are what we limited for this class 1. We have no clinical claims around the product.
For reimbursement, the way that currently the product is reimbursed from the patient perspective is based on the healthcare programs that we work with. Different healthcare programs today, if it’s payers or ACOs, have disease management programs in place that are internally budgeted as part of either wellness programs or part of prevention programs. Our product was reimbursed as part of those ecosystem. The cost of the product is already packaged into this prevention program where the patient itself getting the full service the same way you receive it before, so if a patient is part of a self-insured employer, have a prevention program that they receive, our product will be packaged as part of this service that they already received before.
Yeah. I would support Yechiel’s observations. This year’s big healthcare information management meeting, the HIMS meeting, ACOs that Yechiel mentioned, these accountable care organizations that are, of course, trying to change the landscape to one where payers and providers are incentivized also around cost reduction, as well as, of course, the providing of service. I think that’s changing the landscape considerably. I know they talked about much more this year than I’ve heard it talked about in other years. Obviously, the informatics part aspect that could surround the device are, of course, places where you are hoping to prove that you do, in fact, cause cost reduction as well by better supporting a product just in the way Yechiel described. I think that’s an area where the reimbursement, it makes it a opposite way of thinking about it. It’s about how much can you save and your product is contributing to that so it might get funded that way.
Obviously, it has been a very difficult area in medicine. Many of you in your own healthcare plans will have been suffering through doctors that don’t use email for a number of years and are probably finding, like many of us, that that is now pretty dramatically changing. We are a conservative industry, understandably, we’re dealing with really serious health conditions and so on, so we have to be very careful about how we move, but I feel that we are gradually moving more and more to the situation where it’s accepted. I saw from the big EHR vendors that some of the big brands known to many of you that are dominant in the hospital and big doctor group environments, they’re all showing very ambitious plans around tele-medicine, leveraging platforms, cell phone platforms and tablet platforms, that are very generic. It’s looking at patients with doctors to smooth the path there.
There’s also another aspect that often gets talked about. This is the so-called meaningful use and patient engagement parts of getting reimbursement, or, not so much reimbursement, but getting financial support for information systems that affects both hospitals and doctors practices, and so on. They’re incentivized that they have to meet criteria of meaningful use and patient engagement. At the moment, unfortunately, they co-opted those terms a little bit. Their idea of patient engagement doesn’t actually necessarily mean engaging a patient deeply in their own chronic condition, yet, it might mean getting them to log onto their website and observe a few, click through a few pages. I think as that program develops, we’re going to see companies that offer better support with the informatics that surround their devices and physical products that if they can play into helping with the meaningful use of the organizations they work for and the patient engagements, they’re going to find themselves also better adopted with their devices.
Of course, ultimately, as I stated in my part of the talk, it could be simply that your competitive position needs to be improved or maintained by offering new supports around it, because if you’re not doing it, your competitors may well be doing it. This is very evident in certain chronic disease conditions right now. There’s some very interesting things going on with some of the players in c-pat machines, sleep apnea take home machines, and so on, because there’s some rules around making sure your patients are using this to ensure that you get reimbursement. Some of the leading players in that are doing some very interesting things with medical informatics to support that.
That’s what I would answer that one with. Heather?
Great. We’re going to switch gears a little bit and get into the nitty gritty. How do you manage the multiple mobile devices that are on the market? Looks like this question’s for you, Yechiel. Were you able to make blue tooth connections work across the many platforms, IOS, Android, etc.?
This is great question. The problem is not just the amount of different devices that … The speed of those devices are changing and how many different product we see every month that are completely using different protocols. This was one of the biggest problems in beginning, especially with the Android machines that [inaudible 00:41:07] from one company to another. We’ve seen the last 12 months that more and more companies are using similar protocols. We still have issues not with the connectivity, so, blue tooth was a main problem in the beginning, so yes, we are connected with blue tooth smart phone and different devices. The other problem is now with how you, the UI on those products are being used. We are having different devices, different sizes, different resolutions. We want to make sure that we have the same experience to everybody and this is another problem, so when we see blue tooth is more and more became a unified protocol, we still have issue because of the amount of different machines that are on the markets.
