DeciBio’s Weekly Digital Health Digest

GoodRx announces IPO plans; Amwell files for IPO

TLDR: GoodRx, a patient-facing solution for prescription drug price transparency and discounts, has filed for IPO following its third consecutive year of profitability, a rarity among prior exits in digital health. GoodRx’s H1 2020 profits ($55M on ~$260M total H1 2020 revenues) are up ~75% YoY, which is no anomaly for the company who has been “on and off profitable” since 2013. GoodRx’s monetization strategy involves collecting fees from pharmacy benefits managers when its ~17M patient users purchase drugs using GoodRx discount codes, and the company is now exploring opportunities to play in telehealth. On the telehealth side, Amwell (formerly American Well) has also filed for IPO following a $100M raise from Google (bringing total funding over $900M) and Teladoc’s (TDOC) recent $18.5B buy of “AI+AI” chronic care company Livongo. Considered Teladoc’s biggest competitor, Amwell works with 55 health plans to cover 80M lives.

So what? We expect GoodRx’s IPO to serve as a launching point for deeper strategic expansion into telehealth and secondary revenue opportunities (e.g., the $30B TAM for pharmaceutical manufacturer solutions). GoodRx’s 2019 acquisition of HeyDoctor began enabling virtual consultations, prescription refills and patient self-education regarding medications. We expect GoodRx to use its IPO tailwinds to continue carving out its lane in telehealth. The Google and IPO cash infusions for Amwell are expected to fuel strategic development and help remain competitive with Teladoc’s rapidly evolving platform, with Amwell’s recent Google Cloud partnership perhaps offering a glimpse into the company’s nearest-term goals. The partnership aims to migrate video capabilities and leverage Google’s AI/ML and natural language processing capabilities to transform patient intake / management and patient experience. For reference, we’ve summarized Amwell vs. Teladoc head-to-head below.

Amazon launches Halo Band and suite of AI-powered Halo services, entering the wearables race

TLDR: Last week, Amazon unveiled its multi-sensor, screenless Halo Band wearable, set to enter the market at ~$70 including a 6-month subscription to Amazon Halo services. Halo Band is currently a consumer-grade wearable, as opposed to Apple and Samsung’s watches with FDA-cleared ECG capabilities (Fitbit still awaiting clearance). While Halo Band will incorporate core existing wearables features like activity and sleep tracking, Amazon consciously sought out a few points of differentiation. Halo Band will uniquely feature body fat percentage (BFP) scanning, vocal tone analysis for emotional health monitoring, and intensity and duration-weighted activity goals (e.g. compare to other wearables’ step-counting).

So what? The historically consumer health-oriented wearables space has transformed into an arms race between tech giants aiming to offer medical-grade wearables. In the past year, Apple and Samsung successfully received clearance for the space’s “foothold” medical application — passive ECG monitoring for a-fib detection. While Fitbit awaits clearance and Amazon is newly entering the space, it’s undeniably that all of these giants have their sights set well beyond ECGs, including digital biomarker signatures for presymptomatic and asymptomatic SARS-CoV-2 diagnosis, passive mental health monitoring a la Mindstrong Health (e.g., Amazon Halo tone analysis + activity / sleep monitoring), and pre- / post-surgical behavior monitoring and modification. These applications may represent just the tip of the iceberg for what we may see roll out in the coming years, catalyzed by heightened firsthand consumer experience and adoption of digital health technologies during COVID.

Pear’s Somryst precursor improved sleep health measures among patients with chronic insomnia and depressive symptoms

TLDR: After Pear’s landmark FDA pre-cert clearance in March, the company launched an open-label clinical trial for patients with insomnia and comorbid insomnia-depression, along with two studies on the precursor solution before Somryst’s clearance. New data from one study (N=1,149) on that precursor shows validating efficacy after 9-week treatment, including improvement in sleep-onset latency, wake after sleep onset, total times woken, sleep efficiency, sleep quality, and total sleep time. The second study (N=151) focused on measuring longitudinal patient engagement, from which researchers were able to develop an algorithm for predicting treatment dropout with an AUC of up to 0.9.

So what? The post-clearance (technically, “post-certification”) validation data corroborating Somryst’s efficacy and safety serves as a positive initial indicator for the FDA’s pre-cert program, which has drawn a fair deal of skepticism. Pear’s continued prospective data collection and validation additionally shows commitment to agile development / iteration of its “cleared” therapeutic based on novel patient-level data. Researchers identified several key indicators of intervention dropout, including average time to complete a treatment module, number of email support messages sent, and time to get out of bed after waking. These type of proactive, post-clearance real-world data studies focused on efficacy, safety, and engagement / utilization are key success factors for the FDA’s pre-cert program that may continue generating confidence in fast-tracked SaMD solutions.

In Other News:

• Abbott’s fast, $5, 15-minute COVID-19 antigen test receives EUA; mobile companion app to help display results and return to daily life 
• [Nature Publication] Key Unmet Needs & Challenges for Digital Clinical Trials 
• Medable Achieves 400% Growth in First Half 2020, Expands Ecosystem for Decentralized Clinical Trials
• Elon Musk’s Neuralink is neuroscience theater
• Ellipsis Health’s “Rising Higher” Generates a Machine-Learning-Based Assessment of Anxiety and Depression Symptoms Through Analysis of Patient Speech

Funding and M&A:

• Lyra Health raises $110M, hits $1.1B unicorn valuation
• Bayer reinvests in One Drop, with $98M in commitments
• Aetion rakes in $82M Series B, citing pandemic-era need for RWD
• UK Government Invests $66.6M to Scale Up AI-based Digital Pathology and Imaging
• PatientPop Announces $50M in Series C Funding
• Cecilia Health raises $13M to launch virtual clinic

Telehealth behemoth arises as Teladoc merges with Livongo in $18.5B deal

TLDR: In a merger of two digital health industry veterans, Teladoc will acquire 58% of Livongo in Teladoc shares, plus $11.33 cash per share. The new giant, colloquially dubbed “Telavongo”, set a record high for digital health valuations, comprising over 40% of total VC funding in digital health since 2011 and dwarfing the ~$375M average M&A price for acquisitions made by digital  health companies. The combined company’s telemedicine virtual visit and applied health signals patient engagement platforms are expected to bring in $1.3B in total revenues this year.

So what? The deal has clear benefits for both parties. For Teladoc, the deal offers potential differentiation from other leading virtual visit providers (e.g., AmWell, Doctor on Demand) and the tidal wave of “novel” (yet fairly commoditized) market entrants. Connection to Livongo’s AI+AI chronic disease management solution may provide added sticking points for patient retention, a key challenge for virtual visit companies. For Livongo, incorporation into Teladoc’s network offers an opportunity of enormous scale to distribute its solution with Teladoc’s massive registry of virtual providers and to more readily expand into new disease areas. As Livongo Founder Glen Tullman puts it, “One of the really exciting synergies is to go after the 70 million people that Teladoc already has a relationship with, and have our collective doctors now say to people: ‘You’re having this issue? Here — we have a great solution for you.” The merged company’s end-to-end virtual visit and remote engagement solution is well-positioned to evolve into a digital care ecosystem of its own that extends beyond chronic care. One thing is for certain — virtual visit and chronic care management competitors have their work cut out for them, and the largest of them will likely be looking for opportunistic acquisition opportunities of their own to keep pace with “Telavongo”.

Apple-Google COVID19 contact tracing app launches in Virginia

TLDR: Virginia Department of Health launched COVIDWISE last week, the first contact tracing app built upon Apple and Google’s Exposure Notifications API. The free app leverages Bluetooth technology to trace exposure to individuals with positive COVID-19 test results. Bluetooth tracing aims to mitigate privacy concerns by not collecting actual GPS data, but is fraught with potential inaccuracies to COVID exposure assessments. The Department of Health must confirm positive test results for users through a PIN, which allows the notification system to ping users who may have been exposed to infected individuals. Success of the app in reducing COVID infection rates primarily hinges on downloads and use by Virginia’s population, which remains to be seen over the coming weeks.

So what? Six months and nearly 5 million cases into the COVID pandemic, the need for tools to reduce infection rates is increasingly dire. Other states have released contact tracing apps outside of the Apple-Google API system, which have been met with varying degrees of success. In May, Utah launched the Healthy Together app which combines GPS and Bluetooth data and allows public health workers to access location tracking data and contact exposed individuals. North Dakota also launched its Care19 app in May, but only saw 4% adoption by the end of June due to privacy issues with real-time GPS tracking. Virginia marks the first state to adopt the Apple-Google Bluetooth-only system, and will likely be a key litmus test for the privacy-conserving design, informing other states’ decisions to follow suit in the future. Adoption of contact tracing will likely continue to unfold at the state level, as there do not appear to be any plans for a nation-wide government-sponsored tracing and notification system.

