COVID-19 Recovery

Speaker 1: As clinicians really want the data, we want the actual insights. Speaker 2: We take back medicine. Speaker 1: Now it's starting to shift to Quantified Health. Speaker 3: Wearables being a nice to have to a must have. Speaker 2: That's where Big Data really is. Speaker 3: It's not a specific device anymore that's exciting. It's what we can do with the data. Speaker 2: Thinking bigger, much bigger. Speaker 1: Welcome to Healthy Conversations, the podcast, an open discussion amongst healthcare professionals about what we've learned from the front lines of the pandemic and how it's transforming our industry in real time. I'm Dr. Daniel Kraft. I'm really pleased to be joined by Adam Pellegrini, who's the SVP of Enterprise Virtual Care and Consumer Health at CVS; and Dr. Eric Topol, who's the founder and director of the Scripps Research Translational Institute, professor of molecular medicine at Scripps cardiologist and has many other hats as well. And we're going to be diving into a conversation exploring some of the elements related to covid, big data, future of medicine. So let's get started. I thought I'd start with Adam in the topic of sort of big data for public health, you've dedicated a lot of your career to consumer health tools. You were previous with Fitbit and you've seen these tools evolve and able to capture more data that might have applied to public health purposes. So I was wondering what your view was on sort of the consumer side tying to public health. Speaker 3: Well, thanks for the question. I believe wearables and biometric data as a whole can play a big role in public health. A lot of what I have learned has actually been from Dr. Topol and the work we've done for many, many years together in different hats, trying to look at how can data itself, specifically healthcare wearable data and other biometrics, how can that show trends and potentially down the road even predict trends of what can happen. And the key behind consumer health and this generation of data, you have to have something that is sticky, that is engaging, that is fun in many ways for people to use it on a regular basis. For folks to use it on a regular basis, that's how you generate the corpus of data to be able to do meaningful insights on moving from wearables being a nice to have to a must-have. That transition has to be through meaningful insights and clinical tools that could actually see the population trends and Eric's team is pioneering the work there. Speaker 1: Yeah, I love to call it kind of the combination of predictalytics and where are you and where is that patient or population heading. So Eric, you and your colleagues have been driving a lot of the integration of consumer health tools, particularly in the year of Covid. Maybe you could touch on what you're learning. You're helping lead up the DETECT study. What's the cutting edge and what are the implications now and into the future? Speaker 2: Yeah, well, first Daniel, let me just thank you and Adam to have the chance to have a conversation with you two great long-term friends who share enthusiasm for digital tools to understand people. So on the COVID-19 story back in March, we set off the DETECT study, which is really a very interesting way to get our arms around a kind of sorry scene here in the United States, which is right now it's thought that over eight and a half percent of Americans have been infected, and the spread is still rising and it's very troubling. And everyone talks about test, test, test, but the problem is we can't test 330 million people on a frequent basis. So we have been complementing that with digital assessments. We had already validated that having resting heart rate and steps and if possible sleep metrics that provided an incredible signal for flu. And we published that early this year, and it just by happenstance, not knowing that it would be useful when we did the study, that it would turn out to be a valuable way to get our handle around COVID-19. So we have now 40,000 people who are data donors donating their continuous data, which is a different way to get understand this condition. And we have a signal, which the same as what we saw with flu, if your resting heart rate goes up, the sleep goes up and your steps go down, that could well indicate not for an individual, that's the key, but for a cluster of people. So if the geographic cluster of people, we can say, "Hmm, something is going on here," and we correlate that with onset of symptoms, annotating symptoms. We can pick up asymptomatic infections, presymptomatic infections, all sorts of things with wearable and it's exciting. And if we only could get state covered, but if we had millions or hundreds of thousands of people, we could do a really good job of predicting where would be the next group of people that are suspect to have COVID-19 before it's spread. So that's DETECT. Speaker 1: Think for Adam, you've seen a lot of evolution in just sort of the consumer wearables moving now to health. Some are being FDA approved, we're seeing the evolutions of some that may do real-time blood pressure, maybe blood sugar and others maybe. What's your prognostication of what's most exciting now and what's coming on the wearable side? Speaker 3: Well, you mentioned it, the term check engine light for your health. That is something that I've been very passionate about ever since I think it was James Park that used that first, and I learned a lot from him of this idea that these things should, wearables, they should be like a check engine light. They should be able to have very basic signals that maybe run in the background. But as you go out and you hike, as you go out and you walk, to know that you have some sort of background intelligence service constantly running, constantly crunching the data, looking at the algorithms, trying to tell you, "Hey, listen, something could be up, something could be coming." Right now we see a lot of folks still going to some traditional symptom checkers that don't use streaming