CardioSource WorldNews | Harnessing the Power of Digital Health Technology

An Interview with Samir Damani, MD, PharmD, FACC

Samir Damani, MD, PharmD, FACC, is founder and CEO of MD Revolution, which integrates digital devices, machine learning and high touch care to help physicians improve chronic care management. In addition to leading MD Revolution, Dr. Damani is a cardiologist at Scripps Clinic and a voluntary clinical instructor in the Department of Family & Preventive Medicine at the UC San Diego Medical School. He has directed numerous studies and written more than 40 articles and book chapters. A leader in connected health, Dr. Damani has spoken at national and international forums on personalized medicine, genomics, digital health, and wellness.

Tell us about how you came up with the idea for MD Revolution and the technology platform “RevUp.”

As a little bit of background, I’m a cardiologist by training. I completed my doctorate in pharmacy before going to medical school, so I’ve been involved in chronic disease management for some time. Around 2010, I finished fellowship training and went ahead to get a masters in Clinical Investigation. I did quite a bit of research and was practicing in an economically challenged area. Most of my patients were noncompliant, not taking their blood pressure (BP) medication. At the same time I was doing a lot of genetics and biomarkers research. Realizing that if I couldn’t get patients to take their medication, none of the basic research I was doing was going to make any difference.

I started introducing technology that would allow patients to measure what they were doing in order to better manage their conditions. There is a whole concept in business that what you measure you manage better. That’s been around for decades, but hasn’t been adopted as commonly in medicine. With all the tracking tools coming out I essentially had patients start tracking what they were doing, using an app and sending me emails.

What I found was a level of engagement that had never been seen before. I saw patients who were not previously taking medication at all sending me BP logs and changing the time of their medication based on their BP spikes. This was very unique, so I looked to see if anyone had systemically tested this in any real world setting. Knowing what I was personally doing would not scale—clinicians wouldn’t have the time. But I thought if we could build a model around technology that could enable the personalized human interaction, we could then message patients based on their mindset, mood, personality, disease state, nutrition, and much more.

Through this early experience, I realized that the key to behavior change is to break down barriers for patients to track what they’re doing and then to let them know someone is paying attention to them between clinic visits. The idea is to stay connected to your patient in between visits. This way we’re not just interacting with patients when their disease burden is high, which is frequently the case when you’re simply waiting for a patient to be seen in the office. However, I knew we also needed to build a cost effective solution. This is where my idea for our current product came from.

How did you begin to create a model that had potential to scale?

With about half a million dollars in seed funding in 2011, we opened the first real digital health clinic in the world. Patients were sent to us to have their chronic diseases managed. We weren’t diagnosing or treating; we were using nurses to help manage through six or seven different apps. At that point in time I realized that if you could build software that could scale that chronic care manager, you could create a highly personalized interaction using technology. No one had yet built a software solution that would allow patients to be grouped into discrete cohorts—for example, diabetics who hadn’t walked in the last week, hypertensives who had high BPs over several days that reported poor sleep patterns, patients with uncontrolled diabetes who were experiencing depressed mood or more pain, and so on. By grouping these patients, the care manager could send a personalized message from one to many—and at the same time that group would form a cohort that you could follow and track outcomes based on your intervention. Would their hemoglobin A1c, weight, and blood pressure be better or worse? And then you would be able to see through logistic regression what kinds of things they were doing to drive those outcomes, and your approach could become more personalized as you collected more data. Think Google for health.

Were people given a financial incentive to use it? How were you able to fund it?

We really were in the right place at the right time after developing this technology. In 2014 Medicare came out with a new code around chronic care management. The largest payer in the world started an initiative to pay providers $42 to message patients for 20 minutes per month. This was big as it was a great validation of our initial vision; we now had the biggest payor in the world to fund our business model and data acquisition strategy. Out of 600 billion Medicare dollars, 93% is spent on chronic disease, and Medicare recognized the importance of touching patients between visits. Our software was secure and this was the perfect opportunity. Doctors do not have the additional time to spend messaging each of their patients 20 minutes per month—they’d have to hire a whole staff for that. We help them with that by using nurses to reach out to their patients. On top of that, we aggregate the data in a way that doctors can learn from it and tailor care accordingly. Imagine doctors knowing in the last 30 seconds of their visit how exactly to encourage their patient based on their personality characteristics and what they have or haven’t done in the last month. It really enriches the patient-doctor relationship.

We have a web application and mobile application that push the data collected (BP, logged meals, pain, sleep, mood, glucose readings) and messages sent to the patient to the electronic health record (EHR) so the doctors can bill Medicare at the end of the month. Out of the 35 million patients who qualify for this new code, only 275,000 claims were submitted last year, so doctors are really trying to figure out how to do this cost effectively. We’ve been able to help here.

We do still have a lot of room to grow, and we are interfacing directly with Medicare to help increase patient access to this code. This was a Medicare initiated code, so they really want it to be successful. It doesn’t really add cost to the system and it bridges providers as we move from volume to value-based care.

To date, we’ve signed up over 50 provider groups, representing 750 providers and 300,000+ lives across 17 states. We’re adding between 2,000 and 3,000 new patients per month to our platform, so it’s an exciting time.

Have you looked at outcomes data for patients enrolled in your program?

We’ve gathered early outcomes data on diabetics and hypertensive patients (on the scale of 100’s so far), and it looks quite promising. We are seeing 20-point average drops that are statistically significant in blood glucose readings in our uncontrolled diabetic population. We are also seeing an 8 mm drop in BP in our uncontrolled hypertensives. Accordingly, we know the platform works, but ultimately it’s about constantly changing our solution and approach via incoming data on our patients.

What have been the barriers to getting this up and running?

The first thing we had to figure out was what kind of clinicians we should hire to deliver this service, since nothing like this had been done before. For 4 years, I was refining the prototype of the kind of nurse or care manager we needed. Then it was the software, where the goal was building a user interface and a clinical interface that can engage seniors and be user-friendly for the care manager. Now the challenge is integrating with a variety of EHRs. We’ve succeeded in integrating on a limited basis with the top 10 EHRs. We are now focusing on distribution partnerships with EHRs that can allow for a deeper level of integration with our patient engagement app: RevUp.

The final frontier is scaling the enrollment process across the country. Onboarding thousands of patients a month with a staff of about 100 is a challenge that requires a lot of human and technological ingenuity. The good news is that the response from both providers and patients is better than we anticipated—more than 50% of patients presented with the option of enrolling in our solution are doing so, and physicians have found our services very helpful in extending their reach between visits.

What technology do you anticipate coming out in future years that will drive better care delivery?

It’s not about technology—the technology is a vehicle. It’s about the data that we garner and how we are using that data to care for patients better. The ability to use data from sensors that are already out there and personalize care for patients is what the future holds. Once the data is part of a network, that data can be crunched and be used by clinicians and care managers to take better care of patients. Thus, interoperability of EHR’s with web services platforms like ours is going to be critical. It is great that the government is forcing software vendors to be interoperable, so we can start leveraging data to care for very large groups with chronic disease.

I also believe to fundamentally influence patient behavior outside of the clinic, you must have human interaction. People who think you can take human interaction out of the equation are laboring under a false notion of what is going to improve health. At the end of the day, technology and data are about scaling that human interaction. Enabling the technology to make use of high-touch care models is going to be esssential if the U.S. expects to be economically viable in the future. Not only do patients need this, our society does as well.

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Katlyn Nemani, MD, is a physician at New York University.

Read the full April issue of CardioSource WorldNews at ACC.org/CSWN

Keywords: CardioSource WorldNews, Chronic Disease, Disease Management, Logistic Models, Software

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