Our Continuous Health Future
Harnessing Ubiquitous Computing and Novel Data Science for Better Health Outcomes
Imagine having a heart attack. You feel pain in your chest. You call your doctor who sends you to the emergency room where you are met by an ER doc who doesn’t discern any irregular heartbeat but sends you for some tests. Hours later you’re told you likely suffered a heart attack and you need to start treatment immediately including various prescription medications, an exercise and diet plan, lots more doctor visits, blood tests, expensive imaging and likely double bypass surgery. Congratulations, you’re part of the group of heart disease sufferers who cost the US healthcare system $1B per day. Right, per day! CDC projects that by 2030, the direct cost of cardiovascular disease and the cost of lost productivity will reach $1.1T annually. Worst of all, the appointments, tests, medications and stress will turn your life upside down and strain your financial condition. Your life may never be the same.
Now imagine a differentscenario. Before you feel any pain, your smartwatch notifies you of an irregular heartbeat and asks if you’d like to consult an expert. You’re connected to a specialist via teleconference. You press your thumb across the top of your iPhone where the sensors are, and the specialist can see all of your main vital signs. No pain in your chest yet and no symptoms. You’re referred to a cardiologist who pulls out her connected digital stethoscope, which scores your heartbeat in the cloud to help her determine that you likely have a condition that could lead to heart attack if untreated. You’re sent home with an exercise and diet plan along with remote monitoring equipment, including a wearable, smart scale and a connected blood pressure cuff, which will monitor your symptoms continuously in real time and alert your cardiologist of any anomalies. When you return in a month to see your cardiologist you’re told that your data looks normal and you can carry on with your life. This series of events just saved the health system hundreds of thousands of dollars and may possibly have saved your life.
At Better Ventures, we back mission driven founders leveraging science and technology to address the world’s biggest challenges, and we are enthusiastic about the potential for “Continuous Health” technology to play a critical role in the future of our health. Much has been written about the runaway cost of the American healthcare system and the fact that we spend nearly twice as much per person than other developed countries, but somehow we achieve worse outcomes. We operate today much as we did 50 years ago. Our health system is built to be reactive and episodic. We wait until something goes wrong, and we pay the price as a result. But what if there were a different way enabled by technology? What if we could continuously monitor our health, manage it proactively, flag problems early, predict future problems before they arrive and prevent them altogether? We can.
Two important trends point to the opportunity for our health system to transition from reactive, episodic and clinical care to proactive, continuous health management outside of the clinic, achieving the elusive double benefit of improved health outcomes and lower costs with the potential to usher in our Continuous Health Future.
A Hospital on Every Wrist
The first big trend enabling Continuous Health is the proliferation and coming ubiquity of connected health devices. It’s only recently that we’re seeing so many health-related sensors packed into low-cost devices and in the next few years we will see the big volumes. The sophistication of these devices is nothing short of magical. Apple watch for instance already has heart rate and ECG capability and is able to predict certain heart conditions like AFib. It even senses that a person has fallen and enables a call for help. Recent patent filings by Apple show the intent to add myriad sensors to the iPhone, for blood oxygen level, blood pressure, hydration levels ECG, PPG, you name it. More than you typically get in a hospital visit. How long will it be before Apple integrates these into the back of the Apple Watch and puts a blood pressure cuff in the watchband? Researchers project shipments of smartwatches and fitness trackers to grow from approximately 240M units this year to 300M units in 2023. So three years from now there will be over a billion wearable computing devices in the market that are less than four years old.
Beyond smartwatches and fitness trackers, all manner of other connected monitoring devices are becoming highly accurate, widely available and inexpensive — continuous glucose monitors, connected blood pressure cuffs, smart pills, smart scales, connected contact lenses, wearable cardiac monitoring devices, smart shoes, and even smart toilets using computer vision to analyze your “output” and monitor your metabolic health. The volumes and sophistication of these devices are a new phenomenon and they’re one of the two big reasons why the time has come for Continuous Health.
