Digital Health in Future Pandemics – show notes from Futurized Podcast #19

Intro (00:00:01):

Futurized goes beneath the trends to track the underlying forces of disruption in tech policy, business models, social dynamics, and the environment. I’m your host Trond Arne Undheim, futurist and author. In episode 19 of the podcast, the topic is digital health in future pandemics. Our guest is Greg Licholai, Chief Medical Officer, PRA Health Sciences, faculty at Yale school of management and healthcare innovation columnist for Forbes. We talk about where digital health as a field is right now and where it’s moving promising startups, vaccine innovation, improving clinical trials, and staying ahead by tracking insight in the field.



Trond Arne Undheim (00:00:45): Greg, how are you doing today? I’m doing terrific. Thank you. All right. So I’m excited about having you on this show. I thought, we would go through some of your background, it’s a, it’s a long roster of things that you have been doing in your career, and we’ll get to talk about some of them, but to make it super brief and you can you can help me out here. You certainly have a mix of a lot of different academic training, both medical training and a business school background, and then you worked at McKinsey and and then your career has had a subsequent number of pharmaceutical companies. And you’ve also been in in venture, I think. So with all of that, your CV is almost like a laundry list of brand names, both in industry and academia and on the hospital side, what remains from all of that, that kind of drives you everyday?

Greg teaches at Yale School of Management and is Co-Director of the Center for Digital Health. He is Chief Medical and Information Officer at PRA Health Sciences, a leading pharmaceutical service, healthcare data and contract research provider. Previously, he was President of rare disease at Moderna Therapeutics; President and Chief Medical Officer at Castle Creek Pharmaceuticals and was a partner at McKinsey & Co. where he ran the healthcare data service line. He was also a senior executive at Proteostasis, Amicus Therapeutics and Medtronic Neurological as well as venture investor for Domain Associates. He was co-founder of Immunome Therapeutics. Greg has degrees from Harvard Business School, Yale School of Medicine, Columbia University and Boston College. He trained at the Brigham and Women’s, Children’s, and Massachusetts General Hospitals. He serves on multiple company and non-profit boards including advisor to the Clinical Trials Transformation Initiative (CTTI), a public private partnership co-founded by Duke University and the Food and Drug Administration (FDA). He writes about innovation in healthcare for Forbes.

Personal Inspiration

Trond Arne Undheim (00:01:54): What is the one experience that you draw on when, when you’re, you know, getting inspired? What has taught you the most out of all of these different things that, you know, we’ll get to talk about?

Greg Licholai (00:02:05): Well, you know, I’ve been incredibly fortunate being able to move through several different areas of medicine and medical innovation from being a surgeon to being, being adventures and working in small companies and now working in biotech in a larger company, and I’ve really met phenomenal, phenomenal people. And, and and I guess the there’s the thrill that I get comes from two, two areas. One is actually being able to help and make an impact and move things forward. And the second is being really at the, at the creative start of something. And so I think the, you know, the couple of times where I was on the founding team of a startup have probably been the most, the most fun experiences of my professional life and you know, just everybody kind of banning together and kind of working hard and, and kind of taking the, you know, the rollercoaster ride.

Greg Licholai (00:03:14): It’s really, really been incredibly rewarding. And throughout those experiences, I’ve always been amazed at how companies take on personalities and the personality is always a reflection of the person or people at the top. And I noticed that very strongly in small companies, but I see that also in large companies. So I think it just reminds us that we have almost a moral responsibility to, to not just do what’s right, but to do good and to use that, to be a role models for the people that in our organization and outside

Trond Arne Undheim (00:03:59): Greg, I think that’s fascinating. I would say that resonates with my experience as well, but it is kind of strange. So here’s my question. You have worked in a lot of academic institutions as well, I would guess. And I haven’t really thought about this question for the places that I’ve been, which is also a lot of different universities, but you have experience from Harvard, Yale, Columbia, Boston College, and I’m sure several Duke as well. Right. So you have a very big background there, is it the same thing there, or is that a completely different animal in terms of taking on, because you know, it is depersonalized in these institutions, you know, over hundreds of years, some of them are universities able to escape this logic that you do. Oh, escape. I mean, it can be great. Obviously if the personalities of the leadership are, are very positive people, how does that work out in an academic context?

Greg Licholai (00:04:53): Yeah, you can be entrepreneurial in academia and, you know, in some way a lot of successful academics have to be entrepreneurial because they’re pushing the envelope and, and, you know, whether it’s as small as creating a new class or creating a new department or creating a new division or even creating a new discipline that’s that combines parts of, of other disciplines. And I think

Trond Arne Undheim (00:05:15): I meant in terms of taking on the personality, Greg, do you feel like universities also have the personalities of their either founders or leading executives, the way that you just said startups have their personalities? I was just, I was making a very, I think it’s, yeah, it was a pretty random thought, I guess, because with universities, it is very different. I mean, I startup company, right. You have the founding team and they’re there. So I guess it works a little differently with academic units because they they have a legacy that aren’t tied to the person. Right.

Greg Licholai (00:05:49): Well, what I can tell you from personal experience is that you know, I was a member of a, of a department of neurosurgery at Harvard. That was very much a reflection of the chairman of the department, you know, and then junior surgery was part of general surgery. It was very much a reflection of the personality and the values of the, of the people who led those departments. Now, did that go all the way up to the top of the university? That’s a little bit beyond my visibility, but certainly within our units, it was, it very much reflected the values. And and I was lucky enough to work with people who really had extraordinarily extraordinary values. Got it. You told me that you had biked across the country and I, and I see that you’re just coming back from from exercise. So exercise is important to you.

Greg Licholai (00:06:42): It is, it is mind, body connection. So absolutely. And I I realized that if I, if I’m able to get even a little bit early in the morning, then somehow the rest of my days in balance, you know, it’s interesting you say that, I think we are learning so much more even over the last five years in terms of the connections between mind and body. And we’re finally starting to measure it, which I think goes into some of the stuff we’ll talk about on the digital health side, right? Because it used to be that these were just good pieces of advice and based on kind of like cohort studies and an intuition that people would say, well, you know, you should, you should get exercise, but aren’t you in agreement that the proof points are starting to get there with these, even these devices starting to measure true, a true changes at a micro level.