biometrics, that don't use quantifiable true sort of rigor, FDA rigored data, and then they get afraid frankly of some of the online assessments. I think we have, the future's truly to have that fidelity of biometric streaming data into algorithms that could actually have that vision of a check engine light. And so I think that's the future of these devices. The FDA pre-cert program was launched to allow wearables and other devices to come up with really next generation novel concepts and get through FDA so that we could see a rapid acceleration of smart devices that have that intelligent service in the background. Having folks, teams like Eric's team constantly pressure test and do studies, that's a critical piece to that future because we can all think of incredibly awesome ideas and do a startup and come up with a really next generation, but it's only through that scientific rigor and those peer-reviewed studies that we can actually pressure test even our own inventions and make sure that they are the next generation of health care. So a shout-out to the teams that are out there not doing it just because we can, doing it because we want to prove out an evidence-based model towards population health. Speaker 1: We now have all this quantifications, often called quantified self. Now it's starting to shift to quantified health where it can flow to your healthcare provider. My Fitbit data now goes to my Apple Health kit to my doc at Stanford, but I don't think he ever really looks at that or knows what to do with it. And one of the challenges, and Eric you've addressed this a lot, is how do you then connect the dots to the clinician to leverage this sort of data modeling, et cetera, and use it practically? What are your insights or opportunities in that space? Speaker 2: I think the first step is that we as clinicians don't need to control everything. That was the thesis of The Patient Will See You Now and I think we are control freaks in general. And then the second part is a lot of these apps for sensors are great for capturing the data, but they're not made to integrate well with healthcare professionals. We got great engineers, great sensors, data capture, veracity of data, and that interface, we need much better, to be much better at it. So whether it's glucose or whether it's any important metric. And the idea that we're seeing now where people are being monitored at home with COVID-19 and their oximetry data, for example, no less their vital signs. There's several health systems that are trying to use this now without a validated algorithm. It goes back to Adam's point is you got to nail this down, you got to make sure it's safe and it's working and all that. But one of the most important things is that get that data package that's real time getting to whoever, whether it's a nurse, a doctor, whoever is the overseer of the data. The tech world is really good at certain parts, but not making real world medicine work in a streamlined way. Speaker 1: And as clinicians, we want the data. We want the actionable insights that can be applied with the evidence-based behind it. So no one wants to see every step or sleep point or EKG. The trick is to synthesize that and part of your great book Deep Medicine is how do you block all that as a consumer, as a patient or as a clinician. So we're not overwhelmed and we can use that in really smart, hopefully more crowdsourced, actionable ways. Speaker 3: We're seeing a massive use of at-home technology and what is the most critical element of the healthcare system right now is making sure our ICUs can be staffed and making sure our ICUs have equipment and emergency rooms. So right now we're seeing sort of an evolution of these type of digital tools, telemedicine, virtual care, working with the healthcare system, which is needed for critical things that you have to do in a hospital. So you're really seeing that future now because of Covid. These are huge numbers, and frankly I see this as the future trend. Most reports and analysis believe that we'll get to around 20 to 30% above baseline post Covid and the use of virtual care technologies. Speaker 2: That's so important that you bring that up, Adam. If we get really smart about this, it can be quite objective. There's ways to get most of the physical exam done if need be, there's of the sensor data, so we can go to this 2.0 telemedicine that is closer and closer, simulating not the same, but so many things we'll be able to be shunted to this virtual me. Speaker 1: But imagine when you have your sort of medical tricorder, your pulse oximetry, the synthesis of your past medical history or your wearable data that's put in context for the clinician that it's going to really make these sort of visits upleveled dramatically. Speaker 2: Exactly. Speaker 1: So Adam, I want to switch a bit sort of to what you're seeing sort of next. What gets you most excited? What do you think has the biggest impact for patients going forward? Speaker 3: Well, I'm really excited about, as Eric was talking about, the next generation of telemedicine that can actually leverage more biometrics. I think having a really strong virtual care strategy that actually makes it easy, makes it approachable is critical. Our attain program has a concept of healthy actions that actually is leveraging the biometrics to say, "This is what you should do next." I think the more we can do simple, bite-size actions, we can help enable those for consumers. That's really what gets me excited. Distilling the complexity, distilling the multiple biometric data streams, distilling all of that down so that we can just provide very simple guidance and navigation. And then when a consumer gets into the healthcare system, when they get into the flow that can be fraught with different types of obstacles or confusion points, how do we make that so seamless and frictionless that they breeze through any bureaucracy, so they can get to care and not have to worry about anything else? That is why I got into digital health. As a medic in