Kidney Care Goes Digital, More Accessible

Yonatan Adiri: So I think we're at the cusp of an incredible revolution where we felt we were there three times in the last six to seven years. I think we actually are there right now. Dr. Daniel Kraft: Welcome to Healthy Conversations. I'm Dr. Daniel Kraft and today we're in healthy conversations with Yonatan Adiri, the founder and CEO of Healthy.io. He's coming to us from Israel, Tel Aviv. Great to have you here. I've been fortunate to know you, I think since 2009, when at the time you joined us at Singularity University for a graduate studies program. You were already a superstar. You were the chief technology advisor for Shimon Peres at the time the president of Israel. Maybe give us a little bit of your history before you got into digital health and your role in helping shape the future with someone like Shimon Peres and technology in general. Yonatan Adiri: These were great days. So I grew up, as you said, in the public sector. Culmination of my career in that episode was being the chief technology officer and diplomatic advisor for the president of Israel. At the time Shimon Peres was not just a president. As a colleague of mine in the White House said this is the equivalent of working for someone like Washington or Jefferson. This is a founding father, last of that generation. So that was a great privilege. We were separated by 60 years. I was 26 and he was 86. But nevertheless, it was inspiring to work for a person who with his own hands and with his vision through a political career that spawned 65 years has repeatedly paved the way for Israel to be a competitive contributor to global technology and innovation. I was in charge of Israel's mapping out how competitive is Israel in fields that will determine, I would say, the future of humanity and at that fork in road, if we're competitive, how do we remain competitive and if we're not quantum computing, nanotech and so on and so forth, which by the way ended up being also instrumental going through GSP09 and learning from the folks at NASA and at Singularity. How do we become more competitive and how do we wield diplomatic relations for the better of humanity in a way. The more competitive we are, the contribution that we can make to longevity, to clean energy at Singularity. And this is also critical for how Healthy.io was formed. I got the bug of looking for exponential curves. What can we anticipate to grow exponentially in a compounded nature? And that's where after finishing my episode with the president, one of my focus areas were smartphone cameras that were growing exponentially by capacity optically, computation on the phone, bandwidth, cloud computation, cloud storage, whereby the price performance was declining very rapidly. So we're getting exponentially better tech for exponentially lower price. And that was, if you will, the genesis of Healthy.io and how we thought of harnessing that camera capacity explosion and through AI to keep it simple like the economists called Healthy.io back in the day. How do we usher in the era of the medical selfie in a way? Dr. Daniel Kraft: And speaking of the camera, back when we met, I think we had the iPhone 2. It was magical, it was incredible, but now it's slow and clunky and has a low resolution camera. Maybe just to help folks frame this idea of exponentials, because it often kind of is surprising how much things can change. Yonatan Adiri: In that perspective it's important to understand also the societal elements that drove that curve. So these things don't just grow because tech can go somewhere. Why does the iPhone 14 have a 20 x better performing camera just when you look at the megapixels, but infinitely better camera when you compound computational photography and very low light pictures coming out of the iPhone 14 are just like pixel enhancement. They're not happening on the hardware side. So think about it, back in 2000, even 14, 15, we would pay for text message and today we're doing HD video on our... In Israel it's like a $12 all expense paid monthly plan. I was chatting with my father a couple of weeks ago from a top of a mountain in the Swiss Alps for free. That was not even imaginable when we met in '09 and quite frankly, that wasn't even imaginable in 2014 when Healthy.io was created and some of our early stage investors felt that our vision for where the cameras would go is too aggressive, too exponential. And in hindsight we were actually even too conservative when you look at camera quality and the envelope today. Dr. Daniel Kraft: I'm sort of a amateur photographer. I don't even use my fancy $2,000 camera anymore. My iPhone basically can do everything and much more. But as you mentioned, people tend to underestimate. There's not just Moore's Law, but there's Amara's Law. We tend to overestimate what might happen in one or two years, but underestimate what might happen in a decade. And certainly we have things that are becoming dematerialized. You don't even buy a video camera or a GPS unit anymore, and in this case, we're not going to need to require a lab. Yonatan Adiri: There were a few waves of how digital healthcare, I would say formed. Some of them were more hopeful than what ended up happening and some actually materialized. If you think about Watson, IBM Watson, 2014, 15 and the wearable revolution, there was a concept that was very dominant that digital health will be driven by wearables and will be driven by data such that the more data we produce, the more medical insights in a linear curve we will actually have. [inaudible 00:05:33] was a compelling vision, but at the end of the day did not materialize for a variety of reasons. One of which was in my view, the fact that hardware costs continue to go down. So it's very hard to build a business where the ability to compete with you is growing