Here’s a phrase I’ve never heard during a doctor’s visit: “We need your data, girl!”
I was at MDRevolution’s La Jolla, Calif., office about a month ago, sitting in on a consultation as a patient huffed away on a treadmill. A staff member hovered nearby, monitoring the patient’s heart rate and pushing her to keep up the pace. As the staff member took note after note on the patient’s performance and tapped away at a calculator and keyboard to analyze the results, I felt like I was in a research lab, not a doctor’s office — and a lab modeled after a gleaming Apple store.
According to its founder, cardiologist Samir Damani, that’s the point. The office — with its sleek, spa-like aesthetic and shelves of connected devices — is a showcase for a data-driven future of medicine that puts technology at the center of the patient experience and moves actual doctors into managerial, less visible roles.
As the era of the more-affordable “$1,000 genome” draws closer, the phrase “personalized medicine” is popping up all over the place. But for the most part, matching medical treatments with a patient’s genetic profile is an option for only the wealthiest Americans.
With his patients, Damani is trying to create customized health care that is more accessible and affordable — and he’s doing it by blending cardiology, nutrition science and genetics with emerging mobile technology. But that’s just the first step: He believes he can build a big business by using the data he’s gathering and the algorithms he’s creating to design software that will allow employers and hospitals around the country to replicate his approach.
“I got tired of people saying this is what it’s going to be like. I said, ‘I’m a 37-year-old cardiologist, I need to know what it’s going to be like today,’” said Damani, a slight, well-dressed man with a seemingly boundless memory for medical literature.
So, in 2011, he rustled up $1.6 million in angel funding from several local MDs, Ph.Ds and other supporters (no traditional “vulture capitalists” allowed). He hired an IT guy, an office manager, a metabolic specialist, nutritionist and medical assistant and, about a year later, opened up his doors — all while keeping an active cardiology practice at a local San Diego clinic.
A new medical specialty?
Since launching in February 2012, MDRevolution has worked with about 250 patients; about a quarter of them have a chronic condition, and the balance are people who are generally in good health and who are willing to take that extra step to stay that way (patients continue to see their regular primary care doctor in addition to Damani). He says that each of the last 60 patients has seen statistically significant changes in every health marker analyzed, including weight, body mass index, metabolism and visceral fat (the notoriously hard-to-lose fat that accumulates around organs).
Damani’s model? A new patient starts with a spin through a lab to determine their resting metabolic rates, visceral fat levels and other fitness indicators. They also get a genetic assessment that tells MDRevolution whether they’re a slow processor of caffeine, whether they’re genetically inclined to overeat, and whether they have any other nutrition and fitness-related predispositions. From there, the practice uses proprietary algorithms to craft personalized health plans that include guidance on things like how high and how often to push their heart rates while exercising, what kinds of food to eat, and the types of foods to avoid.
As patients follow the program, fitness trackers like Fitbits (see disclosure), wireless Withings scales and heart monitors report progress back to MDRevolution, while a website enables specialists to give encouragement and direction online. For the genetic assessments, the company partners with Pathway Genomics and 23andMe, and it uses Qualcomm’s 2Net platform to integrate all of its technology. For the 10 percent of patients who live outside the area (and even for some who live close by), Damani conducts virtual visits via Skype.
The financial model
Just about every week, a new activity tracker, personal genome service, iPhone-based medical device or online patient program hits the market. But for the most part, those tools and services exist in isolation. MDRevolution is a first stab at trying to show how mobile health tracking tools, genomic assessments and personalized coaching can work together to show real results.
The fact that the company is based in sunny Southern California is no accident. Between wireless health leader Qualcomm Life, genetics company Pathway Genomics, The Scripps Research Institute and plenty of other National Institutes of Health-funded research institution, San Diego is a hotbed for health innovation and research. Scripps is also the academic home of Eric Topol, a longtime cardiologist and researcher as well as one of the most influential voices in digital health. Before launching MDRevolution, Damani published several peer-reviewed articles with Topol, who he said has been a mentor.
As health reform pushes medicine to a model that rewards doctors based on how well they keep patients healthy, not just the procedures they perform, more doctors are turning to concierge-style practices in which patients pay an annual retainer for a higher level of care. One Medical Group, which has offices in five cities, lets patients book appointments online and renew prescriptions as well as email with doctors. CarenaMD, in Seattle, offers patients 24/7 virtual doctor visits via webcam.
MDRevolution says its model is closer to a gym membership. Patients pay between $25 and $75 per month (depending on the level of service and attention needed) for access to the clinical lab and personnel, as well as its web-based service. The practice also takes most insurance plans, so each time patients visit the office, they’re also charged a co-pay.
Brad Lally, a 46-year-old San Diego executive with an outdoor sports company, said he decided to see Damani in 2011 after a brief episode of cardiac arrhythmia. He wanted to try treating his heart condition without drugs, and also wanted to get rid of his belly fat. In addition to putting more proteins and vegetables in his diet, MDRevolution told him to do metabolic interval training workouts twice a week to push his heart rate into the anaerobic zone. Since genetic testing revealed that he was a slow caffeine metabolizer, Damani’s team told him to stay away from evening cups of coffee.
