Swallowing the "Digital" Pill

A half decade ago I stood on a stage at the 2016 MobCon Digital Health conference with my good friend Dr. Caleb Kennedy sharing our perspectives on the impacts that we expected digital technology would have on health.  At the time, most were thinking of software and the cloud as a necessary evil to try to improve the efficiency of care delivery, and rightly so as this was and still is what drives most of the costs of the US healthcare system.  

We saw the trend of precision medicine holding the promise of mass customization, allowing genomics, pharmaceuticals, and the power of our own immune systems to cooperate to deliver treatments that were most effective for each of our unique biologies.

And with behavior being one of the most significant determinants of health, we noted the largely untapped opportunity to use the power of mobile devices to influence behavior and create and sustain health habits and long term behavior change.

Little did we know then just how true this last prediction would be!  Fast forward to today, and a wide variety of mobile apps and companion diagnostic and therapeutic devices are being combined in exciting ways to tackle the immense challenge of preventing or managing a wide array of chronic conditions.  These chronic conditions are often “co-morbid” with each other - a fancy clinical term for describing them compounding within one person to have even more dramatic effects on that person’s health.  

If you want to have the best odds of preventing chronic conditions from developing, you also have to be able to figure out how to understand and unwind these dependencies with a holistic approach.  You have to understand how bad behavior patterns develop and what kinds of interventions work best to interrupt those negative feedback loops and to introduce new, positive patterns instead.  

And, most importantly, you need to find cost effective ways to teach, monitor, respond, and engage people to take these steps, ideally through low cost digital sensors and systems.  However, if that alone is not enough, then the system should also provide gradual escalation and encouragement from unlicensed “coaches” who bring an accountability that is often needed to keep us honest about setting and achieving our goals.  These coaches can reinforce our education as we educate ourselves through a variety of content mediums all delivered through digital apps.  They can also help us recognize when all of the above are not working and we may need more help in more traditional clinical settings, including assisting with understanding our insurance options for getting the help we need and walking us to the digital front door of the care provider that we need.

The key to effective prevention is not to erect barriers to access to care but to eliminate them - if you provide a seamless spectrum of care then you can ensure that each person is always getting the preventative care they need at the lowest delivery cost and in the most effective way.  In short, the best way to manage the overall cost of care in the clinical setting is to avoid needing it in the first place.  If I had a pill that I could give you that would keep you healthy and prevent you from needing to go to the doctor, we would call it “medicine”.  So, if I have a collection of mobile apps and related devices that can do the same, why not call them “medicine” too?

What did we all learn while we were too young to know better?  If it’s good for us, it tastes bad.  “Medicine” needs sweet candy coating if we are going to consume it willingly, and since most meaningful behavior change requires education and disciplined repetition over a time period measured in months and not in minutes, the digital therapeutic only works if it is engaging enough to allow us to learn, incentivize the right behaviors, and keep us coming back and using it long enough to create the needed change.

This is why a constant flow of engaging content and related notifications are needed like an IV drip that keeps bringing us back to the app to take our medicine.  It’s also why user experience design for the entire service is so important - if it is hard to access or understand how to use, or if the app or service is too difficult to navigate or people get confused and frustrated, then they stop.  It doesn’t take much, because it is in the end still medicine, and adherence is hard even in the simplest of circumstances and even when the benefits to the individual are abundantly clear.

Interested in examples? Here are a few that I know about for various reasons, and there are many, many more available or in development.

Sanvello Health

Between then and now, I had the privilege of working with an amazing team to launch a new mental health provider, Sanvello Health ( https://www.sanvello.com ), which delivers on the pattern and promise described above with Cognitive Behavioral Therapy (CBT) as the “medicine” inside.  Sanvello is focused on stress, anxiety, and depression and is integrating to wearables that measure Meditation, Activity as behaviors that help improve mental health and Heart Rate Variability (HRV) as a biomarker for anxiety.

Kenkou

Even the cameras in our phones have remarkable potential - imagine holding your finger up to the camera on your phone and having the app measure your vitals such as heart rate and HRV and calculating results such as your tension index or recovery ability.  This is what Kenkou (https://kenkou.de/ ) can do with nothing to buy except the cellphone you are already holding in your hand.

Binah.ai

Now let’s take the power of the camera in your cell phone even further - what if you could point that camera at your face and instead of taking a selfie, instead measure your heart rate, HRV, oxygen saturation, respiration rate, stress level, and even blood pressure.  Again, Binah ( https://www.binah.ai/ ) requires no other wearables or devices needed, yet you can quickly measure and trend these vitals any place, any time.

Level2

Apps and wearables are also being used by Level2 ( https://lvl2.com ) to manage pre-diabetic and Type 2 diabetes through the use of fitness tracking and continuous glucose monitoring to help people understand how their diet and activity have a direct impact on blood sugar levels. 

Psious

Virtual reality is being integrated into apps as well as mental health digital therapeutic for trauma, OCD, ADHD, and PTSD ( https://psious.com/ ). With VR, we can provide safe digital environments for people to use that are immersive enough to distract or calm and are realistic enough to help with desensitizing people to situations or environments that cause them anxiety or fear.

InMotion VR

Virtual reality also shows in the world of physical therapy and chronic pain management.  InMotion VR ( https://inmotionvr.com/ )  uses VR to provide adaptive, precise, and personalized exercises in a gamified experience designed to make it possible for you to do your PT at home yet to still get the help you need to make sure that the form and repetition is correct and to help you stick with it long enough to see the benefit.

A "Neural Pathway Pain" Tangent

What you might not know is that some forms or chronic pain are actually phantom in nature; they are very real to the person experiencing them, but they are also the result of learned neural pathways triggering pain responses in anticipation of pain.  The brain is a complicated place, and sometimes these helpful responses to acute pain to avoid further damage are useful, but once the damage has healed they can be problematic.  Neural pathway pain not only hurts for real but also can lead to other issues as your body works to avoid pain that isn’t there.  VR with motion sensors can help you move your body through the range of motion needed for your brain to re-learn that the motion is safe and re-train the neural pathways.  Here’s a deeper dive if you are interested:  VR For Pain

Show Up and Stay

And last but not least, one that is near and dear to my heart.  The unfortunate truth is that all the various conditions I’ve mentioned so far can combine in traumatic ways, and one of those ways is to result in addiction as a way to try to cope with or escape one or more of these challenges.  If this is happening to you, it is difficult to navigate the options and recovery alternatives available to you, and especially difficult to make it through aftercare and into long term recovery.  Show Up and Stay ( https://www.showupandstay.org/ ) is working on educational content, a podcast, and a mobile app to provide you access to resources that may help you with that difficult transition.

Wrapping Up

As I mentioned, these are just a few examples of the innovative ways that mobile apps, wearables, cameras, and other smart devices are being combined in novel ways to provide preventative and therapeutic services for a variety of chronic conditions.  It’s exciting to see the industry as a whole begin to understand the potential of digital therapeutics, and also to see these companies join forces to establish the role they can play in changing healthcare throughout the world.  For more information, check out the Digital Therapeutics Alliance at https://dtxalliance.org/ .

Be well!