Trond Arne Undheim (00:07:37): Would you say that there are some particular tools that you use to track your and monitor your body right now? I mean, how have you tried, are you trying to apply some of your insights from from tracking health applications to using them yourself?

Greg Licholai (00:07:53): You know, I am, but nothing very out of the ordinary. So you know, occasionally I’ll take my own blood pressure. I’ll, I’ll check my own blood sugar, you know, I’ve got sort of a, you know, watches and stuff that measure activity and heart rate, and I don’t have any particular chronic diseases. But it’s just, I find it motivating to see how things sort of change and fluctuate over time. And with the availability of these connected devices it’s so easy to do. That’s another motivating factors that I see, you know, being able to kind of track my activity and calories and steps and et cetera. It just keeps me motivated to turn the wheel day after day after day. Got it, got it. Let’s jump into you know, to our topic a little bit first, I wanted to chat about, I guess, one more thing in your background, which you’re actively doing right now as a clinical trials.

The future of clinical trials

Trond Arne Undheim (00:08:56): It’s a topic that you were either, you were rather interested in it. You know, the people who have to do them are interested in it, but it’s not a topic that gets a lot of press outside of the specialty arenas until you know, COVID and other things where people start realizing, or if you have a rare disease, I should say that also kicks in, right with suddenly you start caring, is there a clinical trial I can take part of, and there’s a digital connection here, definitely as well, right? Because at the moment that these trials started to go online and you could actually search for them and you didn’t have to have a network to know about them right there, there are these sites now where you can actually find trials. Tell me about your, your work with clinical trials you know, professionally, but also in this association.


Trond Arne Undheim (00:09:43): First what’s wrong with clinical trials. And then number two, especially on the digital angle, what are, what is being done right now in terms of digitizing trials, making them more efficient and and, and really what was the problem in the first place?

Greg Licholai (00:10:00): You know, we should all care about clinical trials and clinical development. So hopefully most people that are listening don’t have a disease, but I, it would be remarkable if they weren’t if they didn’t have a close one that had some condition that requires a pharmaceutical agent and we should all care deeply about the development of pharmaceutical agents. I mean, drugs are among the most high tech products that humankind has ever produced. And if you think about just the technology that goes into testing and developing and experimenting the molecular biology, the genetics, I mean, it really is the truly the cutting edge and the pinnacle of, of, of our species, sophistication and science. That being said there are huge gaps in in several areas of, of clinical trial. One is efficiency, and that goes directly to cost it, it can cost over a billion dollars to develop a drug.

Greg Licholai (00:11:06): So what does that mean? That means it drives up the cost of drugs and drives up the cost of healthcare. That’s a problem. Number two is access access to healthcare and access to clinical trials is actually it reflects the same way that there’s poor access to healthcare in the United States. And, and you know, why, why should that be an issue for a couple of reasons? One is diversity. So if we lack diversity in clinical trials, then we’re maybe not developing drugs for the right segment of the, or for the entire population, I should say. So, you know, if only, you know, people like me, you know, sort of middle aged white males are are, are in clinical trials, then you can, you can imagine that the genetics and physiology is perfected for that group, as opposed to the diversity of people who can have different, you know, somewhat, slightly, but somewhat more dramatic effects. But then it also, there’s a final issue. Just sort of one last thing. There’s this well-documented entity called clinical research as a care option. And particularly in deadly diseases, such as oncology, people who have access to clinical research literally live longer, survive better, do better. And I think that’s a reflection of access, but, but it is something that we should, you know, three, the statistics are that only about 3% of people who are eligible actually get involved or hear about clinical trials. That means we’re missing 97% of our target population. It’s just ridiculous.

Trond Arne Undheim (00:12:47): Yeah. What you’re saying is so fundamental though, because as we’re gonna talk about later, some of the startups and the digital therapeutics that are, that are happening now, where we’re, you know, the FDA is actually getting involved in in approving important relationships really where it’s pretty much only knowledge being exchanged between the practitioner and the patient, but this kind of information at the right time is just so pivotal. So yes, I believe that everyone should be engaged in clinical trials. One of the things that I think I wanted to ask you about is what is the best strategy to get more people involved in clinical trials? Because All right. So one thing is making them visible, as you can see. But this is a little bit of a big versus small data problem, right. You know, if we were happy just to have, 15 people involved in a, in a study, those were the old days now we are kind of in the internet days where we are used to big data, but it isn’t, isn’t it it true that in medicine, a lot of very, very important work is still carried out with ridiculously low samples. If I may speak to it as kind of a, with a statisticians or a big data person’s perspective. So we really either have to say, we’re going to accept that the quality of, you know, of treatments is going to remain as it is. And, you know, or we have to say, it’s not just about the technologies and the beautiful therapeutics we actually have, like you pointed out, involve an enormous more, a bigger amount of the population and, and, and also with different characteristics, right? I mean, let’s not forget what you just said about not the entire population being involved. So if you’re just sampling 60 year olds, how can you make sure that, in the United States, how can you make a, a medication for someone, you know, have a different complete social group.

Trond Arne Undheim (00:14:52): In a completely different context, but, but what, what are in your work then for, for instance, this association to clinical trials, transformation initiative, what are some contemporary initiatives to get a lot more people involved?

Greg Licholai (00:15:07): Yeah. You know, and I would, it’s, I would liken this to voting, you know, in the United States of America. So I don’t know exactly what the latest voter turnout, you know, our numbers are, but here we are, you know, lots of people complain about politics, et cetera, et cetera, but lots of people don’t vote. And I’m not going to say it’s as easy, but there need to be fundamental changes both in the system, as well as people’s attitudes in order to engage in something like voting. But same thing in terms of engaging in something like clinical research. I think it’s easy enough for people who are, you know, see their physicians at church, or maybe they’ve got illnesses and stuff just to ask and find out.