the army, you take care of one person at a time. You all are doctors, same the thing. I always said to myself, "Wouldn't it be great if we could do one, I could do one thing and take care of a thousand patients or 10,000 patients?" An algorithm is the answer to that question in many ways. What better time spent than to focus on making sure that we reinforce those capabilities, invest in that research and really champion those type of digital therapeutics and algorithms that can help people in mass? So really it's not a specific device anymore. To me that's exciting. It's what we can do with the data and what we can do to really drive healthy behaviors at a population level. Speaker 1: All this data synthesizing now to make it useful, whether you're the empowered consumer or hopefully the smart clinician. Eric, you've written and researched and helped promulgate this idea of how do we convert all this to be really useful. Maybe we just spend a minute on, maybe start with Eric, what are really the barriers? Often there's misaligned incentives might be reimbursement or regulatory that are holding some of these things back and what's on your wishlist to really accelerate things? Speaker 2: One is that the tech world, health is still not the number one priority. The big tech titans, can they work in this space, which requires F D A and all sorts of landmines that they're not familiar with? The next is the talent. So in order to do this work, you need really top flight AI scientists and teams that are willing to really invest in developing multi-layered complex algorithms, not just deep learning but hybrid models. And we aren't seeing that because these same brilliant young people, they don't get paid well in healthcare. In order to do this work, we need even more than deep learning. Speaker 1: I'm not sure if made up the quote, but I often say the AI's not going to replace your doctor, but the doctor who uses AI will replace those who don't. What are some ways to sort of dispel the myths there, and as you've written about working together, is it where the power is? Speaker 2: The immediate term is that AI can really bolster accuracy and speed and make things more efficient. Like the workflow, the idea that you could interpret a scan of any type. Anything that's got a pattern, you can have machine support to get the answer to get it right. The other thing is to get all the records reviewed and teed up so you don't have to spend scrolling through all these different screens to find out what's going on in the background of a person you're seeing. These are things that machines do better than humans, but that will benefit and free up time. And that's the gift of time. That's the second part, phase two, which is we basically get back to a point where we have an intimate relationship of patients and physicians, patients and nurses because that gift of time now, if we stand up for patients, we can actually override the administrators who have gotten it down to single digit minutes that you spend with a patient. And here you are, you're discussing a really serious matter, a serious diagnosis or worries about a patient and their family, and you have seven minutes and you're typing out a keyboard, looking at a screen. So we have to get eliminate keyboards, restore the relationship. That's the long term and that's going to take active work because the financial bean counters don't want to see productivity impaired. They don't want to see appointments go longer, clinic visits, but that has to happen in order for us to take medicine back. Speaker 1: Absolutely. And you and Abraham Geese on your Medicine and Machine podcast really help identify and elucidate kind of the power of doing that. Now, the topic of the day is obviously Covid, both crushing the curve, eventually getting to recovery. We even to think hopefully we're seeing some positive ailments on vaccines out of UK, out of Oxford, and maybe out of Moderna, eventually it's going to be the need to go to your corner pharmacy or clinician to get your vaccine done. Maybe let's talk about what are some of the roles that CVS can do and the digital health community on recovery and prevention of even the next pandemic. Eric, you must have a lot of thoughts on this. We haven't done a great job, particularly here in the US. What's the biggest opportunities? Speaker 2: In order for us to get out of this mess that we're in right now, we have to get the unity of purpose so we have some tough work ahead. The science part is turns out to be the easy part. That's not easy. In talking to Tony Fauci last week, he reviewed how from the day the Chinese sequenced the virus to having a template vaccine in five days and in the first trial in 62 days from the day the virus was sequenced. That's incredible. It's astonishing. So the science has moved like a velocity. That's unheard of, unprecedented, but the roadblocks that we may be facing are beyond what digital. We could use these tools of social media. I've never been on TikTok, but it seems to be having effects, especially with Sarah Cooper and great talents there. But if we had creative ways that people are receptive to the advances in science, as they should be, because that's what's going to get us out of it. Speaker 1: Yeah, it's not just a pandemic, it's an info demo and we almost need to think proactively now about new ways to meet the people who have particular reviews that are almost anti-public health. Speaker 2: Yeah, yeah. No, we're going to have several really good vaccines I think based on all the data we know so far, phase two data, and making gazillion doses is not the rate limiting step. It's the acceptance of people. Speaker 1: Adam, on the CVS side, a lot of what you do is also integrated, including how you communicate everything about vaccines to wearing a mask is about design thinking and how you message and how you might message it for different folks depending on where they are. Are there sort of lessons that you've gleaned there that would be applicable? Speaker 3: We should