Chairman:Perspective – Simon Cartmell OBE, Ieso Digital Health
Perspectives from Leaders in Digital Health
Interview with Simon Cartmell OBE, Executive Chairman, Ieso Digital Health:
Ieso Digital Health provides evidence-based mental health therapy online with improved outcomes, offering patient choice and more widespread access. Discreet one-to-one therapy is delivered in real time using written conversation, with patients meeting an accredited therapist in a secure virtual therapy room, at a time and location that is both convenient and comfortable for them.
Coulter:Pulse recently interviewed Simon Cartmell OBE to learn more about the Digital Health sector and the role that Ieso is playing in this innovative area of Life Sciences. Simon has been Executive Chairman at Ieso Digital Health since 2015 and has spent a long and distinguished career in healthcare, notably as CEO of ApaTech, a spinout from Queen Mary University of London, which was acquired by Baxter in 2010. He is an Operating Partner at Imperial Innovations plc, and was involved in the sale of their portfolio-company and UCL spinout, Stanmore Therapeutics to Stryker. He is a NED on several UK and European Medtech Boards.
Coulter:Pulse – Please can you give us some idea of the main challenges and opportunities that Ieso faces as a Digital Health company in the mental health arena?
Simon: Digital Health has no single unique definition but rather encapsulates a whole new world of healthcare potential. Seen as a means to more easily connect patients with doctors, certain value propositions and benefits naturally follow. Seen as a way of analysing and using data to make better healthcare decisions, then another set of value creating opportunities come into play. Ieso brings the best of both these worlds, offering something potentially transformative to the delivery of community based mental healthcare.
In the UK, government initiatives around IAPT (Improving Access to Psychological Therapies) are truly ground-breaking and this is an area of medicine where the UK is leading the rest of the world and the major developed markets. Intrinsic to IAPT is a recognition that mental health is a serious healthcare condition with significant economic and physical consequences. What IAPT has achieved is a mechanism enabling patients to be rapidly referred to an appropriate treatment modality and one where commissioning has been aligned to need very effectively.
Under the IAPT regime the government sets targets for increasing access to psychological therapies. With statistics showing a prevalence of mental health issues at around 18% of the adult population at any one time, these targets represent a significant challenge. IAPT has gradually increased the targets for commissioning groups and provider units over time from a starting point of around 3% of this population segment to the most recent target of 25% by 2020. A second IAPT initiative has seen significant investment in the training of 6000 therapists to deliver Cognitive Behavioural Therapy. A proven modality for psychological intervention, CBT is aimed at returning patients from “caseness” to “non-caseness” where they are undetectable from the rest of the population in terms of their mental health or psychological well-being. CBT when appropriately delivered is based on the premise of a correct diagnosis and the formulation of an appropriate intervention pathway.
Programmes we are conducting here and in the US are also exploring how such talking therapies can improve outcomes for chronic physical conditions. Treating patients in chronic care at the point of diagnosis can completely alter the trajectory of the chronic care pathway by changing mind-sets from “oh no, my life is ruined” to “this is a challenge and I can manage this”. A few weeks’ intervention in this way at the start represents significant potential healthcare savings over the longer term. Such new approaches, however, mean educating medical practitioners to think outside their own narrow focus (in diabetes or urology for instance) to consider the patient as a whole person, whose psychological well-being is also of prime importance to their own success.
Coulter:Pulse – How does digitally enabled psychotherapy compare with face to face therapies?
Simon – In the UK, NICE (National Institute for Health and Care Excellence) has advocated talking therapies in the broadest sense and CBT particularly as the modality of choice. A measurement framework was created as part of IAPT so that every provider reports their patient results to central government and most importantly all providers can see the performance of every other provider, by diagnosis and seriousness. Whilst Ieso’s original randomised controlled trial published in the Lancet in 2009 demonstrated clinical effectiveness of Ieso modality equivalent to standard of care face-to-face therapy, we know that many clinical trials are not replicated in the real world. The conditions created by a selected population, a controlled environment and the placebo effect of being thoroughly nurtured are not always mirrored in the real world.
The IAPT regime, however, has provided Ieso with a living laboratory where we can replicate the clinical trial outcome in the real world and learn how to do better. So what we have discovered is that Ieso’s platform is proven not just in a randomised clinical study but also in real life – so it’s not only efficacious but also effective.
Most psychotherapies involve a relationship that is face to face or via video between a patient and a therapist and monitoring of the interaction is often minimal. Inevitably therapists fall into some bad habits or take shortcuts and adherence to protocol is not subject to regular supervision. Ieso by contrast creates a virtual chat room online in which there is a real live therapist with a patient and there is a record of every single letter that is typed. This allows us to control or understand therapists’ formulation vs the diagnosis and therapists’ compliance with protocol or deviation therefrom. We can also then bring to each patient/therapist interaction the sum total of all therapists’ expertise, not just the individual experience of each therapist.