Greg Licholai (00:15:55): And usually there’s plenty of resources being, being thrown at them through traditional methods. But the traditional method of getting people involved in clinical trials is their doctor at their site, you know, at their hospital. Those folks are really busy. I think they’re doing, you know, really incredible jobs, but they’re really busy. It’s hard for them to keep all this in mind. I think for this system to be effective, we need to go outside of it in engage the digital communication, social media, et cetera, in order for people to be better involved in, you know, access. So there’s lots of consumer oriented patient oriented apps and information locations that they can go for a once. They’re doing research on a disease to find out about clinical trials. There’s also a lot of initiatives as you say, set up. So I’m on something called clinical trial transformation initiative funded by the FDA and Duke, the Duke Margolis foundation as a partnership to give create advisory panels around things that can be done better to run, to do better clinical research and clinical work that that’s all being in some of the recommendations that are coming out of that are doing one of the more interesting ones is to do a mobile or decentralized clinical trials where it goes directly to the patient.

Greg Licholai (00:17:29): And patients don’t have to go to the hospital. They can, they can stay at home and get all the information. They you know, drugs get dropped off. You know, the data’s picked up everything can be done remotely. And I think that kind of experience really needs to be the future of clinical research. So I wanted to draw a parallel here and ask

Pandemic Aftermath

Trond Arne Undheim (00:17:50): I wrote about the pandemic this year, I wrote a book called the Pandemic Aftermath. One of the things that I discovered to my dismay really was that the field of public health and this is going to be my opinion. And I’m curious about yours, has not really seen the same pace of innovation as other fields of society has. Certainly not the same influx of technology. And I think it relates to clinical trials actually that we were talking about, it relates to a whole host of other issues. But but as I was reflecting on that, I kind of thought to myself, you know, it is definitely unfair to put all of the blame for that particular challenge, which we saw very much around COVID and are seeing now only on the experts of public health, right? It’s a field that is so complicated.


Trond Arne Undheim (00:18:38): It ties into as we know politics, but more importantly, in this context, it actually ties into the individual responsibility because maybe there are some magic wands that we could have used in public health early on in this crisis. But on the other hand participation in things like clinical trials. I mean, there are a lot of places in health these days where if the experts don’t have the data, then it’s much more difficult to develop new approaches. So could you comment a little bit on, I would say this, this idea that public health hasn’t made the necessary progress and well, tell me, how are you, where are you as surprised as I was at kind of what has happened around the public health dimension of COVID, there’s a lot of opportunities that have been underutilized, especially with COVID. So I think it’s the experiment is playing itself out in other parts of the world.

Greg Licholai (00:19:42): I think for that it’s, it’s testing and tracking that, right. We’re we’re just not, we’re just not doing them. I don’t know. Of course we know once we test, once we track, we have to react to that and behave differently. We’re, you know, we’re way behind the eight ball and in, in doing, in doing that. Right. So when you think about digital healthcare specifically, in terms of COVID, I mean, there, again, you know, we were pre COVID in, in this vessel time where everybody was sort of saying data is coming in, AI is here, it’s going to transform every field, including healthcare. And then I would say, arguably, it hasn’t, it hasn’t, it hasn’t right. I mean, there are so many things coming out. We’ll talk about some of them, some of these startups was it, did it come a little too early in the cycle that, you know, there is a lot of promise. There, there are all of these exciting, but

Trond Arne Undheim (00:20:48): Is it just that this came a little abruptly or is it just that we have this necessary time of adjustment? And we will come back with a vengeance with all these technology tools and, and basically crush it, you know, crush the opposition from the disease you know, in a, in a literal way. So, you know, testing of course being one of them, but, but also many, many more monitoring tools that are of a more digital nature. I mean, do you have faith that the innovation community will come back especially on the digital side and be relevant for this COVID or are we more talking about the next pandemic, all these new tools I’m actually, so, so I think there’s been an overwhelming positive response and I I’ll tell you in, in my field and drug development a year, a couple of years ago, we would have had a really tough time trying to get sponsors to embrace mobile technologies, digital technologies, remote monitoring, et cetera, , probably 10% or less of clinical trials had any kind of that, those elements.
Greg Licholai (00:21:59): So this tragedy that’s happening with the pandemic. The silver lining has been a rush to embrace digital healthcare, and we see that medicine with remote patient care and in drug development, we see that with the embracing of these Mo mobile trials and decentralized trials, I mean, it’s literally gone to a hundred percent of new trials that are being developed, they’re exploring it. So, so I do have actually, you know, I’ll use five cheese phrase, you know, cautiously optimistic that we’ll, we’ll reach a new equilibrium where there’s a lot more embracing of technology in healthcare. You know, it’s been noted by many, many, many observers and authors that healthcare has been very slow to finally embrace basic technology that we see in lots of other industries. But I do think this has been kind of a kickstart, a kind of a kick in the pants and the field to, to move in that direction.

Trond Arne Undheim (00:23:02):
So let’s take two areas then. I mean, drug development, very close to your heart and then vaccines. So let’s just quickly touch on the vaccines first. So I, you know, there, there are some studies that generally show, and I think that’s the fair, fair data that over a last few decades, the average time it takes to get to market with a vaccine is around 10.7 years. Now, it’s kind of hard to reconcile that with the Fowchee and other people’s cautious optimism, you know, or either early on, or even now saying, well, you know, we can do it in 15 months. We can do it in 18 months. On the other hand, you know, there was the Pfizer just yesterday, right? So and as you pointed out, many trials have gone much faster than they have ever gone before. So what one, where is it actually, where are they cutting the time?

Trond Arne Undheim (00:24:02):
So these 10.5 years largely, where are they being cut and to what do you say to people who are saying well, and, and this is, you know, vaccine resistance is a, is a challenge. It’s an interesting problem to have in a society, but I am talking to a lot of people who are not fanatics, but they’re actually smart people who are sitting down and they’re kind of just reflecting around this issue of vaccines. And they’re using this idea that suddenly we can come out with a vaccine in two years instead of 10, and they’re saying, there’s something that’s not right with that. So help us just explain how can we, how is it even possible to go from 10 years to two years? And where are they cutting the time?