Renaissance in Data Science
Meanwhile, the second big trend contributing to the rise of our Continuous Health future is the maturation of data science, particularly machine learning,
convolutional neural networks and deep learning algorithms, fueled by new sources of patient data from the devices described above. The copious quantities of data thrown off of these emerging devices provides data scientists with the historical data they need to train algorithms, which can predict health conditions with uncanny accuracy.
Our portfolio company Eko Health, for instance, is getting some amazing results applying data science to health data from its digital stethoscope. A study undertaken by Eko and Mayo Clinic, published in the Journal Nature, shows remarkable accuracy in detecting low ventricular ejection (a significant precursor to heart disease) in asymptomatic patients. In the graph to the left, the Eko prediction (redline) and the validation set (blueline) are so tightly coupled it’s difficult to tell them apart visually. On AFib arrhythmias, the company has shown 99% detection accuracy. This is MUCH higher than the accuracy of cardiologists, and even higher than the accuracy of general practitioners, who scored just 2 out of 7(!) in diagnosing heart conditions in a recent study.
It’s not hard to imagine this level of accuracy enabling the prediction of just about any health condition. This article, for instance, points to a team at the University of Louisiana that is able to predict epileptic seizures with high accuracy up to an hour before they happen, rendering epileptic seizures preventable. Similarly, algorithms able to predict health outcomes have the potential to help us manage our health proactively — for example, suggesting blueberries to lower your cholesterol, telling you beer spikes your glucose and red wine doesn’t, recommending evening as the ideal time to exercise, and 10:15 pm is your ideal bed time. Why would we wait until we feel sick to go to the doctor when we’ve got supercomputers in our pockets while our wrists are festooned with sensors and algorithms, which can constantly monitor our health, suggest optimal behaviors, and predict problems before we even feel symptoms?
A Trillion Dollar Opportunity
As our US healthcare market is poised to eclipse $4 trillion in the next two years and the global healthcare market reached $10 trillion, it’s not hard to imagine the potential for staggering economic and societal impact from Continuous Health management. Of the $4T US healthcare market, approximately half of that is spent on clinical care and hospital care, nearly all of it is episodic and reactive. What part of that could be addressed by better ongoing, preventive, health monitoring and management outside of the clinic and the hospital? Assuming these technologies can prevent illness and chronic conditions, maybe half of that, or $1 trillion? No one knows exactly, but as we say in the venture business, at some point there’s no need to haggle over the details because the market opportunity is… BIG. Very big. To break things down a bit, here are some spending figures by condition according to the CDC:
Heart Disease: $199B
Cancer: $174B
Diabetes: $237B
Obesity: $147B
Arthritis: $140B
Alzheimer’s: $200B
Epilepsy: $90B
Behavioral health: $186B
Big Tech Rushes In
As the largest tech companies like Apple, Google and Amazon flirt with trillion dollar market valuations and seek new market opportunities, they all have landed on health as a huge opportunity. Healthcare markets are so big and so broken that these large companies are salivating over the potential to be the disruptors and to grab some part of the market. With trillions of dollars in stake it’s no wonder they see this as a growth area.
Apple: Apple is turning the iPhone and the Apple Watch into healthcare devices. iOS ships with the ability to add your medical records using your devices. Customers can import their health record from their provider and grant access to third-party apps as they see fit. Apple HealthKit enables developers to build third-party applications based on Apple customer health data. Similarly, ResearchKit enables researchers to use iOS as a platform for health studies. And Apple is working on using its facial recognition software for early autism detection. Last year, Apple bought an asthma monitoring company, Tueo. Recent patent filings show plans for iPhone figure sensors to monitor blood pressure, body fat, hydration, blood oxygen levels, heart function and more.
Google/Alphabet: Google is going long on healthcare. The explosion of health data prompted by Obamacare plays right into Google’s core competence. With far more Android phones in the world than iPhones, with the recent acquisition of Fitbit and the continued rise in Android watch volumes, Alphabet is well-positioned to be a major player. Alphabet subsidiary Verily in particular is focused on digital health, devices and data. It’s garnered over $1.8 billion in funding from Alphabet and a number of outside investors. The company is partnering with corporations large and small on Parkinson’s, diabetes, baby monitoring, opioid addiction, cardiac care, clinical trial monitoring and on and on.