The only solution at the end is really to make sure that you have teams that are testing and retesting all the different devices in the market. We need to make a decision on how many legacy product we still produce the product for and we may need a decision on both IOS and Android, how much back we are willing to go. We are still supporting product that became in the last 5 years, but nothing beyond this. This is kind of our cut off date that we need to help us to support the number of different product on the market.
Yeah, I have something to add to that as well that kind of broadens out. It is a great question. I think that the one thing that any of us that have worked on this, and I’m sure quite a few of the audience members will also [inaudible 00:42:57], is that you’re actually dealing with so many different teams of software players inevitably, some of which you have quite a bit of control over, the ones that you might be more directly working with, and some of which you really don’t have a lot of control over. Obviously, the one’s we’ve just talked about around the OS’s for the phones, or IOS and Android, but, at the same time, really, in an informatic system, you’ve got a breadth of software and firmware that’s going to get you both through from the device, to an app, to the cloud ,and then you’ve got another set of players in the cloud. You have to take a very systems integration approach, systems architecture approach, to building that system out and make sure that you have someone, or in some group within your organization, that’s really managing the total aspects of the system, not just any one of the specific problems.
For instance, you’ll find on the phone alone, you’ve got to deal with the fact that there’s a blue tooth standard that’s running on those phones that those manufacturers of different IOSs choose to interpret slightly differently or implement, I mean, obviously, on the whole it’s pretty sound, but sometimes it’s the devil to get information out of Apple around how to really drive the low power aspects of a device when you’re using say low e-blue tooth. It’s sometimes really hard to unlock that and figure out how you can make that really work to make that little coin sale on your device work for 6 months or a year or something.
Then, on the other hand, you might be then getting from the app side up to the cloud and you’ve got to think about your choices of players on the cloud side. Do you go from scratch? Do you work with partners that might have white label products? Do you plug in to other people’s electronic health records systems? Some of those EHR players are, in fact, trying to make it easier for people to have windows and places to go in and be in stand at EHRs, so it’s really taking this system level approach and thinking about what you’re integrating, not withstanding understanding how many different browsers you’re going to run on as well. We’ve seen some players, some people in the ecosystem space do apps around using web, doing it entirely on the web and making it look on a phone as if it’s an app, but it’s actually a web app. Of course, we’ve seen plenty of people using completely dedicated apps and then web apps for the permission and patient facing aspects.
I hope that helps fill in some of the dots on that one.
Oh. We had another question, to you, Bill, which is, I’ll just read it. I’m curious about your comment on rewarding patients for adherence. Can you go into some more detail on what you’re finding works best?
That’s a great question and I did a whole talk, which is actually up on our website on how we can, what we can learn from behavior change and behavioral psychology and behavioral economics to help. I specifically in that site a number of places to do that. For instance, I can give you a very concrete example of something that United Healthcare is touting. We didn’t work on it or anything, but it’s a really good, clear example of something that’s in the marketplace. Maybe Yechiel can talk about in his space, there may well be some good examples there, I know that there’s a kid part to the app.
For instance, United Healthcare just launched, and they actually launched it at CVS this year. They launched an app that allows patients in mid tier health plans, 200 to 300 participants, to wear a wearable product, it’s like they take an OEM I think it’s OEM branded or someone else’s health watch. Basically, what they’re doing is incentivizing you to do 3 specific behaviors during each day which are about, not just about the number of steps you take and so on, they’re about rates of doing work. They’re looking for you to do certain kinds of movements, walk a certain amount, have a period where there’s slightly more intense activity. It’s a pretty modest requirement and what they’re finding is that they then reward you by you earn money into payback your reimburseables. In fact, it’s a reasonable amount of money. I’m not suggesting for one minute that rewards need to be financial and so on, but it certainly shows an example in that system and where it really does seem to be working.