exponentially and requires less and less capital. And then Apple stepped in with its incredible Apple Watch and brought its prowess and world famous supply chain and hardware capability. And that I think repositioned an entire area in our industry. The second wave was driven towards home testing, et cetera, and we're all familiar with the Theranos case, the idea of drawing blood at home, et cetera, and how do we enable that? And I think that also showed great promise. And then with how that unfolded was again a deterring factor over the last eight years. The last two years given COVID, we've seen an incredible growth, maybe the watershed moment for digital health. Incredible engagement and couple of months ago the American administration's commitment to finance eight antigen testing per person in the US this year. That's like a $30 billion marketing investment for all of us in the industry. So in hindsight, I think when we look back at the pandemic, this investment would be like the Marshall Plan. So I think we're at the cusp of an incredible revolution where we felt we were there three times in the last six to seven years. I think we actually are there right now and maybe just another point here on where we're going from here. I think clinical grade applications are the way to pave the way going forward. We have a lot of conversations with payers in the US. We serve the National Healthcare Service in the UK, and what we found is technology in digital, not talking molecule or bioinformatically driven interventions, but in digital healthcare, what we find is the catapult or the accelerator for adoption. Yes, technology is that part, but it is the clinical trust that you build with payers and with healthcare systems that is driven by solving for clinical need, for clinical utility. Can we as a community get together, company by company like a swarm of digital health companies and each solving for a specific large enough clinical failure of the analog system and deliver better measurable health care outcomes? That's the ultimate test that all of us are going to be facing over the next three to four years, and those who will be able to do that on a sustainable level will probably lead the IPO window of 2025, 26. That's sort of how I see the industry unfold. Dr. Daniel Kraft: And as you say, we've all now experienced this ability to do home-based diagnostics. Yonatan Adiri: Yeah. Dr. Daniel Kraft: Let's talk about Healthy.io and the company event and what problem are you trying to solve? Yonatan Adiri: The vision has always been about the imminent decentralization of health that would result in two key developments. One is unlocking enormous financial value through showing better health care outcomes. And the second one is a massive, I would say, tectonic shift on the infrastructure level. Our mission though is very unique. When we set out in 2014, we saw those selfie economics. We made a bet on teenagers in a way. We made a bet on Snapchat and on TikTok being what they are. How do we turn this camera to a clinical grade medical scanner without hardware, without dongals, how do we become the best company in the world in introducing the AI layer that takes this camera turns it into a medical device? We committed to three principles. The first one was clinical grade and clinical utility. That means clinical trials. That means developing a relationship of trust with the FDA. That means that everything we do is transparent, published and the medical community can address and access. The second layer was population health. We try to build as a principle for every product services and solutions that can be accessed in a democratized nature. Meaning our target is not direct to consumer affluent people in the UK, in Germany, Israel or US. It is about the masses. It is about the 60 million people in the US that suffer from diabetes or hypertension and will ultimately end up with renal failure potentially in a portion of them that don't test annually for ACR. So the products that we produce have to be affordable. They have to be within the existing CPT codes. So clinical grade population health, not premium products. And the third is obviously digitizing areas that are really failing in delivering healthcare returns in their analog format that are failing the system, and are computer vision based. And the triangulation of those three yielded urine testing as our first product. Digitizing the dipstick based, everybody loves it. It's generic, it's phenomenal clinical utility, hundreds of millions of tests every year. Last year CKD costs $120 billion to the American taxpayer and also to the system at large. At the end of the day, the analog format is computer vision based. So that's the genesis of Healthy.io and how we ended up with urine testing. Dr. Daniel Kraft: And just describe for those folks listening, how does that work today for a user wants to check their urine at home? Yonatan Adiri: Let's talk a bit about the kidney space because I think that's where it's most exciting. And the example is from the UK. This is actually rolling out also in the US as an investigative device. In the UK it's been a phenomenal year in 2021. During COVID three times quarantined, the NHS chose to allow for people with diabetes and hypertension, 600,000 of them to test at home with our system. These are people who suffer from a disease, puts them at risk for cardiovascular and renal failures. The system has tried to get them to engage with annual testing and has failed over the last three to four years and even more so during the pandemic. And as these people don't test four to five years out, cardiovascular events and renal failures manifest themselves and that's very high cost. We just got those folks tested once a year. The medical practice of averting dialysis is very well established and cost-effective. We get