A whole range of conditions are treated, from general anxiety and depression of varying severities to OCD, PTSD and rarer, more complex conditions. Even our clinical lead who has some 27,000 hours of therapy behind her has only encountered some conditions maybe a dozen times in her life. By bringing the sum total of knowledge together however, Ieso can improve outcomes substantially. Compared to the national average Ieso has a population that is 10 to 15% more severe across a range of conditions but is reporting results that are 10 to 15% better than the national average in most conditions (in returning patients from caseness to non-caseness).
And this is achieved needing up to 50% fewer interactions with a patient by a therapist than the national average for any given diagnosis. This is why such digitally enabled live intervention is transformative. Translated into either monetary savings or capacity improvements, this can have a major impact in striving to achieve the treatment target of 25% projected by IAPT. Increasing the number of therapists or changing business processes within healthcare systems cannot happen overnight. But by channelling relatively straight forward cases to Ieso for instance, we have estimated a potential 70% more capacity could be achieved, enabling non-Ieso therapists to focus their efforts on more difficult cases.
Coulter:Pulse – Your work with the NHS must give you a very strong suit as Ieso broadens its horizons and expands into new markets?
Simon – Yes indeed. The NHS in the UK has a trusted brand equity which definitely carries weight in the US. That we have been part of the pioneering NHS/IAPT regime and have such impressive data integrity is highly persuasive to clinicians and psychologists. US Venture Capital investors may at first need some convincing about the NHS, but once they understand that the UK is ten years ahead in this field they too are quickly won over.
Coulter:Pulse – With the proliferation of Digital Health applications now available, how have the market and patients responded to digitally enabled psychotherapy?
Simon – Outside the healthcare world digital advances confront us in every aspect of life. Everywhere we are seeing the ‘uberisation’ or democratisation of industries, enabling choice for individuals. On the borders of healthcare this has resulted in a deluge of self-help apps, online portals and other digital offerings where quality control is so often lacking. Poor experience of inadequate AIguided or video enabled interactions can then result in resistance to online mental health provision.
By comparison Ieso recognises the need to comply with a regulatory framework. The reality for medicine is that information governance and control processes have to be followed. Ieso applies quality controls with the aid of Artificial Intelligence. Because there is a transcript of exactly what was said, data gathered can inform diagnosis and treatment management. Bespoke assessment tools (e.g.GAD7 and PHQ9) are used for analysis – to predict likely response rates to therapy or non-attendance risk for instance. A.I. can be used to prompt therapists to maintain protocols, and asynchronously the therapist can support the patient, for example providing a homework reminder. And via A.I. Ieso has been able to incrementally improve success rates by 1 or 2 % points every 6 months through therapist selection and process quality control. This is unheard of in the face to face or video world.
Digitally enabled psychotherapy can improve the reach of care beyond a once a week appointment and offer more privacy than anything involving voice. Therapy can be conducted during lunch hours or after work with onlookers oblivious to the real purpose of the keyboard tapping. Privacy is a very important component and the internet brings disinhibition – the distancing or “face-saving” effect encouraging openness. Psychological therapy via written correspondence has existed since the 1890s and just as then, the opportunity to take time and be reflective in an online written interaction is very productive in terms of both self-learning and the therapist’s understanding.
We are now able, if only NHS Tariff structures would allow it, to put in place pricing structures based around the predicted therapy units that will be needed for specific types of diagnosis. Care packages can be customised based on the huge amount of data now gathered by Ieso – some 10,000 complete patient data sets in the UK so far, with around 100 million individual data points. The challenge remains how to persuade traditional healthcare organisations like the NHS to adopt these new types of business model.
Coulter:Pulse – How does one address the challenges around patient data in the Digital Health arena?
Simon – Each country has information governance frameworks you need to be cognisant of and there are different views as to who owns the data. In France the individual owns it, while in the UK for example, the NHS does. Different approaches are therefore needed. In the case of inbound patients here who have not been referred we have to close the loop back to their own GP.
Coulter:Pulse – And how does Ieso tackle the challenges around pricing?
We operate different types of contract. Where there is a primary provider in a commissioned area we operate on a sub-contract basis – they send us patients in a category or refer them to us from a waiting list with full information that has come through the healthcare system. In other cases we have contracts with commissioners who offer a number of modalities at certain prices and we go out and find patients in those categories within a defined geography. Our margins may be better but the costs higher, depending on the contract type. A fundamental challenge is that “digital” does not equal cheap! How do you offer better outcomes and better pricing that still allows you to make money? Payment regimes still think very traditionally, despite the clamour for ‘payment by results’ or value based commissioning and although we can be flexible and take on some of the risk when calculating pricing models for some patients it is difficult to get UK Commissioners or Lead Providers to think outside national tariff structures.
Coulter:Pulse – In general what trends in Digital Health do you see as the most promising?