Greg Licholai (00:24:49):
You know, it’s it’s like the Manhattan project. So, so, you know, whose goal was obviously, completely different, but you know, the entire country, God behind building a a weapon that would protect us from, from the threat of a fascist invasion and that Nazi invasion it took a massive, massive effort and it was absolutely a race, but, but that race was one because we went from a linear model to a, a group model.

Greg Licholai (00:25:30):
So to bring that forward to what’s happened right now, there, there are hundreds, I think, I think 1200 trials right now that of the various things that are being tried in COVID literally every single hospital, every single researcher, every single department, and most pharmaceutical companies have done this dramatic pivot to looking at. So, so what does that mean? You know, previously a lot of those 10 years we’d be chewed up in identifying the structure of the conservation that was done in a matter of weeks. And once that was done, some of these other technologies we’re able to harness that and jump in right away and start building potential vaccines based on, based on essentially a global collective effort to understand this and to, and to, and to attack it.

Trond Arne Undheim (00:26:30):
So both on the financing and on the speed of the trials themselves, they’re clearly is some time saved and then you have the government, right? So there’s no waiting time. And, that has one thing where the top

Trond Arne Undheim (00:26:44):
Political leadership in the U S has definitely stepped in and has, you know, doesn’t seem to be slowing things down rather on the, the other end of things. But, you know, there is two things with vaccines, there’s safety and efficacy. I don’t know if, you know, you worked at Moderna, right for a long time?
Greg Licholai (00:27:04): Yes, I was a President of rare diseases there.

Vaccines for COVID-19

Trond Arne Undheim (00:27:06):
Right? So Moderna, and Pfizer’s vaccines and perhaps a few others are these new and marinade vaccines. What, what are some of the main things that are still known and unknown about those? Because you know, it, there’s a lot of excitement about innovation in vaccines, because it’s such a traditional domain. It’s an ancient technology by, by you know, by 2020 standards. And here you have these two candidates that are, that represent a completely new approach. W what, what is known and what is unknown about those two. And should people think about those differently from the way they think about all the other a hundred other vaccine candidates when they think about not just taking it, but just reflecting around what it would mean to, to bring them into, to their family or, or, or even just what we should think of about those vaccines on a societal level. One thing that I definitely know is that they are quicker to produce. So that’s one very basic difference.

Greg Licholai (00:28:11):
Exactly, exactly. I mean, I, you know, going from the traditional way of making vaccines and biologic products to using mRNAs, it’s a little bit, it’s almost like the shift from transistors from, from a vacuum tubes to solid state transistors and, and chips. So, you know, the, the it’s a, it’s a leap forward. So, so, you know, mRNA is more of the solid state chip. And, and the big difference here is that it’s a synthetic process as opposed to a biologic process in order to manufacture. So a synthetic process, it’s manufacturing, you know, you just, you, you basically run machines essentially, and you, and you produce this material as opposed to using biological systems that have a lot of quirks in it in order to produce biological material, the, you know, how, how this affects patients down the road, you know, it’ll be completely invisible, but, but it does mean that you can, you know, once the molecular biology was, was determined for, for the, for the, for the virus, you could go in and literally download the sequence from the, from the published sequence and decide which of, which of the epitopes you want to track to start building a vaccine around you just jumped

Trond Arne Undheim (00:29:36):
Biology. You know, it is fascinating. And, you know, we’re going to be covering that in a deeply on this podcast, but what do you say to people who say synthetic biology is fine, but not into my body. I don’t want anyone to mess with my DNA, RNA, you know, all of that is great, and I love the products coming out from it. And I see some improvements, you know, even, even perhaps in, in, in food, but, but not directly into my own body. What, do you say to those people? Cause I’ve heard that argument from perceptive very, very smart and accomplished individuals. And I, and I wonder what the answer is to that question from, from health professionals.

Greg Licholai (00:30:14):
Well, I mean, there, there are, you know, there are tons of things that are, you know, that have DNA or not RNA. I’m trying to get into our bodies right now, you know, viruses, bacteria, I mean, it’s everywhere. So you know, we’re not, you know, we’re not living in, in some kind of isolation tank. You know, this is the, this is just a smarter way to to produce, to produce medicine. You know, personally, I don’t have much concern around the safety elements, not because they’re automatically safe, but B because we have lots of checks and balances and all these things have to be approved by the FDA, which is under a lot of pressure in order to give permission to start the trials as soon as possible. But I don’t think that that means that they are going to, they’re going to reduce the requirements to safety require requirements to actually say, a drug is approved.

Greg Licholai (00:31:20):
Now is the first one out of the Gates going to be the last one we ever use, probably not. I mean, drugs go through modifications and improvements over time. And my guess is that, you know, the first one or the first couple will be pretty good, but eventually we’ll use combinations and eventually we’ll get, as we learn more about the disease and, and more about the biology and the, and the genetics of it, we’ll get to better and better drugs. So you know, we’ll probably be a well, we’ll probably do a pretty good job to start, but then it’ll probably take a long time before we say, yeah, we’ve got this one completely nailed. I mean, it’s the same way that happened in all types of, you know, I mean, go back all the way to polio and smallpox, you know, there were different improvements on the vaccines that, that eventually got us to where we are

Trond Arne Undheim (00:32:17):
Touch super briefly. On, on, on the drug side, are you more optimistic or on the drug side or on the vaccine side of, of this particular disease, do you think the drugs are going to also make a massive difference here?

Greg Licholai (00:32:31):
I think the drugs will make a massive difference. But to, to the sickest people, you know, it’s some small percentage five 10 of people who actually develop illness. And I, I do think we’ll make some breakthroughs, but you know, we’re talking about, you know ICU patients, you know, who weren’t difficult, got everything debated. So it will be very important for a smaller group.

Trond Arne Undheim (00:32:53): Yeah, well, I think that’s the point we need fixes here on, on many, many levels.

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Digital Healthcare

According to a new report from @Mercom Capital Group, global VC funding for Digital Health companies in the first half of 2020 shattered all previous funding records, bringing in $6.3 billion. Funding activity was up by 24%.