Amazon: Amazon too is making deliberate efforts to enter the health care market. Amazon Web Services has a number of specialized health technologies including natural language processing service Comprehend Medical and various other services. Alexa is now HIPAA compliant. Amazon paid over $1 billion for prepackaged medication company Pill Pack, they own a medical device distribution company, bought a healthcare savings account company, and even make blood glucose monitors under the brand name Choice. Amazon announced a triumvirate called Haven with Chase and Berkshire Hathaway to address employer self-insurance, which has the entire healthcare industry looking over their collective shoulder worried about being “Amazon-ed.”
Early Signs of Success
We consider it early days in the maturation of our Continuous Health future, but a handful of companies have validated the market and shown early signs of success. Many focus on chronic disease like hypertension, diabetes, and obesity, mostly because that’s where 90% of healthcare spending is right now, but we see similar technologies and business models broadening to the health market writ large:
Livongo: leverages smart devices to monitor and manage the health of people with chronic conditions from anxiety to diabetes to behavioral health. Publicly traded with a $2.3B valuation.
Omada and Virta: both similar to Livongo with offerings to monitor and manage chronic conditions like obesity and diabetes. Both venture backed and valued around $500M.
ResMed: maker of continuous remote respiratory monitoring and management systems designed to treat sleep apnea and other respiratory conditions. Publicly traded with a $24B valuation.
iRhythm Technologies: wearable heart monitor providing rich continuous heart health information for people with cardiac conditions. Publicly traded with a $2.4B valuation.
Babylon: telehealth provider offering video consultation with a doctor where and when you need it. Their monitoring capabilities track activity levels, heart health and behavioral mood to inform clinicians and to better manage health outside of the clinic. It’s free for NHS patients in England. VC backed with a $1.5B valuation.
Teledoc: telehealth provider with a broad range of services from general health behavioral health. Publicly traded with a market cap of $8.9B.
Hinge Health: provider of joint and back pain care program which includes a wearable, education and coaching. Venture backed with a valuation of $406M.
Propeller Health: maker of connected inhaler and mobile application to manage asthma and COPD. Acquired by ResMed (see above) for $225M.
Proteus Digital Health: maker of indigestible sensors or “digital pills” which continuously measure medication compliance, effectiveness and enable personalization of medications. Venture backed with a $1.5B valuation.
Pear Therapeutics: maker of FDA approved prescription digital therapeutics (essentially a software platform approved as a therapeutic just like a drug would be). Focused on substance abuse and addiction and often coupled with tele-behavioral health and medications. Venture backed with a $500M valuation.
As valuable as these companies are, it’s our investment hypothesis that these companies are merely scratching the surface of the Continuous Health opportunity. They will continue to grow and address more health conditions and become more accessible to consumers, while other more sophisticated companies will emerge in their wake. While Livongo is a shining success with a multibillion-dollar public market valuation, we consider it “Continuous Health 1.0” in that it’s doing basic monitoring and management with human intervention as needed. We see the real benefits to society coming from the further evolution of these companies to address more conditions, to be more accessible to consumers, and to better leverage artificial intelligence to predict problems and provide closed-loop preventive health management.
Emerging Innovators
In addition to the established companies above, there are countless new, smaller innovators chasing the Continuous Health opportunity. Here are just a few:
ContinUse Biometrics: contact free vital signs monitoring from a distance using cameras and lasers. Futuristic system enabling measurement of heart rate, blood pressure, body temperature, respiratory rate, blood alcohol, and other biomarkers from a distance without contact. Click here for video demonstration. Raised $22M from K3 Ventures, Johnson Controls, Olive Tree Ventures and Lenovo.
Bark: passive monitoring of young people for signs of depression and anxiety. Suicide is the leading cause of death for teens, and this company monitors teen online activity for behavioral health markers, and then alerts parents / caregivers to nip depression and suicide in the bud. Raised $16M from Karlin Ventures, Rightside Capital and Social Starts.
