What Really Determines Health? Your Friends & Family- Part 2 with Khan Siddiqui

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In the first part of my discussion with Dr. Siddiqui we talked about healthcare applications and some of his experience at Microsoft. In this second part, Khan and I discuss some of the social determinants of health- best thought of as your friends and family, where you live. Notably, your doctor, drugs and hospitals are responsible for 10 % of your health. Social determinants make up a whooping 70%.

I want to shift a little bit and talk about your new company, Higi, and value proposition of Higi. Higi maybe one of the biggest companies in Healthcare most people haven’t hear about. Why did you found Higi and what is the unique value proposition of Higi today?

We started Higi to solve a problem that HealthVault had,- not only be a data aggregator for the patient, but also make it easy and accessible to acquire new patients from a health system point of view. Further we wanted to integrate work flows for patient care and population health management, as well as perform payer risk adjustment for stratification kinds of things.

We took a unique approach: We asked ourselves, where do people go normally? Well, you go to your workplace on a daily basis, Also you frequently visit retail outlets such as the grocery and pharmacy—a typical adult goes into a retail location 1.63 times a week. We thought, that’s where the opportunity for engagement is much higher. People don’t get up and say, I want to go to the hospital to get my blood pressure checked, right? But I do want to go get my milk and eggs and bread for next week. So how do you become part of that daily living process? How does it become a habit to do your vitals on a daily basis?

We also realized we needed to have a nationwide footprint before any kind of solution we built for our health systems or payers was interesting enough. So we pretty much became an ambient data collection network. Normally data is collected from the health stations—the biometric kiosks that we put in retail locations—but all wearables and home monitoring devices that are out there- social determinant data, behavioral data that typically the healthcare system and the payer does not collect. When you think of it in terms of all determinants (eg..genetic, environmental, etc..)—social determinants are 70 percent of your outcome.

What do you mean by social determinants of health?

It’s the people in your environment, the messaging in your environment that is impacting how you make decisions on a day-to-day basis. 10 percent of your health is determined by genetics. Another 10 percent is dependent on medical care, the doctors. There are other small factors, and then 70 percent is all social influences.

So whether I decide to buy a pair of sneakers or whether I decide to take my pill probably have similar overlaps—maybe more deterministic or more influential than even what my doctor tells me to do, who I see every 6 months or something.

Let’s say your doctor prescribed a medication and you have three other friends that have the same disease as you. And they say, oh yeah, we did it and we had all these side effects and it didn’t work. You will immediately call your doctor and try to get it changed. We won’t go into the treatment side of things—those are later stages—just what you buy, what you eat, how you exercise. Are you active or not? Life style has much bigger impact on outcomes long-term. From pre-diabetes, pre hypertension—how you control that stuff is how you live your daily life. That has much more impact from your social environment and social influence circle than anything else does.

Doctors kind of ignore that. They just see a patient, they make a diagnosis, they give you a pill, and you go away. But as parents, for instance, we know that the peer group our children have is much more influential than we are. And we really need to think how those [peers] influence choices.

Something else is that when we think about solutions for the patient, we think from the enterprise payer or a physician’s point of view. I’ll give you an example of a health risk assessment. We did some work trying to understand how to get people to do health risk assessment in the right way. And one person in the focus group gave me interesting feedback. He said, listen doc, I came in, I put all this information in about my pharmacy, my labs, my this and that, and the first thing you told me is I am going to die of a heart disease, I’m going to get diabetes, I’m going to get stroke, I’m going to get lung cancer, all awful. It felt like I was in middle school and I got a report card with six As and one B and all my mom scolded me on was that one B. All the things that I’m doing good, there was no focus on, there was no encouragement.  So, we already know from the education industry that demotivating or punishing a lot of defined bad things doesn’t work. Positive motivation is what works. And if penalizing people for doing bad things doesn’t work psychologically in children or even in college students and adults, why would it work in healthcare? So, you think of how you’re going to change that mentality, how you make it more of a positive interaction.

We spend an enormous amount of money on drugs and devices, but we really don’t spend any money on relationship. [Say] I want to talk to you as a doctor. You don’t pay me for that time if I don’t build that relationship, if I don’t provide that positive encouragement. It doesn’t matter what drugs I prescribe and how much they cost, they’re probably not going to have a big impact.

And that’s the gap Higi’s trying to fill, to be the entity that brings that understanding as well as engagement and continuous touch-points with the doctor outside of the health system.

How many people use Higi across the US today? How many lives are we talking about?

We have about 11,000 stations deployed nationwide.

They’re all through retail centers around the US?

Yes, and we’ve expanded into Canada now too. We’ve served over 35 million unique individuals.

35 million. So something like 10 percent of the US population has used it. That’s amazing.

In the last 3 or 4 years since we’ve been out, we’re approaching two hundred million screenings.

Wow. How do you see Higi fitting into this value-based, risk world that we all talk about?

Higi’s designed for that purpose. When you are attributed a population to take care of, you think about how much data you have about that population. Let’s say you’ve got a payer/employer contract that you have to manage as an entity with a population of 400,000. Maybe 10 percent came to the hospital/clinic before. And 90 percent of the patients you’re taking risk on, you have no idea—or on how much it’s going to cost you to bring all those people in to get the screening done. Higi’s an easy way to get it done. You want potential patients to go to a local station [and] share the data securely to the health system.

As a consumer, if I’m a patient, can I just get Higi for free?

Yes, it’s completely free for consumers.

So I can just go and get the Higi app, get involved, and it starts collecting this for me?

Yes.

 Does Higi function in some way to collect data for me so I can get insights into my care?