the list of names from the regional in the UK, what's called CCG commissioning group that says, "Here are patients in our region that are at risk and haven't been in the lab for an ACR test in the last, call it three years. Can you please offer them your service?" And then we engage with those patients on behalf of the NHS at scales. If we get 50,000 names within a week, 50,000 people will get a kit that has the same dipstick that's otherwise used in the lab and folks listening are invited to go www.healthy.io. You'll see a quick 20 second clip. But in essence, we guide every layperson, ages eight to 98 on how to do the test on an app. They dip the stick and they scan and within literally two to three seconds results at clinical grade are offered to them as patients and are also fed into what's called system one, which is the central NHS lab. And we drive 53% compliance among those patients previously non-compliant. Across age groups, the last cohort we did in the UK, 80% of which was above the age of 50, 25% between 71 and 80 years old where we saw 40% compliance. And the way to drive that is a very religious focus on the clinical utility. We developed what we call ColorOS, heavily patented series of AI machine learning algorithms that make all phones see color the same, and then proof points in clinical trials. That's ColorOS. That gives us the right Daniel, to get to your doorstep. That's just a ticket to the game. How do I take a patient who by design your system wants me to offer you something that you refuse to do in the lab or didn't find the time? How do I make you trust this to get tested at home? That's Persuasion OS. That's the other leg, if you will, of what we built at Healthy.io. It's a patient engagement system that knows how to create the behavioral pull that would work with literally each and every person with whom we engage. No two people get the same nudge, if you will, the same messaging. It's all tailored and personalized. That's if you will, the story where we are right now. By the way, agnostic of socioeconomics, if you have a phone anywhere from like a 213 Samsung Galaxy all the way to the iPhone 14 and you have reasonable bandwidth, we will turn your location into a clinical grade lab at site. Dr. Daniel Kraft: It's not an easy nut to crack that you've done. In the UK I believe you've done screening for UTIs as well as for pregnant women and of course screening for albumin-creatinine ratio for folks who have risk developing renal disease from hypertension or diabetes. Any sort of surprises or ways that kind of spell that. Yonatan Adiri: I think first and foremost and you hit the nail on the head, it's one thing to develop AI that makes smartphones kind of see the same and get them to see exactly the same at clinical grade. Those are two different things. In the UK this year we supported 1600 phones with different variants. So an iPhone 12 with iOS 11 or an iPhone 12 with an iOS 13 see color in a different way. So how do you become agnostic to that? That is, if you will, the secret sauce from an AI perspective that drives Healthy.io's innovation and cutting edge technology. There's a series of things that help us predict the best way of communicating with you. What type of phone do you use? How do you respond to our first text message? How do you respond to the second one? The time in between. Those things tell us a lot about how best to approach you, what best language, what best timing, and that gives us those results. Here's a stat that I think is really phenomenal, 80% of the 50% completion, so 40% of the people who do the test do it without a call center. Pure digital means. And for me that was a big surprise. The ability to be, to nano cast, to give every person a tailored experience. Someone in Spanish, someone in English feels so familiar that people choose to trust the smartphone that they trust anyway, and that element of trust was really significant. So 80% purely digital. The other piece is we never anticipated going beyond, I would say 25 to 30% among certain cohorts and age groups. And we've been delivering 40%, 42% compliance in age group 71 to 80. We've delivered 30% compliance, 80 to 90 years old. These are not easy patient cohorts to engage with. For me, that's our single most important source of pride. All the publications on this field, peer reviewed over the last 20 years, we're seeing that those numbers representing themselves at north of a hundred thousand people cohorts and that means prevention of roughly six to 7,000 areas of acute risk for cardiovascular or renal failure for every a hundred thousand people that we test. And for me that's beyond Persuasion OS and beyond ColorOS. That's the mission. That's what we built the company for, whenever it's most convenient for them and ultimately prevent disease or dialysis at the end of that process. Dr. Daniel Kraft: Let's actually extract that a bit. Let's take an individual who may have not brought their urine in for urinalysis is at risk for CKD, the impact of picking that up early, even on a per patient basis in terms of preventing long-term renal dialysis, needing a transplant and even death. Yonatan Adiri: Yep. This is critical. The goal is not to reinvent the wheel. If we find a person at stage two or three through protein in urine, we know what to do with them. NCQA has set up as a HEDIS score that Medicare Advantage has provided incentives for. That's part of the secret of the next three to four years. The cumulative effect that we will all create on this transformation, decentralization of health will have to be Daniel, in areas that matter financially and clinically. So we chose to be in the CKD space because the analog format obviously doesn't yield the expected healthcare outcomes. The cost of that is massive. When we go to a payer, we say, "Hey, don't pay us." We assume full