Cerner invests in Xealth, with plans to incorporate digital health prescription tools into EHR

TLDR: Cerner’s ~$6M investment in Providence-St. Joseph Health spinout Xealth comes with plans to bring their digital health prescription platform to Cerner’s EHR and patient portal. Xealth’s platform supports 30+ digital health programs, with applications spanning from chronic disease to behavioral health support to maternal care. Clinicians can use Xealth to seamlessly integrate, prescribe and monitor digital health tools used by patients through their EHR. With an EHR market share of ~25% in the U.S., Cerner is an ideal partner for Xealth to scale their platform and lower barriers to digital health adoption through centralized, easy access to key solutions.

So what? As the digital heatlh field a growing pool of digital health players attempt to address care gaps in the pandemic era, scalability is more important than ever. Cerner’s investment points to the importance of scalability, as Xealth’s platform provides digital health at scale through its centralized, pre-vetted library of digital health tools. Xealth is among a few key players in the digital health prescription space, including Mount Sinai spinoff  Rx.Health, Kaiser Permanente’s Project Chamai for mental health, and UK NHS Apps Library. These players are well positioned to improve adoption of digital therapeutics and remote monitoring tools by reducing barriers to clinician prescription or recommended adoption by patients.

In Other News:

• GoodRx files for IPO
• Apple and UCLA launch 3-year depression study
• Digital divide study by JAMA highlights barriers to telemedicine access for seniors
• Samsung claims FDA clearance for smartwatch ECG tracking
• FitTrack launches Beebo, smart scale for pregnancy care

Funding and M&A:

• Blackstone acquires Ancestry for $4.7B, privacy speculations abound
• Sight Diagnostics lands $71M for fingerprick blood-testing with smartphone interface, eyes COVID biomarkers 
• APEX Ventures announces €50 million fund for early-stage digital health startups
• Ginger lands $50M for mental health coaching platform
• Symptom-checking startup Infernmedica secures $10.2M for digital triage tool
• VR Medtech startup Immertec scores $6M for surgical training tool

Careology launches remote monitoring platform for cancer care

TLDR: A key trend before the pandemic, remote patient monitoring in oncology is more crucial now than ever to minimize in-person visits and help patients navigate treatment at home. Based in the UK, Careology offers patients and caregivers a mobile app to visualize their care plan, manage medication, record side-effects and keep track of key vitals through integration with health-tracking devices. Their latest product, Careology Professional, allows clinicians to monitor patients’ vitals (e.g., temperature, heart rate, blood pressure, weight, activity), therapy toxicities and medication adherence in real time. The tool also enables the care team to view patients at the cohort-level, in order to triage patient needs and reduce unnecessary adverse events.

So what? Careology’s product launch comes in the wake of Biofourmis’ acquisition of Gaido Health, Takeda’s AI-based RPM oncology solution, in April. Oncology RPM players are seeing emerging partnership interest from pharma (e.g., BMS-Voluntis, Merck-uMotif) and EMR providers (e.g., Varian-Noona, Cerner-Carevive, McKesson-Navigating Cancer, Elekta-Kaiku Health). Partnership activity revolves around collection of patient-reported outcomes (PROs), which are gaining traction as endpoints in clinical trials (e.g., quality of life), an emerging real-world data type, and a key trend in value-based care. Research increasingly suggests that symptom tracking and reporting can reduce ER visits and hospitalizations for oncology patients, resulting in improved outcomes and reduced costs to healthcare systems.  In the UK and across Europe, value-based care is inherently incentivized based on national health systems. In the U.S., the CMS Oncology Care Model offers value-based payment for oncology practices based on improving outcomes relative to costs. The latest draft measures for the Oncology Care First Model would require implementation of electronic PRO capture under value-based payment contracts.

A Machine Learning Approach to Understanding Patterns of Engagement With Internet-Delivered Mental Health Interventions (Microsoft, SilverCloud Health)

TLDR: Microsoft researchers developed a machine learning (ML)-based approach to defining cohorts of patients based on sustained engagement with digital cognitive behavioral therapy (CBT). Roughly 55,000 patients using SilverCloud Health’s 8-module CBT program for depression and anxiety were longitudinally assessed (~14 weeks) for level of engagement (i.e., use of any therapy module and use of each specific module in a given week) and clinical outcomes (e.g., PHQ-9 for depression, GAD-7 for anxiety). Researchers identified 5 cohorts:

• Class 1 — ”low engagers” (~40%) spent the least time on the platform, used fewer modules, and had a steady dropout rate over time. They tended to use Mood / Worry Monitoring modules the most and Activity Scheduling / Listing the least.
• Class 2 — ”late engagers” (~20%) ramped up engagement slowly over time, and were initially less likely to use the To-Do List, “Hierarchy of Fears”, and Graded Quiz activities at the end of modules. They were most likely to engage with “Anxiety: Myths & Facts” and Stress Response modules.
• Class 3 — ”high engagers with rapid disengagement” (~25%) dropped off rapidly despite initial high engagement, and were consistent users of a broad array of core modules. However, these users were the least active in engaging the Activity Goals task.
• Class 4 — ”high engagers with moderate decrease” (~5%) spent significantly more time on the platform, used more modules (and in contrast to Classes 1-3, ones requiring greater introspection and self-evaluation), and remained fairly engaged over time. They were less likely to engage with additional suggested reading material.
• Class 5 — “highest engagers” (~10%) spent the most time on the platform, used the most modules, and remained most engaged over time. They used the Journal and Progress Tracking modules more than other cohorts, and were most frequent users of modules requiring unlocking by a personal coach.

So what? Digital health tools, and mental health ones in particular, have suffered from high user attrition and low levels of engagement (or consider the ~85% of patients in Classes 1-3). While the ultimate goal of these tools is to create added value that non-digital interventions inherently cannot achieve (e.g., continuous outcomes and engagement monitoring, dynamic therapies that adjust in real-time using monitoring data), the more immediate goal is to establish substantial equivalence to traditional interventions like in-person CBT. But successful outcomes evidence requires understanding user behaviors, drivers of patient disengagement, and how “Class 1-4” patients can be kept on-track so that they too demonstrate improved clinical outcomes. Deep characterization of these behaviors can inform development of CDx / CoDx-esque patient stratification and corresponding strategies for dynamically tailoring DTx content, logic, and engagement points (e.g., notifications, clinician outreach).

Proteus Digital Health was once valued at $1.5B. It may be acquired in a $15M ‘stalking horse’ bid

TLDR: Proteus recently declared bankruptcy after a failed partnership with Otsuka to expand Proteus’ ABILIFY MYCITE medication adherence-tracking solution, among other challenges (see Vol. 23). Former partner, Otsuka, has now placed a $15M “stalking horse” acquisition bid that will set a valuation floor for other bidders interested in scooping up the fallen unicorn. Bidding will close on Aug 4, with an auction on Aug 6.

So what? After over 20 years of pioneering the digital health space, Proteus developed a wide portfolio of research and technologies extending beyond medication adherence tracking — one of the key reasons we believe they failed. That being said, there appears to be an interesting potential acquisition opportunity for other pharma or DTx companies looking to expand their digital capabilities who are willing to pick up and repurpose Proteus’ many pieces. In any case, we’d be surprised if no challengers emerged for a >$50M bid and are anxious to see how the incorporation of Proteus’ tech assets unfolds in the coming year.