Trond Arne Undheim (00:33:53):
So let’s move to a more sort of traditional digital healthcare. And I’ve seen some staggering numbers out this year. Markham capital group was talking about the first half of 2020. And that’s, I guess even before COVID shattering funding wreckage bringing in $6.3 billion funding activity of 24%. Why is it that this is happening now? Why was digital healthcare slow for 30 years? And then suddenly it is exploding. Am I made one, am I right? That this is that it was slow for awhile and then exploding and then two, why now?

Greg Licholai (00:34:30):
Yeah, it, you’re absolutely right. It’s exploding right now. You know, we’ve been waiting and it’s finally, it’s finally happening. I’m not, I’m not sure who said this. I’m going to say it’s a Winston Churchill, but maybe your listeners will correct me. Change change is really slow. And then it happens all at once.

Digital Health drivers

Greg Licholai (00:34:51):
And I think it’s kind of the same thing. It’s really a combination of forces that have gotten us to where we are. I think one is you know, we’re, we already talked about kind of the, the pandemic kind of pushing technology forward and, and it being so completely apparent that we needed a different model, but other things the system is, is it’s such a breaking point in terms of the costs of delivering healthcare, distributing healthcare, the problems that we have in access of being able to get to diverse populations. I mean, that’s been in the mindset now for, you know, I don’t know how many, how many half years and as, as we’ve identified those big issues that has spurred on creativity and inspiration to entrepreneurs, to you know, to work on new solutions. And part of the barrier that that has began to get broken down is that you’ve got two domains that need to be combined.

Greg Licholai (00:35:55):
You need, you’ve got digital and medicine. And so you know, on, on one side, you’ve got people like me who, you know, takes 10 or 15 years to get trained in biology and medicine. And really, we don’t have time to learn how to cope. And on, on the other hand you know, people probably close to your background who understand technology. I mean, just think of having to do all that work and take, you know organic chemistry and, you know, back in the day nowadays I think that gap really is becoming an overlap. And I’ve I, I know, I know a number of people who were, who were entering medicine as computer scientists and they know how to code and they wind up getting sort of vacuumed up into really exciting jobs and really exciting positions because now this convergence is, is actually happening. So we need to translate one technology to another,

Trond Arne Undheim (00:36:56):
You know, I’m doing some work now on, on this idea of Pi- shaped expertise. Pi, as in, as in the number of PI or, or at least having to, because the older expression was, you know, society needs a T-shaped expert. So an expert in one domain that can communicate with other domains and has like some surface level awareness, but that’s really not good enough in innovation these days. Right? You have to actually have a deep level knowledge in, I would say minimum two domains and in, in this particular domain it’s medicine and and digital, whatever that happens to mean because you can’t really just outsource that into, into two different people all the time. You you’re just, I mean, wouldn’t you say, I mean, you would miss a lot of connections if, if you were trying to create these power teams of the smart doctor and a, and a smart coder, there are so many companies that I have seen these days that are combining those in one person and in many people, but that several people have to have that expertise. Otherwise you’re just missing the connections.

Greg Licholai (00:38:00):
Yeah, absolutely. Absolutely, if you go back to the days that I was in high school and college, the mantra was be well-balanced go broad. You know, you have to have a well balanced education, a ball bounce career, you have to be good at everything. Right now it is, I think it’s it’s, it’s,, far removed from that. And that’s what I tell my students, you know, what don’t, don’t try to be balanced, don’t try to do everything well, figure out the one or two things that that are your spikes. That’s what, that’s a McKinsey phrase, you know, figure out where your spikes are. And you only need one, maybe two. And if you can, if you can, you know have a real spike that reflects your interests. So first of all, you’ll always be happy with your professional life. And, and secondly it might take a little bit of time, but you will get rewarded for, for, you know, being an expert in something that, that you’re, you’re, you’re truly passionate about.

Trond Arne Undheim (00:39:09):
Got it. So what are the remaining barriers though for change in digital health? Because the mere fact of announcing 6 billion increase in funding, doesn’t say that these will all succeed and we have all seen in other fields, like there have been, you know, AI summers before where people have invested an enormous amount. There are a lot of domains. Like you could just go to the environmental or even energy technology field where clean tech was, was hot and then not hot. So there are a lot of disappointments also waiting for people who are doing innovation. What are some of the remaining barriers that you are worried about in this new landscape, in terms of everybody kind of getting in on the, you know, getting in the boat on this w what, what is it that would keep you up at night thinking, wow, I wonder who’s going to get the dissolution when they, you know, when they find out that things aren’t that easy, where are some of those barriers going to be? Because I think we all know that things go a little cyclically, right? So whenever something is really hot, some of the wrong people get involved and, you know, those people will, will discover that this is not all that easy.

Greg Licholai (00:40:16):
Hmm. You know, I think there are three phases that, that this field has to go through and, you know, maybe you can generalize it to other fields, but there’s the, the solution creation and all this venture capital money is going into creating new solutions. So you identify a problem. You create a solution to get this brand new brand new widget technology. That’s great in medicine, there’s two other big ones. The second one is the you need to verify that the solution works through verification essentially through clinical data medical data. And that’s kind of where we are, we’ve got solutions and there are trials being run papers, being published that say, yeah, so it, not only does it work on your watch, but actually you can treat populations and you can follow people. So, so that kind of you know, that clinical validation step is absolutely important and it needs to go very broad because doctors by nature are conservative and the healthcare systems conservative, we’re sort of in the middle of that.

Greg Licholai (00:41:26):
The third phase is, is, is kind of the most prosaic, but it’s a necessary step. It’s the reimbursement phase. So, so venture is going at the beginning. This is getting people to pay for it at the very end. So it’s insurance companies, Medicare government, et cetera. So you need to take that the validation of clinical data and build up enough evidence that it not just, it works, but it also has, you know, creates value for the system. So, you know you know, tracking, you know, say, say we can, we can track people’s, we can track asthma hotspots. And this is an example from a digital health healthcare company that I think has done a great job of combining both digital technology and public health. So you can track asthma hotspots in cities that are an industrial cities that are, that can be very humid and cause problems.