risk. When you give us a list of names and we serve those patients on your behalf, you don't pay us until we find the missing protein, if you will. So you pay us per completed test. And I think this notion of putting your technology and solution on the same side with the CFO of a plan is part of the art that we are required to develop, not just Healthy.io, we as a community. We can't just operate and then at the end of the day serve half a million to a million people who chose to pay out of pocket. Dr. Daniel Kraft: I'm sure we have some CFOs and Nephrologists listening, but what sort of a summary of how much you save in terms of costs in a patient you pick up early with your technology. Yonatan Adiri: So in every market that changes. NHS have determined their cost structure. For every a hundred thousand people that you test, you can end up saving 50 to 70 million pounds over a three to five year period. So when you run a 600,000 people cohort, you can assume what the cost saving is there. We've done work with the York Health Institution, we've done work with American payers on the whole subsequent decision tree on actuarials. We're looking at 1,500 to $2,000 saved per year. If you're in Medicare Advantage from a quality perspective, you are expected by CMS to have everybody or as many as possible get tested for ACR and subsequently the savings. The pricing has never been an issue because the savings is clear and once we're saying we're going to assume full risk, then I think the math sort of takes care of itself in a way. And again, this is population scale interventions. Dr. Daniel Kraft: So we're speaking now in March of 2022. It's National Kidney Month, if I've got that right. What's the reception been amongst the kidney societies and Nephrologists of the world that have been surprising? Yonatan Adiri: It's been incredible. We came to the National Kidney Foundation 2018 with our first FDA clearance and sharing that we believe we can generate that behavioral change. Dr. Kerry Willis, an incredible leader in this space, told us, wow, this is interesting because we see a lot of algorithms and new biomarkers, which will take maybe seven to 10 years to mature. We never thought of giving people access to do the dipstick. Everybody loves that. So let's see if you're as good as you say you are. And then they kind of supported us in going to Geisinger and running a trial that has since been published on BMC Nephrology. Other than that, the ADA President, Bakris and others, we work very closely with Professor Joe Coresh out of Hopkins. And the work was done also in the UK. We haven't seen any challenge because again, we chose to operate in a space that there is massive consensus door to door. The question of scale was something we dealt with all the way through March 2020. As soon as COVID hit. Again, the $30 billion spent by the American government alone, the six to 7 billion spent in the UK on driving testing at home. The behavioral shift that that created narrowed the imagination gap and the power of that at the population level has been a tremendous outcome. Dr. Daniel Kraft: So Sputnik launched and then within a decade we were on the moon. You think you're on the cover of the Economist, the rise of the medical selfie. You've gone beyond- Yonatan Adiri: Correct, correct. Dr. Daniel Kraft: ... beyond urinalysis. What's sort of next? Yonatan Adiri: I think on the next decade, there are two vectors that are going to drive vision-based innovation in digital healthcare. One is obviously where smartphone optical sensors are going. So are we going to see in a couple of years near infrared spectrometry as being the fourth sensor here? Again, not designed for medical, designed for AR, much like the selfies weren't designed for medical. We believe that would be a massive leverage in Archimedean point in where our industry is going. So that's one vector to look out for. Every medical process that's currently done when a clinician uses his or her eyes or a basic scanner will ultimately be done with a smartphone camera at the end of the decade, at clinical grade. And I think our engagement with CDRH over the last seven years at FDA has been such that we've seen, and again, the EUA track, and we've heard Scott Gottlieb talk about that as a commissioner and also in subsequent days is such that also the regulatory environment is understanding how to do the risk benefit analysis on those things and create the safety regulations. And maybe one last point here, we don't profess the disruption of healthcare. It's the other way around. We actually think that digital is an enhancement tool to do upskilling of nurses, to do upskilling of medical practitioners and to give them the gift of time to engage with the patient. Nowhere has that been more powerful on our journey in the wound space. Chronic wounds, they need to be measured once a week. Nurses are scarce. It's a complicated process. They're literally using paper rulers to measure wounds these days in a subjective manner. We've run a survey with our partners and the most exciting piece, which may sound boring, was 25% reduction in nurse force required per wound. The other way to look at it is the same nurse is doing 25% more patient time because of digitization. That is a massive outcome. And if we can multiply that industry-wide, ecosystem wide, imagine the same nurses kind of growing by 25% what actually just through digital means. And the ultimate vision for 2030 again, is for clinicians to be even more central to the process than they are right now affording them with superpower AI-based tools that allow for them to be the leaders that they are on the clinical side. Dr. Daniel Kraft: Yeah, we've had Dr. Eric Topol on this podcast early on, and he's also shared the thought that AI machine learning these new tools will help give clinicians back