Oura: connected finger ring to measure vital signs and movement during sleep enabling individualized recommendations and sleep optimization. Raised $34M from Jazz, Able Partners, Next Ventures and Proxy Ventures
Tasso: elegant puck shaped blood drawing device that enables painless, simple, self-service home blood draws. Pop it in an envelope and results come to your doc and your mobile app. Raised $7M from TechStars, Cedars Sinai and Vertical Venture Partners.
Myia Health: platform that ingests a wide range of real-world data from curated sensors and sources, transforming it through applied machine intelligence into actionable and objective clinical insights. Great founder blog post consistent with the Continuous Health theme here. Raised $17M from Zetta, Bloomberg Beta, B Capital and Mercy Health.
Feel: emotional and behavioral health monitoring. AI analyzes wearable data for mood and emotional state, enabling behavioral therapy when and where you need it (like at the moment you are depressed or experiencing anxiety) with data to inform clinicians. Raised $16M from Felicis, Anthemis and SOSV.
Swift Medical: brings clinically calibrated wound imaging to your phone. Tracks progress and flags problems. Super cool (and yucky!) wound images that tell the story here. Raised $7M from 7Wire, Data Collective, Relay Ventures and Real Ventures.
Human API: Think of this as the Levi Strauss of Continuous Health, selling the picks and shovels to enable it. Human API simplifies the flow of information between systems so your iPhone can talk to your doctor’s record system, which can talk to your connected blood pressure cuff, etc. With all of these different devices and systems made by different companies using different standards, Human API makes it simple for software developers to enable these systems to talk to each other, while giving users security and control. Raised $17 million from Adreessen Horwitz, Innovation Endeavors and Blue Run Ventures.
Tyto Care: enables telehealth with remote monitoring from a connected stethoscope, a high-definition camera that can evaluate dermatological issues, an infrared thermometer, an otoscope and a tongue depressor adaptor. Raised 102M from Orbimed, Qualcom Ventures, Insight Partners, Echo Health Ventures and Qure Ventures.
Our Past and Future Investments
At Better Ventures, We’ve made a number of great health investments over time, from Eko Health (cardiac audio intelligence) and K4Connect (senior monitoring) to Unnatural Products (AI driven drug discovery), Agathos (clinical variation intelligence), Iris Plans (paliative care telehealth), 54gene (African biobank) and Apostrophe Health (employer self insurance health plan). But two stand out as particularly relevant to Continuous Health.
Our investment in Eko Health, which analyzes heart and body sounds using advanced data science, has been a success by any measure. We wrote the first institutional check into the company, and they’ve since progressed to become the youngest team ever to achieve FDA approval for a Class II medical device, they raised solid Series A and Series B rounds, and they are scaling revenue nicely. For anyone interested, you can find my Mission Driven podcast interview with the CEO and founder, Connor Landgraf here, complete with a heartbeat recording of an emergency room patient who might have died if it weren’t for Eko.
Further, our investment in K4Connect, which monitors the health and well-being of seniors, enabling them to live happier, healthier, longer lives has been a similar success — we invested in their seed round, and the company has since gone one to raise Series A and B rounds, and is scaling revenue into very meaningful territory. The founder, Scott Moody previously founded the company that makes the touch ID on the iPhone and which was bought by Apple. Scott is as mission driven as founders come, and we have high hopes for the company.
Encouraged by our success with Eko and K4Connect, the success of Livongo, iRyhthm, Teledoc, and the Big Tech companies rushing in, we are eagerly seeking new investments in Continuous Health. We skew heavily toward software and rarely do devices. Ideally we are looking for companies applying software and data science to existing devices, particularly off-the-shelf ones like Apple Watch, Fitbit, AndroidWear and others. Our sweet spot is writing first institutional checks into pre-seed and seed stage companies with strong, co-founded, mission driven, highly technical teams. So if that sounds like you, and you have an ambition to change our health system and enable our Continuous Health Future, we’d love to hear from you.