Greg Licholai (00:42:36):
And you can show that, that you can get the technology, you can show that that works, and that’s pretty cool. But then for that to be reimbursed, you have to demonstrate that an intervention actually saves money or saves lives. And that’s what it is, this this company that pioneer, this was able to do that. It giving that information back to the patients and physicians of where the hotspots are, got them to avoid that, avoid those hotspots number one, but number two also got them to use their medications appropriately, which avoided emergency room visits. So it saved the system money. W what was the name of that company? You said that’s called Propeller?

Promising Startups in Digital Health

There are hundreds of startups in this space that could become relevant for re-shaping healthcare, some are having impact already. Although many are in the early stage, some are rapidly maturing. 

Trond Arne Undheim (00:43:19):
Propeller health. Got it. Give me some, some other startups that you have been fascinated by. I know you and I had a, an early interchange on Akili, which has this interesting gamification approach, but it’s more than that, right? It is. Well, you’re telling me what it’s about, but it seems to be stimulating brainwaves in a very interesting way. And I found that pretty fascinating. What, what was your how did you discover Akili?

Greg Licholai (00:43:44):
So, so you know, working with a friend of mine, who’s a psychiatrist and a lawyer at Yale we were doing you know, a consulting project. And we found Akili years ago. I mean, and this is, you know, talk about convergence. So it was founded by neuroscientist at Stanford who is an expert in virtual reality. And it’s, it’s that combination of, of biological science and digital science. And so what they were able to do is track you know, create the, create these, these video games, as you say. So, so the idea of is it’s it’s video games for people with ADHD and behavioral health disorders and help them to focus and know basically pay attention. But the fact that it was the, these things were developed, created and developed, and the effects are tracked by neuroscientists.

Greg Licholai (00:44:54):
They were able to literally sculpt the program to get the desired effect in the brain. And you know, there’s nothing manipulative about it. I mean, you know, we could do this through meditation. We could through this through repetitive behavior, I mean, you know, repeating the same word or repeat repeating the same sort of tennis move over and over and over, you can imagine that that’s culture, your neuronal connections. So that’s how you get better at it. Without having to think about it. They were able to track that through these video games, in order to you know, basically work with what’s going on with ADHD. And they just recently announced approval or clearance, or their product.

Trond Arne Undheim (00:45:39):
Neuroscience is fascinating these days, right? I mean, you have, you’ll have this, and then you have kind of NeuraLink and other companies trying to create a direct connection into your brain.

Trond Arne Undheim (00:45:48):
But I mean, the point is our eyes are the most direct connection to our brain that we have so far, and they’re not that bad actually, if you just use them the right way. So this is a, I guess an example of that that it actually can be, our eyes is a channel as a clinical instrument. Now what some of the other companies we were chatting about earlier. So Valentis and Pear Therapeutics are more in these areas of prescription digital therapeutics. Tell me more about some of those two approaches as well. And while you are excited about those, those other two companies.

Greg Licholai (00:46:28):
The most dramatic thing I can say here is that it, it saves lives. So I’ll give an example of a published, some published work in a disease management that came out a couple of years ago, and then not from these companies, but it’s a study that showed that patients who have cancer and they have access to web based tools, internet tools, in order to track side effects, track disease, progress, get in touch with their doctors versus the traditional approach.

Greg Licholai (00:47:07):
The traditional approach is you get your chemotherapy, you see your doctor once a month, they follow up in six weeks. Maybe they do a cat scan or an X-ray once a month or every six weeks or every couple of months. So obviously disease doesn’t progress in month long intervals, you know,

Trond Arne Undheim (00:47:29):
But it’s more than drug adherence though, Greg it’s, isn’t it, right? Because you know, the simplistic explanation why this is working is that you’re saying, well, of course, because people weren’t taking their meds, but this is about something way different than just adhering to a rigid regiment of medicine. It’s not, it’s much more complicated than just saying, you know, you should take 200 milligrams every two weeks. It’s not just a reminder call. These companies are providing much more aren’t they, they’re, it’s a lot more personalized than,

Greg Licholai (00:47:55):
Oh yeah, absolutely. It’s a lot more than that. And this is in fact, you know, adherence was now what’s what was being measured. It was actually disease progression. And the ability to capture patients basically provide, you know, a safety net that isn’t kind of happening periodically, but happens continuously. And that’s what I think one of the promises of digital medicine is something you’re getting something a little bit closer to care continuity versus this episodic care of seeing your doctor. I mean, if you’ve got a chronic disease, you see your doctor maybe every six months or, or, or even less frequently. So, so certainly adherence to medications is a, is a big, big part of it, but just it’s care continuity of, you know, what symptoms do, what should I be worried about? Is this, is this symptom a trigger that does mean there’s a medication adjustment that requires a call from a nurse from a doctor it’s providing information about a better, better personal management lifestyle management and, and all of these things get wrapped up in these disease, soft disease management software products that are being developed. And, and again, I think it’s, it also has the promise to transcend barriers that we have that are problematic of have access like language and diversity

Akili Interactive and FDA clearance of the first ADHD treatment using “gamification” is significant.

Disease management

Voluntis is an early disease management company with clearance for use in oncology

Pear Therapeutics led the revolution with first clearance of software as a therapeutic in multiple areas including behavioral health and substance abuse.

Public health and digital medicine

Propeller Health pioneer in tracking asthma and respiratory disorders

Verily’s OneFifteen is a digital ecosystem for addiction treatment

Trond Arne Undheim (00:49:17):
As we’re looking into the next decade, which is sort of the timeframe for a lot of the discussions on this podcast. What are some of the things that will start to happen? I mean, through these startups, through the response to COVID and through other factors that, you know that you, feel free to let us know about, what do you think really

Trond Arne Undheim (00:49:40):
Is going to happen over the next decade in terms of improvements in digital health? Is it, so now there’s obviously capital involved, there are some promising startups, and there is this notion of you know, new types of expertise that are being brought together. What, what will all of that result in?