In Other News:

• The looming end to the telehealth boom: How we have a fleeting opportunity to shape the trajectory of healthcare innovation for the next decade
• Cerner partners with Holon to help automate clinical decision-making and identify gaps
• Biofourmis partners with Chugai pharma on multi-variate digital biomarker for objectively assessing pain
• MassChallenge HealthTech accelerator names 2020 winners, with focus on Parkinson’s, home health and cardiac rehab
• Nature: “Outcome measures based on digital health technology sensor data: data- and patient-centric approaches”

Funding and M&A:

• Ro secures $200M and ~$1.5B valuation, for telehealth platforms in men’s health (Ro), women’s health (Rory) and smoking cessation (Zero)
• Indigo Diabetes lands €38M to build under-the-skin CGM sensor
• Sidecar Health closes $20M for customized, self-pay insurance platform
• Sprout clinches $10M for digital autism care and therapist-matching
• UK-based Neurovalens raises £5M to test neurostimulation tech in trials

Roche, PicnicHealth start RWD partnership with multiple sclerosis focus

TLDR: Conceived as a health record concierge service, PicnicHealth collects and aggregates health record data on behalf of individuals looking to track down their past records, stored in siloed EMR systems across disparate care sites. PicnicHealth leverages ML algorithms trained by manual curation to structure medical record data across unstructured notes and reports, including MRI images. After collecting retrospective medical record data, PicnicHealth sustains patient utilization and data capture as a medical record management platform. Picnic’s partnership with Roche and Genentech aims to support accelerated R&D efforts for MS treatments based on real-world data for 5,000 MS patients, including 7 years of retrospective data and 5 years of prospective data. The partnership is set to scale toward neurology, hematology and rare disease (e.g., Huntington’s disease) in the future.

So what? The Roche-PicnicHealth partnership is one of a growing string of investments by pharma in the real-world data space, and aligns with Roche / Genentech’s first digital health moves in multiple sclerosis with Floodlight Open. Roche’s $2B acquisition of Flatiron in 2018 set an industry standard for the tremendous value associated with real-world data in the eyes of big pharma. Several pharma partnerships (e.g., Amgen-Syapse, Novartis-Cota, Sanofi-Aetion, BMS-Concerto HealthAI) have emerged over the past few years, aiming to leverage real-world data across the drug lifecycle, from discovery to clinical trials to label expansion. Existing partnerships and the Roche-PicnicHealth engagement point to longitudinal data capture and analysis of unstructured data fields as key differentiators of RWE players. These differentiators will likely continue to drive pharma partnerships, based on pharma’s vested interest in discovering valuable insights around disease progression, treatment history and clinical outcomes.

Vitls Remote Patient Monitoring Platform Receives U.S. FDA Clearance

TLDR: Vitls, a Houston-based start-up launched by a husband-wife duo looking for an improved RPM solution for their son with febrile seizures, received FDA approval for its Tégo vitals monitoring patch. The disposable adhesive patch measures heart and respiration rates,  heart rate variability, body temperature, and blood oxygenation (SpO2) and has a 6-day battery life. Vitls plans to commercialize their technology in Q3.

So what? A growing number of RPM players are riding the wave of attention, funding, and eased regulatory scrutiny for RPM technologies to meet the COVID-generated need. As simple digitized / remote reporting of biometrics has won trust and broader acceptance from the public, RPM players have begun increasingly looking to incorporate multiple RPM / wearables-based biomarkers into digital signatures that may also be able to predict or detect early disease or add prognostic or monitoring value beyond simply enabling remote measurement of markers that could be read non-digitally.  Accordingly, the RPM space, traditionally dominated by device manufacturers, has begun evolving to require applied analytics and multi-source integration capabilities to capture the larger share of the total addressable market. Among these emerging innovators are “integrated signals” companies like VivifyHealth, Validic, and Human API, which may look to bring device companies like Vitls into their platforms.

Anthem, CloudMedx launch digital tool to help employers, public health officials track impact of COVID-19

TLDR: Leveraging technology partner CloudMedx’s AI capabilities, Anthem has launched its C19 Explorer, C19 Privileged, and C19 Navigator COVID tracking and decision-making solutions for the public, government policy-makers, and Anthem employer groups, respectively. The solutions leverage aggregated public data (e.g., cases, test volumes, hospital bed / ICU utilization, economic performance) and proprietary data (e.g., Anthem claims / member data, level of “social mobility” / adherence to stay-at-home orders, scenario-based modeling outputs for staff and public testing thresholds required for public or workplace re-opening). See here for Anthem’s full webinar walkthrough of the tool.

So what? As COVID cases rapidly climb in states and locales attempting soft re-openings, local and state governments and employers have expressed urgent need for a broad toolkit of solutions that help aggregate, predictively model, and support decision-making for best-practices in managing future attempts at public and workplace re-openings. The Anthem tool provides open-source public information and education while opening a commercial revenue stream for the payor and opportunity to harvest utilization data to prospectively monitor government and employer decision-making.

DeciBio Original Content:

DeciBio’s Q&A with Ramon Felciano, Ph.D., CTO & VP of Strategy for QIAGEN Digital Insights

In Other News:

• UNC Health partners with Google on mental health app for healthcare workers
• Walgreens and DoorDash join forces on over-the-counter meds and product delivery 
• Teva Pharmaceuticals launches prescription ProAir Digihaler for asthma and COPD patients
• Centene scales partnership with Quartet Health, offering telemedicine support for mental health
• Microsoft announces Azure IoT Connector in move towards RPM data security 
• Amazon partners with Crossover Health on healthcare clinics for fulfillment center employees

Funding and M&A:

• Cohere Health raises $10M to drive collaborative approach with patients at center
• Digital pharmacy startup Medly raises $100M
• Caption Health banks $53 Million to make heart scans more accessible
• Needle-free CGM startup Movano exits stealth with $27M in funding
• Online pharmacy start-up NowRx brings in $20M through crowdfunding
• Paige secures additional $15M for AI-based digital pathology  
• GYANT raises $13.6M for its provider admin support solution

Evidation health bags $45M, announces entry into digital therapeutics space

TLDR:  Evidation’s direct-to-patient, virtual research platform currently has 4 million users across the U.S. With its most recent funding, Evidation looks towards offering digital interventions and treatments through its virtual research app. Digital interventions will guide patients through care regiments and generate actionable insights that may be shared with providers. Though specifics around their “virtual therapy” play and target therapeutic areas remain unknown, Evidation notes that virtual health programs are set to launch later this year. Evidation also intends to expand its usership base across the U.S., particularly to capture at-risk or disease-specific populations.

So what? Evidation’s research platform aims to characterize the “behaviorome” by analyzing behavioral data in the context of health. Evidation has conducted over 50 studies to-date across chronic diseases, with a focus on neurodegenerative disorders and mental health conditions. Based on its existing data assets and research studies, Evidation is positioned to launch virtual interventions rooted in behavioral health. Recent FDA approvals in the DTx space attest to the opportunity for behavior-driven digital interventions, including Akili’s EndeavorRx for ADHD and Pear Therapeutics’ Somryst for chronic insomnia.

U.S. Air Force inks deal with MFB Fertility to offer free at-home fertility testing

TLDR: The $1.3M deal aims to provide military couples with free access to MFB Fertility’s Proov at-home fertility tests. Earlier this year, MFB Fertility cinched FDA approval for Proov as the first at-home ovulation test that measures progesterone alongside LH levels. While other rapid test strip solutions historically rely on LH alone to predict ovulation, Proov’s tests are proven to confirm ovulation based on the urine metabolite of progesterone (PdG). Proov’s tests are accompanied by a mobile app, which tracks hormone levels longitudinally.

So what? Infertility affects >10% of couples in the U.S., and disproportionately impacts military families. The fertility space is becoming increasingly saturated with apps, wearables and biosensors aimed to equip women with information about their fertility and menstrual cycles. Key conditions that are linked to infertility (e.g., PCOS, endometriosis) currently have poor screening tools and high rates of misdiagnosis. Digital tools like Proov are well positioned to capture the longitudinal data necessary to develop digital biomarkers in women’s health, based on relevant metrics like cycle length, flow rate, body temperature, and hormone levels.

COVID-19 Updates with Pravene Nath, Roche’s Global Head of Digital Health Strategy

TLDR: The pandemic has spurred rapid adoption of telehealth and digital tools to meet healthcare demands under an extremely strained system. Pravene Nath outlines three key strategies for digital health companies to sustain success in a post-COVID world. Firstly, target underserved populations who truly need telehealth to access care, not out of convenience, but due to challenges like  age, disability or remoteness. Secondly, measure and publish improvements in care quality achieved by digital tools like remote patient monitoring and chat-bots in order to drive recognition by payers and the government. Thirdly,  prioritize patient needs and protect patient data, especially under currently relaxed HIPAA rules.

So what? In light of unprecedented growth, the digital health sector is in its best position yet to generate meaningful data and demonstrate value to the healthcare system. Sustained adoption of digital health solutions relies on continued uptake by payors, providers and ultimately patients. Pravene’s calls to action allude to the importance of addressing patient needs and demonstrating value beyond convenience in the post-COVID world. Digital health companies should continue to drive their value by addressing key weaknesses in the healthcare system, including efficiently collecting data and drawing actionable insights for customers across the ecosystem (e.g., patients, providers, payers, pharma, diagnostics, etc.).