United touts this well, they have great stuff on their website that outlines some of the research they based it on. They’ve got papers showing their successes. That’s the beauty of a company like United healthcare. They’ve been very progressive on trying these ideas out and actually are willing to share that lessons to people. I’d encourage you to go look at that talk I did that and there’s a very good book that I base that on, which is called the Business of Choice, which is written by somebody that’s cited in that talk, written from the point of view of what can we learn from behavioral psychology and behavioral economics. It’s a fairly big question. Difficult to answer briefly.
What about you Yechiel? Any specifics?
Yeah. I’m a little bit more pessimistic about it. We are in the business of creating behavioral change, but we are not, but basically the idea is we are not counting on creating a change to having the impact that we want to create. I think if someone has the find a way to really change behavior with patients, specifically with chronic diseases, he’d probably be a very rich man. I think we try to do it with people that are smoking, people that are overweight, people that have different habits that are causing them different other diseases, those patients sometimes know, sometimes doesn’t, but it’s still one of the hardest thing that we have today. We know that most of the cost of the healthcare system goes because of this. With people not using their medication or not adhering for day to day things that they need to be in order to be a better patient.
We are trying to use different behavioral systems that are existing and known today inside our app and inside the system. When we design it, we test it with different patients and I mentioned different demographics, so we have different, also virtual reward system in the app itself. We are also trying to create goals with the patient, so every small goal that the patient can identify themselves or goals that we identify in the back end and we supply the patient by showing them that we are following up and trying to make sure that they achieve their achievement. We are different section of population, there is a small section, unfortunately, that react very well for information, so we are not following the we know that the paradigm of more information, more education means better patients, but there is a percentage that has this impact, so we make sure that all information is very transparent to the patient so they can’t say anymore, “I didn’t know.”
We use different mechanisms in the app. We’re using a lot of notifications, smart notifications at the right time of the day so the patient is only get bothered when it’s really important, or, we bother them about using the medications only if we see that they, not immediately, but right after, and so on, so, we try to make different system that are based on the behavioral change mechanisms that we can use all of them to create something. At the end of the day, the idea is that we collect information seamlessly with the censor and provide this information to the caregivers or the disease management, this way we can still have an impact even if we didn’t create the behavioral change. This is part of how we design the system. If we have a non-adherence patient and are keep not using the medication, at least now with the system in place, we’ll know about it earlier. We don’t need to wait for the patient to arrive to the hospital to the ER after they have an asthma attack after not using the medication for a couple of weeks.
We can call the patient before. There is a nurse that will be able to speak with the patients or one of the caregivers will be able to get an alert that their father is not using the medications the way he’s supposed to, so, there is different mechanisms that we use in order to make sure that we can still support the entire system even without the behavioral changes we want to have. As I said, it’s one of the hardest thing that we can actually do. We can do our best, but in the end, I believe that we need to find different solutions even if we don’t have this behavioral change.
I’d actually like to add to that a bit. Those are great points and I would whole heartedly agree with you, actually, Yechiel, because it is a fundamentally very difficult problem. One of the big … There’s many challenges in there and I have some suggestions as ways to try and tackle them practically.
One is that there’s a very big difference between the way people will respond to ideas and give you feedback on product ideas when they’re in a usability lab, or a situation when you’re putting them on the spot to answer a question. It’s a very different matter how that might actually work in the wild, so to speak, when the person’s actually living with a chronic condition at home, say, for instance, or if it’s healthcare professional product when they’re in the middle of their busy lives. I think that that means that as an industry, and as people like us, myself, who supports our industry, we’ve had to find ways to get limited smaller tests running in more simulated conditions that mirror more real world situations.
For instance, we’ve seen an example which was very clever, it was a part for home care support for someone who was getting a home care nurse, called them up, and then of course they didn’t escalate that there was a problem, they might get a visit, but they were looking at how the monitoring technology, and the call center, and the web access, and so on, might relate to helping the patient. They decided to do a very limited test with a very simple app that was responding to the patient and asking the patient questions and allowing them to call in, in such a way that they simulated in a room, they had a room full of home care nurses on duty, who had a series of rules that they were supposed to respond to the app prior calling to what they were learning about things. Instead of them building out a complex service system with artificial intelligence and decision support, they were able to get something very quickly to a 50 patient test environment, that was a much better simulation of the real world, that allowed them to let humans behave as if they were out there. That’s a backwards way of thinking about it.
