According to several reports Amazon is the latest company to have a super-secret move into healthcare and healthcare technology. This really should surprise no one as Amazon is not alone in their efforts to transform healthcare. It has been widely reported that Apple, another tech titan, has efforts underway as well as their neighbors in Silicon Valley Google. It’s also not surprising that all three of these tech titans are making the deep dive into the diabetes pool. This as Momma Kliff used to say isn’t news.
The question isn’t whether they are getting in the pool, the question is how big of a splash will they make. And will that splash come from a well-executed dive or a big belly flop.
When we first learned of these efforts our initial reaction was positive as we felt like many others that these titans could use their talent and vast resources to make a real difference when it came to diabetes management. However, our initial enthusiasm has been tempered somewhat as like everyone else who has entered this wacky world these tech titans are not immune to making the same mistakes and poor assumptions about what it will take to succeed.
Apple has invested millions to develop a non-invasive continuous glucose monitor that would become part of a future version of their way cool Apple Watch. An effort that has gone nowhere and even if successful would not yield the millions in revenue many think it would. Besides being based on flawed technology the effort is based on the flawed premise that a non-invasive system would have a positive impact on outcomes.
Way back in the day way before Apple even existed mad scientists were working on non-invasive glucose monitoring. The theory was that the reason patients did not monitor their glucose on a regular basis due to the “pain” associated with performing the test. Back then and still today millions of patients must prick their fingers, draw a small drop of a blood and place that drop on a test strip. It seemed logical that if this test could be performed without the “painful” finger stick patients would test their glucose on a regular basis and by extension use this information to better manage their diabetes.
Back then the SMBG market was growing at double-digit rates and companies in the market were making millions. Back in the day SMBG was a great business as the test strips were made for pennies and sold for dollars. SMBG was a cash cow and became the darling division of some major companies. With all this money being made it was easy for non-invasive companies to raise millions in capital as everyone began to look upon non-invasive BGM as the Holy Grail of diabetes technology.
Now never mind that NONE of these efforts yielded anything more than good copy, millions kept getting thrown at this quest. All because everyone believed that the reason patients didn’t test as often as they should was due to the “pain” associated with performing the test which is a flawed premise. While there are many reasons other than “pain” as to why patients do not test as often as they should, the biggest is the majority of patients did not value or understand the number and getting that number non-invasively would not change that.
The same is now true with what Apple is working on. Even if they could solve the technical issues the same problem exists, how to get patients to value and then use this information to better manage their diabetes. Now here is where everyone will say “Hey isn’t that what a way cool whiz bang app is for, does it not take all this information, analyze it and then make recommendations to the patient?” In theory yes but in the real world it doesn’t work that way.
Yesterday we wrote about Medtronic’s (NYSE: MDT) move into the stand-alone CGM market and how the company is hyping their way cool whiz bang Sugar.IQ app. An app that does have several nice features but what gets lost on everyone is this type of app actually creates MORE not LESS work for the patient, here’s why. Medtronic is targeting patients following multiple daily injection (MDI) therapy for the Guardian Connect. The belief being that these intensively managed patients will heed the advice given to them by Sugar.IQ.
While some certainly will most we suspect will not as all intensively managed patients are not created equal. Most of these patients follow a simple insulin dosing regimen using a long-acting insulin once a day and short-acting when they eat. While some use their glucose readings to calculate how much insulin to dose many do not. For many they follow the instructions provided by their physician who has told them to take X amount of long-acting each night and Y amount with every meal. The physician has basically dumbed down their dosing because from experience they know most of their patients don’t test regularly and even fewer understand concepts such as time to action, duration of action and insulin to carb ratios.
These physicians want to keep things simple believing the simpler it is the more likely a patient will be adherent. Something we won’t argue with. The fact is most of these patients want to think less about their diabetes management. As useful as the advice from Sugar.IQ may be it makes the patient think MORE not LESS about their diabetes management. It also creates another issue that is largely ignored; as it creates MORE not LESS action steps.
Look at it this way let’s say the Sugar.IQ app warns the patient of a POSSIBLE hypoglycemic event coming. To fend off this event the patient has a decision to make, do they do something now to prevent this POSSIBLE event or do they take a wait and see approach to see if the event actually happens?
On the flip side let’s say the app recognizes that a certain food group creates highs for the patient, an example Medtronic used in their presentation. What the company didn’t mention during the presentation was that patient must tell the app what they ate and when they ate it, this is NOT done automatically. As useful as this advice may be getting that advice only happened because the patient took the time to tell the app what and when they ate, the app created MORE work for the patient.
Another example used by the company was the app telling the patient that when they took insulin at a certain time they spend more time above their target range. The app only knows this because the patient told the app when they injected. (Keep in mind that Medtronic does not YET have a “smart” insulin pen which would eliminate this step.) So again, the app created MORE not LESS work for the patient.
In the real-world patients even intensively, managed patients who follow MDI want LESS interaction with their diabetes management NOT more. They want LESS work not MORE. They want LESS interaction with all their damn toys NOT more. The information provided by Sugar.IQ may be useful but to get it the patient must interact with the app entering information not gathered by the Guardian Connect. A sensor which also requires greater patient interaction as unlike the Dexcom (NASDAQ: DXCM) G6 or the FreeStyle Libre the Guardian Connect MUST be calibrated multiple times per day.
So yes, the app can do amazing things PROVIDED the patient does their part and in the real world this is just too much to ask or expect.
Now compare that to what an insulin dosing algorithm can do and will do in the future. These algorithms will create LESS work for the patient. The patient will have FEWER decisions to make. Simply put the algorithm will do most of the heavy lifting making it so the patient has LESS work to do not MORE. In the future about all the patient on MDI will do is inject how much insulin the app recommends, that’s it.
We have nothing against the Guardian Connect or Sugar.IQ and we do understand why the company mentions all the cool things it can do while leaving out how the system would function in a real-world setting. And to be fair Medtronic is not the only company who does this. Everyone does this as they know analysts and investors just love the toys in the toy box. Everyone just loves way cool whiz bang. Most of these people see Sugar.IQ as the equivalent of Uber or Lyft. They think the app does all the work and the patient reaps all the benefits when nothing could be further from the truth.
Now that day looms on the horizon as insulin dosing algorithms move from insulin pumps to MDI but that day is not here yet. The day is coming when MDI therapy will not just be less labor intensive but also produce insulin pump like outcomes at a much cheaper price point. The day is coming when MDI patients will have much less to think about, fewer action steps and a much-improved quality of life. However, that day is not here YET.