In Other News:

• Digital health market sees record-breaking funding of ~$5.4B in H1 2020
• Walmart releases plans for “healthcare supercenters” with comprehensive services
• Health benefits company Accolade goes public in $220M IPO
• Abbott, Tandem finalize course to integrate diabetes CGM and digital insulin delivery system

Funding and M&A:

• Anthem’s PBM IngenioRx acquires pharmacy management company Zipdrug 
• Lululemon set to acquire fitness start-up Mirror for $500M
• Teledoc finalizes acquisition of InTouch Health for $150M, its largest to-date
• Owkin lands $18M for decentralized research platform that tests AI models
• Patient management startup NexHealth lands $15M, aims for EHR/PMS integration
• Genome Medical raises $14M for “telegenomics” platform
• DeepSpin clinches seed funding for portable MRI system, offers ultra-low cost 

[Podcast] Fall of a Pioneer: Unpacking Proteus’ bankruptcy filing (Apple Podcasts, Spotify)

TLDR: After spending nearly 20 years establishing the digital health market, with ~500 patents and a ~$1.5B valuation, Proteus Digital Health filed for Chapter 11 bankruptcy last week. In this podcast, HIMSS’ editors argue that Proteus’ major downfalls were: (1) overambitious scoping and pursuit of products across multiple digital health categories and therapeutic areas, (2) misaligned incentives and goals with former pharma partner Otsuka, (3) poor timing of leadership transitions, and (4) perhaps an inherent shortcoming of a medical device-based adherence tracking solution with high associated costs. With IP that may be worth more than any of Preotus’ pre-commercial products, it’s unlikely that the company draws a partner or cash to make a comeback. See last week’s newsletter for some context.

So what? Proteus’ major downfalls offer valuable “lessons learned” for other digital health start-ups. First, the old-school approach of constraining product development to solution segments or indications that can demonstrably generate revenue before expanding a portfolio should not be dismissed. Proteus had virtually no partnerships with other digital health companies because Proteus had aspirations to become an end-to-end solution provider and viewed others in digital health as competitors. Second, while digital health start-up / pharma partnerships have increasingly been criticized as “doomed to fail” mismatches, careful communication and alignment of goals and expectations and consideration of leadership transitions can help avoid partnership busts. Friction between Proteus’ need for rapid, large-scale revenue generation after spending nearly two decades as a “pre-revenue” company and a pharma partner’s typical metered, stepwise approach to product launches likely played a role in the partnership’s demise. Deal insiders have speculated that the coincidental timing of Otsuka’s U.S. R&D lead leaving the company may have also had a hand in the failure, similar to how Sanofi’s CEO change was a key piece in the Onduo partnership dissolution. Lastly, digital health innovators should work under the assumption that other modalities may be advantaged approaches to solving the same problem. In Proteus’ case, perhaps a pivot from the ~$1,600 Abilify MyCite sensing device (which could cost more than the drug itself) to include video- or AI-based adherence tracking (e.g., a la Wellth) could have been more successful.  Despite its failures, it’s undeniable that Proteus’ early and sustained efforts in digital health played a key role in bringing digital health concepts and solutions into the lexicon of legislators and regulators.

Virtual clinical trials now being used to fast-track drug development during coronavirus crisis

TLDR: With more than 1,100 clinical trials disrupted as a result of COVID, biopharma companies have turned to virtual methods of recruiting, consenting, and monitoring trial participants to minimize derailed trials. Leading companies supporting this virtualization of trials are Evidation, Science 37, Medable, and Unlearn.AI. Similar to telehealth, digital health industry leaders and biopharma R&D directors believe virtual trial solutions will continue to play a significant role post-pandemic as patients and innovators reap the benefits of virtualized care and previously pie-in-the-sky digital “alternatives” enter mainstream healthcare conversations.

So what? The clinical trial engine has been notoriously slow to innovate. Biopharma companies have, somewhat sensibly, adopted an “if it ain’t broke, don’t fix it” mentality, avoiding the potential loss of time and R&D spend by disrupting the status quo of typical clinical trial formats. However, the system is broken. About 90% of clinical trials fail, with patient attrition due to scheduling and financial challenges cited as leading causes. The time and travel barriers gating clinical trial participation disproportionately affect working parents, Medicaid patients, and communities of color. Here, digital health again offers an accessibility advantage to traditional modalities of healthcare. While digital device access and literacy are by no means perfectly equitable, gaps are being closed by increasing smartphone ownership and connectivity in low-income populations globally and device subsidy programs (e.g., Apple Watch via trials). Thoughtful innovation that furthers virtualization of formerly in-person clinical trial procedures alongside advances in equitability of access to digital health tools is well-positioned to disrupt the age-old clinical trial paradigm.

Nationwide EMS calls decline 26% since start of pandemic while EMS-attended deaths have doubled

TLDR: Since early March, 911 calls for emergency medical services (EMS) have dropped ~25% in the U.S., according to an Academic Emergency Medicine study that surveyed ~10,000 EMS agencies across ~45 states. However, EMS units reported increases in severe emergency events (e.g., cardiac arrests), as seen through the doubling of EMS-attended deaths in the period.

So what? These findings have a number of potential implications: (1) that sharply reduced strain on EMS agencies amid a pandemic, sustained even after Phase 4 re-openings of most states, may suggest efficacy of conversational AI / digital triaging, telemedicine / virtual visits, and remote patient monitoring (RPM) solutions in preventing unnecessary emergency calls and visits, (2) that concerns of contracting COVID while visiting a healthcare facility or concerns of burdening the system with non-COVID emergencies is resulting in discerning use of emergency services, (3) that avoidance of accessing emergency services is resulting in delayed, worse outcomes for patients who actually needed them. All three of these implications likely hold some truth, suggesting that any early progress we’ve made in innovation and adoption of “digital front door” solutions is not enough. Digital infrastructures must be simultaneously effective in reducing unnecessary healthcare costs / critical encounters and lowering barriers to basic assessment and effective (i.e., sufficiently “sensitive”, in diagnostic terms) triaging services. We’re optimistic that this is possible through built experience with virtual visits as a new norm, and continued innovation in RPM technologies that leverage patient behavior as a focal point for human-centered design.

Funding and M&A:

• Investors predict the winners and losers in America’s shift to digital health during the pandemic
• Healthy.io acquires fellow smartphone urinalysis startup Inui Health
• Oscar’s health insurance platform nabs another $225 million
• DispatchHealth Raises $135.8 Million for digital in-home care solutions
• BrightInsight raises $40M to develop digital platform for biopharma
• Agamon secures $3M in seed funding for its clinical natural language processing tech 

In an FDA first, game-based therapeutic gets marketing approval

TLDR: Two years and 10 clinical trials since its FDA submission, Akili Interactive earned the FDA’s first approval for a video game digital therapeutic (DTx). Akili’s EndeavorRx is a prescription-only DTx intended for children ages 8-12 with attention deficit hyperactivity disorder (ADHD) and has shown clinically meaningful improvement in gold-standard measurements of impairment severity, both as a standalone therapy and as an adjunct to traditional stimulant therapy. No significant adverse events have been reported to-date.

So what? Unprecedented adoption of telemedicine solutions during COVID has enabled remote consultations and biometric patient monitoring, whose impacts have been most notable in primary, chronic, and mental health care. The FDA’s first video game DTx approval expands the scope of current DTx formularies, helping close the digital loop between virtual doctor visits, diagnoses, treatment, and monitoring. Skepticism remains over digital therapeutics, particularly around their poor user engagement and attrition rates; however, developers like Akili, whose design team is headed by an ex-Star Wars art director and stacked with consumer gaming experts, believe that gamified treatment approaches that leverage psychology may help address these problems. Akili’s pipeline of future video game therapies focuses on autism, depression, Alzheimer’s (in partnership with Pfizer), and multiple sclerosis.

Proteus files for bankruptcy: Where did it falter?