That’s exactly right. Higi has the enterprise side of things where we bring in an understanding of risk population screening and enabling health and wellness for employers as well as population health enablement for the long term. Then, on the consumer side of things, you make it easy for them to track and help them store the data in a PHR (personal health record) on a mobile app or on the website. We also bring in interesting challenges through our retail and brand initiatives to help them keep healthy and fit.

What are 2 or 3 things you think Higi does well as far as engaging people that Microsoft didn’t do? 

It’s not an apples-to-apples comparison. I’m not even sure Microsoft was designed to do what Higi does. 

I remember MS had thousands of lives, not millions, at its peak. It was not nearly as [broad in scope].

Because Microsoft was not designed to focus on user acquisition. Higi’s designed to focus on user acquisition and engagement.

So you tried to get at that problem and learned about it while working on Health Vault.

Exactly right. So one of the things we do is engage with a lot of brands on interesting initiatives. In 2017 we’re going to be doing a lot of work with different TV stations, some NFL sports teams, as well as other industries.

To help with wellness?

Yes. If you think how consumers think, they think about what’s interesting to them. If I’m interested in jazz music, I’ll be exploring that. I’m not going to change what I like just because you tell me to. If someone’s interested in something, how do you enter into the dialogue in what they are interested in?  That’s how we think about Higi. We want to create those health and wellness dialogues [around] what interests you. So if you’re interested in music, we’re working with some music publishers to come and bring the dialogue into that space. If you’re interested in football, we’re working with some NFL teams to bring that dialogue to you in that context. That’s what we’re doing from an engagement and user acquisition point of view. And then obviously we’re working with health systems and payers who also want to drive that engagement. But people would be more interested in hearing from the celebrity, hearing from that sports [figure] they’re interested in, hearing [about health] in that context.

So again it’s tying in your life, and your health is kind of a co-traveler.

That’ s exactly right.

What do you see as the big problems that you’d like to work on in the next 3-5 years in healthcare? Are there things outside of Higi that catch your attention?

We’d be here all day talking about that stuff. If you think of the timeline on digital health, we are in the infancy of this. We are just exploring AI (artificial intelligence/machine learning), just exploring automation, just exploring a lot of things. I’m really excited about what is happening in the genomics space: bio-pharma, pharmacogenomics, personalized medicine. This is the early stage of it. And as you see the trends, they’re accelerating faster than anything else. The technology advancement in genomics is magnitudes faster than Moore’s Law, which says technology doubles every time. This is going tenfold, a hundredfold every year. In 2011, doing one genome sequence cost what? Ten million dollars?  And now there are companies promising it at a hundred bucks. That’s just in 7 years.

Do you think that the patient/consumer, 10-20 years from now, will not really think about their healthcare so much, as things will just happen around them to keep them well? Or do you think it will still be that hard work where you really have to engage, [and the patient has to] be compliant with treatment paths. How do you see that will change, that barrier to actually get the consumer involved?

I don’t know when that will change, but what you’re talking about is normative influence, meaning that it’s the norm to think about it like that. Smoking is the perfect example. It used to be normal to smoke; the normative influence was that if anybody smoked, everybody smoked. Now the normative influence has completely changed; the people who smoke are not the norm. And that’s why you’ve seen a rapid decline in smoking. I think we’ll all be surprised when the change happens; it’ll happen extremely suddenly.   

And that’s not just technology. It’s a cultural change too.

I think cultural change needs to happen for technology to become effective.

So we’re just trying to build those tools so they’re ready when that cultural flip happens. Do you think the technology can catalyze that cultural change?

I think it can. I just don’t have the crystal ball on when and how. I look at all technology adoption curves. So, if you look at radiology, what happened to PACs adoption? It was much faster that EMR adoption. But if you map it out, there was a “hockey stick” that happened when we hit 30 percent of adoption. When we hit 30% PACs film-to-filmless adoption, it accelerated. From film to CDs, same thing, it accelerated when 30 percent of patients demanded some kind of CDs. Same thing with EMR adoption. If I go back and talk with my X-Box team or any of my other teams, they all show the same thing. If you look at the Facebook adoption curve, if you look at others, they all have between 20 to 35 percent that hits and accelerates. You need to get to that normative influence and that initial 30 percent—1/3—of the population for it to become the norm and accelerate, meaning that 1 in 3 persons is doing it on a regular basis. We need to think how we get to that one third, not 100 percent. If you can get to that one third, the natural curve will accelerate.

Do you think that’s going to be led by hospitals? They are often out there trying to grab consumers.

Unless the hospital can capture 30 percent of the US population, I don’t think so. 

It’s interesting because a lot of hospitals are spending an enormous amount of effort trying to capture people and get them to think about the hospital as their place to go for wellness, but I think retail may be a much more nimble market for that.

One thing Facebook and other things have taught me is the concept of ingredient branding . You need to be where people are interested in going. You can’t build everything around one thing because a certain population is just not interested. You need to make sure you are easily everywhere. So what’s your presence on Facebook, on Twitter, on Instagram. Similarly, what’s your presence on Higi, what’s your presence at Rite Aid, what’s your presence at Walgreen’s, what’s your presence in your local grocery store. You need to think through that. You’re not building your own social network. You don’t want to own all of this stuff. Nobody’s going to come to you.

So a hospital trying to own a population may run contrary to the way . . .

Yes, you need to be where people are. What is your experience at an airport? What is your experience at a local sports venue? That’s where people are going.

In my dream, hospital systems change. They become something that helps you with your wellness. They take care of a population in terms of housing, food, healthcare…all of those things, and they somehow figure out how to make money doing that—where we improve the patient/customer experience. And the country does better.

I think the hospitals need to figure out their ingredient brand and all these experiences rather than owning the entire experience.

Khan, I really appreciate your time. This has been very enlightening. I think the big take-away for me is that healthcare has to be part and parcel of daily living, as opposed to something separate.

Exactly. Thanks Alan.

Thank you.