learn from history for one. So that's one of my goals is to make sure we memorialize the lessons learned and how does digital health in some way create templates so that we can in the future leave something for posterity to be able to have really quick tools to deal with a pandemic right away. I think from a design learning perspective, behavior change, we have seen it now with Covid. We've seen that folks shift to telemedicine. That's a behavior change shift. We've seen folks use more apps. So I think if we have those intrinsic drivers around public health that drive the behavior change and it's sustainable and we keep folks engaged after the behavior change happens, I think that's how CVS can play a role leveraging behavior change and making things seamless and easy so that folks can stay both virtual, as well as in the brick and mortar. Speaker 1: And that applies not just the consumer, but the health care provider. They might be initially lessons from Wuhan or Italy to the ICU in Houston or in San Diego. Speaker 3: Exactly. Speaker 1: What would be your view or vision for where we can really take some of the things that have been sparked by Covid in a positive way, reshape healthcare around the planet? Speaker 2: That's a lot to unpack there. The dream for me is to have a planetary health system where you have federated data so it doesn't leave any country or place, but it's used with privacy and security protected and homomorphic encryption. And we learn from each person because this transcends any inner country tension or strife. This is about humankind. I think we can do it. I had a paper with Kai Fui of China in Nature Biotech that outlined how we can do it, we should do it. And I actually think by working together, it might reduce some of the issues that countries have with each other to a common purpose. So that's where big data really, is thinking bigger, much bigger, but more today is we have ridiculous health inequities, as we've seen with COVID-19. The proportion that are affected both with respect to infections and bad outcomes among Blacks and Latinos and Native Americans and all the underrepresented, it's horrific because we don't have a national health system that is accommodating all people. The only one in the world of the developed nations that doesn't have all of its people covered, and that needs to be remedied right away. Speaker 1: Yeah, no time like now and the fierce urgency of now. So to wrap up, maybe we let both of you sort of speak directly to healthcare providers. I'd urge all of you who are listening to follow Eric on Twitter @erictopol. Incredible, I don't know how you do it, but you synthesize so much and share it out and it's super impactful. Speaker 2: I think Adam used the term pressure test, and this has been the ultimate pressure test for medicine. And all the providers that are out there had to deal with the risk and the lack of protective gear and all the issues to take care of patients. And that goes not just for people on the front lines of in the ICU in hospital, but the pharmacist, the paramedics, the entire continuum. This has been really rough. If anything, the public acknowledges the importance of the medical profession more than ever. We are hopefully learning from this, whether we have a second wave or whether we face threats like this again, we'll never let the medical professionals down like what occurred here. Speaker 3: Yeah, I would just echo Eric's comments. First of all, thank you to everyone that is out there on the lines doing really hard, very stressful work every single day. It takes an entire village to keep the machine running. I know that at CVS, we are absolutely committed to health care professionals, pharmacists, nurse practitioners, medical assistants, providers to provide whatever resources we can to deal with this time. And when this is over, we must not forget that this period of time, it's not just going to have an endpoint. It should be a remembrance of how do we make sure that we are better prepared in the future and support the healthcare system. Speaker 1: What do you think is important for health care professionals to know about the digital health, big data convergence from hospital to home, to mobile to virtual, to Omix that we can take forward? Speaker 2: Well, it's the future. We got ways to go. We're at the very nascent phase of that, but eventually it's going to be exceptional. We'll fulfill the dream someday for prevention. That's our best shot, but it's not around the corner. It's going to take a while. Speaker 3: And I would say from someone who builds digital health products, a product strategy perspective, one thing that I've been telling my teams lately is we talk a lot about consumer experience. How do we make an amazing consumer experience? We need to start really preaching about provider experience. And by provider I mean all types of providers. We need to really emphasize both to make it actually work. It takes a doctor to take care of a patient or a provider to take care of a patient just as much as it takes a patient to have a visit with a provider. So I think we need to think about this holistically now. Speaker 1: And in many cases, there's that famous quote from William Gibson, "The future's already here, just not evenly distributed." And I always encourage my physician or clinician colleagues to try out some of the tools and platforms that exist, even if it's not fully reimbursed, but you can get amazing insights into your patient and practice and help catalyze the future of healthcare to bring that future faster. So with that, I really want to thank you, Adam Pellegrini and Dr. Eric Topol, for an amazing conversation and for all both of you are doing to really reshape a much better future of health care for all of us around the planet. Thank you for listening to Healthy Conversations the podcast. It's our mission to reveal the front lines of the health care profession and educate everyone as to the challenges and potential opportunities of a world changed by Corona.