TLDR: Following $500+ million in funding, unicorn valuation, and FDA approval for its medication embedded sensor-patch device, DTx unicorn Proteus Digital Health filed for bankruptcy. Proteus and Otsuka garnered FDA approval for their jointly developed Abilify MyCite system, which combines Otsuka’s drug with Proteus’ ingestible sensor and wearable to treat schizophrenia. Earlier this year, Proteus and Otsuka terminated the partnership due to limited uptake by clinicians and patients with mental illness. Experts estimate the price of the generic drug itself was merely ~1% of the list price for the drug-device combination system (e.g., ~$20 for the generic vs. ~$1,650 for the system). Though drug adherence is a key unmet need in the mental health space, high prices without clear clinical outcomes and limited consumer interest have severely gated adoption by payers and clinicians, ultimately driving the bankruptcy filing.

So what? Proteus’ bankruptcy comes in the wake of an up-and-down year for digital therapeutics. Despite buzz of a pharma “DTxit” amid break-ups of key pharma-digital partnership (e.g., Novartis/Pear, Sanofi/Onduo), recent acquisitions (e.g., Novartis/Amblyotech, Biofourmis/Gaido) and FDA approvals (e.g., Akili, etectRx) have restored confidence in the DTx space. As a pioneer in DTx, Proteus’ initial success and recent burnout serves as a warning to all DTx players eager to convert funding hype into sustained clinical adoption. In developing and scaling their products, DTx players should look to demonstrate value to payers and prioritize the patient experience. Proteus has announced plans to shift toward oncology and infectious disease, where they hope to appeal to payers and deliver clinical outcomes. Meanwhile, Otsuka has acquired the license to use Proteus’ tech in developing mental health treatments and will continue to sell the Abilify MyCite system. 

Walmart acquires CareZone’s digital pharmacy tech and IP

TLDR: Last week, the retail giant scooped up CareZone’s technology for medication management, including features that allow patients to scan insurance cards and drug labels to check coverage and set up home delivery. CareZone’s pharmacy logistics business was excluded from the deal, likely due to ongoing litigation with Cigna’s Express Scripts PBM. An insider to the deal suggested that Walmart paid $200 million.

So what? It’s no secret that Walmart has been closely watching Amazon, CVS, and Walgreens’ strategies in the retail primary care space. In 2018, Amazon acquired PillPack ($753 million) to build out its digital “Amazon Pharmacy”, and has since piloted telehealth primary care and digital symptom checking offerings to its employees. CVS is on-target to open 1,500 HealthHUB primary care centers by the end of 2021, and Walgreens is rapidly ramping up primary care infrastructure via its partnership with VillageMD. In the past couple years, Walmart inked a deal with Anthem to lower OTC drug prices and basic medical supplies for its customers, entered acquisition talks with Humana (a la CVS-Aetna), and cut the ribbon on its first 2 standalone primary clinics. Now in talks with Verizon to equip its retail and medical operations with 5G, Walmart’s president of health claims that these initiatives are “just the start” of their strategy to revolutionize primary care by prioritizing low prices and convenience, analogous to their strategy in the retail space. Analysts estimate that 90% of Americans live within 10 miles of a Walmart store, positioning Walmart as a formidable primary care competitor. 

In Other News:

• Big Tech Zeros in on the Virus-Testing Market
• Fitbit launches return-to-work COVID solution for employers

Funding and M&A:

• Cedar lands $102M for its patient engagement and personalized billing solution
• Behavioral health startup Big Health secures $39M to support product development
• Abacus Insights raises $35M to scale its data interoperability platform for health plans
• Kaia Health clinches $26M, aims to launch into virtual care for COPD and MSK
• Augmedics lands $15M to expand AR-based surgical imaging tech
• Binah.ai secures $13.5M for smartphone-based vital sign monitoring tech
• Plume raises $2.9M to boost its telemedicine services for transgender communities
• Patient engagement startup DocASAP raises undisclosed funds from Optum Ventures

‘I can’t imagine going back’: Medicare leader calls for expanded telehealth access after Covid-19

TLDR: CMS head, Seema Verma, reaffirmed telehealth industry optimism last week, contending that she “can’t imagine going back” to pre-COVID telehealth restrictions. “People recognize the value of this, so it seems like it would not be a good thing to force our beneficiaries to go back to in-person visits,” Verma said during a virtual event hosted by STAT News. Payors and legislators, however, will need to align on best practices and allowable reimbursement amounts relative to traditional in-person visits, which have been at parity during COVID.

So what? Hospital margins have been squeezed by COVID, with healthcare administrators speculating that independent health systems will be swallowed up in post-pandemic M&As. While recouping these losses in the aftermath, hospitals may fight to maximize in-person visits, which have associated facility fees and allow for additional procedures (e.g., labs, imaging).  However, mounting pressure from patients in a reimbursement-friendly environment may leave providers no choice but continue supporting significant virtual visit volumes. Virtual visits for Medicare patients have soared from a few thousand per week to over 1.3M per week since COVID’s onset, while private payor claims for virtual visits skyrocketed nearly 45x year-over-year.  The momentum from both public and private payors has pushed a bipartisan coalition of 30 senators to release a letter urging Senate leadership to make current telehealth policies permanent.  Though reimbursement for virtual visits is unlikely to remain at parity with in-person visits following the pandemic, evolution of a broader suite of remote care technologies are likely to support expansion of virtual care beyond collection of a consultation fee, providing opportunity for hospitals to drive up margins and increase total patient populations.

Babylon Health admits GP at Hand app data breach caused by ‘software issue

TLDR: Last week, telemedicine virtual visit and chatbot company Babylon Health experienced a data breach that resulted in three patients mistakenly receiving recordings of other patients’ consultations. The company reported that a software issue caused the breach and ensured no external security threats were at play.

So what? This incident doesn’t come as a first for Babylon, and follows a trend of growing cynicism around telehealth risks, including privacy and security, malpractice claims, health disparities and equity of access.  Although telehealth platforms are presumably more vulnerable to software issues in these early days of scaling, they may increase vulnerability to malicious attacks and security breaches, as they expose specific vendors’ weaknesses, and diminish patient confidence and trust in telehealth solutions, which already stand at a tipping point for sustained adoption. Other telehealth and remote monitoring companies would do well to use Babylon’s mishap as an opportunity to re-evaluate the robustness of internal and external privacy protections.

Abbott’s real-world data show FreeStyle Libre lowered A1c in Type 2 diabetes, with or without insulin

TLDR: Using real-world data from a French national claims database, Abbott analyzed ~75K FreeStyle Libre CGM  users’ HbA1C levels, and diabetes- and general acute events over the course of a year. The study found average HbA1C reductions of 0.9 and 0.6 percentage points among non-insulin users and long-term insulin users, respectively, over a 6-month window. Additionally, Abbott demonstrated a ~30% drop in diabetes-related acute events among FreeStyle Libre users and a 13% drop in all-cause hospitalizations.

So what? Continuous glucose monitors (CGMs) are an essential hardware component of remote diabetes patient management, a  ~$6B market. Digital diabetes management remains one of the best-established, well-funded segments of the digital health market with perhaps the nearest-term path to at-scale revenue realization. Recent partnerships in the space aim to create an end-to-end solution leveraging CGM hardware and software solutions for trends monitoring, live coaching, and insights delivery (e.g., Dexcom-Livongo, Dexcom-Onduo, Abbott-Omada). This end-to-end digital patient management approach has led to robust funding, valuation, and revenue realization (see Livongo’s Q1 earnings call) for “software” companies in the space, providing a model for other therapeutic areas to follow.   

DeciBio Original Content:

[Forbes Featured Article] — Digital Biomarkers Supersede Theranos: No Blood, No Jokes by Stephane Budel & Chris Lew

In our most recent Forbes article, we break down the 3 key ways in which digital biomarkers are poised to disrupt “traditional” genomic and proteomic biomarkers, and what a fully-digital 22nd century might look like.

In Other News:

• Siemens Healthineers, Geisinger ink 10-year digital health partnership

Funding and M&A:

• Health IT deals on track to hit $15 billion in Q2: 5 things to know
• Walmart snaps up digital health company CareZone’s medication management tool
• Cue Health nabs $100M to validate its at-home molecular testing platform
• Patient Ping scores $60M to expand its care coordination tool
• Headspace raises another $48M
• Virtual care company Conversa Health secures $12M

BARDA taps Evidation Health to digitally monitor healthcare workers for early COVID-19 symptoms

TLDR: RWD and clinical trial solutions provider, Evidation Health, will use the funding to track medical first responders’ self-reported symptoms, behavior, and sleep and activity patterns using wearable devices. Evidation’s COVID-19 Pulse study has already enrolled ~185,000 participants to use wearables and self-reported survey data to characterize healthcare system responses to COVID and digital biomarkers. This new study aims to further drive development of digital biomarker-based predictive algorithms for COVID early detection and prevention.