more time, but also that reestablish more of that human relationship because you're not spending time typing medical records or doing that wound management. Yonatan Adiri: Yeah, and Dr. Topol, just a quick interjection, Dr. Topol has been critical in also voicing that opinion because I think, again, if you kind of take 2018 through 2020, 21, this notion of, oh, what's going to happen to my profession? And I think Eric Topol was an incredible voice to the contrary that made people more comfortable in adopting technologies. It's upon us to be collaborative and to really ask ourselves as we develop products, how do we enhance the practitioners? Dr. Daniel Kraft: So most of our listeners here are clinicians from nurses, physicians, physical therapists, pharmacists. How might they prescribe a Healthy.io kit? Yonatan Adiri: I think that's a broader question than Healthy.io. I think the biggest promise that I see right now is how do you as a clinician gain insight into the time where the patient is in the interval, where you don't see them. When they come in, you spend time trying to understand and there's a lot of subjectivity going on. What they say they did is not necessarily what they did because they were busy. I have four children, at the end of the day I sometimes don't even remember what I've been up to. So when I report what I've been up to might not be as accurate given the intensity of my workload. So I think the focus over the next three to five years for adopting the technology would actually be, at least in my view, what meds were they taking? So were they compliant with their HbA1C's? Were they compliant with balancing their glucose meter when it comes to diabetes? Did they do the physiotherapy drills they were supposed to do within that week or two week interval? I think that's where adoption's going to be, should be fastest, because then that cleans the interval when you actually meet the patient. Before they come in you can see what they were up to and then the conversation is about the here and now. It's about the emotional and it's about all the things that clinicians do so well in guiding us as patients. So that's my kind of simple answer on, so where are we going to see adoption? Does that make sense? Dr. Daniel Kraft: 100%. I always tend to summarize that our current model is very intermittent. Data usually only collected in the four walls of the clinic. Now with technology like HealthEase you can do continuous or regular home based or wherever we might be, and that is going to lead us to more democratized, effective, personalized care that really moves the needle. Yonatan Adiri: And I think that's a low hanging fruit. Dr. Daniel Kraft: Maybe our last few minutes I circle back to where we started with what takeaways you might have after leading this company for a decade. Yonatan Adiri: I would say three takeaways. One, the beginning of the decade and the end of the decade are completely different. That's also driven by COVID. We've all seen the graphs with COVID, the waves. The way to think about the exponentials in this context is not as a single vector, but rather the compounding nature of a lot of things happening together on a number of fronts. So smartphone camera, without bandwidth, if the cameras got so much better, that bandwidth would still, I don't know, a dollar a minute, then the whole revolution doesn't manifest itself. So I think the ways for entrepreneurs to think about the next decade is prices going down that can actually unlock value in care. What are the things that are happening together? And in a way, where are they outside of healthcare like we did with selfies? That's one. I think the second piece, I think what we saw with mRNA and the kind of leap in bioinformatics, and again, the regulatory space, the billions of people being vaccinated in a compound that was created 42 days after decoding the RNA in China. That is just mind-blowing. That's a brave new world. And I think at the end of the decade I would expect the oncology space to look completely different. I don't want to say solved, but radically different in how we engage. That's my second thought is that's been a massive surprise, and that's going to become even further accelerated. The third though, and this is something I've underestimated, and we're talking during the time of horrible conflict in the Ukraine, what reality tells us from time to time is technology can advance. If our social underpinnings are not aligned, then the importance of truth and freedom of speech, those things are at risk actually as technology accelerates. I'm sort of afraid of that in this coming decade, and I think it's upon us to be active there and make sure that as we build technologies we also try to reinforce the institutions that would allow for those technologies to manifest the good and not give up on that in the name of, oh, tech will solve this or that. And the way we, for instance, a couple weeks ago, carved out a humanitarian cloud on our backend system and deployed our technology on the Moldova Ukrainian border because we found that refugees leave everything behind except for their smartphone and their charger. So when they cross into another country, they can test for urine, they can scan their wounds, they can do a lot of things just by carving out that humanitarian cloud. Dr. Daniel Kraft: 100%. It's this convergence of technology, humanity, policy, and global citizens, whether it's in a war zone, and thanks for your work there, and I think you're even going to be flying Healthy.io on SpaceX. Yonatan Adiri: That's correct, in the next few weeks. That's true. Dr. Daniel Kraft: Thank you again Yonatan Adiri and for joining us. Your work I think is exemplary and really building that future health of medicine on this exponential, but doing that with heart, purpose and a social mission as well.