What it’s doing is saying will this work out? It allows them to test out very simply, you can have 3 different cohorts within your group of patients where different algorithms apply to those different cohorts such that you can try out different ideas around behavior change. That’s a very good thing.
Another thing is that as an industry we’ve grappled always on doctors, we’re both consumers of healthcare and, of course, people that work in the industry. We’re well aware of the stick and carrot approach to things. Obviously your finger might get wagged at you’re taking medication, but probably we’re going to be more successful if we incentivize people for help them to do these things properly. I think this is an area, as an industry, were we can learn from the wellness side, the consumer side. I would encourage any of you that aren’t too familiar with ecosystem aspects of medical devices to go out and buy the very inexpensive products that are in the wellness domain that are connected, such as home scales, home blood pressure cuffs. Buy your favorite brand of health watch, and so on. Not because I’m suggesting that you need to become a fan boy of these things or something to buy it hook line and sinker, but instead, experience what it’s like to be a consumer of this healthcare. Experience what it’s like who is making it easier for you to connect.
I’ve used a battery of home care products just to test them out and I wear one of the health watches and it’s really about how do these small nudges help my behavior? I am trying to lose weight. I’d love to lose a pound, I think I’ve got a pound a week. I’m finding, funnily enough, that I’m a sucker to being incentivized in certain ways. Obviously that’s not going to work for everybody, but it’s really interesting when you live it a bit. See how easy some manufacturers make it to connect stuff, and see how difficult some manufacturers make it to connect stuff. Learn from that and think about help it inform your team. I think all of these things connect in concert to try and tackle what Yechiel described is a very toug,h intractable problem, behavior change. Let’s use the evidence based resource. There’s great resources on the web and so on to help. I mentioned some in the other talk I cited.
Thank you. We just have time for one more question and this one came up earlier in the process. Have you had to overcome issues with patient sharing, any sensitivity from patients having to share their secured health data and if so, how did you respond?
Yechiel I’ll let you take that one.
Yeah. It’s a good question and, again, this is not the solution that we invented. At the end of the day, we need to make sure that you are legally obliged to everything, all the privacy and security are regulatory that’s expected from your specific device. We are a class 1 device, there is a very specific privacy issue that we need to make sure that we are taking care of. All the data is, in a different way we are securing the data online and we are making sure that everything is double and triple encrypted in a way that even if we have in breach, no doubt it can naturally be identified and so on. This is on how we keep the information in a safe and making sure that the patients know that this is how we keep the information.
From the patient perspective, when a patient download an app, every app, not just health app, they need to make sure that they are agreeing for different disclaimers and we are, we made it very clear to the patient what kind of data they are sharing and what data is not being shared. We know from our market research and discussions with patients that some patient would never allow this kind of information to get to their app and we respect and we probably want to be able to be support of patients with our product, but once a patients has the agreed to be part of this system, we make sure that what the patient knows exactly where the data is stored, how we store the data and if they want to share information, exactly why they’re sharing it with. As I mentioned, they can share with other caregivers, but they are the one that’s in control. They are the one inviting and they can see who exactly see their information. This is the way we try to solve those issues and to make sure that the patient understand how we are taking care of those.
Great thank you.
If I could have just a couple of … All right sorry Heather.
Go ahead Bill, I was going to wrap up, but go ahead.
Yeah. No, just to reinforce that and also there are sometimes issues inside a health practice around who should get access, how is it shared within the health practice between the health care professionals. Also, we’ve noticed in caregiver type situations that you can surround an app or a web app with circles of access that vary according to whether it’s a caregiver or a patient, a patient with a child and so on, which is something I’m sure that Yechiel had to deal with. Of course, there are also special issues around privacy information say when you’re running the clinical trial on an app should you have an app that’s critical enough that you need to run a trial, so there are lots of things to consider there.
Great. Thank you so much Bill and Yechiel for giving us your insights on product development ecosystems. Thank you to our listeners for attending and have a great day everyone.
Thank you very much, Heather.