For the next 12 months, he reported his workouts and diet to MDRevolution — even on frequent overseas business trips his blood pressure cuff sent back data — and received nearly bi-weekly feedback from staff. After three months on the program, he says he lost 10 percent of his visceral fat and increased his resting metabolic rate and VO2 level — two measures that Damani believes are more predictive of heart health than cholesterol — by more than 10 percent. It’s been a year since he finished the program, and he said he hasn’t had any heart irregularities. Even when he slips, he said, he knows how to quickly correct his diet and exercise plan.
“It’s empowering to know what’s going on,” Lally said. “And the level of interaction you get — it’s really good. It’s nothing like what you get with your regular primary care doctor because they’re so busy seeing patients.”
The real ‘billion-dollar’ business
As MDRevolution tries to help patients reach new levels of fitness and heart health, it is building a robust data set to support what Damani said could be the company’s real ‘billion-dollar’ business idea: a patient-engagement platform.
RevUp, which MDRevolution uses internally for its 250 patients, is a web-based dashboard that aggregates all of a patient’s information, from fitness trackers and other devices to genetic and other health data. It provides each patient with a personalized health plan, including custom fitness and nutrition guidelines depending on their needs and goals. Physicians and other health experts can use it to track patient progress and send updates and guidance. Corporate and health system administrators are able to see what employees are doing in aggregate but not an individuals’ specific information.
According to a recent study from human resources company Aon Hewitt, the average employer spends about 40 percent more on health care now than it did six years ago. Another report found that poor health costs the U.S. economy $576 billion annually, with nearly 40 percent of that due to employee absenteeism or low productivity.
To address those issues, companies like Keas, Healthrageous and ShapeUp pitch employers on corporate wellness programs that integrate with digital devices to keep employees active, healthy and out of the doctor’s office. Damani argues that RevUp will have an edge in this market because its program is backed by clinical results.
He says the data that he’s compiling with just 250 patients is already leading to fresh insights. For example, he said, people can increase their heart and lung capacity independent of age, and women increase oxygen consumption (an indicator of fitness) slower than men. When the company reaches 1,000 patients, he believes, their research could be used to influence public debate about how to maintain health in the population at large.
“Our competitive advantage is that we have a lab driving the software. We’re always going to be creating software based on needs for the practice and outcomes,” Damani says. He says that while other corporate wellness programs tend to only focus on basic health markers like cholesterol and body mass index, the indicators underpinning his program (resting metabolic rates, visceral fat levels and oxygen consumption) will prove to be the key to preventative medicine.
Can MDRevolution compete against tech companies?
The ultimate plan is for the dashboard to serve as a vehicle for gathering even more data, he said; creating a repository that could be a licensable asset in itself. It could also inform the development of future products or make MDRevolution a valuable partner for companies developing medical devices or conducting clinical trials, he said.
With a doctorate, a master’s degree and a medical degree, Damani is clearly not one to shy away from a new challenge. But in turning MDRevolution into a technology company, he’s moving into an uncertain and increasingly competitive terrain. While Damani has led the company so far — he said it has already signed up four corporate customers, a mix of companies and hospital systems, and should be profitable by next year — running a doctor’s office arguably requires a different kind of skill set than building a technology company. The company now employs 15 people, but only the COO, CTO and a new database manager have technical backgrounds. Six contractors work full-time on its software development, and Damani said he plans to bring several programmers in-house in the next year.
Damani may find that the market for his data isn’t what he anticipated. Abhas Gupta, a partner at venture firm Mohr Davidow Partners who focuses on digital health, said that he’s seen promising health startups that have amassed strong and unique datasets but that haven’t been able to generate revenue like they expected. “Who do you sell that data to?” he asked. “There may not be individuals ready to do something with that data.”
The new role for doctors in a tech-driven world
One thing patients at MDRevolution don’t see much of is a doctor. The practice is still small enough that patients know Damani oversees the entire operation but he has delegated much of the day-to-day interacting to patients to metabolic experts and nurse practitioners. Even though the office sees patients five days a week, his face time with them is just five to eight hours weekly. He says MDRevolutions in other locations could operate with barely any doctor oversight at all. (To bill as a doctor’s office, they will need to be led by doctor, but day-to-day operations could be entirely run by a nurse practitioner, he said.)
It makes you wonder if Vinod Khosla’s controversial prediction that technology will replace 80 percent of medical experts is coming true. Damani said his vision isn’t one that minimizes doctors (although the impending doctor shortage means the country will have to make do with fewer doctors, relatively speaking) or one where doctors play CEO and tech entrepreneur. But it is a world where physicians will have to adapt.
“Physicians are going to have to be in a management role as opposed to being the primary person seeing [patients],” he said. “Most physicians out there are unhappy. Because cost-containment pressures are so great, they’ve become assembly-line type physicians who see as many patients as possible in as little time as possible. I want to offer those doctors a new process.”
Disclosure: Fitbit is backed by True Ventures, a venture capital firm that is an investor in the parent company of this blog, Giga Omni Media. Om Malik, founder of Giga Omni Media, is also a venture partner at True.