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Are Digital Health Companies Aiming Too Low -- Or Is Incremental Improvement Underappreciated?

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Breathless language about changing the world and disrupting the known universe aside, most digital health companies I know aren’t proposing radical new treatments for dreadful diseases – or anything close (see this articulate critique by David Whelan, and this one by Matthew Holt).  At the end of the day, most simply hope to make existing approaches somewhat faster, cheaper, or qualitatively better (i.e. improve the experience of cancer patients, rather than develop novel treatment for the underlying disease).   When you think about it, this isn’t much different than the way the biopharma industry (where I work) is often (derisively) described.

To the extent that Silicon Valley’s leading tech investors even consider investments in the health space, they’re generally not contemplating the development of profound new therapies, but rather, seem to be thinking about hot consumer trends, looking at some infrastructure plays, and wondering whether there are any opportunities to dominate access either to healthcare data or to stakeholder segments (think Sage Bionetworks, only run by SMERSH instead of Friend).  This makes perfect sense from a business perspective, but may not be the sort of health-changing innovation many hoped the valley was preparing to deliver.

I see three key themes here:

1.      Reports of the demise of incrementalism have been greatly exaggerated, in the context of both biopharma and digital health. 

Many top-selling drugs – blockbusters, in fact -- continue to represent incremental improvements on established mechanisms of action.  There is still a major market opportunity for best-in-class products, and existing regulatory and commercial hurdles for these products would seem, in medical parlance, to represent relative contraindications, rather than absolute contraindications, as often assumed.

On the digital health side, anxiety about overreaching regulators, as I’ve discussed, has led to a profound aversion to products or approaches that regulators might need to review – hence the explosion of interest in consumer-focused opportunities, especially around wellness, and a dearth of investment in the sort of substantial efforts that could more profoundly impact patient health.  Unclear is whether VC trepidation here reflects hard-won experience or reflexive aversion to uncertainty in an area outside their natural comfort zone.

2.      Incrementalism isn’t (necessarily) lame; this often arrogant assumption frequently overlooks the true unmet needs experienced by real-world patients.

The idea of getting the best use out of existing drug mechanisms (in the case of biopharma), and of ensuring existing available health resources are utilized as effectively and efficiently as possible (in the case of digital health – consider the goals of high profile companies such as Castlight and ZocDoc)  isn’t unreasonable, and can deliver significant benefit to patients (see here,  here and here).

Arguably, the most significant immediate opportunity we have today is the health that could be achieved right now but isn’t because existing healthcare knowledge and resources aren’t optimally deployed.  This uncaptured potential is an unconscionable waste – and of course, a tremendous opportunity.  For example, the technologies of digital health could be used to measure and better define, in an increasingly granular fashion, discrete unmet medical needs in the real world, and to understand where (and for whom) current products and health providers are effective and where they are coming up short, and where better approaches are clearly needed.   To their credit, regulators (as I’ve discussed) have explicitly called out the need for increased investments in such “assessment science.”

3.     Both digital health and biopharma advocates must guard against “the soft bigotry of low expectations,” and at some level must acknowledge that tweaking the current system isn’t the same as radically improving it.

In other words, developing new apps, or new formulations, may be better than making sugared water, but it’s not the same as curing cancer -- essentially what UCSF Chancellor Susan Desmond-Hellman recently commented.

Interestingly, the notion that innovation is underdelivering represents an increasingly common critique not only of biopharma, but also of Silicon Valley; technology veteran Steve Blank tells Derek Thompson in the Atlantic, “The Golden Age of Silicon Valley is over, and we’re just dancing on its grave.”   His point is that investors will go where the money is, and no one will be interested in “commercializing the really hard stuff;” instead, in the era of social media, “VCs are only going to be interested in chasing the billions on their smart phones.”  An unusual Silicon Valley investor manifesto (discussed at length in this New Yorker profile) makes a similar claim, as I recently discussed.

While I appreciate the concern that social media bling-bling will distract us – and investors – from the truly important, and considerably more difficult,  health challenges confronting us, I’m fundamentally optimistic that the technology, the interactivity and open collaboration, the big data analytics that the social media and consumerism revolution has produced will ultimately facilitate the sophisticated study of complex biological phenotypes – ideally in vivo -- and lead to the development of more predictive models that can help us design and develop impactful, radically new treatment approaches. 

 That’s a lofty ambition – but one worthy of our best minds, and most innovative entrepreneurs.

Disclosure: as previously noted, I’ve recently co-founded a new academic initiative, the Center for Assessment Technology and Continuous Health (CATCH), together with MGH Chief of Medicine Dennis Ausiello (who will direct this effort) and several Boston-area colleagues.  The basic idea is that improved phenotypic measurement – measurement of relevant parameters in a fashion more comprehensive and more continuous than typical patient data – could immediately improve care (Theme 2, above) while also advancing future science (Theme 3).