Greg Licholai (00:50:03):
The dream is, you know it’s a science fiction type of dream, but I think it’s pretty, pretty much closer to reality than we think, you know, so, so the dream is that, you know, you’ve got you’re informed early on that you’re, you know, potentially at risk for certain things, and that gives you information to change your behavior. Now, it sounds kind of simple the way I’ve described it, the, to put that together, you, you need to put three vast domains together that right now are not part of this is data. Part of it is analytics and AI. And part of it is, is just a digital technology to sort of give the right assessments and recommendations. So the three domains are genotype, phenotype and outcomes. So genotype is genetics, you know, your biology so much of, of our biology and our gene genes really determine our health status.

Greg Licholai (00:51:04):
The second is phenotype. So it’s the current interaction between your genotype databases are being built. And nowadays, you know, the first, the first human genome was, you know what was cost a billion dollars. You know, now we can get them for, I got mine done for free through, you know, through, through some trials or through some offers. So gene, the genotype data databases are exploding. The phenotype databases. Those are those exist right now in the form of electronic medical records. So what are your symptoms mean? You know, if you, if you do or do not have a diagnosis, how does that manifest itself? But that’s right now separate from the genotypes. We can put that together, but then we have to push it all the way forward more to the world that I’m in the outcomes and the outcomes are based on interventions, whether it’s drugs or surgery or lifestyle, how do we tie an outcome to your particular phenotypic disease state, and even earlier to your particular genotype, what are you at risk for that makes, you know, look, it might not affect you today, but maybe you’re at higher risk for asthma.

Greg Licholai (00:52:17):
Maybe you should think about these types of exercises versus other types of exercises. You know, maybe a you’ll notice that if you do exercise, when it’s say humid out, you’ll develop certain symptoms. So maybe you can change some behaviors. That’s the way we get in front of, in front of a disease process, as opposed to showing up people showing up, you know, decades later, when they’ve they have difficulty breathing and maybe they have COPD or diseases.

Trond Arne Undheim (00:52:45):
So Greg, I would love to be as optimistic as you, but the only thing I would say to that is, think about today, and we don’t even have to think about coed, but if you think about COVID, you could say, well, we know today pretty much that if you are obese, you have a higher you know, worse, worse outcome. That’s not something we need an enormous amount, more research to figure out. So the logical conclusion, if people knew that, which I think a lot of people do is that they should go down and get on a treadmill, or they should start working out every day or they should eat differently. Or there are a thousand different types of interventions for that particular condition. Now that perhaps happening, I don’t know, there’s not conclusive research on whether that has happened yet. So, I mean, I can claim that it isn’t, but I would say I haven’t seen an enormous amount of more people on my morning jog than I saw before. So this is all to say that behavioral science and behavioral interventions, they don’t all stop with the science. If you know what I’m saying. I mean, one thing is to know that you should do a certain thing, a whole other thing is

Trond Arne Undheim (00:53:54):
Willing to do so, how do you think that these new approaches are going to get at that problem and where some of the startups we were talking about, have they found a way into our brain that is more direct so that we will actually follow the excellent doctor’s advice?

Greg Licholai (00:54:11):
Well, let me give you one more example. So, so you’re, you’re right. You know, you know, a little flag on your, on your phone, you know, isn’t necessarily gonna make you a marathon runner. That’s true, but you know, let’s, let’s talk about some, you know, successes. So, so there’s a company called Proteus digital. So they’re, they’re famous for making the chip on a pill. So it’s actually digestible you swallow when you take your prescription drugs. It it’s encapsulated with something that tracks that you’ve actually swallowed it. So what’s the big deal with that. I mean, there’s an enormous amount of technology and tracking that goes into that, and it sends a signal that eventually goes to your, your app into your doctor that says, yes, you’re, you’re adhering to your medication. So let me tell you what the outcome of, of a study that they did.

Greg Licholai (00:55:09):
They took a group of patients that were defined as refractory to medical intervention with their metabolic disease. Basically they took exactly that population that you said and refractory means we’ve given up on them because we think they are genetically are not, their, their bodies are genetically, you know, not able to respond to medication. They took those patients. They put them on this program using the Proteus pill that actually attracted here and sent reminders. It created a continuity of care. It created some sense of control of the patient that was enough to get these refractory patients to actually be in both in blood pressure and diabetic control. I think that’s a remarkable result

Trond Arne Undheim (00:56:06):
Now is that, that is remarkable.

Greg Licholai (00:56:08):
Probably not, but, but I do think, you know, it’s that kind of understanding and not just sort of giving up on the system and say, well, no, no, like you’re, you’re, you know, it’s too, you’re too far gone. I mean, I think we keep on pushing and, you know, we, we, we make these incremental changes and incremental benefits.

How To Stay Up to Date on Trends and Developments?

Trond Arne Undheim (00:56:28):
The landscape we’re talking about is, is incredibly fascinating and it’s an healthcare is a field that everybody cares about and we should definitely keep ourselves informed. How do you personally stay up to date in the fields where you are either paid to track through your daytime job or through many, many of your interests and and sort of site interest and an innovation advisory and consulting. Who, where, who did it, who do you follow? What papers do you read and what do you recommend me and others who would like to track this field, but for whom this is not our day job, or it’s certainly not the only day job. I mean, I have the ambition here on the podcast to track around 20 meta-technologies. So that’s a very big challenge to do that on the side while doing other things. How, how do you personally stay up to date?

Greg Licholai (00:57:25):
Well you’re right. I mean, I’m incredibly lucky. I get to go to conferences and, you know, everything from traditional medical to digital healthcare conferences, although not in the last couple of months, but you know, all of that said that has shifted online these days. But, but I think there’s, there’s, there’s lots of publicly available information. I tend to like stuff that comes from more traditional sources and it would be nature medicine science magazine, scientific American they all have they all publish of frequent free updates and news. There’s science news, there’s nature news, nature reports. And in fact, both of them also have a new digital medicine journals that if you want to go even deeper, you can start looking up stuff there, but I’ve been knowing will general medicine. They all, they all have, you know, technology updates that they, that they provide.