So what? As COVID continues to highlight the importance of real-time, remote, population-scale infectious disease monitoring, wearable and smart device companies like Fitbit, Oura, Apple & Google, Kinsa Health, and Medopad (now Huma) and data-focused companies like Evidation Health and AiCure are using digital-behavioral biomarker signatures to drive earlier detection and prevention of new COVID cases, likely with the aim of launching post-pandemic monitoring solutions or data that helps economies safely reopen while minimizing “aftershock” outbreaks.

McKinsey report estimates $3B telehealth market may reach $250B in the wake of COVID 

TLDR: McKinsey distinguishes five segments of virtual care (see image above) and, using claims data, estimates a share of each care model that could be delivered virtually. While on-demand urgent care has historically represented the largest segment of the telehealth market, McKinsey projects that the largest opportunity (~$125B) lies in the  virtual office visit segment (i.e., physician consults without need for physical exam or concurrent procedures), for which ~25% of all visits may be virtualized.  

So what? Forcing cancelation of ~70% of all in-person visits, COVID has increased telehealth use from ~10% to ~50% of all consumers. Nearly 60% of providers view telehealth more favorably than they did pre-COVID. Last week, UnitedHealth’s CMO claimed that the telehealth “genie is out of the bottle,” suggesting a path to expanded post-COVID reimbursement for virtual services. With the holy grail trio of stakeholders aligned, telehealth is paving the way for other digital health solutions to ride telehealth’s coattails and augment the scope of virtual visits (e.g., wearables and digital diagnostics, digital therapeutics, remote monitoring solutions). Translating current patient and provider behaviors into long-term care and market preferences will be critical in driving McKinsey’s modeled conversion of the existing market; however, a still larger market can be captured through market expansion — i.e., additional visit volume driven or enabled by improved digital offerings.  

Singapore announces plan to provide COVID-monitoring wearables nationwide

TLDR: Last Thursday, Singapore announced that it will outfit each of its 5.7 million residents with a “small wearable device” that can be worn on a lanyard or carried in a bag to enable Bluetooth-based digital contact tracing. It remains unclear whether device use will be legally mandated and what additional digital data or biomarkers the devices will collect.

So what? Singapore’s decision to launch nationwide wearables-based tracking follows weeks of criticism of efficacy and privacy issues with smartphone and app-based contact tracing like Singapore’s TraceTogether app and Google & Apple’s contact tracing API. Wearables leaders in Asia expect “multiple, if not all” governments in Asia to follow suit with aggressive digital surveillance programs. These initiatives, if implemented, will represent the largest real-world clinical use of digital biomarkers. Clear articulation of digital biomarkers’ nascency, current and expected shortcomings, and plans for refinement following these vanguard initiatives will be pivotal in driving success of future digital biomarker programs. 

DeciBio Original Content:

[Podcast] The Outcomes Rocket: The Digital Biomarker Revolution by Chris Lew

Hear DeciBio Senior Associate Chris Lew’s take on how digital biomarkers are revolutionizing care and how DeciBio offers unique value as a  data-driven and precision-medicine focused consultancy in the space.

In Other News:

• VCs called out for missed opportunities to invest in digital health start-ups with Black founders
• NorthShore partners with ActX to expand its DNA-10k program into genomic decision support
• Geisinger partners with Siemens on diagnostic imaging and AI applications
• AWS supports WHO in launching COVID-19 app

Funding and M&A:

• Following recent ~$200M raise, telehealth giant AmWell quietly prepares for IPO
• Bigfoot Biomedical closes out ~$55M in Series C, led by Abbott
• Digital primary care startup Plushcare clinches ~$23M in Series B round
• Israeli digital x-ray startup Nanox lands ~$20M months, just months after last raise
• Ubie raises ~$18.7M to scale its symptom checker and hospital intake and triage software
• Dermasensor lands ~$11.5M in Series A for its point-and-click skin cancer screening tech
• Vara secures ~$7M to fund AI-driven breast cancer image screening tool

Fitbit launches large-scale Heart Study to detect a-fib via heart rate sensors, algorithm

TLDR: Fitbit looks to enroll 200-250K device owners in its new study, which aims to produce clinical and regulatory data validating its PPG a-fib detection algorithm for FDA submissions.

So what? Fitbit continues to close its competitive gap with Apple and expand medical (i.e., non-general health and wellness) use cases. Fitbit began collaborating with BMS and Pfizer last year to bring cardiac arrhythmia detection online, and has completed a clinical trial intended to earn FDA clearance for its ECG capabilities (which Apple earned in September 2018). Fitbit has also picked up mindshare among researchers looking to expand use cases for digital biomarkers, including notable projects to detect and track influenza and COVID-19 symptoms. This new study seeks to enlist all heart-tracking enabled Fitbit devices, including some of its exercise trackers, which start as low as ~$100. If successful, Fitbit could drive further penetration of the general cardiac health screening population Apple has primed with its ~$200+ smartwatches. While Apple had success with enrollment for its ~420K-patient Heart Study, researchers reported nearly 60% attrition of patients notified of an irregular heart rhythm who failed to follow nudges to consult with an HCP. Fitbit will need to harness learnings from Apple’s foray into the space to maximize potential for success.

See our “In other news” section at the end of this digest for leaks on upcoming Apple Watch digital biomarker features.

Health Officials Say ‘No Thanks’ to Contact-Tracing Tech

TLDR: Reception of Apple & Google’s contact tracing tool among state governments and public health agencies has been cold, with key states now planning to ramp up traditional contact tracing workforces to help reopen businesses. California and New York announced plans to each hire ~20,000 contact tracers, while leading public health figures have called on Congress to allot $12B to hire 180,000 contact tracers nationwide.

So what? Public health officials fear the blind optimism of deploying untested technology designed by Silicon Valley “techies” with limited healthcare experience presents undue health, safety, and privacy risks. Instead, they are urging states to evaluate tech-enabled solutions that complement the work of traditional contact tracers (e.g., Utah’s “Healthy Together” app, developed by social app company Twenty, which relays symptom and location history data to contact tracing professionals when a user opts in). Similar in nature, a public safety app, Citizen, which already has an installed base of ~4M in major metro areas, is attracting the attention of major employers looking to use tech-augmented approaches to reopen their offices. These solutions, along with less privacy-minded ones rolled out in China, South Korea, and Singapore, highlight that digital solutions’ adoption and potential to drive positive outcomes are fragile and highly dependent on identity and perceptions of the manufacturer and local sociopolitical and cultural attitudes.

Alveo partners with Johnson & Johnson to develop in-home COVID-19 testing

TLDR: Alveo Technologies’ be.well platform, originally outfitted for at-home influenza and respiratory syncytial virus (RSV) testing, is now preparing for clinical trials with the force of pharma giant J&J behind it. The be.well platform uses an inexpensive reader and cartridges that can be loaded with user-taken samples, and links to a mobile app that can record and relay results to HCPs. The start-up will leverage J&J’s clinical development expertise to push its platform through human trials this month, with hopes of receiving EUA to bring its first test to market.

So what? This comes on the heels of recent FDA emergency approvals of at-home molecular and serology tests for COVID-19 from LabCorp and Quest, respectively, a regulatory milestone for at-home and digitally-enabled diagnostic testing. Although a temporary emergency measure, we believe this could translate to broader acceptance and intensified advocacy for at-home testing of seasonal respiratory viruses or other infectious diseases (e.g., STIs) as stringent public health policies strive to keep patients out of crowded brick-and-mortar testing centers for the reminder of the year. Sustained “pilot” use of these remote testing solutions may drive greater consumer and HCP acceptance that survive the pandemic, as we’ve seen with telehealth.

In Other News:

• Next-gen Apple Watch will reportedly warn wearers of oncoming panic attacks
• Amazon lends its expertise — and its cash — to Covid-19 research
• From now on, every company must become a digital health company
• AMA issues new principles to restore trust in data privacy
• RWD, IoT player BrightInsight inks CSL Behring collaboration

Funding and M&A:

• Alternative Reality (AR) Player, Magic Leap, is turning to a major healthcare company to save its future, potentially raising as much as $100 million
• LetsGetChecked raises $71 million as COVID-19 epidemic makes home testing increasingly vital
• Medable Secures $25M Funding To Reduce Clinical Trial Timelines
• Owkin Raises $25M, Brings Medical AI to the Fight Against COVID-19
• Wellth Raises $10M To Drive Better Health Outcomes Through Behavioral Economics
• Digital Therapeutics VR Company Limbix Secures $9M to Fight Adolescent Mental Health Disorders

Most Americans are not willing or able to use an app tracking coronavirus infections. That’s a problem for Big Tech’s plan to slow the pandemic.