Simon – True success in Digital Health will come to those who create new channels of access allied to measurement frameworks and better data that improve outcomes. This is where real value can be demonstrated.
If we explore the two words more closely, “digital” is all about data collection, connectivity and making information available and integrated. While there clearly is value in this, it needs to be more than just doing what we currently do better with the aid of technology. What drives improvements in “health” on the other hand, is actually the quality of diagnosis and formulation of responses. So my belief is that the real opportunities lie in improving the delivery of healthcare, making it more targeted and patient focused. And this requires us to have a better understanding of patients and their conditions.
There is now a strong focus on developing Artificial Intelligence decision support systems, which go way beyond self-help applications, to put quality health decision resources in place that can substitute for clinicians, with the dual goals of improving access and reducing error. These trends are showing a great deal of promise, creating new therapeutic protocols and improving clinical pathways. This is what Digital Health is really all about in my view, in conjunction with education on how to implement these. Changing behaviour and teaching medical practitioner how to think differently is the most important and biggest challenge in all of this and of course relies on a real willingness to adapt.
Coulter:Pulse – What part are regulatory bodies playing in all of this?
Simon – In such a fast moving world as Digital Health regulators are still behind the curve. Nevertheless, regulatory frameworks are coming as the realisation dawns that it is critical to ensure that the A.I which is driving therapeutic decision making is not putting patient safety at risk. Some West Coast start-ups have forged ahead in order to steal a march on regulators, taking on the risks themselves while they build their databases. Inevitably we are seeing some cases of them coming unstuck as regulation catches up with them.
Coulter:Pulse – To what extent is Digital Health an area that is attracting investors in the US and in Europe? And what effect is Brexit having?
Simon – In the US 9.8 billion dollars were invested last year in Digital Health across insurance processing, healthcare services businesses and other new technologies. In the first 6 months of 2016 the US has continued at about the same rate, typically responding to healthcare technology business opportunities with enthusiasm, even where there are no revenues yet and no business models in place. Europe has traditionally been more conservative about investing in Life Science companies, whether classic biotech, speciality pharma, medical devices or anything else. But there are now a number of funds here created with mandates specifically around Digital Health and Medical Devices, (including the likes of Endeavour Vision, MVM, Gilde and EarlyBird for example.) They all see the potential for Digital Health to be transformative and have started to recognise what people will value and the models where money can be made. Investment has really begun to flow over the last eighteen months, now that it is better understood.
Aside from the general economic uncertainty and concern regarding European central funding of R & D, Brexit has had no discernible impact as yet in this sector and the EIB and EIF appear willing and committed to invest in UK venture funds and start-ups.
Coulter:Pulse – In such a fast paced world how difficult is it to find and attract the right talent and leadership to drive your business towards its goals?
Simon – When it comes to talent in Pharmaceuticals and Biotech, the UK and Europe compete well, covering the whole gamut of what is needed in biological sciences from R&D through to commercial and manufacturing excellence. In medical devices too there is innovation and talent, particularly across middle Europe, where engineering disciplines have held sway. But while we may also have commercial talent here, there is really no substitute for knowing first-hand how to build a business and manage it from beginning to end. Compared to counterparts in the US, Europeans with such comprehensive expertise are in shorter supply in my view, simply because we have had far fewer major medtech corporates than in the US.
For Digital Health, whilst we have strong talent on the technology side, there is less developed skill around commercialisation and deployment of these types of businesses. And while there is a very strong and thriving Fintech world in Europe, there is far less tradition of European businesses based around IT in Healthcare compared to the US, so finding the highest calibre, globally experienced, business leaders or functional heads is more of a challenge.
For Ieso the best opportunities lie in the US. To go through the next development and exploitation stage, we need people who understand commercial models and how to grow revenues to convince investors. An academically orientated problem solving approach that is often the norm here in European Life Sciences is not enough. And to succeed over there we have to understand how the US healthcare system works and how to commercialise across the pond. It isn’t one market of course, just as Europe isn’t a single market, but the practice of medicine and the payment, reimbursement, regulatory and legal processes are very different. To succeed in the US you need to ‘go big’ and look and behave as if you were a US corporate.
Interestingly we are seeing several Pharma companies are now coming to the Digital Health table, as pricing constraints impose limits on their traditional business and they scout around for ‘beyond-the-pill’ or added value services. Medical device companies, facing similar challenges are turning to ‘solutions selling’ and want a piece of the Digital Health pie, even though they are not yet quite clear what it is! In the corporate world the need for a new style of talent is emerging. People with strategic vision do not always have the day to day operational skills or vice versa, to enable the right commercial decisions to be made. Those who own only a small segment of the process don’t always see the bigger picture and those whose role is strategic don’t understand how to drive activity that will help to transform healthcare.
The challenge for Digital businesses in Healthcare is to find people who can cross over and understand the application of technology in Life Science in order to change and improve pathways in the field of healthcare.