Trond Arne Undheim (00:58:29):
Would you say that some of these medical journals have started reaching out to the general population or, or even just, you know, innovators and people who are, who are not expected to be medical personnel more and have more content these days that are digestible? I mean, I happen to be a person who would read even a medical article or, or, or 20. Even though I don’t have a medical professional you know, education, but many, many others would, would prefer to have things in a format that was digestible for them as a nonspecialist audience. So scientific American, those kinds of places. What about some of these more online sources and newsletters and things? I mean, there’s just so much that you could look at, and if you start putting anything into search engines about digital healthcare, there’s accelerators, there’s newsletters, and even just organizations

Trond Arne Undheim (00:59:22):
Catering to this field, it’s easy to get overwhelmed by, by that information. It’s hard to assess quality.

Greg Licholai (00:59:28):
I think is that’s, that’s true. That’s true. And so I write for Forbes you know, on, on innovation in healthcare and general news outlets, I think there’s a difference between an outlet that it has a specific purpose, and it’s difficult to determine if they’re being funded by a corporations or solely by one point of view, but general outlets, such as Science, Nature, Forbes, Scientific American, there’s obviously the New York Times and the Washington Post. I actually put it to the journalists and all of these, including the scientific publications, that vet journalists who were trying really hard to get to get information out there. That’s why…

Trond Arne Undheim (01:00:23):
You trust those sources more than think tanks and specialists sources?

Greg Licholai (01:00:30):
If I’m looking for, to just to generally follow trends, that’s who I would follow, and follow news and sort of your, like, where things are, that’s who I would trust. On the other hand

Trond Arne Undheim (01:00:42):
If you want to go deeper and really trace and perhaps even have the ambition of contributing to innovation, let’s say that you’re interested in starting a, a medical or a digital healthcare startup?

Greg Licholai (01:00:52):
Then I think you have to go down, you have to go deep. And I think you have to go through all those sources. I mean, you know, let me give one other reference to do an organization that I’m on the advisory board for it’s the Digital Medicine Society. So it’s a relatively new organization. It’s a, you know, they’re they go under, under the acronym dime, D I M E for digital medicine, they actually have a terrific online library. They’re trying to be as objective as possible. So it’s a professional society that’s aimed at professionals like physicians. There are other trade organizations like the Digital Healthcare Alliance is, is actually aimed at companies working in this space. Also has a terrific library and they, you know I’m sorry, I misspoke. It’s it’s Digital Therapeutic Alliance is a trade organization. That’s aimed in this area. They’ve got, they provide a lot of information. And I think between the two of them, you kind of get, you know, two sides of the story. You get the, the company side, and then you get the professional side that I think are terrific resources. So DTA and DIME I think, are good places.

Trond Arne Undheim (01:02:13):
What about podcasting, Greg, are you a big podcast listener or is this one of your first forays into, as a, both in terms of listening? And appearing on one, w w what about podcasts, podcasts you’ve seen any medical podcasts?

Greg Licholai (01:02:28):
I do. I, yeah, I do. I mean, there are, there’s some terrific podcasts that I’ve, I’ve learned a lot from, you know, and I do, I do try, I do tend to kind of you know, go either by topic or by, by sort of, you know, by, by you know, subjects that I’m particularly interested in following or, or in some cases, you know, by brand of, of, you know people I trust will do interesting things, you know, I’m a late convert to podcasts but I have experienced that. It’s almost an unfair advantage that podcasters have in the sense that, I mean, you just went on a run, I’m guessing the thing is you’ve got to decide who are you going to let into your ear?

Trond Arne Undheim (01:03:12):
Cause you know, you are extremely influenceable when you’re on your run. I mean, I don’t know on my run historically, I kind of process my entire life. So if I’m going to let in a podcast on my run, I mean, there are podcasts episodes, you know, like 45 minutes, which is my run. I can’t get it out of my head. I remember almost everything in the, in that crazy podcast because, because it has that direct connection to me when I am at my most vulnerable. I’m not thinking about anything else.

Greg Licholai (01:03:43):
That’s right. That’s right. I think it’s fine. And actually, I think it’s fantastic learning and it’s ways for us to keep up with the world. I do exactly the same thing when, you know, when I’m exercising, you know, when I’m, when I’m on a treadmill or doing cardio or running or biking I prefer to either, either listening to books on tape or podcasts.

Trond Arne Undheim (01:04:08):
Got it. Look, Greg, this has been fantastic. I hope that I can have you again. And I would love to call on you for many, many different things. So, your experience is so rich that we were, I think only scratching the surface of what we could have talked about, but thank you so much for coming on the show and for sharing your observations on digital healthcare with us

Greg Licholai (01:05:00): my pleasure, my pleasure, you know, your questions and comments were incredibly insightful. And so you know, you’ll probably get an MD after your name…

Trond Arne Undheim (01:05:15): That would have to be an honorary MD. No one should ever ask me to treat anyone. But that’s a good one.

The following is a set of resources the podcast host used in the research phase of this podcast. They were developed before the interview with Greg Licholai. 

Digital Health News
Email newsletters
Digital Health futurists & influencers

Christina Farr, Science & Technology reporter, CNBC (@chrissyfarr)


Outro (01:04:47):
I’ve just listened to episode 19 of the Futurized podcast with host Trond Arne Undheim, futurist and author. The topic was digital health and future pandemics. Our guest was Greg Licholai, Chief Medical Officer at PRI Health Sciences, faculty at Yale school of management and healthcare innovation columnist. For Forbes, we talked about where digital health as a field is right now and where it’s moving promising vaccine innovation, improving clinical trials. And staying ahead by tracking insight in the field.

My takeaway is that digital health has come quite far, but that its breakaway promises have only just began to manifest themselves. This year, investment in the field has spiked even before COVID-19, which indicates we will move at a rapid pace in the next few years. One exciting field is prescription digital therapeutics. However, the big challenge has remained: progress in healthcare doesn’t come easy. Even with digital tools at our disposal, we are dealing with legacy infrastructures, mindsets, government regulation, and intractable problems coming from left field, such as pandemics and the complexities inherent in any public health intervention.

Thanks for listening. If you liked the show, subscribe at or in your preferred podcast player and rate us with five stars. Futurized–preparing you to deal with disruption.