TLDR: A new poll conducted by the Washington Post and University of Maryland suggests that ~50% of U.S. smartphone users are unlikely to use Google & Apple’s contact tracing app, slated for a mid-May rollout. Oxford estimates ~60% of a country’s population needs to use a contact tracing tool for it to be effective. A recent Kaiser Family Foundation poll, however, found a higher rate of acceptance — nearly ⅔ — “once people heard the argument that this could allow for many schools and businesses to reopen”.

So what? A mounting number of reports posit that Apple and Google’s contact tracing app is doomed to fail.  However, CDC experts estimate that 300,000 contact tracers would be required to safely re-open the country, a feat operationally and financially unlikely without the support of digital contact tracers. However, raw poll data suggests a familiar pre-pandemic take-home message for digital health players — anxieties around data privacy and security extend beyond consumer tech giants and governments, and the personal benefits of using digital health tools are not well understood. While the headline-grabber was that ~55% of polled U.S. smartphone users do not trust Apple or Google to keep data anonymous,  ~45% of respondents also do not trust universities or public health agencies to do so. These polls serve as yet another signal of the urgent and severe need for technology developers to improve transparency and patient literacy with digital tools, establish assurances for data protection, and prioritize features that benefit users at the individual level to incentivize use and develop trust. While cited barriers to adoption of telehealth / RPM tools are distinct, some principles at play are conserved. Consumers’ low risk tolerance and disincentive to disrupt the status quo require demonstration of clear personal gain (e.g., for telehealth and RPM, added convenience without sacrificing quality) and real-world utilization before large-scale buy-in. For contact tracing, potential analogous solutions include returning micro-, community-level disease surveillance insights to users or tying local business re-openings to community-specific performance to demonstrate the real-world benefits of supporting these solutions. Additionally, tech companies and governments may be expected to outline clear limitations for data use and offer legal recourse and resolution should those limitations or data security be compromised.

Apple Watch diagnoses severe coronary ischemia, saves patient’s life

TLDR: Last week, clinicians at a leading academic medical center in Germany used the Apple Watch to diagnose severe cardiac ischemia and prevent myocardial infarction in an 80-year old Apple Watch enthusiast. After presenting to the hospital with chest pain, but normal ECG readings and bloodwork, the physicians cracked open her Apple Watch ECG readings and found repeated patterns of ST segment depression, a strong indicator of severe cardiac ischemia. Immediate surgical response confirmed the watch’s diagnosis and led to successful treatment.

So what? While currently only indicated for detecting cardiac arrhythmias, this success story sheds light on the trajectory for Apple Watch and similar medical-grade wearables expanding into new indications, and in the longer-term, into new therapeutic areas. By passively collecting digital biomarker data, these devices can enable more real-time diagnosis, or as in the recent case, prevention of acute disease incidents before otherwise clinically detectable. This encouraging story also highlights increasing clinician adoption of digital technologies, with practitioners now stepping outside of indicated FDA use guidelines to apply these technologies practically and in novel ways to meet the moment.

Epic rolls out new telehealth service powered by Twilio

TLDR: In the face of unprecedented demand for telemedicine, EHR giant Epic is rolling out  telehealth services in partnership with software provider Twilio. Twilio’s Programmable Video API will fuel Epic’s telehealth services app by allowing providers to initiate televisits. The app offers a solution for providers to hold remote video visits with patients while viewing and updating their medical record within Epic’s interface. Epic contains health record data for over 60% of Americans in its software systems, positioning its telemedicine services for widespread impact across ~250 million potential patients.

So what? The COVID pandemic continues to drive infrastructural changes that support uptake of telemedicine by healthcare providers. From CMS boosting telehealth reimbursement to the FCC devoting $200M to the COVID-19 Telehealth Program, healthcare providers across the U.S. are increasingly incentivized to adopt telemedicine solutions. With improved reimbursement and funding available, Epic’s app will become another telemedicine solution for health systems to choose from. However, Epic’s app will likely offer a workflow edge over its competitors. DrChrono appears to be similarly angled toward workflow advantages with its recent launch of telehealth services integrated with its mobile EHR, including streamlined post-visit billing processes for video consultations. Epic has the opportunity to differentiate by capturing televisit transcription data, facilitating pre-consultation prep, or supporting post-consultation workup, all within the health record software.

DeciBio Original Content:

Forbes Featured Article — The Precision Medicine Revolution Will Be Driven By Diagnostic Technologies by Stephane Budel

In Other News:

• HARMAN enters into a global partnership with Roche to develop a digital therapeutic technology for individuals living with autism
• Pear releases schizophrenia therapeutic after FDA loosens digital health regulations during pandemic
• Using AI and dyes, Novai spots glaucoma 18 months early in a clinical study
• Quest and LabCorp now offering DTC antibody tests — What you need to know

Funding and M&A:

• UnitedHealth’s Optum is in advanced talks to acquire remote mental health provider AbleTo for about $470 million
• Vida Health raises $25 million to treat chronic health conditions remotely
• Particle Health Secures $12M In Menlo-Led Series A To Make Health Care Data Easier To Access
• HeartVista Closes $8.65M Series A Financing Led by Khosla Ventures
• A16Z-backed Tomorrow Health launches with $7.5M seed round to improve in-home healthcare
• Summary of Q1 2020 Funding:  Sectors attracting investment amid COVID-19

Google Cloud opens its Healthcare API to help providers comply with ONC’s new interop rules

TLDR: After over a year of closed-door collaborations with health systems like Mayo Clinic, Ascension Health, and UCSF, Google Cloud has launched its Healthcare API solution, now available to all HCOs. Healthcare API centralizes clinical data from disparate sources (e.g., different EHR systems, lab and imaging software) and harmonizes it into a universal or “interoperable” format that can be shared with authorized third parties, like other providers, digital health apps a patient has consented to sharing data with, or the patient herself. The solution also enables HCOs to perform de-identified analytics and develop machine learning models to run on their patient populations (e.g., for outcomes and quality assessment and predictive analytics, operations, revenue cycle management).

So what? After announcing a March 2022 deadline for health systems to comply with the new interop rules published in March, ONC announced discretionary relaxations to that timeline and others last week as HCOs prioritize their COVID response. As HCOs adopt API solutions to earn compliance, Google Cloud’s Healthcare API will compete with Amazon’s AWS and Microsoft’s Azure, both of which are leveraging partnerships with Cerner and Epic after their Google collabs crumbled. After a rough Q4 2019 battling public outcry from its “Project Nightingale” collaboration with Ascension Health, Google Cloud is now making its Healthcare API available, hoping to reverse bad optics and regain provider trust while helping HCOs work towards true interoperability.

First 6 health systems win telehealth funding from $200M FCC fund & FCC looks toward long-term implementation of telehealth support

TLDR: Earlier this month, the FCC proposed the COVID-19 Telehealth Program, which aims to provide $200M in funding for eligible healthcare providers to invest in telehealth equipment. Telehealth funding intends to allow health systems to better serve low-income and underserved patient populations. Last week, the FCC selected 6 initial health systems and approved a total of $3.2M to be distributed across these first round picks. Individual funding allotment ranges from ~$240k for Neighborhood Health Care in Cleveland to ~$1M for Ochsner Clinic Foundation in New Orleans. A combined ~$1M was also allotted in New York to Hudson River HealthCare and Mount Sinai Health System. The health systems specify the key-use cases for telehealth funding in their applications to the FCC, and many cite remote patient monitoring and tele-visits as crucial to reduce strain on the severely limited PPE supply.

So what? With over $195M remaining in the fund, these initial winning health systems represent only the tip of the iceberg for the many health systems expected to gain funding in the coming weeks. FCC Commissioner Brendan Carr expects the fund to have a lasting impact as the healthcare system realizes the increased savings and improved outcomes that result from telehealth. COVID aside, Carr highlights the long-term opportunity for connected care technologies to alleviate the burden of chronic disease on the healthcare system by reducing emergency visits and improving therapy adherence. This FCC fund is one of the many recent boosts to telehealth infrastructure expected to drive sustained adoption of telehealth after the COVID pandemic. Beyond funding, expanded reimbursement and regulatory decisions have lowered barriers to telemedicine adoption for patients and providers alike.

What is the FDA trajectory for patient- and provider-facing AI in digital diagnostics and remote care?

TLDR: FDA guidance on regulation of AI technologies (published April 2019) has failed to keep pace with the agency’s thinking, creating an opportunity for digital diagnostics, remote patient monitoring, and telehealth players to learn from the FDA’s public meeting notes and approaches of successful initial AI innovators. Patient-facing applications of AI largely focus on video / imaging guidance, at-home IVDs, and digital therapeutics leveraging AI capabilities, while provider-facing applications center around diagnostic imaging and interpretation support, CDS, and patient triaging solutions. While provider-facing guidance has been fairly clear (e.g., act as a support, not substitute for clinician interpretation, avoid “black box” algorithms), patient-facing ones are left more to infer key considerations from pioneers in the space like Butterfly Network, Caption Health, and Ultromics. A common thread seems to be focusing on simplicity, clarity, and “fool-proofing” AI-based user guidance.

So what? As adoption of telehealth and remote patient monitoring solutions continues to accelerate, features that leverage AI will become increasingly relevant. Remote diagnostic technologies will require AI features that guide patients to capture a cardiac ultrasound or retinal image correctly, to accurately detect a signal in at-home IVD tests using their smartphone, or to position themselves in front of a smartphone camera to enable appropriate real-time modification of interactive digital therapeutics. The COVID pandemic is making it increasingly clear that remote care solutions offer many advantages over brick-and-mortar care and are here to stay. While implementation of AI can help bridge some of the shortcomings of contact-free care, effective guardrails must be established that minimize patient user error and simplify the patient experience.

In Other News:

• Under FDA’s relaxed rules on digital products for psychiatric conditions, Akili launches Endeavor video game therapy for children with ADHD
• Aetion and HealthVerity launch RWE solution to evaluate the utilization and safety of treatments for COVID-19
• LabCorp gains FDA’s first approval for “Pixel” at-home COVID-19 test
• Experts warn of technical limitations of contact tracing for coronavirus

Funding and M&A:

• Medici raises $24 million as telehealth demand surges
• Unlearn.AI nabs $12M to build “digital twins” to speed up and improve clinical trialsVR telemedicine platform
• XRHealth raises $7M
• Paige gets $5M boost from Goldman Sachs
• Habitu receives pre-seed funding to improve community health center and clinical trial patient experience

Apple and Google partner on smartphone tool for COVID-19 contract tracing

TLDR: Historic competitors Apple and Google have announced plans to develop a contact tracing system over the coming months, initially relying on official public health apps and eventually building the functionality directly into iOS and Android software.  In May, the tech giants will launch two APIs, for iOS and Android,  which facilitates interoperability and allows users to voluntarily share data through approved apps. Bluetooth contact tracing capabilities will then be built into the system, which will leverage Bluetooth transmissions to collect data on proximity between smartphones without using physical location data. If a user reports infection with COVID-19 through the app,  the system will push alerts to any other phones that have been in close proximity with the infected user’s phone.  Eventually, Apple and Google plan to incorporate these functionalities directly into iOS and Android software so that individuals can opt in without downloading an app.

So what? Apple and Google are not alone in leveraging Bluetooth technology for COVID-19 contact tracing. Existing apps have primarily been launched by academic research institutions, including MIT’s SafeWatch, Stanford’s COVID Watch and the multi-organizational Pan-European Privacy-Preserving Proximity Tracing. Apple and Google have the potential for population-level adoption than existing tools given their massive customer base. Google’s COVID-19 Community Mobility Reports have already begun to demonstrate the value of population-level mobility data for public health officials. However, patient privacy concerns are paramount in tech giants’ efforts to enter the healthcare space, COVID included. Beyond the underlying opt-in nature of the tool,  Apple and Google aim to maintain privacy and security through several underlying mechanisms, including anonymous ID keys that change every ~15 mins per individual to prevent traceable static ID numbers or a master list of phone IDs. Beyond privacy concerns, critics point to other potential weaknesses in the system — namely duration of exposure to infected individuals which may or may not be accurately captured. Mitigating privacy concerns and unnecessary panic will likely be crucial to inspiring adoption of the new system, whose impact relies heavily on population-level adoption to drive accurate behavioral change.

Science 37 partners with Innovo Research to facilitate virtual trials for COVID-19 vaccines and treatment

TLDR: Science 37, an industry leader in decentralized clinical trials, has partnered with Innovo Research, a national leader in trial site networks, on a rapid-start solution to accelerate the start-up time needed for COVID-19-related clinical trials for vaccines, drugs, and diagnostics. Innovo plans to utilize their network of sites and patients for recruitment and screening, while Science 37 plans to leverage their telemedicine platform and at-home nursing capabilities for virtual and at-home clinical trial check-points and  visits.

So what? Science 37 and Innovo Research’s partnership comes at a time when the virtual research model is much needed due to worldwide quarantine measures, and when trials related to COVID-19 require rapid starts. As the use of digital products in clinical trials has continued to increase in recent years, Science 37 has seen growing success in the virtual clinical trial space with an FDA endorsement of the idea following Science 37’s recent publication of a white paper on the subject. Additionally, Science 37 has “penned a pact” with PPD, a leading clinical trial CRO, to help run its trials remotely. Just as virtual visit and remote patient monitoring solutions have ridden adoption and utilization tailwinds ushered in by COVID, virtual clinical trial solutions appear to be on the cusp of inflection, driven by utility in high-urgency applications while eliminating risks associated with in-person interactions.

[Podcast]: How COVID-19 is affecting (and virtualizing) cancer care

TLDR: In this podcast from Andreessen Horowitz,  Dr. Bobby Green (Community Oncologist, Chief Medical Officer of Flatiron Health) and Dr. Sumit Shah (Stanford Cancer Center) discuss how COVID is catalyzing digital transformation in the patient and physician oncology workflow. As with primary care, virtual visits have had enormous value in maintaining care while minimizing risk of viral exposure. In the past 2 weeks, Stanford’s Cancer Center has seen virtual visits grow from 5-10% to >60% of total visit volume, with routine follow-ups, patient symptom discussions, and test results (e.g., blood counts) as primary use cases. Meanwhile, Flatiron’s network of community oncology centers has seen in-person office visits drop by 22% as non-essential appointments are conducted virtually or postponed. Both oncologists noted the significance of virtual tumor boards and online crowdsourcing (via Twitter) to supplement ASCO’s guidance for using cost-benefit analyses and relevant data to support treatment decision-making during the crisis. Lastly, the need to minimize or virtualize non-essential clinical trial check-points is driving value-based, patient-centric care, where patients may have needed to travel and wait for 6+ hours to comply with trial protocols. While certainly not stand-ins for physical care (e.g., therapy administration, human touch), these digital transformations across the cancer care pathway seem to be positively received by patients and clinicians alike.

So what? Industry experts see telehealth solutions improving patient journeys, clinician workflows, and value-based care at-large in primary care and oncology care, and see this lasting beyond the pandemic. However, growing pains exist — virtual delivery of significant diagnostic / prognostic news lacks the humanity of an in-person conversation, screen-sharing and store-and-forward image / video capabilities within telehealth solutions are often not supported, and real-time communication between providers has not fully capitalized on the digital opportunity at-hand. Despite this, oncologists envision a future in which some in-person visits are replaced by virtual follow-ups and at-home therapy administration (e.g., for subcutaneous IVs) overseen via virtual consultation. Oncologists envision a broader network of virtual clinical trials reducing unnecessary travel burden and procedures on the patient as the crisis highlights procedures with dubious value to outcomes. And oncologists envision a future in which virtual care expands clinicians’ insight into who a patient is in their day-to-day environment — home.

DeciBio Original Content:

DeciBio-Emmes Data Insights: Hospital Labs’ Readiness for the Coronavirus Testing Onslaught by Julia Daniel

Here we make sense of the fragmented landscape of coronavirus testing options currently available and examine which tests will likely most easily enter hospital laboratories, based on insights from DeciBio’s Emmes Infectious Disease database.

Funding and M&A:

• Tyto Care lands $50M
• 98point6 raises $43M
• SonderMind scores $27M
• SilverCloud Health raises $16M
• Sweden’s Mindler rakes in €8M
• Dorsata locks in $5.2M